- Email: [email protected]
Safety Analysis of All-Inside Arthroscopic Repair of Peripheral Triangular Fibrocartilage Complex
Safety Analysis of All-Inside Arthroscopic Repair of Peripheral Triangular Fibrocartilage Complex MAJ Scott M. Waterman, M.D., MC, USA, MAJ Dirk Slade, M.D., MC, USA, CPT Brendan D. Masini, M.D., MC, USA, and MAJ Brett D. Owens, M.D., MC, USA
Purpose: The purpose of this study was to determine whether an all-inside peripheral triangular fibrocartilage complex (TFCC) repair using the FasT-Fix device (Smith & Nephew Endoscopy, Andover, MA) is safe by measuring the proximity of the anchors to ulnar-sided anatomic structures. Methods: Eleven fresh-frozen cadaveric wrists were thawed and placed in traction. Under direct arthroscopic visualization, an all-inside arthroscopic peripheral TFCC repair was completed by placing a single FasT-Fix device in a vertical mattress fashion. The wrists were then dissected to visualize the 2 anchors. The distance between these anchors and the flexor carpi ulnaris (FCU), extensor carpi ulnaris (ECU), and dorsal branch of the ulnar sensory nerve (DBUN) were measured with digital calipers and recorded. Results: The peripheral anchor averaged 4.2 mm (range, 0 to 14 mm) from the ECU tendon, 3.8 mm (range, 0 to 9 mm) from the DBUN, and 8.3 mm (range, 1 to 15 mm) from the FCU tendon. The central anchor averaged 9.6 mm (range, 2 to 15 mm) from the ECU tendon, 6.8 mm (range, 1 to 13 mm) from the DBUN, and 7.6 mm (range, 1 to 13 mm) from the FCU tendon. Conclusions: This study exposes some safety concerns with the all-inside peripheral TFCC repair using the FasT-Fix device, which was found to reside in close proximity to the ECU, FCU, and DBUN. In multiple wrists the anchors were noted to underlie the anatomic structure that we measured, making it possible to pierce these structures with the needle before deployment of the anchor. Clinical Relevance: Though technically feasible, all-inside arthroscopic repair of the peripheral TFCC risks injury to the ulnar-sided anatomy.
I
njuries to the triangular fibrocartilage complex (TFCC), an important wrist stabilizer, are a common cause of ulnar-sided wrist pain.1-5 TFCC tears
From the Walter Reed National Military Medical Center (S.M.W.), Bethesda, Maryland; William Beaumont Army Medical Center (D.S.), El Paso, Texas; San Antonio Military Medical Center (B.D.M.), San Antonio, Texas; and Keller Army Community Hospital (B.D.O.), West Point, New York, U.S.A. The opinions of the authors expressed herein do not necessarily state or reflect those of the US Government or the Department of Defense. Supported by the US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX. The authors report no conflict of interest. Received July 11, 2009; accepted February 18, 2010. Address correspondence and reprint requests to MAJ Scott M. Waterman, M.D., MC, USA, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889. E-mail: [email protected] Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America 0749-8063/9413/$0.00 doi:10.1016/j.arthro.2010.02.027
1474
pose a significant treatment challenge for hand and arthroscopic surgeons.6 Traumatic tears that occur in the well-vascularized, peripheral region of the TFCC, Palmer type IB, respond well to surgical repair.7-15 Surgical management is usually performed with arthroscopic-assisted techniques, which have good results and clinical outcomes.5,16,17 These repair techniques have used multiple fixation methods, which have resulted in injuries to the dorsal branch of the ulnar sensory nerve (DBUN), subcutaneous knots, uncomfortable buttons over the skin, and extra incisions.18-22 Recently, all-inside techniques have been proposed to minimize symptomatic fixation methods and limit incisions.6,13 Although these techniques have been used in only small case series, there are no reports of injuries to the DBUN or other ulnar-sided structures.6,23,24 Because of these small numbers, Lee et al.24 recommended further evaluation to determine the safety of this procedure. Proving the safety of suture anchor placement from the all-inside arthros-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 26, No 11 (November), 2010: pp 1474-1477
SAFETY OF ALL-INSIDE PERIPHERAL TFCC REPAIR
FIGURE 1. Arthroscopic view of left wrist with location of proximal and distal anchor labeled. The ECU sub-sheath and location of 6U portal are referenced for appropriate anchor placement.
copic technique would improve the physician’s ability to adequately inform patients and receive their consent, as well as provide the best care possible. This study was designed to evaluate the safety profile of all-arthroscopic techniques using a cadaveric repair model. We hypothesized that the all-inside arthroscopic repair would be a safe procedure with greater than 5 mm between the anchor and the adjacent structures. METHODS Eleven cadaveric wrists were thawed at ambient room temperature before surgery. There were 6 right and 5 left wrists and 5 female and 6 male wrists. The mean age of the cadavers was 42 years (range, 19 to 60 years). The fingers were placed in finger traps with traction placed as needed on the forearm, usually 10 to 12 lb. One of the authors, a fellowship-trained hand surgeon, performed all of the procedures according to the technique described by Yao et al.6,23 By use of the 6R portal for arthroscopic visualization and 3-4 portal for instrumentation, a standard wrist arthroscopy was performed. No peripheral TFCC tears were noted or created, which allowed for an ideal anchor placement. With visualization provided by a 30°, 2.9-mm arthroscope in the 6R portal, a curved FasT-Fix (Smith & Nephew Endoscopy, Andover, MA) was inserted through the 3-4 portal. The prestyloid recess and visualization of the location of the 6U portal were referenced for appropriate anchor placement (Fig 1). The anchor was deployed after feeling a decrease in resistance after penetration of the wrist capsule. The depth penetration limiter was not used. The FasT-Fix was first inserted through the peripheral, distal ulnar capsule, deploying the first poly-L-lactic acid (PLLA)
1475
block. The second FasT-Fix anchor was loaded by use of the trigger and the needle inserted in the central, proximal TFCC, deploying the second PLLA anchor in the same fashion as described previously, forming a vertical mattress configuration. The needle introducer was then removed from the joint and the knot pusher/ cutter introduced to tighten and cut the suture. All arthroscopic equipment and traction were then removed. The wrists were dissected to visualize the embedded PLLA blocks in relation to the ulnar-sided structures. The distances between the PLLA anchors and the flexor carpi ulnaris (FCU), extensor carpi ulnaris (ECU), and DBUN were measured with a digital caliper (Mitutoyo CD– 6-inch CSX; Mitutoyo, Aurora, IL) 3 times by a single author. The mean of all 3 measurements was entered into a spreadsheet (Microsoft Excel; Microsoft, Redmond, WA). The mean distance between the proximal and distal blocks and the anatomic structures was then calculated for the 11 samples.
RESULTS The peripheral anchor averaged 4.2 mm (range, 0 to 14 mm) from the ECU tendon, 3.8 mm (range, 0 to 9 mm) from the DBUN, and 8.3 mm (range, 1 to 15 mm) from the FCU tendon. One anchor was just deep to, but in contact with, the DBUN (Fig 2), whereas another was in contact with the ECU (Fig 3). The central anchor averaged 9.6 mm (range, 2 to 15 mm) from the ECU tendon, 6.8 mm (range, 1 to 13 mm) from the DBUN, and 7.6 mm (range, 1 to 13 mm) from the FCU (Table 1).
FIGURE 2. Peripheral anchor for TFCC repair deep to DBUN. The ECU tendon is exposed through an incision in the ECU sheath.
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FIGURE 3. sheath.
S. M. WATERMAN ET AL.
Peripheral anchor for TFCC repair through ECU
DISCUSSION The TFCC is a group of intimately related ulnarsided wrist structures. Biomechanical studies indicate that the TFCC imparts translational stability to the distal radioulnar joint and buffers compressive forces during axial loading of the wrist.1,25,26 Tears of the TFCC can therefore result in instability of the distal radioulnar joint and ulnar-sided wrist pain.1,26,27 TFCC tears can occur either centrally or peripherally, with peripheral tears being better vascularized and thought to have greater potential for healing.7,15 Peripheral TFCC tears have typically been addressed by use of arthroscopic-assisted outside-in and inside-out techniques, but these techniques require additional incisions, risk injury to the DBUN and ECU tendon, and sometimes require subcutaneous incisions.6,13,18,19,21,24 Although many studies on these techniques have noted that there is no risk to the ulnar neurovascular bundle if the needle is inserted dorsal to the FCU, they do not document the proximity to the DBUN.21,28,29 McAdams and Hentz18 in a cadaveric study noted that the DBUN has a variable course and reported that the sutures passed using an outside-in technique were in close proximity to the DBUN in all specimens. They concluded that a longitudinal incision should be used to minimize risk to the DBUN. Recently, all-inside techniques have been introduced with proponents noting none of the above injuries in small case series.6,13,23 Yao23 recently evaluated his all-inside technique in a cadaveric study using the FasT-Fix. He noted that all anchors were dorsal to the ECU, a mean of 1.8 cm from the ulnar neurovascular bundle, and a mean of 17.1 mm from the DBUN. The author of this study does not document whether he
references any landmarks for anchor placement in his technique. This study does not document the range of distances from the anchors to any of the ulnar-sided structures but just notes the mean distances. This technique differs from our technique in that Yao uses 2 FasT-Fix devices as opposed to the 1 in this study. Our study is the first study to independently evaluate this technique, and in none of our specimens was the distal anchor more than 1 cm away from the DBUN, with 7 of the 11 proximal anchors being within 5 mm. Our results echo the results of McAdams and Hentz in evaluating this new technique, noting that the DBUN is at risk when performing an all-inside TFCC repair and an additional incision is required to protect the DBUN. Although there are no reports of injury to ulnarsided structures from an all-arthroscopic repairs, only a few small case series have reported the results of such repairs.6,24 The DBUN was noted to vary in its anatomic location when overlying the ulnar wrist capsule, making safe placement of anchors difficult. This study documents the close proximity of the anchors to the ECU, FCU, and DBUN. In 2 specimens the anchors were noted to underlie the DBUN and ECU tendon, raising concerns for the safety profile of this procedure. Because of the proximity of the DBUN and ECU to the peripheral anchor, an additional safety incision should be considered to expose and protect ulnar-sided wrist anatomy. The strength of this study was that it was only designed to assess the distance from ulnar-sided structures to PLLA anchors from an all-inside peripheral TFCC repair. This is generalizable to the all-inside techniques that are currently published because these require penetration of the ulnar capsule with a needle. That there were no tears in the TFCC is both a strength and a weakness of this study. This allowed for improved visualization of anchor placement in the area where peripheral tears are located, but it did not replicate the same situation a surgeon is faced with when performing these all-inside repairs. The final weakness of this study is that it does not assess the functional outcomes. Although we note that these anchors TABLE 1.
Proximal anchor Distal anchor
Distances From Anchors
ECU Tendon (mm)
FCU Tendon (mm)
DBUN (mm)
4.2 (0-14.3) 9.6 (2.2-18.2)
8.3 (1.4-14.7) 7.6 (1.2-13.5)
3.8 (0.4-9.4) 6.8 (0.9-13.4)
NOTE. Data are presented as mean (range).
SAFETY OF ALL-INSIDE PERIPHERAL TFCC REPAIR are in close proximity to vital ulnar-sided structures, we were unable to assess whether this would have led to further pain or symptoms. CONCLUSIONS This study exposes some safety concerns with the all-inside peripheral TFCC repair using the FasTFix device, which was found to reside in close proximity to the ECU, FCU, and DBUN. In multiple wrists the anchors were noted to underlie the anatomic structure that we measured, making it possible to pierce these structures with the needle before deployment of the anchor.
12.
13. 14. 15. 16.
17.
Acknowledgment: The authors thank the US Army Institute of Surgical Research for providing the facilities and financial support for this research.
18.
REFERENCES
19.
1. Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist—Anatomy and function. J Hand Surg Am 1981; 6:153-162. 2. Osterman AL. Arthroscopic debridement of triangular fibrocartilage complex tears. Arthroscopy 1990;6:120-124. 3. Menon J, Wood VE, Schoene HR, Frykman GK, Hohl JC, Bestard EA. Isolated tears of the triangular fibrocartilage of the wrist: Results of partial excision. J Hand Surg Am 1984;9:527530. 4. Ahn AK, Chang D, Plate AM. Triangular fibrocartilage complex tears: A review. Bull NYU Hosp Jt Dis 2006;64:114-118. 5. Hermansdorfer JD, Kleinman WB. Management of chronic peripheral tears of the triangular fibrocartilage complex. J Hand Surg Am 1991;16:340-346. 6. Yao J, Dantuluri P, Osterman AL. A novel technique of all-inside arthroscopic triangular fibrocartilage complex repair. Arthroscopy 2007;23:1357.e1-1357.e4. Available online at www.arthroscopyjournal.org. 7. Bednar MS, Arnoczky SP, Weiland AJ. The microvasculature of the triangular fibrocartilage complex: Its clinical significance. J Hand Surg Am 1991;16:1101-1105. 8. Chen AC, Hsu KY, Chang CH, Chan YS. Arthroscopic suture repair of peripheral tears of triangular fibrocartilage complex using a volar portal. Arthroscopy 2005;21:1406.e1-1406.e4. Available online at www.arthroscopyjournal.org. 9. Chou CH, Lee TS. Peripheral tears of triangular fibrocartilage complex: Results of primary repair. Int Orthop 2001;25:392395. 10. Chou KH, Sarris IK, Sotereanos DG. Suture anchor repair of ulnar-sided triangular fibrocartilage complex tears. J Hand Surg Br 2003;28:546-550. 11. Conca M, Conca R, Dalla Pria A. Preliminary experience of fully arthroscopic repair of triangular fibrocartilage complex
20. 21. 22. 23.
24.
25. 26. 27. 28. 29.
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lesions. Arthroscopy 2004;20:e79-e82. Available online at www.arthroscopyjournal.org. Degreef I, Welters H, Milants P, Van Ransbeeck H, De Smet L. Disability and function after arthroscopic repair of ulnar avulsions of the triangular fibrocartilage complex of the wrist. Acta Orthop Belg 2005;71:289-293. Estrella EP, Hung LK, Ho PC, Tse WL. Arthroscopic repair of triangular fibrocartilage complex tears. Arthroscopy 2007;23: 729-737.e1. Available online at www.arthroscopyjournal.org. Palmer AK. Triangular fibrocartilage complex lesions: A classification. J Hand Surg Am 1989;14:594-606. Thiru RG, Ferlic DC, Clayton ML, McClure DC. Arterial anatomy of the triangular fibrocartilage of the wrist and its surgical significance. J Hand Surg Am 1986;11:258-263. Corso SJ, Savoie FH, Geissler WB, Whipple TL, 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. Papapetropoulos PA, Ruch DS. Repair of arthroscopic triangular fibrocartilage complex tears in athletes. Hand Clin 2009; 25:389-394. McAdams TR, Hentz VR. Injury to the dorsal sensory branch of the ulnar nerve in the arthroscopic repair of ulnar-sided triangular fibrocartilage tears using an inside-out technique: A cadaver study. J Hand Surg Am 2002;27:840-844. Tsu-Hsin Chen E, Wei JD, Huang VW. Injury of the dorsal sensory branch of the ulnar nerve as a complication of arthroscopic repair of the triangular fibrocartilage. J Hand Surg Br 2006;31:530-532. Bednar JM, Osterman AL. The role of arthroscopy in the treatment of traumatic triangular fibrocartilage injuries. Hand Clin 1994;10:605-614. Trumble TE, Gilbert M, Vedder N. Isolated tears of the triangular fibrocartilage: Management by early arthroscopic repair. J Hand Surg Am 1997;22:57-65. Whipple TL, Geissler WB. Arthroscopic management of wrist triangular fibrocartilage complex injuries in the athlete. Orthopedics 1993;16:1061-1067. Yao J. All-arthroscopic triangular fibrocartilage complex repair: Safety and biomechanical comparison with a traditional outside-in technique in cadavers. J Hand Surg Am 2009;34: 671-676. Lee CK, Cho HL, Jung KA, Jo JY, Ku JH. Arthroscopic all-inside repair of Palmer type 1B triangular fibrocartilage complex tears: A technical note. Knee Surg Sports Traumatol Arthrosc 2008;16:94-97. Adams BD. Partial excision of the triangular fibrocartilage complex articular disk: A biomechanical study. J Hand Surg Am 1993;18:334-340. Palmer AK, Werner FW, Glisson RR, Murphy DJ. Partial excision of the triangular fibrocartilage complex. J Hand Surg Am 1988;13:391-394. Adams BD, Holley KA. Strains in the articular disk of the triangular fibrocartilage complex: A biomechanical study. J Hand Surg Am 1993;18:919-925. de Araujo W, Poehling GG, Kuzma GR. New Tuohy needle technique for triangular fibrocartilage complex repair: Preliminary studies. Arthroscopy 1996;12:699-703. Skie MC, Mekhail AO, Deitrich DR, Ebraheim NE. Operative technique for inside-out repair of the triangular fibrocartilage complex. J Hand Surg Am 1997;22:814-817.
Purpose: The purpose of this study was to determine whether an all-inside peripheral triangular fibrocartilage complex (TFCC) repair using the FasT-Fix device (Smith & Nephew Endoscopy, Andover, MA) is safe by measuring the proximity of the anchors to ulnar-sided anatomic structures. Methods: Eleven fresh-frozen cadaveric wrists were thawed and placed in traction. Under direct arthroscopic visualization, an all-inside arthroscopic peripheral TFCC repair was completed by placing a single FasT-Fix device in a vertical mattress fashion. The wrists were then dissected to visualize the 2 anchors. The distance between these anchors and the flexor carpi ulnaris (FCU), extensor carpi ulnaris (ECU), and dorsal branch of the ulnar sensory nerve (DBUN) were measured with digital calipers and recorded. Results: The peripheral anchor averaged 4.2 mm (range, 0 to 14 mm) from the ECU tendon, 3.8 mm (range, 0 to 9 mm) from the DBUN, and 8.3 mm (range, 1 to 15 mm) from the FCU tendon. The central anchor averaged 9.6 mm (range, 2 to 15 mm) from the ECU tendon, 6.8 mm (range, 1 to 13 mm) from the DBUN, and 7.6 mm (range, 1 to 13 mm) from the FCU tendon. Conclusions: This study exposes some safety concerns with the all-inside peripheral TFCC repair using the FasT-Fix device, which was found to reside in close proximity to the ECU, FCU, and DBUN. In multiple wrists the anchors were noted to underlie the anatomic structure that we measured, making it possible to pierce these structures with the needle before deployment of the anchor. Clinical Relevance: Though technically feasible, all-inside arthroscopic repair of the peripheral TFCC risks injury to the ulnar-sided anatomy.
I
njuries to the triangular fibrocartilage complex (TFCC), an important wrist stabilizer, are a common cause of ulnar-sided wrist pain.1-5 TFCC tears
From the Walter Reed National Military Medical Center (S.M.W.), Bethesda, Maryland; William Beaumont Army Medical Center (D.S.), El Paso, Texas; San Antonio Military Medical Center (B.D.M.), San Antonio, Texas; and Keller Army Community Hospital (B.D.O.), West Point, New York, U.S.A. The opinions of the authors expressed herein do not necessarily state or reflect those of the US Government or the Department of Defense. Supported by the US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX. The authors report no conflict of interest. Received July 11, 2009; accepted February 18, 2010. Address correspondence and reprint requests to MAJ Scott M. Waterman, M.D., MC, USA, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889. E-mail: [email protected] Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America 0749-8063/9413/$0.00 doi:10.1016/j.arthro.2010.02.027
1474
pose a significant treatment challenge for hand and arthroscopic surgeons.6 Traumatic tears that occur in the well-vascularized, peripheral region of the TFCC, Palmer type IB, respond well to surgical repair.7-15 Surgical management is usually performed with arthroscopic-assisted techniques, which have good results and clinical outcomes.5,16,17 These repair techniques have used multiple fixation methods, which have resulted in injuries to the dorsal branch of the ulnar sensory nerve (DBUN), subcutaneous knots, uncomfortable buttons over the skin, and extra incisions.18-22 Recently, all-inside techniques have been proposed to minimize symptomatic fixation methods and limit incisions.6,13 Although these techniques have been used in only small case series, there are no reports of injuries to the DBUN or other ulnar-sided structures.6,23,24 Because of these small numbers, Lee et al.24 recommended further evaluation to determine the safety of this procedure. Proving the safety of suture anchor placement from the all-inside arthros-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 26, No 11 (November), 2010: pp 1474-1477
SAFETY OF ALL-INSIDE PERIPHERAL TFCC REPAIR
FIGURE 1. Arthroscopic view of left wrist with location of proximal and distal anchor labeled. The ECU sub-sheath and location of 6U portal are referenced for appropriate anchor placement.
copic technique would improve the physician’s ability to adequately inform patients and receive their consent, as well as provide the best care possible. This study was designed to evaluate the safety profile of all-arthroscopic techniques using a cadaveric repair model. We hypothesized that the all-inside arthroscopic repair would be a safe procedure with greater than 5 mm between the anchor and the adjacent structures. METHODS Eleven cadaveric wrists were thawed at ambient room temperature before surgery. There were 6 right and 5 left wrists and 5 female and 6 male wrists. The mean age of the cadavers was 42 years (range, 19 to 60 years). The fingers were placed in finger traps with traction placed as needed on the forearm, usually 10 to 12 lb. One of the authors, a fellowship-trained hand surgeon, performed all of the procedures according to the technique described by Yao et al.6,23 By use of the 6R portal for arthroscopic visualization and 3-4 portal for instrumentation, a standard wrist arthroscopy was performed. No peripheral TFCC tears were noted or created, which allowed for an ideal anchor placement. With visualization provided by a 30°, 2.9-mm arthroscope in the 6R portal, a curved FasT-Fix (Smith & Nephew Endoscopy, Andover, MA) was inserted through the 3-4 portal. The prestyloid recess and visualization of the location of the 6U portal were referenced for appropriate anchor placement (Fig 1). The anchor was deployed after feeling a decrease in resistance after penetration of the wrist capsule. The depth penetration limiter was not used. The FasT-Fix was first inserted through the peripheral, distal ulnar capsule, deploying the first poly-L-lactic acid (PLLA)
1475
block. The second FasT-Fix anchor was loaded by use of the trigger and the needle inserted in the central, proximal TFCC, deploying the second PLLA anchor in the same fashion as described previously, forming a vertical mattress configuration. The needle introducer was then removed from the joint and the knot pusher/ cutter introduced to tighten and cut the suture. All arthroscopic equipment and traction were then removed. The wrists were dissected to visualize the embedded PLLA blocks in relation to the ulnar-sided structures. The distances between the PLLA anchors and the flexor carpi ulnaris (FCU), extensor carpi ulnaris (ECU), and DBUN were measured with a digital caliper (Mitutoyo CD– 6-inch CSX; Mitutoyo, Aurora, IL) 3 times by a single author. The mean of all 3 measurements was entered into a spreadsheet (Microsoft Excel; Microsoft, Redmond, WA). The mean distance between the proximal and distal blocks and the anatomic structures was then calculated for the 11 samples.
RESULTS The peripheral anchor averaged 4.2 mm (range, 0 to 14 mm) from the ECU tendon, 3.8 mm (range, 0 to 9 mm) from the DBUN, and 8.3 mm (range, 1 to 15 mm) from the FCU tendon. One anchor was just deep to, but in contact with, the DBUN (Fig 2), whereas another was in contact with the ECU (Fig 3). The central anchor averaged 9.6 mm (range, 2 to 15 mm) from the ECU tendon, 6.8 mm (range, 1 to 13 mm) from the DBUN, and 7.6 mm (range, 1 to 13 mm) from the FCU (Table 1).
FIGURE 2. Peripheral anchor for TFCC repair deep to DBUN. The ECU tendon is exposed through an incision in the ECU sheath.
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FIGURE 3. sheath.
S. M. WATERMAN ET AL.
Peripheral anchor for TFCC repair through ECU
DISCUSSION The TFCC is a group of intimately related ulnarsided wrist structures. Biomechanical studies indicate that the TFCC imparts translational stability to the distal radioulnar joint and buffers compressive forces during axial loading of the wrist.1,25,26 Tears of the TFCC can therefore result in instability of the distal radioulnar joint and ulnar-sided wrist pain.1,26,27 TFCC tears can occur either centrally or peripherally, with peripheral tears being better vascularized and thought to have greater potential for healing.7,15 Peripheral TFCC tears have typically been addressed by use of arthroscopic-assisted outside-in and inside-out techniques, but these techniques require additional incisions, risk injury to the DBUN and ECU tendon, and sometimes require subcutaneous incisions.6,13,18,19,21,24 Although many studies on these techniques have noted that there is no risk to the ulnar neurovascular bundle if the needle is inserted dorsal to the FCU, they do not document the proximity to the DBUN.21,28,29 McAdams and Hentz18 in a cadaveric study noted that the DBUN has a variable course and reported that the sutures passed using an outside-in technique were in close proximity to the DBUN in all specimens. They concluded that a longitudinal incision should be used to minimize risk to the DBUN. Recently, all-inside techniques have been introduced with proponents noting none of the above injuries in small case series.6,13,23 Yao23 recently evaluated his all-inside technique in a cadaveric study using the FasT-Fix. He noted that all anchors were dorsal to the ECU, a mean of 1.8 cm from the ulnar neurovascular bundle, and a mean of 17.1 mm from the DBUN. The author of this study does not document whether he
references any landmarks for anchor placement in his technique. This study does not document the range of distances from the anchors to any of the ulnar-sided structures but just notes the mean distances. This technique differs from our technique in that Yao uses 2 FasT-Fix devices as opposed to the 1 in this study. Our study is the first study to independently evaluate this technique, and in none of our specimens was the distal anchor more than 1 cm away from the DBUN, with 7 of the 11 proximal anchors being within 5 mm. Our results echo the results of McAdams and Hentz in evaluating this new technique, noting that the DBUN is at risk when performing an all-inside TFCC repair and an additional incision is required to protect the DBUN. Although there are no reports of injury to ulnarsided structures from an all-arthroscopic repairs, only a few small case series have reported the results of such repairs.6,24 The DBUN was noted to vary in its anatomic location when overlying the ulnar wrist capsule, making safe placement of anchors difficult. This study documents the close proximity of the anchors to the ECU, FCU, and DBUN. In 2 specimens the anchors were noted to underlie the DBUN and ECU tendon, raising concerns for the safety profile of this procedure. Because of the proximity of the DBUN and ECU to the peripheral anchor, an additional safety incision should be considered to expose and protect ulnar-sided wrist anatomy. The strength of this study was that it was only designed to assess the distance from ulnar-sided structures to PLLA anchors from an all-inside peripheral TFCC repair. This is generalizable to the all-inside techniques that are currently published because these require penetration of the ulnar capsule with a needle. That there were no tears in the TFCC is both a strength and a weakness of this study. This allowed for improved visualization of anchor placement in the area where peripheral tears are located, but it did not replicate the same situation a surgeon is faced with when performing these all-inside repairs. The final weakness of this study is that it does not assess the functional outcomes. Although we note that these anchors TABLE 1.
Proximal anchor Distal anchor
Distances From Anchors
ECU Tendon (mm)
FCU Tendon (mm)
DBUN (mm)
4.2 (0-14.3) 9.6 (2.2-18.2)
8.3 (1.4-14.7) 7.6 (1.2-13.5)
3.8 (0.4-9.4) 6.8 (0.9-13.4)
NOTE. Data are presented as mean (range).
SAFETY OF ALL-INSIDE PERIPHERAL TFCC REPAIR are in close proximity to vital ulnar-sided structures, we were unable to assess whether this would have led to further pain or symptoms. CONCLUSIONS This study exposes some safety concerns with the all-inside peripheral TFCC repair using the FasTFix device, which was found to reside in close proximity to the ECU, FCU, and DBUN. In multiple wrists the anchors were noted to underlie the anatomic structure that we measured, making it possible to pierce these structures with the needle before deployment of the anchor.
12.
13. 14. 15. 16.
17.
Acknowledgment: The authors thank the US Army Institute of Surgical Research for providing the facilities and financial support for this research.
18.
REFERENCES
19.
1. Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist—Anatomy and function. J Hand Surg Am 1981; 6:153-162. 2. Osterman AL. Arthroscopic debridement of triangular fibrocartilage complex tears. Arthroscopy 1990;6:120-124. 3. Menon J, Wood VE, Schoene HR, Frykman GK, Hohl JC, Bestard EA. Isolated tears of the triangular fibrocartilage of the wrist: Results of partial excision. J Hand Surg Am 1984;9:527530. 4. Ahn AK, Chang D, Plate AM. Triangular fibrocartilage complex tears: A review. Bull NYU Hosp Jt Dis 2006;64:114-118. 5. Hermansdorfer JD, Kleinman WB. Management of chronic peripheral tears of the triangular fibrocartilage complex. J Hand Surg Am 1991;16:340-346. 6. Yao J, Dantuluri P, Osterman AL. A novel technique of all-inside arthroscopic triangular fibrocartilage complex repair. Arthroscopy 2007;23:1357.e1-1357.e4. Available online at www.arthroscopyjournal.org. 7. Bednar MS, Arnoczky SP, Weiland AJ. The microvasculature of the triangular fibrocartilage complex: Its clinical significance. J Hand Surg Am 1991;16:1101-1105. 8. Chen AC, Hsu KY, Chang CH, Chan YS. Arthroscopic suture repair of peripheral tears of triangular fibrocartilage complex using a volar portal. Arthroscopy 2005;21:1406.e1-1406.e4. Available online at www.arthroscopyjournal.org. 9. Chou CH, Lee TS. Peripheral tears of triangular fibrocartilage complex: Results of primary repair. Int Orthop 2001;25:392395. 10. Chou KH, Sarris IK, Sotereanos DG. Suture anchor repair of ulnar-sided triangular fibrocartilage complex tears. J Hand Surg Br 2003;28:546-550. 11. Conca M, Conca R, Dalla Pria A. Preliminary experience of fully arthroscopic repair of triangular fibrocartilage complex
20. 21. 22. 23.
24.
25. 26. 27. 28. 29.
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lesions. Arthroscopy 2004;20:e79-e82. Available online at www.arthroscopyjournal.org. Degreef I, Welters H, Milants P, Van Ransbeeck H, De Smet L. Disability and function after arthroscopic repair of ulnar avulsions of the triangular fibrocartilage complex of the wrist. Acta Orthop Belg 2005;71:289-293. Estrella EP, Hung LK, Ho PC, Tse WL. Arthroscopic repair of triangular fibrocartilage complex tears. Arthroscopy 2007;23: 729-737.e1. Available online at www.arthroscopyjournal.org. Palmer AK. Triangular fibrocartilage complex lesions: A classification. J Hand Surg Am 1989;14:594-606. Thiru RG, Ferlic DC, Clayton ML, McClure DC. Arterial anatomy of the triangular fibrocartilage of the wrist and its surgical significance. J Hand Surg Am 1986;11:258-263. Corso SJ, Savoie FH, Geissler WB, Whipple TL, 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. Papapetropoulos PA, Ruch DS. Repair of arthroscopic triangular fibrocartilage complex tears in athletes. Hand Clin 2009; 25:389-394. McAdams TR, Hentz VR. Injury to the dorsal sensory branch of the ulnar nerve in the arthroscopic repair of ulnar-sided triangular fibrocartilage tears using an inside-out technique: A cadaver study. J Hand Surg Am 2002;27:840-844. Tsu-Hsin Chen E, Wei JD, Huang VW. Injury of the dorsal sensory branch of the ulnar nerve as a complication of arthroscopic repair of the triangular fibrocartilage. J Hand Surg Br 2006;31:530-532. Bednar JM, Osterman AL. The role of arthroscopy in the treatment of traumatic triangular fibrocartilage injuries. Hand Clin 1994;10:605-614. Trumble TE, Gilbert M, Vedder N. Isolated tears of the triangular fibrocartilage: Management by early arthroscopic repair. J Hand Surg Am 1997;22:57-65. Whipple TL, Geissler WB. Arthroscopic management of wrist triangular fibrocartilage complex injuries in the athlete. Orthopedics 1993;16:1061-1067. Yao J. All-arthroscopic triangular fibrocartilage complex repair: Safety and biomechanical comparison with a traditional outside-in technique in cadavers. J Hand Surg Am 2009;34: 671-676. Lee CK, Cho HL, Jung KA, Jo JY, Ku JH. Arthroscopic all-inside repair of Palmer type 1B triangular fibrocartilage complex tears: A technical note. Knee Surg Sports Traumatol Arthrosc 2008;16:94-97. Adams BD. Partial excision of the triangular fibrocartilage complex articular disk: A biomechanical study. J Hand Surg Am 1993;18:334-340. Palmer AK, Werner FW, Glisson RR, Murphy DJ. Partial excision of the triangular fibrocartilage complex. J Hand Surg Am 1988;13:391-394. Adams BD, Holley KA. Strains in the articular disk of the triangular fibrocartilage complex: A biomechanical study. J Hand Surg Am 1993;18:919-925. de Araujo W, Poehling GG, Kuzma GR. New Tuohy needle technique for triangular fibrocartilage complex repair: Preliminary studies. Arthroscopy 1996;12:699-703. Skie MC, Mekhail AO, Deitrich DR, Ebraheim NE. Operative technique for inside-out repair of the triangular fibrocartilage complex. J Hand Surg Am 1997;22:814-817.