TECHNIQUE Arthroscopic Foveal Repair of Triangular ...

1 | TECHNIQUE | Arthroscopic Foveal Repair of TriangularFibrocartilage complex peripheral lesion WithDistal Radioulnar Joint InstabilityAndrea Atzei, MD and Alessandra Rizzo, MDHand Surgery UnitPoliclinico Rossi Verona, ItalyRiccardo Luchetti, MDRimini Hand and Upper Extremity CenterRimini, ItalyTracy Fairplay, RPTP rivate PracticeBologna, Italy|ABSTRACTT here is still controversy regarding the value of ar-throscopic suture of Triangular fibrocartilage complex (TFCC)peripheraltearscomparedwith opentransoss-eous Repair because only the latter method restores fovealinsertions of TFCC in case of distal radioulnar joint(DRUJ) instability. Five classes of TFCC peripheraltears are recognized in a treatment-oriented algorithmbased on Arthroscopic findings, and indications to propertreatment are set accordingly.

2 Complete repairable tears(class 2) and proximal repairable tears (class 3) are asso-ciated with DRUJ instability and require Foveal reattach-ment of the TFCC. We describe a new Arthroscopic tech-nique to Repair the Foveal attachment of the TFCC with theuse of a suture anchor, which is indicated for class 2 and 3 TFCC peripheral tears, instead of an open Repair . Thistechnique requires a dedicated working portal to approachthe fovea ulnaris. This Direct Foveal portal is used to pre-pare the ligament and bone and to drill and insert a sutureanchor loaded with a pair of sutures. Under arthroscopicvision, a suture is passed through each limb of the liga-ment and tied using a small knot-pusher. This arthro-scopic TECHNIQUE restores original TFCC anatomy andadequate DRUJ stability with less morbidity and po-tentially accelerated rehabilitation compared with :arthroscopy, distal radioulnar joint, instabil-ity, Triangular fibrocartilage complex , Repair |HISTORICAL AND ANATOMICPERSPECTIVEA ccording to the classification of Palmer and Werner,1disorders of the Triangular fibrocartilage complex (TFCC) are divided into 2 basic categories, traumatic(class 1) and degenerative (class 2), which are furthersubdivided into different types depending on the locationof the tear and the presence or absence of associatedchondromalacial changes.

3 Class 1 traumatic lesions aresubdivided into 4 types, and Type 1-B injuries are pe-ripheral tears located on the ulnar side of the histology and functional anatomy research dem-onstrates that the ulnar side of the TFCC is arranged in acomplex 3-dimensional manner and separated into3 components: the proximal Triangular ligament, the dis-tal hammock structure, and the ulnar collateral ligament(UCL).2 Although the existence of an UCL is stilldebated,3,4it is considered to be a part of the extensorcarpi ulnaris (ECU) sheath ,6 However, from afunctional standpoint, the UCL can be associated withthe distal hammock structure because they both sharethe same function of supporting and suspending theulnar distal hammock structure and theUCL are considered to make up the distal componentof the TFCC (dc-TFCC), opposite to the proximalcomponent (pc-TFCC), represented by the proximal tri-angular ligament (Fig.)

4 1). The proximal Triangular liga-ment originates from the fovea ulnaris and spans to theulnar corners of the distal radius with 2 limbs, palmarand dorsal. It is considered to be the true radioulnar liga-ment that stabilizes the distal radioulnar joint (DRUJ).7 Depending on the intensity and direction of the appliedAddress correspondence and reprint requests to Andrea Atzei, MD,Hand Surgery Unit, Policlinico Rossi, Verona, Italy. in Hand & Upper Extremity Surgery226 Techniques in Hand & Upper Extremity Surgery 12(4):226 235, 2008 2008 Lippincott Williams & Wilkins, PhiladelphiaCopyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is force, either the dc-TFCC or pc-TFCC or bothmay be torn. Clinical DRUJ stability is still preserved incases of dc-TFCC isolated laceration.

5 Conversely, whena type 1-B TFCC tear involves the disruption of the pc-TFCC, the DRUJ becomes unstable and results in ulnar-sided pain, reduced grip strength, decreased forearmrotation, and clinical signs of DRUJ instability. Contro-versy still exists as to which is the best treatment for type1-B TFCC tears associated with DRUJ Arthroscopic techniques have been pro-posed that suture the torn TFCC to the dorsal ulnocarpaljoint capsule and the ECU tendon restore TFCC tautness by direct suture ofthe lacerated dc-TFCC and thus improve the patient , when TFCC tears involve the pc-TFCCand the DRUJ is clinically unstable, traditional arthro-scopic suturing may be of limited efficacy to provideadequate joint stability because it fails to Repair thepc-TFCC Foveal ,19In these instances.

6 Open Repair is generally recom-mended because it is still considered the only techniquethat allows for restoration of the preinjury anatomyby the direct reattachment of the TFCC s proximal com-ponent to its Foveal ,20 Although good resultshave been documented with open Repair , a carefuland rather extensive exposure of the distal radio-ulno-carpal joint20Y22is required to perform the TFCC reat-tachment via either transosseous sutures18,21or advances in understanding wrist intra-articular anatomy and kinematics and the relentless re-search in finding new surgical techniques to provideimproved surgical accuracy with successful functionaloutcome and potentially accelerated rehabilitation timefor the patient has contributed to the development ofan all- Arthroscopic attitude toward ulnar-sided this line, new Arthroscopic techniques havebeen introduced for the treatment of repairable TFCC peripheral tears associated with DRUJ instability.

7 |CLINICAL PRESENTATION OFTYPE 1-B TFCC TEAR WITHDRUJ INSTABILITYThe typical patients experiencing a peripheral TFCC tearassociated with DRUJ instability complain of ulnar-sidedwrist pain usually after a fall on the outstretched hand ora violent traction and twisting injury of the wrist or fore-arm. The wrist spontaneously gives way when tryingto open a bottle, rotate a steering wheel, turn a doorhandle, or hold an object in their hand during diagnosis is made by eliciting the ulnar fovealsign27of point tenderness over the ulnar capsule just pal-mar to the ECU tendon. Pain is also exacerbated by pas-sive forearm rotation and may be associated with a click or intraarticular grinding sensation. Active andpassive motion of the wrist and DRUJ are usually pre-served, although resisted forearm rotation is often weakand can reproduce painful radioulnar joint laxity is evaluated by passiveanteroposterior translation of the ulna on the radius inneutral rotation and in both full supination and prona-tion.

8 Greater laxity is evident in the painful wrist as com-pared with the opposite side when the forearm musclesare amount of radioulnar translation grades DRUJ laxity as Slight when less than 5 mm, Mild when 5 to10 mm, or Severe when greater than 10 mm. If transla-tion is abnormal in full supination, the dorsal limb of thepc-TFCC is either ruptured or overstretched. On the con-trary, when translation is abnormal in full pronation,laceration of the pc-TFCC s palmar limb is , clinically unstable DRUJ demonstratesa soft end-field resistance to translation compared withthe firm end-field resistance felt in the , hypertonicity of the DRUJ s muscle stabi-lizers may mislead the clinician into making a false-negative diagnosis; thus, it is recommended that DRUJ stability should be confirmed under anesthesia just be-fore the are usually of limited diagnostic help butmay reveal an associated ulnar styloid fracture/nonunion orFIGURE slice of the ulnar wrist.

9 The TFCC isoutlined. It is composed of the distal component of theTFCC (D), formed by the UCL and the distal hammockstructure, and of the proximal component (P), the distalradioulnar ligament that originates from the ulnar foveaand basistyloid and stabilizes the distal radioulnar 12, Issue 4227 Arthroscopic Foveal Repair of TFCCC opyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is ulnar variance. The value of magnetic resonanceimaging (MRI), even with intraarticular gadolinium, iscontroversial. An MRI arthrogram may diagnose a tearbut may not accurately assess the size and location of comparing specificity and sensitivity ofarthrography, MRI, and arthroscopy confirm that arthros-copy is the criterion standard for definitive ,31| Arthroscopic ASSESSMENTOF TYPE 1-B TFCC TEARS: ATREATMENT-ORIENTEDCLASSIFICATIONTear assessment requires Arthroscopic evaluation of boththe proximal and distal components of the TFCC with aradiocarpal joint arthroscopy to evaluate the dc-TFCCand a DRU arthroscopy to evaluate the the scope in the standard 3-4 portal, the tearis visualized during radiocarpal arthroscopy in thedorsoulnar corner of the TFCC and probed through the6-R portal.

10 The TFCC tension is evaluated by the tram-poline test18and the hook test. The trampoline testassesses the TFCC s tautness by applying a compressiveload across it with the probe. The test is positive whenthe TFCC is soft and compliant and suggests a peripheralTFCC tear. The hook test consists of applying traction tothe ulnar-most border of the TFCC, with the probeinserted through the 4-5 or 6-R portal. The test is posi-tive when the TFCC can be pulled upward and radiallytoward the center of the radiocarpal joint (Fig. 2). It is areliable maneuver for detecting the Foveal disruption ofthe pc-TFCC. Furthermore, specific traction on the pal-mar or dorsal TFCC can help detect which limb of thepc-TFCC is radioulnar arthroscopy is the only method thatpermits to see ligamentous pc-TFCC laceration or avul-sion of the Foveal attachments.