Arthroscopic Treatment of Type 1B Triangular Fibrocartilage Complex Tear by "Outside-In" Repair Technique Using Transcapsular Transverse Mattress Suture

Abstract

Triangular fibrocartilage complex (TFCC) injuries are increasingly recognized as a cause of ulnar-sided wrist pain. Palmer grouped these tears into either traumatic or degenerative, with various subclassifications. Magnetic resonance imaging (MRI), arthrogram, and arthroscopy are the methods used to establish the diagnosis. Several arthroscopic methods of TFCC repair including outside-in, inside-out, and all-inside techniques have been described. The outside-in repair, which involves piercing the TFCC via the ulnar side of the wrist, has been described by several authors, but the technique varies among authors with respect to instrumentation and subtle surgical modifications. The purpose of this article was to present the technique of arthroscopic outside-in repair using transverse mattress suture for type 1B TFCC tear by modifying classic vertical mattress sutures into sutures that pass completely through the disc.

Fig 1

Intraoperative photo of traction tower during arthroscopic triangular fibrocartilage complex repair (Linvatec).

Fig 2

Instruments used in triangular fibrocartilage complex repair: 30° 2.3-mm lens, 3-mm cannula with obturator, 3-mm shaver, probe, mosquito forceps, two 18-gauge needles.

Fig 3

The arthroscope in the 3-4 portal of the right wrist joint showing the type 1B TFCC tear, with the probe in the 6R portal pointing to the site of the tear. (TFCC, triangular fibrocartilage complex.)

Fig 4

The arthroscope in the 3-4 portal of the right wrist joint showing debridement of the edge of the tear by shaver through the 6R portal.

Fig 5

Diagram of the right wrist showing the incision on the ulnar side of the wrist to allow passage and tying of stitch with protection of the dorsal sensory branches of the ulnar nerve. Reprinted from McAdams with permission from Elsevier.

Fig 6

With the arthroscope in the 3-4 portal of the right wrist, the first needle loaded with no. 2-0 PDS suture is passed from outside through the capsule and then bellow the TFCC exiting radial to the site of the tear. (TFCC, triangular fibrocartilage complex.)

Fig 7

With the arthroscope in the 3-4 portal of the right wrist, the second straight needle loaded with a loop is inserted at a point dorsal to the first needle to shuttle the first suture.

Fig 8

With the arthroscope in the 3-4 portal of the right wrist, the mattress suture is tied on the capsule through the ulnar-side incision.