Arthroscopic algorithm for acute traumatic triangular fibrocartilage complex (TFCC) tears

Abstract

The triangular fibrocartilage complex (TFCC) is crucial for stability and acts as a shock absorber and load transmitter at the distal radioulnar joint (DRUJ). It is often injured in wrist trauma, particularly in young athletes. Clinical assessment involves patient history, physical examination, and imaging modalities like MRI, with wrist arthroscopy as the gold standard for diagnosing TFCC tears. Multiple classification systems categorize TFCC tears based on location and arthroscopic appearance, guiding treatment decisions.

Surgical options are recommended for tears refractory to conservative management or severe tears. Despite numerous arthroscopic treatments available in the literature, this article aims to simplify the approach. It presents the authors' surgical algorithm for managing acute traumatic TFCC tears arthroscopically. The choice of technique depends on the lesion's location, with various options for peripheral and foveal tears. Post-operative rehabilitation is crucial for optimal recovery.

This article provides a comprehensive review of acute traumatic TFCC injuries, covering anatomy, classification, assessment, and treatment options. Emphasis is placed on accurate diagnosis and appropriate arthroscopic management through a structured approach.

1. Introduction

The triangular fibrocartilage complex (TFCC) is crucial for stability and acts as a shock absorber and load transmitter at the distal radioulnar joint (DRUJ).1, 2, 3 Given its functional role in the ulnar wrist and its use in many activities of daily living, it is frequently injured in the wrist, especially in young athletes.^4,5 Surgical procedures are typically recommended, particularly when non-surgical interventions have not improved or when a severe TFCC tear substantially affects the individual's capacity for daily activities. Such tears may occur in isolation or in combination with other pathologies, such as distal radius fractures or intracarpal ligament tears.^6,7

The increasing number of treatment options for TFCC tears described in the literature is driven by advancements in arthroscopic techniques and understanding. This article aims to detail the anatomy, classification, arthroscopic assessment, and diagnosis of TFCC tears, and proposes a surgical algorithm to address various types of acute traumatic TFCC lesions.

2. Anatomy and pathophysiology

The TFCC is a hammock-like structure that includes the triangular fibrocartilage disc (TFC), ulnar collateral ligament (UCL), extensor carpi ulnaris (ECU) subsheath, the meniscal homologue, and both superficial and deep radioulnar ligaments (RUL).⁸ Notably, the TFC, or the disc proper, is composed of fibrocartilage and exhibits a biconcave shape. It is thicker at its edges (especially on the ulnar side) and becomes thinner towards the center. Radially, the TFC is anchored to the hyaline cartilage of the sigmoid notch, and on the ulnar side, it connects to both the fovea and ulnar styloid via the RULs.⁹ (Fig. 1) The deep RUL fibers, which insert widely at the foveal footprint and extend towards the radial wall of the fovea, provide essential guidance for surgeons in precisely placing suture anchors during repair.¹⁰

Fig. 1.

Artist's impression of the TFCC anatomy. The retracted ECU tendon and subsheath, highlighted with a red vessel loop, provide a clear view of the complete TFCC anatomy.

The blood supply of the TFCC comes from the ulnar artery and the palmar and dorsal branches of the anterior interosseous artery, providing blood to the peripheral 10–40 % of the TFCC, enhancing its healing potential.¹¹ The TFCC stabilizes the DRUJ and ulnar carpus, providing significant stability during neutral and 75 degree of pronosupination.⁸ The RULs tighten and loosen with rotation: dorsal superficial and palmar deep fibers tighten in protonation, while palmar superficial and dorsal deep fibers tighten in supination.¹² The distal ulna transmits about 20 % of the forearm's axial load in neutral position, which increases with positive ulnar variance or TFCC injuries.13, 14, 15

3. Classification of TFCC tears

The Palmer classification, historically used to categorize TFCC tears, distinguishes between type 1 injuries caused by trauma and type 2 injuries due to degeneration.¹⁶ Each class is further subdivided based on the lesion's location (Table 1). Nakamura subdivided the ulnar TFCC into three components: the UCL, the distal hammock structure, and the proximal triangular ligament. The UCL and distal hammock structure merge to form the distal component of the TFCC, which supports and suspends the ulnar carpus. The proximal component of the TFCC inserts ulnarly into the fovea and helps stabilize the DRUJ.¹⁷

Table 1.

Palmer classification for Triangular Fibrocartilage Complex lesions.⁸.

Class 1: Traumatic
A	Central perforation
B	Ulnar avulsion, with or without distal ulnar fracture
C	Distal avulsion
D	Radial avulsion, with or without sigmoid notch fracture
Class 2: Degenerative
A	TFCC wear
B	TFCC wear + lunate and/or ulnar chondromalacia
C	TFCC perforation + lunate and/or ulnar chondromalacia
D	2C + LT ligament perforation
E	Ulnocarpal±DRUJ arthritis

Atzei introduced the iceberg concept, where the submerged portion represents the foveal insertion of the proximal TFCC, visible only through DRUJ arthroscopy. This concept further subdivides Palmer Type 1B lesions based on the specific component of ulnar attachment injuries (Table 2). It integrates clinical, radiographic, and arthroscopic findings for each type of peripheral TFCC lesion and provides guidelines for tailored treatment options for each class.¹⁸

Table 2.

Atzei classification of TFCC peripheral tears. Adapted from the original article (Atzei & Luchetti, 2011).¹⁸ Clinical assessment is performed via DRUJ ballottement; radiological assessment is based on the presence of ulnar styloid fracture; arthroscopic assessment includes inspection, hook, and trampoline tests.

Atzei Classification		Clinical	Radiological	Arthroscopic		Suggested Treatment
		DRUJ ballottement	Ulnar styloid fracture	Appearance (RC arthroscopy)	Hook test
Class 1 Repairable Distal Tear		Slight laxity Hard end point	+/−	Peripheral tear	–	TFCC suture repair (Conservative management in acute cases)
Class 2 Repairable Complete Tear		Mild to severe laxity Soft end point	+/−	Normal	+	TFCC foveal repair
Class 3 Repairable Proximal Tear		Mild to severe laxity Soft end point Variable	+/−
Class 4 Non-repairable Tear			Inconsequential	Massive tear Frayed edges		TFCC reconstruction with tendon graft
Class 5 DRUJ arthritis				Variable		Wrist arthroplasty

Abbreviation: TFCC, triangular fibrocartilage complex; DRUJ, distal radioulnar joint.

In 2022, Schmitt et al. introduced the ‘CUP’ classification, organizing lesions into central (C), ulnar (U), and peripheral (P) based on the three-dimensional anatomy of the TFCC.¹⁹ Herzberg et al., in 2023 proposed a new classification based on arthroscopic findings from the 3–4 portal (Fig. 2). This classification divides lesions into disc (D), reins (R), and wall (W), and considers the patient's ulnar variance and Tolat's type of DRUJ sigmoid notch. Each division is further subcategorized according to the tear location. This classification mirrors the anatomical view during arthroscopy, making it more comprehensive and easier to remember. It describes all known combined tears to date and allows for the addition of future disorders.²⁰

Fig. 2.

Artist's impression of Herzberg et al. classification of TFCC lesions based on arthroscopic findings, divided into disc (D), reins (R), and wall (W) categories, further subcategorized by tear location.

4. Clinical assessment

Patients with TFCC tears often experience ulnar-sided wrist pain (USWP). These tears typically occur from a fall when the wrist is extended and pronated under axial load. Chronic TFCC tears can cause persistent pain, DRUJ instability, and arthritis. The four-leaf clover algorithm, introduced by Kakar and Garcia-Elias, addresses all DRUJ pathologies, including TFCC injury, bone deformity, cartilage damage, and ECU instability, preventing suboptimal diagnosis and management of UWSP.²¹

A comprehensive evaluation of the upper limb, especially the proximal radioulnar joint (PRUJ), is essential to detect associated injuries. Clinically, patients with TFCC lesions may experience pain during active and passive forearm rotation. Severe injuries may lead to DRUJ laxity, evident through a positive piano key sign.²² The fovea sign involves applying pressure between the ulnar styloid and FCU tendon; tenderness here indicates a high likelihood of foveal disruptions or ulnotriquetral ligament lesions, with 95.2 % sensitivity and 86.5 % specificity.²³

Another diagnostic examination is the DRUJ ballottement test.²⁴ With the patient's elbow at a 90-degree angle, the examiner stabilizes the radius to the carpus and translates the ulna volar to dorsal. Greater displacement than the contralateral side indicates a positive result. Other diagnostic maneuvers include the hypersupination and protonation test and the TFCC grind test.²⁵

5. Advanced imaging

Advanced imaging plays a crucial role in the diagnosis and surgical planning for TFCC tears. Magnetic resonance imaging (MRI) has demonstrated excellent performance, with sensitivity, specificity, and accuracy rates reaching up to 92 %, 89 %, and 91 %, respectively.²⁶ Recent advancements, such as high-resolution 3T MRI, further enhance the visualization of the intricate anatomy of the TFCC, addressing diagnostic challenges.²⁷ Arthroscopy remains the gold standard for diagnosing TFCC lesions in the wrist due to its ability to provide a direct visual assessment and facilitate precise diagnosis.^28,29

Computed tomography (CT) wrist arthrography is particularly beneficial in cases where MRI is contraindicated or when a detailed assessment of bony structures is necessary. Studies have demonstrated its reliability in diagnosing TFCC injuries, especially dorsal peripheral detachment and proximal horizontal flap tears.^30,31 MRI arthrography has been found to be marginally superior to conventional MRI in diagnosing TFCC injuries.^32,33 However, arthrography is an invasive procedure, and the risks and additional costs may outweigh the diagnostic benefits. Ultrasonography has also been suggested as a good modality to visualize components of the TFCC and can assist in the precise delivery of injections.³⁴ A meta-analysis by Treiser et al. demonstrated equivalent sensitivity and specificity across various diagnostic imaging modalities for detecting TFCC injuries.³³

6. Non-surgical management

In the absence of unstable and displaced fractures or an unstable DRUJ, the initial management of TFCC injuries can be nonsurgical.³⁵ Lesions in the peripheral 20 % of the TFCC are known to have comparatively better healing potential due to good vascularisation.³⁶ Conservative management of TFCC injuries frequently consists of analgesia, immobilization, activity modification, hand therapy exercises and/or steroid injections. Splinting methods vary but usually include Muenster and/or volar wrist splints for a trial period of 2–6 months, though studies have shown that short-arm immobilization and the presence of DRUJ subluxation leads to poorer outcomes.^37,38 The majority of conservatively managed patients experience symptomatic improvement, with recovery increasing rapidly during the first 6 months. However, about 40 % of patients have been reported to reach a plateau in the recovery process and require subsequent surgical intervention. Given these findings regarding the natural course of recovery of the TFCC, a minimum of 6 months of nonsurgical treatment is recommended before considering surgical intervention.^39,40

To date, only two studies have directly compared the outcomes of conservative therapy to surgical management.^41,42 Both suggest that conservative therapy may be adequate for treating certain TFCC injuries, although the evidence is limited due to retrospective study design and significant confounding factors that were not accounted for. Other studies focusing on conservative management also reported good long-term recovery but were limited by confounding distal radius injuries.^43,44 Corticosteroid injections or PRP injections have been described and shown to reduce inflammation in TFCC injuries, but no long-term outcomes have been reported so far.^45,46

7. Arthroscopic assessment of TFCC lesions

The assessment is typically performed through the 3–4, 6-R, 6-U, and DRUJ portals under regional or general anesthesia with tourniquet control, or using wide awake local anesthesia with no tourniquet.⁴⁷ A 30-degree 1.9-mm or 2.4-mm arthroscope is inserted into the 3–4 portal, and a 3-mm arthroscopic shaver into the 6-R portal. Synovectomy is performed first to enhance visualization and assess TFCC tears, followed by thermal shrinkage to tighten the ligament and restore capsular tension.^48,49 The TFCC is assessed by visualizing the TFC disc. A healthy TFC disc appears thick, white, and 'bouncy,' while a thin, yellow disc with central perforation indicates a chronic lesion. The location of the TFCC tear is identified according to the Palmer classification.⁸ The 6-R portal is used for TFCC assessment and repair, with an arthroscopic probe inserted to evaluate the tear's severity according to the Atzei or Herzberg classification.^18,20

Table 3 lists arthroscopic tests routinely performed for TFCC assessment and tear diagnosis, detailing each test's sensitivity and specificity through the 3–4 viewing portal.50, 51, 52, 53 The 'hook' test has a sensitivity of 100 % and specificity of 70 %, but Ecker's study found that 82.3 % of patients with a positive hook test had intact foveal TFCC fibers on DRUJ arthroscopy, indicating limited diagnostic accuracy.^54,55 DRUJ arthroscopy is crucial for assessing deep RUL or foveal avulsion tears (Fig. 3) not visible from radiocarpal portals, ensuring accurate visualization of deep foveal fibers for appropriate TFCC repair.

Table 3.

Arthroscopic tests for peripheral TFCC tears routinely performed by the authors.

Arthroscopic Test	Technique	Significance
Trampoline sign45	An arthroscopic probe is used to assess TFCC tautness by applying compressive load on the TFCC. A soft or loose TFCC indicates a loss of the ‘trampoline effect,’ which is considered a positive test	Sensitivity 75 % (distal tears), 78.9 % (complete tears), 58.3 % (proximal tears); Specificity 67.3 %18
Hook test46	An arthroscopic probe is placed under the peripheral edge of the torn TFCC. The deep foveal fibers of the TFCC are assessed by attempting to displace or ‘hook’ the peripheral edge of the TFCC towards the center of the ulnar head.	Sensitivity 100 % (distal tears), 100 % (complete and proximal tears); Specificity 96.4 %.18
Suction test47	A shaver is introduced through the 6-R portal, and by using periodic suction, we can observe the loss of TFCC tension as the TFCC rises against the shaver.	–
Ghost sign48	Characterized by a reverse 'trampoline sign,' this involves inserting a probe into the DRUJ and lifting it up and down beneath the TFCC, which demonstrates a 'ghost effect'.	–

Abbreviation: TFCC, triangular fibrocartilage complex.

Fig. 3.

Left wrist, DRUJ portal view showing the avulsed radioulnar ligament (yellow arrows from the foveal footprint (black asterisks).

Abbreviations: DRUJ, Distal Radioulnar Joint; UH, ulnar head.

8. Arthroscopic management and proposed algorithm

8.1. Central tears (Palmer 1A, Herzberg DD/DT)

Central TFCC tears are typically managed with arthroscopic debridement due to the avascular nature of the articular disc. As long as less than two-thirds of the central TFCC is excised, its biomechanical function is not compromised.¹⁶ Cho et al. have shown that most patients experience good outcomes following debridement, with significant improvements in DASH scores, Mayo Wrist Scores, and VAS pain scores. The study found that 86 % of patients had favorable outcomes, while 8.8 % required secondary ulnar shortening osteotomy due to ulnar positive variance. Ulnar positive variance has been identified as a significant predictor of poor prognosis.⁵⁶

8.2. Dorsal peripheral superficial tears (Palmer 1B, Atzei 1, Herzberg W1/W2)

Estrella et al. first described dorsal superficial TFCC tears in 2007.⁵⁷ These tears are typically located between the TFC disc and the dorsal RULs, separating the TFC disc from the dorsal RULs (Fig. 4). Hook tests are usually positive for these tears, with intact foveal TFCC fibers observed on DRUJ arthroscopy.⁵⁸ Some techniques described in the literature for repairing dorsal superficial capsular TFCC tears include outside-in, inside-out, and all-inside repair.59, 60, 61 No significant differences have been shown among all three techniques so far.^62,63

Fig. 4.

Right wrist, 3–4 portal view showing the arthroscopic probe inserted through the 6R portal, attempting to hook the torn dorsal peripheral TFCC tear (yellow arrows). The black asterisk indicates the triangular fibrocartilage disc.

Abbreviations: Tq, triquetrum; SS, extensor carpi ulnaris subsheath; 6U, 6-ulnar portal.

For large dorsal peripheral tears, we prefer performing a double-loop TFCC repair as described by Mathoulin et al.⁵³ (Fig. 5) This procedure involves creating a DRUJ portal and using hypodermic needles to pass absorbable sutures through the TFCC at its dorsal insertion. These sutures are retrieved through the 6R portal using fine mosquito forceps. Two single 3-0 polydioxanone sutures (PDS), one radial and one ulnar, and a central 4-0 PDS suture loop, are placed to form two loops that secure the lateral and medial portions of the TFCC to the dorsal capsule. The loops are pulled to ensure the sutures pass through the TFCC and are tied subcutaneously with the wrist in extension and ulnar deviation. This technique provides a robust repair for extensive dorsal TFCC tears, ensuring stability and promoting healing. If the tear is smaller, a simple single-loop repair in a similar manner, or a suture repair to the dorsal capsule is sufficient.⁵⁹ (Fig. 6).

Fig. 5.

Left wrist, (A) Two single 3-0 PDS, one radial and one ulnar, and a central 4-0 PDS suture loop (black arrow), are placed to form (B) two loops that secure the lateral and medial portions of the TFCC to the dorsal capsule.

Black asterisk depicts the triangular fibrocartilage disc.

Abbreviations: Tq, triquetrum; PDS, polydioxanone sutures.

Fig. 6.

Right wrist, view from 3 to 4 portal. Figure (A) shows the torn dorsal peripheral edge of the TFCC (yellow arrows) repaired with peripheral capsular sutures (outside-in technique) using 3-0 PDS before tightening the sutures. Figure (B) shows the same area after tightening the sutures, closing the separation between the TFC disc and the dorsal radioulnar ligament and capsule.

The black asterisk indicates the triangular fibrocartilage disc.

Abbreviations: Tq, triquetrum; SS, extensor carpi ulnaris subsheath; 6U, 6-ulnar portal.

8.3. Palmar peripheral superficial tears (Palmer 1B/1C, Atzei 1, Herzberg W3/W4/W5)

Isolated palmar TFCC tears are rare. Palmar TFCC tears are often associated with ulnocarpal ligament complex (UCLC) tears and lunotriquetral interosseous ligament (LTIL) tears due to their strong anatomical association.^23,64 In view of such close association, Chung and Merlini have recently described a single suture repair for combined palmar TFCC, UCLC and LTIL tears.⁶⁵ This technique involves creating a 6U portal and using a small curved hemostat to create a safe passage between the UCLC and the ulnar neurovascular bundles (NVB). A curved 21-G needle loaded with a 3-0 PDS suture is inserted through the 6U portal, passing beneath the TFCC and penetrating the palmar TFCC near the volar sigmoid notch (Fig. 7A). The suture end is retrieved from the 6R portal, and the needle is retracted just beneath the TFCC and re-penetrates another section of the palmar TFCC at the ulnar edge (Fig. 7B). Both ends of the suture are retrieved from the 6R portal. The curved hemostat, located between the UCLC and the ulnar NVB, is then used to retrieve the first end of the 3-0 PDS suture (Fig. 7C) so that the suture captures the UCLC out of the 6U portal. The other end of the suture is then retrieved directly from the 6R portal out of the 6U portal (Fig. 7D). The suture is tied with the wrist in partial flexion and ulnar deviation, reinforcing the palmar TFCC, the UCLC, and the volar LTIL complex (Fig. 8).

Fig. 7.

Right wrist, 3–4 portal view. (A) A curved 21-G needle loaded with a 3-0 PDS suture is inserted through the 6U portal, passing beneath the TFCC and penetrating the palmar TFCC near the volar sigmoid notch. The suture end is retrieved from the 6R portal, and the needle is retracted just beneath the TFCC and (B) re-penetrates another section of the palmar TFCC at the ulnar edge. Both ends of the suture are retrieved from the 6R portal. (C) The curved hemostat, located between the UCLC and the ulnar NVB, is then used to retrieve the first end of the 3-0 PDS suture so that the suture captures the UCLC out of the 6U portal. (D) The other end of the suture is then retrieved directly from the 6R portal out of the 6U portal.

The faded red dotted line indicates the interface between the UCLC/Volar ulnar capsule and the palmar TFCC. The faded green dotted line represents the interface between the ECU SS and the dorsal TFCC. The faded grey dotted line represents the edge of the sigmoid notch.

Abbreviations: ECU, Extensor carpi ulnaris; SS, subsheath; Tq, Triquetrum; 6U, 6-ulnar; TFCC, triangular fibrocartilage complex

∗With permission: Chung SR, Merlini L. Arthroscopic repair of combined triangular fibrocartilage complex, lunotriquetral ligament, and ulnocarpal ligament tears. Arthroscopy Techniques. 2024. https://doi.org/10.1016/j.eats.2024.102995.

Fig. 8.

Right wrist, 3–4 portal view. The final suture configuration (light blue line and white arrow), reinforcing the palmar TFCC, the UCLC (black asterisk), and the volar LTIL complex. Yellow shaded area represents the 6-U portal. The faded red dotted line indicates the interface between the UCLC/Volar ulnar capsule and the palmar TFCC.

Abbreviations: SS, subsheath; Tq, Triquetrum; 6U, 6-ulnar; TFCC, triangular fibrocartilage complex.

∗With permission: Chung SR, Merlini L. Arthroscopic repair of combined triangular fibrocartilage complex, lunotriquetral ligament, and ulnocarpal ligament tears. Arthroscopy Techniques. 2024. doi:10.1016/j.eats.2024.102995.

8.4. Dorsal and palmar peripheral deep tears (Palmer 1B, Atzei 2/3, Herzberg R1)

Lim et al. discussed isometric and anatomic TFCC repair concepts.⁶⁶ Isometric TFCC repair reattaches fibers to a isometric point on the DRUJ using a single suture or anchors for stability, whereas anatomic TFCC repair focuses on reattaching the deep RUL fibers to their natural foveal footprint. Although anatomic repair is gaining popularity, no strong evidence favoring it over other. Foveal TFCC reattachment can be achieved through transosseous repair or suture anchors.^67,68 Recent studies show that rein-type capsular repairs are not inferior to foveal reattachment with suture anchors for foveal avulsion tears.⁶⁹ A systematic review found that the transosseous suture technique has better functional outcomes than suture anchor repair.⁶³ Techniques addressing both foveal and superficial fibers and palmar and dorsal RUL limbs simultaneously have shown good outcomes.⁷⁰ We propose using the transosseous repair by Nakamura et al. and the suture anchor repair by Atzei et al. for their simplicity and reproducibility.^67,68

8.4.1. Transosseous foveal reattachment

The procedure begins with radiocarpal (RC) and DRUJ arthroscopy to confirm the presence of a foveal detachment. The targeting device is then inserted through the 6-R portal (Fig. 9A). A 1 cm longitudinal incision is made on the ulnar cortex, 15 mm proximal to the tip of the ulnar styloid. Using the targeting device, two small drill holes, approximately 1.2 mm in diameter, are created from the ulnar cortex to the ulnar half of the TFCC, ensuring they pass through the foveal insertion. A looped nylon 4-0 suture is passed through these holes using a 21-gauge needle. These loop sutures are then retrieved through the 6R portal, and nonabsorbable 3-0 FiberWire are threaded through the loop sutures. The polyester sutures are pulled through the TFCC and out the ulnar cortex, securing the TFCC to the fovea. This creates a mattress-type suture repair (Fig. 9B), effectively reattaching the TFCC to the ulnar fovea and restoring DRUJ stability. Nakamura et al. found that 62.5 % of wrists treated with this technique had no pain, and 70.8 % had no DRUJ instability.⁶⁷

Fig. 9.

The left wrist is shown. (A) The Nakamura target device is inserted through the 6R portal, with the spike placed on the ulnar half of the TFCC. The guide sleeve is advanced to the skin 15 mm proximal to the ulnar styloid tip, where an incision is made. (B) Radiographic appearance of the Nakamura target device, with the tip on the ulnar half of the TFCC. (C) View from the 3–4 portal. A 2-0 FiberWire suture is threaded through the TFCC and out the ulnar cortex via two transosseous tunnels drilled using the target device. The image shows the suture before tightening. (D) The 2-0 FiberWire suture is tightened, securing the TFCC to the fovea.

Abbreviations: 6R, 6-radial; TFCC, triangular fibrocartilage complex.

8.4.2. Suture anchor foveal reattachment

Once the foveal detachment is confirmed, the direct foveal (DF) portal is created approximately 1 cm proximal to the 6-U portal with the forearm in full supination. This displaces the ulnar styloid and ECU tendon dorsally, exposing the ulnar fovea. A 2–2.5 cm longitudinal skin incision is made connecting the 6-U and the DF portals (between the FCU and ECU tendons), and the DCBUN is identified and protected. The extensor retinaculum is split, and the ulnocarpal capsule is incised to expose the distal articular surface of the ulnar head. The fovea is debrided and prepared using a small curette. A suture anchor loaded with a pair of sutures is then inserted into the fovea through the DF portal. Sutures are passed through each limb of the radioulnar ligament using a 25-G needle (Fig. 10A), retrieved through the 6-U portal (Fig. 10B), and tied under arthroscopic vision using a small knot-pusher, ensuring the TFCC is securely anchored to the fovea (Fig. 10C and D). This technique has significantly improved clinical outcomes, with 83.3 % of patients achieving excellent or good Modified Mayo Wrist Scores (MMWS) and significantly reducing pain levels. Additionally, 91.7 % of patients experienced distal radioulnar joint (DRUJ) instability resolution, and 85.5 % resumed their previous activities.^68,71

Fig. 10.

Artist's impression of Atzei's TFCC foveal suture anchor repair. (A) A suture anchor loaded with a pair of sutures is inserted through the DF portal and passed through each limb of the RUL with a 25-G needle. (C) The sutures are tightened under arthroscopic vision using a small knot-pusher, securing the TFCC to the fovea. (D) Radiographic appearance of Atzei's TFCC foveal suture anchor repair with the suture anchor in the fovea.

Abbreviations: DF, direct fovea; RUL, radioulnar ligament.

8.5. Palmar and dorsal radial-sided tears (Palmer 1D, Herzberg R2/R3/R4)

Radial sided TFCC tears' relatively good healing potential, repair may be performed in cases with DRUJ instability.⁹ Suture repair is indicated in cases with pre-Palmer 1D lesions described by Luchetti et al.⁷² This tear differs from typical Palmer 1D lesions, where the RULs are ruptured in the mid-substance before their insertion on the sigmoid notch, at least 5 mm from the radius (Fig. 11A). Such tears are repaired using a 2/0 monofilament suture, passed through the radial stump tear from the ulnar portion of the TFCC via a 21-G shuttle needle (Fig. 11B). A second shuttle needle with a suture loop is introduced similarly, parallel to the first needle, to pull the nylon suture back through the tear. This procedure is repeated for the dorsal RUL, ensuring both ligaments are securely sutured (Fig. 11C).

Fig. 11.

Artist's impression of pre-Palmer 1D repair where the RULs were ruptured at mid-substance just before their insertion on the sigmoid notch. (A) A 2/0 or 3/0 monofilament suture is passed through the radial stump tear from the ulnar portion of the TFCC via a 21-G shuttle needle. (B) A second shuttle needle with a suture loop is introduced similarly, parallel to the first needle. The suture loop pulls the nylon suture back through the tear. (C) The procedure is repeated for the DRUL, ensuring both ligaments are securely sutured.

Abbreviations: PRUL, palmar radioulnar ligament; DRUL, dorsal radioulnar ligament; RUL, radioulnar ligament.

Radial TFCC avulsion is best managed using a suture anchor repair.⁷³ The footprint of the TFCC avulsion is debrided using a shaver or burr to expose healthy, bleeding bone. An 18G needle is used to pass a 2-0 FiberWire suture through the torn avulsed end of the TFCC in an all-inside manner (Fig. 12). Both ends of the same suture are retrieved from the 6U portal and anchored into the sigmoid notch using a mini-PushLock anchor. Tears involving bony avulsions may be managed with screw fixation.

Fig. 12.

Artist's impression of mini-Pushlock anchor repair of radial-sided TFCC avulsion. (A) An 18G needle passes a FiberWire 2-0 suture through the avulsed TFCC end in an all-inside manner. (B) The sutures are retrieved with a mini-arthroscopic suture lasso from the 6U portal. (C) The sutures are threaded into a mini-Pushlock anchor, and a hole is drilled at the sigmoid notch. (D) The TFCC is anchored to the sigmoid notch with the mini-Pushlock anchor.

Abbreviations: TFCC, Triangular fibrocartilage complex; 6U, 6-ulnar.

9. Postoperative rehabilitation

Patients are typically immobilized with a long arm or sugar tong splint or cast for 3–8 weeks, depending on the extent of the repair. This is followed by a short arm cast or removable wrist splint after 2–4 weeks. Strengthening exercises generally begin around 6–8 weeks post-surgery once initial healing has occurred and range-of-motion exercises have started. Patients can usually return to heavy activities and sports around 3–6 months postoperatively.⁶³

10. Complications

Arthroscopic TFCC repair has a complication rate of 5.98 %. Common issues include DCBUN nerve injury (up to 17 %) and extensor tendon problems like ECU tendinitis (up to 19 %). Other complications are infection (0.2 %), thermal injury, and persistent symptoms or instability. Mid-term concerns are suture knot irritation and wrist stiffness, affecting pronation-supination in about 2 % of cases.⁷⁴

11. Conclusion

This article presents our surgical algorithm for managing TFCC tears amidst the various repair techniques and classifications in the literature. Due to the complexity of multiple classification systems, we advocate for a systematic approach to arthroscopic assessment. We aim to guide upper limb surgeons in the decision-making process for arthroscopic treatment of TFCC tears, emphasizing that arthroscopy remains the gold standard for accurate diagnosis and management despite advancements in preoperative imaging.

Conflicts of interest

All named authors hereby declare that they have no conflicts of interest to disclose and have not received any funding to write this article.