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A Novel Technique of All-Inside Arthroscopic Triangular Fibrocartilage Complex Repair
Technical Note
A Novel Technique of All-Inside Arthroscopic Triangular Fibrocartilage Complex Repair Jeffrey Yao, M.D., Phani Dantuluri, M.D., and A. Lee Osterman, M.D.
Abstract: Peripheral triangular fibrocartilage complex (TFCC) tears are amenable to repair. Limitations of current repair techniques include prolonged recovery and button or knot intolerance. We present a novel technique of an all-inside repair using existing technology (FasT-Fix; Smith & Nephew Endoscopy, Andover, MA) to circumvent these complications. This technique is faster, easily performed, safe, and potentially stronger than current repairs. Earlier motion and rehabilitation are instituted after this repair. The tear is debrided to stimulate angiogenesis. The FasT-Fix is inserted through the 3-4 portal with the arthroscope in the 6R portal. The first poly-L-lactic acid block is deposited peripheral to the tear. Upon penetration of the wrist capsule, a distinct decrease in resistance is felt. The introducer is withdrawn, depositing the block outside the capsule. The trigger on the introducer advances the second block into the deployment position. It is advanced and deposited central to the tear, forming a vertical mattress configuration. The introducer is removed, leaving the pre-tied suture. The knot is tightened and cut by use of the knot pusher/cutter. Multiple implants may be inserted to complete the repair. Postoperative care involves a sugartong splint for 2 weeks followed by a short arm cast for 4 weeks. Range of motion is begun thereafter with strengthening started at 10 weeks. Key Words: Wrist arthroscopy—Triangular fibrocartilage complex—All-inside repair.
U
lnar-sided wrist pain remains a common diagnosis and difficult entity to treat for the orthopaedic and hand surgeon. Common causes of ulnar-sided wrist pain include tears of the triangular fibrocartilage complex (TFCC). The TFCC not only is involved in
From Stanford University Medical Center (J.Y.), Palo Alto, California, and The Philadelphia Hand Center, Thomas Jefferson University Hospital (P.D., A.L.O.), King of Prussia, Pennsylvania, U.S.A. The authors report no conflict of interest. Presented at the 2006 Annual Meeting of the Arthroscopy Association of North America, Hollywood, Florida. Address correspondence and reprint requests to Jeffrey Yao, M.D., Stanford University Medical Center, 770 Welch Rd, Suite 400, Palo Alto, CA 94304. E-mail: [email protected] © 2007 by the Arthroscopy Association of North America Cite this article as: Yao J, Dantuluri P, Osterman AL. A novel technique of all-inside arthroscopic triangular fibrocartilage complex repair. Arthroscopy 2007;23:1357.e1-1357.e4 [doi:10.1016/ j.arthro.2007.02.010]. 0749-8063/07/2312-6276$32.00/0 doi:10.1016/j.arthro.2007.02.010
load transmission across the wrist but also acts to help stabilize the distal radioulnar joint. Left untreated, TFCC tears may lead to chronic ulnar-sided wrist pain and, ultimately, distal radioulnar joint instability and arthrosis. Treatment options for TFCC repairs include conservative management, such as cast immobilization, corticosteroid injections, and hand therapy. However, these tears often require surgical treatment. As classified by Palmer,1 peripheral tears (type 1B) are the most amenable to surgical repair in patients with symptoms refractory to conservative treatment. This is because the TFCC has a blood supply very similar to the meniscus of the knee, with most of the vascularity along the periphery, whereas the central disk is essentially avascular with poor healing capability.2 Several techniques currently exist for the repair of these tears. However, many disadvantages are associated with these techniques. These include extra incisions, sensitivity and pain as a result of prominent subcutaneous
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 12 (December), 2007: pp 1357.e1-1357.e4
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J. YAO ET AL.
suture knots, skin problems and patient intolerance of a button tied to the skin, and even septic arthritis of the wrist. We propose a novel technique for the repair of peripheral TFCC tears. By use of existing technology for the repair of the knee meniscus, we have used a device for an all-inside arthroscopic repair of peripheral tears of the TFCC. This all-inside technique provides the benefits of decreased surgical time, fewer incisions, fewer complications related to buttons and suture knots, and ultimately, greater patient satisfaction. We have found that this technique is fast, strong, easily performed, and safe. DESCRIPTION OF TECHNIQUE The standard wrist arthroscopy tower is used, with 10 to 12 lb of longitudinal traction placed on the index and long fingers to distract the radiocarpal joint. The standard 3-4 and 6R portals are used for diagnostic arthroscopy. After a peripheral (Palmer 1B) tear is identified, it is debrided by use of a 3.5-mm full-radius motorized shaver to stimulate angiogenesis at the repair site. With the arthroscope in the 6R portal, the curved FasT-Fix (Smith & Nephew Endoscopy, Andover, MA) is inserted through the 3-4 portal. The first poly-L-lactic acid (PLLA) block is deposited distal and peripheral to the tears (Fig 1A). Upon penetration of the ulnar wrist capsule, a distinct decrease in resistance is felt. The needle introducer is then drawn back, thereby depositing the block outside the capsule. The trigger on the needle introducer is used to advance the second block into the deployment
position. The second block is advanced and deposited in the same fashion proximal and central to the tears, forming a vertical mattress configuration (Fig 1B). The needle introducer is removed from the joint, leaving the pre-tied suture. The suture is tightened and the knot cut by use of the knot pusher/cutter (Fig 2). A second FasT-Fix, if necessary, is placed volar to the initial implant (Fig 3). The wounds are closed with a monofilament suture, and the patient’s extremity is placed in a well-molded short arm splint for 2 weeks. The first postoperative visit involves removal of the skin sutures and placement of a short arm cast for an additional 4 weeks. Wrist range of motion begins thereafter, with strengthening beginning at 10 weeks postoperatively. DISCUSSION Peripheral TFCC tears are a common cause of ulnar-sided wrist pain. These tears may be traumatic or degenerative in nature. Tears may be seen in the face of ulnar impaction syndrome, an acute rotational injury, or an axial load to an outstretched, pronated arm, as seen in falls.1,3-7 The incidence of these tears appears to be on the rise as our population becomes more active and our ability to make the diagnosis improves. In fact, cadaveric studies have shown that 36% to 70% of all wrists had a tear of the TFCC.3 Although these tears may be treated conservatively with cast immobilization, they often need definitive treatment with surgery. Initially, repair via an open technique was the gold standard for the treatment of peripheral TFCC tears. Recently, with more emphasis placed on mini-
FIGURE 1. (A) Cadaveric dissection of TFCC illustrating insertion of first FasT-Fix block. The TFCC is outlined by a surgical marker. (B) Cadaveric dissection of introducer penetrating ulnar capsule and block to be deposited (arrow).
TRIANGULAR FIBROCARTILAGE COMPLEX REPAIR
FIGURE 2. The pre-tied knot is tensioned and cut by use of the knot pusher/cutter.
mally invasive surgery, arthroscopic management of these tears has become more prominent. As with other joints in the body, arthroscopy of the wrist provides the benefits of smaller incisions, less soft-tissue dissection, earlier recovery, and greater patient satisfaction. However, arthroscopic repairs, though minimally invasive, are not without problems. Most of the current techniques also require an additional incision. Suture knots tied to the capsule or the floor of the sixth extensor compartment often irritate the patient as the extensor carpi ulnaris tendon runs against it. This problem is confounded by the fact that being a monofilament, the sutures used in these repairs require multiple throws to ensure a tight knot and minimize
1357.e3
the chance of unraveling. These large, stiff monofilament knots are often directly under the skin and can be irritating to the patient. Tying the sutures over a button placed on the skin will circumvent this problem, but patients also dislike the button on the outside of the skin. It often becomes irritated or malodorous and causes skin maceration or even skin necrosis. There is also an increased risk of infection with pathogens tracking from the skin via the suture into the ulnocarpal joint. In fact, at our institution, 3 patients have had septic arthritis of the wrist develop from TFCC tears repaired over a button. All required a formal irrigation and debridement, and one required a radioscapholunate fusion for the sequelae of severe septic arthritis. We propose an all-inside arthroscopic peripheral (Palmer 1B) TFCC repair technique to eliminate these problems. Using existing technology for the repair of knee menisci, we have adapted the FasT-Fix for use in the wrist. This implant has the advantage of being a suture system with a pre-tied knot to facilitate its use. This technique has been shown to be easily performed, faster, stronger, and safe and may be performed via standard arthroscopic portals without the need for an accessory incision. All-inside arthroscopic repair techniques have previously been reported in the literature. Conca et al.7 describe a technique that uses arthroscopic knot-tying similar to that in the shoulder; however, the wrist is a much smaller joint, and this technique was admittedly technically demanding and is no faster than existing techniques. Bohringer et al.5 use the Mitek Meniscus Fastener Fixation System (Mitek Worldwide, West-
FIGURE 3. (A) Complete cadaveric dissection following FasT-Fix repair technique. The sutures should be noted (arrow). (B) Ulnar view. The 2 PLLA blocks are at the tip of the arrow, flush against the capsule.
1357.e4
J. YAO ET AL.
wood, MA) in the repair of the peripheral TFCC. It is similar to our technique in that it uses existing technology, but the anchor is not as pliable as suture material, may irritate the articular surfaces of the carpus, and requires some modification before its use (cutting 1 mm from each end of the anchors). The 3-4 portal must also be enlarged 6 to 8 mm. The FasT-Fix provides the advantages of having the PLLA blocks on the outside of the capsule with the suture inside, uses the standard portal size (3-4 mm), and may be used “as is” without any modification. This study represents a novel technique for the repair of peripheral TFCC tears via an all-inside technique. This technique is safe, fast, and easily performed; requires no extra incisions; and is comparable in cost to existing techniques. Its safety was examined in a cadaveric study, which revealed that the PLLA blocks were low profile and easily placed safely away from the ulnar neurovascular structures and the extensor carpi ulnaris (Fig 3). Although we have used this implant clinically with preliminary success, long-term clinical studies are necessary to advocate its routine use in repairing pe-
ripheral TFCC tears. Our preliminary clinical results are very promising, and we believe this is certainly a viable option for the treatment of this common clinical entity. REFERENCES 1. Palmer A. Triangular fibrocartilage complex lesions: A classification. J Hand Surg [Am] 1989;14:594-606. 2. Thiru-Pathi R, Ferlic D, Clayton M, McClure D. Arterial anatomy of the triangular fibrocartilage of the wrist and its surgical significance. J Hand Surg [Am] 1986;11:258-263. 3. Viegas S, Patterson R, Hokanson J, Davis J. Wrist anatomy: Incidence, distribution, and correlation of anatomic variations, tears, and arthrosis. J Hand Surg [Am] 1993;18:463-475. 4. Bednar J, Osterman L. The role of arthroscopy in the treatment of traumatic triangular fibrocartilage injuries. Hand Clin 1994; 10:605-614. 5. Bohringer G, Schadel-Hopfner M, Petermann J, Gotzen L. A method for all-inside arthroscopic repair of Palmer 1B triangular fibrocartilage complex tears. Arthroscopy 2002;18:211-213. 6. Corso S, Savoie F, Geissler W, Whipple T, Jiminez W, Jenkins N. Arthroscopic repair of peripheral avulsions of the triangular fibrocartilage complex of the wrist: A multicenter study. Arthroscopy 1997;13:78-84. 7. Conca M, Conca R, Dalla Pria A. Preliminary experience of fully arthroscopic repair of triangular fibrocartilage complex lesions. Arthroscopy 2004;20:e79-e82. Available online at www. arthroscopyjournal.org.
A Novel Technique of All-Inside Arthroscopic Triangular Fibrocartilage Complex Repair Jeffrey Yao, M.D., Phani Dantuluri, M.D., and A. Lee Osterman, M.D.
Abstract: Peripheral triangular fibrocartilage complex (TFCC) tears are amenable to repair. Limitations of current repair techniques include prolonged recovery and button or knot intolerance. We present a novel technique of an all-inside repair using existing technology (FasT-Fix; Smith & Nephew Endoscopy, Andover, MA) to circumvent these complications. This technique is faster, easily performed, safe, and potentially stronger than current repairs. Earlier motion and rehabilitation are instituted after this repair. The tear is debrided to stimulate angiogenesis. The FasT-Fix is inserted through the 3-4 portal with the arthroscope in the 6R portal. The first poly-L-lactic acid block is deposited peripheral to the tear. Upon penetration of the wrist capsule, a distinct decrease in resistance is felt. The introducer is withdrawn, depositing the block outside the capsule. The trigger on the introducer advances the second block into the deployment position. It is advanced and deposited central to the tear, forming a vertical mattress configuration. The introducer is removed, leaving the pre-tied suture. The knot is tightened and cut by use of the knot pusher/cutter. Multiple implants may be inserted to complete the repair. Postoperative care involves a sugartong splint for 2 weeks followed by a short arm cast for 4 weeks. Range of motion is begun thereafter with strengthening started at 10 weeks. Key Words: Wrist arthroscopy—Triangular fibrocartilage complex—All-inside repair.
U
lnar-sided wrist pain remains a common diagnosis and difficult entity to treat for the orthopaedic and hand surgeon. Common causes of ulnar-sided wrist pain include tears of the triangular fibrocartilage complex (TFCC). The TFCC not only is involved in
From Stanford University Medical Center (J.Y.), Palo Alto, California, and The Philadelphia Hand Center, Thomas Jefferson University Hospital (P.D., A.L.O.), King of Prussia, Pennsylvania, U.S.A. The authors report no conflict of interest. Presented at the 2006 Annual Meeting of the Arthroscopy Association of North America, Hollywood, Florida. Address correspondence and reprint requests to Jeffrey Yao, M.D., Stanford University Medical Center, 770 Welch Rd, Suite 400, Palo Alto, CA 94304. E-mail: [email protected] © 2007 by the Arthroscopy Association of North America Cite this article as: Yao J, Dantuluri P, Osterman AL. A novel technique of all-inside arthroscopic triangular fibrocartilage complex repair. Arthroscopy 2007;23:1357.e1-1357.e4 [doi:10.1016/ j.arthro.2007.02.010]. 0749-8063/07/2312-6276$32.00/0 doi:10.1016/j.arthro.2007.02.010
load transmission across the wrist but also acts to help stabilize the distal radioulnar joint. Left untreated, TFCC tears may lead to chronic ulnar-sided wrist pain and, ultimately, distal radioulnar joint instability and arthrosis. Treatment options for TFCC repairs include conservative management, such as cast immobilization, corticosteroid injections, and hand therapy. However, these tears often require surgical treatment. As classified by Palmer,1 peripheral tears (type 1B) are the most amenable to surgical repair in patients with symptoms refractory to conservative treatment. This is because the TFCC has a blood supply very similar to the meniscus of the knee, with most of the vascularity along the periphery, whereas the central disk is essentially avascular with poor healing capability.2 Several techniques currently exist for the repair of these tears. However, many disadvantages are associated with these techniques. These include extra incisions, sensitivity and pain as a result of prominent subcutaneous
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 12 (December), 2007: pp 1357.e1-1357.e4
1357.e1
1357.e2
J. YAO ET AL.
suture knots, skin problems and patient intolerance of a button tied to the skin, and even septic arthritis of the wrist. We propose a novel technique for the repair of peripheral TFCC tears. By use of existing technology for the repair of the knee meniscus, we have used a device for an all-inside arthroscopic repair of peripheral tears of the TFCC. This all-inside technique provides the benefits of decreased surgical time, fewer incisions, fewer complications related to buttons and suture knots, and ultimately, greater patient satisfaction. We have found that this technique is fast, strong, easily performed, and safe. DESCRIPTION OF TECHNIQUE The standard wrist arthroscopy tower is used, with 10 to 12 lb of longitudinal traction placed on the index and long fingers to distract the radiocarpal joint. The standard 3-4 and 6R portals are used for diagnostic arthroscopy. After a peripheral (Palmer 1B) tear is identified, it is debrided by use of a 3.5-mm full-radius motorized shaver to stimulate angiogenesis at the repair site. With the arthroscope in the 6R portal, the curved FasT-Fix (Smith & Nephew Endoscopy, Andover, MA) is inserted through the 3-4 portal. The first poly-L-lactic acid (PLLA) block is deposited distal and peripheral to the tears (Fig 1A). Upon penetration of the ulnar wrist capsule, a distinct decrease in resistance is felt. The needle introducer is then drawn back, thereby depositing the block outside the capsule. The trigger on the needle introducer is used to advance the second block into the deployment
position. The second block is advanced and deposited in the same fashion proximal and central to the tears, forming a vertical mattress configuration (Fig 1B). The needle introducer is removed from the joint, leaving the pre-tied suture. The suture is tightened and the knot cut by use of the knot pusher/cutter (Fig 2). A second FasT-Fix, if necessary, is placed volar to the initial implant (Fig 3). The wounds are closed with a monofilament suture, and the patient’s extremity is placed in a well-molded short arm splint for 2 weeks. The first postoperative visit involves removal of the skin sutures and placement of a short arm cast for an additional 4 weeks. Wrist range of motion begins thereafter, with strengthening beginning at 10 weeks postoperatively. DISCUSSION Peripheral TFCC tears are a common cause of ulnar-sided wrist pain. These tears may be traumatic or degenerative in nature. Tears may be seen in the face of ulnar impaction syndrome, an acute rotational injury, or an axial load to an outstretched, pronated arm, as seen in falls.1,3-7 The incidence of these tears appears to be on the rise as our population becomes more active and our ability to make the diagnosis improves. In fact, cadaveric studies have shown that 36% to 70% of all wrists had a tear of the TFCC.3 Although these tears may be treated conservatively with cast immobilization, they often need definitive treatment with surgery. Initially, repair via an open technique was the gold standard for the treatment of peripheral TFCC tears. Recently, with more emphasis placed on mini-
FIGURE 1. (A) Cadaveric dissection of TFCC illustrating insertion of first FasT-Fix block. The TFCC is outlined by a surgical marker. (B) Cadaveric dissection of introducer penetrating ulnar capsule and block to be deposited (arrow).
TRIANGULAR FIBROCARTILAGE COMPLEX REPAIR
FIGURE 2. The pre-tied knot is tensioned and cut by use of the knot pusher/cutter.
mally invasive surgery, arthroscopic management of these tears has become more prominent. As with other joints in the body, arthroscopy of the wrist provides the benefits of smaller incisions, less soft-tissue dissection, earlier recovery, and greater patient satisfaction. However, arthroscopic repairs, though minimally invasive, are not without problems. Most of the current techniques also require an additional incision. Suture knots tied to the capsule or the floor of the sixth extensor compartment often irritate the patient as the extensor carpi ulnaris tendon runs against it. This problem is confounded by the fact that being a monofilament, the sutures used in these repairs require multiple throws to ensure a tight knot and minimize
1357.e3
the chance of unraveling. These large, stiff monofilament knots are often directly under the skin and can be irritating to the patient. Tying the sutures over a button placed on the skin will circumvent this problem, but patients also dislike the button on the outside of the skin. It often becomes irritated or malodorous and causes skin maceration or even skin necrosis. There is also an increased risk of infection with pathogens tracking from the skin via the suture into the ulnocarpal joint. In fact, at our institution, 3 patients have had septic arthritis of the wrist develop from TFCC tears repaired over a button. All required a formal irrigation and debridement, and one required a radioscapholunate fusion for the sequelae of severe septic arthritis. We propose an all-inside arthroscopic peripheral (Palmer 1B) TFCC repair technique to eliminate these problems. Using existing technology for the repair of knee menisci, we have adapted the FasT-Fix for use in the wrist. This implant has the advantage of being a suture system with a pre-tied knot to facilitate its use. This technique has been shown to be easily performed, faster, stronger, and safe and may be performed via standard arthroscopic portals without the need for an accessory incision. All-inside arthroscopic repair techniques have previously been reported in the literature. Conca et al.7 describe a technique that uses arthroscopic knot-tying similar to that in the shoulder; however, the wrist is a much smaller joint, and this technique was admittedly technically demanding and is no faster than existing techniques. Bohringer et al.5 use the Mitek Meniscus Fastener Fixation System (Mitek Worldwide, West-
FIGURE 3. (A) Complete cadaveric dissection following FasT-Fix repair technique. The sutures should be noted (arrow). (B) Ulnar view. The 2 PLLA blocks are at the tip of the arrow, flush against the capsule.
1357.e4
J. YAO ET AL.
wood, MA) in the repair of the peripheral TFCC. It is similar to our technique in that it uses existing technology, but the anchor is not as pliable as suture material, may irritate the articular surfaces of the carpus, and requires some modification before its use (cutting 1 mm from each end of the anchors). The 3-4 portal must also be enlarged 6 to 8 mm. The FasT-Fix provides the advantages of having the PLLA blocks on the outside of the capsule with the suture inside, uses the standard portal size (3-4 mm), and may be used “as is” without any modification. This study represents a novel technique for the repair of peripheral TFCC tears via an all-inside technique. This technique is safe, fast, and easily performed; requires no extra incisions; and is comparable in cost to existing techniques. Its safety was examined in a cadaveric study, which revealed that the PLLA blocks were low profile and easily placed safely away from the ulnar neurovascular structures and the extensor carpi ulnaris (Fig 3). Although we have used this implant clinically with preliminary success, long-term clinical studies are necessary to advocate its routine use in repairing pe-
ripheral TFCC tears. Our preliminary clinical results are very promising, and we believe this is certainly a viable option for the treatment of this common clinical entity. REFERENCES 1. Palmer A. Triangular fibrocartilage complex lesions: A classification. J Hand Surg [Am] 1989;14:594-606. 2. Thiru-Pathi R, Ferlic D, Clayton M, McClure D. Arterial anatomy of the triangular fibrocartilage of the wrist and its surgical significance. J Hand Surg [Am] 1986;11:258-263. 3. Viegas S, Patterson R, Hokanson J, Davis J. Wrist anatomy: Incidence, distribution, and correlation of anatomic variations, tears, and arthrosis. J Hand Surg [Am] 1993;18:463-475. 4. Bednar J, Osterman L. The role of arthroscopy in the treatment of traumatic triangular fibrocartilage injuries. Hand Clin 1994; 10:605-614. 5. Bohringer G, Schadel-Hopfner M, Petermann J, Gotzen L. A method for all-inside arthroscopic repair of Palmer 1B triangular fibrocartilage complex tears. Arthroscopy 2002;18:211-213. 6. Corso S, Savoie F, Geissler W, Whipple T, Jiminez W, Jenkins N. Arthroscopic repair of peripheral avulsions of the triangular fibrocartilage complex of the wrist: A multicenter study. Arthroscopy 1997;13:78-84. 7. Conca M, Conca R, Dalla Pria A. Preliminary experience of fully arthroscopic repair of triangular fibrocartilage complex lesions. Arthroscopy 2004;20:e79-e82. Available online at www. arthroscopyjournal.org.