All-Arthroscopic Triangular Fibrocartilage Complex Ligamentoplasty: Technique and Results

Abstract

Objective The aim of the study is to describe the modified all-arthroscopic technique for triangular fibrocartilage complex (TFCC) ligamentoplasty in chronic injuries of the TFCC with distal radioulnar joint (DRUJ) instability, and to present the results obtained. Methods A prospective study was conducted including 11 consecutive patients with chronic TFCC injury with DRUJ instability who underwent an all-arthroscopic TFCC ligamentoplasty. During follow-up, the range of joint motion, grip strength, pain according to the visual analog scale (VAS), functional outcomes according to the Mayo Wrist Score (MWS), and the QuickDASH Score were measured, and any complications and necessary reinterventions were recorded Results We analyzed 11 patients with distal radioulnar ligament injury treated using the all-arthroscopic ligamentoplasty technique. Mean follow-up was 31.5 ± 4.4 (range 12-58) months. The technique presented achieved DRUJ stability in 100% of cases at 12 months. Grip strength and pain, showed a statistically significant improvement between the preoperative score and the two postoperative assessments. Functional assessment using the QuickDASH score and the MWS also improved significantly. Conclusion The all-arthroscopic technique for the reconstruction of irreparable peripheral TFCC tears is a reliable technique, intended not only to minimize the surgical trauma to reduce postoperative pain and to facilitate rehabilitation, but also to improve both the quality of the reconstruction and the functional outcome.

Keywords: TFCC ligamentoplasty; distal radioulnar joint; radioulnar ligaments; triangular fibrocartilage complex; wrist arthroscopy.

Fig. 1

Portals used to perform the TFCC reconstruction technique: 3 to 4 and 6R portal, and a VDRU (volar distal radioulnar portal) that gives direct access to the DRUJ. A proximal ulnar mini-incision is also made to create the ulnar tunnel. DRUJ, distal radioulnar joint; TFCC, triangular fibrocartilage complex.

Fig. 2

With the scope in 3 to 4 portal. ( A, B ) A C -shaped guide is introduced through the 6R portal. ( C ) The guidewire is inserted from outside to inside under arthroscopic control. ( D ) Drilling over the guidewire to create a 4-mm tunnel. UH, ulnar head.

Fig. 3

( A ) Direction of the guidewires inserted in the volar and dorsal edges of the radius. ( B ) With the scope in 3 to 4 portal the guidewires are inserted from the 6R portal and VDRU portal. ( C ) The guidewires must be placed in a convergent direction and slightly angled (approximately 30 to 45 degrees) toward the radial metaphysis. ( D ) Subsequent drilling of the tunnels is performed in the volar and dorsal insertions of the radioulnar ligaments. ( E ) Checking from the 3 to 4 portal the correct position of the volar guidewire. ( F ) Checking the correct position of the dorsal guidewire. ( G ) Drilling the 3-mm volar radial tunnel from the volar distal radioulnar portal. The scope is in 3 to 4 portal. R, radius; UH, ulnar head.

Fig. 4

Passing the tendon graft to the ulnar tunnel. ( A ) A grasper is advanced from the 6R portal to the volar portal through the nitinol loop. ( B ) The nitinol loop is previously introduced in the ulnar tunnel. ( C–E ) The grasper is retrieved, grasping one end of the tendon graft and passing it through the loop, leaving one end in the volar ulnar portal, the other in the 6R portal. ( F ) Pulling the nitinol loop, a tendon loop is pulled out through the ulnar tunnel. 6R, 6R portal; L, lunate; R, radius; UH, ulnar head; VDRU, volar distal radioulnar portal.

Fig. 5

With a view from 3 to 4 portal, the two ends of the tendon graft are introduced in the corresponding volar ( A ) and dorsal ( B ) radial tunnels using a Suture Passer needle (Arthrex, Naples, FL). ( C ) Maintaining the tension of the sutures exiting at the radial edge of the wrist, the graft is fixed from the 6R and volar distal radioulnar portal using 3-mm interference screws. ( D ) View from 3 to 4 portal, both ends of the graft have been fixed in the radial tunnels. ( E ) View from the VDRU portal, fixing the graft in the dorsal radial tunnel using 3-mm interference screw. DRU, dorsal radioulnar ligament; L, lunate; R, radius; UH, ulnar head; VRU, volar radioulnar ligament.

Fig. 6

( A ) Finishing the reconstruction of the proximal portion of the TFCC after ulnar tunnel fixation using 4-mm interference screw. ( B ) Completed TFCC reconstruction. ( C ) Completed TFCC ligamentoplasty, view from 3 to 4 portal. ( D ) View from 6R portal. DRU, dorsal radioulnar ligament; R, radius; TFCC, triangular fibrocartilage complex; UH, ulnar head; VRU, volar radioulnar ligament.

Fig. 7

( A ) Assessment of pain by visual analog scale (VAS) preoperatively (0 months) and during the postoperative period (6 and 12 months). Data are expressed as mean ± SEM. Significantly different, * p <0.05, *** p <0.001. ( B ) Assessment of grip strength (in kg) preoperatively (0 months) and during the postoperative period (6 and 12 months). Significantly different, *** p <0.001.

Fig. 8

Assessment of range of joint motion range in flexion-extension ( A ), pronation ( B ), and supination ( C ) (in degrees) preoperatively (0 months) and during the postoperative period (6 and 12 months). Significantly different, * p <0.05; ** p <0.01.

Fig. 9

( A ) Results of the functional assessment with the QuickDASH score preoperatively (0 months) and during the postoperative period (6 and 12 months). Significantly different, ** p <0.01, *** p <0.001. ( B ) Results of the functional assessment with the MSW preoperatively (0 months) and during the postoperative period (6 and 12 months). Significantly different, *** p <0.001.