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Handchir Mikrochir Plast Chir 2014; 46(05): 286-294
DOI: 10.1055/s-0034-1385937
Übersichtsarbeit
© Georg Thieme Verlag KG Stuttgart · New York

Arthroskopische Refixation des TFCC bei ulnarer Ruptur

Arthroscopic Repair for Ulnar-sided Tears of the TFCC
H.- G. Tünnerhoff
1   Praxis für Hand – und Fußchirurgie, Belegabteilung Krankenhaus Marbach, Marbach
,
M. Langer
2   Unfallchirurgie, Universitätsklinik Münster, Münster
› Author Affiliations
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Publication History

eingereicht 06 July 2014

akzeptiert 17 July 2014

Publication Date:
07 October 2014 (online)

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Zusammenfassung

Genaue anatomische und biomechanische Untersuchungen sowie klinische Erfahrungen haben in den letzten Jahren unsere Kenntnisse über die Funktion und Pathologie des distalen Radioulnargelenkes (DRUG) erweitert, sodass eine differenzierte Behandlung möglich ist. Bei Verletzungen reißt häufig der ulnare Teil des triangulären Faserkomplexes (TFCC). Die Entwicklung der verschiedenen arthroskopischen Techniken zur Rekonstruktion und der aktuelle Kenntnisstand werden im Folgenden dargestellt. Der ulnare Teil des TFCC ist in einen oberflächlichen, für die Stabilität weniger bedeutenden und einen wichtigeren, tiefen in der Fovea ansetzenden Teil zu unterscheiden. Beide Teile können zusammen oder jeweils einzeln abreißen. Schlüssel zur Diag­nose sind die klinische Untersuchung und die Arthroskopie. Bei der klinischen Untersuchung ist eine Instabilität im Seitenvergleich und soweit möglich das Ausmaß der Instabilität festzustellen und auf extraartikuläre Begleitverletzungen zu achten. Arthroskopisch wird der TFCC von radiokarpal und mehr und mehr auch vom DRUG her dargestellt und palpatorisch beurteilt. Im Falle einer Avulsion in der Tiefe ist eine anatomisch korrekte Refixation an den Knochen angezeigt und nach den vorliegenden Studien und eigenen Erfahrungen erfolgreich. Im Falle einer sehr ausgeprägten Instabilität ist anzunehmen, dass das Ausmaß der Verletzung über den isolierten Abriss in der Fovea hinausgeht und eine alleinige Reinsertion nicht in allen Fällen ausreichend ist.

Abstract

Accurately performed anatomic and biomechanical studies as well as clinical experience during the last years have widened our knowledge about function and pathology of the distal radioulnar joint (DRUJ) making a differentiated treatment possible. In cases of trauma a rupture of the ulnar part of the triangular fibrocartilaginous complex (TFCC) frequently occurs. An overview is given on the development of different arthroscopic techniques for repair and the state of the art is presented. The ulnar part of the TFCC is constituted of the superficial part which is less important for stability and the deep part which is anchored to the fovea of the ulnar head. This deep part is the most important stabiliser of the DRUJ. Each of these parts may rupture separately or both of them may rupture at the same time. Keystones for diagnosis are clinical examination and arthroscopy. On clinical examination instability of the DRUJ is to be evaluated by comparing it to the contralateral side. Furthermore, the degree of instability should be estimated. Extraarticular associated lesions must also be assessed clinically. On arthroscopy the TFCC may be evaluated from the radiocarpal joint as well as from its undersurface, from the DRUJ. In cases of avulsion from the fovea, an anatomic reconstruction with reinsertion of the deep part to the bone is indicated and may be performed successfully according to the published studies and our own experience. If a severe instability is found on clinical examination it is to be supposed that more stabilising structures – then only the radioulnar ligaments – are affected and reinsertion of the deep fibres to the fovea may not be sufficient.

Schlüsselwörter

Arthroskopie - TFCC Refixation - DRUG - Instabilität -

Key words

arthroscopy - TFCC repair - DRUJ - instability
 

  • Literatur

  • 1 Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist-anatomy and function. J Hand Surg Am 1981; 6: 153-162
    CrossrefPubMedGoogle Scholar
  • 2 Melone Jr CP, Nathan R. Traumatic disruption of the triangular fibrocartilage complex. Pathoanatomy. Clin Orthop Relat Res 1992; 275: 65-73
    PubMedGoogle Scholar
  • 3 Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am 1989; 14: 594-606
    CrossrefPubMedGoogle Scholar
  • 4 Smith TO, Drew BT, Toms AP et al. The diagnostic accuracy of X-ray arthrography for triangular fibrocartilaginous complex injury: a systematic review and metaanalysis. J Hand Surg Eur 2012; 37: 879-887
    CrossrefPubMedGoogle Scholar
  • 5 Moritomo H, Masatomi T, Murase T et al. Open repair of foveal avulsion of the triangular fibrocartilage complex and comparison by types of injury mechanism. J Hand Surg Am 2010; 35: 1955-1963
    CrossrefPubMedGoogle Scholar
  • 6 Watanabe A, Souza F, Vezeridis PS et al. Ulnar-sided wrist pain. II. Clinical imaging and treatment. Skeletal Radiol 2010; 39: 837-857
    CrossrefPubMedGoogle Scholar
  • 7 Baehser-Griffith P, Bednar JM, Osterman AL et al. Arthroscopic repairs of triangular fibrocartilage complex tears. AORN J 1997; 66: 101-102
    PubMedGoogle Scholar
  • 8 Thiru RG, Ferlic DC, Clayton ML et al. Arterial anatomy of the triangular fibrocartilage of the wrist and its surgical significance. J Hand Surg Am 1986; 11: 258-263
    CrossrefPubMedGoogle Scholar
  • 9 Corso SJ, Savoie FH, Geissler WB et al. Arthroscopic repair of peripheral avulsions of the triangular fibrocartilage complex of the wrist: a multicenter study. Arthroscopy 1997; 13: 78-84
    CrossrefPubMedGoogle Scholar
  • 10 Hermansdorfer JD, Kleinman WB. Management of chronic peripheral tears of the triangular fibrocartilage complex. J Hand Surg Am 1991; 16: 340-346
    CrossrefPubMedGoogle Scholar
  • 11 Ruch DS, Anderson SR, Ritter MR. Biomechanical comparison of transosseous and capsular repair of peripheral triangular fibrocartilage tears. Arthroscopy 2003; 19: 391-396
    CrossrefPubMedGoogle Scholar
  • 12 Anderson ML, Larson AN, Moran SL et al. Clinical comparison of arthroscopic versus open repair of triangular fibrocartilage complex tears. J Hand Surg 2008; 33: 675-682
    CrossrefPubMedGoogle Scholar
  • 13 de Araujo W, Poehling GG, Kuzma GR. New Tuohy needle technique for triangular fibrocartilage complex repair: preliminary studies. Arthroscopy 1996; 12: 699-703
    CrossrefPubMedGoogle Scholar
  • 14 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: 298-300
    CrossrefPubMedGoogle Scholar
  • 15 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: 439-447
    CrossrefPubMedGoogle Scholar
  • 16 Trumble TE, Gilbert M, Vedder N. Isolated tears of the triangular fibrocartilage: management by early arthroscopic repair. J Hand Surg Am 1997; 22: 57-65
    PubMedGoogle Scholar
  • 17 Estrella EP, Hung LK, Ho PC et al. Arthroscopic repair of triangular fibrocartilage complex tears. Arthroscopy 2007; 23: 729-737 737 e721
    CrossrefPubMedGoogle Scholar
  • 18 Tünnerhoff HG, Haussmann P. Wann ist die arthroskopische Refixation des Discus ulnocarpalis bei ulnarem Abriss indiziert. Handchir Mikrochir Plastische Chir 2001; 33: 239-244
    PubMedGoogle Scholar
  • 19 Wedemeyer A, Wedemeyer C, Heckelei W et al. Arthroskopische Refixation von Traumatischen1B_Läsionen des Discus ulnocarpalis – eine retrospektive Studie. Handchir Mikrochir Plastische Chir 2009; 41: 135-140
    PubMedGoogle Scholar
  • 20 Gofton WT, Gordon KD, Dunning CE et al. Soft-tissue stabilizers of the distal radioulnar joint: an in vitro kinematic study. J Hand Surg Am 2004; 29: 423-431
    CrossrefPubMedGoogle Scholar
  • 21 Kakar S, Carlsen BT, Moran SL et al. The management of chronic distal radioulnar instability. Hand clinics 2010; 26: 517-528
    CrossrefPubMedGoogle Scholar
  • 22 Stuart PR, Berger RA, Linscheid RL et al. The dorsopalmar stability of the distal radioulnar joint. J Hand Surg Am 2000; 25: 689-699
    CrossrefPubMedGoogle Scholar
  • 23 Kihara H, Short WH, Werner FW et al. The stabilizing mechanism of the distal radioulnar joint during pronation and supination. J Hand Surg Am 1995; 20: 930-936
    CrossrefPubMedGoogle Scholar
  • 24 Hagert CG. Distal radius fracture and the distal radioulnar joint – anatomical considerations. Handchir Mikrochir Plastische Chir 1994; 26: 22-26
    PubMedGoogle Scholar
  • 25 Nakamura T, Takayama S, Horiuchi Y et al. Origins and insertions of the triangular fibrocartilage complex: a histological study. J Hand Surg 2001; 26B: 446-454
    PubMedGoogle Scholar
  • 26 Kleinman WB. Stability of the distal radioulna joint: biomechanics, pathophysiology, physical diagnosis, and restoration of function what we have learned in 25 years. J Hand Surg Am 2007; 32: 1086-1106
    CrossrefPubMedGoogle Scholar
  • 27 Atzei A. New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability. J Hand Surg 2009; 34B: 581-591
    PubMedGoogle Scholar
  • 28 Tay SC, Berger RA, Parker WL. Longitudinal split tears of the ulnotriquetral ligament. Hand Clin 2010; 26: 495-501
    CrossrefPubMedGoogle Scholar
  • 29 Moritomo HM, Tsuyoshi M, Sayuri A et al. Change in the length of the ulnocarpal ligaments during radiocarpal motion: Possible impact on triangular fibrocartilage complex foveal tears. J Hand Surg Am 2008; 33: 1278-1286
    CrossrefPubMedGoogle Scholar
  • 30 Moritomo HM, Murase T, Arimitsu S et al. Change in the Length of the ulnocarpal ligament during radiocarpal motion: Possible impact on triangular fibrocartilage complex foveal tears. J Hand Surg Am 2010; 35: 1955-1963
    CrossrefPubMedGoogle Scholar
  • 31 Nakamura T. Radial side tears of the triangular fibrocartilage complex. In: Pinal P. Arthroscopic Management of Distal Radius Fractures. Heidelberg: Springer 2010; 89-98
    PubMedGoogle Scholar
  • 32 Sagerman SD, Short W. Arthroscopic repair of radial-sided triangular fibrocartilage complex tears. Arthroscopy 1996; 12: 339-342
    CrossrefPubMedGoogle Scholar
  • 33 Iida A, Omokawa S, Moritomo H et al. Effect of wrist position on distal radioulnar joint stability: A biomechanical study. J Orthop Res 2014; 32: 1247-1251
    CrossrefPubMedGoogle Scholar
  • 34 Tay SC, Tomita K, Berger RA. The “ulnar fovea sign” for defining ulnar wrist pain: an analysis of sensitivity and specificity. J Hand Surg Am 2007; 32: 438-444
    CrossrefPubMedGoogle Scholar
  • 35 Reagan DS, Linscheid RL, Dobyns JH. Lunotriquetral sprains. J Hand Surg Am 1984; 9: 502-514
    CrossrefPubMedGoogle Scholar
  • 36 Kip PC, Peimer CA. Release of the sixth dorsal compartment. J Hand Surg Am 1994; 19: 599-601
    CrossrefPubMedGoogle Scholar
  • 37 Burkhart SS, Wood MB, Linscheid RL. Posttraumatic recurrent subluxation of the extensor carpi ulnaris tendon. J Hand Surg Am 1982; 7: 1-3
    CrossrefPubMedGoogle Scholar
  • 38 Ruland RT, Hogan CJ. The ECU synergy test: an aid to diagnose ECU tendonitis. J Hand Surg Am 2008; 33: 1777-1782
    CrossrefPubMedGoogle Scholar
  • 39 Adams BD. Effects of radial deformity on distal radioulnar joint mechanics. J Hand Surg Am 1993; 18: 492-498
    CrossrefPubMedGoogle Scholar
  • 40 Pogue D, Viegas SF, Patterson RM et al. Effects of distal radius fracture malunion on wrist joint mechanics. J Hand Surg Am 1990; 15: 721-727
    CrossrefPubMedGoogle Scholar
  • 41 Dy CJ, Jang E, Taylor SA et al. The Impact of Coronal Alignment on Distal Radioulnar Joint Stability Following Distal Radius Fracture. J Hand Surg Am 2014; 39: 1264-1272
    CrossrefPubMedGoogle Scholar
  • 42 Hahn P, Hausler A, Bruckner T et al. Wertigkeit der MRT hinsichtlich TFCC-Läsionen außerhalb klinischer Studien. Handchir Mikrochir Plast Chir 2012; 44: 310-313
    Article in Thieme ConnectPubMedGoogle Scholar
  • 43 Amrami KK, Moran SL, Berger RA et al. Imaging the distal radioulnar joint. Hand Clin 2010; 26: 467-475
    CrossrefPubMedGoogle Scholar
  • 44 MacLennan AJ, Nemechek NM, Waitayawinyu T et al. Diagnosis and anatomic reconstruction of extensor carpi ulnaris subluxation. J Hand Surg Am 2008; 33: 59-64
    CrossrefPubMedGoogle Scholar
  • 45 Park MJ, Jagadish A, Yao J The rate of triangular fibrocartilage injuries requiring surgical intervention. Orthopedics 2010; 33: 806-813
    PubMedGoogle Scholar
  • 46 Sarmiento A, Cooper JS, Sinclair WF. Forearm fractures. Early functional bracing – A preliminary report. J Bone Joint Surg Am 1975; 57: 297-304
    PubMedGoogle Scholar
  • 477 Millard GM, Budoff JE, Paravic V et al. Functional bracing for distal radioulnar joint instability. J Hand Surg Am 2002; 27: 972-977
    CrossrefPubMedGoogle Scholar
  • 48 Nakamura T, Sato K, Okazaki M et al. Repair of foveal detachment of the triangular fibrocartilage complex: open and arthroscopic transosseous techniques. Hand Clin 2011; 27: 281-290
    CrossrefPubMedGoogle Scholar
  • 49 Slutsky DJ. Arthroscopic evaluation of the foveal attachment of the triangular fibrocartilage. Hand Clin 2011; 27: 255-261
    CrossrefPubMedGoogle Scholar
  • 50 Shinohara T, Tatebe M, Okui N et al. Arthroscopically assisted repair of triangular fibrocartilage complex foveal tears. J Hand Surg Am 2013; 38: 271-277
    CrossrefPubMedGoogle Scholar
  • 51 Iwasaki N, Nishida K, Motomiya M et al. 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: 1371-1378
    CrossrefPubMedGoogle Scholar
  • 52 Garcia-Elias M, Hagert E. Surgical approaches to the distal radioulnar joint. Hand Clin 2010; 26: 477-483
    CrossrefPubMedGoogle Scholar
  • 53 Wysocki RW, Richard MJ, Crowe M et al. Arthroscopic treatment of peripheral triangular fibrocartilage complex tears with the deep fibers intact. J Hand Surg Am 2012; 37: 509-516
    CrossrefPubMedGoogle Scholar
  • 54 Wolf MB, Haas A, Dragu A et al. Arthroscopic repair of ulnar-sided triangular fibrocartilage complex (Palmer Type 1B) tears: a comparison between short- and midterm results. J Hand Surg Am 2012; 37: 2325-2330
    CrossrefPubMedGoogle Scholar
  • 55 Cardenas-Montemayor E, Hartl JF, Wolf MB et al. Subjective and objective results of arthroscopic debridement of ulnar-sided TFCC (Palmer type 1B) lesions with stable distal radio-ulnar joint. Arch Orthop Trauma Surg 2013; 133: 287-293
    CrossrefPubMedGoogle Scholar
  • 56 Nishizuka T, Tatebe M, Hirata H et al. Simple debridement has little useful value on the clinical course of recalcitrant ulnar wrist pain. Bone Joint J 2013; 95-B: 1687-1696
    CrossrefPubMedGoogle Scholar