The progression of management for an individual with a triangular fibrocartilage complex (TFCC) tear is the same for injuries diagnosed as either traumatic or degenerative. You should expect to begin with conservative treatments and rehabilitation overseen primarily by a physiotherapist and your general practitioner (GP). If your injury fails to respond to such conservative measures there are several more invasive orthopaedic surgical management strategies available that repair the TFCC tear directly and restore stability amongst the bones and ligaments that form your wrist. Ultimately all management strategies for TFCC tears aim to restore the greatest amount of function back to your injured wrist whilst preventing any further or future injury. (For more information on conservative management see next post).
Surgical management of TFCC tears involves three types of procedures that are related to traumatic or degenerative aetiologies and whether are is further involvement of other structures within the joint that are contributing to the TFCC tear or that will cause future damage. These management strategies are summarised below:
Wrist arthroscopy involves key hole surgery of the wrist to either remove worn and damaged cartilage from the TFCC if you are diagnosed with a chronic degenerative TFCC tear that didn’t respond to conservative management or to repair with sutures an acute traumatic tear to the TFCC that did not respond to conservative management. Orthopaedic surgeons aim to be as minimally invasive as possible and aim to only remove the required amount of damaged cartilage, in order to maintain the normal joint mechanics post-surgery.
Physiotherapy involvement follows the same principles as those of conservative management in the post-surgery rehabilitation, however with more focus on scar and swelling management. If removal of damaged cartilage was performed alone, mobilisation with motion exercise can begin 5-7 days post surgery and you will be splinted using a Sugar Tong Splint. Wrist arthroscopy is the most commonly used procedure and has excellent functional results post-surgery after full physiotherapy rehabilitation, with a study by Corso and Colleagues (1997) finding 37 months post wrist arthroscopy of 44 participants, 29 had excellent results and 12 had good results.
Open surgery is the most invasive surgical procedure used to repair TFCC injuries and is only used if there is instability in the DRUJ or with overlying fractures of bones surrounding the wrist joint that require fixation with plates or K-wires. This management strategy is associated more so with traumatic TFCC tears requiring significant repairs to return the affected wrist joint back to stability in the hope of regaining normal function post-surgery in conjunction with physiotherapy management.
Physiotherapy involvement follows the same principles as those of conservative management in the post-surgery rehabilitation, however with more focus on scar and swelling management. Open surgery and internal fixation has excellent functional outcomes post-surgery, in a study that compared open surgery to wrist arthroscopy, Anderson and Colleagues (2008) found that there was no statistical difference between techniques for clinical outcomes, however it was concluded that wrist arthroscopy has a reduced operation time, reduced cast immobilisation time and lesser skin irritation due to suture knots, indicating why wrist arthroscopies are the preferred surgical management of TFCC tears.
Ulnar-shortening osteotomy is the last surgical management option available to repair TFCC tears and is used if the ulna at the affected wrist due to ligamentous instability has a greater length than it should (positive ulnar variance) or if wrist arthroscopy debridement has failed to produce a good functional outcome and/or the began treatment for their injury late (greater than six months). The surgical procedure involves your orthopaedic surgeon removing the necessary amount of your ulna bone that is past its normal position within the wrist joint from the shaft of the ulna. This procedure is important as positive ulnar variance leads to ulnar-carpal osteoarthritis within your wrist due to ulna producing degenerative joint mechanics between it and your carpal bones (abnormal joint loading) that accelerates cartilage wear and is severely functionally limiting.
Physiotherapy rehabilitation is consistent across all three types of surgical procedures however with ulnar-shortening osteotomies, your physiotherapist must also consider bone healing mechanisms in prescribing the types and vigour of exercises post-surgery and post-splint removal, in order to rehabilitate the most optimally for your wrist’s function. The benefit of this procedure however to your physiotherapist is that the surgery does not involve the joint directly and maintains the mechanical integrity of all the wrist’s ligamentous structures and is less painful. Minami and Kato (1998) found that amongst 25 individuals at 35 months post-surgery that 23 had complete pain relief or occasional mild pain, they also found that ulnar shortening osteotomy had efficacy for both traumatic and degenerative TFCC tears.
Surgical management of TFCC tears in combination with effective physiotherapy rehabilitation show excellent functional outcomes for the affected wrists in comparison to if no intervention was used at all. Surgical procedures show their greatest efficacy if used only after conservative measures have failed and should not be used as the go to management option due to their inherent higher costs, more invasive nature and greater period of rehabilitation.