Arthroscopic Foveal Reattachment of the Triangular Fibro Cartilaginous Complex

Abstract

Background Foveal attachment of the triangular fibrocartilaginous complex (TFCC) is essential for distal radioulnar joint stability. Controversy still exists as to which is the best treatment in case of foveal lesions. Actual arthroscopic techniques either require mini open steps or are complex and expensive. We present a simple all inside knotless repair, providing a strong bony fixation in the fovea.

Materials and Methods Through 3–4 and 6R portals, the ulnar fovea is debrided and a wire is passed percutaneously through the TFCC to place a mattress suture at its free end. It is then reattached to the fovea with an impacted anchor.

Retrospective Study Between 2013 and 2016, a cohort of 5 patients presenting with isolated Palmer 1B, EWAS 2 lesions of the TFCC were operated on with this technique. Clinical evaluation was based on a compared measurement of the grip strength, pain on a visual analogic scale (VAS), different ranges of motion, and distal radioulnar joint (DRUJ) stability. We also used functional scores: Mayo modified wrist score (MMWS), Quick disability arm, shoulder and hand (DASH), and patient-related wrist evaluation (PRWE). The average follow-up was 29.4 months (range 9–42 months).

Results On postoperative evaluation, pain was reduced by 5 points (range 1–9) and grip strength averaged 94% of the unaffected side. Range of motion averaged 92% on the unaffected side. DRUJ instability was slight in 4 patients and mild in 1 patient. MMWS was excellent for 1, good for 1, and satisfactory for 3 patients. Quick Dash averaged 17.68 (range 0–38.6) compared with preoperative average of 59.48 (range 45–77) with an amelioration of 43 (range 34–57).

PRWE averaged 20 (range 1–41.5) compared with preoperative average of 60.3 (range 33.5–76.5) with an amelioration of 41 (range 32–58). We reported no complications and particularly no lesions of the dorsal sensory branch of the ulnar nerve.

Conclusions We present a simple arthroscopic technique using a single suture anchor placed in the ulnar fovea. Repairs performed with this technique are simple and the results achieved seem to be similar to those obtained with conventional open or arthroscopic techniques, although further investigation with an increased number of patients and follow-up are required. It however became our first choice of treatment in European Wrist Arthroscopy Society (EWAS) 2 lesions of the TFCC.

Keywords

wrist arthroscopy - TFCC - foveal

• References

• 1 Nakamura T, Yabe Y, Horiuchi Y. Functional anatomy of the triangular fibrocartilage complex. J Hand Surg [Br] 1996; 21 (05) 581-586
• 2 Boquet J, Lefebvre B, Van Innis F. Évaluation clinique rétrospective des traitements arthroscopiques des lésions du complexe triangulaire du poignet. Chir Main 2012; 31 (02) 91-96
• 3 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 (04) 226-235
• 4 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 (03) 281-290
• 5 Park JH, Kim D, Park JW. Arthroscopic one-tunnel transosseous foveal repair for triangular fibrocartilage complex (TFCC) peripheral tear. Arch Orthop Trauma Surg 2018; 138 (01) 131-138
• 6 Kleinman WB. Stability of the distal radioulna joint: biomechanics, pathophysiology, physical diagnosis, and restoration of function what we have learned in 25 years. J Hand Surg Am 2007; 32 (07) 1086-1106
• 7 Hermansdorfer JD, Kleinman WB. Management of chronic peripheral tears of the triangular fibrocartilage complex. J Hand Surg Am 1991; 16 (02) 340-346
• 8 Atzei A. New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability. J Hand Surg Eur Vol 2009; 34 (05) 582-591
• 9 Garcia-Elias M, Smith DE, Llusá M. Surgical approach to the triangular fibrocartilage complex. Tech Hand Up Extrem Surg 2003; 7 (04) 134-140
• 10 Chou KH, Sarris IK, Sotereanos DG. Suture anchor repair of ulnar-sided triangular fibrocartilage complex tears. J Hand Surg [Br] 2003; 28 (06) 546-550
• 11 Geissler WB. Arthroscopic knotless peripheral ulnar-sided TFCC repair. J Wrist Surg 2015; 4 (02) 143-147
• 12 Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am 1989; 14 (04) 594-606
• 13 Beighton P, Solomon L, Soskolne CL. Articular mobility in an African population. Ann Rheum Dis 1973; 32 (05) 413-418
• 14 Fontès D. Therapeutic interest of wrist arthroscopy - from a series of 280 cases. Presented at: 6th Congress of IFSSH; 1995: 723-728
• 15 Cooney WP, Bussey R, Dobyns JH, Linscheid RL. Difficult wrist fractures. Perilunate fracture-dislocations of the wrist. Clin Orthop Relat Res 1987; (214) 136-147
• 16 Dubert T, Voche P, Dumontier C, Dinh A. Le questionnaire DASH. Adaptation française d'un outil d'évaluation international. Chir Main 2001; 20 (04) 294-302
• 17 MacDermid JC, Turgeon T, Richards RS, Beadle M, Roth JH. Patient rating of wrist pain and disability: a reliable and valid measurement tool. J Orthop Trauma 1998; 12 (08) 577-586
• 18 Gilbart MK, Gerber C. Comparison of the subjective shoulder value and the Constant score. J Shoulder Elbow Surg 2007; 16 (06) 717-721
• 19 Gaumet G, Fontes D, Wavreille G, Limousin M. La pathologie ligamentaire du poignet. À propos de 32 lésions du complexe fibro-cartilagineux triangulaire du carpe (TFCC). Intérêt pronostique des lésions luno-triquetrales associées. Chir Main 2012; 31 (06) 298-305
• 20 Stuart PR, Berger RA, Linscheid RL, An K-N. The dorsopalmar stability of the distal radioulnar joint. J Hand Surg Am 2000; 25 (04) 689-699
• 21 Haugstvedt J-R, Berger RA, Nakamura T, Neale P, Berglund L, An K-N. 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 (03) 445-451
• 22 Estrella EP, Hung L-K, Ho P-C, Tse WL. Arthroscopic repair of triangular fibrocartilage complex tears. Arthroscopy 2007; 23 (07) 729-737 , 737.e1
• 23 Anderson ML, Larson AN, Moran SL, Cooney WP, Amrami KK, Berger RA. Clinical comparison of arthroscopic versus open repair of triangular fibrocartilage complex tears. J Hand Surg Am 2008; 33 (05) 675-682
• 24 Bain GI, Pourgiezis N, Roth JH. Surgical approaches to the distal radioulnar joint. Tech Hand Up Extrem Surg 2007; 11 (01) 51-56
• 25 Fontès D. Traitement arthroscopique des lésions traumatiques récentes et chroniques du complexe triangulaire du poignet. Chir Main 2006; 25 (Suppl. 01) S178-S186
• 26 Mathoulin C, Atzei A. Réparation du ligament triangulaire (TFCC) : rapport d'une série de 72 cas suivant une nouvelle classification. E-Mem Acad Natl Chir 2010; 9 (01) 21-27
• 27 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 (07) 1323-1326