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Hand Surgery, Vol. 20, No. 1 (2015) 1–9 © World Scientific Publishing Company DOI: 10.1142/S0218810415010017
REVIEW ARTICLE BY EDITOR-IN-CHIEF TRIANGULAR FIBROCARTILAGE COMPLEX TEARS
Hand Surg. 2015.20:1-9. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/17/15. For personal use only.
Akio Minami Department of Orthopaedic Surgery Hokkaido Chuo Rosai Hospital Spinal Cord Injury Center Japan Labor Health and Welfare Organization Bibai, Hokkaido, Japan Received 3 March 2014; Accepted 11 September 2014; Published 20 January 2015 Keywords: Triangular Fibrocartilage Complex Tear; Distal Radioulnar Joint; Scopic Debridement; Ulnar Shortening Osteotomy; Arthroplasty.
INTRODUCTION
the ulna, and the most superficial layer attaches to the meniscus homologue and ulnar styloid process. Recent functional anatomic and biomechanical studies have revealed that the deep layer of the TFCC mainly contributes to the dynamic stability of the distal radioulnar joint (DRUJ).3–6 This fact is also used as an explanation of the reason for not having a big influence on the stability of DRUJ, since 40–60% of distal radius fractures associate with tip fracture of the ulnar styloid process.7–11 Nakamura and his associates have reported functional anatomies of the TFCC by meticulous anatomical and biomechanical studies.2–4 They have reported that TFCC is presenting a hammock-like structure and ulnar side of the TFCC is merged to meniscus homologue and UCL (Fig. 1). When pulling the ulnar side of the TFCC, the so-called pulling up of the string supporting a hammock, the entire TFCC has tension (Fig. 2). By performing an ulnar shortening osteotomy, the whole TFCC becomes tense, and it is assumed that the stability of the DRUJ is acquired, and this serves as a reason for the usefulness of performing ulnar shortening osteotomy for DRUJ instability. Moreover, as described before, they have named the triangular ligament which combines the dorsal and palmar distal radioulnar ligaments, and inserts to the fovea of the ulna and gives
The terminology of triangular fibrocartilage complex (TFCC) is almost accepted in the field of hand surgery since Palmer named it in 1981.1 Before being called TFCC, it was called an articular disc because of the structural similarity of a meniscus of the knee joint. However, now, many hand surgeons have come to use the name unified as TFCC.
FUNCTIONAL ANATOMY The main structural component of TFCC is triangular fibrocartilage (TFC) proper which originates from the ulnar border of the sigmoid notch and attaches to the fovea and the styloid process of the ulna. Other main structures of TFCC include dorsal and palmar capsules, meniscus homologue, ulnar collateral ligament (UCL), dorsal and palmar distal radioulnar ligaments (triangular ligament named by Nakamura and his associates2 ), ulnocarpal ligaments (ulnolunate and ulnotriquetral ligaments) and tendon floor of the extensor carpi ulnaris tendon. TFC proper consists of two layers, superficial and deep layers. Both originate from the sigmoid notch of the radius where a great portion of the deep layer attaches to the fovea of
Correspondence to: Prof. Akio Minami, Hokkaido Chuo Rosai Hospital Spinal Cord Injury Center, Japan Labor Health and Welfare Organization, Higashi-4, Minami-1, Bibai, Hokkaido 072-0015, Japan. Tel: (þ81) 126-63-2151, Fax: (þ81) 126-63-2853, E-mail: [email protected] 1
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Fig. 1 Diagram of the three-dimensional structure of the TFCC. (From Nakamura T et al. Copyright, British and European Societies for Surgery of the Hand, by permission of SAGE Publications Ltd.)
great restraints of the DRUJ stability. Although most hand surgeons have not always accepted, this concept regarding the name of the triangular ligament has permeated considerably. Blood supply and nerve innervation of the TFCC show a close similarity with those of meniscus of the knee joint.12–14 The area from sigmoid notch of the radius to central portion of the TFC proper has no blood supply and nerve innervation. The peripheral margin of the TFCC is a red zone like a meniscus of the knee joint, and the central portion of the TFC proper can be called white zone. These anatomical findings reveal that the tear around the red zone is repairable, however, the suture of the TFCC tear around the white zone is not theoretically carried out. These facts will be greatly related also to the classifications and the treatments for TFCC tear which are indicated below.
CLASSIFICATION The classification of TFCC tear was reported by Palmer in 1990, which is widely well known.1,15 The TFCC tears are classified into two types — Class 1, traumatic and Class 2, degenerative. Each type is again classified into four and five subtypes. There have been other classifications.16–20 They should be considered as reference since these classifications have also indicated the treatment options according to their classification. Palmer classified TFCC tear into traumatic and degenerative, and considered the Class 2, degenerative lesion as
Fig. 2 Diagram of structure and function of the TFCC. The TFCC is separated into three components: the proximal triangular ligament, the distal hammock structure, and the UCL. These three components of the TFCC suspend each other and the loose internal structure of the TFCC absorbs the strain so that stability and mobility of the ulnar side of the wrist can be achieved. (From Nakamura T et al. Copyright, British and European Societies for Surgery of the Hand, by permission of SAGE Publications Ltd.)
synonymous with ulnar abutment syndrome.1,15 However, most of hand surgeons do not always agree that the TFCC Class 2 lesion is in the same category as the ulnar abutment syndrome.21–23
DIAGNOSES Clinical Diagnoses A wrist pain is an essential symptom of the TFCC tear. A pain usually occurs from rotation of the forearm rather than dorsiflexion–palmar flexion of the wrist. Although dorsiflexion– palmar flexion of the wrist joint and the rotation of the forearm may not have so much restriction, the terminal pain in each movemental direction exists in many cases. Grip strength is seen to be declining in many cases as compared with an unaffected side. Although there are not so many classic signs that the painful click at the time of a forearm rotation exists especially at the time of motion, if the painful click exists at the time of rotation, existence of TFCC tear can be suspected strongly. When severe instability of the DRUJ is present, a giving-way sensation at similar to heaviness of the fist may exist. They include wrist pain and sense of exhaustion during daily living activities such as
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trying to get change from a palm and while opening the shutter of a bad garage at supinated position of the forearm. These complaints have been expressed by patients in many cases. As tender areas, they exist in the dorsum of the DRUJ and ulnocarpal space in many cases. Piano-key sign and ulnocarpal ballotement test which suggest the instability of the DRUJ are remarkable. It is not easy to clinically evaluate the instability of the ulnar head correctly. If piano-key sign is present in young women, it is positive by remarkable frequency in many cases. If apparent ulnar head instability exists when the forearm is enforced into the maximum supinated position, i.e. the components of DRUJ become tight, the instability of DRUJ can be suspected strongly. Fovea sign is defined to be positive if a tenderness is present proximal to pisiform and ulnar to flexor carpi ulnaris tendon. If the fovea sign is positive the existence of Class 1B lesion is strongly suspected.24 Ulnocarpal compression test, in which a wrist joint is strongly ulnarly deviated at the maximum extremes of both pronation and supination of the forearm, is also a special test. Ulnocarpal compression test is a laboratory technique with high sensitivity, but low specificity.
Image Diagnoses Fundamentally, plain X-rays are not useful for diagnosis of the TFCC tear except for determining the existence of osteoarthritis of the DRUJ and ulnar abutment syndrome with positive ulnar variance. Earlier, the TFCC tear was diagnosed in the outpatient clinic by arthrography of the wrist.7,25,26 When contrast medium has intercourse to DRUJ by way of contrast medium injected to the radiocarpal joint, the existence of TFCC tear is clear. However, the positive ratio of arthrography of the wrist was just above or below 70% in our series. Even if communication of the contrast medium does not exist between radiocarpal joint and DRUJ by arthrography, it is important that sometimes the TFCC tear is about 30%. From this reason, Palmer and his associates have recommended the means of threecompartment injection method in wrist arthrography.26 In the case where after contrast medium is injected into the radiocarpal joint, the communication to the DRUJ is not apparent, they further performed the contrast medium injection to the DRUJ and midcarpal joint. Although this three-compartment injection method is very useful to detect the existence of the TFCC tear, the technique is relatively complicated. In order to accurately diagnose, the second and the third injection should be performed after waiting for absorption of the contrast
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medium. Therefore, I do not feel that this technique is especially more useful compared with the usual arthrography method. With the recent remarkable development of apparatus and technique of MR diagnosis of tear and thinning of the TFCC are becoming possible. In recent times, wrist arthrography is not regularly performed.25,27–29 MR arthrography is common in America and European countries, and it can be said that the diagnostic probability of TFCC tear is further increased.25 Although CT, scintigraphy, etc. also are useful methods in diagnosis, it is hard to accurately diagnose of TFCC tear. These diagnoses consist mainly of these clinical symptoms and findings, and image findings are judged synthetically. Diagnosis of TFCC tears to many is possible.
TREATMENTS Conservative Treatments When traumatic TFCC tear is suspected clinically, it is common to perform conservative treatments first. When traumatic TFCC tears are suspected, they are classified into three stages according to the time the patient suffered injury. They include an acute phase (after injury two weeks or before), a subacute phase (2–6 weeks after injury), and a chronic phase (after injury six weeks or subsequent ones) from the time of injury to the first visit. Conservative treatments should be performed for TFCC tears in the subacute and chronic phases.17 Many hand surgeons have reported various conservative treatment options. The bandage is expanded and contracted so that the 1–2 cm proximal portion of ulnar head may be approached against a radius covering a width of 2–3 cm. It is also one method.30 It has been reported that symptoms reduce in 60–70% of cases with TFCC tears on the whole by fixation for 4–6 weeks. Although we have little experience in this conservative treatment, we think that it will be useful as an easy treatment option which should be tried first. During the period of conservative treatment, although there are some hand surgeons who recommend injection of the corticosteroids into the DRUJ, we consider it is better to also consider other possibilities, such as a direct repair, to be carried out. I want to emphasise that my opinion has not always received consensus, but it is a personal opinion. If the function of TFCC will be considered, the splint including above elbow should be applied, but when the elbow is included in the fixed part, the patients who surely dislike the above elbow splint in
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number, and the direction of the decoration for fixation of only a wrist joint, think on the contrary that the compliance of wearing is high. We suppose that a wrist fixation splint which fixes a wrist joint by slight dorsiflexion will be carried out. The wrist fixated splint should be applied for 4–6 weeks. If severe pain is reported by a patient in the chronic phase, in addition to medication including pasting of medication and non-steroidal anti-inflammatory drugs, wrist fixating splint is applied. However, when a sense of giving-way exists, a suture of the TFCC or TFCC reconstruction should be considered.
Operative Treatments Hand Surg. 2015.20:1-9. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/17/15. For personal use only.
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Since Class 1A TFCC lesion is the so-called tear in the white zone, generally it is invalid to directly suture the TFCC tear and it is therefore effective to debride TFCC flap. Class 1D TFCC lesion is tear avulsed at the sigmoid notch of the radius and may be accompanied by the avulsion fracture of the sigmoid notch. When avulsion fracture exists at the sigmoid notch, the possibility of the suture of TFCC tear to a bone is high, but it is considered to be difficult when fracture is not associated. However, there is still an argument about this approach and is regarded controversial and in conclusive. From our experience, Class 1D TFCC lesion was treated by the direct repair of the TFCC tear to the sigmoid notch of the radius associated with hemiresection-interposition arthroplasty of the DRUJ, as reported by Bowers.31 In our experience, 80% of TFCC tears were confirmed to be repaired during the second look by wrist arthroscopy, which suggested that Class 1D TFCC lesion had possibility of repairability, although the site of Class 1D TFCC lesion had no blood supply.32 However, these data are not always accepted by most of the hand surgeons. Partial excision of the TFCC33–41
When the flap of the TFCC tear is caught by the forearm rotation in Class 1A and Class 2 lesions, I think that partial excision of the flap of the TFCC should be indicated. It is common to perform scopic debridement so that it may partially exercise the flap around the TFCC tear in Class 1A lesion to prevent a catch by the forearm rotation. Although there were reports describing that partial excision of the TFCC tear was absolutely effective in all types of TFCC injuries, we reported that postoperative results were very unstable when the tear existed in the cases with positive ulnar variance or the carpal ligament tears.38
We conclude that arthroscopic partial excision of the TFCC tear is indicated in cases with Class 1 lesion, positive ulnar variance less than 2 mm and even in Class 2 with ulnar variance less than 0 mm. Repair of the TFCC19,35–37,41–59
The instability of DRUJ is most remarkable in many cases with Class 1B TFCC lesion, therefore operative procedure should be indicated in such cases. The extensor carpi ulnaris tendon sheath is incised to open the fifth extensor compartment and after reflection of the extensor carpi ulnaris tendon the tendon floor is exposed. The tendon floor is incised longitudinally to expose the DRUJ. After evaluating the state of the TFCC tear, the margin of the flap of the TFCC tear is minimally debrided to freshen the stump. The cortex of the fovea of the ulnar head is excised to make a bone tunnel from the ulnar cortex of the proximal ulna. The ulnar margin of the TFCC is drawn into the bone tunnel of the ulna by using non-absorbable suture, 2-0 Surgironr and tied firmly over the ulnar cortex of the ulna. Postoperatively, the long arm cast is applied with the forearm at 30–60 supinated position for 3–4 weeks. After removal of the cast, active and passive physiotherapy is begun. The patients do not return to their jobs until three months postoperatively. Although various methods have been reported of scopic repair of the TFCC, we have employed the method reported by Iwasaki, my colleague.52,59 After evaluating the state of the TFCC tear by a wrist arthroscopy, a flap margin of the TFCC tear is debrided to prepare for suture when the lesion belongs to Class 1B. Then, the proximal ulnar portion of the ulna is incised to expose the ulnar cortex between the extensor carpi ulnaris tendon and the flexor carpi ulnaris tendon. A bone hole with diameter of 2.9 mm produced from this part to the fovea of the ulna obliquely and the stump of the TFCC tear is drawn in a bone hole, and it will suture firmly on the ulnar cortex of the ulna (Fig. 3). Therefore, if our method is to be defined correctly, it can be called minimum invasive surgery, not entire scopic surgery. There are many methods of open and scopic TFCC repairs. Hand surgeons should examine literatures regarding TFCC repair in detail, and should choose a favourite method. Partial resection of the ulnar head41
When the ulna is presenting positive variance, the method of excising the ulnar head of only the portion of the positive
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(A)
(B)
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Fig. 3 (A) An osseous tunnel 2.9 mm in diameter from the ulnar neck to the foveal surface. Using a suture loop, the end of the repair suture is delivered out of the osseous tunnel. (B) The 2 free ends of the repair surface are pulled through the osseous tunnel to bring the suture onto the TFCC surface. (C) The avulsed portion of the TFCC is anchored to the fovea with near-normal tension. The suture is tied onto the ulnar periosteum around the proximal entrance of the osseous tunnel. (From Iwasaki N and Minami A. Copyright, American Society for Surgery of the Hand, by permission of Elsevier, Inc.)
variance under open or scopic is used. This method is called wafer procedure.41 Although the author does not have many experiences, when the instability of the DRUJ is not remarkable, it is supposed that wafer procedure is performed about the positive variance portion of the ulnar head. Then, although consensus is not yet obtained about what millimeters of ulnar positive variance of wafer procedure is effective, it has been recommended by Feldon, who developed and described wafer procedure that 6 mm or less of ulnar positive variance is effective. Although it remains unknown whether the turning point of ulnar positive variance is 6 mm or less, the case of a large ulnar positive variance is invalid. Moreover, although wafer procedure has an effect of decompression between the ulnar head and carpal bone similar to the ulnar shortening osteotomy, I think that there is no effect which strains the entire TFCC unlike an ulnar shortening osteotomy, and gives the stability of the DRUJ. Therefore, the author thinks that indication of wafer procedure is quite restrictive. However, while considering a comparatively easy operation under an arthroscopy in the case of ulnar abutment syndrome, many hand surgeons highly recommend indications of wafer procedure. Ulnar shortening osteotomy21,41,53,60,61
An ulnar shortening osteotomy is often indicated to the cases of TFCC tears associated with the positive ulnar variance in many
cases. Since the case of TFCC tear with especially Class 2 lesion has associated with the ulnar abutment syndrome in which the ulna presents positive variance in many cases, an ulnar shortening osteotomy is comparatively likely to be performed. When slight to mild instability of the DRUJ exists in the case of TFCC tear, it is still controversial whether ulnar shortening osteotomy should be performed after partial resection or repair of the TFCC tear. It is also controversial whether scopic debridement or partial resection of the TFCC should be performed in association with ulnar shortening osteotomy. Author recommends to commonly carry out a wrist arthroscopy in order to sufficiently evaluate the state and degree of the TFCC tear and to perform partial excision of the TFCC tear even before the ulnar shortening osteotomy. The rationale of the effect of an ulnar shortening osteotomy shortens an ulna and aims at strain and acquires the stability of DRUJ as described previously.2 However, it is well known that osteoarthritis may occur in high frequency due to the incongruity of the DRUJ after the ulnar shortening osteotomy as author has also reported.21 Characteristic osteoarthritic findings at the DRUJ after ulnar shortening osteotomy include bone sclerosis and bony spur at the sigmoid notch of the radius and ulnar head articulated with the radius. Fortunately, osteoarthritic changes do not influence the clinical symptoms such as a pain and movemental restriction of the forearm rotation. We should carefully follow up and check clinical symptoms due to osteoarthritis of the DRUJ in future. Since many hand surgeons
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recently prefer to do an ulnar shortening osteotomy for the DRUJ instability due to the TFCC tear with positive ulnar variance, author would like to emphasise strongly that we should carefully carry out an ulnar shortening osteotomy for the TFCC tear. When the osteoarthritic changes beyond a moderate degree exist in DRUJ before the operation, operative indication of an ulnar shortening osteotomy does not exist in principle, but some hand surgeons recommend an ulnar shortening osteotomy for cases of TFCC tears with preoperative existence of slight osteoarthritic changes. Another argument is about the shortening of the postoperative ulnar variance. Most of the hand surgeons try to obtain postoperative zero (neutral) ulnar variance. Since the grade of the postoperative osteoarthritis of the DRUJ is sometimes strong when the amount of shortening is large, author recommends that a strain of TFCC can be obtained by shortening of about 2 mm, even if the amount of positive variance before an operation is how much.21 However, consensus is not obtained about the amount of ulnar shortening. Reconstruction of the TFCC19,62,63
When the repair of the TFCC is not directly made in most of the chronic phases of the TFCC tear, a TFCC reconstructive procedure is indicated. Many procedures of reconstruction of the TFCC tear have been reported. Among them, Nakamura et al. reported that good and excellent postoperative outcome were obtained with the reconstructive procedure of the TFCC using the extensor carpi ulnaris tendon.19 We have experienced only two cases of Nakamura’s method and further investigations are needed in future. The reconstructive procedure of the TFCC is indicated in the chronic case of the TFCC tear with severe pain and instability of the DRUJ. We prefer to perform the reconstructive procedure described by Adams and Berger63 for chronic TFCC tear and good results are acquired at about 80%. The method of Adams and Berger is fixed to the fovea of the ulnar head through the bone hole added to the dorsal and palmar sigmoid notch of the radius using palmaris longus tendon, so palmar and dorsal radioulnar ligament (triangular ligament) are reconstructed. The arthroplasty of the DRUJ31,32,64–68
When osteoarthritic changes arise in the DRUJ by TFCC tear, arthroplasties of the DRUJ are indicated which are similar to those of the operative indication of osteoarthritis of the DRUJ.
We prefer to perform three procedures, the so-called Darrach’s procedure, hemiresection-interposition arthroplasty and Sauvë– Kapandji procedure for osteoarthritis of the DRUJ. We reported operative indications and outcomes of three procedures.65,68 Of the three procedures, I think that Darrah’s procedure is indicated to a patient with low activity in old age because of postoperative decrease of grip strength and instability of the distal end of the ulna after Darrah’s procedure. The Sauvë–Kapandji procedure is indicated for patients for whom osteoarthritis of the DRUJ exists and there is no function of TFCC or unrepairable TFCC function (Fig. 4). Hemiresection-interposition arthroplasty reported by Bowers is indicated for the osteoarthritis of the DRUJ which has a TFCC function.64,68 As described above, operative indication of the ulnar shortening osteotomy is another useful arthroplasty of the DRUJ.
DISCUSSION Since Palmer1 named TFCC, which was earlier called by various other names, there were many reports about pathogenesis, diagnosis, and treatment. Now, TFCC tear has become one of
Fig. 4 Following the Sauve–Kapandji procedure, a 3.5-mm hole was drilled from the dorsoulnar aspect of the ulnar shaft into the intramedullary cavity. The extensor carpi ulnaris tendon was the split in the central sulcus and the radial half released at the ulnocarpal level. It was the reflected proximally, leaving it attached at the musculotendinous junction. This proximal-based strip was then at the distal stump of the ulna, and then sutured back on itself in an interlacing fashions. (From Minami A et al. Copyright, American Society for Surgery of the Hand, by permission of Elsevier, Inc.)
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the important topics in the field of hand surgery. After Palmer’s reports, we reported some papers on surgical treatments for TFCC tears.21,32,38,65–68 Although the results of TFCC Class 1 lesion, i.e. traumatic TFCC tear, were good in the report about partial resection under wrist arthroscopy, the postoperative results of the case of TFCC Class 2 lesion were unsatisfactory. We concluded that these results were because most of the TFCC Class 2 lesions were associated with positive ulnar variance and lunotriquetral ligament tear.38 Then, we reported results of the ulnar shortening osteotomy for the cases of TFCC tears associated with positive ulnar variance.21 More than 80–90% of TFCC tears belonging to both classes obtained good or excellent results by the ulnar shortening osteotomy. We concluded that the ulnar shortening osteotomy was very useful for the TFCC lesion associated with positive ulnar variance. Moreover, we also reported the possibility of the repair of the TFCC tear belonging to Class 1D lesion as described above.32 Then, Iwasaki, my colleague, has reported a novel technique for the suture of the TFCC Class 1B lesion arthroscopically and also described usefulness of the new technique.52,59 If it is evaluated using Mayo wrist score, in 90–95% or more of patients, it shall be effective. Although further verification will be required from now on, it is considered that it may be widely carried out by this new minimum invasive technique. In the pathogenesis, diagnosis and conservative and operative treatments for TFCC tear, further investigations are required which may lead to newer developments.
ACKNOWLEDGEMENTS The author expresses sincere thanks to Professor Richard A. Berger, Department of Orthopaedics, Surgery of the Hand, Mayo Clinic, Rochester, Minnesota, USA for his suggestions and advice throughout this investigation.
References 1. Palmer AK, Werner FW, The triangular fibrocartilage complex of the wrist-anatomy and function, J Hand Surg 6A:153–162, 1981. 2. Nakamura T, Yabe Y, Horiuchi Y, Functional anatomy of the triangular fibrocartilage complex, J Hand Surg 21B:581–586, 1996. 3. Nakamura T, Yabe Y, Histological anatomy of the triangular fibrocartilage complex of the human wrist, Ann Anat 182:567–572, 2000.
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4. Nakamura T, Takayama S, Horiuchi Y, Yabe Y, Origins and insertions of the triangular fibrocartilage complex: A histological study, J Hand Surg 26B:446–454, 2001. 5. Sasao S, Beppu M, Kihara H, Hirata K, Takagi M, An anatomical study of the ligaments of the ulnar compartment of the wrist, Hand Surg 8:219–226, 2003. 6. Schmidt HM, The anatomy of the ulnocarpal complex, Orthopaedics 33:628–637, 2004. 7. Grechenig W, Peicha G, Fellinger M, Seibert FJ, Preidler KW, Wrist arthrography after acute trauma to the distal radius: Diagnostic accuracy, technique, and sources of diagnostic errors, Invest Radiol 33:273–278, 1998. 8. Lindau T, Adlercreutz C, Aspenberg P, Peripheral tears of the triangular fibrocartilage complex cause distal radioulnar joint instability after distal radial fractures, J Hand Surg 25A:464–468, 2000. 9. B€ohringer G, Schädel-H€opfner M, Junge A, Gotzen L, Primary arthroscopic treatment of TFCC tears in fractures of the distal radius, Handchir Mikrochir Plast Chir 33:245–251, 2001. 10. Scheer JH, Adolfsson LE, Patterns of triangular fibrocartilage complex (TFCC) injury associated with severely dorsally displaced extra-articular distal radius fractures, Injury 43:926–932, 2012. 11. Wysocki RW, Richard MJ, Crowe MM, Leversedge FJ, Ruch DS, Arthroscopic treatment of peripheral triangular fibrocartilage complex tears with the deep fibers intact, J Hand Surg 37A:509–516, 2012. 12. Gupta R, Nelson SD, Baker J, Jones NF, Meals RA, The innervation of the triangular fibrocartilage complex: Nitric acid maceration rediscovered, Plast Reconstr Surg 107:135–139, 2001. 13. Shigemitsu T, Tobe M, Mizutani K, Murakami K, Ishikawa Y, Sato F, Innervation of the triangular fibrocartilage complex of the human wrist: Quantitative immunohistochemical study, Anat Sci Int 82:127–132, 2007. 14. Unglaub F, Kroeber MW, Thomas SB, Wolf MB, Arkudas A, Dragu A, Horch RE, Incidence and distribution of blood vessels in punch biopsies of Palmer 1A disc lesions in the wrist, Arch Orthop Trauma Surg 129:631–634, 2009. 15. Palmer AK, Triangular fibrocartilage disorders: Injury patterns and treatment, Arthroscopy 6:125–132, 1990. 16. Bowers WH, Problems of the distal radioulnar joint, Adv Orthrop Surg 7:289–303, 1984. 17. Cooney WP, Tears of the triangular fibrocartilage of the wrist, in Cooney WP et al. (eds.) The Wrist: Diagnosis and Operative Treatment, 1st edn., Mosby, St. Louis, pp. 710–742, 1998. 18. Jeffries AO, Craigen MA, Stanley JK, Wear patterns of the articular cartilage and triangular fibrocartilaginous complex of the wrist: A cadaveric study, J Hand Surg 19B:306–309, 1994. 19. Nakamura T, Nakano Y, Ikegami H, Sato K, Open repair of the ulnar disruption of the triangular fibrocartilage complex with double threedimensional mattress suturing technique, Tech Hand Upp Ext Surg 8:116–123, 2004. 20. Atzei A, Luchetti R, Foveal TFCC tear classification and treatment, Hand Clin 27:263–272, 2011.
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21. Minami A, Kato H, Ulnar shortening for triangular fibrocartilage complex tears associated with ulnar positive variance, J Hand Surg 23A:904–908, 1998. 22. De Smet L, Ulnar variance and its relationship to ligament injuries of the wrist, Acta Orthop Belg 65:416–417, 1999. 23. Zahiri H, Zahiri CA, Ravari FK, Ulnar styloid impingement syndrome, Int Orthop 23:1233–1237, 2010. 24. Tay SC, Tomita K, Berger RA, The \ulnar fovea sign" for defining ulnar wrist pain: An analysis of sensitivity and specificity, J Hand Surg 32A:438–444, 2007. 25. Cerofolini E, Luchetti R, Pederzini L, Soragni O, Colombini R, D’Alimonte P, Romagnoli R, MR evaluation of triangular fibrocartilage complex tears in the wrist: Comparison with arthrography and arthroscopy, J Comput Assist Tomogr 14:963–967, 1990. 26. Levinsohn EM, Rosen ID, Palmer AK, Wrist arthrography: Value of the three-compartment injection method, Radiology 179:231–239, 1990. 27. Totterman SM, Miller RJ, MR imaging of the triangular fibrocartilage complex, Magn Reson Imaging Clin N Am 3:213–228, 1995. 28. De Smet L, Magnetic resonance imaging for diagnosing lesions of the triangular fibrocartilage complex, Acta Orthop Belg 71:396–398, 2005. 29. Tanaka T, Yoshioka H, Ueno T, Shindo M, Ochiai N, Comparison between high-resolution MRI with a microscopy coil and arthroscopy in triangular fibrocartilage complex injury, J Hand Surg 31A:1308–1314, 2006. 30. Mizusaki T, Treatment of TFCC injury-conservative treatment, Surg Joint 13:981–994, 1994 (in Japanese). 31. Bowers WH, Distal radioulnar joint arthroplasty: The hemiresectioninterposition technique, J Hand Surg 10A:169–178, 1985. 32. Minami A, Kaneda K, Itoga H, Hemiresection-interposition arthroplasty of the distal radioulnar joint associated with repair of triangular fibrocartilage complex lesions, J Hand Surg 16A:1120–1125, 1991. 33. Osterman AL, Arthroscopic debridement of triangular fibrocartilage complex tears, Arthroscopy 6:120–124, 1990. 34. Osterman AL, Terrill RG, Arthroscopic treatment of TFCC lesions, Hand Clin 7:277–281, 1991. 35. Whipple TL, Geissler WB, Arthroscopic management of wrist triangular fibrocartilage complex injuries in the athlete, Orthopedics 16:1061– 1067, 1993. 36. Gan BS, Richards RS, Roth JH, Arthroscopic treatment of triangular fibrocartilage tears, Orthop Clin North Am 26:721–729, 1995. 37. De Smet L, De Ferm A, Steenwerckx A, Dauwe D, Zachee B, Fabry G, Arthroscopic treatment of triangular fibrocartilage complex lesions of the wrist, Acta Orthop Belg 62:8–13, 1996. 38. Minami A, Ishikawa J, Suenaga N, Kasashima T, Clinical results of treatment of triangular fibrocartilage complex tears by arthroscopic debridement, J Hand Surg 21A:406–411, 1996. 39. Husby T, Haugstvedt JR, Long-term results after arthroscopic resection of lesions of the triangular fibrocartilage complex, Scand J Plast Reconstr Surg Hand Surg 35:79–83, 2001. 40. Tomaino MM, Weiser RW, Combined arthroscopic TFCC debridement and wafer resection of the distal ulna in wrists with triangular
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fibrocartilage complex tears and positive ulnar variance, J Hand Surg 26A:1047–1052, 2001. Bernstein MA, Nagle DJ, Martinez A, Stogin JM Jr, Wiedrich TA, A comparison of combined arthroscopic triangular fibrocartilage complex debridement and arthroscopic wafer distal ulna resection versus arthroscopic triangular fibrocartilage complex debridement and ulnar shortening osteotomy for ulnocarpal abutment syndrome, Arthroscopy 20:392–401, 2004. Zachee BM, De Smet L, Fabry G, Arthroscopic suturing of TFCC lesions, Arthroscopy 9:242–243, 1993. Sennwald GR, Lauterburg M, Zdravkovic V, A new technique of reattachment after traumatic avulsion of the TFCC at its ulnar insertion, J Hand Surg 20B:178–184, 1995. Sagerman SD, Short W, Arthroscopic repair of radial-sided triangular fibrocartilage complex tears, Arthroscopy 12:339–342, 1996. Trumble TE, Gilbert M, Vedder N, Arthroscopic repair of the triangular fibrocartilage complex, Arthroscopy 12:588–597, 1996. de Araujo W, Poehling GG, Kuzma GR, New Tuohy needle technique for triangular fibrocartilage complex repair: Preliminary studies, Arthroscopy 12:699–703, 1996. 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 13:78–84, 1997. B€ohringer G, Schädel-H€opfner M, Petermann J, Gotzen L, A method for all-inside arthroscopic repair of Palmer 1B triangular fibrocartilage complex tears, Arthroscopy 18:211–213, 2002. Chou KH, Sarris IK, Sotereanos DG, Suture anchor repair of ulnar-sided triangular fibrocartilage complex tears, J Hand Surg 28B:546–550, 2003. Miwa H, Hashizume H, Fujiwara K, Nishida K, Inoue H, Arthroscopic surgery for traumatic triangular fibrocartilage complex injury, J Orthop Sci 9:354–359, 2004. Yao J, Dantuluri P, Osterman AL, A novel technique of all-inside arthroscopic triangular fibrocartilage complex repair, Arthroscopy 23:1357.e1–4, 2007. Iwasaki N, Minami A, Arthroscopically assisted reattachment of avulsed triangular fibrocartilage complex to the fovea of the ulnar head, J Hand Surg 34A:1323–1326, 2009. Papapetropoulos PA, Wartinbee DA, Richard MJ, Leversedge FJ, Ruch DS, Management of peripheral triangular fibrocartilage complex tears in the ulnar positive patient: Arthroscopic repair versus ulnar shortening osteotomy, J Hand Surg 35A:1607–1613, 2010. Moritomo H, Masatomi T, Murase T, Miyake J, Okada K, Yoshikawa H, Open repair of foveal avulsion of the triangular fibrocartilage complex and comparison by types of injury mechanism, J Hand Surg 35A:1955– 1963, 2010. Kovachevich R, Elhassan BT, Arthroscopic and open repair of the TFCC, Hand Clin 26:485–494, 2010. Argintar E, Mantovani G, Pavan A, TFCC reattachment after traumatic DRUJ instability: A simple alternative to arthroscopic management, Tech Hand Up Extrem Surg 14:226–229, 2010.
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57. Yao J, Lee AT, All-arthroscopic repair of Palmer 1B triangular fibrocartilage complex tears using the FasT-Fix device, J Hand Surg 36A:836–842, 2011. 58. Nakamura T, Sato K, Okazaki M, Toyama Y, Ikegami H, Repair of foveal detachment of the triangular fibrocartilage complex: Open and arthroscopic transosseous techniques, Hand Clin 27:281–290, 2011. 59. Iwasaki N, Nishida K, Motomiya M, Funakoshi T, Minami A, Arthroscopic-assisted repair of avulsed triangular fibrocartilage complex to the fovea of the ulnar head: A 2- to 4-year follow-up study, Arthroscopy 27:1371–1378, 2011. 60. Hulsizer D, Weiss AP, Akelman E, Ulna-shortening osteotomy after failed arthroscopic debridement of the triangular fibrocartilage complex, J Hand Surg 22A:694–698, 1997. 61. Trumble TE, Gilbert M, Vedder N, Ulnar shortening combined with arthroscopic repairs in the delayed management of triangular fibrocartilage complex tears, J Hand Surg 22A:807–813, 1997. 62. Scheker LR, Belliappa PP, Acosta R, German DS, Reconstruction of the dorsal ligament of the triangular fibrocartilage complex, J Hand Surg 19B:310–318, 1994.
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63. Adams BD, Berger RA, An anatomic reconstruction of the distal radioulnar ligaments for posttraumatic distal radioulnar joint instability, J Hand Surg 27A:243–251, 2002. 64. Watson HK, Gabuzda GM, Matched distal ulna resection for posttraumatic disorders of the distal radioulnar joint, J Hand Surg 17A:724– 730, 1992. 65. Minami A, Ogino T, Minami M, Treatment of distal radioulnar disorders, J Hand Surg 12A:189–196, 1987. 66. Minami A, Suzuki K, Suenaga N, Ishikawa J, Hemiresection-interposition arthroplasty for osteoarthritis of the distal radioulnar joint, Int Orthop 19:35–39, 1995. 67. Minami A, Kato H, Iwasaki N, Modification of the Sauve-Kapandji procedure with extensor carpi ulnaris tenodesis, J Hand Surg 25A:1080–1084, 2000. 68. Minami A, Iwasaki N, Ishikawa J, Suenaga N, Yasuda K, Kato H, Treatments of osteoarthritis of the distal radioulnar joint: Long-term results of three procedures, Hand Surg 10:243–248, 2005. 69. Ambrose L, Posner MA, Lunate-triquetral and midcarpal joint instability, Hand Clin 8:653–668, 1992.
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Hand Surgery, Vol. 20, No. 1 (2015) 1–9 © World Scientific Publishing Company DOI: 10.1142/S0218810415010017
REVIEW ARTICLE BY EDITOR-IN-CHIEF TRIANGULAR FIBROCARTILAGE COMPLEX TEARS
Hand Surg. 2015.20:1-9. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/17/15. For personal use only.
Akio Minami Department of Orthopaedic Surgery Hokkaido Chuo Rosai Hospital Spinal Cord Injury Center Japan Labor Health and Welfare Organization Bibai, Hokkaido, Japan Received 3 March 2014; Accepted 11 September 2014; Published 20 January 2015 Keywords: Triangular Fibrocartilage Complex Tear; Distal Radioulnar Joint; Scopic Debridement; Ulnar Shortening Osteotomy; Arthroplasty.
INTRODUCTION
the ulna, and the most superficial layer attaches to the meniscus homologue and ulnar styloid process. Recent functional anatomic and biomechanical studies have revealed that the deep layer of the TFCC mainly contributes to the dynamic stability of the distal radioulnar joint (DRUJ).3–6 This fact is also used as an explanation of the reason for not having a big influence on the stability of DRUJ, since 40–60% of distal radius fractures associate with tip fracture of the ulnar styloid process.7–11 Nakamura and his associates have reported functional anatomies of the TFCC by meticulous anatomical and biomechanical studies.2–4 They have reported that TFCC is presenting a hammock-like structure and ulnar side of the TFCC is merged to meniscus homologue and UCL (Fig. 1). When pulling the ulnar side of the TFCC, the so-called pulling up of the string supporting a hammock, the entire TFCC has tension (Fig. 2). By performing an ulnar shortening osteotomy, the whole TFCC becomes tense, and it is assumed that the stability of the DRUJ is acquired, and this serves as a reason for the usefulness of performing ulnar shortening osteotomy for DRUJ instability. Moreover, as described before, they have named the triangular ligament which combines the dorsal and palmar distal radioulnar ligaments, and inserts to the fovea of the ulna and gives
The terminology of triangular fibrocartilage complex (TFCC) is almost accepted in the field of hand surgery since Palmer named it in 1981.1 Before being called TFCC, it was called an articular disc because of the structural similarity of a meniscus of the knee joint. However, now, many hand surgeons have come to use the name unified as TFCC.
FUNCTIONAL ANATOMY The main structural component of TFCC is triangular fibrocartilage (TFC) proper which originates from the ulnar border of the sigmoid notch and attaches to the fovea and the styloid process of the ulna. Other main structures of TFCC include dorsal and palmar capsules, meniscus homologue, ulnar collateral ligament (UCL), dorsal and palmar distal radioulnar ligaments (triangular ligament named by Nakamura and his associates2 ), ulnocarpal ligaments (ulnolunate and ulnotriquetral ligaments) and tendon floor of the extensor carpi ulnaris tendon. TFC proper consists of two layers, superficial and deep layers. Both originate from the sigmoid notch of the radius where a great portion of the deep layer attaches to the fovea of
Correspondence to: Prof. Akio Minami, Hokkaido Chuo Rosai Hospital Spinal Cord Injury Center, Japan Labor Health and Welfare Organization, Higashi-4, Minami-1, Bibai, Hokkaido 072-0015, Japan. Tel: (þ81) 126-63-2151, Fax: (þ81) 126-63-2853, E-mail: [email protected] 1
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Fig. 1 Diagram of the three-dimensional structure of the TFCC. (From Nakamura T et al. Copyright, British and European Societies for Surgery of the Hand, by permission of SAGE Publications Ltd.)
great restraints of the DRUJ stability. Although most hand surgeons have not always accepted, this concept regarding the name of the triangular ligament has permeated considerably. Blood supply and nerve innervation of the TFCC show a close similarity with those of meniscus of the knee joint.12–14 The area from sigmoid notch of the radius to central portion of the TFC proper has no blood supply and nerve innervation. The peripheral margin of the TFCC is a red zone like a meniscus of the knee joint, and the central portion of the TFC proper can be called white zone. These anatomical findings reveal that the tear around the red zone is repairable, however, the suture of the TFCC tear around the white zone is not theoretically carried out. These facts will be greatly related also to the classifications and the treatments for TFCC tear which are indicated below.
CLASSIFICATION The classification of TFCC tear was reported by Palmer in 1990, which is widely well known.1,15 The TFCC tears are classified into two types — Class 1, traumatic and Class 2, degenerative. Each type is again classified into four and five subtypes. There have been other classifications.16–20 They should be considered as reference since these classifications have also indicated the treatment options according to their classification. Palmer classified TFCC tear into traumatic and degenerative, and considered the Class 2, degenerative lesion as
Fig. 2 Diagram of structure and function of the TFCC. The TFCC is separated into three components: the proximal triangular ligament, the distal hammock structure, and the UCL. These three components of the TFCC suspend each other and the loose internal structure of the TFCC absorbs the strain so that stability and mobility of the ulnar side of the wrist can be achieved. (From Nakamura T et al. Copyright, British and European Societies for Surgery of the Hand, by permission of SAGE Publications Ltd.)
synonymous with ulnar abutment syndrome.1,15 However, most of hand surgeons do not always agree that the TFCC Class 2 lesion is in the same category as the ulnar abutment syndrome.21–23
DIAGNOSES Clinical Diagnoses A wrist pain is an essential symptom of the TFCC tear. A pain usually occurs from rotation of the forearm rather than dorsiflexion–palmar flexion of the wrist. Although dorsiflexion– palmar flexion of the wrist joint and the rotation of the forearm may not have so much restriction, the terminal pain in each movemental direction exists in many cases. Grip strength is seen to be declining in many cases as compared with an unaffected side. Although there are not so many classic signs that the painful click at the time of a forearm rotation exists especially at the time of motion, if the painful click exists at the time of rotation, existence of TFCC tear can be suspected strongly. When severe instability of the DRUJ is present, a giving-way sensation at similar to heaviness of the fist may exist. They include wrist pain and sense of exhaustion during daily living activities such as
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trying to get change from a palm and while opening the shutter of a bad garage at supinated position of the forearm. These complaints have been expressed by patients in many cases. As tender areas, they exist in the dorsum of the DRUJ and ulnocarpal space in many cases. Piano-key sign and ulnocarpal ballotement test which suggest the instability of the DRUJ are remarkable. It is not easy to clinically evaluate the instability of the ulnar head correctly. If piano-key sign is present in young women, it is positive by remarkable frequency in many cases. If apparent ulnar head instability exists when the forearm is enforced into the maximum supinated position, i.e. the components of DRUJ become tight, the instability of DRUJ can be suspected strongly. Fovea sign is defined to be positive if a tenderness is present proximal to pisiform and ulnar to flexor carpi ulnaris tendon. If the fovea sign is positive the existence of Class 1B lesion is strongly suspected.24 Ulnocarpal compression test, in which a wrist joint is strongly ulnarly deviated at the maximum extremes of both pronation and supination of the forearm, is also a special test. Ulnocarpal compression test is a laboratory technique with high sensitivity, but low specificity.
Image Diagnoses Fundamentally, plain X-rays are not useful for diagnosis of the TFCC tear except for determining the existence of osteoarthritis of the DRUJ and ulnar abutment syndrome with positive ulnar variance. Earlier, the TFCC tear was diagnosed in the outpatient clinic by arthrography of the wrist.7,25,26 When contrast medium has intercourse to DRUJ by way of contrast medium injected to the radiocarpal joint, the existence of TFCC tear is clear. However, the positive ratio of arthrography of the wrist was just above or below 70% in our series. Even if communication of the contrast medium does not exist between radiocarpal joint and DRUJ by arthrography, it is important that sometimes the TFCC tear is about 30%. From this reason, Palmer and his associates have recommended the means of threecompartment injection method in wrist arthrography.26 In the case where after contrast medium is injected into the radiocarpal joint, the communication to the DRUJ is not apparent, they further performed the contrast medium injection to the DRUJ and midcarpal joint. Although this three-compartment injection method is very useful to detect the existence of the TFCC tear, the technique is relatively complicated. In order to accurately diagnose, the second and the third injection should be performed after waiting for absorption of the contrast
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medium. Therefore, I do not feel that this technique is especially more useful compared with the usual arthrography method. With the recent remarkable development of apparatus and technique of MR diagnosis of tear and thinning of the TFCC are becoming possible. In recent times, wrist arthrography is not regularly performed.25,27–29 MR arthrography is common in America and European countries, and it can be said that the diagnostic probability of TFCC tear is further increased.25 Although CT, scintigraphy, etc. also are useful methods in diagnosis, it is hard to accurately diagnose of TFCC tear. These diagnoses consist mainly of these clinical symptoms and findings, and image findings are judged synthetically. Diagnosis of TFCC tears to many is possible.
TREATMENTS Conservative Treatments When traumatic TFCC tear is suspected clinically, it is common to perform conservative treatments first. When traumatic TFCC tears are suspected, they are classified into three stages according to the time the patient suffered injury. They include an acute phase (after injury two weeks or before), a subacute phase (2–6 weeks after injury), and a chronic phase (after injury six weeks or subsequent ones) from the time of injury to the first visit. Conservative treatments should be performed for TFCC tears in the subacute and chronic phases.17 Many hand surgeons have reported various conservative treatment options. The bandage is expanded and contracted so that the 1–2 cm proximal portion of ulnar head may be approached against a radius covering a width of 2–3 cm. It is also one method.30 It has been reported that symptoms reduce in 60–70% of cases with TFCC tears on the whole by fixation for 4–6 weeks. Although we have little experience in this conservative treatment, we think that it will be useful as an easy treatment option which should be tried first. During the period of conservative treatment, although there are some hand surgeons who recommend injection of the corticosteroids into the DRUJ, we consider it is better to also consider other possibilities, such as a direct repair, to be carried out. I want to emphasise that my opinion has not always received consensus, but it is a personal opinion. If the function of TFCC will be considered, the splint including above elbow should be applied, but when the elbow is included in the fixed part, the patients who surely dislike the above elbow splint in
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number, and the direction of the decoration for fixation of only a wrist joint, think on the contrary that the compliance of wearing is high. We suppose that a wrist fixation splint which fixes a wrist joint by slight dorsiflexion will be carried out. The wrist fixated splint should be applied for 4–6 weeks. If severe pain is reported by a patient in the chronic phase, in addition to medication including pasting of medication and non-steroidal anti-inflammatory drugs, wrist fixating splint is applied. However, when a sense of giving-way exists, a suture of the TFCC or TFCC reconstruction should be considered.
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Since Class 1A TFCC lesion is the so-called tear in the white zone, generally it is invalid to directly suture the TFCC tear and it is therefore effective to debride TFCC flap. Class 1D TFCC lesion is tear avulsed at the sigmoid notch of the radius and may be accompanied by the avulsion fracture of the sigmoid notch. When avulsion fracture exists at the sigmoid notch, the possibility of the suture of TFCC tear to a bone is high, but it is considered to be difficult when fracture is not associated. However, there is still an argument about this approach and is regarded controversial and in conclusive. From our experience, Class 1D TFCC lesion was treated by the direct repair of the TFCC tear to the sigmoid notch of the radius associated with hemiresection-interposition arthroplasty of the DRUJ, as reported by Bowers.31 In our experience, 80% of TFCC tears were confirmed to be repaired during the second look by wrist arthroscopy, which suggested that Class 1D TFCC lesion had possibility of repairability, although the site of Class 1D TFCC lesion had no blood supply.32 However, these data are not always accepted by most of the hand surgeons. Partial excision of the TFCC33–41
When the flap of the TFCC tear is caught by the forearm rotation in Class 1A and Class 2 lesions, I think that partial excision of the flap of the TFCC should be indicated. It is common to perform scopic debridement so that it may partially exercise the flap around the TFCC tear in Class 1A lesion to prevent a catch by the forearm rotation. Although there were reports describing that partial excision of the TFCC tear was absolutely effective in all types of TFCC injuries, we reported that postoperative results were very unstable when the tear existed in the cases with positive ulnar variance or the carpal ligament tears.38
We conclude that arthroscopic partial excision of the TFCC tear is indicated in cases with Class 1 lesion, positive ulnar variance less than 2 mm and even in Class 2 with ulnar variance less than 0 mm. Repair of the TFCC19,35–37,41–59
The instability of DRUJ is most remarkable in many cases with Class 1B TFCC lesion, therefore operative procedure should be indicated in such cases. The extensor carpi ulnaris tendon sheath is incised to open the fifth extensor compartment and after reflection of the extensor carpi ulnaris tendon the tendon floor is exposed. The tendon floor is incised longitudinally to expose the DRUJ. After evaluating the state of the TFCC tear, the margin of the flap of the TFCC tear is minimally debrided to freshen the stump. The cortex of the fovea of the ulnar head is excised to make a bone tunnel from the ulnar cortex of the proximal ulna. The ulnar margin of the TFCC is drawn into the bone tunnel of the ulna by using non-absorbable suture, 2-0 Surgironr and tied firmly over the ulnar cortex of the ulna. Postoperatively, the long arm cast is applied with the forearm at 30–60 supinated position for 3–4 weeks. After removal of the cast, active and passive physiotherapy is begun. The patients do not return to their jobs until three months postoperatively. Although various methods have been reported of scopic repair of the TFCC, we have employed the method reported by Iwasaki, my colleague.52,59 After evaluating the state of the TFCC tear by a wrist arthroscopy, a flap margin of the TFCC tear is debrided to prepare for suture when the lesion belongs to Class 1B. Then, the proximal ulnar portion of the ulna is incised to expose the ulnar cortex between the extensor carpi ulnaris tendon and the flexor carpi ulnaris tendon. A bone hole with diameter of 2.9 mm produced from this part to the fovea of the ulna obliquely and the stump of the TFCC tear is drawn in a bone hole, and it will suture firmly on the ulnar cortex of the ulna (Fig. 3). Therefore, if our method is to be defined correctly, it can be called minimum invasive surgery, not entire scopic surgery. There are many methods of open and scopic TFCC repairs. Hand surgeons should examine literatures regarding TFCC repair in detail, and should choose a favourite method. Partial resection of the ulnar head41
When the ulna is presenting positive variance, the method of excising the ulnar head of only the portion of the positive
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(A)
(B)
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Fig. 3 (A) An osseous tunnel 2.9 mm in diameter from the ulnar neck to the foveal surface. Using a suture loop, the end of the repair suture is delivered out of the osseous tunnel. (B) The 2 free ends of the repair surface are pulled through the osseous tunnel to bring the suture onto the TFCC surface. (C) The avulsed portion of the TFCC is anchored to the fovea with near-normal tension. The suture is tied onto the ulnar periosteum around the proximal entrance of the osseous tunnel. (From Iwasaki N and Minami A. Copyright, American Society for Surgery of the Hand, by permission of Elsevier, Inc.)
variance under open or scopic is used. This method is called wafer procedure.41 Although the author does not have many experiences, when the instability of the DRUJ is not remarkable, it is supposed that wafer procedure is performed about the positive variance portion of the ulnar head. Then, although consensus is not yet obtained about what millimeters of ulnar positive variance of wafer procedure is effective, it has been recommended by Feldon, who developed and described wafer procedure that 6 mm or less of ulnar positive variance is effective. Although it remains unknown whether the turning point of ulnar positive variance is 6 mm or less, the case of a large ulnar positive variance is invalid. Moreover, although wafer procedure has an effect of decompression between the ulnar head and carpal bone similar to the ulnar shortening osteotomy, I think that there is no effect which strains the entire TFCC unlike an ulnar shortening osteotomy, and gives the stability of the DRUJ. Therefore, the author thinks that indication of wafer procedure is quite restrictive. However, while considering a comparatively easy operation under an arthroscopy in the case of ulnar abutment syndrome, many hand surgeons highly recommend indications of wafer procedure. Ulnar shortening osteotomy21,41,53,60,61
An ulnar shortening osteotomy is often indicated to the cases of TFCC tears associated with the positive ulnar variance in many
cases. Since the case of TFCC tear with especially Class 2 lesion has associated with the ulnar abutment syndrome in which the ulna presents positive variance in many cases, an ulnar shortening osteotomy is comparatively likely to be performed. When slight to mild instability of the DRUJ exists in the case of TFCC tear, it is still controversial whether ulnar shortening osteotomy should be performed after partial resection or repair of the TFCC tear. It is also controversial whether scopic debridement or partial resection of the TFCC should be performed in association with ulnar shortening osteotomy. Author recommends to commonly carry out a wrist arthroscopy in order to sufficiently evaluate the state and degree of the TFCC tear and to perform partial excision of the TFCC tear even before the ulnar shortening osteotomy. The rationale of the effect of an ulnar shortening osteotomy shortens an ulna and aims at strain and acquires the stability of DRUJ as described previously.2 However, it is well known that osteoarthritis may occur in high frequency due to the incongruity of the DRUJ after the ulnar shortening osteotomy as author has also reported.21 Characteristic osteoarthritic findings at the DRUJ after ulnar shortening osteotomy include bone sclerosis and bony spur at the sigmoid notch of the radius and ulnar head articulated with the radius. Fortunately, osteoarthritic changes do not influence the clinical symptoms such as a pain and movemental restriction of the forearm rotation. We should carefully follow up and check clinical symptoms due to osteoarthritis of the DRUJ in future. Since many hand surgeons
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recently prefer to do an ulnar shortening osteotomy for the DRUJ instability due to the TFCC tear with positive ulnar variance, author would like to emphasise strongly that we should carefully carry out an ulnar shortening osteotomy for the TFCC tear. When the osteoarthritic changes beyond a moderate degree exist in DRUJ before the operation, operative indication of an ulnar shortening osteotomy does not exist in principle, but some hand surgeons recommend an ulnar shortening osteotomy for cases of TFCC tears with preoperative existence of slight osteoarthritic changes. Another argument is about the shortening of the postoperative ulnar variance. Most of the hand surgeons try to obtain postoperative zero (neutral) ulnar variance. Since the grade of the postoperative osteoarthritis of the DRUJ is sometimes strong when the amount of shortening is large, author recommends that a strain of TFCC can be obtained by shortening of about 2 mm, even if the amount of positive variance before an operation is how much.21 However, consensus is not obtained about the amount of ulnar shortening. Reconstruction of the TFCC19,62,63
When the repair of the TFCC is not directly made in most of the chronic phases of the TFCC tear, a TFCC reconstructive procedure is indicated. Many procedures of reconstruction of the TFCC tear have been reported. Among them, Nakamura et al. reported that good and excellent postoperative outcome were obtained with the reconstructive procedure of the TFCC using the extensor carpi ulnaris tendon.19 We have experienced only two cases of Nakamura’s method and further investigations are needed in future. The reconstructive procedure of the TFCC is indicated in the chronic case of the TFCC tear with severe pain and instability of the DRUJ. We prefer to perform the reconstructive procedure described by Adams and Berger63 for chronic TFCC tear and good results are acquired at about 80%. The method of Adams and Berger is fixed to the fovea of the ulnar head through the bone hole added to the dorsal and palmar sigmoid notch of the radius using palmaris longus tendon, so palmar and dorsal radioulnar ligament (triangular ligament) are reconstructed. The arthroplasty of the DRUJ31,32,64–68
When osteoarthritic changes arise in the DRUJ by TFCC tear, arthroplasties of the DRUJ are indicated which are similar to those of the operative indication of osteoarthritis of the DRUJ.
We prefer to perform three procedures, the so-called Darrach’s procedure, hemiresection-interposition arthroplasty and Sauvë– Kapandji procedure for osteoarthritis of the DRUJ. We reported operative indications and outcomes of three procedures.65,68 Of the three procedures, I think that Darrah’s procedure is indicated to a patient with low activity in old age because of postoperative decrease of grip strength and instability of the distal end of the ulna after Darrah’s procedure. The Sauvë–Kapandji procedure is indicated for patients for whom osteoarthritis of the DRUJ exists and there is no function of TFCC or unrepairable TFCC function (Fig. 4). Hemiresection-interposition arthroplasty reported by Bowers is indicated for the osteoarthritis of the DRUJ which has a TFCC function.64,68 As described above, operative indication of the ulnar shortening osteotomy is another useful arthroplasty of the DRUJ.
DISCUSSION Since Palmer1 named TFCC, which was earlier called by various other names, there were many reports about pathogenesis, diagnosis, and treatment. Now, TFCC tear has become one of
Fig. 4 Following the Sauve–Kapandji procedure, a 3.5-mm hole was drilled from the dorsoulnar aspect of the ulnar shaft into the intramedullary cavity. The extensor carpi ulnaris tendon was the split in the central sulcus and the radial half released at the ulnocarpal level. It was the reflected proximally, leaving it attached at the musculotendinous junction. This proximal-based strip was then at the distal stump of the ulna, and then sutured back on itself in an interlacing fashions. (From Minami A et al. Copyright, American Society for Surgery of the Hand, by permission of Elsevier, Inc.)
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the important topics in the field of hand surgery. After Palmer’s reports, we reported some papers on surgical treatments for TFCC tears.21,32,38,65–68 Although the results of TFCC Class 1 lesion, i.e. traumatic TFCC tear, were good in the report about partial resection under wrist arthroscopy, the postoperative results of the case of TFCC Class 2 lesion were unsatisfactory. We concluded that these results were because most of the TFCC Class 2 lesions were associated with positive ulnar variance and lunotriquetral ligament tear.38 Then, we reported results of the ulnar shortening osteotomy for the cases of TFCC tears associated with positive ulnar variance.21 More than 80–90% of TFCC tears belonging to both classes obtained good or excellent results by the ulnar shortening osteotomy. We concluded that the ulnar shortening osteotomy was very useful for the TFCC lesion associated with positive ulnar variance. Moreover, we also reported the possibility of the repair of the TFCC tear belonging to Class 1D lesion as described above.32 Then, Iwasaki, my colleague, has reported a novel technique for the suture of the TFCC Class 1B lesion arthroscopically and also described usefulness of the new technique.52,59 If it is evaluated using Mayo wrist score, in 90–95% or more of patients, it shall be effective. Although further verification will be required from now on, it is considered that it may be widely carried out by this new minimum invasive technique. In the pathogenesis, diagnosis and conservative and operative treatments for TFCC tear, further investigations are required which may lead to newer developments.
ACKNOWLEDGEMENTS The author expresses sincere thanks to Professor Richard A. Berger, Department of Orthopaedics, Surgery of the Hand, Mayo Clinic, Rochester, Minnesota, USA for his suggestions and advice throughout this investigation.
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