Triangular Fibrocartilage Complex (TFCC) Tears: Over-the-Top Repair

Triangular Fibrocartilage Complex (TFCC) Tears: Over-the-Top Repair

This video will provide a cadaveric surgical repair of a tear in the wrist’s T F C C, or triangular fibrocartilage complex. The surgeon will use a technique known as the over-the-top repair which uses the minimally invasive arthroscopic-assisted repair using a small camera, instruments, and suture. A right hand is shown, and the surgeon has already made 3 incisions on the top of the wrist, which will be used to provide access to the wrist joint. The camera has already been placed in the incision just above the radius bone.

Before the repair starts, the surgeon is shown shaving fragments of the tear and the capsule of the tissue surrounding the TFCC. This is done to optimally see the TFCC and ensure the repair is done with healthy tissue. Once the unhealthy tissue is shaved away, 1 final incision will be made to the outside of the wrist, just over the ulna bone and TFCC. The surgeon carefully approaches the TFCC and is mindful of a nearby nerve, which provides sensation to a portion of the hand's skin. The surgeon tags the nerve with the suture, which helps protect this structure during the procedure.

Small retractors will be used to move the tissues out of the way. The end of the ulna bone is exposed here. The surgeon identifies the location of the TFCC, which is just above the end of the ulna bone. The camera has now been moved to 1 of the portals closer to the TFCC. A cannula and instruments will be passed through the portal on the opposite side of the wrist. An instrument that helps pass the suture will be placed into the cannula which the surgeon can directly see with the camera.

The instrument will be brought closer to the TFCC, and its sharp end will be pushed through the TFCC and a small portion of the top of the ulna bone, creating a small tunnel in this bone. A wire will be threaded into the end of the suture passer handle and pushed through the instrument's body, the TFCC, and the ulna bone, as shown. The suture passer is then removed. A strong suture will be threaded in the looped end of the wire. The wire and the attached suture will be passed through the path previously created by the wire. The wire is removed, leaving the suture in place.

A strong suture will be threaded in the looped end of the wire. The wire and the attached suture will be passed through the path previously created by the wire. The wire is removed, leaving the suture in place. Then, the process is repeated. The suture passer will pierce another location on the TFCC, this time just capturing the edge of the tissue. The wire will be placed through the passer, TFCC, and out of the ulnar-side incision. The suture passer will be removed, and the other end of the suture will be placed in the wire loop and pulled down.

The newly placed suture is nicely visualized, holding the TFCC down back to the bone. The exact process will be repeated with another suture to hold the tear back to the bone. The surgeon will use another type of flat braided suture. This broad suture is strong but also prevents the suture from pulling through delicate tissue like the TFCC. The camera view shows both sutures holding the TFCC down securely. The surgeon will then secure the tail ends of the suture with small and low-profile knots. The suture tag holding the nerve will be gently removed.

The surgeon is shown checking the TFCC repair, which is now tightly repaired in place with the 2 sutures. The incisions will be closed, and the surgery is now complete.