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Anatomic Foveal Reconstruction of the Triangular Fibrocartilage Complex With a Tendon Graft

Bain, Gregory I. MBBS, FRACS, FA (Orth) A, PhD; McGuire, Duncan MBBCH, FCS (Orth), MMed; Lee, Yu Chao MBBS; Eng, Kevin MBBS, FRACS; Zumstein, Matthias MD

Techniques in Hand & Upper Extremity Surgery: June 2014 - Volume 18 - Issue 2 - p 92–97
doi: 10.1097/BTH.0000000000000044

An acute injury to the triangular fibrocartilage complex (TFCC) with avulsion of the foveal attachment can produce distal radioulnar joint (DRUJ) instability. The avulsed TFCC is translated distally so the footprint will be bathed in synovial fluid from the DRUJ and will become covered in synovitis. If the TFCC fails to heal to the footprint, then persistent instability can occur. The authors describe a surgical technique indicated for the treatment of persistent instability of the DRUJ due to foveal detachment of the TFCC. The procedure utilizes a loop of palmaris longus tendon graft passed through the ulnar aspect of the TFCC and into an osseous tunnel in the distal ulna to reconstruct the foveal attachment. This technique provides stability of the distal ulna to the radius and carpus. We recommend this procedure for chronic instability of the DRUJ due to TFCC avulsion, but recommend that suture repair remain the treatment of choice for acute instability. An arthroscopic assessment includes the trampoline test, hook test, and reverse hook test. DRUJ ballottement under arthroscopic vision details the direction of instability, the functional tear pattern, and unmasks concealed tears. If the reverse hook test demonstrates a functional instability between the TFCC and the radius, then a foveal reconstruction is contraindicated, and a reconstruction that stabilizes the radial and ulnar aspects of the TFCC is required. The foveal reconstruction technique has the advantage of providing a robust anatomically based reconstruction of the TFCC to the fovea, which stabilizes the DRUJ and the ulnocarpal sag.

*Department of Orthopaedic Surgery, Modbury Public Hospital

Department of Orthopaedics and Trauma, Royal Adelaide Hospital

Department of Anatomy, University of Adelaide, Adelaide, Australia

§Upper Extremity Unit, Department of Orthopaedic Surgery Traumatology, University of Bern, Inselspital, Bern, Switzerland

Conflicts of Interest and Source of Funding: The authors report no conflicts of interest and no source of funding.

Address correspondence and reprint requests to Gregory I. Bain, MBBS, FRACS, FA (Orth) A, PhD, 196 Melbourne Street, North Adelaide 5006, SA, Australia. E-mail:

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