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TFCC Reconstruction​

The triangular fibrocartilage complex (TFCC) is a critical structure in the wrist that plays a vital role in stabilizing the distal radioulnar joint (DRUJ) and supporting the ulnar side of the wrist. Injuries to the TFCC can cause significant pain, instability, and loss of function, impacting daily activities and quality of life. TFCC reconstruction is a specialized surgical procedure aimed at restoring the integrity and function of this complex, especially in cases where conservative treatments have failed.

This article provides a comprehensive overview of TFCC reconstruction, including the anatomy and function of the TFCC, causes and symptoms of injury, diagnostic methods, treatment options, surgical techniques, and postoperative care.

Understanding the TFCC

The TFCC is a complex structure composed of several components:

  • Triangular fibrocartilage disc: A cartilage-like structure that cushions and stabilizes the ulnar side of the wrist.
  • Dorsal and volar radioulnar ligaments: Ligaments that stabilize the distal radioulnar joint.
  • Ulnolunate and ulnotriquetral ligaments: Ligaments that support the ulnar carpal bones.
  • Meniscus homologue: A fibrocartilaginous structure that helps distribute load across the wrist.

Together, these components allow smooth rotation of the forearm (pronation and supination) and absorb compressive forces during gripping and weight-bearing activities.

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Causes of TFCC Injury

TFCC injuries can result from acute trauma or degenerative changes:

  • Acute trauma: Falls on an outstretched hand, wrist hyperextension, or rotational injuries can cause tears or ruptures in the TFCC.
  • Repetitive stress: Activities involving repetitive wrist rotation or loading, such as racquet sports, gymnastics, or manual labor, can lead to microtrauma and degeneration.
  • Ulnar variance: A longer ulna relative to the radius (positive ulnar variance) increases stress on the TFCC, predisposing it to injury.
  • Degenerative changes: Age-related wear and tear can weaken the TFCC, making it more susceptible to tears.

Symptoms of TFCC Injury

Patients with TFCC injuries often present with:

  • Ulnar-sided wrist pain, especially during rotation or gripping.
  • Swelling and tenderness over the ulnar wrist.
  • Clicking or popping sensations.
  • Decreased grip strength.
  • Instability or a feeling of looseness in the wrist.
  • Limited range of motion, particularly in pronation and supination.

Diagnosis

Diagnosing TFCC injuries involves a combination of clinical examination and imaging studies:

  • Physical examination: Tests such as the ulnar fovea sign, TFCC compression test, and piano key test help identify pain and instability.
  • X-rays: Used to rule out fractures and assess ulnar variance.
  • Magnetic Resonance Imaging (MRI): Provides detailed images of soft tissues, including the TFCC, to detect tears or degeneration.
  • Arthroscopy: Considered the gold standard for diagnosis, wrist arthroscopy allows direct visualization of the TFCC and any associated injuries.

Treatment Options

Non-Surgical Management

Initial treatment for TFCC injuries typically involves conservative measures:

  • Rest and activity modification to avoid aggravating movements.
  • Immobilization with a splint or cast for 4-6 weeks.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain and inflammation.
  • Physical therapy to restore range of motion and strengthen surrounding muscles.

Many patients improve with non-surgical treatment, especially those with minor or degenerative tears.

Surgical Treatment

Surgery is considered when:

  • Symptoms persist despite conservative treatment.
  • There is significant instability or mechanical symptoms.
  • The tear is complex or involves the ligamentous components.

Surgical options include:

  • Arthroscopic debridement: Removal of frayed or torn tissue to reduce pain.
  • TFCC repair: Suturing the torn edges to restore continuity.
  • TFCC reconstruction: Used in cases of irreparable tears or chronic instability, reconstruction involves replacing the damaged TFCC with a graft to restore stability.

TFCC Reconstruction: Indications and Goals

TFCC reconstruction is indicated for patients with:

  • Chronic DRUJ instability due to TFCC deficiency.
  • Irreparable TFCC tears.
  • Failed previous repairs.
  • Significant functional impairment.

The primary goals of reconstruction are to:

  • Restore DRUJ stability.
  • Relieve pain.
  • Improve wrist function and range of motion.
  • Prevent progression of degenerative changes.

Surgical Technique for TFCC Reconstruction

TFCC reconstruction is a technically demanding procedure that requires expertise in wrist anatomy and microsurgical skills. The general steps include:

  1. Preoperative Planning: Imaging studies are reviewed to assess the extent of injury and plan graft selection.

  2. Anesthesia and Positioning: The patient is placed supine with the arm on an arm table. Regional or general anesthesia is administered.

  3. Surgical Approach: A dorsal or volar approach to the wrist is used depending on the tear location.

  4. Harvesting the Graft: Autografts (e.g., palmaris longus tendon) or allografts may be used to reconstruct the TFCC.

  5. Preparation of the Bone Tunnels: Small tunnels are drilled in the distal radius and ulna to anchor the graft.

  6. Graft Passage and Fixation: The graft is threaded through the tunnels and secured with sutures or interference screws to mimic the native TFCC anatomy.

  7. Closure and Immobilization: The wound is closed in layers, and the wrist is immobilized in a splint or cast.

Preoperative Evaluation

Surgical Technique

The percutaneous scaphoid screw fixation procedure generally follows these steps:

  1. Anesthesia and Positioning: The patient is placed supine with the arm on a radiolucent hand table. Regional or general anesthesia is administered.

  2. Imaging Guidance: Fluoroscopy (real-time X-ray) is used throughout the procedure to guide screw placement.

  3. Approach: A small skin incision (usually 1-2 cm) is made either on the volar (palmar) or dorsal side of the wrist, depending on fracture location and surgeon preference.

  4. Guidewire Insertion: Under fluoroscopic control, a guidewire is carefully advanced across the fracture site, ensuring proper alignment and central placement within the scaphoid.

  5. Drilling and Tapping: A cannulated drill is passed over the guidewire to prepare the screw path. Tapping may be performed if necessary.

  6. Screw Insertion: A headless, cannulated compression screw (such as a Herbert or Acutrak screw) is inserted over the guidewire. The screw compresses the fracture fragments, promoting stability and healing.

  7. Verification: Final fluoroscopic images confirm correct screw position and fracture reduction.

  8. Closure: The small incision is closed with sutures or steri-strips, and a sterile dressing is applied.

Postoperative Care and Rehabilitation

Successful outcomes depend on meticulous postoperative care:

  • Immobilization: The wrist is immobilized for 4-6 weeks to allow graft healing.
  • Physical Therapy: Gradual mobilization begins after immobilization, focusing on restoring range of motion, strength, and proprioception.
  • Activity Modification: Patients are advised to avoid heavy lifting and repetitive wrist motions during recovery.
  • Follow-up: Regular clinical and imaging assessments monitor healing and detect complications.

Conclusion

TFCC reconstruction is a valuable surgical option for patients with chronic wrist instability and irreparable TFCC injuries. By restoring the anatomy and function of the TFCC, reconstruction helps alleviate pain, improve wrist mechanics, and enhance quality of life. If you experience persistent ulnar-sided wrist pain or instability, consult a hand specialist to explore diagnostic and treatment options tailored to your needs.

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