Palmer type 1B Atzei class 1 TFCC tears are stable because no radicular ligament injury is involved. This type of TFCC tears was managed firstly with conservative treatment using immobilization, including splints or casts [18]. However, some patients who do not respond to conservative treatment must convert to operation and can be treated with debridement and capsular sutures depending on arthroscopy. Palmer type 1B Atzei class 1 TFCC tears are most amenable to successful repair and healing because of abundant blood supply [3]. In this consecutive treatment series, a new technique of outside-in transfer, all-inside repair was used to repair the torn TFCC. This repair technique showed constant and reliable clinical results in terms of pain relief and TFCC tear healing.
A new arthroscopic intracapsular suture repair technique called outside-in transfer, all-inside repair was used for Palmer type 1B Atzei class 1 TFCC tears in this study. This new method is a modification from the technique for meniscal tears by Wang in 2019 [19]. This repair technique using arthroscopy provides several advantages to other reported repair techniques. First, it is easy to accomplish because it first uses the outside-in technique and then transfer to using the needle of 10-mL sterile syringe, which is cheaper than other instruments. Second, its allows the use of a vertical mattress suture, which is useful for the alignment of the edge of TFCC tear and is easier to heal. Third, the suture knots of this outside-in transfer, all-inside technique can be performed without an additional skin incision and placed inside the joint instead of subcutaneously to avoid irritating the skin and injuring the dorsal branch of the ulnar nerve and extensor carpi ulnaris tendon.
Several suture techniques are available for Palmer type 1B Atzei class 1 TFCC tears. The currently used techniques of arthroscopic repair for class 1 tears include the inside-out, outside-in, or all-arthroscopic technique [10–14]. An outside-in technique using 2 needles guiding 2 sutures to repair the TFCC was first described by Zachee et al in 1993 [20]. Both Trumble et al. and Skie et al. advocated an inside-out technique for Palmer type 1B TFCC repair using 2 − 0 meniscal repair sutures [21, 22]. Although these techniques have been modified, they require an extra incision to tie the sutures subcutaneously, which confers a risk of injury to the extensor carpi ulnaris tendon or the sensory branch of the ulnar nerve. Furthermore, the suture knot lies subcutaneously, causing skin problems and even septic arthritis [23–26]. A study of an all-arthroscopic repair technique for TFCC with the outside-in technique in fresh-frozen cadaveric wrists showed that the PDS knot was 4.6 mm from the dorsal branch of the ulnar nerve, which may be injured by the knot, and injured an extensor carpi ulnaris tendon [23]. Another cadaver study showed that the mean minimum distance between the suture and the dorsal branch of the ulnar nerve was 1.9 mm in the inside-out technique [27]. In a previous study, Bayoumy reported that 37 patients with TFCC tears were treated with the arthroscopic outside-in repair technique, in which two patients showed complications, including dorsal ulnar nerve neurapraxia in one patient and weakness in extension of the little finger in the other patient [28]. The goal of surgeons has always been to reduce the risk of surgery and complications as much as possible by developing a new method that can increase TFCC tear healing and reduce complications. In our consecutive treatment series, none of the patients had complications such as skin problems, injury of the dorsal branch of the ulnar nerve, and injury of the extensor carpi ulnaris tendon.
As in knee arthroscopy, an all-inside technique should be fast and safe to use and avoid the disadvantages of the other techniques. A study by Conca et al in 2003 described an all-inside repair technique for Palmer type 1B TFCC tears using a small suture hook and three portals [29]. Böhringer et al. used a meniscus fastener fixation system to repair Palmer 1B TFCC tears [26]. A novel all-inside approach for Palmer type 1B TFCC tears with a spinal needle and no additional incision was introduced and described by Lee [13]. Kuremsky assessed the safety of an all-inside arthroscopic TFCC repair technique in 13 above-the-elbow human cadaver specimens. The results of this study showed that the all-inside technique was safe in terms of proximity to important structures [30]. However, the technique had a significant drawback in that the intra-articular working space in the wrist was so narrow that the range of manipulation with the suture devices through the portal was restricted. Our technique is simpler than the other all-inside techniques, although one portal without special equipment is required.
A new arthroscopic intracapsular suture repair technique called outside-in transfer, all-inside repair was used for Palmer type 1B Atzei class 1 TFCC tears in this study. This new method is a modification of the technique for meniscal tears introduced by Wang in 2019 [19]. This repair technique using arthroscopy provides several advantages to other reported repair techniques. First, this technique is easy to accomplish because, first, it uses the outside-in technique and then transfer to using the needle of 10-mL sterile syringe, which is cheaper than other instruments. Second, it allows the use of a vertical mattress suture, which is useful for the alignment of the edge of the TFCC tear and faster tear healing. Third, the suture knots of this outside-in transfer, all-inside technique can be performed without an additional skin incision and placed inside the joint instead of subcutaneously to avoid irritating the skin and injuring the dorsal branch of the ulnar nerve and extensor carpi ulnaris tendon. Finally, this technique is easier to perform than other techniques.
In conclusion, our outside-in transfer, all-inside repair technique is suitable for Palmer type 1B Atzei class 1 TFCC tears, which is as simple as the previously described arthroscopic techniques. We believe that this technique could provide a good alternative for surgeons and recommend this technique as a useful alternative to other methods of repairing Palmer type 1B TFCC tears.