Chapter 8 Arthroscopic Repair of Peripheral Tears of the Triangular Fibrocartilage Complex

10.1055/b-0035-121118

Chapter 8 Arthroscopic Repair of Peripheral Tears of the Triangular Fibrocartilage Complex

Introduction

The triangular fibrocartilage complex (TFCC) is a fibrocartilaginous structure located between the medial surface of the distal radius and the ulnar head. The most common injury is a tear of the dorsal peripheral and medial part of the TFCC (Palmer type 1B1 or European Wrist Arthroscopy Society (EWAS) Atzei 12) ( Table 8.1 ). This type of lesion is commonly seen in young, active individuals and does not cause instability of the distal radioulnar joint (DRUJ). However, it often causes very annoying pain with any strenuous activities, especially sports (tennis, golf, fencing, basketball, etc.). Open repair often entails large incisions and results in stiffness, especially in pronosupination. Arthroscopy allows for better visualization and understanding of these lesions. It is easy to perform repairs of these peripheral lesions arthroscopically, resulting in less morbidity.

**Table 8.1** Atzei’s classification of triangular fibrocartilage (TFCC) tears
Stage	Distal component	Proximal component	Distal radioulnar joint stability	Treatment
1: Distal tear	Tear	Intact	No	Peripheral TFCC suture
2: Foveal avulsion	Intact	Tear	Yes	Foveal reinsertion
3: Complete tear	Tear	Tear	Yes	Foveal reinsertion ± peripheral TFCC suture
4: Massive rupture irreparable	Tear	Tear	Yes	Tendinous graft

Operative Technique

Patient Preparation and Setup

The procedure is performed under local/regional anesthesia. The arm is fixed firmly to the arm table, and longitudinal traction is applied to the wrist for distraction of the wrist joint.

The forearm is in supination with the ulnar styloid slightly dorsal. The TFCC lesion is therefore in a more dorsal position (i.e., opposite the 6R portal rather than the 6U portal).

Exploration

The arthroscope is introduced through the 3–4 radiocarpal portal. After routine examination of the radiocarpal joint, the arthroscope is directed toward the medial aspect of the wrist toward the TFCC. Transillumination of the skin is helpful for locating the 6R portal. A hypodermic needle is inserted to ascertain the exact position of the 6R portal, which is located ~3 or 4 mm distal to the peripheral insertion of the TFCC. A shaver is introduced through the 6R portal to excise the excess synovial tissue that is typically seen in these peripheral lesions.

Three tests are performed with a hook probe:

The loss of the “trampoline” effect indicates a peripheral tear of the TFCC. The hook probe is pushed directly on the ligament, and a depression of the TFCC is noted without a spontaneous return to its original position. However, this classic test gives a false-negative more frequently than is reported in the literature. In fact, painful, small, peripheral tears of the TFCC seldom show a loss of the trampoline effect. In addition, nontraumatic degenerative central perforations of the TFCC, frequently seen after the fourth decade, also demonstrate a loss of the trampoline effect.
The hook probe can be slid underneath the peripheral tear of the TFCC on the dorsal side ( Fig. 8.1a, b ). The distal peripheral insertion of TFCC can sometimes have a pseudo appearance intact. Indeed, scar tissue formed by the natural healing of the body (not effective in these cases) does not allow a sufficiently strong attachment to the dorsal capsule. When the peripheral distal insertion of TFCC is intact, the probe can follow the edge of the TFCC to the lateral ligaments component dorsal capsule without creating depression. It is therefore impossible to pass under the TFCC. In chronic peripheral lesions, the scar tissue often masks the injury; however, it is very easy to pass under the TFCC by placing the probe between the TFCC and the collateral ligaments. This scarring often obscures this type of lesion ( Figs. 8.2a, b and 8.3a, b ).
The hook probe is then brought to the styloid recess and the pull test is performed by passing the probe from outside in underneath the TFCC. In isolated peripheral tears of the TFCC, the foveal insertion is intact, and the pull test is negative.