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Arthroscopic Treatment of Triangular Fibrocartilage Lesions Terry L. Whipple, M.D. Richmond, Virginia Function of TFCC A. Sling for lunate and triquetrum B. DRUJ stability through thickened peripheral portion Anatomy A. Central fibrocartilage disc merges with: – Volar UC ligaments and – Dorsal wrist capsule / floor of EDQ, ECU compartments B. Volar and dorsal periphery thickened, attaches to triquetrum as "ulnar collateral ligament" C. Central disc is avascular Anatomy (continued) F.Peripheral disc and thickened periphery vascularized by volar and dorsal branches from ulnar artery III. Mechanisms of Injury A. Forced pronation - dorsal peripheral detachment B. Axial load - central perforation or avulsion from sigmoid notch C. Forced hyperextension and radial deviation - avulsion of volar UC ligaments proximally or distally IV. Diagnosis A. History - recreate mechanism of injury B. Exam 1. tender volar, dorsal 2. painful pronation or supination through the hand stresses central disc 3. forceful pronation or supination through the forearm stresses thickened peripheral ligaments C. Arthrogram - RC space, DRUJ space D. Arthroscopy - always probe Arthroscopic Treatment Remove unstable fragments, flaps 1. arthroscope in 3-4 portal, approach sigmoid notch from 6-R or 6-U portal with suction punch 2. arthroscope in 6-R portal, approach ulnar aspect of central disc through 3-4 portal with suction punch, shaver 3. arthroscope in 3-4 portal, excise central disc with small joint arthroscopy knife (banana blade, hook blade) Disc Resection • instruments required: 2.7 mm arthroscope, traction mechanism, arthroscopy knives, basket forceps, suction punch, shaver • central disc resection appropriate for Palmer tears type IA, ID Repair dorsal peripheral detachment of central disc 1. arthroscope in 3-4 or 1-2 portal, debride dorsal edge of central disc with shaver or suction punch through 6-R portal 2. longitudinal incision extending proximally from 6-R portal over sixth compartment, incise common extensor and ECU retinacula, retract ECU radial or ulnarward Repair (cont.) 3.suture central disc to floor of ECU tendon sheath. Inteq TFCC repair kit, curved cannulated needle inserted through floor of ECU tendon sheath over DRUJ, upward through edge of TFC disc. Capture suture with retriever through more distal puncture. Repeat 2 to 4 sutures. Repair (cont.) 4.place forearm in neutral rotation and tie sutures over floor of ECU compartment. Close common extensor retinaculum only. Sub-Q skin closure. LAC x 3 weeks, then gradual mobilization. Repair (cont.) 5.instruments required: 2.7 mm arthroscope, traction mechanism, TFCC repair kit, 2-0 or 3-0 PDS suture 6.appropriate for Palmer tears type IB Repair dorsal peripheral avulsion from radius 1. Semi-open technique, wrist flexed, dorsal approach between fourth and fifth extensor compartments, scope in 6U 2. Mitek suture anchor in dorsal edge of sigmoid notch, subchondral bone. Sutures through avulsed bone fragment or dorsal edge of TFC. 3. close and immobilize in slight pronation x4 wks Repair of volar UC ligaments 1. complex open reconstruction. Reference Bowers. 2. prolonged rehabilitation protecting in position of supination, flexion, and ulnar deviation Prominent ulna/abutment 1. resect most of central disc to decompress interval 2. open or arthroscopic wafer procedure (Feldon) Abutment alternative - formal ulnar shortening with plate fixation or oblique sliding ulna osteoplasty with screw fixation Results A. IA, ID resection - excellent B. IB repair - good to excellent C. Ulna leveling 1.wafer procedure - fair 2.oblique sliding ulna osteoplasty - good Endoscopic Carpal Tunnel Release Single Portal Technique Two Portal • Chow Single Portal • Menon • Palm Incision ø ECTR • Efficacious • Avoids palm incision – Comfort – Early function – Palm callous ø Single Portal Technique • Anesthesia – Local – Bier block – Axillary block – General • Tourniquet ECTR Risk Surgeon’s learning curve • Neurovascular structures Good Judgement Reticulous Technique Landmarks • Cardinal line of Kaplan • Longitudinal - ulnar border ring • Hook of hamate • Motor branch cardinal line/thenar crease Exposure • Incision 1cm, oblique from distal wrist crease at palm, long. • Puncture antebrachial fascia • Dilate to 5.5 mm
"Arthroscopic Treatment of Triangular Fibrocartilage Lesions"