Keywords
triangular fibrocartilage complex (TFCC) - radial-sided - type 1d tears - suture anchor
repair technique
Introduction
Advances in wrist arthroscopy have led to a better understanding of the structure
of the triangular fibrocartilage complex (TFCC), and the choice of treatment has changed
from open surgery to an arthroscopic approach. This structure, first described by
Palmer, mostly manifests itself with rupture of the ulnar side, while ruptures of
the radial side (type 1d) are rare.[1] Although there are different arthroscopic approaches in the literature for this
rare injury, the most preferred method is to open osseous tunnels along the radius
from the sigmoid notch with additional incision and fixation of sutures in the radial
aspect of the radius.[2]
In this report, we aim to describe our suture screw anchor repair technique, which
is a novel technique in type 1d TFCC rupture and present its short-medium-term clinical
results.
Indications and Contraindications
Indications and Contraindications
The suture screw anchor repair technique we have described is a valid application
for type 1d traumatic isolated ruptures. It is indicated in patients whose complaints
such as pain and instability continue despite conservative treatment applied for 2–3
months, without any age restriction. It is not recommended for type 1d ruptures accompanied
by bone avulsion, TFCC lesions that do not approach the sigmoid notch, where retraction
is advanced, and type 2 ruptures with a degenerative background.
Surgical Anatomy
TFCC; attaches to two points (fovea and styloid) from the radius styloid notch to
the ulnar with its intrinsic structures such as the articular disc, meniscus homologue,
and dorsal-volar distal radioulnar ligaments. Extrinsic structures are formed by the
extensor carpi ulnaris tendon sheath, ulnocarpal ligaments, pronator quadratus, and
joint capsule. Most of its blood supply is peripheral, while its radial part is supplied
by the dorsal and palmar branches of the anterior interosseous artery. Its main function
is the transfer of loads from the wrist to the ulna and stabilizing the distal radioulnar
joint. Among the portals used during the arthroscopic repair of TFCC radial side rupture,
the dorsal 3–4 portal is between the extensor pollicis longus and the extensor digitorum
communis, and the 6U is the portal in the ulnar part of the extensor carpi ulnaris
tendon.
Surgical Technique
The procedure was performed under regional anesthesia with the usage of a pneumatic
tourniquet. In the supine position, the wrist was distracted by ∼8–10 pounds with
the ELA Traction Tower (Bozoq, Istanbul, Turkey). Diagnostic arthroscopy was performed
from the 3–4 (viewing) and 6U (working) portal. TFCC radial side rupture was observed
([Fig. 1]). First, the radial side of TFCC was debrided with a shaver, then the cartilage
layer in the radius TFCC reattachment area was debrided down to the bleeding cancellous
bone with the help of a burr and shaver. A 2.0 mm suture screw anchor (Tulpar, Ankara,
Turkey) was placed in the middle part of the radius sigmoid notch at a right angle
under fluoroscopy control ([Fig. 2],[3]). A 22-gauge (22G) needle with a carrier loupe was passed from the upper side of
the TFCC to the lower side of the 6U portal to carry the anchor sutures from the lower
side to the upper side of the TFCC ([Fig. 4]). This loop under TFCC was taken out of the 6U portal with the aid of a hemostat
([Fig. 5]). One of the anchor sutures was taken into this loupe, which was taken out to be
passed under the TFCC and pulled ([Fig. 6]). To apply the same procedure to the second suture of the anchor, another needle
with a loupe was passed through the TFCC at a horizontal distance of ∼0.6–0.8 mm from
the place where the first suture passed. Thus, the two sutures of the anchor were
taken out with a distance between them on the horizontal axis ([Fig. 7]). The refixation of the TFCC radial side to the sigmoid notch was achieved by tying
these two sutures outside ([Fig. 8]). Fixation strength was checked with a hook. The process was terminated by closing
the portals.
Fig. 1 Demonstration of TFCC radial side rupture with hook. (red *: TFCC radial side, blue
+: ulna head, yellow #: radius).
Fig. 2 Placement of 2–0 mm suture screw anchor on TFCC attachment site under fluoroscopy
control.
Fig. 3 Illustration after placing suture screw anchor.
Fig. 4 Passing a 22-gauge needle with a loupe from the upper side to the lower side of the
TFCC.
Fig. 5 The loupe under TFCC was taken out of the 6U portal with the help of a hemostat.
Fig. 6 Passing one of the anchor sutures through the loupe and pulling direction.
Fig. 7 Removing the two sutures of the anchor with 0.6 mm-0.8 mm on the horizontal axis
between them.
Fig. 8 Demonstrating the refixation of the TFCC radial side to the sigmoid notch by knotting
the two sutures outside.
Postoperative Management
In the early postoperative period, a long arm splint was applied to the wrist in a
neutral position in a way that allowed metacarpophalangeal joint movement. Dressing
changes every 3–4 days and skin stitches removal in the second week were recommended.
At the end of the 4th week, the long arm splint was terminated, and active-passive
elbow motion was started. Wrist movement restriction was continued with a 2-week removable
wrist brace. At the end of the 6th week, the brace was removed, while only active
and passive movement exercises were practiced until the 12th week, accompanied by
a physiotherapist specialized in hand rehabilitation, while strengthening exercises
were started after the 12th week, which permitted to engage in unrestricted activity.
We did not encounter any complications in this surgery.
Pearls And Pitfalls
First, the anatomical localization of the retracted TFCC with the pulling effect should
be examined. Due to its positive contribution to healing, bleeding cancellous bone
must be seen by debriding the sigmoid notch before the repair. It would be better
to use a 6U portal to place the anchor at a right angle. Since the 6U portal is both
the process portal and the portal where the sutures pass, an additional 6R portal
can be opened to make the process easier. During the tying of the sutures, a knot-pusher
can be used for ease of knot placement.
Case Illustration
A 23-year-old non-smoker, right-hand dominant student with no comorbidity. He had
complained of pain in the ulnar side of his left wrist, and limitations in performing
daily activities, that persisted for 6 months, which started after a fall on an outstretched
hand. He had a history of irregular splint application (2 weeks) and analgesic anti-inflammatory
treatment in his previous treatments. On physical examination of the patient, forced
wrist rotations were painful. TFCC compression and ulnar impaction test were positive.
The Piano Key Test was negative. There was no difference in the contralateral wrist
side comparative active supination-pronation and flexion-extension range of motion
(ROM) before surgery. The Visual Analogue Score (VAS) was 6, The Disabilities of the
Arm, Shoulder, and Hand (DASH) Score was 40.8, and the grip strength was 72% in comparison
with the contralateral side. The patient had no radiographic findings. The main findings
obtained in Magnetic Resonance (MR) arthrography included a tear at the radial attachment
site of the TFCC-associated peripheral retraction and the contrast agent passing from
radiocarpal joint to distal radioulnar joint ([Fig. 9]). Although the literature on early surgical intervention is controversial, the general
approach is to try conservative treatment first, consisting of analgesic, anti-inflammatory,
static wrist splint and movement modification for ∼2 months. As his complaints continued,
arthroscopic surgery was decided. There was no additional intra-articular pathology
except TFCC radial side rupture during surgery. Postoperatively 1 year, the patient's
VAS improved to 0. ROM was the same as the pre-surgical value, the DASH score was
2,5, and the comparative grip strength measurement on the other hand had progressed
to 92%. The 1st year postoperative control MR arthrography showed that the contrast agent was only
in the radiocarpal joint, not passing to the radioulnar joint ([Fig. 10]).
Fig. 9 Preoperative MRI arthrography images (contrast passing from radiocarpal joint to
distal radioulnar joint is visible).
Fig. 10 Postoperative MRI arthrography images (contrast is observed only at the radiocarpal
joint. Not passing to the distal radioulnar joint).
Discussion
Radial side TFCC ruptures are a very rare type of rupture among other TFCC ruptures,
and treatment options are controversial. There was a view that TFCC radial side ruptures,
which were previously considered avascular, could not respond well to repair and even
similar results could be obtained with isolated debridement.[3] The first repair technique of this region was described by Cooney et al. In this
technique, the two ends of the horizontal mattress suture placed on the radial border
of the TFCC, reached by dorsal arthrotomy, were fixed by opening two drill holes just
proximal to the lunate fossa or from the dorso-radial to the ulna-palmare. In his
series of 23 cases, he got 18 good or excellent, 4 fair, and 1 poor result. Control
MRI performed on 5 patients operated by Cooney showed that TFFC was solidly healed
on the radial side in 4 patients.[4] These results, which they published, led to more positive opinions about the healing
of the repair of radial side tears, and later authors supported this view with 'The
combination of vascular ingrowth and synovial fluid provided enough nutritional support
to allow the TFCC to heal.[4]
[5] Advances in wrist arthroscopy have led to the widespread use of arthroscopic repair
of TFCC tears. The first arthroscopic technique was defined by Thomas et al; they
repaired the rupture into these two tunnels with the help of two drilling holes drilled
from the sigmoid notch along the radial aspect of the radius.[5] In their series of 11 cases, they achieved 90% success in a range of motion, reduction
of pain, and return to profession.
While ulnar side ruptures are easier to repair with the advantage of anatomy, radial
side ruptures are more difficult to treat. Most of the new techniques that have been
described to make the double drill hole process easier have been in the form of minor
revisions of this technique. For example, Jantea et al. fabricated a jig to aid in
arthroscopic repair.[6] Fellinger et al. defined the repair technique in which a single drill hole can be
sufficient with a T-Fix-device (Smith and Nephew, Andover, MA), which can cause a
T-shaped buttress effect.[7] Tang et al. on the other hand, provided easier drill hole opening by designing the
double-barrel cannula technique used for meniscus sutures for TFCC.[8]
Trumble first defined an all-arthroscopic repair technique as an alternative to all
these drill hole techniques.[2] He fixed the two ends of the horizontal mattress suture that he passed through the
TFCC to the radius sigmoid notch assisted by a mini–Push Lock anchor (Arthrex, Naples,
FL). Cho, on the other hand, applied the direct repair technique of the ruptured TFCC
with a 2–0 poly-dioxanone suture hook to the TFCC radial side residues (2–3mm) remaining
in the sigmoid notch, which is a cheaper and more practical method.[9]
The most important advantage of our technique is that there is no need for additional
incisions in the radial aspect of the radius since the drill hole is not drilled from
the radius. Drill hole is an application that may cause excessive fluoroscopy exposure
during surgery and more pain for the patient after surgery. An additional incision
may result in both radial nerve superficial branch injury, more incision pain, aesthetic
complaints, and irritation under the skin, especially of non-absorbable sutures. Despite
all this, the need for anchors; may increase the cost somewhat compared with simple
suture techniques. In previous studies, ulnoradial pin fixation was applied to protect
the repair after repair.[4]
[10] However, today, although the necessity of this pin fixation has not been revealed
by studies, many authors do not prefer pin fixation and restrict supination pronation
with cast application on the elbow.[2] We do not prefer pin fixation due to the necessity of dressing at the bottom of
the pin, the fact that the pin is a different source of pain after surgery, and complications
such as infection. We restrict forearm rotations with a four-week supra-elbow splint
application.
In studies, it is stated that sometimes repair is not possible, and reconstruction
may be required in delayed cases.[11] In our case, when we observed that the torn and retracted TFCC in the arthroscopic
examination could easily come to the area where it was attached with the pulling effect,
we performed a repair with a screw anchor. Generally, a single horizontal suture is
preferred in these tears, although there are authors who use more than one horizontal
suture.[10] We think that a single anchor may be sufficient with the stable fixation we obtained
in the post-repair hook-assisted examination.
The new technique we defined; TFCC may be an alternative treatment method in radial
side ruptures due to some advantages it provides compared with the previously defined
drill hole techniques. The present report has several limitations; one of them is
the presentation of clinical results in a short-medium period, such as 1 year. In
addition to clinical results, showing improvement with second-look arthroscopy will
reveal more objective results of the technique. To determine the usefulness of this
technique; There is a need for a larger number of patients with clinical studies evaluating
long-term clinical-radiological results.
