Keywords
triangular fibrocartilage complex - wrist arthroscopy - hand surgery
Introduction
The triangular fibrocartilage complex (TFCC) is an anatomical structure that functions
as the main stabilizer of the distal radioulnar joint (DRUJ) and absorbs axial loads
from the ulnar edge of the wrist. The volar and dorsal radioulnar ligaments, mainly
in their foveal insertion, are of special importance to joint stability, especially
in pronosupination movements.[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
Palmer[9] initially classified TFCC injuries into two large groups: traumatic injuries and
degenerative injuries. Degenerative lesions are usually generated in the context of
an ulnocarpal impingement syndrome due to repeated low-energy traumas, usually in
fist pronation, which lead to a chronic process with specific anatomical alterations.
Traumatic injuries may initially go unnoticed or even be underestimated, and they
may manifest as persistent wrist pain, which is attributed to symptomatic instability
of the DRUJ, and have a different clinical behavior than acute traumatic injuries.
The present article tries to establish what should be considered a chronic traumatic
injury and thereby guide the diagnosis and propose a treatment algorithm, in which
we include a novel surgical technique for TFCC reconstruction.
Anatomy and Biomechanics of the TFCC
Anatomy and Biomechanics of the TFCC
The TFCC is an anatomical complex made up of fibrocartilaginous and ligamentous structures
that extend from the ulnar margin of the distal radius towards the distal ulna. It
is functionally related to the DRUJ and the ulnocarpal joint, and it is the main stabilizer
of the DRUJ, providing anchorage for the fibers that confer stability to the ulnocarpal
joint, thus participating in the transmission and distribution of axial loads on the
ulnar edge of the carpus.[1]
[2]
[3]
[4]
This complex is composed of the dorsal and volar radioulnar ligaments, the ulnocarpal
ligaments, the articular disc or fibrocartilage itself, the homologous meniscus or
ulnocarpal meniscus (a structure of loose, vascularized tissue of variable shape and
size), the ulnar collateral ligament, and the floor of the sheath of the extensor
carpi ulnaris (ECU) ([Fig. 1]). The volar and dorsal distal radioulnar ligaments are themselves the main stabilizers
of the DRUJ, and their fibers in each fascicle are oriented longitudinally, which
provides them resistance to tensile forces, and their rich peripheral vascularization
enables them to have healing potential in the periphery. They originate from the volar
and dorsal borders of the sigmoid fossa of the radius, and, on their way to the ulna,
each divides in the coronal plane into two portions, deep and superficial. The deep
portion of each inserts into the center of the ulna in a region called the fovea,
at a point where there is synovial proliferation called the ligamentum subcruentum,
while the superficial portion of each inserts into the superior portion of the ulnar
styloid. From the distal radioulnar ligament, at its volar margin, the insertion of
the ulnocarpal ligaments projecting distallly can be recognized, comprising three
ligaments (the ulnotriquetral, ulnolunate and ulnocapitate ligaments), which additionally
act as restrictors of the dorsal translation of the distal ulna relative to the carpus.
The ulnar collateral ligament and the floor of the ECU sheath provide additional reinforcement
to the dorsal capsule of the DRUJ, regardless of the dynamic stabilizing role of the
ECU ([Fig. 1]).[1]
[2]
[3]
[4]
Fig. 1 Anatomy of the TFCC.
From a kinetic point of view, the ulnocarpal joint transmits approximately 20% of
the axial loads of the wrist proximally. Palmer and Werner[10] demonstrate in a cadaveric model that this ratio changes with ulnar variance, increasing
for positive ulnar variance and decreasing for negative ulnar variance. Independently,
with the excision of the articular disc, the loads that are transferred through the
ulnar edge of the carpus decrease by up to 55%, in the context of neutral ulnar variance.[10]
The volar and dorsal radioulnar ligaments vary their tension in a complementary manner
to restrict volar-dorsal rotational and translational movements. This is possible
since the different portions of each radioulnar ligament have insertion sites and
are differentially tensed due to their angle of insertion, with the deep portions
having insertions with more obtuse angles than those of the superficial portions.[4]
[11]
[12]
[13]
[14]
[15] Thus, in supination, the fibers of the deep portion of the dorsal distal radioulnar
ligament are tense and the superficial portion is lax, and the fibers of the volar
superficial portion are tense and the deep portion is lax ([Fig. 2]).
Fig. 2 Arrangement of the superficial and deep fibers of the TFCC in pronation and supination
movements.
Time of occurrence of the Injury
Time of occurrence of the Injury
It is important to try to define when the injury occurred, since the ability to heal
can change over time and, consequently, the therapeutic approach.
In the literature, there is no precise temporal definition to differentiate an acute
traumatic injury from a chronic one. One way to approach this is primarily in relation
to the clinical outcomes of patients undergoing TFCC repair surgeries.
There are multiple works in the literature that show good and excellent functional
results in patients who were operated on for traumatic TFCC injuries with the foveal
reinsertion technique through transosseous tunnels with an average injury time before
surgery of 7 to 8 months.[16]
[17] Park et al.[18] carried out a comparative study of functional results in patients undergoing foveal
insertion repair with different evolution times. The authors found no differences
in the functional results of patients undergoing surgery before 6 months of evolution,
between 6 and 12 months, and in patients with evolution time of more than 12 months.
In a different study, Nakamura et al.[19] showed that patients who had an average of 19 months of evolution (range: 7 months
to 4 years) had poor results compared to patients with shorter evolution times before
repair. Takagi et al.[20] described a TFCC capsular repair technique in which they perform a suture without
the use of transosseous tunnels, and they reported that patients with more than 15
months of evolution presented worse clinical results than those who were operated
on earlier. These differences could be due to the potential benefit of techniques
that include bone tunnels, which could expose a bloody bone bed that could favor the
healing of the reinsertion of fibrocartilage in the fovea, with the potential to benefit
patients with a longer duration of the injury.
Although there is not enough evidence to describe the chronicity of a TFCC lesion
based on the time it occurred, according to the previously mentioned functional results,
we can infer that patients with more than 15 months of evolution would have worse
results when subjected to techniques of foveal reattachment that those patients who
are operated on earlier, and that foveal reattachment techniques using transosseous
tunnels could provide an additional biological factor, with a potential greater benefit
in cases of delayed repair.
Repair Potential
The repair potential of an injury is related to its ability to achieve adequate healing
so that the injured structure regain its functionality; when we refer to the TFCC
specifically, this means re-establishing the stability of the DRUJ. In the case of
detection of acute injuries, this could be achieved with conservative management,
immobilizing the limb to achieve adequate in-situ healing of the TFCC, or surgically,
performing a repair of the TFCC, and, in both situations, rehabilitation programs
suitable for recovering neuromuscular control and the proprioceptive capacity of the
joint are required.
The repair potential of a TFCC lesion may be conditioned by the irrigation of the
TFCC, the precise site of the lesion and the quality of the remaining tissue.
TFCC Irrigation
The TFCC blood supply comes from dorsal and palmar branches of the radiocarpal arteries
from both the ulnar artery and dorsal and palmar branches of the anterior interosseous
artery[21] ([Fig. 3]). It has been described that between 10% and 40% of the most peripheral portion
of the TFCC is irrigated, leaving the central area avascular. In addition, the TFCC
receives practically no blood supply from its radial border, which is why this region
is also considered avascular. These findings enable us to infer that the more irrigated
peripheral zones have greater healing potential than the central zone and the radial
region, which are considered avascular.[22]
Fig. 3 Blood supply to the TFCC.
Remaining Tissue Quality
It is necessary to evaluate the quality of the remaining tissue against a TFCC lesion,
since even when it is usual for them to be repairable, there are lesions that imply
greater tissue damage, among which we can find massive acute or chronic lesions with
insufficient residual tissue or whose edges are so friable that they cannot be repaired
([Fig. 4]).
Fig. 4 Arthroscopic view of different TFCC lesions. (A) Acute foveal injury. (B) Massive acute injury. (C) Chronic central lesion. (D) Chronic TFCC destruction with no remaining tissue.
Atzei and Luchetti,[13] when presenting their classification and treatment of TFCC injuries, describe this
type of injury as “irreparable”, since they are injuries that do not have enough tissue
to achieve a stable surgical repair. For the treatment of this type of injury, they
propose the performance of TFCC reconstruction techniques with some form of tendon
graft.
The gold standard for an adequate evaluation of the condition of the TFCC lesion and
its repair potential is wrist arthroscopy. Although an adequate clinical examination
and complementary imaging studies can bring us closer to the diagnosis, they are usually
insufficient for the comprehensive evaluation of this type of injury, especially the
evaluation of the quality of the remaining tissue, since, with the use of the tester
and needles, the ability to withstand mechanical loads to accept sutures can be established
and the outcome of a repair can be predicted.
Patient Consultation
The patient with a chronic TFCC traumatic injury generally presents after attending
multiple prior consultations or with prolonged onset of discomfort. We frequently
meet patients in the context of an ulnar wrist pain syndrome with multiple possible
causes, so it is essential to take the time to take a thorough history and perform
a detailed physical examination.[23]
The existence of traumatic history should be specifically investigated, which are
usually falls with axial load with hyperextension and ulnarization of the wrist. However,
this history may be absent since it may correspond to a traumatic event that is not
so significant for the patient.
During the physical examination, the physician should look directly if there is an
eventual or specific site of pain, the active ranges of motion of the wrist, the strength
of the fist, and evaluate specifically and directly the stability of the DRUJ, with
specific tests that we detail below.
The foveal sign is of special importance when examining the TFCC ([Fig. 5]). It consists of reproducing the pain symptomatology when making a direct digital
compression with the tip of the finger, usually the examiner's thumb, placed on the
medial region of the wrist, in the space between the vertex of the ulnar styloid and
the proximal region of the pyramidal bone, dorsal to the flexor carpi ulnaris (FCU)
tendon. This sign has been shown to have a sensitivity of up to 95.2% and a specificity
of 86.5% for TFCC and ulnocarpal ligament injuries.[24]
Fig. 5 Foveal sign.
Regarding the provocation tests, the ulnocarpal stress test, which consists of axial
compression in pronosupination and ulnarization movement, enables us to distinguish
the pathology of ulnocarpal origin from the differential diagnoses.[25] A positive test suggests ulnocarpal pathology without being specific for TFCC traumatic
injuries.
To evaluate DRUJ stability, we use the ballottement test, in which the ability to
bear loads without pain or abnormal displacement of the segment is tested; therefore,
it should always be performed in a standardized way and in comparison with the opposite
side. It is necessary to repeat the test both in neutral rotation, pronation and supination.
The wrist in neutral position and radialization tenses the ulnocarpal ligaments, increasing
the stability of the DRUJ, significantly decreasing the translation of the ulna ([Fig. 6]), thus enabling the differentiation of hypermobile patients from patients with complete
injuries, in whom instability is present both with the wrist in neutral position and
with radial deviation.
Fig. 6 Ballottement test for the evaluation of DRUJ stability. (A) In neutral position. (B) In radialization.
Complementary Imaging
Given the suspicion of a chronic TFCC traumatic injury, the study begins with plain
radiographs of the wrist. These enable us to assess the presence of sequelae of old
fractures of the distal radius and ulnar styloid, ulnar variance, suspect ulnar impaction
syndrome, and assess the presence of DRUJ osteoarthritis. As a more advanced study,
magnetic resonance imaging (MRI) is usually sufficient to evaluate TFCC lesions and
define their location. In addition, it helps us rule out chronic degenerative pathology.
It is always important to correlate the images with the patient's symptoms, since
up to 38% of asymptomatic patients with stable DRUJs have TFCC lesions on MRI, and
this percentage increases as the age of the subjects evaluated increases.[26]
[27]
Images with intra-articular injection of contrast medium (arthro-computed tomography
[arthro-CT] and arthro-MRI) improve the performance of MRI scans without contrast
both in terms of sensitivity and specificity, with no significant differences between
the use of both contrasted techniques.[28] These tests enable a better characterization of the TFCC lesion and provide us with
more anatomical information, but they involve an invasive technique, so they must
be requested according to the degree of clinical suspicion.
It is important to remember that the gold standard remains direct or arthroscopic
visualization of the lesion.
Therapeutic Alternatives
Once the diagnosis is established, all the aforementioned variables must be considered
in order to make a correct therapeutic indication. In patients with clinically-stable
DRUJs, the initial indication is to carry out conservative management with medical
treatment,[29] since the natural history of a TFCC lesion in the presence of a stable DRUJ is complete
recovery in 30% of the patients at 6 months and of up to 50% at 1 year of follow-up.[30]
Rest and initial immobilization and the use of non-steroidal anti-inflammatory drugs
are suggested for symptomatic management. After that, rehabilitation with directed
physical therapy is carried out in order to recover the dynamic stabilizers of the
joint and improve their proprioceptive control.
Depot corticosteroids have not been widely used in this group of patients, and there
is no evidence in the literature in this regard, so it is not a treatment that we
routinely recommend. We suggest maintaining the conservative treatment for a period
that fluctuates between 6 weeks and 6 months due to the aforementioned data and always
considering the expectations and needs of the patient. In the event of failure of
the medical treatment or in those patients with frank instability of the DRUJ, surgical
management is indicated ([Fig. 7]).
Fig. 7 Algorithm for the management of TFCC traumatic injuries.
Surgical Treatment
The surgical treatment is initially indicated to patients with failed medical management
or unstable injuries. The surgical alternatives will depend on the remaining tissue
the patient has, and they may correspond to TFCC repair or reconstruction techniques.
If the arthroscopic evaluation shows good-quality remnant tissue, it is managed as
an acute injury; if, on the contrary, the tissue is irreparable or we are facing a
failure of a previous repair, a reconstruction technique must be chosen ([Fig. 8]).
Fig. 8 Surgical treatment algorithm for chronic traumatic TFCC injuries.
Reconstruction of the TFCC
Reconstruction of the TFCC
The techniques for TFCC reconstruction are indicated in symptomatic patients with
irreparable lesions and usually in the context of DRUJ instability. It is very important
to emphasize that these techniques are contraindicated in the presence of DRUJ arthrosis.[31]
[32]
There are multiple reconstructive techniques described to achieve DRUJ stability.
They are divided into anatomical techniques, in which an attempt is made to reconstruct
the volar and dorsal radioulnar ligaments with a tendon graft, and non-anatomical
techniques, among which is the reconstruction of the oblique distal band of the interosseous
membrane.[15]
[33]
[34]
[35]
[36]
[37]
[38]
The technique described by Adams[33] consists of reconstructing the volar and dorsal portions of the radioulnar ligament
with an autologous (palmaris longus) tendon graft through a tunnel in the ulnar edge
of the radius and subsequently a tunnel at the level of the fovea in the distal ulna.
This technique has shown good and excellent results in the medium and long terms,
achieving an overall success rate of up to 86% at 5 years, with 90.8% of patients
maintaining DRUJ stability, 75.9% of them with mild or no residual pain.[39]
[40]
There are descriptions of the performance of this technique and of other similar ones
with arthroscopic assistance, in an attempt to reduce the impact of the invasion of
soft tissues and to keep unharmed other stabilizing structures of the DRUJ that can
be compromised with the classic open surgery techniques.[15]
[35]
[37] These techniques have also been shown to have good and excellent clinical results
similar to those found with open techniques, and there are even studies[15]
[35] that show that these techniques have advantages in terms of recovering better ranges
of motion of the wrist.
Arthroscopically-Assisted Reconstruction of the TFCC with Brachioradialis Tendon Graft
Our working group has developed a reconstruction technique for the volar and dorsal
radioulnar ligaments using the brachioradialis tendon with arthroscopic assistance,
keeping its distal insertion on the radius fixed. ([Fig. 9])
Fig. 9 Scheme of the arthroscopic reconstruction technique with brachioradialis graft. (A) Brachioradialis graft fixed at its insertion and divided into two strands. (B) Axial diagram of the radial tunnels and posterior cubital tunnel. (C) Final scheme with fixed graft with interference screw in the ulna.
Description of the Technique
-
We perform a diagnostic arthroscopy according to the classic technique with dry arthroscopy,
using a 5-Kg traction tower and limb ischemia. We use 2.7-mm optics with an angle
of 30°.
-
a) Diagnostic arthroscopy: we perform an arthroscopic diagnosis of the compromised
structures of both the radiocarpal and midcarpal joints through the 3-4, 6R, radial
midcarpal (MCR), and ulnar midcarpal (MCU) portals. Then, we evaluate the presence
and quality of the remnant tissue of the TFCC and test its stability by palpation
and traction with the arthroscopic tester. In this step, the surgical decision is
made, since the indication for reconstruction will be determined by the irreparability
of the lesion under arthroscopic visualization. If an injury is considered irreparable,
the reconstruction continues. In this step, joint cleaning is performed with a shaver,
as well as a thorough resection of the TFCC remnants, to prepare the joint for subsequent
reconstruction.
-
b) Graft harvesting: we remove the traction and perform a wide inclined “s” approach
on the distal middle segment of the brachioradialis tendon. We make a careful dissection
respecting the branches of the superficial radial nerve. Then, we take the graft by
sectioning the tendon at the level of the proximal myotendinous junction, achieving
a graft of approximately 12 cm in length, leaving its distal insertion in the radius
intact ([Fig. 9],[10],[11])
Fig. 10 Images of the technique to harvest the brachioradialis tendon graft. (A) Graft harvesting, leaving its distal insertion fixed and up to the myotendinous
union. (B) Total length of the graft obtained after rescuing it from the distal incision. (C) Graft preparation: the graft is held fixed at its origin and divided proximally
into two strands of equal size. It is increased with FiberWire (Arthrex, Naples, FL,
US) 2.0 with a Krakow suture in each of the strands.
Fig. 11 Images of the graft preparation. (A) Division of the tendon into two strands. (B) Augmentation with FiberWire 2.0.
-
c) Tunnel carving: under arthroscopic assistance, two radial tunnels are carved from
the lateral margin of the radius 0.2 cm below the apex of the radial styloid. For
this, a guide needle is initially used, and then the canal is carved with a cannulated
drill of progressive diameter until sufficient space is achieved for an easy passage
of the graft, which is usually achieved with diameters between 2.5 and 3.0 mm. Each
tunnel leads to the dorsal ulnar and volar ulnar corners respectively. Under arthroscopic
visualization from the 6R portal, the correct position of the tunnels in the ulnar
edge of the radius is confirmed ([Fig. 12]). A bone tunnel is then made in the ulna, from the medial margin, about 2 cm below
the ulnar styloid, directed towards the foveal region, using a 3.0-mm drill bit.
Fig. 12 Carving of the radius tunnels. (A) Carving of the radial tunnels under arthroscopic view. (B) Scheme of the arthroscopic visualization of the exit of the radial tunnels through
the 6R portal.
-
d) Graft passage: under arthroscopic assistance, a grasper is passed from the 6U portal
through each of the tunnels in the radius, and the tendon graft strand is retrieved.
This step must be careful to avoid damaging the graft (it is performed from the 6U
portal and not from the 6R, since the angle of the radial tunnels does not allow it).
Subsequently, both strands of the graft are rescued from the 6U portal to the ulnar
tunnel using the lasso or loop technique, to position the graft in the fovea. ([Fig. 13])
Fig. 13 Passage of the graft through the tunnels. (A) Diagram of the passage of the graft strands from the 6U portal to the ulnar tunnel.
(B) Arthroscopic view of both graft strands in their final position.
e) Fixation of the graft in the ulna: both strands of the graft are fixed with a Fastlock-type
(GMReis, Campinas, SP, Brazil) screw at the ulnar edge, 1 cm proximal to the exit
of the tunnel ([Fig. 14]). After this step, the stability of the graft is tested thorugh arthroscopy and
the stability of the DRUJ is confirmed clinically.
Fig. 14 Graft fixation with the Fastlock system.
f) Postoperative rehabilitation: we use a removable wrist immobilizer for the first
two weeks until the removal of the skin stitches, and gentle finger exercise is recommended
since the first postoperative day. We then use an antebrachiopalmar cast for an additional
four weeks. At six weeks postoperatively, the cast is removed, and a progressive rehabilitation
scheme begins with targeted physical therapy.
Results and Patients
We have operated two patients with this technique with a follow-up longer than 2 years.
Patient 1: a 19-year-old female patient with a history of arthroscopic cleaning surgery
and TFCC stabilization of her left wrist at 14 years of age. She had persistent pain
in the ulnar region of the wrist that worsened with pronosupination activities and
axial load. The physical examination highlighted an asymmetrical lump compared to
the contralateral and positive foveal signs. The preoperative score on the Patient-Rated
Wrist Evaluation (PRWE) was of 66 (40/26). Diagnostic arthroscopy was performed, and
we found practically non-existent remaining TFCC tissue, so we decided on the previously-described
reconstruction technique with autologous brachioradialis graft. The patient evolved
favorably. At the 3-year postoperative follow-up, the patient maintained a painless
wrist, with a stable DRUJ, with return to activities without limitation. The postoperative
PRWE score was of 35 (14/21) at 4 months, of 6 (4/2) at 8 months, and of 4.5 (4/0.5)
at the completion of the 3-year follow-up ([Fig. 15]).
Fig. 15 Clinical images of patient 1.
Patient 2: a 61-year-old female patient who had long-standing pain in the ulnar edge
of the left wrist after a car rollover several years prior to consultation. She was
evaluated at another center, where ulnocarpal impingement syndrome was diagnosed,
and she underwent ulnar shortening surgery without arthroscopic visualization of the
radiocarpal joint or the DRUJ. The patient evolved with persistent pain and non-union
of the osteotomy focus. She was evaluated by our team, who observed, in addition to
the nonunion of the ulna, severe distal radioulnar instability. We decided to carry
out the management sequentially. In the first stage, the non-union was managed by
performing a new osteosynthesis, with cruentation of the non-union focus and the contribution
of a non-vascularized autologous graft, and an arthroscopic evaluation of the wrist
was carried out to evaluate the remaining TFCC tissue and to define the management
of the fracture instability once the osteotomy was consolidated. The arthroscopy showed
irreparable tissue, so the reconstruction of the TFCC was performed with the brachioradialis
technique, and the patient presented a favorable evolution in pain (score of 2/10
on the Visual Analog Scale) and in joint range ([Fig. 16]).
Fig. 16 Clinical images of patient 2.
Discussion
Chronic traumatic TFCC injuries have not been defined as such in the literature. These
are injuries that behave differently from an acute traumatic injury and from those
degenerative injuries in the context of ulnocarpal impaction syndrome.
To understand these injuries and be able to correctly manage them, it is important
to understand the aforementioned concepts. The time since the occurrence of the injury,
although it does not exactly distinguish an acute traumatic injury from a chronic
one, it indicates to us that those injuries with a longer evolution time would have
less predictable results compared to repair surgeries, such as foveal reinsertion
techniques with transosseous tunnels, in which lesions with an average evolution of
7 to 8 months have categorically better results than those with 15 to 19 months of
evolution, especially if the techniques are performed without bone scaling.[16]
[17]
[19]
[20]
The repair potential is determined by the site of the lesion, according to the areas
of irrigation of the TFCC and the quality of the remaining tissue. Patients with poor-quality
tissue, friable edges, massive lesions, or nonexistent residual tissue are deemed
to have irreparable lesions, which should be managed as such.[13] It is important to know these concepts given that, when making a surgical decision,
one must take into account that the physical examination and imaging are not sufficient
to provide an adequate estimate of the real state of the remaining tissue, and, in
the event of performing a surgical indication, one must be prepared for the different
scenarios.
It is essential to have a high clinical suspicion to deal with our patients correctly.
Advanced imaging techniques are of great diagnostic help, but the current gold standard
is arthroscopic visualization of the lesion.
To correctly indicate the management, it is imperative to carry out a correct evaluation
of the DRUJ, specifically seeking the presence of degenerative signs and osteoarthritis
and clinical and functional stabilities in activity. The repairability of the TFCC
lesion and the stability of the DRUJ are key to the correct indication of treatment.
The techniques for TFCC reconstruction are complex, but they have been shown to yield
good long-term results.[39] The arthroscopic TFCC reconstruction techniques described by Luchetti and Atzei[15] and Carratalá Baixauli et al.[41] seem to be reproducible, and good clinical results were observed in their case series.
In both cases, they follow principles similar to those of the technique herein described,
using an autologous graft, attempting to reconstruct the volar and dorsal radioulnar
ligaments, and fixing them in a tunnel at the level of the distal ulna to achieve
DRUJ stability.
The technique proposed in the present review with brachioradialis tendon graft and
arthroscopic assistance is an alternative to the previously-described techniques,
and the results in the two patients we have operated on are promising, although we
recognize that it is necessary to carry out a series with a larger number of patients
and a longer follow-up than those presented so far.
Conclusion
Chronic TFCC lesion has not been previously described as such. It requires a comprehensive
evaluation geared towards the patient to carry out the correct management. The state
of the TFCC remnants is crucial when making surgical decisions, and it will be affected
by the time since the occurrence of the injury and its repair potential. Arthroscopy
seems to be essential to perform a correct evaluation of the TFCC and guide the surgical
technique. The proposed arthroscopy-assisted reconstruction technique is a therapeutic
alternative with good results.
