Anatomical Reattachment of the TFCC to the Ulnar Fovea Using an ECU Half-Slip

Abstract

Background Since 1998, we treated 25 wrists with foveal detachment of the triangular fibrocartilage complex (TFCC) by our original reattachment technique using a half-slip of the extensor carpi ulnaris (ECU) tendon with a very small titanium interference screw. We examine the clinical outcome of this procedure with a minimum of 2 years follow-up.

Patients and Methods There were 25 wrists of 24 patients (16 right, 7 left, 1 bilateral, mean age, 34.8 years) with a minimum follow-up of 2 years (range 2–7 years, average 3.1). There was a neutral ulnar variance in 19 wrists and positive in 6. In the positive-variance wrists, an ulnar shortening was performed to prevent ulnar abutment before the reattachment. The diagnosis of a TFCC injury was done by arthrogram, magnetic resonance imaging (MRI), and distal radioulnar (DRUJ) arthroscopy. The clinical outcome was evaluated using our original DRUJ evaluating system.

Technique A distally based ECU half-slip was harvested, introduced into the TFCC, sutured to the remnant of the TFCC, and pulled out through a 2.5-mm bone tunnel at the center of the fovea. The ECU half-slip was subsequently anchored to the ulnar fovea with a small titanium interference screw.

Results At the final follow-up, 21 wrists had no pain, 3 wrists indicated mild pain, and 1 wrist severe pain. One patient had a loss of supination by 30 degrees. The DRUJ was stable in 22 wrists, moderately unstable in 2 wrists, and severely unstable in 1 wrist. There were 21 excellent, 2 good, 1 fair, and 1 poor results.

Conclusions Anatomic reattachment of the TFCC to the ulnar fovea using an ECU half-slip tendon is a promising procedure. This technique is effective for severe DRUJ instability due to chronic foveal avulsion of the TFCC.

Keywords

reattachment - triangular fibrocartilage complex - extensor carpi ulnaris - foveal avulsion - interference screw

• References

• 1 Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist—anatomy and function. J Hand Surg Am 1981; 6 (2) 153-162
• 2 Nakamura T, Yabe Y, Horiuchi Y. Functional anatomy of the triangular fibrocartilage complex. J Hand Surg [Br] 1996; 21 (5) 581-586
• 3 Nakamura T, Makita A. The proximal ligamentous component of the triangular fibrocartilage complex. J Hand Surg [Br] 2000; 25 (5) 479-486
• 4 Nakamura T, Yabe Y. Histological anatomy of the triangular fibrocartilage complex of the human wrist. Ann Anat 2000; 182 (6) 567-572
• 5 Nakamura T, Takayama S, Horiuchi Y, Yabe Y. Origins and insertions of the triangular fibrocartilage complex: a histological study. J Hand Surg [Br] 2001; 26 (5) 446-454
• 6 Nakamura T, Nakao Y, Ikegami H, Sato K, Takayama S. Open repair of the ulnar disruption of the triangular fibrocartilage complex with double three-dimensional mattress suturing technique. Tech Hand Up Extrem Surg 2004; 8 (2) 116-123
• 7 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 (3) 281-290
• 8 Haugstvedt JR, Berger RA, Nakamura T, Neale P, Berglund L, An KN. Relative contributions of the ulnar attachments of the triangular fibrocartilage complex to the dynamic stability of the distal radioulnar joint. J Hand Surg Am 2006; 31 (3) 445-451
• 9 Moritomo H, Masatomi T, Murase T, Miyake J, Okada K, Yoshikawa H. Open repair of foveal avulsion of the triangular fibrocartilage complex and comparison by types of injury mechanism. J Hand Surg Am 2010; 35 (12) 1955-1963
• 10 Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am 1989; 14 (4) 594-606
• 11 Atzei A. New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability. J Hand Surg Eur Vol 2009; 34 (5) 582-591
• 12 Nishiwaki M, Nakamura T, Nagura T , et al. Ulnar shortening effect on the distal radioulnar joint pressure: a biomechanical study. J Hand Surg [Br] 2007; 33A: 198-205
• 13 Nishiwaki M, Nakamura T, Nakao Y, Nagura T, Toyama Y. Ulnar shortening effect on distal radioulnar joint stability: a biomechanical study. J Hand Surg Am 2005; 30 (4) 719-726
• 14 Iwasaki N, Minami A. Arthroscopically assisted reattachment of avulsed triangular fibrocartilage complex to the fovea of the ulnar head. J Hand Surg Am 2009; 34 (7) 1323-1326
• 15 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 (4) 226-235
• 16 Hermansdorfer JD, Kleinman WB. Management of chronic peripheral tears of the triangular fibrocartilage complex. J Hand Surg Am 1991; 16 (2) 340-346
• 17 Sennwald GR, Lauterburg M, Zdravkovic V. A new technique of reattachment after traumatic avulsion of the TFCC at its ulnar insertion. J Hand Surg [Br] 1995; 20 (2) 178-184
• 18 Hui FC, Linscheid RL. Ulnotriquetral augmentation tenodesis: a reconstructive procedure for dorsal subluxation of the distal radioulnar joint. J Hand Surg Am 1982; 7 (3) 230-236
• 19 Sanders RA, Hawkins B. Reconstruction of the distal radioulnar joint for chronic volar dislocation. A case report. Orthopedics 1989; 12 (11) 1473-1476
• 20 Scheker LR, Belliappa PP, Acosta R, German DS. Reconstruction of the dorsal ligament of the triangular fibrocartilage complex. J Hand Surg [Br] 1994; 19 (3) 310-318
• 21 Shih JT, Hou YT, Lee HM, Tan CM. Chronic triangular fibrocartilage complex tears with distal radioulna joint instability: A new method of triangular fibrocartilage complex reconstruction. J Orthop Surg (Hong Kong) 2000; 8 (1) 1-8
• 22 Adams BD, Berger RA. An anatomic reconstruction of the distal radioulnar ligaments for posttraumatic distal radioulnar joint instability. J Hand Surg Am 2002; 27 (2) 243-251
• 23 Hunter JM, Kirkpatrick WH. Dacron stabilization of the distal ulna. Hand Clin 1991; 7 (2) 365-371
• 24 Nakamura T, Matsumura N, Iwamoto T, Sato K, Toyama Y. Arthroscopy of the distal radioulnar joint. Handchir Mikrochir Plast Chir 2014; 46 (5) 295-299