Οξείες Ρήξεις Τρίγωνου Χόνδρου- Acute TFCC Tears 2015
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Transcript of Οξείες Ρήξεις Τρίγωνου Χόνδρου- Acute TFCC Tears 2015
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Acute TFCC tearsAcute TFCC tears
Nickolaos A. Darlis, MD, PhD
Journal of Hand Surgery (Am), 1981
Palmer, JHS (A) 1981
Triangular FibroCartilage Complex
MH: Meniscal HomologueAD: Articular DiscUCL: Ulnar Collateral LigRUL: Radio Ulnar Lig
Triangular fibrocartilage (TFC) Dorsal radio-ulnar lig. Palmar radio-ulnar lig. Articular disc
Ulnocarpal ligaments Volar ulno-lunate Volar ulno-triquetral Volar ulno-capitate
Infratendinous extensor retinaculum( ECU sub sheath)
Triangular FibroCartilage Complex
Triangular FibroCartilage Complex
Palmer Classification of TFCC tears
Confusing
TFCC 3-D structure Nakamoura T et al, 1996
Hyaline cartilage at the tip of the ulnar styloid
Sharpey’s fibers at the fovea
The Hammoc paradigm Nakamoura T et al 1996
TFCC impaction test
Nakamura/ ulnocarpal stress test
The Iceberg Concept Atzei &Lucetti 2011
radius
ulna
N.D
radius
ulna
N.D
radius
ulna
N.D
Volar & Dorsal Radioulnar Lig
Foveal attachement
TFCC MENISCUS
radiusulna
N.D
radiusulna
N.D
TFCC CRUCIATE Lig
Volar & Dorsal RU lig.-Foveal Attachment
Class 1: Traumatic InjuriesA Central perforation of the disk properB Peripheral avulsion from the ulna
Without styloid fractureWith styloid fracture
C Distal avulsion from the carpusD Radial avulsion
Without sigmoid notch fractureWith sigmoid notch fracture
Class 2: Degenerative InjuriesA TFCC wearB TFCC wear + lunate and/or head chondromalaciaC TFCC perforation + lunate and/or head chondromalaciaD TFCC perforation + lunate and/or head chondromalacia +
lunotriquetral ligament perforationE TFCC perforation + ulnocarpal arthritis
Palmer Classification
Palmer Classification• Traumatic (Class 1)
• Degenerative (Class 2)- associated with ulnocarpal impaction syndrome
Central tear
Peripheral tear)
Radial tear
Tear location
Deep bundle of TFCC
Volar radioulnar lig.
radiusulna
N.D
Acute TFCC tearsISOLATED WITH DISTAL RADIUS Fx
Wrist arthroscopy in distal radius FxConcomitant lesions increasingly recognized:• ΤFCC ≈60% (43-78%)• SL lig.≈ 40% (32-75%)
• LT lig. ≈20% (15-61%)
• Chondral lesions ≈20% (19-32%)
Highly possible when:• shortening >5-7mm
Highly possible when:• shortening >5-7mm• radialy displaced fx base
of the ulnar styloid
Common misconceptions• TFCC tear ≠ DRUJ instability
– In fact: most tears do not have evident instability• Ulnar styloid fracture ≠ DRUJ instability
– Styloid fractures may co-excist with TFCC tears
Highly possible when:• shortening >5-7mm• radialy displaced fx base
of the ulnar styloid, • angulation >25-300 any
plane
Highly possible when:• shortening >5-7mm• radialy displaced fx base
of the ulnar styloid• angulation >25-300 any
plane• DRUJ diastasis in PA Rö
projection
• Radial translocation- sigmoid notch malreduction
Acute TFCC treatment
“Initial conservative treatment for 8 -12 weeks”
Literature, Conservative treatment
Literature, TFCC with Distal Radius Fx• Contradicting …
Treatment algorithm
Isolated TearIsolated Tear ConservativeConservative
Distal Radius Fx Conservative Conservative
Distal Radius Fx OperativeDistal Radius Fx Operative Consider Arthroscopy*Consider Arthroscopy*
DRUJ Instability Consider Arthroscopy*/ Cross pinning
* Especially in young, high demand patients
Follow-up all conservative patients closely
Timing of operative repair
ACUTEGood Healing Potential
SUBACUTEUnpredictable
CHRONICPoor Healing Potential
0 6 months 1 year
3mo 6mo
Conservative treatment
• Sugartongue or Long Arm splint 3-4 weeks• Short Arm Splint 1-2 weeks
Who would treat a meniscus lesion open nowadays?
Central tear
Peripheral tear)
Radial tear
Tear location
Deep bundle of TFCC
Volar radioulnar lig.
radiusulna
N.D
1. Central TFCC lesions• Poorly vascularized- healing potential minimal• Arthroscopic debridement up to 2/3 of articular disc
Shaver debridement
1. Central TFCC lesions
Arthroscopic TFCC debridement using radiofrequency probes Darlis NA & Sotereanos DG, JHS(B)2005
1. Central TFCC lesions
1. Central TFCC lesions
• Often degenerative and associated with ulnocarpal impaction syndrome
• Ulnar recession procedure to prevent symptom recurrence
Ulnocarpal Impaction SyndromeClinical features:• Ulnar sided wrist pain • Associated degenerative changes:
– Ulnar side of the lunate– Radial side of the ulnar dome– TFCC central tear– Triquetrum- LunoTriquetrum lig.
• Usually positive or neutral ulnar variance
Arthroscopic Wafer procedure
Arthroscopic Wafer procedure
Open Ulna Recession Procedures• Several options…
Open Ulna Recession ProceduresAnother approach: Keep it simple…• Step-Cut Ulnar Shortening Osteotomy
Darlis & Sotereanos JHS(A), 2005
2. Radial TFCC tears• Repair or debridement?
• Repair if:– VRUL or DRUL are involved– DRUJ instability
2. Radial TFCC tears
3. Peripheral (ulnar) TFCC tears• Well vascularized• Repairable
Usual location of peripheral tears
Dorsal
Usual location of peripheral tears
REPAIR TO CAPSULE REATTACH TO FOVEAOR
TFCC TFCC
3. Peripheral (ulnar) TFCC tears
REPAIR TO CAPSULE
REATTACH TO FOVEA
3. Peripheral (ulnar) TFCC tears
• Clinical DRUJ instability• Fracture through the fovea• MRI findings• Arthroscopic findings
– Positive Hook Test– Direct Foveal Portal Arthroscopy
Foveal attachment involvement
Hook test
REPAIR TO CAPSULE
REPAIR TO CAPSULE
1. Mini open: Sotereanos
Chou, Sarris, Sotereanos, JHS(B), 2003
U
EDM ECU
Incision
Chou, Sarris, Sotereanos JHS(B), 2003
REATTACH TO FOVEA
2. All Arthroscopic, Knotless: Geissler
REATTACH TO FOVEA
TFCC6R
ACC 6R
TFCC6R
ACC 6R
TFCC6R
ACC 6R
TFCC6R
ACC 6R
TFCC6R
ACC 6R
Cross Pinning• In Congruent DRUJ reduction
with an unstable joint • To protect a TFCC repair
Beware of pin breakage
Take Home Messages• Debridement ± Ulnar Shortening
• Repair or
ACUTEGood Healing Potential
SUBACUTEUnpredictable
CHRONICPoor Healing Potential
0 3 months 6 months
REATTACH TO FOVEA
REPAIR TO CAPSULE
Thank you
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