Differentiated Approaches to Treat Lesions of the TFCC Based on new arthroscopic Classification

Abstract

In this article, pathology of the TFCC lesions, image diagnosis and arthroscopic examination were described. According to the radiocarpal arthroscopic findings, TFCC lesions are classified into intra-disc lesions (Class 1), radial lesion (Class 2), peripheral disc lesions which indicate slight to moderate DRUJ instability (Class 3) and degenerative lesion (Class 4). The radioulnar ligament (RUL) lesions that indicate moderate to severe DRUJ instability were classified with staging system with DRUJ arthroscopic findings (Stage 1 to 5). Author’s treatment algorism with wrist arthroscopic findings including DRUJ arthroscopy was demonstrated and along with this algorism, various arthroscopic and open techniques to treat TFCC injuries were selected and resulted in success. Precise diagnosis of the TFCC lesions helped to select an adequate treatment for each lesion.

Zusammenfassung

Dieser Artikel beschreibt die pathologischen Veränderungen des TFCC sowie deren Befunde in der Bildgebung und Arthroskopie. Am TFCC lassen sich mittels Arthroskopie bei Sicht von radiokarpal zentrale (Typ 1), radiale (Typ 2) sowie periphere Läsionen (Typ 3), die mit einer moderaten Instabilität des distalen Radioulnargelenkes (DRUG) einhergehen, und degenerative Läsionen (Typ 4) unterscheiden. Läsionen der radioulnaren Bänder, die mit einer moderaten bis ausgeprägten Instabilität des DRUG vergesellschaftet sind, werden anhand der Befunde bei der DRUG-Arthroskopie in fünf Stadien eingeteilt. Diesen unterschiedlichen Befunden angepasst wurde ein Behandlungsalgorithmus mit verschiedenen arthroskopischen und offenen Verfahren entwickelt, der sich als erfolgreich erwies. Eine exakte Klassifizierung von TFCC-Läsionen ermöglicht die Wahl des für die jeweilige Läsion adäquaten Therapieverfahrens.

Key words

Triangular fibrocartilage complex - arthroscopic exploration - arthroscopic repair - open repair - reconstruction

Schlüsselwörter

Triangulärer fibrokartilaginärer Faserknorpel - arthroskopische Untersuchung - arthroskopische Behandlung - offene Behandlung - Rekonstruktion

Publication History

Received: 22 May 2022

Accepted: 23 May 2022

Article published online:
29 August 2022

• References

• 1 Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist-anatomy and function. J Hand Surg 1981; 6: 153-162
• 2 Nakamura T, Yabe Y, Horiuchi Y. Functional anatomy of the triangular fibrocartilage complex. J Hand Surg Br 1996; 21: 581-586
• 3 Nakamura T, Nakao Y, Ikegami H. et al. Open repair of the ulnar disruption of the triangular fibrocartilage complex with double 3D-mattress suturing technique. Tech Up Extrem Surg 2004; 8: 116-123
• 4 Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am 1989; 14: 594-606
• 5 Haugstvedt JR, Berger RA, Nakamura T. et al. Relative contributions of the ulnar attachment of the triangular fibrocartilage complex to the dynamic stability of the distal radioulnar joint. J Hand Surg Am 2006; 26: 445-451
• 6 Nakamura T, Moy OJ, Peimer CA. Relationship between fracture of the ulnar styloid process and DRUJ instability: A biomechanical study. J Wrist Surg 2021; 10: 111-115
• 7 Lindau T, Adlercreutz C, Aspenberg P. Peripheral tears of the triangular fibrocartilage complex cause distal radioulnar joint instability after distal radius fractures. J Hand Surg Am 2000; 25: 464-468
• 8 Fukuoka M, Nakamura T, Nishiwaki M. et al. Effects of peripheral tears of the triangular fibrocartilage complex on distal radioulnar joint instability: A biomechanical study. J Orthop Sci 2021; 26: 1008-1013
• 9 Nakamura T, Yabe Y. Histological anatomy of the triangular fibrocartilage complex of the human wrist. Ann Anat 2000; 182: 567-572
• 10 Nakamura T, Yabe Y, Horiuchi Y. et al. Origins and insertions of the triangular fibrocartilage complex – A histological study. J Hand Surg Br 2001; 26: 446-454
• 11 Nakamura T, Makita A. The proximal ligamentous component of the triangular fibrocartilage complex: functional anatomy and three-dimensional changes in length of the radioulnar ligament during pronation-supination. J Hand Surg Br 2000; 25: 479-486
• 12 Atzei A. New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability. J Hand Surg Eur 2009; 34: 582-591
• 13 Nakamura R, Horii E, Imaeda T. et al. The ulnocarpal stress test in diagnosis of ulnar-sided wrist pain. J Hand Surg 1997; 22B: 719-723
• 14 Moriya T, Aoki M, Iba K. et al. Effect of triangular ligament tears on distal radioulnar joint instability and evaluation of three clinical tests: a biomechanical study. J Hand Surg Eur 2009; 34: 219-223
• 15 Nakamura T, Yabe Y, Horiuchi Y. Fat-suppression magnetic resonance imaging of the triangular fibrocartilage complex – comparison with spin echo, gradient echo pulse sequence and histology. J Hand Surg Br 1999; 24: 22-26
• 16 Tanaka T, Yoshioka H, Ueno T. et al. Comparison between high-resolution MRI with a microscopy coil and arthroscopy in triangular fibrocartilage complex injury. J Hand Surg Am 2006; 31: 1308-1314
• 17 Zinberg EM, Palmer AK, Coren AB. et al. The triple-injection wrist arthrogram. J Hand Surg Am 1988; 13: 803-809
• 18 Moritomo H, Arimitsu S, Kubo N. et al. Computed tomography arthrography using a radial plane view for the detection of triangular fibrocartilage complex foveal tears. J Hand Surg Am 2015; 40: 245-251
• 19 Estrella EP, Hung LK, Ho PC. et al. Arthroscopic repair of triangular fibrocartilage complex tears. Arthroscopy 2007; 23: 729-737
• 20 Nakamura T, Matsumura N, Iwamoto T. et al. Arthroscopy of the distal radioulnar joint. Handchir Mikrochir Plast Chir 2014; 46: 295-299
• 21 Osterman AL. Arthroscopic debridement of triangular fibrocartilage complex tears. Arthroscopy 1990; 6: 120-124
• 22 Del Pinal F, Nakamura T. Coronal tears of the triangular fibrocartilage. In: Del Pinal F, Mathoulin C, Nakamura T (eds). Arthroscopic management of ulnar side pain. Springer; New York: 2012: 199-211
• 23 Nakamura T, Sato K, Okazaki M. et al. Repair of the foveal detachment of the triangular fibrocartilage complex: Open and arthroscopic transosseous techniques. Hand Clinics 2011; 27: 281-290
• 24 Nakamura T. Radial sided tear of the triangular fibrocartilage complex. In: Del Pinal F, Mathoulin C, Lucchetti R (eds). Arthroscopic repair of fracture of the distal radius. Springer; New York: 2010: 89-98
• 25 Morisawa Y, Nakamura T, Tazaki K. Dorsoradial avulsion of the triangular fibrocartilage complex with an avulsion fracture of the sigmoid notch of the radius: A report of two cases. J Hand Surg Eur 2007; 32: 705-708
• 26 Haugstvedt JR, Husby T. Results of repair of peripheral tears in the triangular fibrocartilage complex using an arthroscopic suture technique. Scan J Plast Reconstr Surg 1999; 33: 439-447
• 27 Takagi T, Nakamura T, Fukuoka M. Arthroscopic capsular repair for triangular fibrocartilage complex tears. J Wrist Surg 2021; 10: 249-254
• 28 Manami A, Kato H. Ulnar shortening for triangular fibrocartilage complex tears associated with ulnar positive variance. J Hand Surg Am 1998; 23: 904-908
• 29 Nakamura T, Yabe Y, Horiuchi Y. et al. Ulnar shortening procedure for the ulnocarpal and distal radioulnar joints disorders. J Jap Soc Surg Hand 1998; 15: 119-126
• 30 Wnorowski DC, Palmer AK, Werner FW. et al. Anatomic and biomechanical analysis of the arthroscopic wafer procedure. Arthroscopy 1992; 8: 204-212
• 31 Slade JF, Gillon T. Osteochondral shortening osteotomy for the treatment of ulnar impaction syndrome: a new technique. Tech Hand Up Extrem Surg 2007; 11: 74-82
• 32 Feldon P, Terrono AL, Belsky MR. The “wafer” procedure. Partial distal ulnar resection. Clin Orthop Relat Res 1992; 275: 124-129
• 33 Nakamura T. Anatomical Reattachment of the TFCC to the Ulnar Fovea Using an ECU Half-Slip. J Wrist Surg 2015; 4: 15-21
• 34 Nakamura T, Obara Y. The clinical outcome of anatomical re-attachment of the TFCC to the ulnar fovea using an ECU half-slip and interference screw. Handchir Mikrochir Plast Chir 2015; 47: 290-296
• 35 Nakamura T, Abe K, Nishiwaki M. et al. Medium- to long-term outcomes of anatomical reconstruction of the radioulnar ligament to the ulnar fovea. J Hand Surg Eur 2017; 42: 352-356
• 36 Adams ND, Berger RA. An anatomic reconstruction of the distal radioulnar ligaments for posttraumatic distal radioulnar joint instability. J Hand Surg Am 2002; 27: 241-251
• 37 Nishiwaki M, Nakamura T, Nakao Y. et al. Ulnar shortening effect on the distal radioulnar stability: a biomechanical study. J Hand Surg Am 2005; 30: 719-726
• 38 Nishiwaki M, Nakamura T, Nagura T. et al. Ulnar shortening effect on the distal radioulnar joint pressure: a biomechanical study. J Hand Surg Am 2007; 33: 198-205
• 39 Nakamura T, Ho PC, Atzei A. et al. Revolutions in arthroscopic surgeries of the wrist. J Hand Surg Eur 2022; 47: 52-64
• 40 Tse WL, Lau SW, Wong WY. et al. Arthroscopic reconstruction of triangular fibrocartilage complex (TFCC) with tendon graft for chronic DRUJ instability. Injury 2013; 44: 386-390
• 41 Luchetti R, Atzei A. Arthroscopic assisted tendon reconstruction for triangular fibrocartilage complex irreparable tears. J Hand Surg Eur 2017; 42: 346-351