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TFCC Repair

- Discussion:
    - indicated primary for traumatic peripheral ulnar sided TFCC tears;
    - negative predictive factors for successful repair include concomitant ulnocarpal impaction syndrome (associated w/ degenerative tears) and peripheral radial tears (due to the relative avasucularity of the disc in this region;
           - some surgeons feel that radial sided TFCC tears are not a significant risk factor for healing after a repair;
           - ulnar positive variance is another negative risk factor;
    - best candidates for repair are patients who have had a single traumatic wrist injury such as a fall or an MVA (driver gripping the steering wheel at the time of impact);

- Arthroscopic Treatment:
    - outcomes: in the study by Trumble, et al (1997), 3/24 patients (undergoing arthroscopic repair) had continued wrist pain;
    - arthroscopic evaluation: (see: wrist arthroscopy)
           - determine whether the TFCC has a resilient quality when probed (which is normal);
           - when the arthroscopic probe elicits gross softness, then a peripheral tear may be present;
           - peripheral tears are often located at the dorsal ulnar peripheral border;
           - peripheral detachments are ideal for repair, where as central attritional tears are not good candidates for repair;
           - TFCC attachment to the sigmoid notch of the radius gives successful results despite having poor vascularity;
    - arthroscopic debridement:
           - may be indicated for tears occupying the central 2/3 of the disc;
           - relative contra-indication: postive ulnar variance:
           - hazards: avoid injury to the dorsal and volar wrist ligaments;
           - Isolated tears of the TFCC: management by early arthroscopic repair.

- Open Repair:
    - outcomes: in the report by Hermansdorfer and Kleinman (1991), over 20% of patients had an unsatisfactory result;
    - open repair: (for peripheral tear at ulnar styloid);
           - make a 5 cm longitudinal incision centered over the distal ulna;
                  - take care to avoid the dorsal sensory brach of the ulnar nerve;
           - dorsal incision in made between the 4th and 5th compartments;
           - incise the dorsal wrist capsule in line with the incision;
           - the incision should be extended to the lunotriquetral joint;
           - a radially based retinacular flap is fashioned;
           - enter the ulnar-carpal joint (inverted T incision) between EDQ and ECU;
           - scar tissue surrounding the torn TFCC and its bed are debrided w/ scope;
           - w/ ulnar positive variance, exposure is facilitated w/ an ulnar shortening procedure (such as the wafer procedure);
           - likewise, placement of a small lamina spreader in the RU joint may facilitate the exposure;
           - repair of ulnar detachment:
                  - sutures are then passed through drill holes made at the medial base of the styloid, which are then placed through the torn medial edge of the TFCC;
                  - a suture passer can be helpful to pass the suture through the drill holes;
           - repar of radial TFCC detachment:
                  - drill holes are made in the ulnar side of the dorsal distal radius, from a dorso-radial to a palmar ulnar direction;
                  - horizontal matress sutures are passed through the TFCC and are then brought thru the distal radial drill holes;
           - RU stabilization and closure:
                  - place the arm in neutral rotation or slight supination and insert 2 K wires across the RU joint (or just proximal to the joint);
                  - the TFCC sutures are then tied down;
                  - the radially based retinacular flap is then passed underneath the ECU tendon in order to help prevent subluxation
                  - Management of chronic peripheral tears of the triangular fibrocartilage complex.

Isolated tears of the triangular fibrocartilage: management by early arthroscopic repair.

Repair of the triangular ligament in Colles' fracture. No effect in a prospective randomized study.

Ulnar shortening combined with arthroscopic repairs in the delayed management of triangular fibrocartilage complex tears.

Operative technique for inside-out repair of the triangular fibrocartilage complex.

Current Concepts Review.  Carpal Instability.

Traumatic disruption of the triangular fibrocartilage complex. Pathoanatomy.

Triangular fibrocartilage tears.

Triangular fibrocartilage complex lesions: a classification.

Partial excision of the triangular fibrocartilage complex.

Ulnar shortening combined with arthroscopic repairs in the delayed management of triangular fibrocartilage complex tears.