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Arthroscopic repair of peripheral avulsions of the triangular fibrocartilage complex of the wrist: A multicenter study
Arthroscopic Repair of Peripheral Avulsions of the Triangular Fibrocartilage Complex of the Wrist: A Multicenter Study Salvatore J. Corso, M.D., Felix H. Savoie, M.D., William B. Geissler, M.D., Terry L. Whipple, M.D., Wayne Jiminez, R.RT., and Nan Jenkins, R.N.
Summary: A multicenter study to assess arthroscopic reconstruction of the peripheral attachment of the triangular fibrocartilage complex was undertaken. A total of 44 patients (45 wrists) from three institutions were reviewed. Twenty-seven of the 45 wrists had associated injuries, including distal radius fracture (4), partial or complete rupture of the scapholunate (7), lunotriquetral (9), ulnocarpal (2), or radiocarpal (2) ligaments. There were two fractured ulnar styloids and one scapholunate accelerated collapse (SLAC) wrist deformity. The peripheral tears were repaired using a zone-specific repair kit. The patients were immobilized in a munster cast, allowing elbow flexion and extension, but no pronation or supination for 4 weeks, followed by 2 to 4 weeks in a short arm cast or VersaWrist splint. All patients were reexamined independently 1 to 3 years postoperatively by a physician, therapist, and registered nurse. The results were graded according to the Mayo modified wrist score. Twenty-nine of the 45 wrists were rated excellent, 12 good, 1 fair, and 3 poor. Overall, 42 of the 45 patients (93%) rated as satisfactory and returned to sports or work activities. One patient had chronic pain, and two patients had ulnar nerve symptoms, although motion was normal in all, and their grip strength was at least 75% of the opposite hand. Arthroscopic repair of peripheral tears of the triangular fibrocartilage complex (TFCC) is a satisfactory method of repairing these injuries. Key Words: Arthroscopic repair--Peripheral--Triangular fibrocartilage complex--Traumatic tears.
lthough initially controversial, recent investigation has established tears of the triangular fibrocartilage complex (TFCC) as a primary cause of ulnarsided wrist pain and instability of the distal radioulnar joint (DRUJ). The TFCC can tear either in its avascular central portion or peripherally, and these lesions have been well classified by Palmer. 1 Treatment options for TFCC tears have varied from simple debridement to complete excision, ulna shortening to a Darrach procedure, or open repair, dependent
A
From Tuckahoe Orthopaedic Associates, Richmond, Virginia; and the Mississippi Sports Medicine & Orthopaedic Center, Jackson, Mississippi, U.S.A. Address correspondence and reprint requests to Salvatore J. Corso, M.D., Orthopaedics and Sports Associates of Long Island, 205 Froehlich Farm Blvd, Woodbury, NY 11797, U.S.A. © 1997 by the Arthroscopy Association of North America 0749-8063/97/1301-141253.00/0
78
on the type of tear present. 18'12 The recognition of the role of the triangular fibrocartilage as a major DRUJ stabilizer and a buffer to compressive forces 9 indicates the importance of preserving as much of this structure as possible. Open repair of the vascularized peripheral margin has been described using an extensive exposure of the ulnar side of the wrist. Recent advances in wrist arthroscopy have allowed the realization of performing conventional open procedures arthroscopically. The purpose of the current study is to show that this repair can be achieved with precision using an arthroscopic technique, avoiding a significant open exposure, with excellent clinical results.
MATERIALS AND METHODS A multicenter study to assess distal radio-ulnar joint instability managed by arthroscopic reconstruction of
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 13, No 1 (February), 1997: pp 78-84
ARTHROSCOPIC REPAIR OF THE WRIST
TABLE 1. Injuries Associated With TFCC Tears Injury • Rupture of: Lunotriquetral ligament Scapholunate ligament Ulnocarpal ligament Radiocarpal ligament Fracture of: Distal radius Ulnar styloid SLAC wrist
Number 9 7 2 2 4 2 1
the peripheral attachment of the TFCC from January 1990 to February 1993 was undertaken. A total of 44 patients (45 wrists) from three institutions were reviewed. Clinical instability was initiated by a traumatic event in 41 of 45 wrists. Twenty-six male and 18 female patients ranging in age from 14 to 52 years, with a mean of 32.5 years, were evaluated. The dominant hand was involved in 22 cases. Twenty-six of the injuries involved the left hand, and nineteen the right hand. Most patients commonly complained of ill-defined pain referable to the ulna side of the wrist with an occasional description of a clicking sensation. On clinical evaluation, the most consistent finding, although nonspecific, included tenderness to direct palpation over the dorsal or volar aspect of the distal ulna, usually just distal to the styloid. Pain also may be elicited by passively pronating or supinating the wrist while stabilizing the forearm. In most patients, power grip was significantly diminished. A positive magnetic resonance imaging (MRI) scan was obtained in 17 cases. Fifteen patients had positive arthrograms, including four patients in whom the MRI was negative. Five patients had a negative MRI and arthrogram. The remaining patients did not have any preoperative studies, and had tears discovered during arthroscopy of the wrist for other injuries. Twentyseven of the 45 wrists had associated injuries, including distal radius fracture, partial or complete rupture of the scapholunate, lunotriquetral, ulnocarpal, or radiocarpal ligament. There were two fractured ulnar styloids and one scapholunate accelerated collapse (SLAC) wrist (Table 1).
Surgical Technique All procedures were performed by three surgeons (T.L.W., F.H.S., W.B.G.) using a zone-specific repair kit, (INTEQ, Linvatec, Largo, FL) placed through a small incision over the sixth extensor compartment under arthroscopic guidance. Wrist arthroscopy was performed under general or regional (axillary block,
79
Bier block) anesthesia. After sterile preparation and draping, the hand was placed in a Tower traction device. Inflow is established through a 6U or 1-2 portal. Tears of the TFCC are well visualized through a 3-4 portal, although some peripheral tears initially may not be apparent. Presence of hypertrophic synovium may mask tears parallel to either the volar or dorsal margin1°; however, this may be evidence that an underlying tear exists. A probe may be placed in the 6R portal, and the TFCC can be probed for defects and its elasticity assessed. If significant laxity exists in the body of the TFCC as it runs from the radius to ulna (loss of the trampoline effect), this is evidence that it is detached peripherally. Whipple 1° has described squeezing the dorsal and volar aspect of the DRUJ capsule, which may evert the edges of a torn TFCC as fluid is forced into the radiocarpal space. Once the tear is established, a power shaver can be placed through the 6R portal to debride the edges of the tear and overlying synovium. The shaver is removed, and a small 1.5-cm. incision is made over the head of the ulna (Fig 1). The extensor carpi ulnaris tendon is retracted ulnarly, to expose the floor of the sixth extensor compartment. The curved cannulated suture passer is then inserted through the floor of the extensor carpi ulnaris (ECU) sheath and under arthroscopic guidance is passed through the peripheral edge of the torn TFCC (Fig 2). The second component of the repair kit, the loop suture retriever, is placed over the end of the suture passer. The 2 - 0 PDS suture is then passed through the hook by spinning the wheel on the passer (Fig 3). The suture retriever is then pulled back out of the joint, bringing the end of the suture with it, and leaving a suture in the peripheral edge (Fig 4). After placing two to three sutures dorsal to volar, with tension on the sutures, the wrist is pronated and supinated to assess the position of the wrist that would best reduce the tear. The wrist is then held in this position, and the sutures are tied down over the floor of the sixth extensor compartment (Fig 5). The superficial extensor retinaculum is reapproximated, and the wound is closed with a subcuticular suture.
Postoperative Care The patient is placed in a Munster or long arm cast postoperatively for 4 weeks. At this point, the wrist is placed in a short arm splint or Versa wrist splint, allowing progressive motion to the wrist. The patients can then continue range of motion and grip-strengthening exercises and usually can resume normal activity by 3 months postoperatively.
S. J. CORSO E T AL.
80
increased to an average of 87.5. This increase was statistically significant as calculated using a Student's t-test for analysis of variance (P < .05). Improvement in pain and function were immediate and dramatic. Improvements in grip strength and motion were more moderate and took longer to develop. In most cases, full motion returned at an average of 10 to 12 weeks postoperatively.
A
3-~
- 6R portal -
1.5 c m incision
FIG 1. A 1.5-cm incision is made over the head of the ulna to expose the sixth extensor dorsal compartment.
RESULTS All patients were reexamined independently at a range o f 6 months to 3 years postoperatively by a physician, therapist, or registered nurse. The average follow-up was 37 months. The results were graded according to the M a y o modified wrist score (Table 2) and compared with preoperative scores. The average preoperative wrist score was 45.9. Postoperatively this
FIG 2. (A) Graphic illustrating the curved cannulated suture passer with tip through the edge of the torn tfcc. (B) Arthroscopic view. L, lunate.
ARTHROSCOPIC REPAIR OF THE WRIST
Twenty-nine of the 45 wrists were rated as excellent, 12 as good, one as fair, and three as poor. Overall, 42 of the 45 patients (93%) rated as satisfactory and returned to sports or work activities. O f the three patients who had a poor result, one had chronic pain and two patients had ulnar nerve dysesthesias that were complications of portal placement. Also one had an associated S L A C wrist and eventually required a wrist fusion. The two patients with ulnar nerve dysesthesias continued to be followed. After conservative treatment including antiinflammatories and local cortisone injections, their symptoms resolved. Motion was normal in all three, and their grip strength was at least 75% of the opposite
81
A
FIG 4. (A) Suture retriever is removed from the wrist joint, bringing with it the free end of the suture. (B) Arthroscopic view.
hand. The two patients with ulnar nerve symptoms displayed clinical signs of superficial neuromas and were being treated accordingly. DISCUSSION
FIG 3. (A) Illustration shows the suture retriever in place over the tip of the suture passer. 2-0 PDS suture is passed through by spinning the wheel on the passer. (B) Arthroscopic view.
With recent advances in evaluation and arthroscopy of wrist pathology, tears of the T F C C have been found to be a cause of ulnar-sided wrist pain. The type of tear found has a direct effect on treatment options and subsequent prognosis. Chronic degenerative tears of the T F C C are common, and after the age of 50, are believed by some
82
S.J.
CORSO E T AL.
C
FIG 5. (A) Peripheral tfcc tear (arrow). L, lunate; d, dorsal. (B) Three 2-0 PDS sutures in place reapproximating the avulsed tfcc to the dorsal capsule. (C) Drawing shows suture tied down over the sixth extensor compartment.
to be universal, paralleling cartilage changes in other joints. 11 These are associated with an ulnar-neutral or ulnar-positive variance causing c o m p r e s s i o n o f the disc b e t w e e n ulnar head and carpus. A l t h o u g h the tear itself m a y be a s y m p t o m a t i c , ulnolunate abutment m a y be the cause o f chronic ulnar-sided wrist pain. Traumatic tears m a y occur either centrally at the
thin attachment to the s i g m o i d notch o f the radius ~° or from the ulnar styloid extending along the ulnocarpal ligaments. 2 These m a y occur in association with distal radius fractures, a subluxated distal radioulnar joint, carpal ligament disruption, or even m i n o r injury to the wrist.2,3, I3-27 A s with m e n i s c a l lesions o f the knee, treatment op-
A R T H R O S C O P I C REPAIR OF THE WRIST
T A B L E 2. M a y o Modified Wrist Score Points Pain (25 points)
Functional status
Motion (25 points) Percentage of normal 90-100 80-90 70-80 50-70 25-50 0-25 Grip strength (25 points)
25 20 15 0 25 20 15 0
No pain Mild, occasional Moderate, tolerable Severe to untolerable Return to regular employment Restricted employment Able to work, unemployed Unable to work, pain
25 20 15 10 5 0 25 15 10 5 0
Total motion 120° or more 100°-120° 90°-100 ° 600-90° 300-60° 0°-30° 90%-100% 75%-90% 50%-75% 25%-50% 0%-25%
NOTE. Result Score: Excellent: 90-100 points, Good: 80-90, Fair: 65-80, Poor: <65.
tions for tears of the TFCC should be dependent on where the tear occurs. Imbriglia and Boland 28 recommended excision of the articular disc in patients with avulsion of the TFCC from the dorsal ligamentous attachment. If the tear occurs in this well-vascularized region, however, the potential for healing exists, and therefore repair should be performed to restore normal functional anatomy. In 1991, Hermansdorfer and Kleinmen 29 reported the largest series to date of open repair of chronic peripheral tears of the TFCC, in which 8 of 11 patients returned to painless normal activity. With advances in wrist arthroscopy, Zachee et al 3° described a technique for TFCC repairs, although they did not report any clinical results. Using a zone-specific repair kit, we combined the results of three institutions to report the largest series of arthroscopic repairs of peripheral TFCC tears. Pathological conditions of the wrist, and specifically the ulnar side, cover a spectrum of abnormalities, making diagnosis difficult. As was the case in this study, a TFCC tear may be associated with other lesions of the wrist. Diagnostic testing, including arthrography and MRI, are not only invasive and expensive, but may be nonspecific. Arthrography was shown to be reliable by confirming the diagnosis in 15 patients, but it will not differentiate peripheral versus central degenerative tears, as reported by othersY Although the accuracy of MRI has been demonstrated to be as
83
high as 95% in detecting TFCC tears, 31 in our study, four patients with a negative MRI had a tear found by arthrogram and at arthroscopy.
CONCLUSION In summary, tears of the TFCC are a major cause of ulnar-sided wrist pain. It is important to preserve its integrity, when possible, because of its importance as a buffer to compression forces at the wrist and as a major DRUJ stabilizer. When detached at its vascularized peripheral portion, open repair can be performed, with an extensive approach, although access through an arthrotomy may be difficult. There is no question of the value of arthroscopy, therefore, in the diagnosis and differentiation of TFCC pathological conditions. Its value in minimizing soft tissue trauma, cosmesis, and quicker recovery are realized only if the arthroscopic technique is precise and yields good results. We have described an arthroscopically assisted technique that we believe is precise and results in an accurate approximation of peripheral avulsions of the TFCC. Our patients returned to normal activity by 3 months, with 92% achieving satisfactory results.
REFERENCES 1. Palmer AK. Triangulate fibrocartilage complex lesions: A classification. J Hand Surg Am 1989; 14:594-606. 2. Bowers WH. The distal radioulnar joint. In: Green DP, ed. Operative hand Surgery. Ed 2. New York: Churchill Livingstone, 1988; 946-952. 3. Coleman HM. Injuries of the articular disc at the wrist. J Bone Joint Surg Br 1960;42:522-529. 4. Darrow JC, Linscheid RL, Dobyns JH, Mann JM, Wood MB, Beckenbaugh RD. Distal ulnar recession for disorders of the distal radioulnar joint. J Hand Surg Am 1985; 10:482-491. 5. Faupel L, Kunze K, Rehm K. Indikation and ergebruisse du verkurzungsosteotome der ulna. Unfallchirurgie 1984; 10:250253. 6. Linscheid RL. Ulnar lengthening and shortening. Hand Clin 1987;3:69-79. 7. Menon J, Wood V, Schoene H, et al. Isolated tears of t~e triangular fibrocartilage of the wrist: Results of partial excision. J Hand Surg Am 1984;9:527-530. 8. Van der Linden A. Disk lesion of the wrist. J Hand Surg Am 1986; 11:490-497. 9. Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist: Anatomy and function. J Hand Surg 1981;6:153162. 10. Whipple TL. The triangular fibrocartilage complex. In: Whipple TL, ed. Arthroscopic surgery of the wrist. Ed 1. Philadelphia: Lippincott, 1992; 103-118. 11. Mikic ZDG. Age changes in the triangular fibrocartilage of the wrist joint. J Anat 1978; 126:367-384. 12. Albert SM, Wohl MD, Rechtman AM. Treatment of the disrupted radioulnar joint. J Bone Joint Surg Am 1963;45:13731381. 13. Alexander HA. Bilateral traumatic dislocation of the dis-
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14. 15. 16. 17. 18. 19. 20. 21. 22.
S. J. C O R S O
tal radioulnar joint, ulna dorsal. Clin Orthop 1977; 129:238244. Dameron TB. Traumatic dislocation of the distal radioulnar joint. Clin Orthop 1972;83:55-63. Darrach N. Anterior dislocation of the head of the ulna. Ann Surg 1912;56:802-803. DeSault M. Extrait d'un memoire de M. DeSault sur la luxation de l'extremite inferieure du radius. J Chir 1791; 1:78-87. Essex-Lopresti P. Fractures of the radial head with distal radioulnar dislocation. J Bone Joint Surg Br 1951;33:244-247. Gartland JJ, Nerley CN. Evaluation of healed Colles' fractures. J Bone Joint Surg Am 1951;33:895-907. Habert CG. Functional aspects of the distal radioulnar joint. J Hand Surg 1979;4:585. Hamlin C. Traumatic disruption of the distal radioulnar joint. Am J Sports Med 1977;5:93-97. Heiple KG, Freehafer AA, VanThof H. Isolated traumatic dislocation of the distal end of the ulna or distal radioulnar joint. J Bone Joint Surg Am 1962;44:1387-1394. Liebolt FL. A new method for repair of the distal radioulnar ligaments. NY State J Med 1950; 2817-2819.
ET AL.
23. Martinek H, Spangler H. Zur traumotologie des discus articularis des handgelenks. Arch Orthop Trauma Surg 1977; 87:299-308. 24. Milch H. So-called dislocation of the lower end of the ulna, Ann Surg 1942; 116:282-292. 25. Rose-Innes AP. Anterior dislocation of the ulna at the inferior radioulna joint. J Bone Joint Surg Br 1960; 42:515-521. 26. Taylor GW, Parsons CL. The role of the discus articularis in Colles' fractures. J Bone Joint Surg Am 1938;20:149-152. 27. Weigh K, Spira E. The triangular fibrocartilage of the wrist joint. Reconstr Surg Traumatol 1969; 11:139-153. 28. Imbriglia JE, Boland DS. Tears of the articular disc of the triangular fibrocartilage complex: Results of excision of the articular disc. J Hand Surg 1983;8:620. 29. Hermansdorfer JD, Kleinman WB. Management of chronic peripheral tears of the triangular fibrocartilage complex. J Hand Surg Am 1991; 16:340-346. 30. Zachee B, DeSmet L, Fabry G. Arthroscopic suturing of TFCC lesions. Arthroscopy 1993;9:242-243. 31. Golimbu CN, Firooznia H, Melone CP, Rafii M, Weinreb J, Leber C. Tears of the triangular fibrocartilage of the wrist: MR imaging. Radiology 1989; 173:731-733.
Summary: A multicenter study to assess arthroscopic reconstruction of the peripheral attachment of the triangular fibrocartilage complex was undertaken. A total of 44 patients (45 wrists) from three institutions were reviewed. Twenty-seven of the 45 wrists had associated injuries, including distal radius fracture (4), partial or complete rupture of the scapholunate (7), lunotriquetral (9), ulnocarpal (2), or radiocarpal (2) ligaments. There were two fractured ulnar styloids and one scapholunate accelerated collapse (SLAC) wrist deformity. The peripheral tears were repaired using a zone-specific repair kit. The patients were immobilized in a munster cast, allowing elbow flexion and extension, but no pronation or supination for 4 weeks, followed by 2 to 4 weeks in a short arm cast or VersaWrist splint. All patients were reexamined independently 1 to 3 years postoperatively by a physician, therapist, and registered nurse. The results were graded according to the Mayo modified wrist score. Twenty-nine of the 45 wrists were rated excellent, 12 good, 1 fair, and 3 poor. Overall, 42 of the 45 patients (93%) rated as satisfactory and returned to sports or work activities. One patient had chronic pain, and two patients had ulnar nerve symptoms, although motion was normal in all, and their grip strength was at least 75% of the opposite hand. Arthroscopic repair of peripheral tears of the triangular fibrocartilage complex (TFCC) is a satisfactory method of repairing these injuries. Key Words: Arthroscopic repair--Peripheral--Triangular fibrocartilage complex--Traumatic tears.
lthough initially controversial, recent investigation has established tears of the triangular fibrocartilage complex (TFCC) as a primary cause of ulnarsided wrist pain and instability of the distal radioulnar joint (DRUJ). The TFCC can tear either in its avascular central portion or peripherally, and these lesions have been well classified by Palmer. 1 Treatment options for TFCC tears have varied from simple debridement to complete excision, ulna shortening to a Darrach procedure, or open repair, dependent
A
From Tuckahoe Orthopaedic Associates, Richmond, Virginia; and the Mississippi Sports Medicine & Orthopaedic Center, Jackson, Mississippi, U.S.A. Address correspondence and reprint requests to Salvatore J. Corso, M.D., Orthopaedics and Sports Associates of Long Island, 205 Froehlich Farm Blvd, Woodbury, NY 11797, U.S.A. © 1997 by the Arthroscopy Association of North America 0749-8063/97/1301-141253.00/0
78
on the type of tear present. 18'12 The recognition of the role of the triangular fibrocartilage as a major DRUJ stabilizer and a buffer to compressive forces 9 indicates the importance of preserving as much of this structure as possible. Open repair of the vascularized peripheral margin has been described using an extensive exposure of the ulnar side of the wrist. Recent advances in wrist arthroscopy have allowed the realization of performing conventional open procedures arthroscopically. The purpose of the current study is to show that this repair can be achieved with precision using an arthroscopic technique, avoiding a significant open exposure, with excellent clinical results.
MATERIALS AND METHODS A multicenter study to assess distal radio-ulnar joint instability managed by arthroscopic reconstruction of
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 13, No 1 (February), 1997: pp 78-84
ARTHROSCOPIC REPAIR OF THE WRIST
TABLE 1. Injuries Associated With TFCC Tears Injury • Rupture of: Lunotriquetral ligament Scapholunate ligament Ulnocarpal ligament Radiocarpal ligament Fracture of: Distal radius Ulnar styloid SLAC wrist
Number 9 7 2 2 4 2 1
the peripheral attachment of the TFCC from January 1990 to February 1993 was undertaken. A total of 44 patients (45 wrists) from three institutions were reviewed. Clinical instability was initiated by a traumatic event in 41 of 45 wrists. Twenty-six male and 18 female patients ranging in age from 14 to 52 years, with a mean of 32.5 years, were evaluated. The dominant hand was involved in 22 cases. Twenty-six of the injuries involved the left hand, and nineteen the right hand. Most patients commonly complained of ill-defined pain referable to the ulna side of the wrist with an occasional description of a clicking sensation. On clinical evaluation, the most consistent finding, although nonspecific, included tenderness to direct palpation over the dorsal or volar aspect of the distal ulna, usually just distal to the styloid. Pain also may be elicited by passively pronating or supinating the wrist while stabilizing the forearm. In most patients, power grip was significantly diminished. A positive magnetic resonance imaging (MRI) scan was obtained in 17 cases. Fifteen patients had positive arthrograms, including four patients in whom the MRI was negative. Five patients had a negative MRI and arthrogram. The remaining patients did not have any preoperative studies, and had tears discovered during arthroscopy of the wrist for other injuries. Twentyseven of the 45 wrists had associated injuries, including distal radius fracture, partial or complete rupture of the scapholunate, lunotriquetral, ulnocarpal, or radiocarpal ligament. There were two fractured ulnar styloids and one scapholunate accelerated collapse (SLAC) wrist (Table 1).
Surgical Technique All procedures were performed by three surgeons (T.L.W., F.H.S., W.B.G.) using a zone-specific repair kit, (INTEQ, Linvatec, Largo, FL) placed through a small incision over the sixth extensor compartment under arthroscopic guidance. Wrist arthroscopy was performed under general or regional (axillary block,
79
Bier block) anesthesia. After sterile preparation and draping, the hand was placed in a Tower traction device. Inflow is established through a 6U or 1-2 portal. Tears of the TFCC are well visualized through a 3-4 portal, although some peripheral tears initially may not be apparent. Presence of hypertrophic synovium may mask tears parallel to either the volar or dorsal margin1°; however, this may be evidence that an underlying tear exists. A probe may be placed in the 6R portal, and the TFCC can be probed for defects and its elasticity assessed. If significant laxity exists in the body of the TFCC as it runs from the radius to ulna (loss of the trampoline effect), this is evidence that it is detached peripherally. Whipple 1° has described squeezing the dorsal and volar aspect of the DRUJ capsule, which may evert the edges of a torn TFCC as fluid is forced into the radiocarpal space. Once the tear is established, a power shaver can be placed through the 6R portal to debride the edges of the tear and overlying synovium. The shaver is removed, and a small 1.5-cm. incision is made over the head of the ulna (Fig 1). The extensor carpi ulnaris tendon is retracted ulnarly, to expose the floor of the sixth extensor compartment. The curved cannulated suture passer is then inserted through the floor of the extensor carpi ulnaris (ECU) sheath and under arthroscopic guidance is passed through the peripheral edge of the torn TFCC (Fig 2). The second component of the repair kit, the loop suture retriever, is placed over the end of the suture passer. The 2 - 0 PDS suture is then passed through the hook by spinning the wheel on the passer (Fig 3). The suture retriever is then pulled back out of the joint, bringing the end of the suture with it, and leaving a suture in the peripheral edge (Fig 4). After placing two to three sutures dorsal to volar, with tension on the sutures, the wrist is pronated and supinated to assess the position of the wrist that would best reduce the tear. The wrist is then held in this position, and the sutures are tied down over the floor of the sixth extensor compartment (Fig 5). The superficial extensor retinaculum is reapproximated, and the wound is closed with a subcuticular suture.
Postoperative Care The patient is placed in a Munster or long arm cast postoperatively for 4 weeks. At this point, the wrist is placed in a short arm splint or Versa wrist splint, allowing progressive motion to the wrist. The patients can then continue range of motion and grip-strengthening exercises and usually can resume normal activity by 3 months postoperatively.
S. J. CORSO E T AL.
80
increased to an average of 87.5. This increase was statistically significant as calculated using a Student's t-test for analysis of variance (P < .05). Improvement in pain and function were immediate and dramatic. Improvements in grip strength and motion were more moderate and took longer to develop. In most cases, full motion returned at an average of 10 to 12 weeks postoperatively.
A
3-~
- 6R portal -
1.5 c m incision
FIG 1. A 1.5-cm incision is made over the head of the ulna to expose the sixth extensor dorsal compartment.
RESULTS All patients were reexamined independently at a range o f 6 months to 3 years postoperatively by a physician, therapist, or registered nurse. The average follow-up was 37 months. The results were graded according to the M a y o modified wrist score (Table 2) and compared with preoperative scores. The average preoperative wrist score was 45.9. Postoperatively this
FIG 2. (A) Graphic illustrating the curved cannulated suture passer with tip through the edge of the torn tfcc. (B) Arthroscopic view. L, lunate.
ARTHROSCOPIC REPAIR OF THE WRIST
Twenty-nine of the 45 wrists were rated as excellent, 12 as good, one as fair, and three as poor. Overall, 42 of the 45 patients (93%) rated as satisfactory and returned to sports or work activities. O f the three patients who had a poor result, one had chronic pain and two patients had ulnar nerve dysesthesias that were complications of portal placement. Also one had an associated S L A C wrist and eventually required a wrist fusion. The two patients with ulnar nerve dysesthesias continued to be followed. After conservative treatment including antiinflammatories and local cortisone injections, their symptoms resolved. Motion was normal in all three, and their grip strength was at least 75% of the opposite
81
A
FIG 4. (A) Suture retriever is removed from the wrist joint, bringing with it the free end of the suture. (B) Arthroscopic view.
hand. The two patients with ulnar nerve symptoms displayed clinical signs of superficial neuromas and were being treated accordingly. DISCUSSION
FIG 3. (A) Illustration shows the suture retriever in place over the tip of the suture passer. 2-0 PDS suture is passed through by spinning the wheel on the passer. (B) Arthroscopic view.
With recent advances in evaluation and arthroscopy of wrist pathology, tears of the T F C C have been found to be a cause of ulnar-sided wrist pain. The type of tear found has a direct effect on treatment options and subsequent prognosis. Chronic degenerative tears of the T F C C are common, and after the age of 50, are believed by some
82
S.J.
CORSO E T AL.
C
FIG 5. (A) Peripheral tfcc tear (arrow). L, lunate; d, dorsal. (B) Three 2-0 PDS sutures in place reapproximating the avulsed tfcc to the dorsal capsule. (C) Drawing shows suture tied down over the sixth extensor compartment.
to be universal, paralleling cartilage changes in other joints. 11 These are associated with an ulnar-neutral or ulnar-positive variance causing c o m p r e s s i o n o f the disc b e t w e e n ulnar head and carpus. A l t h o u g h the tear itself m a y be a s y m p t o m a t i c , ulnolunate abutment m a y be the cause o f chronic ulnar-sided wrist pain. Traumatic tears m a y occur either centrally at the
thin attachment to the s i g m o i d notch o f the radius ~° or from the ulnar styloid extending along the ulnocarpal ligaments. 2 These m a y occur in association with distal radius fractures, a subluxated distal radioulnar joint, carpal ligament disruption, or even m i n o r injury to the wrist.2,3, I3-27 A s with m e n i s c a l lesions o f the knee, treatment op-
A R T H R O S C O P I C REPAIR OF THE WRIST
T A B L E 2. M a y o Modified Wrist Score Points Pain (25 points)
Functional status
Motion (25 points) Percentage of normal 90-100 80-90 70-80 50-70 25-50 0-25 Grip strength (25 points)
25 20 15 0 25 20 15 0
No pain Mild, occasional Moderate, tolerable Severe to untolerable Return to regular employment Restricted employment Able to work, unemployed Unable to work, pain
25 20 15 10 5 0 25 15 10 5 0
Total motion 120° or more 100°-120° 90°-100 ° 600-90° 300-60° 0°-30° 90%-100% 75%-90% 50%-75% 25%-50% 0%-25%
NOTE. Result Score: Excellent: 90-100 points, Good: 80-90, Fair: 65-80, Poor: <65.
tions for tears of the TFCC should be dependent on where the tear occurs. Imbriglia and Boland 28 recommended excision of the articular disc in patients with avulsion of the TFCC from the dorsal ligamentous attachment. If the tear occurs in this well-vascularized region, however, the potential for healing exists, and therefore repair should be performed to restore normal functional anatomy. In 1991, Hermansdorfer and Kleinmen 29 reported the largest series to date of open repair of chronic peripheral tears of the TFCC, in which 8 of 11 patients returned to painless normal activity. With advances in wrist arthroscopy, Zachee et al 3° described a technique for TFCC repairs, although they did not report any clinical results. Using a zone-specific repair kit, we combined the results of three institutions to report the largest series of arthroscopic repairs of peripheral TFCC tears. Pathological conditions of the wrist, and specifically the ulnar side, cover a spectrum of abnormalities, making diagnosis difficult. As was the case in this study, a TFCC tear may be associated with other lesions of the wrist. Diagnostic testing, including arthrography and MRI, are not only invasive and expensive, but may be nonspecific. Arthrography was shown to be reliable by confirming the diagnosis in 15 patients, but it will not differentiate peripheral versus central degenerative tears, as reported by othersY Although the accuracy of MRI has been demonstrated to be as
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high as 95% in detecting TFCC tears, 31 in our study, four patients with a negative MRI had a tear found by arthrogram and at arthroscopy.
CONCLUSION In summary, tears of the TFCC are a major cause of ulnar-sided wrist pain. It is important to preserve its integrity, when possible, because of its importance as a buffer to compression forces at the wrist and as a major DRUJ stabilizer. When detached at its vascularized peripheral portion, open repair can be performed, with an extensive approach, although access through an arthrotomy may be difficult. There is no question of the value of arthroscopy, therefore, in the diagnosis and differentiation of TFCC pathological conditions. Its value in minimizing soft tissue trauma, cosmesis, and quicker recovery are realized only if the arthroscopic technique is precise and yields good results. We have described an arthroscopically assisted technique that we believe is precise and results in an accurate approximation of peripheral avulsions of the TFCC. Our patients returned to normal activity by 3 months, with 92% achieving satisfactory results.
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