Keywords
triangular fibrocartilage complex - arthroscopy - foveal reinsertion
Introduction
The triangular fibrocartilage complex (TFCC), initially described by Palmer and Werner,[1] plays a fundamental role in stabilizing the distal radioulnar (DRU) joint.[2]
[3]
[4]
[5]
[6] It plays a key role during pronosupination, and in softening the axial load in the
ulnocarpal joint.[4] Its complex structure and anatomical location predispose it to a high risk of acute
injuries due to wrist trauma and degenerative injuries.[5]
Currently, biomechanical and anatomical studies[7] confirm the relevance of deep fibers and foveal insertion in DRU joint stability.
Tears to the TFCC, both chronic and acute, are one of the most common causes of ulnar
wrist pain, especially during pronosupination, causing a decrease in fist strength
and in global function.[8] These lesions may go unnoticed and therefore underdiagnosed, and are found in 42%
of the patients with posttraumatic wrist pain and a negative initial radiological
study.[9]
Many of these injuries, especially those that are peripheral, can be successfully
managed conservatively and rarely require immediate surgical intervention.[3] However, given the failure of the conservative treatment, with persistent pain,
or the presence of DRU instability that is more frequently observed in larger lesions
or those involving the foveal portion, surgical repair of the TFCC would be indicated.[3]
Lesions to the TFCC have been classified by Palmer[10] according to their chronicity and compromised structure, and more recently by Atzei
and Luchetti,[3] who subdivide Palmer Type-1B lesions and take into account the severity of the damage,
make a therapeutic proposal, and provide a prognosis. Certain Palmer Type-1B lesions,
which correspond subclasses 2 and 3 in the classification by Atzei and Luchetti, are
those that generally present with DRU joint instability, frequently requiring a surgical
intervention that consists of the reinsertion of the deep or foveal fibers of the
TFCC to the distal ulna.
The surgical alternatives for foveal reattachment can be divided into two large groups:
open surgery and arthroscopically-assisted surgery. Both techniques have shown to
be effective in restoring stability and reducing pain.[4]
[11]
[12]
[13] Arthroscopic-assisted techniques have become popular in recent years due to their
high diagnostic accuracy[3]
[4] of the injury, and because they minimize soft tissue damage, which in many cases
translates to a reduction in postoperative pain.[12]
Within the fixation options of the foveal portion to the distal ulna, the most commonly
used methods are reinsertion with bone anchors (RAs) and reinsertion with sutures
through transosseous tunnels (TOs).[4]
[8]
[14]
[15]
[16]
[17] Both techniques have shown satisfactory results,[4]
[8]
[14]
[15]
[16]
[17] but no studies comparing them have not been found in the international literature.
The present study aims to compare the functional results of the foveal reinsertion
of the TFCC in acute lesions, performed with arthroscopic assistance and RAs versus
TOs.
Materials and methods
A retrospective observational study comparing patients undergoing surgery for a foveal
lesion of the TFCC, operated on with arthroscopic assistance by the same senior hand
surgeon. They were divided into two groups according to the type of fixation to the
distal ulna, either with by RAs or TOs.
We included 24 patients (11 in the RAs group, and 13 in the TOs group) with a mean
age of 28.5 years (range: 19 to 44 years), 58% of whom were male, with no statistical
differences between both groups.
Patients older than 18 years of age, with ulnar wrist pain with a history of a traumatic
event, who underwent orthopedic treatment for 3 months and persisted with pain, were
included. The patients had an arthro-computed tomography (arthroTC) scan compatible
with a foveal lesion of the TFCC (Palmer 1B or Atzei 2 and 3). Patients with concomitant
acute injuries of the same wrist and those with a history of previous surgery of the
ipsilateral upper limb were excluded. The demographic and clinical data were obtained
from the electronic medical records (Medysin 3.0, TISAL S.A, Santiago, Chile), and
the arthroTC images in the IMPAX (Agfa Healthcare, Mortsel, Bélgica) software were
informed by a radiologist specialist in musculoskeletal pathology and evaluated by
a senior hand surgeon. Surgical treatment was indicated to patients with persistent
pain despite adequate conservative treatment for a minimum of 3 months, with immobilization
for 6 weeks and later rehabilitation treatment. The surgical technique applied in
both groups involved upper limb ischemia, in a wrist traction tower and classic 3-4
arthroscopic portals, and a mini-ulnar incision. In the RAs group, a 3.5-mm anchor
(Corkscrew FT, Arthrex, Naples, FL, Unites States) was used, while in the TOs group,
the technique with 2 bone tunnels described by Nakamura et al.[4] was used. The surgical techniques used are shown in [figures 1] and [2]. The lesions found on arthroscopy were correlated with those found on the arthroTC
in all cases.
Fig. 1 Diagram of the Reinsertion Technique with Transosseous Tunnels.
[4] (A) A 2-cm incision is made on the ulnar edge of the wrist at 1 cm from the tip of the
styloid, in which 2 tunnels are made with 1.25-mm Kirschner Wires, displaying the
correct exit through the triangular fibrocartilage complex (TFCC) in the area of the
fovea, with arthroscopic assistance. (B) A hypodermic needle is passed using a 3-0 non-absorbable monofilament suture through
one of the bone tunnels, which is taken out through the 6R portal. (C-D) A second hypodermic needle with a suture loop is passed through another bone tunnel,
which is rescued through the same portal. (E) Outside the wrist, the first suture is passed through the loop, and (F) the loop filaments are pulled from the ulnar incision. (G) Finally, the two ends of the suture are tied on the ulnar cortex, and the stability
of the TFCC is checked arthroscopically. (H) Example of a patient managed with this technique: (I.1) preoperative radiograph and (I.2) postoperative radiographic control. The arrow shows the transosseous tunnels.
Fig. 2 Diagram of the Reinsertion Technique with Anchors. (A) A bone anchor is inserted through a mini-ulnar incision, and (B-C), under fluoroscopy, it is positioned in the fovea, and (DE), through the dorsal radiocarpal capsule, an epidural anesthesia trocar is passed
through the TFCC and exits through the mini-ulnar incision. (F-G-H) Outside the skin, one of the anchor sutures is threaded into the anesthesia trocar
and passed over the TFCC, the anesthesia trocar is removed, and the suture thread
is rescued through the 6R portal. The same procedure is repeated for the second filament
of suture. (I-J) Outside the skin, an arthroscopic knot is made and with a Knot Pusher, the suture
is placed on the TFCC. (K) The filaments are cut over the knot, and the stability is tested with a probe. (L-M) Pre- and postoperative radiographs of the reinsertion with anchors.
The surgical time was equivalent to the ischemia time described in all cases, since
emptying begins just before making the incision, and the ischemia is removed immediately
after skin closure.
All patients were managed with a sugar-tong cast postoperatively for 6 weeks, and
then underwent at least 10 sessions of rehabilitation therapy with exercises for wrist
and elbow range of motion and DRU joint stability. The clinical assessment of the
load-bearing pain was performed with the visual analog scale (VAS) and the Modified
Mayo Wrist Score (MMWS),[18] and ranges of motion were evaluated with a goniometer in the preoperative period
and six months postoperatively.
For the statistical analysis, the differences found in means and medians of the evaluated
variables were analyzed. Values of p <0.05 were considered statistically significant. The STATA software (Statacorp LLC,
College Station, TX, United States), version 15, was used.
Results
The time of evolution until surgery averaged 13.9 weeks (range: 12 to 16 weeks) in
the RAs group, and 14.2 weeks (range: 12 to 18 weeks) in the TOs group, without statistical
significance (p = 0.7266). In the two groups, a pain reduction of 4.33 points was observed on the
VAS (standard deviation [SD]: 1.16), with no statistically significant difference
between the two groups (p = 0.98). The MMWS improved in both groups, with an average of 30.09 points (SD: 0.94)
in the RAs group and of 31.92 points (SD: 1.32) in the TOs group, and this difference
was statistically significant (p = 0.0004). Flexion-extension increased by 5.2° (SD: 2.3°) in the RAs group and by
6.9° (SD: 1.32°) in the TOs group, and this difference was also statistically significant
(p = 0.01). Pronation improved by 15.9° (SD: 1.7°) in the RAs group and by 15.8° (SD:
1.72°) in the TOs group, which was not statistically significant (p = 0.46), and supination improved by 17.09° (SD: 2.46°) in the RAs group and by 17.5°
(SD: 1.61°) in the TOs group, and this difference was statistically significant (p = 0.004). The results are shown in [tables 1] and [2] and [charts 1], [2], and [3].
Tabla 1:
|
PACIENTE
|
EDAD
|
EVA PREOP
|
EVA 6 MESES
|
FLEXO - EXTENSIÓN PREOP
|
FLEXO - EXTENSIÓN 6 MESES
|
SUPINACIÓN PREOP
|
SUPINACIÓN 6 MESES
|
PRONACIÓN PREOP
|
PRONACIÓN 6 MESES
|
ESCALA MAYO PREOP
|
ESCALA MAYO 6 MESES
|
TIEMPO A LA CIRUGÍA (SEMANAS)
|
|
1
|
30
|
8
|
2
|
94
|
102
|
53
|
70
|
60
|
78
|
37
|
65
|
16
|
|
2
|
27
|
7
|
4
|
101
|
106
|
50
|
65
|
57
|
75
|
40
|
70
|
14
|
|
3
|
19
|
9
|
3
|
110
|
114
|
48
|
63
|
55
|
70
|
42
|
72
|
13
|
|
4
|
22
|
9
|
2
|
95
|
105
|
42
|
55
|
45
|
60
|
45
|
75
|
12
|
|
5
|
33
|
7
|
3
|
94
|
100
|
46
|
61
|
47
|
65
|
35
|
65
|
16
|
|
6
|
37
|
8
|
3
|
110
|
114
|
45
|
60
|
51
|
67
|
48
|
80
|
12
|
|
7
|
22
|
8
|
4
|
114
|
118
|
54
|
70
|
54
|
68
|
47
|
78
|
13
|
|
8
|
31
|
8
|
3
|
98
|
105
|
50
|
60
|
50
|
65
|
38
|
68
|
16
|
|
9
|
23
|
9
|
4
|
104
|
108
|
45
|
65
|
46
|
62
|
40
|
70
|
14
|
|
10
|
44
|
8
|
4
|
112
|
115
|
53
|
67
|
60
|
77
|
44
|
74
|
14
|
|
11
|
31
|
7
|
2
|
108
|
110
|
42
|
58
|
57
|
70
|
45
|
75
|
13
|
Tabla 2:
|
PACIENTES
|
EDAD
|
EVA PREOP
|
EVA 6 MESES
|
FLEXO - EXTENSIÓN PREOP
|
FLEXO - EXTENSIÓN 6 MESES
|
SUPINACIÓN PREOP
|
SUPINACIÓN 6 MESES
|
PRONACIÓN PREOP
|
PRONACIÓN 6 MESES
|
ESCALA MAYO PREOP
|
ESCALA MAYO 6 MESES
|
TIEMPO A LA CIRUGÍA (SEMANAS)
|
|
1
|
39
|
7
|
3
|
100
|
105
|
35
|
55
|
45
|
60
|
40
|
72
|
16
|
|
2
|
33
|
6
|
3
|
105
|
110
|
45
|
63
|
48
|
62
|
32
|
65
|
16
|
|
3
|
20
|
9
|
5
|
102
|
108
|
55
|
70
|
58
|
75
|
48
|
80
|
12
|
|
4
|
26
|
8
|
4
|
92
|
100
|
52
|
68
|
55
|
70
|
50
|
80
|
13
|
|
5
|
37
|
9
|
4
|
108
|
116
|
35
|
55
|
55
|
70
|
30
|
64
|
18
|
|
6
|
29
|
6
|
3
|
110
|
116
|
42
|
60
|
50
|
65
|
45
|
78
|
12
|
|
7
|
18
|
6
|
3
|
96
|
105
|
50
|
66
|
42
|
58
|
35
|
65
|
14
|
|
8
|
25
|
7
|
2
|
95
|
102
|
46
|
65
|
60
|
75
|
35
|
66
|
15
|
|
9
|
20
|
6
|
4
|
100
|
106
|
37
|
55
|
56
|
74
|
44
|
76
|
14
|
|
10
|
24
|
6
|
2
|
103
|
110
|
40
|
58
|
46
|
60
|
42
|
75
|
13
|
|
11
|
22
|
9
|
4
|
105
|
112
|
49
|
65
|
51
|
68
|
42
|
75
|
12
|
|
12
|
30
|
7
|
4
|
95
|
102
|
42
|
60
|
50
|
65
|
38
|
70
|
14
|
|
13
|
42
|
7
|
2
|
105
|
114
|
50
|
66
|
52
|
72
|
40
|
70
|
15
|
Chart 1 Pre- and Postoperative Load-Bearing Pain in Both Surgical Techniques. Abbreviations: VAS, Visual Analog Scale; RAs, reinsertion with anchors; TOs, transosseous
tunnels.
Chart 2 Pre- and Postoperative Ranges of Motion in Both Surgical Techniques. Abbreviations: RAs, reinsertion with anchors; TOs, transosseous tunnels.
Chart 3 Pre- and Postoperative Modified Mayo Wrist Score (MMWS)
[18]
in Both Surgical Techniques. Abbreviations: RAs, reinsertion with anchors; TOs, transosseous tunnels.
The mean ischemia time was of 34.2 minutes (SD: 4.36 minutes) in the TOs group and
of 78.9 minutes (SD: 9.39 minutes) in the RAs group, and this difference was also
statistically significant (p = 0.000). The result is shown in [chart 4].
Chart 4
Ischemia Time in Minutes in the reinsertion with anchors (RAs) and transosseous tunnels
(TOs).
There were no complications associated with the techniques described in the present
series of patients.
Discussion
The TFCC is a primary stabilizer of the DRU joint, and its foveal portion is the most
important that performs this function.[2]
[3]
[4]
[5]
[6]
[7] In patients with lesions of this structure and who, despite medical treatment, remain
symptomatic and with an unstable DRU joint, it is necessary to perform a reinsertion
of the foveal portion of the TFCC to the distal ulna to recover the correct biomechanics
of the wrist and thus reduce pain and improve overall function.[4]
[8]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
Currently, arthroscopic techniques have become very important, since, as a result
of the magnification and implementation of small instruments, it enables an accurate
diagnosis of these injuries.[4]
[8] In addition, they enable the performance of advanced techniques that have shown
clinical results similar to those of open techniques, and with even better results
in terms of the remaining ulnar pain.[12] This may be due to the minimization of soft-tissue damage and the full preservation
of other structures relevant to the stability of the DRU joint.
Both the technique of foveal reinsertion of the TFCC with bone anchorage and that
with TOs are effective in reducing load-bearing pain, and improving the range of motion
of the joints and the functional score,[3]
[4]
[8]
[11]
[12]
[13]
[14]
[15]
[16]
[17] and the present work is the first to compare both techniques with arthroscopic assistance.
Regarding the limitations of the present study, it is necessary to highlight that
it presents the limitations of a retrospective study, which is why it is necessary
to carry out prospective and randomized studies in the future.
Although we found statistical differences in the improvement in the MMWS, in flexion-extension,
and in supination, these did not exceed the minimally-significant clinical differences,
which is why they are irrelevant to the daily function of our patients.
We found significant differences with respect to surgical time, which was longer in
the RA technique. This last difference can be attributed to a change in behavior in
the management of the patients, with the first patients being operated by RAs and,
currently, through TOs, so that the surgeon's experience in the arthroscopic management
of these lesions could be the cause of the shorter surgical time. Similarly, in none
of the cases did the ischemia time exceeded the 120 minutes recommended to safely
maintain the vitality of the tissues.
Our functional clinical results are similar to those found in the international literature.[3]
[4]
[8]
[11]
[12]
[13]
[14]
[15]
[16]
[17] Clinically, both groups of patients had a satisfactory and similar evolution. We
believe that both techniques are effective in reducing pain and improving wrist functional
ranges of motion, with suturing through TOs being our surgery of choice given its
shorter ischemia time.
Conclusion
Both techniques are effective in reducing load-bearing pain and improving the function
and ranges of motion of the wrist. There is a significant difference in the functional
scores and flexion-extension and supination ranges in favor of TOs; this difference
does not exceed the minimally-significant clinical difference. The TO surgery has
a significantly shorter ischemic time than the RA surgery.
