Novel Triple-Loop Technique for Suturing TFCC Injuries without Transosseous Tunnel

Currently, suturing techniques for TFCC injuries primarily include intra-capsular and transosseous tunnel suture techniques. However, this way has its shortcoming and difficulties. We have developed an improved triple-loop technique, which allowed for suturing of both the deep and the superficial layers of the TFCC without the need for a transosseous tunnel.

In recent years, aesthetic technology has been widely used in the clinical practice of sports medicine. Surgeons need to restore structural stability and function with minimal trauma.

Clinical follow-up results show that this is a safe, effective, and simple surgical method for treating TFCC injuries.

[Narrator] To begin, place the patient in the supine position and administer general anesthesia. Position the affected limb on the operating table beside the bed. Apply a tourniquet to the proximal upper arm, ensuring it lies flat without folds or twists. Secure the tourniquet with a sterile dressing to prevent shifting, and set the tourniquet pressure to 35 kilopascals. Now, perform ballottement tests under anesthesia in the neutral, pronation, and supination positions. Fix the wrist joint, pinch the ulna, and move it to assess stability. If the amplitude is less than five millimeters, it is stable. Compare the results with those of the healthy side. Then, disinfect the affected limb using complex iodine and cover it with a waterproof surgical sheet. Abduct the shoulder joint 90 degrees, and flex the elbow joint 90 degrees. Fix the affected limb on the traction support. Next, tuck and vertically pull the index, middle, and ring fingers, applying a traction force of approximately five kilograms according to the traction frame graduation. Equip the arthroscope with a 2.7 millimeter 30 degree lens, and set up the hand-controlled mini handle with a 2.0 millimeter planer head. Now, use a sterile marker to mark the 3/4, 6R, and 6U approaches. Inflate the tourniquet and insert a 2.7 millimeter lens through the 3/4 approach located proximal to Lister's node for observation. If needed, insert a needle through the 6U approach for drainage. Explore wrist joint structures radially and ulnarly, moving from proximal to distal. Then, use the 6U and 6R approaches as the operative routes, and probe the radial edge, central part, and ulnar edge of the TFCC micro disc. To perform a trampoline test, press the fiber disc with a probe hook under the microscope and assess the TFCC tension. Conduct a probe test to detect tears at the TFCC recess. For radial edge tears or central perforation tears, use a planer to clean the site and perform plasma shrinkage. For a positive probe test, employ the three-loop method to suture the TFCC and use a planer to freshen the ulnar edge and recess. Next, make a five millimeter incision with a sharp knife 1.5 centimeters proximal to the midpoint between the 6R and 6U approaches. Using a five milliliter syringe needle, penetrate the 3-0 PDS close to the anterior ulna, moving in a posterior and superior direction, approximately two to three millimeters from the ulnar edge of the TFCC. Leave the 3-0 PDS in place and remove the needle. Now, use the 4-0 PDS along the same approach and penetrate about two millimeters in front of, or behind the 3-0 PDS. Then, leave the 4-0 PDS and remove the needle. For the 6R approach, use mosquito forceps to pull the 3-0 and 4-0 PDS out of the same soft tissue tunnel. Tie a knot with the 4-0 PDS, insert the 3-0 PDS, and use the 4-0 PDS to bring the 3-0 PDS out, to complete the first loop without tying a knot yet, and fix the end with mosquito forceps. Then, use the 6R and 6U approaches, 1.5 centimeters proximally to the midpoint, and make a 0.5 centimeter incision with a scalpel. With a five milliliter syringe needle, penetrate the 3-0 PDS close to the posterior ulna, moving anterior superior, approximately two to three millimeters from the ulnar edge of the TFCC. Leave the 3-0 PDS and remove the needle. Now, use the 4-0 PDS along the same approach and penetrate about two millimeters in front of, or behind the 3-0 PDS. Leave the 4-0 PDS and withdraw the needle. Complete the second loop without tying a knot, and fix the line end with mosquito forceps and mark it. Through the 6U approach, insert the 3-0 PDS with a five milliliter syringe needle and suture the TFCC from outside to inside. Leave the 3-0 PDS in place and remove the needle. Use the 4-0 PDS to directly penetrate the joint cavity through the 6U approach, and pull the 3-0 and 4-0 PDS through the same soft tissue tunnel using mosquito forceps through the 6R approach. Then, tie a knot with the 4-0 PDS, insert the 3-0 PDS, and use the 4-0 PDS to bring the 3-0 PDS out, completing the third loop without tying a knot. When satisfied with the tension, tie the knots under the skin sequentially from the first to the third loop. After completion, perform the ballottement test again and the trampoline test in parallel, without performing the hook test. Suture the incisions individually using 4-0 polydioxanone sutures, avoiding deep stitches that might involve nerves and tendons. Finally, apply elbow-over-elbow long arm plaster with the elbow bent at 90 degrees, and fix it in a neutral position. 20 patients underwent the surgical method to treat TFCC injuries. After surgery, there was a significant decrease in Visual Analogue Scale score, the Patient Rated Wrist Evaluation score, and the Disabilities of the Arm, Shoulder, and Hand score, compared to the preoperative values. Wrist flexion, extension, and rotation ranges were all significantly improved after surgery. The surgical time for the triple-loop technique was significantly shorter at around 25.85 minutes compared to 99 minutes for the bone tunnel surgery.