Surgical Options for Triangular Fibrocartilage Complex Tears
Surgical Options for Triangular Fibrocartilage Complex Tears
These tears do not heal due to lack of vascularity and are thus treated with simple debridement to a stable edge using a 3.5-mm full-radius motorized shaver and/or a radiofrequency probe (Figure 1A, B). If a radiofrequency probe is to be used, it is important apply it intermittently and to have an adequate outflow portal to avoid overheating. Degenerative tears in the setting of a stable DRUJ also are treated with simple debridement to a stable edge. Biomechanical studies have shown that up to 80% of the central articular disc may be resected prior to causing instability.
(Enlarge Image)
Figure 1.
Central tear is hooked to assess stability (A) and then debrided back to a stable edge (B).
While several authors advocate for the use of a DRUJ portal to visually assess the foveal attachment of the TFCC, we tend to favor a capsular-based repair of peripheral tears that do not cause frank instability of the DRUJ. These tears are debrided with a shaver to stimulate angiogenesis at the repair site (Figure 2A). While multiple repair options are described, we prefer to use a FasT-Fix method. With the arthroscope in the 6R portal, the curved TFCC FasT-Fix (Smith & Nephew Endoscopy, Andover, MA, USA) is inserted through the 3–4 portal with the assistance of the split cannula (Figure 2B). The first poly-Lactic acid (PLLA) block is inserted radial to the tear and then advanced through the articular disc of the TFCC and further advanced through the ulnar capsule. The trigger on the needle introducer is then deployed, releasing the block from the introducer and depositing it on the outside of the ulnar wrist capsule. The introducer is withdrawn back to the starting point, and then the needle is reinserted and the second block is advanced and deposited in the same fashion ulnar to the tear (approximately 3 mm from the first block), forming a vertical mattress configuration (Figure 2C). The needle introducer is then removed from the joint, leaving the pre-tied suture (Figure 2D). The suture is tightened and the knot cut by use of the knot pusher/cutter (Figure 2E). Once the repair is completed, adequate restoration of the trampoline effect should be achieved (Figure 2F). A second implant, if necessary, is placed adjacent (typically dorsal) to the initial implant. Stability of the DRUJ is confirmed at this point.
(Enlarge Image)
Figure 2.
A 3.5-mm motorized shaver is used to debride the peripheral tear (A). The curved FasT-Fix is inserted through the 3–4 portal then through the TFCC radial to the tear and then the ulnar capsule (C). Deployment of the second block forms a vertical mattress configuration (D) which is then cut using an arthroscopic knot cutter (E, F).
The ulnar extrinsic ligaments should also be evaluated. If a longitudinal split tear is encountered, an outside-in repair is performed as described by Tay et al. A 1-cm longitudinal incision is made just volar to the extensor carpi ulnaris tendon starting distal to the ulnar styloid process, protecting the dorsal sensory branch of the ulnar nerve and basilic vein. This incision is then used to pass suture-using meniscal needles from outside-to-inside and then tied down to close the split tear.
While open peripheral TFCC repair was once the gold standard and only option for repair, this has largely been supplanted by arthroscopic and arthroscopic-assisted procedures in recent years. To date, only two studies have specifically compared outcomes between open and arthroscopic repair. Anderson et al. compared open and arthroscopic repair in 75 patients, finding no difference in clinical outcomes and a nonsignificant trend towards superficial ulnar nerve pain in the open group. Of the 75 patients, however, only 27 had DRUJ instability, and these would theoretically be the cases of most interest to differentiate between open and arthroscopic techniques. Luchetti et al. reported 49 patients who all had DRUJ instability treated with open and arthroscopic-assisted suture-anchor foveal repair. While global wrist function as measured by the Mayo Wrist Score was equivalent between the two groups, patients in the arthroscopic group had greater improvements in DASH and Patient-Rated Wrist Evaluation (PRWE) scores, indicating a more satisfactory outcome. The authors attributed the improved outcomes in the arthroscopic group to a smaller capsulotomy, less local proprioceptive denervation, and greater accuracy in suture-anchor placement under direct arthroscopic viewing.
Peripheral TFCC tears generally are categorized according to whether the tear involves the superficial aspect attaching to the ulnar styloid or the deep aspect attaching to the ulnar fovea. Repair constructs are either capsular based or involve direct reattachment to the ulnar fovea. Numerous capsular repair constructs have been described, including variations of inside-out and outside-in suture repair, suture welding, and the FasT-fix as described above, with most of the more recently described techniques being exclusively arthroscopic. The FasT-fix construct has been shown to have greater pullout strength than traditional suture techniques. Arthroscopic-assisted and open foveal repair constructs include transosseous suturing, suture anchors, and knotless push-lock anchors. While some authors advocate capsular based repairs for superficial TFCC tears and foveal repairs for deep TFCC tears with concomitant DRUJ instability, the outcomes data are lacking. To date, there are no head-to-head clinical trials comparing capsular to foveal-based repairs. Biomechanical data have shown DRUJ stability to rely most heavily on the foveal attachment of the TFCC; however, the one biomechanical study comparing DRUJ stability after foveal and capsular-based repairs showed no difference.
These tears are first debrided back to a stable margin. While multiple techniques have been reported for repair, we prefer simple debridement because of the lack of vascularity of the radial aspect of the TFCC. However, if DRUJ instability is present because of the radial avulsion, repair may be indicated. We prefer a modified technique described by Sagerman and Short. Debridement is performed to a bleeding bony surface at the insertion site on the sigmoid notch of the radius. A 1.5-cm longitudinal incision is made over the ulnar wrist to protect the dorsal sensory branch of the ulnar nerve, and over the radial wrist proximal to the styloid to protect the superficial radial nerve. The arthroscope is placed in the 3–4 portal, and a probe is placed in the 6R portal and used as a retractor. A cannula is inserted through the ulnar incision and through the capsule into the joint. A 0.062-inch Kirschner wire (K-wire) is advanced through the distal aspect of the sigmoid notch and out the radial wrist incision (Figure 3A). The K-wire is withdrawn and readvanced in the same manner starting 2 mm volar or dorsal to the first pass. With the two drill holes in place, the radial border of the TFCC is pierced with a meniscal needle in line with the first drill hole and advanced under arthroscopic vision through the drill hole (Figure 3B). A second meniscal needle, attached to the first by 2-0 PDS suture, is passed in the same manner, and both needles retrieved through the radial wrist incision. This pulls the PDS suture in horizontal mattress fashion, closing the tear. The knot is tied over a bone bridge on the radial side of the radius (Figure 3C).
(Enlarge Image)
Figure 3.
A 0.062 inch Kirschner wire (k-wire) is advanced through the distal aspect of the sigmoid notch and out the radial wrist incision (A). The radial border of the TFCC is pierced with a meniscal needle in line with the first drill hole and advanced under arthroscopic vision through the drill hole (B). The PDS suture is placed in a horizontal mattress fashion, closing the tear. The knot is tied over a bone bridge on the radial side of the radius (C).
Operative Treatment
Central (Palmer 1A Tear)
These tears do not heal due to lack of vascularity and are thus treated with simple debridement to a stable edge using a 3.5-mm full-radius motorized shaver and/or a radiofrequency probe (Figure 1A, B). If a radiofrequency probe is to be used, it is important apply it intermittently and to have an adequate outflow portal to avoid overheating. Degenerative tears in the setting of a stable DRUJ also are treated with simple debridement to a stable edge. Biomechanical studies have shown that up to 80% of the central articular disc may be resected prior to causing instability.
(Enlarge Image)
Figure 1.
Central tear is hooked to assess stability (A) and then debrided back to a stable edge (B).
Peripheral (Palmer 1B, C)
While several authors advocate for the use of a DRUJ portal to visually assess the foveal attachment of the TFCC, we tend to favor a capsular-based repair of peripheral tears that do not cause frank instability of the DRUJ. These tears are debrided with a shaver to stimulate angiogenesis at the repair site (Figure 2A). While multiple repair options are described, we prefer to use a FasT-Fix method. With the arthroscope in the 6R portal, the curved TFCC FasT-Fix (Smith & Nephew Endoscopy, Andover, MA, USA) is inserted through the 3–4 portal with the assistance of the split cannula (Figure 2B). The first poly-Lactic acid (PLLA) block is inserted radial to the tear and then advanced through the articular disc of the TFCC and further advanced through the ulnar capsule. The trigger on the needle introducer is then deployed, releasing the block from the introducer and depositing it on the outside of the ulnar wrist capsule. The introducer is withdrawn back to the starting point, and then the needle is reinserted and the second block is advanced and deposited in the same fashion ulnar to the tear (approximately 3 mm from the first block), forming a vertical mattress configuration (Figure 2C). The needle introducer is then removed from the joint, leaving the pre-tied suture (Figure 2D). The suture is tightened and the knot cut by use of the knot pusher/cutter (Figure 2E). Once the repair is completed, adequate restoration of the trampoline effect should be achieved (Figure 2F). A second implant, if necessary, is placed adjacent (typically dorsal) to the initial implant. Stability of the DRUJ is confirmed at this point.
(Enlarge Image)
Figure 2.
A 3.5-mm motorized shaver is used to debride the peripheral tear (A). The curved FasT-Fix is inserted through the 3–4 portal then through the TFCC radial to the tear and then the ulnar capsule (C). Deployment of the second block forms a vertical mattress configuration (D) which is then cut using an arthroscopic knot cutter (E, F).
The ulnar extrinsic ligaments should also be evaluated. If a longitudinal split tear is encountered, an outside-in repair is performed as described by Tay et al. A 1-cm longitudinal incision is made just volar to the extensor carpi ulnaris tendon starting distal to the ulnar styloid process, protecting the dorsal sensory branch of the ulnar nerve and basilic vein. This incision is then used to pass suture-using meniscal needles from outside-to-inside and then tied down to close the split tear.
Open Versus Arthroscopic Repairs
While open peripheral TFCC repair was once the gold standard and only option for repair, this has largely been supplanted by arthroscopic and arthroscopic-assisted procedures in recent years. To date, only two studies have specifically compared outcomes between open and arthroscopic repair. Anderson et al. compared open and arthroscopic repair in 75 patients, finding no difference in clinical outcomes and a nonsignificant trend towards superficial ulnar nerve pain in the open group. Of the 75 patients, however, only 27 had DRUJ instability, and these would theoretically be the cases of most interest to differentiate between open and arthroscopic techniques. Luchetti et al. reported 49 patients who all had DRUJ instability treated with open and arthroscopic-assisted suture-anchor foveal repair. While global wrist function as measured by the Mayo Wrist Score was equivalent between the two groups, patients in the arthroscopic group had greater improvements in DASH and Patient-Rated Wrist Evaluation (PRWE) scores, indicating a more satisfactory outcome. The authors attributed the improved outcomes in the arthroscopic group to a smaller capsulotomy, less local proprioceptive denervation, and greater accuracy in suture-anchor placement under direct arthroscopic viewing.
Peripheral Repair Constructs
Peripheral TFCC tears generally are categorized according to whether the tear involves the superficial aspect attaching to the ulnar styloid or the deep aspect attaching to the ulnar fovea. Repair constructs are either capsular based or involve direct reattachment to the ulnar fovea. Numerous capsular repair constructs have been described, including variations of inside-out and outside-in suture repair, suture welding, and the FasT-fix as described above, with most of the more recently described techniques being exclusively arthroscopic. The FasT-fix construct has been shown to have greater pullout strength than traditional suture techniques. Arthroscopic-assisted and open foveal repair constructs include transosseous suturing, suture anchors, and knotless push-lock anchors. While some authors advocate capsular based repairs for superficial TFCC tears and foveal repairs for deep TFCC tears with concomitant DRUJ instability, the outcomes data are lacking. To date, there are no head-to-head clinical trials comparing capsular to foveal-based repairs. Biomechanical data have shown DRUJ stability to rely most heavily on the foveal attachment of the TFCC; however, the one biomechanical study comparing DRUJ stability after foveal and capsular-based repairs showed no difference.
Radial-sided (Palmer 1D) Avulsions
These tears are first debrided back to a stable margin. While multiple techniques have been reported for repair, we prefer simple debridement because of the lack of vascularity of the radial aspect of the TFCC. However, if DRUJ instability is present because of the radial avulsion, repair may be indicated. We prefer a modified technique described by Sagerman and Short. Debridement is performed to a bleeding bony surface at the insertion site on the sigmoid notch of the radius. A 1.5-cm longitudinal incision is made over the ulnar wrist to protect the dorsal sensory branch of the ulnar nerve, and over the radial wrist proximal to the styloid to protect the superficial radial nerve. The arthroscope is placed in the 3–4 portal, and a probe is placed in the 6R portal and used as a retractor. A cannula is inserted through the ulnar incision and through the capsule into the joint. A 0.062-inch Kirschner wire (K-wire) is advanced through the distal aspect of the sigmoid notch and out the radial wrist incision (Figure 3A). The K-wire is withdrawn and readvanced in the same manner starting 2 mm volar or dorsal to the first pass. With the two drill holes in place, the radial border of the TFCC is pierced with a meniscal needle in line with the first drill hole and advanced under arthroscopic vision through the drill hole (Figure 3B). A second meniscal needle, attached to the first by 2-0 PDS suture, is passed in the same manner, and both needles retrieved through the radial wrist incision. This pulls the PDS suture in horizontal mattress fashion, closing the tear. The knot is tied over a bone bridge on the radial side of the radius (Figure 3C).
(Enlarge Image)
Figure 3.
A 0.062 inch Kirschner wire (k-wire) is advanced through the distal aspect of the sigmoid notch and out the radial wrist incision (A). The radial border of the TFCC is pierced with a meniscal needle in line with the first drill hole and advanced under arthroscopic vision through the drill hole (B). The PDS suture is placed in a horizontal mattress fashion, closing the tear. The knot is tied over a bone bridge on the radial side of the radius (C).
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