67: Arthroscopic Triangular Fibrocartilage Complex Repair

Procedure 67 Arthroscopic Triangular Fibrocartilage Complex Repair



William B. Geissler, Daniel C.M. Williams


imageSee Video 49: Arthroscopic TFCC Repair



Indications




image Traumatic peripheral ulnar tears of the triangular fibrocartilage complex (TFCC)



Examination/Imaging



Clinical Examination




image Patients complain of pain with twisting of the wrist, such as opening jars or doors.


image They may have pain over the prestyloid recess with hyperpronation and supination of the forearm and have point tenderness at the prestyloid recess.


image In more severe injuries to the TFCC, instability of the distal radial ulnar joint may be appreciated. The distal ulna may lie more dorsal in relation to the radius compared with the opposite side, and patients may have increased anterior and posterior translation of the distal ulna in relation to the radius.



Imaging




image Plain radiographs with the wrist in neutral position are mandatory to assess the relationship of the ulna to the radius. In patients who are markedly ulnar positive, the treating surgeon may consider repair, ulna shortening, or a combination of both.


image Wrist arthrograms frequently will yield false-negative results. This is because synovitis resulting from the tear will cover up the peripheral lesion.


image Magnetic resonance imaging is specific and sensitive for detection of peripheral ulnar tears to the TFCC.



Surgical Anatomy




image The TFCC is a complex soft tissue support system that stabilizes the ulnar side of the wrist and also serves to extend the articular surface of the radius to support the proximal carpal row. As described by Palmer, it is composed of the fibrocartilage articular disk, the volar and dorsal radioulnar ligaments, the meniscus homolog, and the floor of the ECU tendon sheath.


image The ulnar aspect of the articular disk has two main bundles. One bundle inserts on the ulnar styloid, and the second bundle inserts at its base. The deep bundle is called the ligamentum subcruentum. The deep bundle of the articular disk is not visible arthroscopically. With pronation and supination of the forearm, the superficial and deep layers lie opposite each other.


image The arterial blood supply of the TFCC has been thoroughly studied. Thiru evaluated 12 cadaver specimens using latex injections. The ulnar artery supplies most of the blood to the ulnar portion of the TFCC through its dorsal and palmar radiocarpal branches. Thiru documented a complex of vessels that supplies the peripheral 15% to 20% of the articular disk. A similar study by Bedner and colleagues of 10 cadavers found penetration of vessels into the peripheral 10% to 40% of the articular disk. These studies confirm intact blood supply to the periphery of the articular disk with a potential to heal when repaired.



Positioning




image The wrist is suspended with about 10 pounds of traction in a traction tower (Fig. 67-1).


image The wrist is slightly flexed 10 to 20 degrees to allow easier access of the arthroscope and instrumentation. A small joint arthroscope (≤2.7 mm) is used. Small joint arthroscopy instrumentation is recommended. Large joint instrumentation is not appropriate for wrist arthroscopy.


image For the outside-in technique, an 18-gauge needle, 2-0 PDS suture, and a suture retriever are all that are needed.


image For the all-arthroscopic knotless technique, the Arthrex TFCC repair kit is required.


image

FIGURE 67-1



Exposures




image The arthroscope is in the 3-4 portal. A working 6R portal is made (Fig. 67-2).


image For the outside-in technique, following arthroscopic evaluation of the wrist, the 6R portal is elongated to about 2 cm in length along the radial border of the ECU tendon sheath. The tendon sheath is then opened, and the ECU tendon is retracted ulnarly.


image For the all-arthroscopic knotless technique, the arthroscope is in the standard 3-4 viewing portal, and the standard working 6R portal is made. An accessory 6-R portal is made about 1.5 cm distal to the 6R portal.


image The accessory 6R portal is made in line with the 6R portal and identified by using an 18-gauge needle to palpate the base of the ulna at the ulnar styloid.


image

FIGURE 67-2



Pearls




When incising the ECU tendon sheath for the outside-in technique, it is important to use sharp dissection through the sheath so that there will be a good layer to close to avoid instability to the ECU tendon.


Initial arthroscopic evaluation may not reveal a peripheral tear. It is important to palpate the articular disk with a probe to assess tension of the disk. If there is loss of normal tension, a peripheral tear is highly suspected.


Frequently, synovitis will cover up the peripheral tear. It is important to shave away the synovitis to evaluate for separation of the articular disk from the capsule.



Pitfalls




When exposing the ECU tendon sheath, it is important to use blunt dissection to identify the transarticular branch of the dorsal sensory branch of the ulnar nerve. Frequently, this small nerve branch runs across the surgical field and should be retracted to avoid a potentially painful neuroma in this area.


It is important when making arthroscopy portals to incise the skin only by pulling the skin with the thumb against the tip of a no. 11 blade (Fig. 67-3). Blunt dissection is carried out with a hemostat to the joint capsule. The arthroscope is introduced with a blunt trocar in the 3-4 portal. In this manner, injury to the superficial cutaneous nerves and the articular cartilage can be avoided.


image

FIGURE 67-3



Procedure




Step 1




image Palmer type IB peripheral ulnar tears are amenable to arthroscopic repair. The tear usually presents on the dorsal ulnar aspect of the articular disk just ulnar to the 6R portal. The arthroscope is in the traditional 3-4 viewing portal, and a 6R portal is made just radial to the ECU tendon. Synovitis about the periphery of the articular disk is débrided to visualize the tear.


image The articular disk is palpated with a probe to verify loss of tension to the articular disk (Fig. 67-4).


image

FIGURE 67-4



Step 1 Pearls




It is important to assess the entire wrist from both the radiocarpal and midcarpal portals. A portion of the greater injury to the ulnar side of the wrist involves the lunotriquetral interosseous ligament. The lunotriquetral interosseous ligament cannot be well visualized with the arthroscope in the 3-4 portal and needs to be visualized with the arthroscope in the 6R portal.


In addition, the midcarpal space should be further evaluated for midcarpal instability.


Subluxation of the ECU tendon is usually associated with a peripheral tear to the articular disk. If subluxation is suspected, the wrist is arthroscopically evaluated for a peripheral ulnar tear to the articular disk.



Step 1 Pitfalls


Related posts:

34: Reconstruction of the Central Slip with the Transverse Retinacular Ligament for Boutonnière Deformity 32: Crossed Intrinsic Tendon Transfer 26: Reconstruction of Key Pinch in Tetraplegia Patients 33: Correction of Swan-Neck Deformity in the Rheumatoid Hand 50: Open Reduction and Internal Fixation of Phalangeal Shaft Comminuted Fractures 30: Synovectomy

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Mar 5, 2016 | Posted by in Hand surgery | Comments Off on 67: Arthroscopic Triangular Fibrocartilage Complex Repair

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