Anatomic Foveal Reconstruction of the Triangular Fibrocartilage Complex With a Tendon Graft

Abstract

An acute injury to the triangular fibrocartilage complex (TFCC) with avulsion of the foveal attachment can produce distal radioulnar joint (DRUJ) instability. The avulsed TFCC is translated distally so the footprint will be bathed in synovial fluid from the DRUJ and will become covered in synovitis. If the TFCC fails to heal to the footprint, then persistent instability can occur. The authors describe a surgical technique indicated for the treatment of persistent instability of the DRUJ due to foveal detachment of the TFCC. The procedure utilizes a loop of palmaris longus tendon graft passed through the ulnar aspect of the TFCC and into an osseous tunnel in the distal ulna to reconstruct the foveal attachment. This technique provides stability of the distal ulna to the radius and carpus. We recommend this procedure for chronic instability of the DRUJ due to TFCC avulsion, but recommend that suture repair remain the treatment of choice for acute instability. An arthroscopic assessment includes the trampoline test, hook test, and reverse hook test. DRUJ ballottement under arthroscopic vision details the direction of instability, the functional tear pattern, and unmasks concealed tears. If the reverse hook test demonstrates a functional instability between the TFCC and the radius, then a foveal reconstruction is contraindicated, and a reconstruction that stabilizes the radial and ulnar aspects of the TFCC is required. The foveal reconstruction technique has the advantage of providing a robust anatomically based reconstruction of the TFCC to the fovea, which stabilizes the DRUJ and the ulnocarpal sag.Key Words: triangular fibrocartilage complex, foveal tear, DRUJ instability, wrist arthroscopy, TFCC repair (Tech Hand Surg 2014;18: 92-97) HISTORICAL PERSPECTIVEThe triangular fibrocartilage complex (TFCC) is a complex 3-dimensional structure made up of the proximal triangular ligament or the radioulnar ligaments (RUL), the distal hammock structure, and the ulnar collateral ligaments. 1,2 The distal hammock structure and the ulnar collateral ligaments are distal components, inserting into the ulnar styloid. The palmar and dorsal portions of the RUL originate from the distal margin of the sigmoid notch and converge to attach to the ulna. As the ligaments extend ulnarly, they divide into a distal component that attaches to the ulnar styloid and a proximal component that attaches to the fovea. [3][4][5][6] The articular disk extends from the ulnar edge of the lunate fossa at the distal rim of the sigmoid notch and blends peripherally with the RUL.The foveal insertion of the TFCC contributes more to DRUJ stability than the styloid insertion because of its closer relationship to the rotational axis of the forearm. 4 In fractures of the ulnar styloid with disruption of the distal components of TFCC, patients may not experience DRUJ instability due to an intact foveal attachment. 7 However, disruption of the TFCC at its foveal attachment can result in DRUJ instability. 3,5 Palmer 8 proposed a classification syst...

Arthroscopic Transosseous Repair for both Proximal and Distal Components of Peripheral Triangular Fibrocartilage Complex Tear

“… 9 13 Accumulated evidence indicates that suturing only the dc-TFCC to the surrounding soft tissue or capsule without healing of the proximal portion of the TFCC to its anatomical insertion site is not enough to attain sufficient DRUJ stability. 11 14 With a stable DRUJ, however, repairing the dc-TFCC still results in a good clinical outcome, especially from the aspect of pain relief. 9 15 We anticipated that repairing the dc-TFCC would have a synergistic effect on the outcome in a complete tear pattern, especially after achieving stability of the DRUJ by foveal repair.…”

Arthroscopic-assisted repair of triangular fibrocartilage complex foveal avulsion in distal radioulnar joint injury

“…So, DRUJ reconstruction would be indicated if severely persistent instability was seen in physical examination and ulnar shortening osteotomy could be an another option by the effect of increasing the tension of distal radioulnar ligament. 21 …”

Classification of ulnar triangular fibrocartilage complex tears. A treatment algorithm for Palmer type IB tears

“…Recently, techniques of TFCC augmentation have been proposed to treat irreparable TFCC tears that still retain some ligamentous tissue. A slip of either the ECU (Nakamura, 2015) or a palmaris longus graft (Bain et al, 2014) is passed through TFCC remnants into the fovea. However, these techniques cannot be used for complete rupture or wide degeneration of the TFCC, whereby tendon graft reconstruction is required.…”