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J Wrist Surg 2025; 14(05): 400-405
DOI: 10.1055/s-0044-1787749
Editor's Pick: Mobilization after TFCC Reconstruction

The Comparison between Direct Graft Fixation using a Biotenodesis Screw Combined with Early Mobilization versus a Traditional Knot Fixation with 6-Week Immobilization of Adams–Berger Triangular Fibrocartilage Complex Reconstruction

Authors

  • Nadia S. Scholtmeijer

    1   Department of Plastic Surgery, Martini Hospital, Groningen, The Netherlands

  • Hans van den Berg

    1   Department of Plastic Surgery, Martini Hospital, Groningen, The Netherlands

  • Marius A. Kemler 

    1   Department of Plastic Surgery, Martini Hospital, Groningen, The Netherlands
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Abstract

Several surgical techniques exist for triangular fibrocartilage complex (TFCC) reconstruction, one being the Adams–Berger technique. Direct graft fixation is an emerging option for this reconstructive technique. This study compared the outcomes of TFCC reconstruction according to the Adams–Berger technique using direct graft fixation with a biotenodesis screw and early mobilization against the traditional knot technique with a 6- week cast immobilization. Results demonstrated that the direct fixation technique with early mobilization led to significantly higher patient satisfaction and earlier return to work. A more rapid recovery of range of motion and grip strength, as well as reduced pain intensity, was also noted. The study supports the effectiveness of direct graft fixation with a biotenodesis screw and early mobilization in TFCC reconstruction, offering improved patient outcomes and potentially reducing health care costs. Further research with larger sample sizes is warranted to reconfirm these findings.


 

Keywords

TFCC reconstruction - early mobilization - Adams–Berger procedure - DRUJ instability - ulnar sided wrist pain

The triangular fibrocartilage complex (TFCC) is a critical structure located on the ulnar side of the wrist, providing stability and support to the distal radioulnar joint (DRUJ).[1] [2] It has a significant role in wrist mobility, and injuries are frequently encountered. TFCC injuries can be categorized into either traumatic or degenerative. Commonly traumatic tears are associated with a fall on the outstretched wrist, combined with a twisting motion. TFCC tears can occur as isolated injuries or be associated with other wrist pathologies. Degenerative tears are associated with chronic wear and tear due to repetitive loading of the wrist.[2] [3] [4] [5] Symptoms associated with TFCC tears include pain, swelling, and a limited range of motion of the wrist. This can be accompanied by clicking sensations, indicating DRUJ instability.[2] [6] [7] To identify the location of the injury, physical examination, radiological assessment, and diagnostic arthroscopy are necessary for an accurate diagnosis and treatment plan. If conservative treatment is not successful or diagnostics show that the injury is too severe, there are several surgical options ranging from repair to reconstruction of the TFCC. An important criterion for surgical intervention is DRUJ instability, as this is the main cause of pain and wrist dysfunction.[8]

The literature describes various surgical methods to treat TFCC tears. TFCC repair is often performed arthroscopically. When repair is no longer possible due to the extent of damage, reconstruction can be performed. Numerous techniques have been previously described, such as the Adams–Berger,[6] Fulkerson–Watson,[9] Bowers, and Scheker[10] techniques. These surgical techniques require a tendon graft for reconstruction. Studies show that the technique described by Adams–Berger reproduces the most anatomical reconstruction with normal DRUJ kinematics.[11] [12] During this procedure, the tendon graft is secured with sutures, followed by a 6-week period of cast immobilization for healing and optimal graft strength. A modification to this procedure can be made by using a biotenodesis screw. This provides immediate graft fixation, permitting a shorter postoperative immobilization period and early mobilization of the affected limb.

This study will focus on comparing two different fixation techniques of the tendon graft during TFCC reconstruction using the Adams–Berger technique.[6] There are several perceived positive aspects to using the biotenodesis screw. One of them is when the tendon graft does not have the required length to be secured with the Adams–Berger technique. The usage of the biotenodesis screw omits the need for another tendon graft as less length is needed when secured with a screw. The aim of this study is to gain insight into whether immediate fixation of the graft using biotenodesis screws leads to an improved range of motion of the wrist and therefore to a reduced rehabilitation period, compared with the classic suturing technique. Hypothetically immediate graft fixation would result in improved mobility at final follow-up after TFCC reconstruction, as early mobilization and rehabilitation are feasible due to immediate graft fixation. The rehabilitation period is therefore potentially shorter, as there is no long period of cast immobilization, patients can resume daily activities earlier after surgery.

Materials and Methods

Patients were eligible for the study if they were 18 to 65 years old and had an arthroscopically confirmed TFCC lesion. Exclusion criteria were the presence of DRUJ arthritis, another condition affecting the function of the diseased or contralateral extremity, and inability to speak the Dutch language. The study complied with the provisions of the Declaration of Helsinki with regard to research involving human subjects and was approved by the medical ethics committee of our institution (MEC 2023-079).


 

Group Assignment

Two groups of each 10 patients were compared. No randomization was applied. Patients were assigned in order of inclusion. The first group of 10 patients was treated with the Adams–Berger procedure using a biotenodesis screw for graft fixation followed by 1 week of cast immobilization (biotenodesis screw group). The second group of 10 patients was treated with the traditional Adams–Berger procedure using a knot for graft fixation followed by 6 weeks of cast immobilization (control group).


 

Surgical Procedure

In both groups, the reconstructive technique was performed as described by Adams and Berger.[6] A vertical dorsal incision is made after which the fifth compartment is opened and an L-shaped flap is created in the DRUJ capsule. The fovea is debrided, while remaining functional TFCC components are preserved. The palmaris longus tendon is harvested as a graft. Then, the radial tunnel is drilled under fluoroscopic control using a guidewire. It should be placed just proximal to the lunate fossa and radial to the articular surface of the sigmoid notch. After confirming accurate wire placement, the tunnel is drilled using a cannulated drill bit. The tunnel should be large enough in diameter to accommodate the tendon graft. The ulnar tunnel is drilled using the same technique. The guidewire is inserted through the fovea and should exit the ulnar neck palmar to the extensor carpi ulnaris (ECU). The final tunnel should be large enough to accommodate both ends of the tendon graft. Another vertical incision is made on the volar side of the wrist, exposing the radial tunnel opening after which a suture retriever is passed through from the dorsal to palmar side. Next one end of the tendon graft is grasped using the suture retriever and pulled through the radial tunnel. The other end of the tendon graft is then retrieved and pushed through the DRUJ capsule, making sure not to entrap neighboring structures such as nerves and vessels. Both endings of the tendon graft now lie on the dorsal side of the wrist. The tendon graft is then inserted into the ulnar tunnel, a loose tyding snare can be used to ease the process of pulling both ends through. The tendon graft is then tensioned while the forearm is held in neutral position and the DRUJ is manually compressed. In the biotenodesis screw group, the biotenodesis screw of 4 mm × 10 mm (Arthrex, Napels, FL) is then screwed into the ulnar neck side of the ulnar tunnel, while maintaining the desired tension on the tendon graft. In the control group, both ends of the tendon graft are used to make a secure knot ([Fig. 1]). A few absorbable sutures are passed through the knot to provide extra stability. Then, in both groups, the DRUJ capsule and extensor retinaculum are closed and incisions are sutured.

Zoom
Fig. 1 Anatomical depiction of the Adams–Berger technique, on the left shown with knot fixation and on the right shown with biotenodesis screw fixation. (A) Posterior view of the reconstruction. (B) Reconstruction viewed from the articular surface.

 

Postoperative Regimen

In the biotenodesis screw group, a lower arm cast was applied which was removed 7 days postoperatively after which hand therapy was started. A removable wrist splint was used for another 4 weeks during daily activities. In the control group, the extremity was immobilized in a long-arm cast with the forearm in neutral rotation for 4 weeks, followed by the use of a short-arm cast for 2 weeks. Hand therapy was started, and a removable wrist splint was used for another 4 weeks during daily activities.


 

Data Collection and Follow-Up

Outcome measures were assessed before surgery (baseline) and 6 weeks, 3 months, 6 months, and 1 year after the initiation of treatment. Active range of motion of the wrist was measured using geometry. To measure grip strength, a Jamar dynamometer was used. For all patients, the device was set to handle position 2. Wrist function was measured with the patient-rated wrist hand evaluation and the short version of the Disabilities of the Arm, Shoulder, and Hand (quickDASH). These questionnaires had previously been validated and translated into Dutch. A numeric rating scale was used to assess pain. At 12-month postoperatively, patients rated the global perceived effect on a seven-point scale (1, worst ever; 2, much worse; 3, worse; 4, not improved and not worse; 5, improved; 6, much improved; 7, best ever) and the moment at which they returned to work. Furthermore, complications of the surgical procedure have been documented.


 

Statistical Analysis

Differences between the baseline values and the values at 1 year were calculated for each patient for all outcome measures. The values of the two groups were compared using t-tests for independent samples. If results were not normally distributed, nonparametric tests were used. As there were no pretreatment data for the global perceived effect and return to work, only differences were calculated between the two groups. Two-tailed p-values of less than 0.05 were considered to indicate statistical significance.


 

Results

Patients were enrolled and operated between October 2019 and December 2020. Ten patients were treated using the Arthrex biotenodesis screw followed by 1-week immobilization (biotenodesis screw group), and ten patients were treated by fixating the graft using the knot technique which was followed by 6 weeks of immobilization (control group). Baseline characteristics show that there were no significant differences between both patient groups ([Table 1]). At 1-year follow-up, all 20 patients have been analyzed. Some patients had not been evaluated at the 6-week, 3-month, or 6-month follow-up. There were no unforeseen events hindering analysis, and no complications have been reported. One-year results are thus based on 10 patients in both the biotenodesis screw group and 10 patients in the control group.

Table 1

Patient baseline characteristics

Baseline characteristics

Biotenodesis screw group (n = 10)

Control group (n = 10)

p-Value

Age (years)

44.9 (4.8)

30.0 (5.2)

ns

Sex

4M, 6F

3M, 7F

ns

Side

6R, 4L

2R, 8L

ns

AROM wrist (degrees)

Flexion

54.1 (5.9)

57.1 (8.7)

ns

Extension

63.8 (4.9)

60.6 (7.4)

ns

Pronation

86.0 (2.1)

79.0 (6.0)

ns

Supination

78.8 (6.9)

80.1 (6.2)

ns

Radial deviation

23.9 (1.7)

21.6 (3.7)

ns

Ulnar deviation

40.5 (4.8)

38.9 (5.5)

ns

Grip strength (kg)

28.6 (3.3)

28.8 (4.7)

ns

Function

PRWHE

46.3 (7.8)

56.5 (7.0)

ns

QuickDASH

37.8 (6.5)

44.5 (5.6)

ns

Pain intensity

4.3 (0.6)

5.0 (0.8)

ns

Abbreviations: AROM, active range of motion; F, female; L, left; M, male; ns, nonsignificant; PRWHE, Patient-Rated Wrist Hand Evaluation; QuickDASH, Quick Disabilities of the Arm, Shoulder, and Hand; R, right.


Note: Values in [Table 1] are represented as mean (standard error of the mean).


At 1-year postsurgery, the results were compared with the baseline data ([Table 2]). For the global perceived effect, the mean score in the biotenodesis screw group was 6.3, which correlates to much improved. This was compared with the control group, where patients gave a mean score of 5.6 meaning they improved. This shows that the biotenodesis screw group patients experienced significantly (p = 0.01) more improvement after their surgery compared with the control group.

Table 2

Results 1-year postsurgery compared with baseline data (Delta 0–4)

Delta 0–4

Biotenodesis screw group (n = 10)

Control group (n = 10)

p-Value

AROM wrist (degrees)

Flexion

11 (3.9)

12.1 (5.4)

ns

Extension

7.7 (4.0)

9.3 (8.4)

ns

Pronation

−3.4 (1.9)

3.0 (6.3)

ns

Supination

3.8 (4.3)

3.5 (7.4)

ns

Radial deviation

2.2 (2.6)

4.6 (4.5)

ns

Ulnar deviation

7.7 (3.0)

11.5 (5.9)

ns

Grip strength (kg)

4.8 (2.1)

1.0 (2.4)

ns

Function

PRWHE

−36.3 (6.9)

−24.8 (3.7)

ns

QuickDASH

−23.4 (7.0)

−21 (5.8)

ns

Pain intensity

−3.9 (0.4)

−2.5 (0.6)

ns

GPE

6.3 (0.2)

5.6 (1.8)

0.01

RTW (days)

114.7 (19.5)

171.0 (18.5)

0.049

Abbreviations: AROM, active range of motion; GPE, global perceived effect; ns, nonsignificant; PRWHE, Patient-Rated Wrist Hand Evaluation; QuickDASH, Quick Disabilities of the Arm, Shoulder, and Hand; RTW, return to work.


Note: Values in [Table 2] are represented as mean (standard error of the mean).


Return to work was also noted. Patients were asked when they resumed their normal work activities. The biotenodesis screw group showed a significantly earlier return to full work activities (p = 0.049), where patients could resume work at a mean of 115 days after surgery, 56 days earlier compared with the control group. The control group resumed full work activity after a mean of 171 days after surgery. Patients from the biotenodesis screw group regained more range of motion in the early stages of the rehabilitation period. The final range of motion after 1 year is fairly similar between both groups ([Figs. 2] and [3]). The biotenodesis screw group gained more grip strength, with a faster recovery starting early in the rehabilitation period ([Fig. 4]). Statistical analysis did not show a significant difference in these last results between the two patient groups.

Zoom
Fig. 2 Wrist flexion. Mean scores of degrees of wrist flexion comparing biotenodesis screw group to control group with knot fixation (T0 is baseline, T1 is 6 weeks, T2 is 3 months, T3 is 6 months, and T4 is 1 year after surgery).
Zoom
Fig. 3 Wrist extension. Mean scores of degrees of wrist extension comparing biotenodesis screw group to control group with knot fixation (T0 is baseline, T1 is 6 weeks, T2 is 3 months, T3 is 6 months and T4 is 1 year after surgery).
Zoom
Fig. 4 Grip strength. Mean scores of grip strength measured in kilograms comparing biotenodesis screw group to control group with knot fixation (T0 is baseline, T2 is 3 months, T3 is 6 months, and T4 is 1 year after surgery).

 

Discussion

A nonrandomized controlled trial was conducted in which direct graft fixation with a biotenodesis screw and early mobilization were compared with the traditional know fixation and 6-week cast immobilization after Adams–Berger TFCC reconstructive surgery. The results of this study show that direct graft fixation with a biotenodesis screw and early mobilization leads to a significantly higher patient satisfaction level and earlier return to work compared with the standard Adams–Berger technique.

The literature shows that numerous different techniques can be used to reconstruct the TFCC structure, including the original Adams–Berger technique.[6] [9] [10] These techniques all require a lengthy postoperative cast immobilization of at least 6 weeks, leading to stiffness and pain for the patient. Rehabilitation and return to work is known to be a lengthy process taking up to 12-month postsurgery. By using a biotenodesis screw to secure the tendon graft instead of the original knot technique, direct fixation of the tendon graft is acquired. Gillis et al[13] have compared the outcomes of different ligament fixation techniques. They demonstrate that suture anchors are favored over other fixation techniques when looking at 5-year outcome and graft failure. However, there was no early mobilization applied in patient categories, and the original Adams–Berger graft fixation technique was performed slightly differently.

During the follow-up of this study, no graft failures were reported. This indicates that the graft is properly fixated by the biotenodesis screw, and it is safe to omit cast immobilization. There is no reason to fear loosening of the ligament fixation, as the biotenodesis screw fills up the bone tunnel completely with the ligament. When twisting the screw into the bone tunnel, the ligament also twists around the screw leading to an even larger area of fixation. Therefore, there is no friction of the transplant in the bone tunnel, making it impossible for the bone tunnel to expand. The only possibility is for the biotenodesis screw to break out entirely; however, this has not occurred in this study.

Although other results at 1 year show to be not statistically significant in this small group of patients, [Figs. 3] and [4] show a difference in the timeline when the range of motion is recovered. Patients that could mobilize early on in recovery regained function more quickly, whereas patients that were immobilized took longer to regain the range of motion. Patients in the biotenodesis screw group also showed to have a larger decrease in pain intensity 1 year after the procedure, compared with the control group. This shows that early mobilization of the operated wrist leads to less stiffness and pain, possibly also reducing the amount of physical therapy needed for patients to regain full range of motion after surgery.

Furthermore, patients treated with the direct fixation technique showed to be able to resume normal work activities 56 days faster compared with the control group. It is to be noted that return to work varied largely between the individual patients. This was due to the nature of the jobs, where some patients could return quickly to desk jobs while other patients took longer to return to more physically demanding work.

This study is one of the first to compare two fixation techniques for TFCC reconstructive surgery. Although it is a controlled trial, it was nonrandomized and contained a small sample size. It gave insight into the different outcomes and can be used to calculate sample sizes that are required for a larger study. This study reconfirmed that the rehabilitation process after the original Adams–Berger surgery is lengthy and full recovery can take up to 12-month postsurgery for patients. It shows that direct fixation combined with early mobilization has an added value for the patient, namely a faster rehabilitation process and higher patient satisfaction rate. With a period of 1 year for follow-up, it is arguable that graft failure cannot be properly investigated; however, this was not the aim of this study. Furthermore, it is unlikely for outcomes such as range of motion, grip strength, and patient satisfaction to improve after this period. Overall the Adams–Berger procedure is a successful technique for TFCC reconstruction, both study groups show a high patient satisfaction rate. Implementing the biotenodesis screw fixation method makes the procedure more inviting for patient groups that do not have time for a lengthy rehabilitation process, such as athletes. It could be argued that using a biotenodesis screw causes an unnecessary increase in the costs of the procedure. This is partly true, as the tendon graft does not have a cost and the biotenodesis screws do. However, as the results of this study show patients to regain range of motion faster after surgery due to early mobilization, the rehabilitation period could be shorter leading to less demand for physical therapy sessions. Also, an earlier return to work reduces costs for society.

To conclude, immediate graft fixation using a biotenodesis screw during Adams–Berger TFCC reconstruction is a safe alternative technique which allows patients to mobilize early in the rehabilitation period after surgery. This leads to improved patient satisfaction and earlier return to work.


 

 

Conflict of Interest

None declared.

Ethical Approval

Ethical approval for this study was obtained from the Medical Ethics Committee of Martini Hospital, Groningen (2023-079). Written informed consent was obtained from all subjects before the study.



Address for correspondence

Nadia S. Scholtmeijer, MD
Department of Plastic Surgery, Martini Hospital
PO Box 30033, 9700 RM, Groningen
The Netherlands   

Publication History

Received: 05 March 2024

Accepted: 21 May 2024

Article published online:
26 June 2024

© 2024. Thieme. All rights reserved.

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Zoom
Fig. 1 Anatomical depiction of the Adams–Berger technique, on the left shown with knot fixation and on the right shown with biotenodesis screw fixation. (A) Posterior view of the reconstruction. (B) Reconstruction viewed from the articular surface.
Zoom
Fig. 2 Wrist flexion. Mean scores of degrees of wrist flexion comparing biotenodesis screw group to control group with knot fixation (T0 is baseline, T1 is 6 weeks, T2 is 3 months, T3 is 6 months, and T4 is 1 year after surgery).
Zoom
Fig. 3 Wrist extension. Mean scores of degrees of wrist extension comparing biotenodesis screw group to control group with knot fixation (T0 is baseline, T1 is 6 weeks, T2 is 3 months, T3 is 6 months and T4 is 1 year after surgery).
Zoom
Fig. 4 Grip strength. Mean scores of grip strength measured in kilograms comparing biotenodesis screw group to control group with knot fixation (T0 is baseline, T2 is 3 months, T3 is 6 months, and T4 is 1 year after surgery).