Inter- and Intraobserver Reliability of Wrist Arthroscopy for TFCC Tears: An International Study

To evaluate the interobserver and intraobserver reliability of wrist arthroscopy for the diagnosis and classification of triangular fibrocartilage complex (TFCC) tears among experienced European hand surgeons, to assess the effect of a consensus meeting on reliability, and to determine whether reliability differs between different tears.

Five hand surgeons from Europe reviewed 43 standardized wrist arthroscopy cases at two time points separated by 6 weeks. Each case included a clinical vignette, radiographs, and arthroscopy video. Surgeons assessed for the presence of a TFCC tear, classified tears using the Palmer and Atzei-Luchetti systems, and recorded treatment decisions. A consensus meeting was held between rounds. For the whole cohort, interobserver reliability was assessed using Fleiss' kappa and intraobserver reliability using Cohen's kappa. For subgroup analyses, interobserver reliability was assessed using pairwise agreement.

Interobserver agreement for TFCC tear presence was fair in both rounds, with modest improvement after the consensus meeting. Agreement for TFCC classification was slight-to-fair, and agreement for treatment decisions was low. Intraobserver agreement was consistently higher than interobserver agreement and generally moderate. Subgroup analyses showed higher interobserver agreement for central tears than peripheral tears in assessing TFCC tear presence/absence (central: 94.3% in both rounds versus peripheral: 80.0% and 85.0%). In contrast, for Palmer classification, agreement was higher for peripheral tears, particularly in Round 2 (peripheral: 61.3% versus central: 38.6%). Similar patterns were observed when combined tears were included. The consensus meeting did not meaningfully increase agreement within subgroups between rounds.

Arthroscopy demonstrated only moderate reliability for the assessment of TFCC pathology in this study, even among experienced hand surgeons. Although tear presence is commonly recognized, substantial variability persists in classification and decision making for treatment.

These findings highlight limitations of current arthroscopic classification systems and underscore the need for improved education and classification optimization to enhance diagnostic reproducibility.