Allinside Anatomic Arthroscopic (3A) Reconstruction of Irreparable TFCC Tear

Abstract

Background In recent years, new arthroscopic techniques have been introduced to address the irreparable tears of the triangular fibrocartilage complex (TFCC) (Palmer type 1B, Atzei class 4) by replicating the standard Adams–Berger procedure. These techniques, however, show the same limitations of the open procedure in relation to the anatomically defective location of the radial origins of the radioulnar ligaments (RUL) and the risk of neurovascular and/or tendon injury. Aiming to improve the quality of reconstruction and reduce surgical morbidity, a novel arthroscopic technique was developed, with the advantages of reproducing the anatomical origins of the RUL ligaments and providing all-inside tendon graft (TG) deployment and fixation.

Description of Technique The Allinside anatomic arthroscopic (3A) technique is indicated for TG reconstruction of irreparable TFCC tears in the absence of distal radioulnar joint (DRUJ) arthritis. Standard wrist arthroscopy portals are used. A small incision in the radial metaphyseal area and arthroscopic control are required to set a Wrist Drill Guide and create two converging tunnels, whose openings are at the radial anatomical origins of the RUL. An ulnar tunnel is drilled at the fovea from inside-out via the 6U portal. A 3-mm tendon strip, from the palmaris longus or extensor carpi radialis brevis, is woven through the tunnels and then secured into the ulnar tunnel with an interference screw. Postoperative immobilization with restricted forearm rotation is discontinued at 5 weeks, and then postoperative rehabilitation is started.

Patients and Methods The 3A technique was applied on 5 patients (2 females and 3 males), with an average age 42 years. DRUJ stability, range of motion (ROM), pain (0–10 visual analogue scale [VAS]), grip strength, modified Mayo wrist score (MMWS), and patient satisfaction were used for evaluation before surgery and at follow-up.

Results No intraoperative or early complications were registered. At a mean follow-up of 26 months, DRUJ was stable in all patients, which recovered 99% ROM. Pain VAS decreased from 7 to 0.6. Grip strength increased from 38 to 48.8 Kgs. There were 4 excellent results and 1 good result on MMWS. All patient showed high satisfaction.

Conclusions Although the 3A technique requires dedicated instrumentation and arthroscopic expertise, it takes advantage of improved intra-articular vision and minimized surgical trauma to reduce the risk of complications and obtain promising functional results.

Keywords

Wrist - Arthroscopy - TFCC - Chronic Tear - DRUJ - Instability - Reconstruction - Tendon Graft

Note

The study was performed at Pro-Mano, Hand Surgery and Rehabilitation, Treviso (Italy) and Casa di Cura Giovanni XXIII, Monastier di Treviso, Treviso (Italy).

Publication History

Received: 14 April 2021

Accepted: 10 August 2021

Article published online:
05 October 2021

• References

• 1 Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am 1989; 14 (04) 594-606
• 2 Atzei A, Luchetti R. Foveal TFCC tear classification and treatment. Hand Clin 2011; 27 (03) 263-272
• 3 Adams BD, Berger RA. An anatomic reconstruction of the distal radioulnar ligaments for posttraumatic distal radioulnar joint instability. J Hand Surg Am 2002; 27 (02) 243-251
• 4 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
• 5 Tse WL, Lau SW, Wong WY. et al. Arthroscopic reconstruction of triangular fibrocartilage complex (TFCC) with tendon graft for chronic DRUJ instability. Injury 2013; 44 (03) 386-390
• 6 Luchetti R, Atzei A. Arthroscopic assisted tendon reconstruction for triangular fibrocartilage complex irreparable tears. J Hand Surg Eur Vol 2017; 42 (04) 346-351
• 7 Badur N, Luchetti R, Atzei A. Arthroscopic wrist anatomy and setup. In: Geissler WB. ed. Wrist and Elbow Arthroscopy: A Practical Surgical Guide to Techniques. New York: Springer Science þ Business Media; 2015: 1-28
• 8 Mansat M, Mansat Ch, Martinez Ch. L'articulation radio-cubitale inférieure. Pathologie traumatique. In: Razemon JP, Fisk GR. eds. Le poignet. Monographies du Groupe d'Etude de la Main. Paris: Expansions Scientifiques Francaise; 1983: 187-195
• 9 Gofton WT, Gordon KD, Dunning CE, Johnson JA, King GJ. Comparison of distal radioulnar joint reconstructions using an active joint motion simulator. J Hand Surg Am 2005; 30 (04) 733-742
• 10 Teoh LC, Yam AK. Anatomic reconstruction of the distal radioulnar ligaments: long-term results. J Hand Surg [Br] 2005; 30 (02) 185-193
• 11 Gillis JA, Soreide E, Khouri JS, Kadar A, Berger RA, Moran SL. Outcomes of the Adams-Berger Ligament Reconstruction for the Distal Radioulnar Joint Instability in 95 Consecutive Cases. J Wrist Surg 2019; 8 (04) 268-275
• 12 Kootstra TJM, van Doesburg MH, Schuurman AH. Functional effects of the adams procedure: a retrospective intervention study. J Wrist Surg 2018; 7 (04) 331-335
• 13 Scheker LR, Ozer K. Ligamentous stabilization of the distal radioulnar joint. Tech Hand Up Extrem Surg 2004; 8 (04) 239-246
• 14 Martineau PA, Bergeron S, Beckman L, Steffen T, Harvey EJ. Reconstructive procedure for unstable radial-sided triangular fibrocartilage complex avulsions. J Hand Surg Am 2005; 30 (04) 727-732
• 15 Henry M. Anatomic reconstruction of the radioulnar ligament. Hand (N Y) 2012; 7 (04) 413-419
• 16 Bowers WH. The distal radioulnar joint. In: Green DP, Hotchkiss RN, Peterson WC. eds. Green's Operative Hand Surgery. 4th ed.. Philadelphia: Churchill Livingstone; 1999: 986-1032
• 17 Chu-Kay Mak M, Ho PC. Arthroscopic-assisted triangular fibrocartilage complex reconstruction. Hand Clin 2017; 33 (04) 625-637
• 18 Carratalá Baixauli V, Lucas García FJ, Martínez Andrade C, Carratalá Baixauli R, Guisasola Lerma E, Corella Montoya F. All-arthroscopic triangular fibrocartilage complex ligamentoplasty for chronic DRUJ instability. Tech Hand Up Extrem Surg 2019; 23 (01) 44-51