REVIEW ARTICLE pissn 1598-3889 eissn 2234-0998 J Korean Soc Surg Hand 2014;19(2):87-94. http://dx.doi.org/10.12790/jkssh.2014.19.2.87 JOURNAL OF THE KOREAN SOCIETY FOR SURGERY OF THE HAND Open Repair of Triangular Fibrocartilage Complex Type 1B Tear In Hyeok Rhyou Upper Extremity and Microsurgery Center, Department of Orthopedic Surgery, Semyeong Christianty Hospital, Pohang, Korea Received: May 15, 2014 Accepted: June 5, 2014 Correspondence to: In Hyeok Rhyou Department of Orthopedic Surgery, Pohang Semyeong Christianty Hospital, 351 Posco-daero, Nam-gu, Pohang 790-822, Korea TEL: +82-54-289-1765 FAX: +82-54-289-1766 E-mail: osdrrih@gmail.com Most common traumatic type 1B tear of triangular fibrocartilage complex (TFCC), according to the Palmer s classification, may lead to the loss of the stability of distal radioulnar joint and is known to be one cause of the persisted ular side wrist pain. Recently as the knowledge of the anatomical structures of the TFCC accumulates and the deep fiber of the distal radioulnar ligament is recognized to play a central role, an attempt to repair it to the original ulnar fovea insertion site has been done and reported successful results. Since the introduction of open technique, numerous arthroscopic technique has been developing. Here careful considerations ought to be given during open repair will be taken with review of the related articles. Keywords: Open repair, Type 1B tear, Triangular fibrocartilage complex This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/bync/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 서론 원위요척골관절은 sigmoid notch 와척골두의반경이서로다른타고난불안정한관절로골성요인은 20% 정도만기여하며나머지 80% 정도는연부조직의안정성에의존한다 1. 연부조직의안정성기여도에대한여러생역학적연구에의하면삼각섬유연골복합체 (triangular fibrocartilage complex, TFCC) 가가장중요한역할을하는것으로알려져있다 2. TFCC는요골의 sigmoid notch, 척골의 ulnar styloid proocess와 fovea, 그리고척수근골인대 (ulnocarpal ligament) 를통해수근골과연결된 hammock-like structure 로원위요척골관절의안정성에기여한다. Palmer 3 은손상기전에따라외상성파열인 type 1과퇴행성요인인 type 2로분 류하고파열된위치에따라 type 1을세부분류하고, 퇴행성인 type 2의경우병의진행정도에따라세부분류하여최근까지많이이용되고있었다. 하지만 TFCC의해부학적구조가좀더밝혀지면서 sigmoid notch 에서기인된 TFCC가척골측에부착하면서 ulnar fovea 에붙는 deep fiber와 ulnar styloid process에붙는 superficial fiber가있으며각기 forearm의 supination 과 pronation 에따라다른역할을담당하는것이알려지고 4 type 1B로진단된 TFCC 손상의관절경적치료에서파열된 TFCC 변연부를 capsule 에봉합하였을경우원위요척골관절의불안정성이잔존하여재수술적치료가필요하였다는사실이알려지면서 5 ulnar fovea 부착하는 deep fiber에대한중요성이조금씩인식되게되었다. 이후많은저자들에의해 fovea tear의경우관혈적인봉합술로치 Copyright c 2014. The Korean Society for Surgery of the Hand http://www.jkssh.org/ 87
J Korean Soc Surg Hand Vol. 19, No. 2, June 2014 료하는방법이소개되었으며 6-9 이후관절경적인술기의발달로관절경적봉합술이여러가지다양한방법으로소개되어왔다 5,8,10,11. 최근 Atzei 11 은 TFCC type 1B파열의경우첫째, 손상된부분이 superficial fiber인지아니면 deep fiber인지아니면둘다손상되었는지의여부, 둘째, 손상된부분이봉합이가능한지의여부, 셋째, 원위요척골관절에관절염이동반되어있는지의여부를고려하여새로운치료방침을제안하고있으며이는임상적인치료방침을결정하는데있어매우유용하며점차많은지지를얻어가고있다. 수술시고려사항 첫째, 손상후적어도 1년이경과하며 ulnar fovea 에부착하는 distal radioulnar ligament (DRUL) 가위축되고퇴화되어없어질수있으므로수상후 1년이내일경우는관혈적봉합술방법이유용하며 8 만약이보다시간이더경과된경우나이미위축되고퇴화되어 DRUL이 attenuation 된경우는 tendon graft을이용한 DRUL의 ulnar fovea 부분을재건하거나 12 기존에알려진 Adam-Berger s technique 로 DRUL 전체를재건하는방법 13 을이용해야한다. 둘째, TFCC 손상이 sigmoid notch 에서파열되거나 (Palmer s type 1D) 혹은척수근골인대가수근골 (carpal bone) 에서파열되면서 (Palmer type s 1C) 동시에 ulnar fovea 에서파열된경우 (Plamer s type 1B) 는관절경적봉합술시그술기가복잡하므로동시에시야를확보할수있는관혈적방법이더유용할수있다. 셋째, TFCC 손상의경우손상기전상월상삼각골간불안정성 (ulnotriqetral instability), 유두유구골간불안정성 (capitohamate instability) 같은다른완관절척측부병변 (ulnar side lesion) 을동반할수있다. TFCC 파열만치료할경우완관절철측부통증이남을수있어이러한동반병변에대한치료를함께하는것이좋다. 따라서수술전진단적방사선검사상복합손상이나다른병변의동반이의심되는경우나아니면통상적으로관혈적봉합을실시하기전에관절경적검사를통해 TFCC 의복합손상이나동반손상에대한평가를먼저하는것이추천된다. 흔히 ulnar fovea 부분이파열될경우관절경적검사상 Hook test상양성소견이보이고 trampoline tension 도떨어진것을볼수있다. 만약 radial side 에서파열이함께동반된경우 (Palmer s type 1D) 의경우는 radial side 에서 probe 로달길경우 TFCC가접히는현상 (reverse Hook test 양성 ) 을볼수있으며척수근골인대가수근골에서파열된경우 (Palmer s type 1C) 는 DRUL volar side에부착하는 ulnolunate ligament 와 ulnotriquetral ligament 의 tension 이현저히떨어진것으로 TFCC 복합손상을어느정도의심할수있다. 그리고 ulnar fovea 파열이있는경우원위요척골관절경검사시비교적쉽게관절경삽입이가능하며파열된 TFCC의 deep fiber가 ulnar fovea 에부착하는부분의위축이나퇴화된정도를직접확인할수있다. 셋째, Ulnar positive variance로인하여척골의갑입 (ulnar impaction) 증상이명확한경우에는이에대한단축절골술또는척골두 Wafer 성혈술 (wafer procedure) 등이필요할수있기때문에처음부터관헐적으로접근하는것이유리하며일반적으로 2 mm 이상의척골양성위일경우는척골단축술이추천되고있다. 넷째, 관혈적봉합술시수장측접근 (volar approach) 이냐배부측접근 (dorsal approach) 이냐의접근방향에대한문제로처음배부측접근방법이소개된후지금까지표준으로받아들여지고있다 6-9. 하지만최근 Moritomo 등 14,15 의연구에의하면 TFCC에대한손상기전은완관절신전 (wrist extension) 과전완부회전 (forearm rotation) 두가지로완관절신전은먼저 volar DRUL에부착된척수근골인대의견인에의해 deep fiber가 ulnar fovea 에서먼저떨어지게되고 forearm이 supination 이냐 pronation 이냐의여부에따라 volar superficial fiber혹은 dorsal superficial fiber가순차적으로파열되게된다. Forearm rotation 의경우과도할경우먼저 superfial fiber가파열되며이어 deep fiber 파열이뒤따른다. 따라서그는가장흔한 TFCC 파열의경우가 forearm pronation 상태에서완관절신전이되며넘어지는경우이므로항상 ulnar fover 의 deep fiber는파열되지만진행정도에따라 dorsal superficial fiber는온전한경우가있어 dorsal approach 시는온전한 dorsal superficial fiber을손상시킬수있어 volar approach을새롭게소개하고있다. 다섯째, dorsal approach 의경우처음술기에서는 extensor digiti minimi (EDM) 을싸고있는 fifth extensor compartment 을열고 dorsal DRUL을 capsule에서분리하며척측으로진행하여 ulnar fovea 을노출하는소개되고있지만최근 Nakamura 8 는척수근굴근 (extensor carpi ulnaris, ECU) 의 extensor retinaculum의 radial side 로접근하며 subsheath 까지연후 ECU을척측으로견인하고원위요척골관절에종절개를가한후보다 ulnar fovea 에직접적으로가깝게접근하는새로운방법을소개하고있으며수술후다시 ECU을 reposition 시킨후에도 ECU로인한문제는없었다고소개하고있다. 여섯째, 원위요척골관절을이루는 sigmoid notch 가편평하거나 hypermobility가있는경우는우선적으로보존적인치료를시도하는것이좋으며, 보존적인치료가실패할경 88 http://www.jkssh.org/
In Hyeok Rhyou, Open Repair of Triangular Fibrocartilage Complex Type 1B Tear 우수술적치료를고려하는것이좋다. 일곱째, 항상원위요척골관절을이루는요골및척골의부정유합같은골성변형이존재할경우는먼저골성변형을위한교정절골술 (corrective osteotomy) 후에원위요척골관절에대한안정술시행여부를생각해야한다. 특히원위요골의 dorsal tilting을동반한부정유합과함께원위요척골관절불안정성이존재할경우는먼저원위요골부정유합에대한교정절골술을시행하여야한다. 부정유합된원위요골의교정절골술후원위요척골관절불안정성이소실되는경우도많으며그래도불안정성이잔존하면원위요척골관절안정술을고려하여야한다. 수술수기 관혈적으로손상된 TFCC를봉합해주는방법으로는몇가지가소개되고있으나일반적으로많이사용되는방법을기술해보고자한다 9. 먼저원위척골등부위 (5, 6 신전구획 ) 에척골신경분지의손상에유의하면서척골두의중앙까지 5 cm 가량의피부절개를가하고 EDM 를노출하여 retraction 한다 (Fig. 1A). 먼저 TFCC의원위요척골관절면부분에접근하기위해 23-gauge 바늘로 DRUJ 으로생각되는부위를찔러확인하고 (Fig. 1B) L 자형태로원위요척골관절의관절막이나중에일차봉합될수있게요골에약 2 mm 정도남긴후관절막에종절개를하여 DRUJ 를노출한다 (Fig. 1C) 이때종축 Fig. 1. (A-J) Pictures showing the operative procedure of the dorsal approach of open repair. http://www.jkssh.org/ 89
J Korean Soc Surg Hand Vol. 19, No. 2, June 2014 절개는척골경부에서 S 자절흔원위경계까지가하고, 횡축절개는배부요척인대 (dorsal radioulnar ligament) 에서시작하여 ECU tendon 의요측경계까지시행한다. 이후 TFCC 의수근관절면부분에접근하기위해배부요척인대원위부경계를따라서횡방향으로척수근관절막절개를가하고 TFCC의척측부위를노출시킨다 (Fig. 1D). 절개된관절막을근위부로당겨손상된 TFCC의근위부를노출시키고 ulnar fovea 부착부위에붙는 DRUL의위축이나퇴화된정도를확인한다. 이후 TFCC을원위부로견인하면서 forearm을완전히 pronation 시키고 small Hohman을척골두의 volar side 에걸어 deep fiber가부착하는기시부를노출한다. 이어 ulnar fovea 에형성된 fibrous tissue을철저히제거하고 decortications 하여준후 (Fig. 1E) 0.045-inch K-강선을이용하여척골두에서약 1.5 cm 근위부에서 ulnar fovea 의수장측및배부측 marigin보다안쪽을통과하게 2개의 transosseous tunnel 을만들어준다. 만약 ulnar fovea margin을벗어나 trans-osseous tunnel 이만들어지면 ulnar fovea 에부착하는부분외에 superficial fiber도일부포함될수있어 forearm supination 이나 pronation 이방해받을수있어주의를요한다. 이때, trans-osseous tunnel 의위치는봉합매듭 (suture knot) 의자극을줄여주기위해서척골경부의등부분을지나도록만들어준다. TFCC 기시부근처의척측변연에서 4-0 fiber wire 2개를이용하여의 horizontal mattress sutures 를시행한다 (Fig. 1F). 이후직침에 3-0 nylon 을끼운후이미형성된 trans-osseous tunnel 을통해직침을근위부에서원위부로역으로통과시킨후 (Fig. 1G) 3-0 nylon 의 loop을 shuttle relay 시켜 2개의 fiber wire을 trans-osseous tunnel 로통과시키고전완부중립위에서매듭을지어준다 (Fig. 1H). 이후수술장에서 DRUJ stress test 을시행하여수술전에비해 DRUJ 의안정성이회복되었는지확인한다. 원위요척골관절의안정성회복이좀의심스럽거나환자의 compliance가의심스러울경우는 1.8-2.0 mm K-강선을이용하여전완부를회외 (supination) 시킨상태로 transfixation 하여준다. 이후 dorsal DRUJ 관절막과 retinaculum 을층층이봉합하고 (Fig. 1I) 견인된 EDM 은봉합된 extensor retinaculum위에위치시키거나원래의위치로위치시킨후 extenstor retinaculum을봉합한다 (Fig. 1J). 안정위에서전완부를회전한상태로장상지석고부목 (long arm splint) 를수술후 2주간착용한뒤장상지석고붕대 (long arm cast) 를 2주간, 그리고필요시단상지석고붕대는 2주간추가적으로착용한다. 이후탈착이가능한보호대를 2주간 활동시착용한다. 능동적완관절운동은수술후 4-6주지나서시작하며수술후 12 주까지는완전한관절운동회복을목표로한다. 스포츠활동은적어도 16주는지나허용한다. 결과 TFCC type 1B 손상을단독으로한관혈적봉합술의결과는아직까지보고된예는없지만일반적으로 TFCC의관혈적봉합술의결과는만족할만하다. Hermansdorfer와 Kleinman 6 은관혈적 TFCC 봉합술과척골경상돌기골절불유합원위단의제거수술을통하여 80% 에서만족할만한결과를얻었다고하였으며, 20% 의불만족스러운결과는척-수근관절의퇴행성변화가있는경우였다고하였다. Cooney 등 7 은 33 예의관혈적 TFCC 봉합술의 Mayo modified Wrist Score (MMWS) 를통한분석에서 11예에서탁월 (excellent), 15예에서우수 (good), 6예에서양호 (fair), 1예에서불량 (poor) 한결과를보고하였으며, 33예중 17예에서척골의절제성형술을추가적으로시행하였다고하였다. Anderson 등 16 도39 예의관헐적 TFCC 봉합술의 MMWS 를이용한분석에서 17예의탁월, 9예의우수한결과를발표하였다. Nakamura 등 8 은 TFCC 기시부손상에대해서관헐적방법과관절경적봉합술의결과를보고하였는데, 관헐적봉합술의결과는 66예중탁월 56 예, 우수 6예, 양호 2예, 불량 2예였으며, 관절경적봉합에서급성기치료한결과가좋았던것과는달리손상된시점 (acute, subacute, chronic) 에따른결과의차이는보이지않았다고보고하였다. 저자들도 6개월이상추시가능하였던 8 예에서 MMWS와 disability of the arm, shoulder and hand (DASH) score 가수술전 42.7 및 38.1.4에서수술후 82.5 및 13.4로향상된결과를얻었다 (Figs. 2, 3). 결론 완관절부의척측통증의흔한원인인 TFCC 손상중 type 1B는수술적치료의좋은적응증이며그결과도좋은것으로알려져있다. 최근에는관절경술기및장비의발달로인하여, 관혈적인수술법보다비교적수술이환도가낮은관절경적치료가많은정형외과의사들에게선호되는치료법으로받아들여지고있지만많은경험과기술적술기를요한다. 하지만관혈적인접근법은다른척측병변을동반하거나 TFCC 자체의복합적손상의경우, 또는과도한척골양성소견으로척골단축술이필요할경우는관절경적방법보다우선적으로선택될 90 http://www.jkssh.org/
In Hyeok Rhyou, Open Repair of Triangular Fibrocartilage Complex Type 1B Tear Fig. 2. Case of patient presenting with persisted ulnar side wrist pain after the initial injury 5 years ago. (A) Dorsal subluxation of the ulnar head (black arrow) on the lateral view of simple radiographs was found. (B) The detachment of deep fiber of triangular fibrocartilage complex (TFCC) from the ulnar fovea (pink arrow) was observed in coronal view of magnetic resonance imaging scans. (C) Slight restriction of the pronation was seen. (D) During the arthroscopic examination, synovitis around the prestyloid recess was found with the loss of the tension of the TFCC (positive trampoline test) and traction induced inward folding of the TFCC from the ulnar fovea (positive Hook test). Other combined injuries did not accompany. TFC, triangular fibrocartilage; C, capitate; H, hamate; L, lunate; T, triquetrum. (E) Open repair of the deep fiber of TFCC to the original ulnar fovea (black arrow) was done using the transosseous suture technique. (F) The reduced state of the preoperatively subluxated ulnar (pink arrow) head was seen on the follow-up radiographs taken at five years after operation. (G) Functional outcomes measured by Mayo modified wrist score and disability of the arm, shoulder and arm score improved from 55 preoperatively to 100 postoperatively and 35 to 3.3, separately. http://www.jkssh.org/ 91
J Korean Soc Surg Hand Vol. 19, No. 2, June 2014 Fig. 3. Case of patient presenting with persisted ulnar side wrist pain after the initial injury 6 months ago despite of the initial conservative management using long arm cast for 4 weeks. (A) Except the finding of the interpositional arthroplasty of fourth and fourth carpometacarpal joint of the right side (pink arrow), specific finding was not found around the ulnar head (pink circle). The detachment of deep fiber of triangular fibrocartilage complex (TFCC) from the ulnar fovea (pink arrow) was observed in coronal view of magnetic resonance imaging scans (B) and computed tomography arthrogam (black arrow) (C). (D) Slight restriction of the volar and dorsiflexion was seen preoperatively. (E) During the arthroscopic examination (black arrow), synovitis (black arrow) around the prestyloid recess was found with the loss of the tension of the TFCC (positive trampoline test) and traction induced inward folding of the TFCC from the ulnar fovea (positive Hook test). Other injuries of the capitohamate instability and lunotrique - tral instability accompanied. TFC, triangular fibrocartilage; C, capitate; H, hamate; L, lunate; T, triquetrum. (F) Open repair of the deep fiber of TFCC to the original ulnar fovea was done using the transosseous suture technique. (G) On the intraoperative fluoroscopic examination, well-positioned screws at the lunotriqetral and capitohamate joints was observed with the temoporary fixation of the distal radioulnar joint using two 2.0 mm K-wires. (H) Solid union of the lunotriquetral and capitohamate joints was seen on the simple radiographs taken at seven months after operation. (G) Functional outcomes measured by Mayo modified wrist score and disability of the arm, shoulder and hand score improved from 55 preoperatively to 99 postoperatively and 28.3 to 15, separately. (I) Near full range of motion except the slight limitation of the volar flexion was recovered. 92 http://www.jkssh.org/
In Hyeok Rhyou, Open Repair of Triangular Fibrocartilage Complex Type 1B Tear 수있을것으로생각된다. REFERENCES 1. Stuart PR, Berger RA, Linscheid RL, An KN. The dorsopalmar stability of the distal radioulnar joint. J Hand Surg Am. 2000;25:689-99. 2. Gofton WT, Gordon KD, Dunning CE, Johnson JA, King GJ. Soft-tissue stabilizers of the distal radioulnar joint: an in vitro kinematic study. J Hand Surg Am. 2004;29: 423-31. 3. Palmer AK. Triangular fibrocartilage disorders: injury patterns and treatment. Arthroscopy. 1990;6:125-32. 4. Hagert E, Hagert CG. Understanding stability of the distal radioulnar joint through an understanding of its anatomy. Hand Clin. 2010;26:459-66. 5. Estrella EP, Hung LK, Ho PC, Tse WL. Arthroscopic repair of triangular fibrocartilage complex tears. Arthroscopy. 2007;23:729-37, 37 e1. 6. Hermansdorfer JD, Kleinman WB. Management of chronic peripheral tears of the triangular fibrocartilage complex. J Hand Surg Am. 1991;16:340-6. 7. Cooney WP, Linscheid RL, Dobyns JH. Triangular fibrocartilage tears. J Hand Surg Am. 1994;19:143-54. 8. 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;27:281-90. 9. Garcia-Elias M, Smith DE, Llusa M. Surgical approach to the triangular fibrocartilage complex. Tech Hand Up Extrem Surg. 2003;7:134-40. 10. Pederzini LA, Tosi M, Prandini M, Botticella C. Allinside suture technique for Palmer class 1B triangular fibrocartilage repair. Arthroscopy. 2007;23:1130.e1-4. 11. Atzei A. New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability. J Hand Surg Eur Vol. 2009;34:582-91. 12. Bain GI, McGuire D, Lee YC, Eng K, Zumstein M. Anatomic foveal reconstruction of the triangular fibrocartilage complex with a tendon graft. Tech Hand Up Extrem Surg. 2014;18:92-7. 13. Adams BD, Divelbiss BJ. Reconstruction of the posttraumatic unstable distal radioulnar joint. Orthop Clin North Am. 2001;32:353-63. 14. 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: 176-81. 15. Moritomo H, Masatomi T, Murase T, Miyake J, 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: 1955-63. 16. Anderson ML, Larson AN, Moran SL, Cooney WP, Amrami KK, Berger RA. Clinical comparison of arthroscopic versus open repair of triangular fibrocartilage complex tears. J Hand Surg Am. 2008;33:675-82. http://www.jkssh.org/ 93
J Korean Soc Surg Hand Vol. 19, No. 2, June 2014 삼각섬유연골복합체손상제 1B 형의관혈적봉합술 류인혁포항세명기독병원정형외과 외상성삼각섬유연골복합체손상의가장흔한형태인 plamer 분류제1B형의경우원위요척골관절의안정성이소실되고지속적인완관절척측부통증의원인이되고있다. 최근에삼각섬유연골복합체의해부학적구조가알려지고 ulnar fovea 에부착하는원위요척골관절인대의심부섬유가중요한역할을하고있다는사실이인정받으며파열된심부섬유를 ulnar fovea 에부착하고자하는노력이있어왔으며좋은결과를보고하고있다. 가장먼저시도된관혈적봉합술후관절경적술기의발달과함께여러술기가소개되고있다. 가장기본적인관혈적봉합술에대해여러논문고찰과함께수술시유의해야할사항에대해논문고찰과함께고찰해보고자한다. 색인단어 : 관혈적봉합술, 제 1B 형파열, 삼각섬유연골복합체 접수일 2014 년 5 월 15 일게재확정일 2014 년 6 월 5 일교신저자류인혁경북포항시남구포스코대로 351 포항세명기독병원정형외과 TEL 054-289-1765 FAX 054-289-1766 E-mail osdrrih@gmail.com 94 http://www.jkssh.org/