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What are the Indications for Transosseous Reinsertion of Ulnar Avulsion of the TFCC
Heinrich Tünnerhoff, MD
Marbach Hospital, Marbach, Germany

During the last years it has become evident, that the deep ulnar insertion of the TFCC is important for the stability of the distal radioulnar joint (DRUJ). A special type of avulsion involving only the deep part with the superficial fibers intact, which is difficult to detect during arthroscopy of the radiocarpal joint, does exist. First results using an arthroscopically assisted technique of transosseous reinsertion of the deep part have been encouraging. An important step using this technique is a carefull debridement of the fovea to cancellous bone making a groove to pull the TFCC in by two transoseous sutures. In the beginning the indication has been limited to moderate instability of the DRUJ. By expanding the indication to cases of more severe instability the results have been slightly less reliable. The results using this technique in 80 patients (50 female, 30 male) from 2000 to 2009 are presented. In the first group of 39 patients operated until 2007 as well as in the other group of 41 patients operated from 2007 to 2009 pain on a numeric rating scale and function as measured by the MMW -Score and the DASH- Score improved significantly. The average DASH Score in the first group improved from 46 points pre - OP to 5 points post - OP, in the second group from 52 to 14 points pre – to post- OP. Possibilities of conservative management are addressed. Different factors which might be relevant for the result of operative tretament are discussed:

  1. The degree of instability: moderate instability, which can be found only by careful examination using the ballotment test versus severe instability, which is clearly visible with positive piano key sign.
  2. Quality of the ligamentous tissue employed for reattachment
  3. Time from trauma to operation
  4. Degenerative changes of the TFCC and ulnokarpal area e. g. ulna abutment
  5. Residual malunion after distal radius fractures
Considering these points the questions are discussed, when to remain conserative, when to operate doing only a reinsertion of the TFCC, doing only a ulnar shortening or simultaneously doing both, or at least employing a ligamentoplasty technique.
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