Long-Term Outcomes of All-Arthroscopic Pre-Tied Suture Device Triangular Fibrocartilage Complex Repair

Abstract

Background  A pre-tied suture device has been utilized for all-arthroscopic peripheral triangular fibrocartilage complex (TFCC) repairs with promising early clinical results.

Purpose  The purpose of this study was to evaluate long-term functional outcomes of these repairs.

Patients and Methods  A retrospective review of patients undergoing arthroscopic TFCC repair was performed. Inclusion criteria were the Palmer type 1B TFCC tears diagnosed on arthroscopy and repaired using the all-arthroscopic pre-tied suture device. Patients with any evidence of concomitant wrist injury at the time of surgery, history of prior wrist surgery, or nonrepairable and nonperipheral TFCC tears were excluded. Postoperative complications, range of motion, grip strength, and outcome assessments were recorded for each patient.

Results  Eleven patients (mean age, 36 years; range, 20–64 years) satisfied our inclusion criteria and comprised the study cohort. The mean follow-up period was 7.0 years (range, 4.3–10.9 years). Mean range of motion of the wrist revealed flexion of 76 ± 11 degrees and extension of 73 ± 12 degrees. Mean grip strength was 98 ± 15% of the nonsurgical extremity. QuickDASH, modified Mayo, and patient-rated wrist evaluation (PRWE) average scores were 9 ± 8, 80 ± 6, and 12 ± 12, respectively. No surgical complications were observed and no patient required any further surgical intervention.

Conclusions  Our cohort of patients following all-arthroscopic pre-tied suture device repair of isolated Palmer type 1B TFCC tears demonstrated excellent clinical function at a mean follow-up of 7 years. These findings indicate that the pre-tied suture device is a reliable, safe, effective, and most importantly, durable treatment option for repair of peripheral TFCC tears.

Level of Evidence  This is a Level IV, therapeutic study.

Ulnar-sided wrist pain is commonly due to pathology of the triangular fibrocartilage complex (TFCC) which is a key dynamic stabilizer of the distal radioulnar joint (DRUJ). ^{1 2 3 4 5 6} Anatomically, the TFCC consists of dorsal and palmar fibers that arise from the radius and insert onto the fovea at the base of the ulnar styloid (termed “deep fibers” or ligamentum subcruentum) and onto the ulnar styloid itself or the surrounding joint capsule (termed “superficial fibers”). ¹ Palmer classified tears by their etiology (i.e., traumatic or degenerative) and subclassified the traumatic tears based on the location within the TFCC structure (i.e., radial, central, and peripheral). ⁶

Palmer IB or peripheral traumatic tears involve detachment of the TFCC from its peripheral attachment to the ulnar styloid and capsule. These peripheral tears often heal with nonoperative management, including a brief period of immobilization, due to the rich vascular supply present at the volar and dorsal margins of the TFCC periphery. ^{7 8 9} However, some patients may develop debilitating symptoms due to tears causing mechanical symptoms (popping, clicking, pain with forearm rotation, axial loading, and ulnar deviation), decreased grip strength, ulnar-sided wrist pain, and instability of the DRUJ. ^{7 10} In patients with significant DRUJ instability, the standard of care is repair of the “deep” fibers to their insertion in the fovea. However, most patients present without DRUJ instability but with decreased grip strength and persistent ulnar-sided wrist pain particularly with gripping and rotation. ¹¹ These patients benefit from surgical management which may be in the form of open, arthroscopic-assisted, or arthroscopic alone repair. ¹² Although studies have shown equivalent outcomes between these three treatment methods, arthroscopic techniques offer the ability to perform a diagnostic examination of the entire joint for coexisting injury and minimize soft tissue trauma which may provide a more rapid recovery. ^{13 14 15 16 17} Various arthroscopic techniques for repairing peripheral TFCC tears have been described, including “inside-out,” “outside-in,” and “all-inside” techniques, all with good-to-excellent clinical outcomes. ^{18 19}

One all-arthroscopic technique utilizes a pre-tied suture device (TFCC Fast-Fix, Smith & Nephew, Andover, MA), which uses a delivery device to deploy two PEEK (polyetheretherketone) blocks connected by a pre-tied #3–0 nonabsorbable polyester suture to anchor the TFCC to the peripheral capsule. There is a pre-tied suture knot between the two blocks that simply requires tightening once placed, which obviates the need for arthroscopic knot tying. Prior studies have demonstrated its speed, ease of use, and biomechanical superiority to the traditional outside-in suture technique. ^{20 21} In addition, it avoids additional incisions and prominent subcutaneous suture knots that may cause irritation of the ulnar skin. Previously published clinical outcomes showed promising results at 1-year follow-up. ²²

The purpose of this study was to report long-term clinical outcomes after repair of Palmer 1B peripheral TFCC tears without DRUJ instability, using this all-arthroscopic pre-tied suture device. The authors hypothesized that this repair technique would demonstrate improvement in terms of grip strength, motion, and functional outcome scores which would remain durable at long-term follow-up.

Patients and Methods

After obtaining institutional review board approval, the authors performed a retrospective review of all patients who underwent isolated arthroscopic TFCC repair by one hand fellowship-trained surgeon at a large tertiary referral center between 2005 and 2013. All patients, more than 18 years old, who had failed nonoperative management and underwent repair of a peripheral (Palmer type 1B) and Atzei class 1 ²³ TFCC tear using the pre-tied suture device during the designated time period were included. Nonoperative treatment included a minimum of 12 weeks of rest, activity modification, immobilization, nonsteroidal anti-inflammatory medications, occupational therapy, and/or corticosteroid injections.

The arthroscopic repair technique used by the senior author has been previously described. ^{20 22} In brief, following diagnostic wrist arthroscopy using the standard 3–4 and 6R portals, the peripheral tear was visualized and debrided with a 3.5 mm, full-radius, and motorized shaver to stimulate angiogenesis at the repair site. With the arthroscope in the 6R portal, the pre-tied suture device was introduced through the 3–4 portal into the ulnocarpal joint to sequentially deploy one PEEK block radial to the tear and then the 2nd block ulnar to the tear, creating a vertical mattress configuration with the implants anchored outside the capsule. The pre-tied and nonabsorbable polyester suture was then tightened, and the knot cut with a knot pusher/cutter instrument. Arthroscopy of the DRUJ was not performed because foveal tears were not suspected and DRUJ instability was not present. Postoperatively, patients were placed in a short arm splint for 2 weeks, and at the first postoperative visit wrist range of motion exercises began and strengthening exercises began at 4 to 6 weeks after surgery, as the patient tolerated.

Exclusion criteria included patients with less than 4 years follow-up, prior wrist surgery, polytrauma in which both wrists were traumatically injured, evidence of DRUJ instability, any coexisting wrist injury requiring treatment during the index surgery, and tears of the TFCC not located at the periphery. At their initial preoperative visit, all patients demonstrated tenderness to palpation over the ulnar side of the wrist at the fovea (fovea sign) aggravated by ulnar deviation and TFCC grind testing. ^{17 22} Magnetic resonance imaging was obtained for each individual and confirmed the pathology. Prior to surgery, all patients signed a comprehensive informed consent with disclosure of this device being used for their surgery.

Authors not present at the index surgical procedures reviewed the patients' charts. Demographics, such as gender, age, hand dominance, and laterality, were collected. Patients were contacted to see if they were willing to participate in the research study. Questionnaires and measurements of grip strength and range of motion were then obtained in person. All grip strength measurements were obtained by the same calibrated Jamar hydraulic hand dynamometer (NexGen Ergonomics Inc., Quebec, Canada) on the 2nd setting. A goniometer was used to obtain all range of motion measurements. The majority of patients (8/11) had preoperative Quick Disabilities of the arm, shoulder, and hand (QuickDASH) scores available. Upon follow-up, each patient completed a questionnaire packet including three standardized outcome measures: QuickDASH, patient-rated wrist evaluation (PRWE), and modified Mayo wrist score (MMWS). This packet also contained questions regarding whether the patient: (1) had received any subsequent injections or surgery for their operative wrist, (2) would have elected to undergo the surgery again knowing their current functional state, and (3) had returned to function at the same or higher level than prior to their injury. In addition, the patient was asked to indicate current level of pain, using a visual analogue scale (VAS) on a 10 cm horizontal line anchored at the end as “no pain (score of 0)” and “worst imaginable pain (score of 100),” as well as average pain level over the past 2 to 3 months. ²⁴ Collected data were reported using descriptive statistics (mean, range). Comparison of pre- and postoperative QuickDASH scores involved a paired t -test with statistical significance set at p  < 0.05.

Results

Between 2005 and 2013, 22 patients were identified who underwent all-arthroscopic repair of an isolated peripheral (Palmer type 1B) TFCC tear having met all inclusion and exclusion criteria. Of these, 11 patients were available for follow-up at an average of 7 years (range, 4.3–11 years) with 73% (8/11) men and a mean age of 36 years old (range, 20–64 years). Nine of the patients had surgery on their dominant wrist.

At the time of follow-up, only one patient had received subsequent treatment for his operative wrist, but was still completely satisfied with his outcome. One month prior to presentation and after 6 years of relief, he had received a corticosteroid injection into the dorsocentral region of the wrist for dorsal impingement syndrome. This injection was away from the area of the previous surgery, which improved his symptoms to baseline. No postoperative complications, such as failure of repair, requiring surgical intervention occurred in any patient. Overall, 91% of patients were completely satisfied with the procedure and would undergo it again, if needed, with their current knowledge of the outcome. Current VAS score was 1.7 (standard deviation [SD] = 3; range, 0–10) and VAS score averaged over the past 2 to 3 months was 1.7 (SD = 2; range, 0–6).

Individual grip strength, range of motion, QuickDASH, MMWS, and PRWE scores are shown in Table 1 . Overall, grip strength improved to a mean of 98% of the contralateral hand (range, 81–135%). Mean wrist flexion, wrist extension, radial deviation, ulnar deviation, pronation, and supination were 76 degrees (range, 60–95 degrees), 73 degrees (range, 50–90 degrees), 17 degrees (range, 10–30 degrees), 42 degrees (range, 20–60 degrees), 81 degrees (range, 65–90 degrees), and 86 degrees (range, 80–90 degrees), respectively. For all patients, the mean postoperative QuickDASH, PRWE, and MMW scores were 8.7 (range, 0–30), 12.3 (range, 0–39), and 81 (range, 70–90), respectively. For the eight patients (73%) with both pre- and postoperative QuickDASH scores available, a significant improvement was observed from 41 (range, 23–64) preoperatively to 10 (range, 2–30) postoperatively ( p  = 0.001).

Table 1. Clinical outcomes after all-arthroscopic pre-tied suture device repair of peripheral triangular fibrocartilage complex tears.

Case		Preoperative	Postoperative
	Follow-up (y)	Quick DASH	Quick DASH	Grip strength (%) a	Wrist flex	Wrist ext.	Radial dev.	Ulnar dev.	Pron.	Supin.	MMWS	PRWE
1	10	–	9	82	90	70	25	45	90	85	70	22
2	11	–	4	92	80	90	15	40	85	90	75	14
3	6	50	30	81	65	65	10	40	80	85	75	38
4	7	41	11	110	80	65	30	60	75	90	85	6
5	9	64	2	87	70	90	10	40	80	85	80	4
6	9	–	0	99	60	50	15	35	65	80	80	0
7	4	27	9	106	85	85	15	45	90	90	85	12
8	7	39	11	90	80	70	10	20	80	80	80	23
9	4	23	2	135	95	80	10	35	75	80	90	0
10	4	46	9	92	70	70	15	55	85	90	80	7
11	6	43	7	103	65	70	30	45	85	90	85	10

Abbreviations: dev., deviation; ext., extension; flex., flexion; MMWS, modified Mayo wrist score; pron., pronation; PRWE, patient-rated wrist evaluation; QuickDASH, quick disabilities of the arm, shoulder, and hand; Supin., supination.

^aGrip strength in operative hand, as a percentage, compared with contralateral wrist.

Discussion

This study presents long-term clinical outcomes after repair of Palmer 1B peripheral TFCC tears using an all-arthroscopic pre-tied suture device. At a mean 7-year follow-up, this repair technique demonstrates long-term durability with predominantly excellent objective and subjective outcomes. One-year follow-up using this repair technique was previously published demonstrating grip strength of 64% (of the contralateral side) in addition to mean QuickDASH and PRWE scores of 11 and 19, respectively. ²² At 7-year follow-up, this study demonstrates that patients may regain near full grip strength (98%) and wrist motion. Mean QuickDASH, PRWE, and MMW scores were 8.7, 12.3, and 81, respectively, demonstrating that patients continue to improve beyond 1 year, especially in terms of grip strength.

The limitations of this study include its retrospective design with its inherent biases, the relatively small sample size, and the incomplete preoperative measures. However, the long-term follow-up is a major strength of this study. As a large tertiary referral center, our institution attracts many patients seeking treatment from regions abroad in addition to the local community. Also, many of our younger population are transient. Once completing their university training, they tend to move to other parts of the country. This geographical broadness made it impossible to obtain follow-up data on all patients meeting the study criteria. Although a larger sample size would be preferable, the stringent exclusion criteria utilized allowed examination of peripheral TFCC repair in isolation.

In patients with significant DRUJ instability, repair of the deep fibers of the TFCC is required. However, most TFCC-injury patients present with ulnar-sided wrist pain or mechanical symptoms localized to the TFCC in the absence of gross DRUJ instability. At the time of wrist arthroscopy, tears of the superficial fibers will demonstrate a loss of recoil of the articular disc, when depressed by a probe (trampoline sign), but with intact resistance to lifting up the TFCC from proximal to distal with a probe (hook test) beneath the TFCC articular disc. In these patients, repair of the superficial fibers of the TFCC to the wrist capsule, such as with the pre-tied suture device, has been shown to reliably improve grip strength, mechanical symptoms, wrist motion, and pain. ^{11 25} Both open and arthroscopic techniques to repair the superficial fibers of the TFCC have been described. ¹¹ However, arthroscopic techniques theoretically offer the advantage of smaller incisions, less soft-tissue dissection, earlier recovery, higher patient satisfaction, and the ability to visualize the radiocarpal and midcarpal joints to diagnose and treat coexisting pathology. ²⁰ Anderson et al demonstrated improved wrist motion and a lower rate of dorsal cutaneous ulnar nerve (DCUN) irritation (50 vs. 22%) and ECU (extensor carpi ulnaris) tendonitis (26 vs. 11%) with arthroscopic techniques when compared with open techniques. ²⁶ Arthroscopic techniques can be further divided into “arthroscopic-assisted” (inside-out, outside-in) and “all-arthroscopic.” Arthroscopic-assisted involves a small separate incision in addition to arthroscopic portals and places the suture knot extra-articularly within the subcutaneous layer where it may be palpable and can irritate the adjacent dorsal branch of ulnar nerve (DBUN) or extensor tendons. DBUN palsy and extensor tendon injury have been reported in 3 to 22% and 3 to 11% of cases, respectively. ^{11 14 15 26 27 28 29 30}

Arthroscopic-assisted techniques have shown good results at follow-up ranging from 11 months to 4.8 years with pain reduction by VAS, grip strength returning to a mean of 71 to 95% of the contralateral hand, near full wrist and forearm motion, and improved outcome scores with mean DASH, PRWE, and MMW scores of 9 to 22, 33, and 71 to 91, respectively. ^{11 14 15 26 27 28 29 31 32 33 34 35 36}

All-arthroscopic techniques are performed solely through the arthroscopic portals and knots are placed intra-articularly. ³⁰ Few studies have reported on outcomes following all-arthroscopic repair of Palmer 1B peripheral TFCC tears. Bohringer described a technique using an intra-articularly placed T-shaped polydioxanone (PDS) fastener that required intraoperative modification by cutting-off the tips of the device to allow it to fit the wrist. ³⁷ Other prior studies have demonstrated methods to pass suture through the TFCC and capsule all-arthroscopically with the knot tied intra-articularly with various cannulated passing devices. ^{16 38 39 40} Millants et al reported a technique using intra-articular knots on two pieces of suture used to tether the peripheral TFCC, which was secured to the ulnar wrist capsule with a third knot tied subcutaneously in the 6U portal. They reported mean DASH scores of 15 at 4.8 years of follow-up with 46% of patients still reporting some limitation on their activities due to their wrist. ⁴¹ Although these all-arthroscopic techniques place the knot intra-articularly, similar to the pre-tied suture device, they are significantly more technically difficult to perform due to their use of arthroscopic knot tying.

The advantage of the pre-tied suture device is that the pre-tied knot is placed intra-articularly (avoiding superficial prominence and irritation on the ulnar capsule) by placing two small low profile PEEK blocks on the outside of the wrist capsule, avoiding the added technical difficulty of arthroscopic knot tying within the small wrist joint. ^{22 30} Biomechanically, this repair technique has shown superior strength when compared with traditional techniques for TFCC repair. ^{21 22} Due to this superior strength, our current postoperative protocol for patients treated with this device consists of a short arm splint only for 2 weeks followed by supervised hand therapy. This is a dramatic improvement over traditional postoperative immobilization, which consists of 6 weeks in a long-arm cast or splint. The shorter period of immobilization has vastly improved our patient satisfaction.

Three cadaver studies have looked at the proximity of these polymer blocks to adjacent tendons and nerves. ^{21 42 43} Waterman et al reported an average of 4 to 10 mm and 4 to 7 mm from the ECU tendon and DBUN, respectively. This is in contradiction to studies by Yao showing the DBUN was located within 17 mm and Kuremsky et al demonstrating that the closest structure (DBUN or ulnar nerve proper in 69 and 23% of cases, respectively) was within 9 mm. ^{21 43} Kuremsky et al noted that these differences from the Waterman et al's study may be due to the lack of insufflation, which is commonly used intraoperatively and utilized in both of the latter studies. ⁴³

In summary, this cohort of patients following all-arthroscopic pre-tied suture device repair of isolated Palmer type 1B TFCC tears demonstrated excellent clinical function at a mean follow-up of 7 years. These findings indicate that the pre-tied suture device is a reliable, safe, effective, and most importantly, durable treatment option for repair of peripheral TFCC tears.