Paper 177: Arthroscopic Repair Of Combined TFCC Tears: A New Clinical Entity with Long Term Follow up

Abstract

In recent years, appreciation for the role of triangular fibrocartilage complex tears in ulnar sided wrist pain has significantly increased (TFCC - triangular fibrocartilage complex). The TFCC functions as the major stabilizer of the distal radioulnar joint. It is the focal point that allows the carpus to rotate with the radius around the ulna. As a stabilizer of the ulnar carpus, the TFCC transmits 20% of an axially applied load from the ulnar carpus to the distal ulna. Severe twisting and loading injuries of the wrist are commonly responsible for tears of the TFCC. These patients will not only present with ulnar sided wrist pain, but pain with the extremes of supination and pronation as well as repetitive activity. Injuries to the TFCC have presented a challenge in regards to treatment. We have previously reported on a successful technique for arthroscopic repair of peripheral TFCC tears. The technique involves the use of spinal needles placed percutaneously through the safe zone and the use of a Shuttle relay (Linvatec) and absorbable braided suture to create a mattress type repair. Follow up for a minimum of 24 months has produced excellent results when evaluated using the Mayo Modified wrist score. As our series of patients has grown, we have noted an interesting subset of patients that have had not only peripheral TFCC tears, but central tears as well. To the best of our knowledge, lesions of the TFCC involving both central and peripheral tears have not previously been described. Past studies have demonstrated successful outcomes with debridement of central lesions and repair of peripheral lesions. Both arthroscopic as well as open techniques have been described. However, when we first encountered a TFCC tear with both a central and a peripheral component; what we have termed a Combined TFCC lesion, we were perplexed as to how to approach the problem. We ultimately did a thorough debridement of the central component and a secure arthroscopic repair of the peripheral component and then treated the patient post-operatively as we would any other peripheral repair. This first patient post operatively had and excellent outcome with a Modified Mayo wrist score of 100. Since that first patient, review of our series of TFCC repairs has yielded thirty three additional patients with combined lesions of the TFCC. This report is an evaluation of these thirty four patients with combined TFCC lesions. There were twenty four males and ten female patients. Their average age was thirty-three years old. There were twenty right wrist injuries and fourteen left wrist injuries. The dominant wrist was injured 28/34 times. Mechanism of injuries included thirty one sports related injuries (baseball, american football, hockey and tennis), two MVA's and one assault. Associated pathology involved one scapholunate ligament rupture and four ECU sling ruptures. Follow up ranged from 48 to 110 months and averaged 72 months. Average Mayo Modified wrist score was 90. This compared favorable with our previous series of peripheral TFCC repairs where the average score was 92.5 We believe that debridement of the central portion of a Combined TFCC lesion in conjunction with repair of the peripheral portion can lead to good and excellent results. Without repair of the peripheral portion of the combined lesion, the laxity caused by the tear of the central portion would lead to biomechanical instability. Despite the lack of continuity of the central portion of the TFCC, repair of the peripheral portion leads to increased stability by creating a suspension bridge type configuration. Burkhart popularized this concept in regards to partial repair of massive rotator cuff tears and we believe this biomechanical theory is applicable for Combined lesions of the TFCC as well. Debridement of the central portion in conjunction with repair of the peripheral portion of a combined TFCC lesion gives the surgeon a viable surgical option, that withstands the test of time, when faced with this difficult variant of TFCC pathology.