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Triangular Fibrocartilage Complex Tears in the Athlete
ARTHROSCOPIC SURGERY FOR ATHLETIC ELBOW AND WRIST INJURIES
0278-5919/01 $15.00 + .OO
TRIANGULAR FIBROCARTILAGE COMPLEX TEARS IN THE ATHLETE Daniel J. Nagle, MD
Injury to the triangular fibrocartilagecan occur as a result of athletic activity ranging from racquet sports to baseball to contact sports. The basic principles of treatment of triangular fibrocartilage complex (TFCC) tears in the athlete are similar to those applied to the general population. The postoperative rehabilitation, however, must be tailored to the patient’s sport. ANATOMY OF THE TRIANGULAR FIBROCARTILAGE COMPLEX
The goal of treatment of TFCC tears is restoration of anatomy and function. The anatomy of the TFCC has been well studied. The base of the triangular fibrocartilage attaches to the distal radius at the distal edge of the sigmoid notch. Its distal surface blends imperceptibly with the hyaline cartilage of the lunate fossa of the distal radius. The triangular fibrocartilage narrows as it passes from radial to ulnar. Its deep fibers (ligamentum subcruatum) insert in the fovea at the base of the ulnar styloid. The superficial fibers attach on the ulnar styloid. Dorsally and palmarly, the TFCC thickens to form the distal radioulnar ligaments. The integrity of these two ligaments is critical to the stability of the distal radioulnar joint. The triangular fibrocartilage meniscal homologue passes distally to attach at the ulnar aspect of the triquetnun. The interval between the ulnotriquetral ligament and the meniscal homoFrom the Department of Orthopaedics, Northwestern University Medical school, Chicago, Illinois CLJNICS IN SPORTS MEDICINE
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VOLUME 20 NLTMBER 1 JANUARY 2001
155
156
NAGLE ULNOLUNATE LIQAMENT
TRIQUETRUM
\ ULNOTRIQUETRAL LIGAMENT ULNAR CAPSULE SCAPHOID FOS PRESTYLOID RECESS LUNATE FOSS
DORSAL
'SHEATH OF ECU
Figure 1. Anatomy of the triangular fibrocartilage complex (TFCC). (from lshii S,Palmer AK, Werner FW, et al: An anatomic study of the ligamentous structure of the triangular fibrocartilage complex. J Hand Surg [Am] 23:977-985, 1998;with permission.)
logue and ulnar collateral ligament is known as the prestyloid recess or the pisotriquetral recess (Fig. 1). Palmer and others have demonstrated an inverse relationship between the thickness of the triangular fibrocartilage and ulnar variance: the more positive the ulnar variance, the thinner the triangular fibrocartilage." This relationship explains the observed coincidence of ulnar plus variance and TFCC tears (ulnar abutment syndrome). The ulnar abutment syndrome is characterized by an ulnar plus variance, central tears of the triangular fibrocartilage, and chondromalacia of the adjacent articular surfaces of the lunate, triquetrum, and ulnar head. Palmer and Werner14have studied the effect of ulnar length on load transmission across the triangular fibrocartilage. They demonstrated a direct relationship between the length of the ulna and the amount of force transmitted across the TFCC. As the ulna gets longer, the force transmitted across the TFCC increases. The opposite occurs with ulnar shortening. In addition, these authors demonstrated that dbbridement of the triangular fibrocartilage has the same effect as an ulnar shortening; it leads to a decrease in the load transmitted across the ulnocarpal joint. The vascular supply of the triangular fibrocartilage is characterized by a peripheral vascular zone and a central avascular zone? The lack of central blood supply precludes any healing of central TFCC tears and dictates the choice of debridement as the treatment for such tears. DIAGNOSIS
The diagnosis of a triangular fibrocartilage tear is not always easy. The classic complaint is ulnar-sided wrist pain associated with popping
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or clicking. Pain at the ulnar aspect of the ulnocarpal joint just palmar to the extensor carpi ulnaris (ECU) often is associated with a peripheral rather than central tear of the TFCC. Physical examination can demonstrate tenderness over the TFCC. Ulnar deviation of the wrist combined with supination and pronation and the application of an axial load will produce a clicking and popping sensation and reproduce the patient's pain. Lester et a15 have described the "press test," in which the patient is asked to lift himself out of a chair while bearing weight on the extended wrists. Lester found a 100% sensitivity for detection of triangular fibrocartilage tears using this technique. In addition to physical examination, arthrography and MR imaging have been used to diagnose TFCC tears. Arthrography is slowly being replaced by arthroscopy as a diagnostic tool for the assessment of the painful wrist. Nagle and Benson7reported that wrist arthrography demonstrated all wrist pathology present in only 11% of patients. MR imaging is an evolving technology. Early studies by Zlatkin and Osterman16 suggested up to a 95% accuracy rate in the MR imaging diagnosis of TFCC tears, but more recent studies by Shionova13suggest the accuracy of MR imaging may be less. Arthroscopy has become the standard against which other diagnostic techniques must be compared. TEAR CLASSIFICATION
Palmer9 and associates devised a classification scheme for TFCC tears, which divides them into traumatic tears, type 1, and degenerative tears, type 2. This article deals with those tears (1A-D and 2C-D) that lend themselves to arthroscopic treatment (Fig. 2). DEBRIDEMENT
Before starting arthroscopic treatment of TFCC tears, the ulnar variance must be evaluated. This is done by taking an x-ray-with the shoulder abducted to 90" and the elbow flexed to 90" with the hand flat on the x-ray cassette (90 X 90 view of Palmerlo).Triangular fibrocartilage debridement in the presence of an ulnar plus variance is doomed to fail, as the simple debridement of the TFCC is insufficient to decompress the ulnar side of the wrist. In such cases of ulnar abutment syndrome, an ulnar shortening is needed. In patients with an ulnar zero variance, the results of TFCC debridement can be good but there lingers the possibility of having to perform an ulnar shortening later. This possibility should be discussed with the patient preoperatively. In contrast to the patient with an ulnar plus variance, the patient who presents with an ulnar minus variance is likely to respond to simple debridement of the central portion of the triangular fibrocartilage.8 The instruments used for triangular fibrocartilage debridement have
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1B
Figure 2. Palmer classification of TFCC tears. (From Palmer AK: Triangular fibrocartilage complex lesions: A classification. J Hand Surg [Am] 14:594-606, 1989; with permission.)
evolved over the last two decades. In the 1980s and early 1990s, TFCC dkbridement was carried out using mechanical devices such as mini banana blades, mini suction punches, graspers, and motorized cutters and abraders. More recently, lasers and radio frequency probes have begun to replace mechanical tools for dkbridement of the TFCC. MECHANICAL DEBRIDEMENT
The patient undergoing a TFCC dkbridement is placed on the operating room table in the supine position. The arm is prepped and draped and the wrist is distracted using traction applied through sterile finger traps and a commercially available wrist distraction device. The distraction device should be solid. Improvised traction systems are unreliable and can fail during the procedure. A viewing portal is established at the 3 4 portal (the portal is placed at the interval between the extensor pollicis longus and the extensor digitorum communis tendons just distal to Lister’s tubercle). The instrument portals can include the 4 5 portal, the 6R portal, and the 6U portal. (The 4 5 portal corresponds to the interval between the tendons of the fourth and fifth dorsal compartments. The 6R portal corresponds to the interval between the extensor digiti quinti and the extensor carpi ulnaris,
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and the 6U portal corresponds to the portal established just palmar to the extensor carpi ulnaris.) With the scope in the 3-4 portal and the instruments passing through the 4 5 portal, debridement of the palmar and radial aspects of the triangular fibrocartilage tear is relatively straightforward (Fig. 3). Access to the ulnar and dorsal aspects of the TFCC through these portals is a bit more challenging. These areas sometimes can be approached using the standard 3-4/45 portal combination with the help of a curved banana blade and angled punches. One must be careful to avoid injury to the overlying tendons and nerves when passing the banana blade in and out of the joint. Often, however, access to the dorsal and ulnar TFCC necessitates switching the portals such that the instruments are passed through the 3-4 portal and across the radiocarpal joint while the scope is placed in the 4-5 portal. There are two potential problems with this setup. First, the passage of the instruments across the radiocarpal joint places those joints at risk of scuffing. Second, the close proximity of the scope to the operative site (TFCC) can distort the operator’s perception of the ulnocarpal joint. The dkbridement of the TFCC is adequate when there are no loose edges and a smooth rim of TFCC has been fashioned. Great care must be taken to preserve the dorsal and palmar radioulnar ligaments and the ulnar attachment of the triangular fibrocartilage. The size of the TFCC defect created during the dkbridement will measure between 7 and 15 mm, depending on the size of the patient. A probe should be passed into the joint to verify the stability of the remaining triangular fibrocartilage. Once the dkbridement is completed, the traction should be released, the wrist brought into ulnar deviation, then axially loaded
STT
I
MCR
1-2
Figure 3. Wrist arthroscopy portals.
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and repeatedly supinated and pronated. If any clicking or popping is noted, either further dkbridement is required or another source of the clicking and popping should be sought. The preceding description assumes an ulnar minus or zero variance. In patients who present with a central triangular fibrocartilage tear and an ulnar plus variance (ulnar abutment syndrome), the TFCC debridement should be combined with an ulnar shortening. This can be carried out arthroscopically as a variation of the Feldon wafer procedure15or as a formal extra-articular ulnar shortening with ulnar osteotomy and plate fixation.6 Palmer has suggested that there are several advantages to arthroscopically assisted ulnar shortening over open distal ulnar resection (Feldon procedure). These include more rapid recovery and less tissue trauma. The distal ulnar resection, whether arthroscopically assisted or open, avoids the morbidity associated with an ulnar osteotomy (e.g., nonunion and the need for plate removal).
Radial (Palmer 1D) and ulnar (Palmer 1B) detachments of the triangular fibrocartilage can be repaired arthroscopically. Two methods are used routinely for repair of detachment of the TFCC from the ulna. One involves repair techniques similar to those developed for meniscorrhesis.3 The other uses a Tuohy needle as popularized by Dr. Gary Poehling. The technique popularized by Whipple involves the placement of the scope in the 3 4 portal while the repair is accomplished through the 4-5 or 6R portal. In addition, a 2- to 3-cm incision is made along the extensor carpi ulnaris just distal to the ulnar head to permit visualization of the ulnar capsule and tying of the repair sutures. Care is taken to avoid injuring the dorsal branch of the ulnar nerve or opening the sixth dorsal compartment proximal to the ulnar styloid. (If one is too liberal with release of the extensor carpi ulnaris sheath, subluxation of the extensor carpi ulnaris can result.) The tom edges of the triangular fibrocartilage are dkbrided and freshened using the full radius cutters. The extensor carpi ulnaris is retracted with a Penrose drain and the proposed reattachment points are defined by passing a 20-gauge spinal needle through the ulnar capsule under arthroscopic control. Using the “Inteq” TFCC Repair Kit or the “Instrument Maker’’ meniscal repair kit, a 2-0 PDS suture is passed from outside-in through the TFCC repair needle, following the path defined by the spinal needle. The needle passes through the ulnar capsule and through the free ulnar edge of the TFCC. A second needle containing a small wire loop is passed either adjacent to the first needle (to create a horizontal mattress stitch) or just distal to the first needle (to create a simple stitch). The suture is passed through the first needle and threaded through the wire loop of the second needle. The wire loop, along with the snared suture, is pulled from the ulnar capsule. The first needle also is removed, leaving the
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suture in place to be tied down over the ulnar capsule. This process is repeated two or three times as needed. Avoid tying the knots within the extensor carpi ulnaris sheath, as this can lead to chronic tenosynovitis. The sheath should be repaired at the conclusion of this repair. Remember that there are two layers of the sheath-the deep sheath, which is the major stabilizer, and the superficial sheath or extension of the dorsal retinaculum. Repair Using the Tuohy Needle
Poehling et all have described a relatively simple technique for the repair of peripheral (Palmer IB) TFCC tears. This technique takes advantage of the blunt tip of the Tuohy needle, usually used for epidural anesthesia. To repair the TFCC using this technique the scope is placed in the 4-5 portal. A 20-guage Tuohy needle is passed through the 1-2 portal, engages the free edge of the TFCC, and continues through the region of the ulnar attachment of the TFCC, passing through the skin just palmar to the ECU. A 2-0 polydioxanone-PDS suture is passed through the needle, leaving a tail extending out of the tip of the needle. The needle is pulled back into the joint, moved either dorsally or palmarly, and again passed through the free edge of the TFCC and out through the skin. (The blunt tip of the Tuohy needle pushes the suture through the TFCC and skin without cutting it.) An incision is made in the skin at the exit of the suture to permit tying the suture down on the ulnar capsule. Care must be taken to avoid injuring the dorsal branch of ulnar nerve. The technique is repeated as many times as necessary to affect a solid repair (Fig. 4). Repair of Radial Avulsion
Avulsion of the TFCC from the sigmoid notch of the radius can lead to distal radioulnar joint instability. The repair of these Palmer 1D lesions can be accomplished using a technique developed by Short.12 This technique places the scope in the 3 4 portal, and a motorized abrader is brought into the joint through the 6R portal. The abrader freshens the area of attachment of the TFCC to the radial sigmoid notch. A small incision is made over the interval between the first and second compartments. A .045 Kirschner’s wire is passed through a 14-gauge hypodermic needle (which acts as soft tissue protector) and is used to drill four tunnels from the dorsal aspect of the radius into the abraded surface of the sigmoid notch. (Fluoroscopy is needed to guide the Kirschner wires.) The arthroscope cannula is placed in the 6U portal, and long meniscal repair needles armed with 2-0 polydioxanonePDS suture are passed through the cannula, through the radial edge of the TFCC, and into the tunnels drilled with the Kirschner wire. The sutures are tied over the dorsal aspect of the radius (Fig. 5).
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Figure 4. A, Tuohy needle repair of peripheral TFCC tear. Visualized and debrided type IC lesion (inset). 6, Needle with a 2-0 PDS suture is placed. The needle is withdrawn into the joint while both ends of the suture are held outside the skin (inset). Needle is removed dorsally and reinserted. C,Needle is placed through the skin with the suture adjacent and through the needle (inset). Suture is pulled through the needle and then the needle is removed, leaving the horizontal mattress stitch. (From Araujo W, Poehling GG, Kuzma GR: New Tuohy needle technique for triangular fibrocartilage complex repair: Preliminary studies. Arthroscopy 12:69!3-703,1996; with permission.)
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FL.cannola
Figure 5. A, Palmer ID radial peripheral TFCC tear. B, Exposure of subchondral cancellous bone at distal sigmoid notch. C, Radial holes drilled with small Kirschner’s (K) wire. 0, Suture passed through the radial edge of the TFCC and into the radial drill holes using long meniscal repair needles. €, Sutures tied on the surface of the radius. (From Sagerman SD, Short W: Arthroscopic repair of the radial-sided triangular fibrocartilage complex tears. Arthroscopy 12:339-342,1996; with permission.)
POSTOPERATIVE REGIMEN
The postoperative regimen after the debridement of triangular fibrocartilage tears includes the application of a bulky dressing and a volar splint. The patient gradually is weaned from this splint over a 6week period. The author’s experience has been that premature return to
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activities can aggravate the postsurgical synovitis. Return to full activity can be expected by the 12th postoperative week. With repair of a peripheral tear of the triangular fibrocartilage, the arm must be held in a cast in neutral rotation for 6 weeks, after which time therapy is instituted to regain the range of motion. Throwing athletes require a graded rehabilitation program starting with simple range-of-motion exercises and strengthening. Light swinging of the fungo bat is permitted 4 weeks after cast removal and progresses to hitting off the tee and ultimately to hitting live pitching over the following 4 to 6 weeks. Throwing is permitted at the same time that batting is started (i.e., at 4 weeks after the removal of the cast). ARTHROSCOPICALLY ASSISTED ULNAR SHORTENING The ulnar abutment syndrome (the combination of an ulnar plus variance and a triangular fibrocartilage tear) is the most common indication for arthroscopically assisted ulnar shortening. Simple dkbridement of the TFCC in the presence of an ulnar plus variance is inadequate treatment of an ulnar abutment syndrome. The ulnar aspect of the wrist must be decompressed, and arthroscopically assisted ulnar shortening has proven to be effective in this ~ituati0n.l~ Arthroscopic ulnar shortening is accomplished by placing the scope in the 3-4 portal and introducing the instruments through the 4 5 portal. Occasionally the 6U portal can be used as can the distal radioulnar joint portal. We have found the Holmium: Yag laser to be useful for ulnar shortening. The Holmium:Yag laser is introduced through the 6 5 portal, and the cartilage and subchondral bone of the ulnar seat of the distal ulna are vaporized rapidly. Once the trabeculations of the distal ulna are visible, the laser becomes less efficient and the 2.9-mm barrel abrader is brought in to finish the shortening. Care must be taken to avoid injury to the sigmoid notch,
Figure 6. Treatment of ulnar abutment syndrome: Preoperative (A) and postoperative (6).
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and frequent fluoroscopic monitoring of the amount of bone resected is mandatory. The wrist must be fully supinated and pronated to dkbride the ulnar head adequately. Occasionally, a small ridge of bone will be left ulnarly; however, this usually does not impinge on the proximal carpal row. At the end of the procedure, all instruments are removed and the wrist is ulnarly deviated, axially loaded, and supinated and pronated to be sure no clicking or popping is noted. If clicking or popping is noted and appears to be emanating from the area of the surgery, further ulnar resection may be required. The goal of the surgery is to create an ulnar minus variance of 1 to 2 mm. The irregularities of the remaining distal ulna should be minimized; however, they tend to flatten out with the passage of time. The postoperative care of these patients includes the application of a volar splint followed by early range of motion. Open ulnar shortening has been reported to be associated with a recovery period of up to 6 months: but arthroscopic dkbridement is associated with a shorter recovery timeI5 (Fig. 6). SUMMARY
The treatment of triangular fibrocartilage tears in the athlete presents more of a rehabilitation challenge than a surgical technique challenge. The rehabilitation regimen is a function of the sport. Although injuries to the shoulder and knee can be career ending, injuries to the TFCC usually, but not always, can be treated successfully. References 1. Araujo W, Poehling GG, Kuzma G R New Tuohy needle technique for triangular fibrocartilage complex repair: Preliminary studies. Arthroscopy 12699-703,1996 2. Bednar MS, Amoczky SP, Weiland AJ: The microvasculature of the Triangular fibrocartilage complex: Its clinical significance. J Hand Surg [Am] 161101-1105,1991 3. Corso SJ, Savoie FH, Geissler WB, et al: Arthroscopic repair of peripheral avulsions of 4.
5. 6. 7.
8. 9. 10.
the triangular fibrocartilage complex of the wrist: A multicenter study. Arthroscopy 13:78-84, 1997 Feldon P, Terrono AL, Belsky MR Wafer distal ulna resection for triangular fibrocartilage tears and/or ulna impaction syndrome. J Hand Surg [Am] 17731-737, 1992 Lester B, Halbrecht J, Levy IM, et al: ”Press test” for office diagnosis of triangular fibrocartilage complex tears of the wrist. Ann Plast Surg 35:41-45, 1995 Minami A, Kato H: Ulnar shortening for triangular fibrocartilage complex tears associated with ulnar positive variance. J Hand Surg [Am] 233904-908,1998 Nagle DJ, Benson L S Wrist arthroscopy: Indications and results. Arthroscopy 8:198203, 1992 Osterman AL: Arthroscopic debridement of triangular fibrocartilage complex tears. Arthroscopy 6:12&124, 1990 Palmer AK Triangular fibrocartilage complex lesions: A classification. J Hand Surg [Am] 14594406,1989 Palmer AK, Glisson RR, Werner Fw:Ulnar variance determination. J Hand Surg [Am] 7376-379, 1982
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11. Palmer AK, Glisson RR, Werner Fw:Relationship between ulnar variance and triangular fibrocartilage complex thickness. J Hand Surg [Am] 9:681-682,1984 12. Sagerman SD, Short W Arthroscopic repair of the radial-sided triangular fibrocartilage complex tears. Arthroscopy 12(3):339-342, 1996 13. Shionova K, Nakamura R, Imaeda T, et a1 Arthrography is superior to magnetic resonance imaging for diagnosing injuries of the triangular fibrocartilage. J Hand Surg [Br] 23:402-405, 1998 14. Werner FW, Glisson RR, Murphy DJ, et al: Force transmission through the distal radioulnar carpal joint: Effect of ulnar lengthening and shortening. Handchir Mikrochir Plast Chir 18304-308,1986 15. Wnorowski DC,Palmer AK, Werner FW, et al: Anatomic and biomechanical analysis of the arthroscopic wafer procedure. Arthroscopy 8204-212, 1992 16. Zlatkin MB, Chao PC, Osterman AL, et a1 Chronic wrist pain: evaluation with highresolution MR imaging. Radiology 173723-729, 1989
Address reprint requests to Daniel J. Nagle, MD 448 East Ontario Street Suite 500 Chicago, IL 60611
0278-5919/01 $15.00 + .OO
TRIANGULAR FIBROCARTILAGE COMPLEX TEARS IN THE ATHLETE Daniel J. Nagle, MD
Injury to the triangular fibrocartilagecan occur as a result of athletic activity ranging from racquet sports to baseball to contact sports. The basic principles of treatment of triangular fibrocartilage complex (TFCC) tears in the athlete are similar to those applied to the general population. The postoperative rehabilitation, however, must be tailored to the patient’s sport. ANATOMY OF THE TRIANGULAR FIBROCARTILAGE COMPLEX
The goal of treatment of TFCC tears is restoration of anatomy and function. The anatomy of the TFCC has been well studied. The base of the triangular fibrocartilage attaches to the distal radius at the distal edge of the sigmoid notch. Its distal surface blends imperceptibly with the hyaline cartilage of the lunate fossa of the distal radius. The triangular fibrocartilage narrows as it passes from radial to ulnar. Its deep fibers (ligamentum subcruatum) insert in the fovea at the base of the ulnar styloid. The superficial fibers attach on the ulnar styloid. Dorsally and palmarly, the TFCC thickens to form the distal radioulnar ligaments. The integrity of these two ligaments is critical to the stability of the distal radioulnar joint. The triangular fibrocartilage meniscal homologue passes distally to attach at the ulnar aspect of the triquetnun. The interval between the ulnotriquetral ligament and the meniscal homoFrom the Department of Orthopaedics, Northwestern University Medical school, Chicago, Illinois CLJNICS IN SPORTS MEDICINE
-
VOLUME 20 NLTMBER 1 JANUARY 2001
155
156
NAGLE ULNOLUNATE LIQAMENT
TRIQUETRUM
\ ULNOTRIQUETRAL LIGAMENT ULNAR CAPSULE SCAPHOID FOS PRESTYLOID RECESS LUNATE FOSS
DORSAL
'SHEATH OF ECU
Figure 1. Anatomy of the triangular fibrocartilage complex (TFCC). (from lshii S,Palmer AK, Werner FW, et al: An anatomic study of the ligamentous structure of the triangular fibrocartilage complex. J Hand Surg [Am] 23:977-985, 1998;with permission.)
logue and ulnar collateral ligament is known as the prestyloid recess or the pisotriquetral recess (Fig. 1). Palmer and others have demonstrated an inverse relationship between the thickness of the triangular fibrocartilage and ulnar variance: the more positive the ulnar variance, the thinner the triangular fibrocartilage." This relationship explains the observed coincidence of ulnar plus variance and TFCC tears (ulnar abutment syndrome). The ulnar abutment syndrome is characterized by an ulnar plus variance, central tears of the triangular fibrocartilage, and chondromalacia of the adjacent articular surfaces of the lunate, triquetrum, and ulnar head. Palmer and Werner14have studied the effect of ulnar length on load transmission across the triangular fibrocartilage. They demonstrated a direct relationship between the length of the ulna and the amount of force transmitted across the TFCC. As the ulna gets longer, the force transmitted across the TFCC increases. The opposite occurs with ulnar shortening. In addition, these authors demonstrated that dbbridement of the triangular fibrocartilage has the same effect as an ulnar shortening; it leads to a decrease in the load transmitted across the ulnocarpal joint. The vascular supply of the triangular fibrocartilage is characterized by a peripheral vascular zone and a central avascular zone? The lack of central blood supply precludes any healing of central TFCC tears and dictates the choice of debridement as the treatment for such tears. DIAGNOSIS
The diagnosis of a triangular fibrocartilage tear is not always easy. The classic complaint is ulnar-sided wrist pain associated with popping
TRIANGULAR FIBROCARTILAGE COMPLEX TEARS IN THE ATHLETE
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or clicking. Pain at the ulnar aspect of the ulnocarpal joint just palmar to the extensor carpi ulnaris (ECU) often is associated with a peripheral rather than central tear of the TFCC. Physical examination can demonstrate tenderness over the TFCC. Ulnar deviation of the wrist combined with supination and pronation and the application of an axial load will produce a clicking and popping sensation and reproduce the patient's pain. Lester et a15 have described the "press test," in which the patient is asked to lift himself out of a chair while bearing weight on the extended wrists. Lester found a 100% sensitivity for detection of triangular fibrocartilage tears using this technique. In addition to physical examination, arthrography and MR imaging have been used to diagnose TFCC tears. Arthrography is slowly being replaced by arthroscopy as a diagnostic tool for the assessment of the painful wrist. Nagle and Benson7reported that wrist arthrography demonstrated all wrist pathology present in only 11% of patients. MR imaging is an evolving technology. Early studies by Zlatkin and Osterman16 suggested up to a 95% accuracy rate in the MR imaging diagnosis of TFCC tears, but more recent studies by Shionova13suggest the accuracy of MR imaging may be less. Arthroscopy has become the standard against which other diagnostic techniques must be compared. TEAR CLASSIFICATION
Palmer9 and associates devised a classification scheme for TFCC tears, which divides them into traumatic tears, type 1, and degenerative tears, type 2. This article deals with those tears (1A-D and 2C-D) that lend themselves to arthroscopic treatment (Fig. 2). DEBRIDEMENT
Before starting arthroscopic treatment of TFCC tears, the ulnar variance must be evaluated. This is done by taking an x-ray-with the shoulder abducted to 90" and the elbow flexed to 90" with the hand flat on the x-ray cassette (90 X 90 view of Palmerlo).Triangular fibrocartilage debridement in the presence of an ulnar plus variance is doomed to fail, as the simple debridement of the TFCC is insufficient to decompress the ulnar side of the wrist. In such cases of ulnar abutment syndrome, an ulnar shortening is needed. In patients with an ulnar zero variance, the results of TFCC debridement can be good but there lingers the possibility of having to perform an ulnar shortening later. This possibility should be discussed with the patient preoperatively. In contrast to the patient with an ulnar plus variance, the patient who presents with an ulnar minus variance is likely to respond to simple debridement of the central portion of the triangular fibrocartilage.8 The instruments used for triangular fibrocartilage debridement have
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NAGLE
1B
Figure 2. Palmer classification of TFCC tears. (From Palmer AK: Triangular fibrocartilage complex lesions: A classification. J Hand Surg [Am] 14:594-606, 1989; with permission.)
evolved over the last two decades. In the 1980s and early 1990s, TFCC dkbridement was carried out using mechanical devices such as mini banana blades, mini suction punches, graspers, and motorized cutters and abraders. More recently, lasers and radio frequency probes have begun to replace mechanical tools for dkbridement of the TFCC. MECHANICAL DEBRIDEMENT
The patient undergoing a TFCC dkbridement is placed on the operating room table in the supine position. The arm is prepped and draped and the wrist is distracted using traction applied through sterile finger traps and a commercially available wrist distraction device. The distraction device should be solid. Improvised traction systems are unreliable and can fail during the procedure. A viewing portal is established at the 3 4 portal (the portal is placed at the interval between the extensor pollicis longus and the extensor digitorum communis tendons just distal to Lister’s tubercle). The instrument portals can include the 4 5 portal, the 6R portal, and the 6U portal. (The 4 5 portal corresponds to the interval between the tendons of the fourth and fifth dorsal compartments. The 6R portal corresponds to the interval between the extensor digiti quinti and the extensor carpi ulnaris,
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and the 6U portal corresponds to the portal established just palmar to the extensor carpi ulnaris.) With the scope in the 3-4 portal and the instruments passing through the 4 5 portal, debridement of the palmar and radial aspects of the triangular fibrocartilage tear is relatively straightforward (Fig. 3). Access to the ulnar and dorsal aspects of the TFCC through these portals is a bit more challenging. These areas sometimes can be approached using the standard 3-4/45 portal combination with the help of a curved banana blade and angled punches. One must be careful to avoid injury to the overlying tendons and nerves when passing the banana blade in and out of the joint. Often, however, access to the dorsal and ulnar TFCC necessitates switching the portals such that the instruments are passed through the 3-4 portal and across the radiocarpal joint while the scope is placed in the 4-5 portal. There are two potential problems with this setup. First, the passage of the instruments across the radiocarpal joint places those joints at risk of scuffing. Second, the close proximity of the scope to the operative site (TFCC) can distort the operator’s perception of the ulnocarpal joint. The dkbridement of the TFCC is adequate when there are no loose edges and a smooth rim of TFCC has been fashioned. Great care must be taken to preserve the dorsal and palmar radioulnar ligaments and the ulnar attachment of the triangular fibrocartilage. The size of the TFCC defect created during the dkbridement will measure between 7 and 15 mm, depending on the size of the patient. A probe should be passed into the joint to verify the stability of the remaining triangular fibrocartilage. Once the dkbridement is completed, the traction should be released, the wrist brought into ulnar deviation, then axially loaded
STT
I
MCR
1-2
Figure 3. Wrist arthroscopy portals.
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and repeatedly supinated and pronated. If any clicking or popping is noted, either further dkbridement is required or another source of the clicking and popping should be sought. The preceding description assumes an ulnar minus or zero variance. In patients who present with a central triangular fibrocartilage tear and an ulnar plus variance (ulnar abutment syndrome), the TFCC debridement should be combined with an ulnar shortening. This can be carried out arthroscopically as a variation of the Feldon wafer procedure15or as a formal extra-articular ulnar shortening with ulnar osteotomy and plate fixation.6 Palmer has suggested that there are several advantages to arthroscopically assisted ulnar shortening over open distal ulnar resection (Feldon procedure). These include more rapid recovery and less tissue trauma. The distal ulnar resection, whether arthroscopically assisted or open, avoids the morbidity associated with an ulnar osteotomy (e.g., nonunion and the need for plate removal).
Radial (Palmer 1D) and ulnar (Palmer 1B) detachments of the triangular fibrocartilage can be repaired arthroscopically. Two methods are used routinely for repair of detachment of the TFCC from the ulna. One involves repair techniques similar to those developed for meniscorrhesis.3 The other uses a Tuohy needle as popularized by Dr. Gary Poehling. The technique popularized by Whipple involves the placement of the scope in the 3 4 portal while the repair is accomplished through the 4-5 or 6R portal. In addition, a 2- to 3-cm incision is made along the extensor carpi ulnaris just distal to the ulnar head to permit visualization of the ulnar capsule and tying of the repair sutures. Care is taken to avoid injuring the dorsal branch of the ulnar nerve or opening the sixth dorsal compartment proximal to the ulnar styloid. (If one is too liberal with release of the extensor carpi ulnaris sheath, subluxation of the extensor carpi ulnaris can result.) The tom edges of the triangular fibrocartilage are dkbrided and freshened using the full radius cutters. The extensor carpi ulnaris is retracted with a Penrose drain and the proposed reattachment points are defined by passing a 20-gauge spinal needle through the ulnar capsule under arthroscopic control. Using the “Inteq” TFCC Repair Kit or the “Instrument Maker’’ meniscal repair kit, a 2-0 PDS suture is passed from outside-in through the TFCC repair needle, following the path defined by the spinal needle. The needle passes through the ulnar capsule and through the free ulnar edge of the TFCC. A second needle containing a small wire loop is passed either adjacent to the first needle (to create a horizontal mattress stitch) or just distal to the first needle (to create a simple stitch). The suture is passed through the first needle and threaded through the wire loop of the second needle. The wire loop, along with the snared suture, is pulled from the ulnar capsule. The first needle also is removed, leaving the
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suture in place to be tied down over the ulnar capsule. This process is repeated two or three times as needed. Avoid tying the knots within the extensor carpi ulnaris sheath, as this can lead to chronic tenosynovitis. The sheath should be repaired at the conclusion of this repair. Remember that there are two layers of the sheath-the deep sheath, which is the major stabilizer, and the superficial sheath or extension of the dorsal retinaculum. Repair Using the Tuohy Needle
Poehling et all have described a relatively simple technique for the repair of peripheral (Palmer IB) TFCC tears. This technique takes advantage of the blunt tip of the Tuohy needle, usually used for epidural anesthesia. To repair the TFCC using this technique the scope is placed in the 4-5 portal. A 20-guage Tuohy needle is passed through the 1-2 portal, engages the free edge of the TFCC, and continues through the region of the ulnar attachment of the TFCC, passing through the skin just palmar to the ECU. A 2-0 polydioxanone-PDS suture is passed through the needle, leaving a tail extending out of the tip of the needle. The needle is pulled back into the joint, moved either dorsally or palmarly, and again passed through the free edge of the TFCC and out through the skin. (The blunt tip of the Tuohy needle pushes the suture through the TFCC and skin without cutting it.) An incision is made in the skin at the exit of the suture to permit tying the suture down on the ulnar capsule. Care must be taken to avoid injuring the dorsal branch of ulnar nerve. The technique is repeated as many times as necessary to affect a solid repair (Fig. 4). Repair of Radial Avulsion
Avulsion of the TFCC from the sigmoid notch of the radius can lead to distal radioulnar joint instability. The repair of these Palmer 1D lesions can be accomplished using a technique developed by Short.12 This technique places the scope in the 3 4 portal, and a motorized abrader is brought into the joint through the 6R portal. The abrader freshens the area of attachment of the TFCC to the radial sigmoid notch. A small incision is made over the interval between the first and second compartments. A .045 Kirschner’s wire is passed through a 14-gauge hypodermic needle (which acts as soft tissue protector) and is used to drill four tunnels from the dorsal aspect of the radius into the abraded surface of the sigmoid notch. (Fluoroscopy is needed to guide the Kirschner wires.) The arthroscope cannula is placed in the 6U portal, and long meniscal repair needles armed with 2-0 polydioxanonePDS suture are passed through the cannula, through the radial edge of the TFCC, and into the tunnels drilled with the Kirschner wire. The sutures are tied over the dorsal aspect of the radius (Fig. 5).
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Figure 4. A, Tuohy needle repair of peripheral TFCC tear. Visualized and debrided type IC lesion (inset). 6, Needle with a 2-0 PDS suture is placed. The needle is withdrawn into the joint while both ends of the suture are held outside the skin (inset). Needle is removed dorsally and reinserted. C,Needle is placed through the skin with the suture adjacent and through the needle (inset). Suture is pulled through the needle and then the needle is removed, leaving the horizontal mattress stitch. (From Araujo W, Poehling GG, Kuzma GR: New Tuohy needle technique for triangular fibrocartilage complex repair: Preliminary studies. Arthroscopy 12:69!3-703,1996; with permission.)
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FL.cannola
Figure 5. A, Palmer ID radial peripheral TFCC tear. B, Exposure of subchondral cancellous bone at distal sigmoid notch. C, Radial holes drilled with small Kirschner’s (K) wire. 0, Suture passed through the radial edge of the TFCC and into the radial drill holes using long meniscal repair needles. €, Sutures tied on the surface of the radius. (From Sagerman SD, Short W: Arthroscopic repair of the radial-sided triangular fibrocartilage complex tears. Arthroscopy 12:339-342,1996; with permission.)
POSTOPERATIVE REGIMEN
The postoperative regimen after the debridement of triangular fibrocartilage tears includes the application of a bulky dressing and a volar splint. The patient gradually is weaned from this splint over a 6week period. The author’s experience has been that premature return to
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activities can aggravate the postsurgical synovitis. Return to full activity can be expected by the 12th postoperative week. With repair of a peripheral tear of the triangular fibrocartilage, the arm must be held in a cast in neutral rotation for 6 weeks, after which time therapy is instituted to regain the range of motion. Throwing athletes require a graded rehabilitation program starting with simple range-of-motion exercises and strengthening. Light swinging of the fungo bat is permitted 4 weeks after cast removal and progresses to hitting off the tee and ultimately to hitting live pitching over the following 4 to 6 weeks. Throwing is permitted at the same time that batting is started (i.e., at 4 weeks after the removal of the cast). ARTHROSCOPICALLY ASSISTED ULNAR SHORTENING The ulnar abutment syndrome (the combination of an ulnar plus variance and a triangular fibrocartilage tear) is the most common indication for arthroscopically assisted ulnar shortening. Simple dkbridement of the TFCC in the presence of an ulnar plus variance is inadequate treatment of an ulnar abutment syndrome. The ulnar aspect of the wrist must be decompressed, and arthroscopically assisted ulnar shortening has proven to be effective in this ~ituati0n.l~ Arthroscopic ulnar shortening is accomplished by placing the scope in the 3-4 portal and introducing the instruments through the 4 5 portal. Occasionally the 6U portal can be used as can the distal radioulnar joint portal. We have found the Holmium: Yag laser to be useful for ulnar shortening. The Holmium:Yag laser is introduced through the 6 5 portal, and the cartilage and subchondral bone of the ulnar seat of the distal ulna are vaporized rapidly. Once the trabeculations of the distal ulna are visible, the laser becomes less efficient and the 2.9-mm barrel abrader is brought in to finish the shortening. Care must be taken to avoid injury to the sigmoid notch,
Figure 6. Treatment of ulnar abutment syndrome: Preoperative (A) and postoperative (6).
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and frequent fluoroscopic monitoring of the amount of bone resected is mandatory. The wrist must be fully supinated and pronated to dkbride the ulnar head adequately. Occasionally, a small ridge of bone will be left ulnarly; however, this usually does not impinge on the proximal carpal row. At the end of the procedure, all instruments are removed and the wrist is ulnarly deviated, axially loaded, and supinated and pronated to be sure no clicking or popping is noted. If clicking or popping is noted and appears to be emanating from the area of the surgery, further ulnar resection may be required. The goal of the surgery is to create an ulnar minus variance of 1 to 2 mm. The irregularities of the remaining distal ulna should be minimized; however, they tend to flatten out with the passage of time. The postoperative care of these patients includes the application of a volar splint followed by early range of motion. Open ulnar shortening has been reported to be associated with a recovery period of up to 6 months: but arthroscopic dkbridement is associated with a shorter recovery timeI5 (Fig. 6). SUMMARY
The treatment of triangular fibrocartilage tears in the athlete presents more of a rehabilitation challenge than a surgical technique challenge. The rehabilitation regimen is a function of the sport. Although injuries to the shoulder and knee can be career ending, injuries to the TFCC usually, but not always, can be treated successfully. References 1. Araujo W, Poehling GG, Kuzma G R New Tuohy needle technique for triangular fibrocartilage complex repair: Preliminary studies. Arthroscopy 12699-703,1996 2. Bednar MS, Amoczky SP, Weiland AJ: The microvasculature of the Triangular fibrocartilage complex: Its clinical significance. J Hand Surg [Am] 161101-1105,1991 3. Corso SJ, Savoie FH, Geissler WB, et al: Arthroscopic repair of peripheral avulsions of 4.
5. 6. 7.
8. 9. 10.
the triangular fibrocartilage complex of the wrist: A multicenter study. Arthroscopy 13:78-84, 1997 Feldon P, Terrono AL, Belsky MR Wafer distal ulna resection for triangular fibrocartilage tears and/or ulna impaction syndrome. J Hand Surg [Am] 17731-737, 1992 Lester B, Halbrecht J, Levy IM, et al: ”Press test” for office diagnosis of triangular fibrocartilage complex tears of the wrist. Ann Plast Surg 35:41-45, 1995 Minami A, Kato H: Ulnar shortening for triangular fibrocartilage complex tears associated with ulnar positive variance. J Hand Surg [Am] 233904-908,1998 Nagle DJ, Benson L S Wrist arthroscopy: Indications and results. Arthroscopy 8:198203, 1992 Osterman AL: Arthroscopic debridement of triangular fibrocartilage complex tears. Arthroscopy 6:12&124, 1990 Palmer AK Triangular fibrocartilage complex lesions: A classification. J Hand Surg [Am] 14594406,1989 Palmer AK, Glisson RR, Werner Fw:Ulnar variance determination. J Hand Surg [Am] 7376-379, 1982
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11. Palmer AK, Glisson RR, Werner Fw:Relationship between ulnar variance and triangular fibrocartilage complex thickness. J Hand Surg [Am] 9:681-682,1984 12. Sagerman SD, Short W Arthroscopic repair of the radial-sided triangular fibrocartilage complex tears. Arthroscopy 12(3):339-342, 1996 13. Shionova K, Nakamura R, Imaeda T, et a1 Arthrography is superior to magnetic resonance imaging for diagnosing injuries of the triangular fibrocartilage. J Hand Surg [Br] 23:402-405, 1998 14. Werner FW, Glisson RR, Murphy DJ, et al: Force transmission through the distal radioulnar carpal joint: Effect of ulnar lengthening and shortening. Handchir Mikrochir Plast Chir 18304-308,1986 15. Wnorowski DC,Palmer AK, Werner FW, et al: Anatomic and biomechanical analysis of the arthroscopic wafer procedure. Arthroscopy 8204-212, 1992 16. Zlatkin MB, Chao PC, Osterman AL, et a1 Chronic wrist pain: evaluation with highresolution MR imaging. Radiology 173723-729, 1989
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