Arthroscopic Foveal Repair of the Triangular Fibrocartilage Complex

Abstract

Background Foveal disruption of the triangular fibrocartilage complex (TFCC) is associated with distal radioulnar joint (DRUJ) instability. TFCC fixation onto the fovea is the suitable treatment, which is not achieved by conventional arthroscopic techniques. We describe an all-inside arthroscopic technique that uses a suture anchor through distal DRUJ arthroscopy for foveal repair of the TFCC.

Materials and Methods Forty-eight patients with TFCC foveal tear and DRUJ instability were selected according to the Atzei–European Wrist Arthroscopy Society (EWAS) algorithm of treatment. Retrospective evaluation included pain, DRUJ instability, range of motion (ROM), grip strength, Modified Mayo Wrist Score (MMWS), and the Disabilities of the Arm, Shoulder, and Hand (DASH) Score.

Description of Technique DRUJ arthroscopy was performed to débride the TFCC and the foveal area. Under arthroscopic guidance, a suture anchor was inserted via the distal foveal portal to repair the TFCC onto the fovea. Sutures were tied on the radiocarpal surface of the TFCC. Postoperative immobilization of forearm rotation was maintained for 4 weeks. Heavy tasks were allowed after 3 months.

Results After a mean follow-up of 33 months, pain improved significantly but remained moderate in four patients, severe in one. DRUJ instability resolved in 44 patients. Wrist ROM increased. Grip strength, MMWS, and DASH score improved significantly. Excellent and good MMWS equaled 83.3%. Forty-one patients (85.5%) resumed previous work and sport activities. As a postoperative complication, five patients experienced neuroapraxia of the dorsal sensory branch of the ulnar nerve (DSBUN) with full spontaneous recovery.

Conclusions With appropriate indications and patient selection, arthroscopic foveal repair of the TFCC may restore DRUJ stability and provide satisfactory results without significant complications.

Keywords

triangular fibrocartilage complex - TFCC - foveal repair - arthroscopy - DRUJ instability

Note

Work was done at Fenice Hand Surgery and Rehabilitation Team, Treviso, Pordenone, Italy

• References

• 1 Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am 1989; 14 (4) 594-606
• 2 Atzei A. New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability. J Hand Surg Eur Vol 2009; 34 (5) 582-591
• 3 Atzei A, Luchetti R. Foveal TFCC tear classification and treatment. Hand Clin 2011; 27 (3) 263-272
• 4 Estrella EP, Hung LK, Ho PC, Tse WL. Arthroscopic repair of triangular fibrocartilage complex tears. Arthroscopy 2007; 23 (7) 729-737 , 737.e1
• 5 Lindau T, Adlercreutz C, Aspenberg P. Peripheral tears of the triangular fibrocartilage complex cause distal radioulnar joint instability after distal radial fractures. J Hand Surg Am 2000; 25 (3) 464-468
• 6 Anderson ML, Larson AN, Moran SL, Cooney WP, Amrami KK, Berger RA. Clinical comparison of arthroscopic versus open repair of triangular fibrocartilage complex tears. J Hand Surg Am 2008; 33 (5) 675-682
• 7 Moriya T, Aoki M, Iba K, Ozasa Y, Wada T, Yamashita T. Effect of triangular ligament tears on distal radioulnar joint instability and evaluation of three clinical tests: a biomechanical study. J Hand Surg Eur Vol 2009; 34 (2) 219-223
• 8 Atzei A, Luchetti R. DRUJ arthroscopy. In: Slutsky D, , ed. Operative Orthopaedics of the Upper Extremity. New York, NY: McGraw-Hill; 2014: 407-418
• 9 Haugstvedt JR, Berger RA, Nakamura T, Neale P, Berglund L, An KN. Relative contributions of the ulnar attachments of the triangular fibrocartilage complex to the dynamic stability of the distal radioulnar joint. J Hand Surg Am 2006; 31 (3) 445-451
• 10 Slutsky DJ. Distal radioulnar joint arthroscopy and the volar ulnar portal. Tech Hand Up Extrem Surg 2007; 11 (1) 38-44
• 11 Atzei A, Rizzo A, Luchetti R, Fairplay T. Arthroscopic foveal repair of triangular fibrocartilage complex peripheral lesion with distal radioulnar joint instability. Tech Hand Up Extrem Surg 2008; 12 (4) 226-235
• 12 Badia A, Jiménez A. Arthroscopic repair of peripheral triangular fibrocartilage complex tears with suture welding: a technical report. J Hand Surg Am 2006; 31 (8) 1303-1307
• 13 Böhringer G, Schädel-Höpfner M, Petermann J, Gotzen L. A method for all-inside arthroscopic repair of Palmer 1B triangular fibrocartilage complex tears. Arthroscopy 2002; 18 (2) 211-213
• 14 Corso SJ, Savoie FH, Geissler WB, Whipple TL, Jiminez W, Jenkins N. Arthroscopic repair of peripheral avulsions of the triangular fibrocartilage complex of the wrist: a multicenter study. Arthroscopy 1997; 13 (1) 78-84
• 15 Chou KH, Sarris IK, Sotereanos DG. Suture anchor repair of ulnar-sided triangular fibrocartilage complex tears. J Hand Surg [Br] 2003; 28 (6) 546-550
• 16 de Araujo W, Poehling GG, Kuzma GR. New Tuohy needle technique for triangular fibrocartilage complex repair: preliminary studies. Arthroscopy 1996; 12 (6) 699-703
• 17 del Piñal F, García-Bernal FJ, Cagigal L, Studer A, Regalado J, Thams C. A technique for arthroscopic all-inside suturing in the wrist. J Hand Surg Eur Vol 2010; 35 (6) 475-479
• 18 Haugstvedt JR, Husby T. Results of repair of peripheral tears in the triangular fibrocartilage complex using an arthroscopic suture technique. Scand J Plast Reconstr Surg Hand Surg 1999; 33 (4) 439-447
• 19 Hermansdorfer JD, Kleinman WB. Management of chronic peripheral tears of the triangular fibrocartilage complex. J Hand Surg Am 1991; 16 (2) 340-346
• 20 Henry M. TFCC: a DRUJ perspective. In: del Pinal F, Mathoulin Ch, Nakamura T, , eds. Arthroscopic Management of Ulnar Pain. Heidelberg, Germany: Springer-Verlag; 2012: 121-135
• 21 Iwasaki N, Minami A. Arthroscopically assisted reattachment of avulsed triangular fibrocartilage complex to the fovea of the ulnar head. J Hand Surg Am 2009; 34 (7) 1323-1326
• 22 Iwasaki N, Nishida K, Motomiya M, Funakoshi T, Minami A. Arthroscopic-assisted repair of avulsed triangular fibrocartilage complex to the fovea of the ulnar head: a 2- to 4-year follow-up study. Arthroscopy 2011; 27 (10) 1371-1378
• 23 Kim B, Yoon HK, Nho JH , et al. Arthroscopically assisted reconstruction of triangular fibrocartilage complex foveal avulsion in the ulnar variance-positive patient. Arthroscopy 2013; 29 (11) 1762-1768
• 24 Mathoulin C, Levadoux M, Martinache X. Intérêt thérapeutique de l'arthroscopie du poignet: a propos de 1000 cas. e-Mémoires de l'Académie Nationale de Chirurgie 2005; 4 (3) 42-57
• 25 Millants P, De Smet L, Van Ransbeeck H. Outcome study of arthroscopic suturing of ulnar avulsions of the triangular fibrocartilage complex of the wrist. Chir Main 2002; 21 (5) 298-300
• 26 Moritomo H, Masatomi T, Murase T, Miyake J, Okada K, Yoshikawa H. Open repair of foveal avulsion of the triangular fibrocartilage complex and comparison by types of injury mechanism. J Hand Surg Am 2010; 35 (12) 1955-1963
• 27 Nakamura T, Nakao Y, Ikegami H, Sato K, Takayama S. Open repair of the ulnar disruption of the triangular fibrocartilage complex with double three-dimensional mattress suturing technique. Tech Hand Up Extrem Surg 2004; 8 (2) 116-123
• 28 Nakamura T, Sato K, Okazaki M, Toyama Y, Ikegami H. Repair of foveal detachment of the triangular fibrocartilage complex: open and arthroscopic transosseous techniques. Hand Clin 2011; 27 (3) 281-290
• 29 Pederzini LA, Tosi M, Prandini M, Botticella C. All-inside suture technique for Palmer class 1B triangular fibrocartilage repair. Arthroscopy 2007; 23 (10) 1130.e1-1130.e4
• 30 Sennwald GR, Lauterburg M, Zdravkovic V. A new technique of reattachment after traumatic avulsion of the TFCC at its ulnar insertion. J Hand Surg [Br] 1995; 20 (2) 178-184
• 31 Shinohara T, Tatebe M, Okui N, Yamamoto M, Kurimoto S, Hirata H. Arthroscopically assisted repair of triangular fibrocartilage complex foveal tears. J Hand Surg Am 2013; 38 (2) 271-277
• 32 Skie MC, Mekhail AO, Deitrich DR, Ebraheim NE. Operative technique for inside-out repair of the triangular fibrocartilage complex. J Hand Surg Am 1997; 22 (5) 814-817
• 33 Trumble TE, Gilbert M, Vedder N. Isolated tears of the triangular fibrocartilage: management by early arthroscopic repair. J Hand Surg Am 1997; 22 (1) 57-65
• 34 Yao J, Dantuluri P, Osterman AL. A novel technique of all-inside arthroscopic triangular fibrocartilage complex repair. Arthroscopy 2007; 23 (12) 1357.e1-1357.e4
• 35 Zachee B, De Smet L, Fabry G. Arthroscopic suturing of TFCC lesions. Arthroscopy 1993; 9 (2) 242-243
• 36 Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà M. Set-up, portals, and normal exploration in wrist arthroscopy [in French]. Chir Main 2006; 25 (Suppl. 01) S131-S144
• 37 del Piñal F, García-Bernal FJ, Pisani D, Regalado J, Ayala H, Studer A. Dry arthroscopy of the wrist: surgical technique. J Hand Surg Am 2007; 32 (1) 119-123
• 38 Luchetti R, Atzei A, Cozzolino R, Fairplay T, Badur N. Comparison between open and arthroscopic-assisted foveal triangular fibrocartilage complex repair for post-traumatic distal radio-ulnar joint instability. J Hand Surg Eur Vol 2014; 39 (8) 845-855