Allinside Anatomic Arthroscopic (3A) Reconstruction of Irreparable TFCC Tear

Abstract

Background In recent years, new arthroscopic techniques have been introduced to address the irreparable tears of the triangular fibrocartilage complex (TFCC) (Palmer type 1B, Atzei class 4) by replicating the standard Adams-Berger procedure. These techniques, however, show the same limitations of the open procedure in relation to the anatomically defective location of the radial origins of the radioulnar ligaments (RUL) and the risk of neurovascular and/or tendon injury. Aiming to improve the quality of reconstruction and reduce surgical morbidity, a novel arthroscopic technique was developed, with the advantages of reproducing the anatomical origins of the RUL ligaments and providing all-inside tendon graft (TG) deployment and fixation. Description of Technique The Allinside anatomic arthroscopic (3A) technique is indicated for TG reconstruction of irreparable TFCC tears in the absence of distal radioulnar joint (DRUJ) arthritis. Standard wrist arthroscopy portals are used. A small incision in the radial metaphyseal area and arthroscopic control are required to set a Wrist Drill Guide and create two converging tunnels, whose openings are at the radial anatomical origins of the RUL. An ulnar tunnel is drilled at the fovea from inside-out via the 6U portal. A 3-mm tendon strip, from the palmaris longus or extensor carpi radialis brevis, is woven through the tunnels and then secured into the ulnar tunnel with an interference screw. Postoperative immobilization with restricted forearm rotation is discontinued at 5 weeks, and then postoperative rehabilitation is started. Patients and Methods The 3A technique was applied on 5 patients (2 females and 3 males), with an average age 42 years. DRUJ stability, range of motion (ROM), pain (0-10 visual analogue scale [VAS]), grip strength, modified Mayo wrist score (MMWS), and patient satisfaction were used for evaluation before surgery and at follow-up. Results No intraoperative or early complications were registered. At a mean follow-up of 26 months, DRUJ was stable in all patients, which recovered 99% ROM. Pain VAS decreased from 7 to 0.6. Grip strength increased from 38 to 48.8 Kgs. There were 4 excellent results and 1 good result on MMWS. All patient showed high satisfaction. Conclusions Although the 3A technique requires dedicated instrumentation and arthroscopic expertise, it takes advantage of improved intra-articular vision and minimized surgical trauma to reduce the risk of complications and obtain promising functional results.

Keywords: Arthroscopy; Chronic Tear; DRUJ; Instability; Reconstruction; TFCC; Tendon Graft; Wrist.

Fig. 1

Arthroscopic portals and accessory miniopen approach (AMA) required for the Allinside Anatomic Arthroscopic (3A) technique. The 1–2 viewing portal is preferred in small wrists. The AMA is centered approximately 3 cm proximal to the Lister's tubercle on the ulnar aspect of the extensor carpi radialis brevis (ECRB) tendon. It can also be used to harvest a strip of the ECRB, and then a counterincision at the base of the 2nd metacarpal is required (yellow dotted line).

Fig. 2

After debridement of the central disk, the interval between the ulnocarpal ligaments is perforated just distal to the palmar radioulnar ligament (RUL) ( A ) and a shuttle suture is introduced ( B ) for later passage of the tendon graft.

Fig. 3

A 10- to 12-cm strip of extensor carpi radialis brevis tendon is harvested through the accessory miniopen approach (AMA) and a counterincision at the base of the 2nd metacarpal is required (yellow dotted line), as an alternative to the standard palmaris longus graft. A 3-mm width usually suffices.

Fig. 4

On artist's rendering and intraoperative pictures: The Wrist Drill Guide (Arthrex Co., Naples, FL) is accommodated with the sleeve against the radial cortex at the accessory miniopen approach (AMA) and the aiming tip over the origin of the radioulnar ligaments on the palmar corner of the radius, via the 4–5 portal, under arthroscopic guidance (see round insert). The palmar tunnel is created using a 3.0-mm cannulated drill bit.

Fig. 5

On artist's rendering and intraoperative pictures: the aiming tip of the Wrist Drill Guide is introduced in the palmar tunnel (PT) through the accessory miniopen approach (AMA) and its sleeve is set over the origin of the radioulnar ligaments, the dorsal corner of the radius, via the extended 4–5 portal. Care is taken to protect the extensor digiti quinti tendon.

Fig. 6

Artist's rendering of the Y-shaped tunnel created in the radial metaphysis. Note the placement of the tunnels' entrances at the anatomical origins of the radioulnar ligaments.

Fig. 7

On intraoperative pictures and artist's rendering: A SutureLasso (Arthrex Co., Naples, FL) is used to deploy a shuttle suture within the Y-shaped tunnel with a back and forth maneuver, so that both extremities are retrieved outside the 4–5 portal. Taking advantage of the curvature of the SutureLasso, the extremity of the suture is deployed through the exit of the dorsal tunnel firstly (1), then the SutureLasso is introduced in the palmar tunnel, so that the suture protrudes into the joint, creating a loop (2), which is easily retrieved and deployed outside the joint. Then, a FiberTape (Arthrex Co., Naples, FL) is switched and swing back and forth several times to compact the metaphyseal cancellous bone of the radius.

Fig. 8

On artist's rendering and intraoperative pictures: the palmar extremity of the tendon graft is shuttled from 4–5 portal ( A ) to the palmar origin of the radioulnar ligament (RUL) ( B ) and through the interval of the ulnocarpal ligaments (interrupted line shows the medial border of the lunate facet); yellow dotted lines represent tunnel's profile under the lunate facet ( C ). It exits through the 6U portal (interrupted lines show the palmar RUL), where the dorsal extremity is also retrieved ( D ).

Fig. 9

On artist's rendering and intraoperative pictures: the tendon graft is pulled percutaneously and secured into the ulnar tunnel using a 4 × 10 mm polyether ether ketone (PEEK) interference screw.