The Hip: Preservation, Replacement and Revision

TFCC Repair

- Discussion:
    - indicated primary for traumatic peripheral ulnar sided TFCC tears;
    - negative predictive factors for successful repair include concomitant ulnocarpal impaction syndrome (associated w/ degenerative tears) and peripheral radial tears (due to the relative avasucularity of the disc in this region;
           - some surgeons feel that radial sided TFCC tears are not a significant risk factor for healing after a repair;
           - ulnar positive variance is another negative risk factor;
    - best candidates for repair are patients who have had a single traumatic wrist injury such as a fall or an MVA (driver gripping the steering wheel at the time of impact);

- Arthroscopic Treatment:
    - outcomes: in the study by Trumble, et al (1997), 3/24 patients (undergoing arthroscopic repair) had continued wrist pain;
    - arthroscopic evaluation: (see: wrist arthroscopy)
           - determine whether the TFCC has a resilient quality when probed (which is normal);
           - when the arthroscopic probe elicits gross softness, then a peripheral tear may be present;
           - peripheral tears are often located at the dorsal ulnar peripheral border;
           - peripheral detachments are ideal for repair, where as central attritional tears are not good candidates for repair;
           - TFCC attachment to the sigmoid notch of the radius gives successful results despite having poor vascularity;
    - arthroscopic debridement:
           - may be indicated for tears occupying the central 2/3 of the disc;
           - relative contra-indication: postive ulnar variance:
           - hazards: avoid injury to the dorsal and volar wrist ligaments;
           - Isolated tears of the TFCC: management by early arthroscopic repair.

- Open Repair:
    - outcomes: in the report by Hermansdorfer and Kleinman (1991), over 20% of patients had an unsatisfactory result;
    - open repair: (for peripheral tear at ulnar styloid);
           - make a 5 cm longitudinal incision centered over the distal ulna;
                  - take care to avoid the dorsal sensory brach of the ulnar nerve;
           - dorsal incision in made between the 4th and 5th compartments;
           - incise the dorsal wrist capsule in line with the incision;
           - the incision should be extended to the lunotriquetral joint;
           - a radially based retinacular flap is fashioned;
           - enter the ulnar-carpal joint (inverted T incision) between EDQ and ECU;
           - scar tissue surrounding the torn TFCC and its bed are debrided w/ scope;
           - w/ ulnar positive variance, exposure is facilitated w/ an ulnar shortening procedure (such as the wafer procedure);
           - likewise, placement of a small lamina spreader in the RU joint may facilitate the exposure;
           - repair of ulnar detachment:
                  - sutures are then passed through drill holes made at the medial base of the styloid, which are then placed through the torn medial edge of the TFCC;
                  - a suture passer can be helpful to pass the suture through the drill holes;
           - repar of radial TFCC detachment:
                  - drill holes are made in the ulnar side of the dorsal distal radius, from a dorso-radial to a palmar ulnar direction;
                  - horizontal matress sutures are passed through the TFCC and are then brought thru the distal radial drill holes;
           - RU stabilization and closure:
                  - place the arm in neutral rotation or slight supination and insert 2 K wires across the RU joint (or just proximal to the joint);
                  - the TFCC sutures are then tied down;
                  - the radially based retinacular flap is then passed underneath the ECU tendon in order to help prevent subluxation
                  - Management of chronic peripheral tears of the triangular fibrocartilage complex.

Isolated tears of the triangular fibrocartilage: management by early arthroscopic repair.

Repair of the triangular ligament in Colles' fracture. No effect in a prospective randomized study.

Ulnar shortening combined with arthroscopic repairs in the delayed management of triangular fibrocartilage complex tears.

Operative technique for inside-out repair of the triangular fibrocartilage complex.

Current Concepts Review.  Carpal Instability.

Traumatic disruption of the triangular fibrocartilage complex. Pathoanatomy.

Triangular fibrocartilage tears.

Triangular fibrocartilage complex lesions: a classification.

Partial excision of the triangular fibrocartilage complex.

Ulnar shortening combined with arthroscopic repairs in the delayed management of triangular fibrocartilage complex tears.

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, December 12, 2012 11:16 am