Surgical Techniques for Repairing Foveal Tear of the Triangular Fibrocartilage Complex: Arthroscopic Transosseous Repair

Jong Woong Park

doi:10.12790/jkssh.2014.19.2.95

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Park: Surgical Techniques for Repairing Foveal Tear of the Triangular Fibrocartilage Complex: Arthroscopic Transosseous Repair

REVIEW ARTICLE

J Korean Soc Surg Hand 2014;19(2):95-102.

Published online: 11 June 2014

DOI: https://doi.org/10.12790/jkssh.2014.19.2.95

Surgical Techniques for Repairing Foveal Tear of the Triangular Fibrocartilage Complex: Arthroscopic Transosseous Repair

Jong Woong Park

Department of Orthopedic Surgery, Korea University College of Medicine, Seoul, Korea

Correspondence to: Jong Woong Park, Department of Orthopedic Surgery, Korea University Ansan Hospital, 516 Gojan-dong, Danwon-gu, Ansan 425-707, Korea, TEL: +82-31-412-6583, FAX: +82-31-412-5549, E-mail: ospark@korea.ac.kr

Received 12 May 2014 Accepted 5 June 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

As the importance of the foveal attachment of the triangular fibrocartilage complex (TFCC) on the stability of the distal radioulnar joint (DRUJ) is emphasized, the traditional repair techniques such as arthroscopic capsular repair for the 1B TFCC tear become accepted as ineffective method for treating DRUJ instability. Recently, several techniques which repair the TFCC directly to the ulnar fovea have been developed and introduced. Further advances of the techniques will be expected with increasing knowledge of the anatomy and biomechanics of the TFCC and DRUJ. Regardless of the techniques, fundamental principle of anatomical repair of the TFCC to the ulnar fovea is utmost important. Herein we present our technique of arthroscopic transosseous repair by making a drill hole in the ulnar and securing the sutures with Pushlock anchors.

Keywords: Triangular fibrocartilage complex, Arthroscopic transosseous repair

References

1. 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; 12:226–35.

2. 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; 25:464–8.

3. 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.

4. Nakamura T, Makita A. The proximal ligamentous component of the triangular fibrocartilage complex. J Hand Surg Br. 2000; 25:479–86.

5. Nakamura T, Yabe Y. Histological anatomy of the triangular fibrocartilage complex of the human wrist. Ann Anat. 2000; 182:567–72.

6. 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; 27:281–90.

Fig. 1.

Positive hook test indicates 1B pc-TFCC foveal attach tear. TFCC, triangular fibrocartilage complex.

Fig. 2.

TFCC guide is helpful to make a transosseous tunnel at isometric poistion. TFCC, triangular fibrocartilage complex.

Fig. 3.

2.7 mm cannulated drilling for initial drilling. A TFCC guide is helpful to make transosseous tunnel at accurate position. TFCC, triangular fibrocartilage complex.

Fig. 4.

4 mm drilling provides more space for stable fixation.

Fig. 5.

A bent fiberwire at needle tip prevents pull-out of suture from the joint when the needle is pulled-back from the bone tunnel.

Fig. 6.

(A, B) Fiberwire suture is pulled-out through the 8-R portal.

Fig. 7.

A nitinol looped wire is passed through the 18-gauge needle.

Fig. 8.

The fiber wire is passed through the looped wire and pulled-back through the bone tunnel.

Fig. 9.

(A, B) FIberwire is securely fixed with Pushlock.

Fig. 10.

Additional suture with cross configuration adds stability.

Table 1.

Classification of Palmer 1B triangular fibrocartilage complex tear (Modified from Atzei et al.¹)

Class	DRUJ instability	Involved TFCC component		TFCC healing potential	Status of DRUJ cartilage	Treatment
Class	DRUJ instability	Distal	Proximal	TFCC healing potential	Status of DRUJ cartilage	Treatment
Class 1: repairable distal tear	None or slight	Torn	Intact	Good	Good	Repair: suture (lig-to-capsule)
Class 2: reparable complex tear	Mild or severe	Tom	Tom	Good	Good	Repair (foveal refixation)
Class 3: reparable proximal tear	Mild or severe	Intact	Torn	Good	Good	Repair (foveal refixation)
Class 4: non-reparable	Severe	Tom	Tom	Poor	Good	Reconstruction (tendon graft)
Class 5: DRUJ arthritis	Mild or severe	^*	^*	^*	Poor	Salvage (arthroplasty or joint replacement)

Novel classification based on arthroscopic findings provides guidelines for treatment of different TFCC peripheral tears.

TFCC, triangular fibrocartilage complex; DRUJ, distal radioulnar joint.

^* Class 5, whose main characteristic consists of DRUJ cartilage degeneration, includes different conditions.

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