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TFCC Repair:TFCC Repair:from hammock to icebergfrom hammock to iceberg

Nickolaos A. Darlis, MD, PhD

TFCC 3-D structure Nakamoura T et al, 1996

The Hammoc paradigm Nakamoura T et al 1996

Hyaline cartilage at the tip of the ulnar styloid

Sharpey’s fibers at the fovea

Volar & Dorsal RU lig.-Deep bundle

The Iceberg Concept Atzei &Lucetti 2011

Class 1: Traumatic InjuriesA Central perforation of the disk properB Peripheral avulsion from the ulna

Without styloid fractureWith styloid fracture

C Distal avulsion from the carpusD Radial avulsion

Without sigmoid notch fractureWith sigmoid notch fracture

Class 2: Degenerative InjuriesA TFCC wearB TFCC wear + lunate and/or head chondromalaciaC TFCC perforation + lunate and/or head chondromalaciaD TFCC perforation + lunate and/or head chondromalacia +

lunotriquetral ligament perforationE TFCC perforation + ulnocarpal arthritis

Palmer Classification

Palmer Classification• Traumatic (Class 1)

• Degenerative (Class 2)- associated with ulnocarpal impaction syndrome

Central tear

Peripheral tear)

Radial tear

Tear location

Deep bundle of TFCC

Volar radioulnar lig.

radiusulna

N.D

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

Shaver debridement

1. Central TFCC lesions

Arthroscopic TFCC debridement using radiofrequency probes Darlis NA & Sotereanos DG, JHS(B)2005

1. Central TFCC lesions

1. Central TFCC lesions

• Often degenerative and associated with ulnocarpal impaction syndrome

• Ulnar recession procedure to prevent symptom recurrence

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

Pronated Grip View Radiographs

MRI

Arthroscopic Wafer procedure• Preferred when modest shortening needed

Open Ulna Recession Procedures• Several options…

Open Ulna Recession Procedures

Another approach: Keep it simple…• Step-Cut Ulnar Shortening Osteotomy

Darlis & Sotereanos JHS(A), 2005

2. Radial TFCC tears• Repair or debridement?

• Repair if:– VRUL or DRUL are involved– DRUJ instability

2. Radial TFCC tears

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

Usual location of peripheral tears

Dorsal

Usual location of peripheral tears

Timing of the repair

ACUTEGood Healing Potential

SUBACUTEUnpredictable

CHRONICPoor Healing Potential

0 6 months 1 year

3mo 6mo

Ligament reconstruction (Adams/Berger)

radiusulna

N.D

REPAIR TO CAPSULE REATTACH TO FOVEAOR

TFCC TFCC

3. Peripheral (ulnar) TFCC tears

REPAIR TO CAPSULE

REATTACH TO FOVEA

OR

3. Peripheral (ulnar) TFCC tears

Atzei classification

Atzei classification

Class 1Repairabledistal tear

Class 2Repairablecomplete tear

Class 3Repairableproximal tear

Atzei classification

Class 4-ANonrepairableMassive tearNonreducible

Class 4-BNonrepairableFailed sutureFrayed ligament

Class 5Arthritic DRUJ

• Arthroscopic or arthroscopic assisted repairs– Inside-out– Outside-in – All inside– Specialized Kits

REPAIR TO CAPSULE

TFCC

6R

REPAIR TO CAPSULE

TFCC

6R

REPAIR TO CAPSULE

TFCC

6R

REPAIR TO CAPSULE

TFCC

6R

REPAIR TO CAPSULE

TFCC

REPAIR TO CAPSULE

REPAIR TO CAPSULE

TFCC

REPAIR TO CAPSULE

TFCC

REPAIR TO CAPSULE

TFCC

Indications:• DRUJ instability• Fracture through the fovea• MRI findings• Arthroscopic findings

– Positive Hook Test– Direct Foveal Portal Arthroscopy

REATTACH TO FOVEA

Isometry important

Neutral DORSAL Supination

REATTACH TO FOVEA

1. Mini open: Sotereanos

Chou, Sarris, Sotereanos, JHS(B), 2003

U

EDM ECU

Incision

Chou, Sarris, Sotereanos JHS(B), 2003

REATTACH TO FOVEA

2.Mini open –Arthroscopic Assisted: Atzei- Luchetti

REATTACH TO FOVEA

REATTACH TO FOVEA

2.Mini open –Arthroscopic Assisted: Atzei- Luchetti

© 2011 Arthroscopy Association of North America

REATTACH TO FOVEA

3. Arthroscopic Assisted (Transosseous): Nakamura

4. All Arthroscopic, Knotless: Geissler

REATTACH TO FOVEA

1-2 6U3-4 4-5 6R ACC 6R

TFCC

6R

ACC 6R

REATTACH TO FOVEA

TFCC

6R

ACC 6R

REATTACH TO FOVEA

TFCC

6R

ACC 6R

REATTACH TO FOVEA

TFCC

6R

ACC 6R

REATTACH TO FOVEA

TFCC

6R

ACC 6R

REATTACH TO FOVEA

TFCC

6R

ACC 6R

REATTACH TO FOVEA

TFCC

6R

ACC 6R

REATTACH TO FOVEA

TFCC

6R

ACC 6R

REATTACH TO FOVEA

TFCC

6R

ACC 6R

REATTACH TO FOVEA

TFCC

6R

ACC 6R

REATTACH TO FOVEA

TFCC

6R

ACC 6R

REATTACH TO FOVEA

TFCC

6R

ACC 6R

TFCC

6R

ACC 6R

TFCC

6R

ACC 6R

TFCC

6R

ACC 6R

TFCC

6R

ACC 6R

TFCC

6R

ACC 6R

TFCC

6R

ACC 6R

TFCC6R

ACC 6R

TFCC

6R

ACC 6R

alternative techniqueREATTACH TO FOVEA

TFCC

6R

ACC 6R

alternative techniqueREATTACH TO FOVEA

alternative technique

TFCC

6R

ACC 6R

REATTACH TO FOVEA

alternative technique

TFCC

6R

ACC 6R

REATTACH TO FOVEA

alternative technique

TFCC

6R

REATTACH TO FOVEA

alternative techniqueREATTACH TO FOVEA

TFCC

alternative techniqueREATTACH TO FOVEA

TFCC

alternative techniqueREATTACH TO FOVEA

TFCC

Take Home Message

• Debridement ± Ulnar Shortening

• Debridement or Repair

• Repair or

ACUTEGood Healing Potential

SUBACUTEUnpredictable

CHRONICPoor Healing Potential

0 3 months 6 months

REATTACH TO FOVEA

REPAIR TO CAPSULE

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