Chapter 11 Arthroscopic Reconstruction of the Triangular Fibrocartilage Complex Using a Free Tendon Graft

10.1055/b-0035-121121

Chapter 11 Arthroscopic Reconstruction of the Triangular Fibrocartilage Complex Using a Free Tendon Graft

Introduction

Instability of the distal radioulnar joint (DRUJ) results from injury or laxity of the ligaments responsible for stabilizing the joint. Of these, the triangular fibrocartilage complex (TFCC) plays a crucial role in maintaining DRUJ stability. It may be impossible to repair the TFCC due to degenerative changes in the TFCC, or the repair might be inadequate to maintain DRUJ stability if the extrinsic stabilizers are also torn (e.g., radioulnar ligament [RUL] interosseous membrane). In such patients, DRUJ reconstruction is possible provided there a re no arthritic changes in the DRUJ. This technique, using a free tendon graft, was first described by Mansat et al in 19831 and was modified and popularized by Adams and Berger in 2002.2 This procedure is used to reconstruct the ligament and restore function, thus providing multidirectional stability. A tendon graft, preferably from the palmaris longus (PL), is woven through transosseous tunnels in the distal radius, converging at the fovea through a distal ulnar transosseous tunnel. This procedure can be performed as an open surgery or as minimally invasive arthroscopically assisted surgery. The arthroscopic technique uses several incisions, the length of which depends on the surgeon’s experience in protecting the underlying structures. A more experienced surgeon will use shorter incisions.

Operative Technique

Patient Preparation

The procedure comprises two steps: (1) harvesting the tendon graft and (2) reconstructing the TFCC. In the first step the hand is flat on the table arm. During the second step, 5 to 7 kg axial traction is applied to the hand with Chinese finger traps. A pneumatic tourniquet is applied, and the arm is fixed to the table. The entire procedure is carried out under regional anesthesia.

Harvesting the Tendon Graft

The tendon graft must be strong and long enough to stabilize the DRUJ and thin enough to pass through the bone tunnels. Usually, a PL tendon graft suffices. If the PL is absent, a hemi flexor carpi radialis or a plantaris tendon graft may be harvested. The PL tendon graft is harvested through a small incision at the distal flexion crease of the wrist joint at the base of the carpal tunnel. A tendon stripper is used to harvest the graft ( Fig. 11.1 ). A grasping suture is applied to the two ends of the tendon graft using 4–0 Ethilon (Ethicon, Somerville, New Jersey, USA) or similar nonbraided suture. The suture is passed several times (Krackow suture), ~1.5 cm on both ends of the tendon graft to create a strong, grasping suture construct, and the ends of the suture are left long for retrieval while passing the tendon graft through the transosseous tunnels.