Introduction

Ulnar-sided wrist pain is a common disorder that encompasses a broad range of diagnoses. One cause of ulnar-sided wrist pain can be triangular fibrocartilage complex (TFCC) trauma. The TFCC and its supporting ligaments suspend the ulnar carpus, bear carpal load through the wrist to the ulna, and permit the carpus and radius to rotate as a unit around the axis of the ulna.

Because the TFCC plays a vital role in normal wrist function, any injury that does not heal on its own can lead to pain, stiffness, loss of strength, and significant patient dissatisfaction. The TFCC is frequently compared to the menisci of the knee because they have similar biomechanical roles, biochemical composition, diminished blood supply, and poor intrinsic healing capacity. As in the meniscus, peripheral tears of the TFCC are more amenable to healing after repair than central lesions due to a greater peripheral blood supply. Arthroscopic repair techniques for peripheral tears of the TFCC have been shown to provide a successful and minimally invasive approach to a difficult problem.

Anatomy and Biomechanics

The anatomy of the triangular fibrocartilage complex (TFCC) is primarily composed of the articular disc (or triangular fibrocartilage), a meniscus homologue, dorsal and volar radioulnar ligaments, the extensor carpi ulnaris (ECU) tendon subsheath, and the ulnocarpal ligaments (ulnolunate, ulnotriquetral, and ulnocapitate)—as depicted in Figures 5.1 and 5.2. The triangular fibrocartilage is a meniscus-like structure composed predominantly of type I collagen. Surrounding the periphery of the triangular fibrocartilage is the meniscal homologue, a fibrocartilaginous rim of dense irregular connective tissue that confluences with the dorsal and volar radioulnar ligaments.¹

FIGURE 5.1 The distal radioulnar ligaments extend from the sigmoid notch of the distal radius to the base of the ulnar styloid. The triangular fibrocartilage is suspended between these ligaments.

FIGURE 5.2 An open approach to the TFCC typically occurs between the fifth (extensor digiti minimi or EDM) and sixth (extensor carpi ulnaris or ECU) compartments. After flap exposure of the dorsal joint capsule overlying the DRUJ, the TFCC as well as the ulnar carpus can be visualized (USN = dorsal sensory branch of the ulnar nerve, UCL = ulnocarpal ligaments, Tq = triquetrum, L = lunate, LT = lunotriquetral, R = radius, U = ulna, EIP = extensor indicis proprius, TFCC = triangular fibrocartilage complex).

The ligaments and the triangular fibrocartilage form a three-walled structure that supports the distal radioulnar joint and ulnar portion of the carpus. The TFC, with its bordering volar and dorsal radioulnar ligaments, acts as the base of this structure. These ligaments originate as a unit from the fovea of the ulnar head and the very base of the ulnar styloid (Figure 5.3) and diverge distally into dorsal and volar stabilizers for the distal radius as it rotates around the distal ulna to achieve forearm rotation.² The ulnotriquetral, ulnolunate, and ulnocapitate ligaments form the volar wall of this box, and the dorsal radial triquetral ligament (along with the dorsal fibers of the ECU subsheath) forms the dorsal wall.

FIGURE 5.3 A normal MRI demonstrates the insertion of the distal radioulnar ligaments of the TFCC at the ulnar fovea and base of ulnar styloid (marked by the asterisk).

The dorsal ECU subsheath has Sharpey fiber connections to the ulnar head at the fovea.² The ulnar fibers of the ECU subsheath make up the ulnar-sided wall. The ulnotriquetral and ulnolunate ligaments along the volar wall of the TFCC have been shown to extend distally from the volar margin of the triangular fibrocartilage and the volar radioulnar ligament, rather than from the ulna itself.^2,3 This confluence of many ligaments on the ulnar aspect of the wrist stabilizes the ulnar carpus to the triangular fibrocartilage as the radius rotates around the ulna.

The blood supply and innervation of the triangular fibrocartilage enters from the periphery.^4,5 Thiru et al. evaluated the vascular perforators to the TFCC in a cadaveric study.⁶ The ulnar artery provides the blood supply to the ulnar portion of the TFCC through dorsal and palmar radiocarpal branches. This ulnar periphery of TFCC has the richest blood supply and the best potential for healing after repair. The dorsal and palmar branches of the anterior interosseous artery supply the more radial periphery and the attachment to the distal radius. The central portion of the TFCC is essentially avascular and is not amenable for repair. Similarly, the radial/central portion has been shown to have essentially no innervation.⁷ The majority of nerve supply to the TFCC is also peripheral, with contributions from the posterior interosseous nerve, the ulnar nerve, and the dorsal sensory branch of the ulnar nerve (DSBUN).

The volar and dorsal radioulnar ligaments are the primary stabilizers of the distal radioulnar joint (DRUJ) during rotation and translation at the DRUJ. As the forearm supinates from a position of full pronation, the volar radioulnar ligament is under stress and lengthens in a viscoelastic manner to accommodate.^8,9 Pronation, from a position of full supination, causes the dorsal radioulnar ligament to be stressed and subsequently lengthen.^8,9 A majority of the load from the carpus are directed to the radius (80%), whereas the remainder (20%) is directed to the ulna through the TFCC.¹⁰

There continues to be dispute among authors as to the advantages of either arthroscopic or open surgery for tears of the TFCC. Significant DRUJ instability has been demonstrated with complete release of the foveal attachments of the TFCC.^11,12 In one study, the DRUJ instability was corrected with an open suture repair of the volar and dorsal radioulnar ligaments through bone tunnels to the fovea or an open version of the arthroscopic repair of the ulnar TFCC to the ECU subsheath.¹² Biomechanical testing demonstrated significant improvements in the stability of the DRUJ for both groups. However, it was noted that the weakest aspect of each repair was not the type of repair but the bioabsorbable polydioxanone suture used.

Patient Presentation

Isolated injuries to the TFCC commonly occur with extension and pronation of the axially loaded carpus, as with falling on an outstretched hand. Activities involving rapid twisting of the hand in relationship to the forearm with ulnar-sided loading (as in racquet sports or golf) may cause subluxation, dislocation, or fracture of the structures of the distal radioulnar joint and the TFCC. Patients often delay treatment or are misdiagnosed as having a “wrist sprain” that fails to get better. Symptoms of TFCC injury include ulnar-sided wrist pain characterized by a diffuse and sometimes burning deep ache that can radiate dorsally or volarly. A clicking sensation in the wrist may be experienced by the patient as the forearm is rotated and the wrist is held in ulnar deviation, as when using a key to unlock a door.

Upon physical examination, acute TFCC injuries present with ulnar-sided wrist swelling. Point tenderness occurs when palpating the ulnar side of the wrist in the ballotable region between the ulnar styloid and the triquetrum. Forearm rotation with the wrist maintained in ulnar deviation may also elicit pain or a wrist click. The TFCC compression test is positive if axial loading of the ulnar side of the hand with ulnar deviation of the wrist results in significant pain. Similarly, de Araujo et al.¹³ described an ulnar impaction test that elicits pain by wrist hyperextension and ulnar deviation with axial compression. Although radiographs may not directly diagnose soft-tissue pathology in cases of suspected TFCC tears without carpal or distal radioulnar joint instability, indirect information can be obtained from the ulnar variance, the distal radioulnar joint congruency, and the presence or absence of a prior ulnar styloid or distal radius fracture.

Magnetic resonance imaging (MRI) with intra-articular gadolinium has become the imaging modality of choice for the diagnosis of soft-tissue injuries, and TFCC injuries are no exception (Figures 5.4 and 5.5). Although an MRI arthrogram may be both sensitive and specific in diagnosing a tear,¹⁴ at this point it has not been shown to be accurate in assessing tear size. In one study, Fulcher and Poehling felt that MRI understaged some TFCC pathology and overstaged others.¹⁵ Pederzini et al. performed arthrography, MRI, and arthroscopy on 11 patients with TFCC injuries.¹⁶ Although these authors found 100% specificities with sensitivities of 80 and 82% for arthrography and MRI (respectively), arthroscopic visualization of a TFCC tear continues to be the gold standard for definitive diagnosis.

FIGURE 5.4 This coronal MRI demonstrates a normal peripheral attachment of the TFCC.

FIGURE 5.5 Here, the coronal MRI shows a tear or disruption of the peripheral TFCC at its ulnar and distal attachment, just proximal to the articular base of the triquetrum.

Classification of TFCC Injuries

Anatomic, clinical, and biomechanical investigations have led to a classification of the triangular fibrocartilage complex injuries. Originally proposed by Palmer,¹⁷ this classification helps differentiate between traumatic and degenerative lesions. Repairable peripheral tears are generally classified as either type 1B or type 1C tears. Type 1B lesions are peripheral tears that occur as the ulnar side of the TFCC complex is avulsed from its capsule ulnar ligamentous attachments. These injuries are amenable to arthroscopic repair of the TFCC if there is no associated ulnar styloid fracture and no associated DRUJ instability. The type 1C injury involves rupture along the volar attachment of the TFCC or tears of the ulnocarpal ligaments. Type 1C tears may be amenable to repair if the ligamentous injury is vertically oriented. Arthroscopic repair of transverse or horizontally oriented tears of the ulnocarpal ligaments has not yet been described to our knowledge.

TFCC tears can be subdivided further by their time course from injury to treatment (Table 5.1).¹⁸ Tears are classified as acute when treated within three months from the time of injury. Arthroscopic repairs of acute tears can result in the recovery of up to 85% of the contralateral grip strength and range of motion.¹⁸ Acute injuries have a better prognosis than subacute injuries and chronic injuries.¹⁹ Subacute tears are treated from three months to one year after injury. Although subacute tears are still amenable to direct repair, in general they tend to regain less strength and range of motion than patients with repair of acute injuries.¹⁹ Chronic tears (more than one year) are repairable, but the results are inconsistent—presumably due to contraction of TFCC ligaments and degeneration of the torn fibrocartilage margins. Chronic injuries frequently require ulnar shortening osteotomy with or without TFCC debridement to decrease the load distributed to the ulna via the TFCC.

Table 5.1 Classification of TFCC Injuries

Contraindications

Contraindications to arthroscopic repair begin with DRUJ instability. If the DRUJ is unstable due to fracture or complete disruption of the distal radioulnar ligaments, fracture repair and open repair of the origin of the distal radioulnar ligaments should be considered. In chronic cases of symptomatic DRUJ instability, reconstruction of the ligamentous stabilizers of this joint is warranted. Similarly, in chronic Essex-Lopresti injuries and cases of interosseous instability TFCC repair is unlikely to alter the axial stability (or lack thereof) of the forearm.

An arthritic radiocarpal joint is certainly a reason to reconsider the outcome of an isolated arthroscopic TFCC repair. If the arthritis remains untreated, the return of the trampoline effect of the TFCC will unlikely change a patient’s entire wrist pathology. Last, cases of ulnar positive variance—where the ulna abuts the ulnar carpus with the TFCC sandwiched between—demand ulnar shortening osteotomy (either alone or in concert with arthroscopic TFCC repair).¹⁹ A final relative contraindication exists for cases in which the TFCC tear is irreducible, either due to its large size or contracture (Figure 5.6). TFCC tears that cannot be adequately reapproximated or reduced should undergo debridement to a smooth rim.

FIGURE 5.6 This arthroscopic view depicts a wide circular tear of the peripheral TFCC that was not amenable for repair. An arthroscopic shaver is being used to smooth the frayed surfaces.

Surgical Technique

Next, the placement of the arthroscopic portals should be planned (Figure 5.7). Landmarks such as Lister’s tubercle, the DRUJ, the ulnar styloid, and the potential path of the dorsal sensory branch of the ulnar nerve are outlined. The 3-/,4 portal is placed between the extensor pollicis longus (EPL) tendon and the extensor digitorum communis (EDC) tendons, one centimeter distal to Lister’s tubercle between the scaphoid and the lunate. The 4-/,5 portal is positioned also 1 cm distal to Lister’s tubercle, but between the EDC and the EDQ tendons. If desired, a 6-R portal can be marked at the same axial level but just radial to the ECU. The point of outflow can also be designated at the 6-U position just ulnar or volar to the ECU tendon. Midcarpal portals should also be outlined, but will not be used specifically for the TFCC repair.

FIGURE 5.7 The 3,4 arthroscopic portal is typically located distal to Lister’s tubercle between the third and fourth extensor compartments. The 4,5 portal is created just ulnar to the fourth extensor compartment, also at the level of the radiocarpal joint.

At this point, the arm can be exsanguinated with an esmarch bandage and the tourniquet inflated to a pressure of 250 mmHg of mercury. Not all surgeons perform wrist arthroscopy under tourniquet control, but it is our preference—especially in cases of TFCC repair, in that a bloodless field facilitates identification of the dorsal branch of the ulnar sensory nerve. Lidocaine or marcaine with epinephrine is injected to distend the radiocarpal joint, through the area of the planned 3-/,4 portal.

A #15 blade is used to create a 5- to 7-mm vertical skin incision at the planned location for the 3-/,4 portal. Blunt dissection with a fine hemostat (Jacobson) or a tenotomy scissors is carried down to the wrist capsule. The wrist capsule should be palpated and balloted with this instrument to ensure accurate placement of this radiocarpal portal in the proximal to distal axis. Once a soft spot in the capsule is confirmed, the tips of the fine hemostat or tenotomy scissors are gently driven into the radiocarpal joint, with the utmost care taken to avoid iatrogenic chondral injury. It is reasonable to check the traction across the wrist prior to entering the joint, as the initial level of traction often changes as the wrist is manipulated throughout the case. Once the joint has been entered, the tips of the instrument are spread to expand the size of the aperture to allow placement of the blunt arthroscopic trocar followed by the arthroscope itself. Most hand surgeons are comfortable with this technique, which relies on a knowledge of the anatomy, palpation of anatomic landmarks, and a tactile sense of the joint capsule.

Alternatively, a fluoroscopic-guided technique has been advocated and utilized by some wrist arthroscopists.^22,23 Although this technique may seem burdensome at first, it can prevent iatrogenic chondral injury in a reliable fashion. A small or mini fluoroscopy unit is required, such as a XiScan (XiTec, East Windsor, CT). The fluoroscopy unit is positioned with the arm parallel rather than perpendicular to the floor. It is brought in directly from the end of the hand table at the height of the wrist joint. With a minimal adjustment, the fluoroscopy unit can be directed at the wrist joint in such a way that it avoids the vertical steel rod of the wrist arthroscopy tower. Under direct fluoroscopic control, 18-gauge needles can then be placed easily and atraumatically into the radiocarpal joint (marking the 3-/,4, 4-/,5 or 6-R, and 6-U portals). The small fluoroscopy unit is simply pulled from the field and the formal portals are made using the 18-gauge needles as guides to portal placement and direction.

Once the 3-/,4 portal has been established, a 2.7-mm arthroscope inserted, and flow of the arthroscopic fluid has begun (either by pump or gravity feed—our preference), it is critical to initiate and maintain an outflow portal. The outflow portal will allow controlled clearance of the arthroscopic lavage and improved intra-articular visualization. We prefer to use a single 1.5-inch 18-gauge needle at the 6-U location for radiocarpal outflow. In placing this needle under direct arthroscopic visualization (so as to not inadvertently injure the triangular fibrocartilage), we direct the sharp bevel of the needle longitudinally or vertically to avoid injury to the dorsal sensory branch of the ulnar nerve. A transverse or horizontally directed bevel of a sharp 18-gauge neeedle could conceivably transect nerve fibers rather than separating them along a vertical axis, as in the case of a vertically directed bevel.

For the initial diagnostic examination, the arthroscope is placed into the 3-/,4 portal and a small probe is placed into either a 4-/,5 or 6-R portal. The 3-/,4 portal is the workhorse visualization portal for radiocarpal arthroscopy. A majority of the TFCC repairs performed at our institution are completed with the arthroscope in the 3-/,4 portal throughout the repair. The 4-/,5 or 6-R portal provides an aperture for instrumentation, specifically a probe or nerve hook, the arthroscopic shaver, a grasper, or a radiofrequency probe. Typically, we will use a 4-/,5 portal as our working portal for instrumentation. The radioscaphoid articulation, scapholunate interval, volar ligaments, radiolunate articulation, lunotriquetral interval, and TFCC should all be assessed with direct arthroscopic visualization and probe examination. Next, it is important to examine the midcarpal joint for intercarpal instability through separate portals typically 1 cm distal to the 3-/,4 and 4-/,5 radiocarpal portals.

After complete arthroscopic examination of the wrist, attention can be directed to the TFCC repair. First, it is important to have undisturbed visualization of the TFCC tear itself. If synovitis impedes direct visualization, a partial synovectomy may be performed using a 2.5-mm small-joint shaver/debrider (e.g., Stryker, Sunnyvale, CA) with a full-radius blade. If visualization of the TFCC is not satisfactory after debridement of synovitis or redundant dorsal capsule, consideration can be made to placing the arthroscope into the 4-/,5 portal.

This portal is slightly more ulnar and will provide a great view of the volar and ulnar aspects of the TFCC, but may limit the view of the dorsal-most aspect of the TFCC’s periphery. In cases of poor visualization from the 3-/,4 portal, we prefer to bring the arthroscope back to the scapholunate interval and then advance the arthroscope directly volar under the scapholunate ligament until it is just past the convexity of the lunate. At this point, the arthroscope can frequently be swept ulnarly in an atraumatic fashion from its current position toward the TFCC. This maneuver with the arthroscope slid under the lunate provides a more direct view of the TFCC from the 3-/,4 portal. Now, the camera is looking directly ulnar and in a right wrist its view can be rotated toward the 9 o’clock position to look volarly or toward the 3 o’clock position to look dorsally.

Using a small arthroscopic probe, the diagnosis of peripheral detachment is made by the trampoline test of the TFCC as described by Hermansdorfer and Kleinman.²⁴ A normal TFCC is taut when indented with the probe, as shown in Figure 5.8. With release of indentation pressure the probe will be felt to “bounce” off the robust intact TFCC, similar to rebounding off a trampoline. If the TFCC is redundant or easily deformed when pressed by the arthroscopic probe, the diagnosis of a TFCC injury can be made. Careful arthroscopic inspection is required to differentiate radial-sided (type 1D), central (type 1A), and peripheral (ulnar type 1B or distal type 1C) lesions. One easy intra-articular landmark for TFCC tears is the ulnar head.

FIGURE 5.8 The trampoline sign can be visualized by downward pressure on the TFCC with an arthroscopic probe. An intact TFCC (as depicted here) will be taut against the pressure of the probe.

If the ulnar head is visible from the 3-/,4 or 4-/,5 portal, the TFCC is incompetent either centrally (type 1A or 2C) or radially (type 1D). A TFCC with a typical ulnar-sided lesion will usually still cover the ulnar head. To improve visualization of the more common dorsal ulnar-sided lesion, the camera on the arthroscope needs to be angled toward the ulnar and dorsal aspect of the wrist (looking toward the 3 o’clock position in a right wrist and the 9 o’clock position in a left wrist). Volar ulnar-sided lesions may require slight radial deviation of the wrist (accomplished by angling the pull of the traction tower radially) to better visualize the volar attachment of the TFCC and its ulnolunate and ulnotriquetral ligaments.

Once a peripheral lesion is identified, it must be debrided to clean edges. A full-radius 2.5-mm shaver is the ideal tool for this debridement, but occasionally a small biter may be necessary to debride larger flaps of torn or redundant tissue (Figures 5.9 and 5.10). An adequate debridement allows for complete assessment of the tear and provides a stimulus for a fibrin clot to form at the repair site. This fibrin clot will incite an appropriate repair response at the biological level. At this point, the size of the tear can be assessed with an arthroscopic probe (by knowing the length of the probe hook, one can measure the intra-articular extent of the TFCC tear). Tears greater than 5 mm in length will typically require at least two sutures to appropriately maintain the TFCC in a reduced position.

FIGURE 5.9 Debridement of the edges of the TFCC tear can be performed with an arthroscopic shaver and should help stimulate the formation of a fibrin clot.

FIGURE 5.10 After debridement, the torn peripheral edge of this TFCC can then be approximated to the overlying wrist capsule just dorsal and ulnar to it.

After the tear is identified, a 25- or 27-gauge 1.5-inch needle (with the bevel vertically aligned) is placed into the wrist joint at the level of the tear. The small-diameter needle is used to localize a 1- to 1.5-cm longitudinal incision over the ulnar aspect of the wrist. This ulnar incision is a prerequisite to avoiding injury to the DSBUN, which is the most common complication following these repairs. Using a blunt spreading technique with tenotomy scissors or a fine hemostat, the DSBUN is localized as it travels obliquely from proximal-volar to distal-dorsal at the level of the ulnar head distally. Dissection should be carried down to wrist capsule if possible. If visualization is not sufficient to comfortably document protection of the DSBUN and neighboring tendons, this limited incision should be extended until adequate visualization is obtained.

Our preferred repair method of ulnar-sided TFCC injuries is an outside-in technique. Prior to beginning the repair, the surgeon should decide if the repair suture will be horizontally or vertically oriented. A horizontal mattress-type suture is very effective in drawing a peripherally torn edge of the triangular fibrocartilage out toward the ulnar wrist capsule to reestablish the trampoline effect. Similarly, multiple vertically oriented sutures can be effective in coapting the edges of a peripheral tear. Either technique begins with puncturing the ulnar wrist capsule and TFCC using an 18-gauge needle after localization of the stitch with the finer 25-gauge needle to avoid iatrogenic trauma caused by multiple passes with the larger-bore needle. The needle should pass just inferior (for horizontal tears) or radial (for vertical tears) to the torn edge of the TFCC. The repair suture is then threaded into an 18-gauge needle and inserted into the wrist joint via the ulnar-sided 6-U incision under arthroscopic control (Figure 5.11).

FIGURE 5.11 In this case, a nonabsorbable 2-0 suture was passed through the intact portion of the TFCC via an 18-gauge needle.

There are different suture retrieval techniques that work well. The intra-articular suture can be grasped using a small arthroscopic grasping forceps or wire suture grasper. With either instrument, a separate intra-articular puncture is required to retrieve the suture (Figures 5.12 and 5.13). The tissue bridge between the just-inserted suture grasper and the 18-gauge needle is the area over which the repair will be tied down. Although all of this work can be done through the small ulnar-sided incision, it is not necessary. The needles and suture must be passed such that the best possible repair is obtained.

FIGURE 5.12 Next, the suture can be retrieved from the joint using a suture grasper.

FIGURE 5.13 This line drawing demonstrates the incision utilized for ulnar-sided arthroscopic repairs. In a majority of cases, a single small incision can be used to pass all of the sutures required for repair. By creating a small incision and protecting the dorsal sensory branch of the ulnar nerve, sutures can be retrieved and tied safely.

Frequently, one limb of the suture may need to be passed more dorsal (at the 6-R position, for example). In these circumstances, the overlying subcutaneous tissues can be undermined off the dorsal capsule—and with the DSBUN safely retracted, the sutures can still be retrieved into the ulnar-sided 6-U portal incision and tied under direct visualization. Certainly, when tying the repair sutures it is imperative that the DSBUN or an extensor tendon is not trapped under the tie. Tension is then placed on the sutures to ensure that there is reestablishment of TFCC tension and obliteration of any gapping between the articular disc and peripheral capsular tissue (Figure 5.14). In some cases, to establish a tension-free reduction of the torn edges the hand may be taken out of the traction device and the sutures tied with the wrist in slight ulnar deviation and forearm in neutral rotation. However, in a majority of cases the torn edges have not contracted and the suture can be tied with the wrist remaining in the traction tower (Figures 5.15 and 5.16). Two or three sutures are passed and tied using these techniques.

FIGURE 5.14 Prior to tying the suture, the reduction of the tear can be assessed. Here, the avulsed edge of the TFCC has been reapproximated to the overlying wrist capsule.

FIGURE 5.15 This outside view of the wrist demonstrates retraction of the ulnar-sided soft tissues and safe protection of the sensory nerve branches while tying the suture with simultaneous direct and arthroscopic visualization.

FIGURE 5.16 After the suture is tied, the repaired edge of the TFCC is now held firmly against the ulnar wrist capsule to allow for peripheral healing.

In cases of coincidental lunotriquetral ligament injury or longitudinal injury to the ulnolunate and lunotriquetral ligaments, the repair of these structures follows. Two 0.045-inch Kirschner wires can then be driven across the lunotriquetral articulation to stabilize the joint after reduction of the lunate using a percutaneously placed Kirschner wire (0.045 inch). The palmar ulnolunate and ulnotriquetral ligaments are then lassoed by sutures passed through the 6-U portal to augment the pinning of the lunotriquetral interval (Figure 5.17). Great care is to be taken to avoid inadvertent injury to the ulnar neurovascular bundle lying just volar to the ulnar wrist capsule and ulnocarpal ligaments. If necessary, the ulnar nerve and artery can be identified through the ulnar-sided 6-U incision and safely retracted. The sutures are tied over the capsule after the 6-U portal is enlarged, to bring all sutures out through this portal so that they can be tied under direct vision while protecting the dorsal sensory branch of the ulnar nerve. The pins are left in place for six weeks while the wrist is immobilized following the combined repair of the TFCC and the lunotriquetral ligament.

FIGURE 5.17 Tears of the ulnocarpal ligaments often occur in concert with lunotriquetral ligament tears. After pinning of the reduced lunotriquetral interval under arthroscopic and fluoroscopic control, vertical tears between the ulnolunate and lunotriquetral ligaments can be reapproximated arthroscopically with one or two sutures passed using outside-in techniques.

If there has been prior surgery involving the ulnar radiocarpal joint or DRUJ, scar tissue formation can make arthroscopy extremely difficult. With an open exposure of the TFCC using an approach between the fifth and sixth compartments (Figure 5.2), the same technique can be applied to repair peripheral tears of the TFCC. As previously mentioned, when clinically significant instability of the DRUJ exists open reattachment of the distal radioulnar ligaments to the ulnar fovea or open reconstruction should be considered.

Rehabilitation

Postoperatively, forearm rotation and wrist motion should be restricted with an above-elbow splint that accommodates swelling and egress of arthroscopic fluid. It is our preference to immobilize the wrist in a neutral position, which theoretically minimizes stress at the repair site. Typically, the splint is maintained until the initial postoperative visit after two weeks. During this time, patients are encouraged to maintain supple finger joints with range-of-motion exercises. Sutures are removed at 10 to 14 days and then the patient is placed in a custom-molded long-arm cast or Munster-type brace to control wrist rotation.

At the fourth postoperative week, the cast or brace is changed to a removable short-arm wrist brace for an additional two weeks. Gentle active wrist and forearm motion can be started at this time, but radial and ulnar deviation should be avoided to protect the repair. After the sixth postoperative week, passive range-of-motion exercises and gentle strengthening may be added to the regimen as the patient is gradually weaned from the brace. Typically, patients return to full activities after approximately 10 to 12 weeks.

Results

To evaluate the efficacy of arthroscopic repair of the TFCC, functional outcome was determined after arthroscopic repair of 22 wrists.²⁵ Average follow-up was 36 months, with a range from 26 to 48 months. There was a significant relief of pain and increase in work and sports activities (p < 0.01). Postoperative range of motion averaged 86% +/− 9% of the contralateral side and grip strength averaged 82% +/− 20% of the contralateral side. There were significant correlations between the delay from injury to surgical repair and the final total range of motion and grip strength, with repairs of acute tears having better outcomes. Arthroscopic repair of peripheral TFCC tears results in significant relief of pain and increased function during work or sports.