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Handchir Mikrochir Plast Chir 2015; 47(05): 290-296
DOI: 10.1055/s-0035-1559652
Original Article
© Georg Thieme Verlag KG Stuttgart · New York

The Clinical Outcome of Anatomical Reattachment of the TFCC to the Ulnar Fovea using an ECU Half-Slip and an Interference Screw

Klinische Ergebnisse nach Reinsertion des TFCC in der Fovea ulnaris unter Verwendung der halbe ECU-Sehne und einer Interferenzschraube
T. Nakamura
1   Clinical Research Center, Department of Orthopaedic Surgery, Sanno Hospital, International University of Health and Welfare, Tokyo, Japan
,
Y. Obara
1   Clinical Research Center, Department of Orthopaedic Surgery, Sanno Hospital, International University of Health and Welfare, Tokyo, Japan
› Author Affiliations
Further Information

Publication History

received 12 March 2015

accepted 15 July 2015

Publication Date:
20 August 2015 (online)

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Abstract

We developed an original reattachment technique using a half-slip of the extensor carpi ulnaris (ECU) tendon with a very small titanium interference screw for chronic foveal avulsion of the TFCC. The clinical outcome of 66 wrists with foveal detachment of the TFCC treated by this procedure was examined.

A distally based ECU half-slip was harvested, inserted into the TFCC, sutured to the remnant of the TFCC, and pulled out through a 2.5-mm bone tunnel at the centre of the fovea. The ECU half-slip was subsequently anchored to the ulnar fovea with a small titanium interference screw. We evaluated 66 wrists of 65 patients with a minimum follow-up of 1 year. Ulnar variance was neutral in 47 wrists, negative in 5 and positive in 14 wrists. Causes of injury were falls in 34 patients, traffic accidents in 12, sports activities in 9, labour in 2 and unknown in 8 patients. In the positive variance wrists, ulnar shortening was performed before the reattachment. The clinical outcome was evaluated using our original DRUJ evaluating system.

Preoperatively, severe wrist pain was reported in 50 wrists and moderate pain in 16 wrists. Severe no-endpoint DRUJ instability was noted in 65 wrists, while 1 wrist demonstrated moderate DRUJ instability. Only 2 wrists had supination loss by 20 degrees. At the final follow-up, no pain was felt in 55 wrists, mild pain in 3 wrists, and 8 patients had moderate pain. One wrist exhibited a 30-degree loss of supination. The DRUJ was stable in 55 wrists, mildly unstable in 3, moderately unstable in 4 and severely unstable in 4 wrists. There were 50 excellent, 9 good, 3 fair and 4 poor results.

The technique of anatomical reattachment of the TFCC to the ulnar fovea using an ECU half-slip tendon is effective for chronic foveal avulsion of the TFCC with severe DRUJ instability.

Zusammenfassung

Wir entwickelten eine Technik zur Reinsertion des TFCC an seinem originären Ansatz in der Fovea ulnaris unter Verwendung der halben Sehne des M. extensor carpi ulnaris (ECU) und einer sehr kleinen Interferenzschraube aus Titan für veraltete Abrisse. Die klinischen Ergebnisse von 66 Handgelenken, die mit dieser Methode operiert wurden, werden dargestellt.

Ein distal gestielter Sehnenstreifen des ECU wird gehoben, in die Reste des TFCC eingeflochten und mit ihnen vernäht und dann durch einen 2,5 mm im Durchmesser großen Bohrkanal durch das Zentrum der Fovea ulnaris gezogen. Der Sehnenstreifen wird unter Verwendung einer kleinen Interferenzschraube aus Titan in der Fovea ulnaris verankert.

65 Patienten mit 66 in dieser Technik operierten Handgelenken konnten mit einer Mindestnachuntersuchungszeit von 1 Jahr nachkontrolliert werden. 47 Handgelenke wiesen eine Ulna-neutral-Variante, 5 ein Ulna-minus und 14 ein Ulna-plus auf. Verletzungsursache war 34-mal ein Sturz, 12-mal ein Verkehrsunfall, 9-mal eine Sportverletzung und 2-mal ein Arbeitsunfall. In 8 Fällen ließ sich kein konkretes Ereignis benennen. Bei Ulna-plus-Situation wurde vor Wiederanheftung des TFCC eine Ulnaverkürzung durchgeführt. Die klinischen Ergebnisse wurde entsprechend unserem eigenen Bewertungsschema ausgewertet. Präoperativ bestanden an 50 Handgelenken starke, an 16 moderate Schmerzen. 65-mal fand sich eine ausgeprägte Instabilität (kein Endpunkt) des distalen Radioulnargelenkes (DRUG), einmal eine moderate. Die Supination war 2-mal um 20 Grad reduziert im Seitenvergleich.

Bei der abschließenden Nachuntersuchung lagen 55-mal keine, 3-mal geringe und 8-mal moderate Schmerzen vor. In einem Fall fand sich eine Einschränkung der Supination von 30 Grad. Das DRUG wurde 55-mal als stabil, 3-mal als gering, 4-mal als deutlich und 4-mal als ausgeprägt instabil eingestuft. Insgesamt fanden sich 50 sehr gute, 9 gute, 3 befriedigende und 4 schlechte Ergebnisse.

Die Reinsertion des TFCC an seinem originären Ansatz in der Fovea ulnaris unter Verwendung eines distal gestielten ECU-Sehnenstreifens hat sich uns bei veralteten Avulsionen mit ausgeprägter Instabilität des DRUG als effektiv erwiesen.

Key words

TFCC - ECU-slip - ulnar fovea

Schlüsselwörter

TFCC - ECU-Sehnen-Streifen - Fovea ulnaris
 

  • References

  • 1 Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist -anatomy and function. J Hand Surg 1981; 6: 153-162
    CrossrefPubMedGoogle Scholar
  • 2 Nakamura T, Yabe Y, Horiuchi Y. Functional anatomy of the triangular fibrocartilage complex. J Hand Surg 1996; 21B: 581-586
    PubMedGoogle Scholar
  • 3 Nakamura T, Makita A. The proximal ligamentous component of the triangular fibrocartilage complex: functional anatomy and three-dimensional changes in length of the radioulnar ligament during pronation-supination. J Hand Surg Br 2000; 25: 479-486
    PubMedGoogle Scholar
  • 4 Nakamura T, Yabe Y. Histological anatomy of the triangular fibrocartilage complex of the human wrist. Ann Anat 2000; 182: 567-572
    CrossrefPubMedGoogle Scholar
  • 5 Nakamura T, Yabe Y, Horiuchi Y et al. Origins and insertions of the triangular fibrocartilage complex – A histological study. J Hand Surg Br 2001; 26: 446-454
    CrossrefPubMedGoogle Scholar
  • 6 Nakamura T, Nakao Y, Ikegami H et al. Open repair of the ulnar disruption of the triangular fibrocartilage complex with double three-dimensional mattress suturing technique. Tech Hand Up Extrem Surg 2004; 8: 116-123
    CrossrefPubMedGoogle Scholar
  • 7 Nakamura T, Sato K, Okazaki M et al. Repair of foveal detachment of the triangular fibrocartilage complex: open and arthroscopic transosseous techniques. Hand Clin 2011; 27: 281-290
    CrossrefPubMedGoogle Scholar
  • 8 Haugstvedt JR, Berger RA, Nakamura T et al. Relative contributions of the ulnar attachments of the triangular fibrocartilage complex to the dynamic stability of the distal radioulnar joint. J Hand Surg 2006; 31A: 445-451
    PubMedGoogle Scholar
  • 9 Moritomo H, Masatomi T, Murase T et al. Open repair of foveal avulsion of the triangular fibrocartilage complex and comparison by types of injury mechanism. J Hand Surg 2010; 35A: 1955-1963
    PubMedGoogle Scholar
  • 10 Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am 1989; 14: 594-606
    CrossrefPubMedGoogle Scholar
  • 11 Atzei A. New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability. J Hand Surg 2009; 34E: 582-591
    PubMedGoogle Scholar
  • 12 Iwasaki N, Minami A. Arthroscopically assisted reattachment of avulsed triangular fibrocartilage complex to the fovea of the ulnar head. J Hand Surg 2009; 34A: 1323-1326
    PubMedGoogle Scholar
  • 13 Atzei A, Rizzo A, Luchetti R et al. Arthroscopic foveal repair of triangular fibrocartilage complex peripheral lesion with distal radioulnar joint instability. Tech Hand Upper Extrem Surg 2008; 12: 226-235
    CrossrefPubMedGoogle Scholar
  • 14 Hermansdorfer JD, Kleinman WB. Management of chronic peripheral tears of the triangular fibrocartilage complex. J Hand Surg Am 1991; 16: 340-346
    CrossrefPubMedGoogle Scholar
  • 15 Sennward GR, Lauterburg M, Zdravkovic V. A new technique of reattachment after traumatic avulsion of the TFCC at its ulnar insertion. J Hand Surg Br 1995; 20: 178-184
    CrossrefPubMedGoogle Scholar
  • 16 Hui FC, Linscheid RL. Ulnotriquetral augmentation tenodesis: a reconstructive procedure for dorsal subluxation of the distal radioulnar joint. J Hand Surg Am 1982; 7: 230-236
    CrossrefPubMedGoogle Scholar
  • 17 Sanders RA, Hawkins B. Reconstruction of the distal radioulnar joint for chronic volar dislocation. Orthopaedics 1989; 12: 1473-1476
    PubMedGoogle Scholar
  • 18 Scheker LR, Belliappa PP, Acosta R et al. Reconstruction of the dorsal ligament of the triangular fibrocartilage complex. J Hand Surg Br 1994; 19: 310-318
    CrossrefPubMedGoogle Scholar
  • 19 Shih JT, Hou YT, Lee HM et al. Chronic triangular fibrocartilage complex tears with distal radioulnar joint instability: a new method of triangular fibrocartilage complex reconstruction. J Orthop Surg 2000; 8: 1-8
    PubMedGoogle Scholar
  • 20 Adams BD, Berger RA. An anatomic reconstruction of the distal radioulnar ligaments for posttraumatic distal radioulnar joint instability. J Hand Surg Am 2002; 27: 243-251
    CrossrefPubMedGoogle Scholar
  • 21 Nakamura T. Anatomical reattachment of the TFCC to the ulnar fovea using an ECU half-slip. J Wrist Surg 2015; 4: 15-21
    Google Scholar
  • 22 Nakamura T, Matsumura N, Iwamoto T et al. Arthroscopy of the distal radioulnar joint. Handchir Mikrochir Plast Chir 2014; 46: 295-299
    Article in Thieme ConnectPubMedGoogle Scholar
  • 23 Nakamura T. Causes and management of acute and chronic distal radioulnar joint instability. In: Slutsky D. (eds.). Operative Orthopedics of the Upper Extremity: A palette of procedures. McGraw Hill; New York: 2014: 387-396
    Google Scholar