State of the art in Triangular FibroCartilage Complex lesion management. Current concepts in anatomy biomechanics and treatment with special focus in arthroscopic techniques. Detailed step by step description of the surgical technique with animations and video. See also https://www.youtube.com/watch?v=rgbemvKbtFk. Visit www.orthoinfo.gr Συγχρονες τεχνικές αντιμετώπισης των βλαβών του Τρίφωνου Ινοχόνδρινου Συμπλέγματος στον Καρπό

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TFCC Repair:
from hammock to iceberg
Nickolaos A. Darlis, MD, PhD

2. TFCC 3-D structure Nakamoura T et al, 1996

3. The Hammoc paradigm
Nakamoura T et al 1996

5. Hyaline cartilage at the
tip of the ulnar styloid
Sharpey’s fibers at the
fovea

7. Volar & Dorsal RU lig.-Deep bundle

8. The Iceberg Concept Atzei &Lucetti 2011

9. Class 1: Traumatic Injuries
A Central perforation of the disk proper
B Peripheral avulsion from the ulna
Without styloid fracture
With styloid fracture
C Distal avulsion from the carpus
D Radial avulsion
Without sigmoid notch fracture
With sigmoid notch fracture
Class 2: Degenerative Injuries
A TFCC wear
B TFCC wear + lunate and/or head chondromalacia
C TFCC perforation + lunate and/or head chondromalacia
D TFCC perforation + lunate and/or head chondromalacia +
lunotriquetral ligament perforation
E TFCC perforation + ulnocarpal arthritis
Palmer Classification

10. Palmer Classification
• Traumatic (Class 1)
• Degenerative (Class 2)- associated with
ulnocarpal impaction syndrome

11. Central tear
Peripheral tear)
Radial tear
Tear location
Deep bundle
of TFCC
Volar radioulnar lig.radius
ulna

12. 1. Central TFCC lesions
• Poorly vascularized- healing potential minimal
• Arthroscopic debridement up to 2/3 of articular disc

13. Shaver debridement
1. Central TFCC lesions

14. Arthroscopic TFCC debridement using radiofrequency probes
Darlis NA & Sotereanos DG, JHS(B)2005
1. Central TFCC lesions

15. 1. Central TFCC lesions
• Often degenerative and associated
with ulnocarpal impaction
syndrome
• Ulnar recession procedure to
prevent symptom recurrence

16. Ulnocarpal Impaction Syndrome
Clinical features:
• Ulnar sided wrist pain
• Associated degenerative changes:
– Ulnar side of the lunate
– Radial side of the ulnar dome
– TFCC central tear
– Triquetrum- LunoTriquetrum lig.
• Usually positive or neutral ulnar variance

17. Pronated Grip View Radiographs

18. MRI

19. Arthroscopic Wafer procedure
• Preferred when modest shortening needed

20. Open Ulna Recession Procedures
• Several options…

21. Open Ulna Recession Procedures
Another approach: Keep it simple…
• Step-Cut Ulnar Shortening Osteotomy
Darlis & Sotereanos JHS(A), 2005

22. 2. Radial TFCC tears
• Repair or debridement?

23. • Repair if:
– VRUL or DRUL are involved
– DRUJ instability
2. Radial TFCC tears

24. 3. Peripheral (ulnar) TFCC tears
• Well vascularized
• Repairable

25. Usual location of peripheral tears
Dorsal

26. Usual location of peripheral tears

27. Timing of the repair
ACUTE
Good Healing Potential
SUBACUTE
Unpredictable
CHRONIC
Poor Healing Potential
0 6 months 1 year
3mo 6mo

28. Ligament reconstruction
(Adams/Berger)
radius
ulna

29. REPAIR TO CAPSULE REATTACH TO FOVEAOR
TFCC TFCC
3. Peripheral (ulnar) TFCC tears

30. REPAIR TO CAPSULE
REATTACH TO FOVEA
OR
3. Peripheral (ulnar) TFCC tears

31. Atzei classification

32. Atzei classification
Class 1
Repairable
distal tear
Class 2
Repairable
complete
tear
Class 3
Repairable
proximal tear

33. Atzei classification
Class 4-A
Nonrepairable
Massive tear
Nonreducible
Class 4-B
Nonrepairable
Failed suture
Frayed ligament
Class 5
Arthritic DRUJ

34. • Arthroscopic or arthroscopic assisted repairs
– Inside-out
– Outside-in
– All inside
– Specialized Kits
REPAIR TO CAPSULE

35. TFCC
6R
REPAIR TO CAPSULE

36. TFCC
6R
REPAIR TO CAPSULE

37. TFCC
6R
REPAIR TO CAPSULE

38. TFCC
6R
REPAIR TO CAPSULE

39. TFCC
REPAIR TO CAPSULE

40. REPAIR TO CAPSULE
TFCC

41. REPAIR TO CAPSULE
TFCC

42. REPAIR TO CAPSULE
TFCC

43. Indications:
• DRUJ instability
• Fracture through the fovea
• MRI findings
• Arthroscopic findings
– Positive Hook Test
– Direct Foveal Portal Arthroscopy
REATTACH TO FOVEA

44. Isometry important
Neutral DORSAL Supination
REATTACH TO FOVEA

45. 1. Mini open: Sotereanos
Chou, Sarris, Sotereanos, JHS(B), 2003
U
EDM ECU
Incision
Chou, Sarris, Sotereanos JHS(B), 2003
REATTACH TO FOVEA

46. 2.Mini open –Arthroscopic Assisted: Atzei- Luchetti
REATTACH TO FOVEA

47. REATTACH TO FOVEA
2.Mini open –Arthroscopic Assisted: Atzei- Luchetti

48. © 2011 Arthroscopy Association of North America
REATTACH TO FOVEA
3. Arthroscopic Assisted (Transosseous): Nakamura

49. 4. All Arthroscopic, Knotless: Geissler
REATTACH TO FOVEA

50. 1-2
6U
3-4 4-5 6R

51. TFCC
6R
ACC 6R
REATTACH TO FOVEA

52. TFCC
6R
ACC 6R
REATTACH TO FOVEA

53. TFCC
6R
ACC 6R
REATTACH TO FOVEA

54. TFCC
6R
ACC 6R
REATTACH TO FOVEA

55. TFCC
6R
ACC 6R
REATTACH TO FOVEA

56. TFCC
6R
ACC 6R
REATTACH TO FOVEA

57. TFCC
6R
ACC 6R
REATTACH TO FOVEA

58. TFCC
6R
ACC 6R
REATTACH TO FOVEA

59. TFCC
6R
ACC 6R
REATTACH TO FOVEA

60. TFCC
6R
ACC 6R
REATTACH TO FOVEA

61. TFCC
6R
ACC 6R
REATTACH TO FOVEA

64. TFCC
6R
ACC 6R

65. TFCC
6R
ACC 6R

66. TFCC
6R
ACC 6R

67. TFCC
6R
ACC 6R

68. TFCC
6R
ACC 6R

71. TFCC
6R
ACC 6R

72. TFCC
6R
ACC 6R

74. TFCC
6R
ACC 6R

75. TFCC
6R
ACC 6R
alternative techniqueREATTACH TO FOVEA

76. TFCC
6R
ACC 6R
alternative techniqueREATTACH TO FOVEA

77. alternative technique
TFCC
6R
ACC 6R
REATTACH TO FOVEA

78. alternative technique
TFCC
6R
ACC 6R
REATTACH TO FOVEA

79. alternative technique
TFCC
6R
REATTACH TO FOVEA

80. alternative techniqueREATTACH TO FOVEA
TFCC

81. alternative techniqueREATTACH TO FOVEA
TFCC

82. alternative techniqueREATTACH TO FOVEA
TFCC

83. Take Home Message
• Debridement ± Ulnar Shortening
• Debridement or Repair
• Repair or
ACUTE
Good Healing Potential
SUBACUTE
Unpredictable
CHRONIC
Poor Healing Potential
0 3 months 6 months
REATTACH TO FOVEA
REPAIR TO CAPSULE

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