Open and Arthroscopic Triangular Fibrocartilage Complex (TFCC) Repair.

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.

The triangular fibrocartilage complex (TFCC) plays a crucial role in stabilizing the distal radioulnar joint; TFCC injuries commonly cause ulnar-sided wrist pain and functional impairment of the hand. Arthroscopic wrist surgery is an effective and minimally invasive treatment option; however, domestic reports remain limited. Therefore, we conducted the study entitled “Preliminary outcomes of arthroscopic wrist surgery for the repair of traumatic triangular fibrocartilage complex injuries” with the aims of describing the clinical and paraclinical characteristics of TFCC injuries and evaluating treatment outcomes following arthroscopic wrist surgery. Subject and Methods: A total of 15 patients aged 18 years and older with triangular fibrocartilage complex (TFCC) injuries were included in this study. The diagnosis was confirmed through clinical examination, wrist X-ray, and MRI. Patients underwent arthroscopic TFCC repair at Thong Nhat Hospital from June 2021 to June 2024. Results:The study cohort consisted predominantly of female patients, with a mean age of 36.8 ± 9.14 years, the right wrist was the most commonly affected side, with household accidents being the primary cause of injury, palmer type IB TFCC injury was the most frequently observed type, the mean surgical time was 62 ± 15 minutes, the mean hospital stay was 4.4 ± 1.24 days, the VAS pain score significantly improved from 6.01 ± 0.88 preoperatively to 0.36 ± 0.63 at 6 months postoperatively (p<0.05), the MMWS score improved from 45.33 ± 3.52 to 91 ± 5.07 at 6 months postoperatively (p<0.05). Conclusion: arthroscopic TFCC repair is a minimally invasive, effective, and safe surgical approach that alleviates pain and restores wrist function.

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.

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.

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.

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

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.

Cardiopulmonary resuscitation (CPR) is physically demanding and may result in work-related musculoskeletal injuries in healthcare providers. We report a case of triangular fibrocartilage complex (TFCC) and dorsal distal radioulnar ligament injuries sustained by an orthopedic resident during prehospital CPR events, to increase awareness of this underrecognized occupational hazard. A 31-year-old orthopedic resident performed prolonged CPR twice in one shift and subsequently developed marked tenderness, instability, and pain in the left wrist with pronation, as well as a sensation of clicking subluxation. A second physician recalled persistent wrist pain after CPR in previous years. Imaging demonstrated a tear of the TFCC and dorsal distal radioulnar ligament as well as joint effusion and extensor carpi ulnaris sheath edema in the affected wrist. The retrospective magnetic resonance imaging of the second physician indicated chronic TFCC change. Conservative management with nonsteroidal anti-inflammatory drugs, plaster splint immobilization, and subsequent wrist bracing was implemented for the resident; self-treatment with nonsteroidal anti-inflammatory drugs and wrist brace was reported by the second physician. The orthopedic resident achieved resolution of instability after 6 weeks with restoration of full wrist motion and strength by 2 years. The second physician's symptoms persisted for 2 years before mostly resolving. Musculoskeletal injuries, including TFCC and distal radioulnar ligament tears, may occur in CPR providers but are often underrecognized and underreported. Early recognition, appropriate management, and preventive strategies such as alternating roles, prompt initiation of automated compression devices, and ergonomic device placement may mitigate injury risks. Encouraging timely reporting and self-care among healthcare professionals is essential for provider well-being and care quality.

The distal radioulnar joint (DRUJ) is stabilized by the bony anatomy of the contact surfaces. The authors analyzed the morphologic characteristics and radiologic parameters at the sigmoid notch of patients with a peripheral triangular fibrocartilage complex (TFCC) tear compared with asymptomatic patients. Preoperative axial computed tomography scans were reviewed for 76 wrists with peripheral TFCC injuries, including foveal avulsion, and 76 wrists of age- and sex-matched control subjects. The authors used axial computed tomography scans of the DRUJ to classify the patients into 4 groups according to the type of sigmoid notch, namely, flat face, ski-slope, C-type, and S-type. They also measured the tilting angle, depth, width of the sigmoid notch, and radioulnar ratio (RUR). Statistical analyses were performed with the chi-square test or paired t test (P<.05). The mean proportions of flat face, ski-slope, C-type, and S-type sigmoid notches among patients with peripheral TFCC injuries were 42%, 22%, 29%, and 7%, respectively, whereas those for the control group were 33%, 1%, 65%, and 1%, respectively (P<.05). The tilting angle was lower (TFCC injury, 84.5°; control, 86.2°; P<.05) and the RUR was significantly higher (TFCC injury, 0.67; control, 0.56) in the TFCC group, particularly for men (P<.05). Depth (TFCC injury, 1.0 mm; control, 1.3 mm; P>.05) and width (TFCC injury, 14.8 mm; control, 14.5 mm; P>.05) were similar between the groups. Patients with ski-slope or dorsally tilted sigmoid notches may be at greater risk for peripheral TFCC injuries. [Orthopedics. 2021;44(6):e729-e734.].

Background Magnetic resonance (MR) is the most important imaging technique to assess intra-articular pathology of the wrist. Among various MR imaging protocols, the diagnostic performance of indirect MR arthrography needs further investigation. Purpose The purpose of this study was to assess the diagnostic performance of pre- and postcontrast, 3 T indirect MR arthrography in the diagnosis of scapholunate intrinsic ligament (SLIL) and triangular fibrocartilage complex (TFCC) injuries, using wrist arthroscopy as reference standard. Patients and Methods We retrospectively evaluated consecutive patients with suspected SLIL or TFCC injury, who had indirect MR arthrography done before arthroscopy. Images were assessed independently by two senior radiologists. Results Arthroscopy of the 53 wrists demonstrated 16 Geissler stages II and III partial tears and 6 stage IV total SLIL ruptures. Central perforation of the TFCC was found in 24 wrists, and 12 wrists had an ulnar class 1B lesion. To detect any SLIL tear, accuracy was higher for the two observers using postcontrast indirect MR arthrography (0.77 and 0.72) than for precontrast MR imaging (0.60 and 0.60). No difference was found for total SLIL ruptures "0.85 and 0.89" versus "0.85 and 0.89." To diagnose class 1B TFCC injuries, accuracy was higher using postcontrast indirect MR arthrography (0.85 and 0.75) than for precontrast MR imaging (0.70 and 0.72). No difference in accuracy was demonstrated for TFCC central tears "0.75 and 0.75" versus "0.70 and 0.77." Conclusion Postcontrast images at 3 T indirect MR arthrography, compared with precontrast images, have an improved diagnostic performance for the overall detection of SLIL injuries and as well as class 1B TFCC tears. Level of Evidence This is a Level II, diagnostic study.

Objectives: We evaluated the functional results of treatment in 55 patients who were found to have Triangular Fibrocartilage Complex (TFCC) tears during wrist arthroscopy.Methods: A total of 104 patients with chronic wrist pain underwent arthroscopic evaluation, during which 55 patients showed TFCC injuries. Primary suturing (n=2) and TFCC debridement (n=53) were performed. The functional results were evaluated using a modified Mayo scale.Results: Functional mean scores with modified Mayo scale were 47 and 74 before and at the end of the treatment, respectively. Excellent, good, moderate, and fair results were obtained in 30 (54%), 17 (31%), six (11%), and two (4%) patients, respectively.Conclusion: Arthroscopic surgery appears to be the best method of treatment in TFCC injuries.

Background: Managing ulnar wrist pain without ulnar plus variance presents a clinical challenge. This study aimed to compare the causes of symptom onset and surgical outcomes between arthroscopic triangular fibrocartilage complex (TFCC) repair and ulnar shortening osteotomy (USO) and analyse factors influencing pain reduction following arthroscopic TFCC repair. Methods: Twenty-four patients without ulnar plus variance who underwent either arthroscopic TFCC repair or USO at our institution were retrospectively reviewed. Demographic data, symptom onset causes, time from onset to surgery, pre- and postoperative range of motion (ROM), grip strength ratio (injured to uninjured wrist), numeric pain rating scale (NRS), change in NRS and Hand20 scores were compared between the two treatment groups. For TFCC repair, correlations were investigated between NRS change and time from onset to surgery and between NRS change and age. Results: Of 24 patients, 14 underwent arthroscopic TFCC repair and 10 underwent USO. Only two patients in the USO group had no clear onset trigger, whereas most had identifiable triggers. Both groups showed no significant differences in pre- and postoperative ROM, grip strength ratio, NRS and Hand20 score. The change in NRS was significantly greater in the USO group (p = 0.049). For the TFCC repair group, NRS change was significantly negatively correlated with age (Spearman's rank correlation coefficient -0.603, p = 0.029). Conclusions: Our findings indicate that patients without ulnar plus variance who experience symptom onset including trauma often have an underlying degenerative component as well as instability. USO provides significant pain relief in such cases. Arthroscopic TFCC repair was effective in young patients in whom instability was the primary cause of pain and age was associated with pain reduction rather than time from onset to surgery. Effective treatment strategies for ulnar wrist pain without ulnar plus variance should consider both age and wrist arthroscopy findings to optimise outcomes. Level of Evidence: Level IV (Therapeutic).

To compare the short-term effectiveness of arthroscopic suture of triangular fibrocartilage complex (TFCC), arthroscopic suture of TFCC combined with open reduction and internal fixation, and simple open reduction and internal fixation in the treatment of distal radius fractures combined with ulnar styloid base fractures and TFCC injury. A clinical data of 97 patients with distal radius fractures combined with ulnar styloid base fracture and TFCC injury, who were admitted between September 2019 and September 2022 and met the selective criteria, was retrospectively analyzed. After reduction and internal fixation of distal radius fractures, 37 cases underwent arthroscopic suture of TFCC (TFCC group), 31 cases underwent arthroscopic suture of TFCC combined with open reduction and internal fixation of ulnar styloid base fractures (combination group), and 29 cases underwent simple open reduction and internal fixation of ulnar styloid base fractures (internal fixation group). There was no significant difference in baseline data between groups ( P>0.05), such as gender, age, injury side, time from injury to operation, and preoperative radius height, palm inclination, ulnar deviation, grip strength, wrist range of motion (ROM) in rotation, ulnar-radial deviation, and flexion-extension. The differences (change value) in radius height, metacarpal inclination angle, ulnar deviation angle, grip strength, and wrist ROM in rotation, ulnar-radial deviation, and flexion-extension between preoperative and 12 months after operation in 3 groups were compared. The effectiveness was evaluated according to the modified Gartland-Werley score at 12 months after operation. All incisions healed by first intention. All patients were followed up 12-18 months (mean, 14 months). X-ray films showed that there were 4 patients with non-union of ulnar styloid base fracture in TFCC group, and the remaining patients had fracture healing at 3 months after operation. The radius height, palm inclination, and ulnar deviation of 3 groups at 12 months after operation were significantly better than those before operation ( P<0.05); however, the differences in the change values of the above indexes between groups was not significant ( P>0.05). At 12 months after operation, the change values of wrist ROM in rotation, ulnar-radial deviation, and flexion-extension in the TFCC group and the combination group were significantly greater than those in the internal fixation group ( P<0.05), and there was no significant difference between the TFCC group and the combination group ( P>0.05). The change values of grip strength was significantly greater in the combination group than in the internal fixation group ( P<0.05); there was no significant difference between the other groups ( P>0.05). The excellent and good rates according to the modified Gartland-Werley score were 91.89% (34/37), 93.54% (29/31), and 72.41% (21/29) in the TFCC group, the combination group, and the internal fixation group, respectively. The excellent and good rates of the TFCC group and the combination group were significantly higher than that of the internal fixation group ( P<0.05); there was no significant difference between the TFCC group and the combination group ( P>0.05). For ulnar styloid base fractures with TFCC injury, compared with simple open reduction and internal fixation, arthroscopic suture of TFCC or suture TFCC combined with internal fixation treatment are both beneficial for wrist function recovery, and their short-term effectiveness are similar. Therefore, arthroscopic suture of TFCC may be a better choice.

삼각 섬유성 연골(TFCC) 손상 환자의 평가를 위하여 fat suppressed 3D fast spoiled gradient recalled T1 기법과 fat suppressed Isotropic 3D fast spin echo T1 기법을 이용하여 영상을 획득하였다. 정량적 평가를 위해 각각의 영상에서 signal to noise ratio 및 contrast to noise ratio 값을 측정하고, Mann-Whitney U 검정으로 두 기법 간의 통계적 유의성을 검증하였다. 또한 정성적 평가를 위해 영상의학의 2명이 각각의 영상을 관찰하여, TFCC의 형태, 영상 내 인공음영, 병변의 묘사 정도의 3가지 항목을 선정한 후 이를 4점 척도(0: 진단 불가, 1: 부족함, 2: 충분함, 3: 좋음)로 평가하였고, Kappa-value 검정을 이용하여 두 관찰자 간의 일치도 검증을 하였다. 영상획득에는 3.0 Tesla MR 장비와 8-channel RF coil을 사용하였다. 정량적 평가 결과, 모든 영상 단면에서 signal to noise ratio 및 contrast to noise ratio 값이 Isotropic 3D fast spin echo T1 기법이 높게 나타났으며, Mann-Whitney U 검정을 이용한 두 영상기법 간의 검증도 통계적으로도 유의하였다(p < 0.05). 정성적 평가 결과, 관찰자 1, 2 모두에서 Isotropic 3D fast spin echo T1 기법의 평가 결과가 더 높게 나타났으며, Kappa-value 검증을 이용한 두 관찰자 간 평가 결과의 일치도 검증도 통계적으로 유의하였다(p < 0.05). 결론적으로 TFCC 손상 환자의 자기공명영상 검사 시 fat suppressed Isotropic 3D fast spin echo T1 기법의 적용은 TFCC 병변의 감별에 보다 유용한 진단적 정보를 제공 할 수 있을 것이라 생각된다. In this study, For assessment of triangular fibrocartilage complex (TFCC) injury, we acquired images by fat suppressed 3D fast spoiled gradient recalled T1 and fat suppressed Isotropic 3D fast spin echo T1 techniques. For quantitative evaluation, measured signal to noise ratio and contrast to noise ratio and verified statistical significance between two imaging techniques by Mann-Whitney U verification. And for qualitative evaluation, marked 4-grade scoring (0: non diagnostic, 1: poor, 2: adequate, 3: good) on shape of TFCC, artifacts by partial volumes, description of the lesions by two radiologist, verified coincidence between 2 observer using Kappa-value verification. We used 3.0 Tesla MR equipment and 8-channel RF coil for imaging acquisition. As quantitative evaluation results, signal to noise ratio and contrast to noise ratio value of Isotropic 3D fast spin echo T1 technique is higher in every image sections, also between two imaging techniques by Mann-Whitney U verification was statistically significant (p < 0.05). As qualitative results, observer 1, 2 marked a higher grade on Isotropic 3D FSE T1 technique, coincidence verification of evaluation results between two observers by Kappa-value verification was statistically significant (p < 0.05). As a result, during MRI examination on TFCC injury, fat suppressed Isotropic 3D fast spin echo T1 technique is considered offering more useful information about abnormal lesion of TFCC.