Morphology of the Ulnar Insertion of the Triangular Fibrocartilage Complex and Related Osseous Landmarks

Complications after arthroscopic triangular fibrocartilage complex (TFCC) surgery

Wrist arthroscopy is a valuable and widely utilized tool in the treatment of triangular fibrocartilage complex (TFCC) injuries. These procedures include synovectomy alone, peri-capsular or transosseous repair, and arthroscopic-assisted reconstruction, and each are associated with specific complications. This review describes the types of complications and their rates in different types of arthroscopic TFCC surgery reported in the literature and in our centre. Across the spectrum of arthroscopic TFCC surgery, complication rates and the learning curve increase with surgical complexity. Relevant anatomy, prevention and management of complications including nerve injury and irritation, extensor tendon injury and tendinitis, fracture, stiffness, and persistence of symptoms or instability are discussed. Vigilance to anatomical details and careful dissection can help to reduce complications that may result in disturbing pain and functional loss.

Effectiveness of suture anchor and transosseous suture technique in arthroscopic foveal repair of the triangular fibrocartilage complex: a systematic review

BACKGROUND

Currently, there were two major surgical methods for arthroscopic triangular fibrocartilage complex (TFCC) foveal repair: suture anchor (SA) and transosseous suture (TOS). The purpose of this systematic review is to examine the relevant outcome improvement and safety of SA and TOS technique.

METHODS

Literature review of electronic databases for studies investigating the effects of SA and TOS in patients undergoing arthroscopic TFCC foveal repair was performed. We compared the pre-operative and postoperative functional outcomes, clinical outcomes [pain, range of motion (ROM) and grip strength], and complications of two methods. Minimal clinically important difference (MCID) was used to determine clinically meaningful improvement.

RESULTS

There were 1263 distinct studies identified, with 26 (904 patients) meeting the inclusion criteria. The mean age of participants ranged from 21.4 to 41 years, and the mean follow-up time ranged from 6 to 106 months. Both SA and TOS groups reported significant improvement in the modified mayo wrist score, the disabilities of the arm, shoulder, and hand (DASH) score, quick DASH score, patient-reported wrist evaluation (PRWE) score, and the visual analog scale (VAS) score. According to MCID, all the studies from both groups reporting DASH, quick DASH, PRWE and VAS score achieved clinically meaningful improvement. (MCID: 10 for DASH, 14 for quick DASH, 14 for PRWE and 1.6-18 for VAS). The ROM changes in both groups varied from improvement to deterioration. Grip strength improved in both SA and TOS group. Most complications were self-limited. The reoperation rates in SA and TOS ranged from 0 to 20% and 0 to 27.3%, respectively.

CONCLUSIONS

Both SA and TOS technique for arthroscopic TFCC foveal repair could achieve improvement in postoperative functional outcomes, pain, and grip strength with low reoperation rate. However, the ROM improvement was still inconclusive.

LEVEL OF EVIDENCE IV

Systematic review of level III and IV studies.

Morphology of the Radial Attachment of the Radioulnar Ligament and Surrounding Landmarks

PURPOSE

The triangular fibrocartilage complex (TFCC) is composed of dorsal and palmar radioulnar ligaments (RULs). A common injury pattern of the RUL is the avulsion of the ulnar insertion, which can be treated by arthroscopic or open repair. Although the general method of TFCC reconstruction is a tendon graft with a bone tunnel, detailed information regarding the radial attachment of the RUL is unclear. This study aimed to clarify the morphology of the radial attachments of the palmar radioulnar ligament (PRUL), dorsal radioulnar ligament (DRUL), and short radiolunate ligament (SRL) using three-dimensional imaging.

METHODS

A total of 29 upper limbs (16 formalin-fixed and 13 embalmed by Thiel's embalming method) of Japanese cadavers were used. After gross observation, we marked the attachments of the PRUL, DRUL, and SRL using 0.7-mm diameter pins. We created three-dimensional images of the radius, outlining the PRUL, DRUL, and SRL attachments. The software application calculated the centers of the PRUL and DRUL attachments.

RESULTS

The PRUL attachment was horizontally shaped. The center of the PRUL was 1.5 mm proximal and 5.8 mm radial to the tip of the palmar pyramid formed by the palmar cortex and the radioulnar and radiocarpal joint surfaces. The DRUL attachment was vertically shaped. The center of the DRUL was 2.0 mm proximal and 1.7 mm radial from the tip of the dorsal pyramid formed by the dorsal cortex and the radioulnar and radiocarpal joint surfaces. The length of the SRL was 9.2 mm. The SRL and PRUL were strongly conjoined.

CONCLUSIONS

The anatomical center on the RUL attachment of the radius can be determined from osseous landmarks.

CLINICAL RELEVANCE

The findings of this study contribute to the understanding of RUL attachment to the distal radius and may assist surgeons in performing anatomical reconstruction of TFCC.

Editorial Commentary: Arthroscopic Capsular Repair of Wrist Triangular Fibrocartilage Complex Tears: Beware That Apparent Isolated Atzei Class 1 (Isolated Distal Component) Tears May Include a Proximal Component

Accumulating knowledge about the anatomy of the triangular fibrocartilage complex (TFCC) and its function has revealed that the foveal insertion of the TFCC plays a key role in distal radioulnar joint stability rather than the superficial fibers that insert into the ulnar styloid. Recently, the interest in torn peripheral TFCC repair has been shifting from capsular repair for Atzei class 1 to foveal repair for Atzei class 2 or 3. Most acute Atzei class 1 tears spontaneously heal without surgical repair; in contrast, in cases of sustained pain and distal radioulnar joint instability even after successful Atzei class 1 repair, the unrecognized proximal component TFCC tear concomitant with a distal component TFCC tear may exist and appropriate treatment for the proximal component TFCC tear should be combined. Although overall successful results have been reported using various repair techniques, the most important consideration is re-establishing biologic regeneration potential at the insertion site of torn TFCC.

Arthroscopic transosseous foveal footprint repair of the triangular fibrocartilage complex

Foveal disruption of the triangular fibrocartilage complex contributes to the instability of distal radioulnar joint. We have developed an arthroscopic transosseous foveal footprint repair technique, which maximizes the contact between the disrupted triangular fibrocartilage complex and its foveal footprint for better healing by using four sutures in a divergent configuration through a 1.6-mm bone tunnel. Twelve patients with triangular fibrocartilage complex foveal injuries who had undergone this repair technique were reviewed with a mean follow-up of 53 months. All patients achieved significant improvement in the modified Mayo wrist score and the Disabilities of the Arm, Shoulder and Hand score. All patients had stable distal radioulnar joints with comparable ranges of motion and grip strengths between the operated and contralateral wrists. There was no significant difference in functional score in those who were treated more than 6 months after injury.Level of evidence: IV.