Dec. 02, 2025
A new surgical procedure to repair a triangular fibrocartilage complex (TFCC) injury along with an improved camera system at Mayo Clinic in Minnesota offers patients new options for this surgery. The procedure is called an arthroscopic inside-out transosseous technique or an "over-the-top" (OTT) triangular fibrocartilage complex repair. The name sounds like a superlative but instead physically describes the technique used to stabilize the patient's distal radioulnar joint.
TFCC wrist injury and development of the over-the-top TFCC technique
TFCC injuries are common, especially after a fall or a twisting injury to the wrist in sports such as tennis, golf, hockey and other stick-handling sports. Oftentimes, these injuries can be treated without surgery, and treatment may include above-elbow splinting, corticosteroid injections or platelet-rich plasma, followed by work with a certified hand therapist. Sometimes, however, surgery may be indicated, using many different approaches. At Mayo Clinic, surgeons have been working on a method that obviates some of the risks with conventional techniques, says Sanj Kakar, M.D., an orthopedic surgeon and sports medicine specialist at Mayo Clinic's Minnesota campus.
Compared with some TFCC injury repair techniques, the OTT procedure benefits patients in these ways:
- Faster completion.
- Less radiation exposure.
- Less fracture risk.
- Predictable suture placement.
During an OTT procedure, an arthroscope is placed within the wrist joint to ascertain the extent of the injury. The TFCC is assessed by four key maneuvers, including:
- Trampoline test.
- Hook test.
- Suction test.
- Arthroscopic examination of the distal radioulnar joint (DRUJ).
Many times, the tear of the TFCC is within the fovea and may not be seen until the arthroscope is placed within the DRUJ. This can be difficult with traditional arthroscopes, says Dr. Kakar. However, using a smaller, more flexible camera system has allowed him to diagnose and treat these tears more predictably.
"Sometimes, MRI scans may miss these injuries," says Dr. Kakar. "So having a camera system to allow us to directly view the foveal insertion of the TFCC has been a game changer."
Once the injury has been confirmed, the foveal footprint is debrided to healthy bleeding bone.
Under direct vision, the surgeon places the sutures over the top through the TFCC and bone, providing a secure repair.
In this way, the surgeon can direct the stitches where they are needed without creating a bone tunnel within the ulna, which can be technically challenging and risk fracture.
About TFCC wrist injuries
The mechanism for a TFCC wrist injury often involves trauma. This most frequently occurs in stick-handling athletes playing sports such as golf, tennis or pickleball. Yet, Dr. Kakar says when surgeons listen closely to their patients, they encounter TFCC wrist injuries unrelated to trauma. The injuries occur due to the aging process through repetitive tasks.
In the latter scenario, Dr. Kakar says patients recount stories such as, "I wasn't doing anything forceful and developed pain in my wrist as I was lifting."
Athletes with a TFCC injury may experience pain alone, pain with instability or pain with arthritis, leading to functional impairment with daily tasks such as washing one's hair or pouring water into a glass. They begin to mistrust their wrists and are unable to play to the level they would like without pain.
A patient with a TFCC wrist injury typically senses wrist pain with twisting motions such as unscrewing a jar lid or opening a door, where the pain level may reach 7 to 10 out of 10, forcing the patient to stop the activity. At rest, however, the pain may be minimal.
Dr. Kakar says that a TFCC wrist injury is common yet confusing even for physicians, especially as a standard MRI cannot detect the tears characterizing this injury.
"This is often called 'the low back pain of the wrist' and can be like a black box," he says. "It's hard to diagnose and treat. There are many causes of ulnar-sided wrist pain, so a detailed history and physical examination is critical when seeing patients."
Why seek help with a TFCC wrist injury and Mayo Clinic referral
Dr. Kakar notes that patients with a TFCC wrist injury often "gut it out" initially, taking NSAIDs and using ice, heat and over-the-counter splints.
When patients seek help for this injury, consider referring them to a Mayo Clinic wrist specialist. Mayo Clinic has been a leader in ulnar wrist pain with a deep-seated clinical and research interest and expertise over many decades, notes Dr. Kakar. He suggests calling his medical administrative assistant at Mayo Clinic in Minnesota at 507-284-3664 to refer a patient.
Awareness of TFCC injuries increasing
Dr. Kakar notes that he and his team's work on the OTT procedure and the new camera system has prompted them to look for TFCC injuries more frequently. Working with researchers such as Kristin D. Zhao, Ph.D., M.S., a Mayo Clinic investigator in physical medicine and rehabilitation, and physiology and biomedical engineering, they continue to expand their appreciation of these injuries and treatments continue to evolve.
"We've come a long way in our understanding of these injuries and continue to look at better ways to diagnose and treat them," says Dr. Kakar.
He notes he is glad the injury is being detected more often so it can be repaired, and patients can be restored to their regular activities without pain.
For more information
Refer a patient to Mayo Clinic.