**16. Arthroscopic evaluation and treatment of the triangular fibrocatilage complex (TFCC) injuries**

The development of our understanding and management of TFCC tears has been developed with important contributions including Palmer's classification of TFCC tears (**Table 9**), G. Poehling's inside-out suture technique, F. Del Piñal's all inside suture technique [122], A. Atzei's and R. Luchetti's TFCC tear classification (**Figure 41**), T. Nakamura's anatomical and clinical studies [123] and J.R. Haugstvedt's


#### **Table 9.** *Palmer's classification of TFCC tears.*


#### **Figure 41.**

*A. Atzei's and R. Luchetti's classification of TFCC tears (reprinted by permission).*

developed techniques for the TFCC tears and lunotriquetral tears as well as studies about DRUJ functional anatomy and pathomechanics [1, 124].

TFCC – is one of the instrinsic ligaments of the wrist, with load bearing function between the lunate, triquetrum and ulnar head. TFCC acts as stabilizer for the ulnar aspect of the wrist joint [125].

TFCC consists of five parts: fibrocartilaginous disc and the meniscal homolog, volar ulnocarpal ligaments (ulnolunate and ulno-triquetral), dorsal and volar radioulnar ligaments (each with a superficial and deep part), ulnar collateral ligament as well as the floor of the fibrous 5th and 6th extensor compartments [125, 126].

Palmer had a two-dimensional view of the TFCC [127]. Nakamura described it as a three dimensional structure, and separated TFCC in three components: the distal component which acted like a hammock to suspend the carpus, the triangular ligament as the proximal component which stabilized the radius to the ulna, and the UCL as the ulnar component which stabilized the carpus to the ulna [128, 129]. Atzei and Luchetti updated previous "hammock" concept to the novel "iceberg" concept [130]. In analogy with the iceberg, during arthroscopy of the radiocarpal joint (RCJ) the TFCC shows its "emerging" tip. The tip of the iceberg represents that part of the TFCC that functions as a shock absorber. This part is much more smaller than "submerged" part which can be seen only in case of the DRUJ arthroscopy. The submerged TFCC represents the foveal insertions of the TFCC and functions as the stabilizer of the DRUJ and of the ulnar carpus. The larger size of the submerged portion of the iceberg corresponds to its greater functional importance.

TFCC biomechanics:


• The central disc works as the distribution mechanism for the mechanical stress onto proximal triquetrum and the lunate

Clinical assessment of TFCC tears:


Imaging assessment of TFCC tears:


Arthroscopic examination of TFCC. Three arthroscopic tests are used to check the type of TFCC injury:


Atzei's/Luchetti's classification also shows the stability/instability of the DRUJ joint and possible surgical treatment to corresponding TFCC tear.

An algorithm of treatment according to Atzei's/Luchetti's classification: CLASS 0 – isolated styloid fracture without TFCC tear. Frequently associated with distal radial fractures. DRUJ is stable. If isolated treatment is wrist splinting for 3 weeks.

CLASS 1 – periferal tear of the TFCC distal component, the DRUJ may be slightly lax. Hook test negative. Small tear requires 4 weeks of wrist immobilization followed by two weeks splinting. A larger tears requires arthroscopic TFCC suture.

CLASS 3 – periferal tear of the TFCC proximal component. Mild to severe laxity of the DRUJ joint. Hook test is positive. TFCC foveal reattachment is required by transosseus sutures or a suture anchor.

CLASS 4 – nonrepairable peripheral TFCC tear due to the massive defect or poor healing potential. This condition requires reconstruction with tendon graft.

#### *Arthroscopy*

CLASS 5 – DRUJ arthritis following peripheral TFCC tear. Arthroscopy shows significant degenerative or traumatic cartilage defect. Suggested treatment – arthroplasty or prosthetic replacement.

In cases of peripheral repairable TFCC tears, authors use debridement and synovectomy to detect and refresh the site of the rupture. Usually 6R portal is used for shaver and 3-4 portal for visualization. Occasionally 6 U portal can be used if tears are localized more volarly. Once the size of tear is recognized, portal can be elongated to vizualise extensor tendons by transillumination of the capsule. Needle with suture loop is passed a little bit proximally from the margin to the TFCC to capture capsule together with the TFCC. Once recognized in the joint, suture is captured with mosquito forceps and one part of it passed via the portal or, in cases if several sutures necessary, via extra holes in the capsule. Location of the extensor tendons is evaluated to avoid capture of them in the suture and knots are tightened extra-articulary (**Figure 42a**–**c**). The reattachment can be performed with an inside-out, outside-in, or all-inside technique, providing good to excellent results, which tend to persist over time, in 60–90% of cases [138].

In cases of proximal reparable TFCC foveal detachment, we prefer to use the transosseus refixation of the TFCC described by T. Nakamura [139]. We use the original Arthrex target device through 6R portal and an approximately 1 cm longitudinal incision on the ulnar side of the ulnar cortex, 10–15 mm proximal from the tip of the ulnar styloid. Then target device is set on the TFCC and two parallel channels with original 1.6 mm K-wires are made from the ulnar cortex through the head of ulna and TFCC. Then follows a manipulation with needles, suture loops and main suture, where different techniques of the suture insertion are possible (**Figure 43a**–**c**).

After the main suture is passed through the bone channels to make outside-in pullout suture of the TFCC to the fovea and tensed with knot over the cortex. Another option is to hide the knot inside the ulna and tense with a push-lock anchor.

After treament includes 2-3 weeks in long arm plaster cast, following 3 weeks in short cast with following rehabilitation after the cast is removed.

In cases of unrepearable TFCC injuries or degenerative tears, an anatomic reconstruction with free tendon graft is recommended. The arthroscopic reconstruction is a mini invasive option of the Adams-Berger procedure [140], but it requires an experience in arthroscopic surgery. Nowadays tendon grafts can be fixed in the bone channel with interference screw, instead of the original procedure where tendons were wrapped around the bone and sutured together. Nevertheless,

**Figure 42.**

*Periferal, reconstructable TFCC tear. (a) tear after the debridement, (b) sutures passed the TFCC and capsule, (c) sutures tightened extra-articulary via 6R portal.*

**Figure 43.**

*Proximal reparable detachement of TFCC. (a) Arthrex targeting device over the foveal area, view from 4-5 portal, (b) sutures passed through the TFCC and head of ulna, (c) sutures tightened and TFCC reattached to foveal region.*

when well done, this technique provides good stabilization of the DRUJ, while maintaining good mobility of the wrist in all directions [141].

A systemic review by Liu et al. about the surgical repair of TFCC tears confirms that arthroscopic techniques achieve overall better outcomes compared with open repair technique. For foveal tears, transosseous sutures achieve overall better functional outcomes compared with suture anchors. Current evidence demonstrates that TFCC repair achieves good clinical outcomes, with low complication rates [142].
