Fibrocartilagine triangolare e stiloide ulnare: artroscopia a secco

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The patient, 19, presents instability in the left wrist and pain at its ulnar edge. The symptoms, which limit its functionality, appear after a second injury (he had suffered a previous wrist fracture in childhood) and have their origin in a pseudoarthrosis of the ulnar styloid and the rupture of the insertion of the triangular fibrocartilage (TFC) in the ulnar fovea (bony cavity next to the styloid).

Initial situation — In the MRI (left), the white arrow indicates the fracture of the ulnar styloid of the patient (which is also observed in the central radiograph), while the black arrow allows us to note how the fovea of the ulna is empty, that is, there is a rupture of the insertion of the triangular fibrocartilage (TFC). This tear is also visible on the right radiograph, in which the fibrocartilage is represented by the red lines.

The triangular fibrocartilage or articular disc is one of the elements which compose the radioulnar distal joint. It’s a structure formed by a combination of fibrous and cartilaginous tissues, which goes from the edge of the sigmoid notch of the radius to the fovea of the ulna. The fibrocartilage is involved in load distribution in the upper limb and balances various complex structures in the wrist.

Furthermore, it is part of the so-called triangular fibrocartilage complex (TFCC), a mixture of non-bony elements such as the fibrocartilage itself, which allows us harmonic movements and strength in the grip.

The density of elements in a very small space makes the radioulnar joint prone to the appearance of combined injuries, as in the case at hand, with a styloid fracture and the simultaneous disinsertion of the fibrocartilage (isolated fibrocartilage injuries are unusual).

The problem

The pseudoarthrosis of the ulnar styloid, that is, its non-consolidated fracture and the lesion of the triangular fibrocartilage, make it impossible for the patient’s wrist to function optimally (due to the instability and pain noted), which prevents proper practice of motocross ; a sports activity in which mobility and grip play a determining role.

The goals

The goals of the procedure designed by Dr Piñal go through the elimination of pain and the return of the wrist to a level of function consistent with the demands of use of the patient.

The plan

To facilitate the approach and correct identification of the injury, Dr Piñal uses his dry arthroscopy technique (‘Dry arthroscopy of the wrist: surgical technique’, Journal of Hand Surgery American Edition Vol 32A, Issue 1, January 2007, Pages 119-123), which offers far superior visibility than conventional fluid infusion technique.

The video shows Dr Piñal elevating the fibrocartilage and showing that it is loose with respect to the fovea. In this case, dry arthroscopy is key in identifying the injury.

Piñal takes advantage of the same arthroscopic mini-insertion to remove the fractured fragment of the ulnar fovea and, in turn, introduce a surgical anchor that acts as a tie point for the suture that re-inserts the triangular fibrocartilage into the fovea.

Removal of the styloid fragment and reinsertion of the TFC — In the left image we can see the removal of the fractured ulnar styloid fragment (which no longer appears on the right radiograph). The radiograph shows the anchor inserted into the fovea that serves as a fixation for the arthroscopy-guided suture (in yellow) that connects it to the fibrocartilage (in red).

To suture the fibrocartilage, Dr Piñal uses all-inside suturing, that is, his arthroscopic suturing technique from inside the joint itself without additional incisions, described in his article ‘A technique for arthroscopic all-inside suturing in the wrist ‘(Journal of Hand Surgery European Volume (2010) 35: 475-479).

Arthroscopic view of the suture procedure — Arthroscopic view of the fibrocartilage suture procedure. On the left, we observe the detachment of the fibrocartilage (TFC) in addition to the position of the probe entry under it (white arrow – PROBE IN 6R UNDER TFC) and the situation of the lunate bone (LUNATE). As noted in the body text, a surgical anchor inserted into the ulnar fovea facilitates the suture (center) that joins the fovea to the fibrocartilage through a mattress stitch (black arrow). The use of dry arthroscopy significantly improves the execution of this type of semi-open surgery.

Exterior view of the suturing — Exterior view of the triangular fibrocartilage suture.

The results

Recovered patient — The patient, already recovered and in full sport practice.

The procedure carried out by Dr Piñal is a success. The pain and instability of the wrist disappear and the patient fully recovers the function of the injured area, allowing him to return to his sport activity.

Contenuti correlati:

Cosa c’è dietro il dolore ulnare?: fibrocartilagine triangolare e altre patologie

Triangular fibrocartilage injury: surgery on posterior tear

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Rottura della fibrocartilagine triangolare e frattura dello stiloide ulnare: chirurgia artroscopica a secco

10 maggio, 2021

The video shows Dr Piñal elevating the fibrocartilage and showing that it is loose with respect to the fovea. In this case, dry arthroscopy is key in identifying the injury.