Arthroscopic algorithm for acute traumatic triangular fibrocartilage complex (TFCC) tears

Arthroscopic repair of a peripheral triangular fibrocartilage complex (TFCC) tear is a promising, minimally invasive surgical technique, especially in patients with symptomatic distal radioulnar joint (DRUJ) instability. The purpose of this study was to evaluate the clinical result of arthroscopic one-tunnel transosseous foveal repair for peripheral TFCC tears. Sixteen patients who underwent TFCC foveal repair were retrospectively evaluated. The mean follow-up period was 31.1months. The torn TFCC of all patients was repaired with the arthroscopic one-tunnel transosseous foveal repair technique. Postoperative outcomes were evaluated using the visual analogue scale (VAS) for pain, wrist range of motion, grip strength, Mayo wrist score, Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH) score, and postoperative complications. On arthroscopic examination, all 16 patients showed Palmer 1B type peripheral TFCC tears with foveal disruption. Among them, 13 patients had a proximal component TFCC tear (Atzei class 3) and 3 patients had a complete TFCC tear (Atzei class 2). At the final follow-up, the mean range of the pronation-supination arc (P = 0.03) and grip strength (P = 0.001) was significantly increased. Twelve patients had normal stability of the DRUJ and six patients showed mild laxity compared with the contralateral side. The mean VAS for pain perception decreased from 3.7 to 0.8 (P = 0.001). The modified Mayo wrist (P = 0.001) and Quick DASH (P = 0.001) scores showed significant functional improvement. No surgery-related complications occurred. The present study shows that arthroscopic one-tunnel transosseous repair is a good treatment strategy for TFCC foveal tears in terms of reliable pain relief, functional improvement, and re-establishment of DRUJ stability.

PurposePersistent ulnar-sided wrist pain, often because of triangular fibrocartilage complex (TFCC) tears, can lead to instability of the distal radioulnar joint (DRUJ) and the ulnocarpal joint (UCJ). Although the TFCC's role in stabilizing the DRUJ is well established, its contribution to UCJ stability has gained increasing recognition. This study evaluates the clinical outcomes of combined Herbert Sling and suture repair for (UCJ) instability secondary to TFCC tears.MethodsEighty-eight patients (91 wrists) with TFCC tears and UCJ instability, unresponsive to nonsurgical management, underwent combined Herbert sling (HS) and suture repair. The HS technique stabilizes both the DRUJ and UCJ by advancing an extensor retinaculum flap to the radius. Suture repair for the TFCC was performed using a commercially available all-inside-repair device. Postoperative care involved immobilization followed by structured rehabilitation. Outcomes were assessed at 6 months and 1 year and included visual analog scale pain scores, range of motion, and supination test results.ResultsVisual analog scale pain scores improved considerably from 4.5 before surgery to 1.1 at 6 months, with sustained improvement at 1 year. The flexion-extension arc decreased from 133° before surgery to 113° at 6 months but returned to 135° at 1 year. The pronation-supination arc decreased slightly from 177° to 171° at 6 months, with full recovery by 1 year. Supination testing showed a considerable improvement in UCJ stability, with 92% of wrists stable at 6 months and 87% stable at 1 year. Four wrists experienced recurrent instability between 6 months and 1 year.ConclusionsThe combined HS and suture repair effectively restores stability to both the DRUJ and UCJ in patients with TFCC-related ulnocarpal instability, considerably reducing pain and preserving range of motion. This technique provides a promising approach to the treatment of ulnocarpal instability while minimizing tissue disruption.Type of study/level of evidenceTherapeutic IV.

Triangular fibrocartilage complex (TFCC) tears, whether acute or chronic, can result in persistent ulnar-sided wrist pain. Although diagnosis and nonsurgical management of TFCC tears is well described, there remains ongoing discussion about the optimal surgical technique, specifically open or arthroscopic. This article reviews the most up-to-date literature regarding TFCC injury including demographics, risk factors for TFCC injury, classification of acute and chronic TFCC tears, history and physical examination, appropriate diagnostic imaging, surgical indications, pertinent surgical anatomy, open and arthroscopic TFCC repair, fixation biomechanics and techniques, postoperative rehabilitation, and clinical outcomes.

Distal radioulnar joint (DRUJ) instability is a common yet underdiagnosed cause of ulnar-sided wrist pain, often associated with triangular fibrocartilage complex (TFCC) injuries. Clinical assessment of DRUJ instability is challenging due to the limited reliability of existing tests. This study introduces the wind off test (WOT) as a novel clinical test for detecting TFCC tears and evaluates its diagnostic accuracy compared to arthroscopic findings. A retrospective audit was conducted on patients who underwent diagnostic wrist arthroscopy over 12 months. The WOT result (positive or negative) was compared with arthroscopically confirmed TFCC tears. Sensitivity, specificity, positive predictive value (PPV), negative predictive value, and diagnostic accuracy were calculated. Patients without a recorded WOT result preoperatively were excluded. About 79 patients met the inclusion criteria for this study. Of these, 76 had a TFCC tear confirmed at arthroscopy. The WOT demonstrated a sensitivity of 92.1%, a specificity of 0.0%, a PPV of 95.9%, and a diagnostic accuracy of 88.6%. Notably, all patients without a TFCC tear had a positive WOT, resulting in no true negatives. The WOT is a highly sensitive test for detecting TFCC tears but lacks specificity, leading to false positives. While the test may serve as a useful screening tool, it should be interpreted alongside other clinical findings, imaging studies, and arthroscopy when necessary. Further prospective studies are needed to assess interobserver reliability and compare the WOT with existing clinical tests for TFCC tears.

Background:Tears of the triangular fibrocartilage complex (TFCC) can result in instability of the distal radioulnar joint (DRUJ) and ulnar-sided wrist pain. This study evaluates clinical results of arthroscopic transosseous repair for both proximal and distal components of TFCC tear with DRUJ instability.Materials and Methods:Ten patients who underwent both proximal component and distal component of TFCC repair were retrospectively reviewed. The proximal component of TFCC was repaired through arthroscopic one-tunnel transosseous suture technique, and the combined distal component tear was repaired to the ulnar capsule using same transosseous tunnel in all cases. Visual analog scale (VAS) score for pain, wrist range of motion, grip strength, and postoperative complications were evaluated after a mean followup period of 23.5 months, and each patient was rated according to modified Mayo wrist score and quick disabilities of the arm, shoulder, and hand (DASH) questionnaire.Results:On arthroscopic findings, the hook test confirmed the proximal component of the TFCC tear and visible capsular detachment from TFCC confirmed combined distal component tear in all patients. At final followup, 7 patients had normal stability of DRUJ and 3 patients showed mild laxity compared with the contralateral side. The mean VAS for pain perception decreased from 4.1 to 0.7, and grip strength was increased significantly. The modified Mayo wrist score and Quick DASH score showed significant functional improvement. No surgery-related complications occurred.Conclusions:Arthroscopic one-tunnel transosseous TFCC foveal repair and simulatneous transosseous capsular repair of distal component can be a safe and effective strategy for repair of complete TFCC tear combined with DRUJ instability.

The purpose of this study was to assess the effects of traction during MR arthrography of the wrist on joint space widening, cartilage visibility, and detection of tears of the triangular fibrocartilage complex (TFCC) and intrinsic ligaments. A prospective study included 40 wrists in 39 patients (25 men, 14 women; mean age, 35 years). MR arthrography was performed with a 3-T MRI system with and without axial traction. Two radiologists independently measured wrist and carpal joint space widths and semiquantitatively graded articular cartilage visibility. Using conventional arthrography as the reference standard and working in consensus, they assessed for the presence of tears of the TFCC, lunotriquetral ligament (LTL), and scapholunate ligament (SLL). Visibility of a tear before traction was compared with visibility after traction. With traction, all joint spaces in the wrist and carpus were significantly widened (change, 0.15-1.01 mm; all p < 0.006). Subjective cartilage visibility of all joint spaces improved after traction (all p ≤ 0.048) except for that of the radioscaphoid space, which was well visualized even before traction. Conventional arthrography depicted 24 TFCC tears, seven LTL tears, and three SLL tears. The accuracy of tear detection improved after traction for the TFCC (98% after traction vs 83% before traction), the LTL (100% vs 88%), and the SLL (100% vs 95%). Tear visibility improved after traction for 54% of TFCC tears, 71% of LTL tears, and 66% of SLL tears. Wrist MR arthrography with axial traction significantly improved the visibility of articular cartilage and the detection and visibility of tears of the TFCC and intrinsic ligaments. The results favor more widespread use of traction during MR arthrography of the wrist.

Objective To evaluate the effect of wrist arthroscopy-assisted repair of stable or slightly unstable type I B triangular fibrocartilage complex (TFCC) injury of distal radio-ulnar joint (DRUJ). Methods A retrospective case series study was conducted to analyze the clinical data of 42 patients with type I B TFCC injuries admitted from May 2015 to August 2017, including 17 males and 25 females, aged 18-64 years, with an average of 38 years. Among the patients, 20 were injured on the left side, and 22 on the right side. During the operation, if the injury was diagnosed as type I B injury under wrist arthroscopy, outside in method with 3-0 purdis stitch was adopted to repair TFCC after joint cleaning. After the operation, the wrist joint was fixed in a neutral rotation position for 3 weeks with a long arm plaster over the elbow and then replaced with a short arm plaster for 2-3 weeks. Visual analogue scale (VAS), grip strength, joint mobility, modified Mayo wrist function score, and disabilities of arm, shoulder and hand score (DASH) before operation and at the last follow-up were compared. Results All patients were followed up for 6-24 months, with an average of 11 months. No infection or nerve injury occurred after operation. At the last follow up, wrist pain disappeared in 13 cases completely, while 29 cases still had pain during moderate activities. VAS was decreased from preoperative (2.7±0.9) points to (1.2±1.0) points (P 0.05), (40.0±10.6)°(P<0.05), and (148.9±21.4)°(P<0.05). The modified Mayo wrist function score increased from preoperative (67.3±9.6)points to postoperative (84.4±6.7)points. The results were excellent in 13 cases, good in 24, and fair in five, with an excellent and good rate of 88%. The DASH score decreased from (34.6±10.2)points to (10.4±6.5)points after operation (P<0.05). Conclusion For patients with stable or slightly unstable type IB TFCC injury of DRUJ, synovial membrane cleaning under wrist arthroscopy plus capsule repair combined with active rehabilitation training can effectively reduce wrist pain, and improve wrist radial ulnar deviation, forearm rotation and grip strength as well as improve wrist joint function. Key words: Wrist injuries; Arthroscopy; Triangular fibrocartilage; Surgical procedures, minimally invasive

The purpose of this study was to report our experience of wrist arthroscopy in children and adolescents with chronic wrist pain in a retrospective single surgeon series. Therefore, technical differences or obstacles compared to standard wrist arthroscopy in adults, and complications were highlighted. A retrospective data review of all patients undergoing wrist arthroscopy between 2002 and 2011 was performed. The basic inclusion criteria was chronic, therapy refractory wrist pain for more than three months in children and adolescents aged 18 years and younger. In total, 34 arthroscopies in 27 girls and six boys were reviewed. The mean age at time of arthroscopic exploration was 14.6 years (range, 9.8-17.9 years). A total of 28 wrists showed a triangular fibrocartilage complex (TFCC) tear (82.4%). In 26 of 34 (76.5%) inspected wrist joints additional pathologies besides TFCC tears were documented. As a consequence, 14 arthroscopic TFCC resections, two arthroscopic TFCC repairs and seven open resection arthroplasties were performed. Other concomitant procedures (e.g., ulna shortening) were performed in 25 patients (26 wrists) because of predisposing malformations. No intraoperative or postoperative complications related to the arthroscopies were observed. No relevant technical differences to wrist arthroscopy in adults were experienced apart from cases of major anatomical malformations. Wrist arthroscopy has been shown to be a safe procedure to detect and treat paediatric wrist disorders. Nevertheless, we believe that this procedure should only be carried out by well-trained, experienced hand surgeons.

This study compares the diagnostic performance of multidetector CT arthrography (CTA), conventional 3-T MR and MR arthrography (MRA) in detecting intrinsic ligament and triangular fibrocartilage complex (TFCC) tears of the wrist. Ten cadaveric wrists of five male subjects with an average age 49.6years (range 26-59years) were evaluated using CTA, conventional 3-T MR and MRA. We assessed the presence of scapholunate ligament (SLL), lunotriquetral ligament (LTL), and TFCC tears using a combination of conventional arthrography and arthroscopy as a gold standard. All images were evaluated in consensus by two musculoskeletal radiologists with sensitivity, specificity, and accuracy being calculated. Sensitivities/specificity/accuracy of CTA, conventional MRI, and MRA were 100%/100%/100%, 66%/86%/80%, 100%/86%/90% for the detection of SLL tear, 100%/80%/90%, 60%/80%/70%, 100%/80%/90% for the detection of LTL tear, and 100%/100%/100%, 100%/86%/90%, 100%/100%/100% for the detection of TFCC tear. Overall CTA had the highest sensitivity, specificity, and accuracy among the three investigations while MRA performed better than conventional MR. CTA also had the highest sensitivity, specificity, and accuracy for identifying which component of the SLL and LTL was torn. Membranous tears of both SLL and LTL were better visualized than dorsal or volar tears on all three imaging modalities. Both CT and MR arthrography have a very high degree of accuracy for diagnosing tears of the SLL, LTL, and TFCC with both being more accurate than conventional MR imaging.

Injuries of the triangular fibrocartilage complex (TFCC), particularly those involving the foveal insertion, may lead to significant ulnar-sided wrist pain, grip weakness, dysfunction, and progressive degenerative changes within the distal radioulnar joint (DRUJ). Arthroscopic repair is the preferred surgical approach for peripheral TFCC tears requiring intervention. Multiple techniques have been described to address the peripheral and/or foveal attachments of the TFCC. This report presents an arthroscopic repair method that concurrently addresses both foveal and peripheral TFCC tears using a single combined suture construct. This approach has the potential to enhance the stability of TFCC fixation and improve overall DRUJ stability.

Background Proximal horizontal tears of the triangular fibrocartilage complex (TFCC) represent the tears at the proximal surface of the articular disk with a normal appearance of the distal surface. Preoperative diagnosis of TFCC flap tears is challenging. Objectives This report aims to present a diagnostic method using computed tomography (CT) arthrography for the proximal horizontal flap tears of the TFCC and to report our clinical outcomes. Patients and Methods Six patients were included who were preoperatively suspected to have proximal horizontal flap tears of the TFCC via CT arthrography. Arthrography was conducted by injecting dye into the distal radioulnar joint (DRUJ), and CT images were obtained immediately following arthrography. We performed arthroscopic or direct flap debridement with concomitant surgeries: ulnar shortening with positive ulnar variance and corrective osteotomy with the malunion following distal radius fracture. Results Preoperative CT arthrography clearly revealed the flaps to be flipped over toward the radiopalmar side of the DRUJ in four cases and a teardrop-shaped dye defect in two. We were able to identify the dislocated flap by arthroscopy avulsed from the proximal aspect of the articular disk within the DRUJ in all six cases. The mean pain level decreased from 10 preoperatively to 0.3 postoperatively on the visual analog scale. The mean patient-rated wrist evaluation score decreased from 43.5 preoperatively to 11.2 postoperatively. Conclusions Our study shows that CT arthrography can be a promising method for diagnosing proximal horizontal flap tears of the TFCC. Debridement of the flaps and concomitant surgeries showed satisfactory clinical results. Level of Evidence This is a Level 4, diagnostic study.

Introduction: Paediatric distal radius fractures are considered benign, and associated ulnar styloid injury is mostly ignored. Although a significant portion evolves to non-union, only a minority present associated complications such as ulnar pain, ulnocarpal abutment, or distal radio-ulnar instability. Distal radio-ulnar dislocations are rare and point to failure of the stabilizing mechanisms of this joint, warranting urgent reduction. Case Report: 18-years old male presents to the emergency department with a volar distal radio-ulnar joint dislocation after a twisting motion of the left wrist. Patient was submitted to urgent closed reduction under general anesthesia and cast immobilization, and surgical repair of ulnar styloid non-union and triangular fibrocartilage complex tear was performed 1 week later. At 6 months follow up the patient as achieved pain free full mobility without instability. Conclusion: The triangular fibrocartilage complex and distal radio-ulnar joint may be affected by seemingly benign injuries, later presenting with acute complications. Fracture and subsequent non-union of the ulnar styloid in the setting of a distal radius fracture is common and underdiagnosed, but clinical significance of and optimal treatment of this injury are still undefined.

The purpose of this article is to illustrate MRI examples of acute triangular fibrocartilage complex (TFCC) injuries following the Palmer classification, including subtypes of the acute traumatic injuries originally described. In the discussion of these athletic TFCC injuries, recent studies and references are discussed with regard to implications in diagnosis and treatment. The article also reviews the role of ulnar abutment in degenerative injury to the TFCC and surgical approaches to correction. Recent findings regarding the role of the TFCC in distal radioulnar joint stability (DRUJ) and the importance of MRI in preoperative planning of the wrist are reviewed. New studies emphasizing the importance of repair of partial tears of the foveal attachment of the TFCC, the association of TFCC tears with distal radius fractures, and wafer procedures are also discussed. Injuries of the triangular fibrocartilage complex (TFCC) are commonplace in athletes across multiple sports. The TFCC acts to cushion forces transmitted from the ulnar side of the wrist to the upper extremity. Athletic activities tend to deliver an increased axial load and greater twisting motion upon the wrist. The Palmer classification system for TFCC injuries was first introduced in 1989, but is still used for both acute traumatic and degenerative injuries of the TFCC. MRI plays a pivotal role in diagnosing and classifying athletic injuries of the TFCC, helping guide orthopedists and hand surgeons in caring for patients with ulnar-sided wrist pain.

Background: The clinical picture of ulnar-sided wrist pain is oftentimes confusing because various pathologies may be coexistent. In this study, we aimed: (1) to compare the prevalence of potential causes of ulnar-sided wrist pain on magnetic resonance imaging (MRI) in patients who underwent triangular fibrocartilage complex (TFCC) repair and control subjects: and (2) to evaluate whether inferior clinical results were associated with specific patient characteristics or other potential causes of ulnar-sided wrist pain. Methods: We included 67 patients who underwent a TFCC repair and 67 control subjects. The MRI scans were examined for sources of ulnar-sided wrist pain. After TFCC repair, 42 patients (63%) completed surveys, including Quick Disabilities of the Arm, Shoulder and Hand and pain scores. Bivariate analysis was performed to compare our groups and to identify factors associated with our outcomes. Results: We found significantly higher rates of distal radioulnar joint (DRUJ) arthritis (P = .033), extensor carpi ulnaris (ECU) pathology (P = .028), and ulnar styloid fractures (P = .028) in patients with TFCC repairs. With increasing age, increasing pathology in the pisotriquetral joint (P = .040), more ulnocarpal abutment (P = .0081), and more degenerative tears (P < .001) were seen in both groups. No demographic characteristics or MRI findings were significantly associated with our outcomes. Conclusions: We observed higher rates of DRUJ arthritis and ECU pathology in patients with TFCC tears undergoing repair compared with age- and sex-matched controls. This may be due to damage to the TFCC itself altering relationships of the DRUJ and the ECU subsheath, or it may reflect various pathologies that cause ulnar-sided wrist pain and drive patients toward surgery.

As the importance of the foveal attachment of the triangular fibrocartilage complex (TFCC) on the stability of the distal radioulnar joint (DRUJ) is emphasized, the traditional repair techniques such as arthroscopic capsular repair for the 1B TFCC tear become accepted as ineffective method for treating DRUJ instability. Recently, several techniques which repair the TFCC directly to the ulnar fovea have been developed and introduced. Further advances of the techniques will be expected with increasing knowledge of the anatomy and biomechanics of the TFCC and DRUJ. Regardless of the techniques, fundamental principle of anatomical repair of the TFCC to the ulnar fovea is utmost important. Herein we present our technique of arthroscopic transosseous repair by making a drill hole in the ulnar and securing the sutures with Pushlock anchors.