Styloid Ulna Window Approach for Repair of Avulsed Foveal Attachment of Triangular Fibrocartilage Complex

Published:November 10, 2022DOI:


      To describe a surgical approach for open repair of the triangular fibrocartilage complex foveal avulsion via ulnar styloid osteotomy, and to assess its clinical results.


      We reviewed 12 patients with distal radioulnar joint (DRUJ) instability due to isolated foveal avulsion of DRUJ ligaments. Wrist arthroscopy was conducted for all patients to exclude the presence of concomitant tear of the superficial part of the triangular fibrocartilage complex and to corroborate the diagnosis with a positive hook test. Through an ulnar approach between flexor and extensor carpi ulnaris, an ulnar styloid osteotomy was performed under image intensifier control just ulnar to the fovea of the head of the ulna. The avulsed foveal attachment was anchored through transosseous sutures passing from the fovea to the neck of the ulna. The ulnar styloid was fixed by means of screws or tension band wires. Outcome measures included clinical assessment of pain (visual analog scale), grip strength, DRUJ instability, range of motion of the wrist, and modified Mayo wrist score. Radiographic assessment was done to determine union of the ulnar styloid osteotomy, DRUJ subluxation, and any hardware-related problems.


      Outcome measures were evaluated after a mean follow-up of 21 months. Healing of the osteotomy was obtained in all cases by 11 weeks. The DRUJ laxity, visual analog scale, and modified Mayo wrist score improved, while grip strength and range of motion remained unchanged. One patient had prominent hardware necessitating removal after union of the osteotomy. There were no reported cases of injury or neuropraxia of the dorsal cutaneous branch of the ulnar nerve.


      Open repair of an avulsed foveal attachment of the triangular fibrocartilage complex using an ulnar styloid osteotomy is an alternative to either open or arthroscopic repair approaches.

      Type of study/level of evidence

      Therapeutic IV.

      Key Words

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        • Moritomo H.
        • Masatomi T.
        • Murase T.
        • Miyake J.I.
        • Okada K.
        • Yoshikawa H.
        Open repair of foveal avulsion of the triangular fibrocartilage complex and comparison by types of injury mechanism.
        J Hand Surg Am. 2010; 35: 1955-1963
        • Nakamura T.
        • Sato K.
        • Okazaki M.
        • Toyama Y.
        • Ikegami H.
        Repair of foveal detachment of the triangular fibrocartilage complex: open and arthroscopic transosseous techniques.
        Hand Clin. 2011; 27: 281-290
        • Shinohara T.
        • Tatebe M.
        • Okui N.
        • Yamamoto M.
        • Kurimoto S.
        • Hirata H.
        Arthroscopically assisted repair of triangular fibrocartilage complex foveal tears.
        J Hand Surg. 2013; 38: 271-277
        • Iwasaki N.
        • Nishida K.
        • Motomiya M.
        • Funakoshi T.
        • Minami A.
        Arthroscopic-assisted repair of avulsed triangular fibrocartilage complex to the fovea of the ulnar head: a 2-to 4-year follow-up study.
        Arthroscopy. 2011; 27: 1371-1378
        • Geissler W.B.
        Arthroscopic knotless peripheral ulnar-sided TFCC repair.
        Hand Clin. 2011; 27: 273-279
        • Garcia-Elias M.
        • Hagert E.
        Surgical approaches to the distal radioulnar joint.
        Hand Clin. 2010; 26: 477-483
        • Moritomo H.
        Advantages of open repair of a foveal tear of the triangular fibrocartilage complex via a palmar surgical approach.
        Tech Hand Up Extrem Surg. 2009; 13: 176-181
        • Moritomo H.
        Open repair of the triangular fibrocartilage complex from palmar aspect.
        J Wrist Surg. 2015; 4: 2-8
        • Nakamura T.
        • Nakao Y.
        • Ikegami H.
        • Sato K.
        • Takayama S.
        Open repair of the ulnar disruption of the triangular fibrocartilage complex with double three-dimensional mattress suturing technique.
        Tech Hand Up Extrem Surg. 2004; 8: 116-123
        • Chou K.H.
        • Sarris I.K.
        • Sotereanos D.G.
        Suture anchor repair of ulnar-sided triangular fibrocartilage complex tears.
        J Hand Surg Br. 2003; 28: 546-550
        • Atzei A.
        • Luchetti R.
        Foveal TFCC tear classification and treatment.
        Hand Clin. 2011; 27: 263-272
        • Atzei A.
        New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability.
        J Hand Surg Eur Vol. 2009; 34: 582-591
        • Aitken R.C.
        Measurement of feelings using visual analogue scales.
        Proc R Soc Med. 1969; 62: 989-993
        • Slutsky D.J.
        Outcomes assessment in wrist surgery.
        J Wrist Surg. 2013; 2: 1-4
        • Park J.H.
        • Kim D.
        • Park J.W.
        Arthroscopic one-tunnel transosseous foveal repair for triangular fibrocartilage complex (TFCC) peripheral tear.
        Arch Orthop Trauma Surg. 2018; 138: 131-138
        • Iwasaki N.
        • Minami A.
        Arthroscopically assisted reattachment of avulsed triangular fibrocartilage complex to the fovea of the ulnar head.
        J Hand Surg. 2009; 34: 1323-1326
        • Tünnerhoff H.G.
        • Langer M.
        Arthroscopic repair for ulnar-sided tears of the TFCC.
        Handchir Mikrochir Plast Chir. 2014; 46: 286-294
        • Andersson J.K.
        • Åhlén M.
        • Andernord D.
        Open versus arthroscopic repair of the triangular fibrocartilage complex: a systematic review.
        J Exp Orthop. 2018; 5: 6
        • Atzei A.
        • Luchetti R.
        • Braidotti F.
        Arthroscopic foveal repair of the triangular fibrocartilage complex.
        J Wrist Surg. 2015; 4: 22-30