Management of Complications Following Surgery to the Triangular Fibrocartilage Complex

19 Management of Complications Following Surgery to the Triangular Fibrocartilage Complex

Simon MacLean, Greg Bain, and Andrea Atzei

Abstract

Preventing complications in triangular fibrocartilage complex (TFCC) repair begins with a systematic approach. Patient history and clinical examination determines tear chronicity, stability, and the patient’s functional demands. Basic and advanced imaging modalities define the anatomy of the tear, and the etiology of symptoms—whether it be primarily osseous, soft tissue, or a combination of both. Surgical treatment can then be directed appropriately. Arthroscopy plays a crucial role in both diagnosis and treatment. Complex procedures or salvage options may be warranted in advanced cases.

In this chapter we outline the complications of TFCC repair and our approach to this challenging injury. We present specific examples of challenging TFCC cases, and our TFCC tear management algorithm to help direct appropriate treatment for the wrist surgeon when treating these injuries.

Keywords: TFCC tear, TFCC reconstruction, algorithm, complications, salvage procedures

19.1 Introduction

Triangular fibrocartilage complex (TFCC) repairs are indicated in cases of persistent pain or instability of the distal radioulnar joint (DRUJ) following TFCC injury. Traumatic TFCC injuries are caused by axial loading, ulnar deviation and forced extremes of wrist rotation. Early diagnosis of an isolated TFCC tear is a challenge. In the absence of clear radiographic signs, the diagnosis is often missed at initial presentation. Other TFCC injuries occur in the setting of forearm or distal radius fractures and are often missed at the time of osteosynthesis.1 Many TFCC injuries settle with nonoperative treatment. As a result, many TFCC tears remain undiagnosed, although a cohort will present later with ulnar-sided wrist pain or mechanical symptoms. Difficulty in initial diagnosis and delay in presentation presents a significant challenge to the wrist surgeon; chronic tears may have a poor capacity to heal following repair.

In the international literature, numerous papers report different surgical techniques of repair and reconstruction of the peripheral TFCC, using either traditional open or arthroscopic approach. Being mostly technical reports, these studies often lack adequate information regarding the type and incidence of complications. Even data from the few systematic reviews are lacking regarding the complications of these procedures: only limited reference can be found on persistence of pain and recurrence of DRUJ instability.²^,³^,⁴^,⁵ For both open and arthroscopic techniques, the incidence for postoperative pain is reported as high as 41%, and for DRUJ instability an incidence up to 16% is also reported. Furthermore, a detailed account of the causes for these complications is poorly reported.

Several challenges exist for the treating surgeon. A clear history is fundamental. Careful interpretation of clinical findings is required—particular coexisting injuries to the other ulnar-sided structures, and assessment of DRUJ instability. In addition, a careful review of radiological findings is required—including previous fractures, malunions, degenerative change, ulnar variance, and each individual TFCC component to assess for the anatomy of the tear. These parameters, as well as other patient and surgical factors, help direct repair strategy. As a result of this complex interplay of factors, surgical outcomes may be suboptimal and complications can occur.

19.1.1 Definition and Causes of Complications Following TFCC Repair and Reconstruction

For the purpose of this chapter, a complication is defined as an unfavorable event that arises during or in addition to a surgical procedure of TFCC repair and reconstruction, and is directly or indirectly linked to the surgical technique, either open or arthroscopic. For the evaluation of the possible causes of complications and failures of a surgical procedure, four phases were considered during the entire process: (1) preoperative diagnostic phase; (2) operative surgical phases, further divided in: (2A) perioperative and (2B) intraoperative; and finally (3) the rehabilitation phase.⁶ Due to the number of technical advancements recently introduced to improve accuracy and facilitate surgery of TFCC repair and reconstruction, some complications have been recognized to be specifically related to the surgical procedures of TFCC repair and reconstruction. Accordingly, this chapter will focus on complications arising in the intraoperative phase. Undoubtedly, poor diagnostic work-up as well as wrong indications may doom surgery to failure. Even though peripheral TFCC tears represent the most common cause of ulnar-sided wrist pain and loss of function, it is also important to understand that, besides TFCC injury, there are other three main groups of pathologies that should be assessed: bone deformity, cartilage damage, and muscle/tendon disorders. Failure to recognize these disorders in the diagnostic approach may lead to complications and eventually failure of the surgical treatment. Thus, following the principles suggested by the “Four-Leaf Clover Algorithm” will facilitate decisions on treatment of DRUJ disorders.⁷ Complications of arthroscopic surgery may occur in the perioperative phase of setup, but they may be strongly prevented with use of nonischemic finger traps and a traction force not exceeding 4 to 5 kg.⁸ More accurately, these conditions relate to the learning curve and are absolutely rare in the operating room of an experienced surgeon. Intraoperative complications following TFCC repair and reconstruction may cause clinical complaints which are divided into two broad groups, as related to persistence or recurrence of (1) pain and (2) DRUJ instability.

19.2 Clinical Assessment

19.2.1 History and Examination

A number of TFCC tears following repair present with persistent instability of the DRUJ. In some cases, the surgeon performs a peripheral repair to the capsule and ECU subsheath but fails to appreciate or repair the foveal attachment onto the ulnar head. In other cases, a foveal repair is performed, which fails to heal, or a suboptimal technique is used. Patient factors—including comorbidities, hyperlaxity, or compliance with splinting or therapy—may also contribute to repair failure.

DRUJ instability is a spectrum and therefore clinical assessment can be challenging. In extreme cases, asymmetry and dorsal prominence of the ulnar are present on initial inspection. Previous scars from TFCC surgery may indicate the nature of previous surgery. Persistent foveal tenderness with a positive “foveal sign” is a sensitive and specific test for a persistent TFCC tear.9 The press test and piano-key test may be positive. All instability tests should be performed on the contralateral wrist—appreciating that DRUJ laxity may be normal for the patient. An overall assessment of laxity, with the “Beighton Score” should be performed.¹⁰ Other important tests include an ulnocarpal stress test and tests for DRUJ arthritis including the Grind test.

Other causes of ulnar-sided wrist pain should be considered, particularly ECU instability, lunotriquetral instability, or pisotriquetral osteoarthritis.

19.2.2 Investigations

Radiographic assessment includes inspection for previous fractures, particularly distal radius malunion at the DRUJ. A basal ulnar styloid fracture may affect the insertion of the TFCC foveal fibers. Nonunions in this region are not uncommon, which may in themselves produce pain, and associated persistent instability. Previous drill holes and anchors on radiographs may affect planned reconstruction techniques. Ulnocarpal abutment is not always associated with positive ulnar variance on static imaging, as it is a dynamic phenomenon. Abutment can occur with loading (clenched-fist view) and rotation (pronated view) (Fig. 19‑1). Degenerative changes at the DRUJ or radiocarpal joint can occur and may warrant a salvage procedure.

Fig. 19.1 Ulnocarpal abutment is usually associated with positive ulnar variance but this is not always the case such as in this patient. (a) Plain radiograph in the midpronated position. (b) Pronated view showing positive ulnar variance. (c) Clenched fist view showing further increase in ulnar variance.

3-Dimensional imaging includes computed tomography (CT) scanning of both wrists. Axial slices allow assessment of the morphology of the sigmoid notch, and review of the contralateral side allows comparison to a normal template, which is particularly useful if osteotomy (“notchplasty”) is indicated.11 Some patients will have dysplasia of both wrists and this will affect options for reconstruction.

Dynamic 4D CT scanning allows dynamic assessment of prosupination.¹² Cine images can be reformatted from different aspects depending on the surgeon’s preference. Dynamic 2D axial sequences define the extent of DRUJ instability at different degrees of forearm rotation (Fig. 19‑2). The distal ulna is not tightly constrained in the sigmoid notch and a degree of dorsal and volar translation will occur in a normal wrist. This proportion is not well defined in the literature, but comparison to the asymptomatic side will assist the surgeon in cases of mild DRUJ instability. 4D scanning allows diagnosis of ulnar styloid triquetral impingement (Fig. 19‑3) and ulnocarpal abutment. 4D scanning also allows dynamic assessment of the failed distal ulnar salvage procedure that presents with instability.

Fig. 19.2 A 20-year-old male with ulnar wrist pain following open reduction and internal fixation of his radial shaft. Plain lateral radiographs (a) showing full overlap of the radius and ulna at the forearm with only partial overlap at the wrist. Anteroposterior (AP) view (b) showing no gapping at the distal radioulnar joint (DRUJ). 4D-CT (computed tomography) scans of the normal (c) and symptomatic (d) wrist showing DRUJ incongruence, dynamic instability, and notching at the ulnar head due to bony impingement.

Fig. 19.3 (a,b) Ulnar styloid-triquetral impingement on 4D-CT (computed tomography) scanning. 3D reformats.

Magnetic resonance imaging (MRI) allows assessment of fixation failure. Metal suppression sequences can be helpful in cases where metallic anchors or other hardware has been used. Cystic change in the proximal ulnar lunate, triquetrum, or ulnar head can occur with ulnocarpal abutment. Ulnocarpal abutment may be seen directly on the 4D scan. On PD (proton density) views, the overall status of articular cartilage can be evaluated.

19.2.3 Arthroscopy

Arthroscopy may be both diagnostic and therapeutic. For arthroscopic assessment of the TFCC, we utilize a 3–4 portal with a 6-radial (6R) working portal on the radiocarpal joint, and DRUJ portal with the direct foveal portal for DRUJ exploration. Dry arthroscopy has several benefits. It allows accurate assessment of synovitis—as fluid insufflation tends to force blood out of synovial capillaries, it allows accurate assessment of tissue tension, and reduces postoperative edema and pain. The TFCC should be inspected for tissue quality and tear configuration. Previous sutures (broken or intact) may be present and may necessitate removal. A normal intact TFCC is naturally under tension and will “rebound” on trampoline testing. A positive trampoline test occurs when a probe ballots the surface and no rebound occurs, suggesting a tear of the peripheral attachments, as the TFCC loses its usual tautness.⁶ A hook test is used to pull the ulnar insertion of the TFCC radial-wards to check for the integrity of the underlying foveal attachments.¹³ The “reverse-hook” test checks the integrity of the radial attachments. Ballottement should occur with the wrist in neutral, pronation, and supination, which will selectively tension different volar and dorsal components of the TFCC.

19.3 General Overview of Complications Following TFCC Repair and Reconstruction

TFCC repairs are indicated in cases of posttraumatic pain or DRUJ instability, which persist after conservative treatment. Early clinical diagnosis of TFCC tears is a challenge to the wrist surgeon. Tears of the superficial component are amenable to simple capsular sutures. If there is significant involvement of the foveal insertions and chronic instability, the TFCC needs to be repaired to the ulnar fovea. Arthroscopy may also reveal chronic tears with poor healing capacity: for those tears, a reconstructive procedure is indicated. In the current clinical practice, arthroscopy is considered a mandatory completion to the diagnostic staging of TFCC tear. Based on the arthroscopic findings, indications can be established safely according to the different classes of Palmer 1B-type tears described in the treatment-oriented classification proposed by Atzei.14^,¹⁵ A systematic presentation of the complications occurring following the surgical treatment of the peripheral TFCC tears will be presented accordingly, along with the recommendations for a strategy of prevention and treatment, as summarized in Table 19‑1.

19.3.1 Complications Following Repair of Superficial Tears

Diagnosis of Class 1 distal peripheral tear is made exclusively by arthroscopy. Thus, the arthroscopic technique is also mandatory to perform the repair of the TFC proper to the dorsal capsule, in order to avoid the obvious drawbacks related to the soft tissue damage following the open approach to the tear. Since the first description of the different outside-in 16 and inside-out¹⁷ techniques, the intolerance to the knot in the subcutaneous tissues has been a main issue, often requiring a second operation for knot removal, even when a resorbable suture is used.¹⁸ Del Piñal et al recently described a technique for all-inside suturing that should be preferred for the treatment of Class 1 TFCC tear to circumvent the problem of knot intolerance.¹⁹ Otherwise, it is recommended to refer the patient to the physiotherapist for skin desensitization. If physical therapy (PT) is not effective, surgery to remove the suture can be planned at least after 3 months postoperatively, to allow for proper healing of the repair. Another problem with the suture is related to the use of resorbable material, as it may cause a painful inflammatory synovitis due to the intra-articular suture resorption process. Use of high-strength nonabsorbable suture (such as FiberWire) is preferred. Furthermore, high-strength sutures offer the advantage of greater strength with smaller diameters, thus being preferable to use in small joint surgery. PT local anti-inflammatory treatment is recommended. Rare cases may require arthroscopic debridement if patient’s complaints persist after 3 months postoperatively. The percutaneous suturing showed a significant risk of entangling the dorsal sensory branch of the ulnar nerve (DSBUN) or the tendons of either the extensor carpi ulnaris (ECU) or extensor digiti quinti (EDQ).²⁰ Commonly, Class 1 tears are located close to the 6R portal, whose area is often crossed by the transverse accessory branch of dorsal sensory branch of ulnar nerve (TAB of DSBUN), which is at risk of being caught and severed by the knot (Fig. 19‑4). Respect of anatomical landmarks and careful surgical technique, also to prepare a mini-open approach, may minimize this risk. Blunt dissection of the soft tissues around the arthroscopic portals and the use of dry arthroscopy, as popularized by del Piñal et al is recommended in order to reduce soft tissues infiltration and facilitate the smooth passage of the suture and grasper in and out of the joint, and prevent entanglement of the sutures along the path.²¹ In case of tendon entrapment, tenolysis after suture removal is recommended, usually after 3 months postoperatively. In case of entrapment of the DSBUN or the TAB of DSBUN, desensitization therapy is recommended as a first choice of treatment. However, often the nerve may be damaged so severely, or even actually severed, that even neurolysis may not suffice and neuroma revision and protection may be necessary.

Fig. 19.4 Bifurcation of the dorsal sensory branch of ulnar nerve (DSBUN) and the transverse accessory branch of the dorsal sensory branch of ulnar nerve (TAB of DSBUN) crossing the ulnar side of the wrist tears in close relationship with the arthroscopic portals. Abbreviations: DF, direct foveal portal; DRUJ, distal radioulnar joint portal; 6R, 6-radial portal; 6U, 6-ulnar portal.

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