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Topics in Hand Surgery-Fellowship Debate Series Wrist Arthroscopy: What You Should Know and Pearls From The Masters
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Topics in Hand Surgery-Fellowship Debate Series Wrist Arthroscopy: What You Should Know and Pearls From The Masters
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Segment:0 .
JEFF YAO: I want to welcome everybody back to Hand Fellowship Virtual Debates. We have a brand new fellowship class 2020, 2021. Hope you're all doing well.
JEFF YAO: And this is something we started back in March during the middle of COVID to try and look for ways of enhancing the fellowship education and also really just increasing collaboration and education across institutions and really trying to create a platform for us to share ideas and also for the Fellows to really build that collegiality.
JEFF YAO: I really want to thank everybody for supporting us, and for all the faculty, for making this happen. So traditionally the format has been really a fellow versus fellow, more of a face off. We had a couple of cage matches with four different programs going at it. And I think it's been a great way to a little bit of playful banter and also learn off of each other.
JEFF YAO: And the Fellows last year certainly did a phenomenal job and set the bar very high. But as this is the beginning of the year, we thought it might be a little bit tough to throw them back into the ring right away and kind of get their feet wet and get used to their fellowship and give some knowledge of training under their belt before going into the cage match. So instead, we're very excited to welcome the professors who are going to be educating the forum today on wrist arthroscopy.
JEFF YAO: We're going to be starting off with Dr. Osterman from the Philadelphia Hand center, followed by Dr. Goldfarb from Wash U, Saint Louis, and the anchor will be Dr. Kakar from the Mayo Clinic. So they're going to give us kind of a tour of wrist arthroscopy and looking at TFCC and offering the Fellows tour some pearls for both their fellowship and also as they go to practice a year from now. So as far as the format for the virtual debate middle of Covid, we're doing a once a week and everybody's going to be busy clinically.
JEFF YAO: We're going to be looking at the fourth Thursday of every month. Once we get a more firm schedule in place, we'll email this out to all the programs and program directors across the country. So the next one will also be more of a didactic session by the faculty in September just to get the Fellows used to it. And the virtual debates will be starting back up at the end of October
JEFF YAO: as far as a fellow versus fellow format and really, you know, please share this with your colleagues at other institutions as well and also other Hand Fellows. Really encourage participation from as many programs as possible to really make this successful. And we're going to be hopefully going back to the cage match in a couple of months again. As far as wrist arthroscopy, I think this has really come a long way.
JEFF YAO: It was first really popularized by Terry Whipple, his paper in arthroscopy in 1986, talking about wrist arthroscopy as a very promising new technique for evaluation of wrist pain and dysfunction is really a diagnostic tool. Back then, not a lot of techniques for repair or reconstruction, and these words by Dr. Whipple with further miniaturization of precision equipment and refinement of techniques, we expect those modalities to emerge as an important clinical tool for treatment as well as diagnosis of wrist disorders.
JEFF YAO: And certainly our faculty panel will be able to discuss some of the pearls they have and also how they expand the wrist arthroscopy into their clinical practice. As far as initial indications of wrist arthroscopy that most of our Fellows will learn to do throughout the year is looking at a diagnostic wrist arthroscopy, looking at TFCC pathology, scapholunate, lunotriquetral and also looking at articular cartilage defects, looking at the best treatment option for various conditions and also arthroscopic TFCC techniques
JEFF YAO: and Dr. Osterman will be going over. As you become more and more advanced throughout your training also practice, you'll venture into disarray and scaphoid fracture fixation and potentially looking at scaphoid non-union, doing everything arthroscopically, including bone grafting. I know Doctor Kakar has looked at doing arthroscopy for scapholunate as well.
JEFF YAO: And then potentially doing a intercarpal fusion with arthroscopic guidance. So certainly a huge growth across the world, looking at wrist arthroscopy as a community and as a society. This is a course by Dr. Atzei and also Lucchetti these passed about a year ago, from zero to hero, looking at arthroscopy and the powers and potential techniques, and innovations of wrist arthroscopy. So now I'm going to pass it off to our esteemed faculty going over wrist arthroscopy portals, anatomy, arthroscopic peripheral TFCC repair techniques, looking at central and radial tears, open techniques, foveal repair arthroscopically and also look into split tear.
LEE OSTERMAN: So my charge really is to talk about anatomy, arthroscopy and ulnar wrist pain. I really don't have anything that's relevant to the topics tonight. Well, when I was starting fellow in resident, ulnar wrist pain was one reason people didn't go into hand Surgery. It was considered the low back pain and you didn't have much action. It was right up there with global warming in terms of controversy about what we do.
LEE OSTERMAN: And part of the problem with the wrist is it's a complex joint with all the carpal bones, articulations and ligaments that you see in a complex space with nerves and tendons and arteries surrounding it. And when we look at the wrist, it has to be both mobile, it has to provide stability and it has to be able to transfer the loads across that area. When I think about the wrist, I think in a sense, divide it into the radial side of the wrist and the ulnar side of the wrist.
LEE OSTERMAN: Not being too sexist. The radial side of the wrist, I think, is the power. It basically bears 80% of the load and it's relatively simple. Now, that doesn't mean that scapholunate repair is a simple or predictable result, but at least we understand it. We may not be able to solve it. By contrast, the ulnar side of the wrist is involved with balance and versatility and is complex.
LEE OSTERMAN: In fact, if we look at our inheritance genetically, we always talk about the opposable thumb as differentiating lower species from man and ape. But in fact, the ulnar wrist liberation, where essentially the wrist has receded from the carpus, which has allowed us 180 degrees of rotation, it's improved the versatile motions that we have, and that may be as defining an achievement of evolution as, in fact, we have.
LEE OSTERMAN: If we look at the ulnar side of the wrist, there are 112 diagnoses that often challenge us. We can look at mechanical problems, soft tissue problems, which range from certain arthritis, to certain ligament lesions. Tonight we're really going to spend time on the TFC, ulnar extrinsics and ulnar impaction. Well, the TFC is a classic structure that defines the radiocarpal joint, separating it from the distal radioulnar joint.
LEE OSTERMAN: It has its origin in the foveal base of the ulnar styloid and a superficial insertion to move towards the radius, inserting it the articular margin. If we look at the TFC proper, it's thin in the center and volarly and dorsally it's defined by dorsal and volar, radial ulnar ligaments. If we look mechanically, the center portion of the ligament has no nerves and very few vessels and therefore very little healing potential.
LEE OSTERMAN: By contrast, the peripheral more ligamentous portion has nerve fibers proprioceptors etc. Michael Bednar, when he was a fellow, did an elegant study as seen here looking at the vascularity of the TFC and showed the peripheral portions were well vascularized. The central and radial portions were not. We also now understand that the TFC has two insertions, one superficial and the deep fibers which insert at the foveal area.
LEE OSTERMAN: Dick Berger and the Mayo Clinic defined what happens when you section this. It gives its instability, whereas superficial TFC tears very seldom result in instability and changes occur when we lose that foveal connection. Again, this was an area of controversy which I think Bill Kleinman really helped define by showing that the TFC and its fibers really divide into superficial and deep fibers.
LEE OSTERMAN: The deep fibers have a much more obtuse insertion such that they cover more of the stability of the edges of the distal radioulnar joint. The superficial fibers come in more of an acute angle for this. He had this wonderful illustration of thinking of the deep so-called ligamentum subquantum fibers as really being the outrigger guides for your team of horses and the TFC superficial fibers as helping to guide the central portion, keeping everybody on track.
LEE OSTERMAN: Andy Palmer defined the triangular fibrocartilage really is a complex and in that he included the ulnocarpal ligaments. These are the ulno, lunate and ulnar triquetral ligaments which we can see arthroscopically and are easily defined. The key point is that they are stabilizers of the ulnar carpus from supination, they are not stabilizers of the distal radioulnar joint, but they can clearly be seen here in a normal thing with the TFCC in the lower portion, the two ulno lunate and ulno triquetral and the posterior and the prestyloid recess.
LEE OSTERMAN: The function of the TFC. It extends the gliding surface of the radiocarpal joint. It acts as a cushion and helps stabilize with its attachment through the ulnar extrinsic the ulnar carpus and stabilizes the distal radioulnar joint. Again, Palmer and crew defined that if you can take out the central two thirds of the CFC, you have no change in mechanical bearing at the distal radioulnar joint.
LEE OSTERMAN: The mechanism of injury is usually a fall on the outstretched hand with the wrist extended and the forearm pronated, but it isn't as obvious as this obvious open dislocation is. So when you're doing your ulnar wrist pain workup for the TFC remember history, remember a physical examination? Remember provocative, provocative maneuvers. I always test grip strength and find that helpful.
LEE OSTERMAN: Sometimes trial injection and then imaging and arthroscopy. Certainly physical examination is the key to, I think, a lot of understanding the wrist. Make sure that you look for asymmetry and tenderness between the two wrists, perform a TFC test et cetera. So if you're looking, you want to be able to isolate distal radioulnar joint pain from TFC pain which is dorsal, from foveal pain which is just over the pisiform.
LEE OSTERMAN: You can also do a TFC stress test where you're going to take the wrist and ulnar deviation and either rotate the wrist or move the ulnar up and down, generating a click, which if it is symptomatic and produces the pain of the patient, will tell you that you're probably in the right neighborhood. When it comes to imaging, plain X-rays should include comparison views, grip loaded views, and often you will see something like positive ulnar variance with the so-called lunate impaction lesion.
LEE OSTERMAN: Arthrography has gone by the boards, but it was often a good way to find the tear. And certainly wrist MRI became the standard which we all use. And MRI is sensitive to central tears. It is less sensitive, however, to peripheral TFC tears, both superficial, both superficial and foveal and ulnar extrinsic tears. One pearl, I would say, is that 90% of ulnar wrist pain is ulnar.
LEE OSTERMAN: 50% of radial wrist pain has an ulnar origin. And third, not all ulnar wrist pain is caused by the TFC. Remember that as we age, we get a wear related perforation in the TFC, in fact, in this illustration from a German textbook on normal anatomy shows a classic TFC tear, and when you get to my age, i.e. past 50, 50% of us have an asymptomatic TFC tear. So here is a patient sent to me with a positive MRI for a central TFC tear.
LEE OSTERMAN: And when you scope it, there certainly was a central TFC tear. But as we use that ulnar wrist arthroscopy portal, we find the real problem is the lunate chondral lesion where there's been a shear across the lunate. So wrist arthroscopy has come into its own. It basically allows us to look both diagnostically and therapeutically. It augments the MRI, some would argue replaces it.
LEE OSTERMAN: It certainly replaces arthrography. It allows us not only to evaluate joint reaction, which I believe gives us clinical relevance for what we're seeing, but also to treat it therapeutically. It is, however, become the diagnosis and treatment of TFC lesions and a gold standard way. If you in fact hit an internet search and arthroscopic TFC treatment, in about half a second, you get 60,000 references on the treatment of TFC's.
LEE OSTERMAN: Arthroscopy using small scopes.
LEE OSTERMAN: My favorites are the 2.7 and a 1.9, and traction is needed to separate the carpal bones. You then need a probe which acts as your finger to look at ligament stability to elevate the TFC tear. And we have a number of instruments very similar, just downsized from knee and shoulder arthroscopy. We have probes which allow us to do synovectomies and clear the area.
LEE OSTERMAN: We have shavers, we have shrinkage devices which work in the wrist because of immobilization, where they didn't work in other joints. In looking into the wrist, most of the portals and gateways to the wrist are defined dorsally. We have essentially the workhorse, which is defined between the extensor tendon compartments and here the third, fourth between the EPL and the common extensors defines the workhorse portal.
LEE OSTERMAN: We then have accessory portals, be it the excuse me, the 6-R interval, the 4-5 interval, 1-2 and we even have a volar portal when necessary. We can also scope the radial, the midcarpal joint through radial and ulnar midcarpal portals classically, but we have accessory portals there and when necessary, though often not used, we can look in the distal radioulnar joint.
LEE OSTERMAN: So here we have a relatively normal 3-4 view. You see the radial extrinsic ligaments, the RSL, SL and the long radial lunate ligament, scaphoid above. As we look at the scapholunate, you see the ligament of Testu,t the lunate is now in phase. We see the short radial lunate ligament as we come on the ulnar side, the probe coming in from the 6-R, we do have a very thin degenerative TFC tear with a positive ulnar variant in this a patient.
LEE OSTERMAN: And you get a fairly good view, as you can see, of the radiocarpal joint, but because of its c-shaped nature, you do need for complete accuracy to do an ulnar portal because you can't look directly at the pisotriquetral joint, the LT ligament. For that you need an ulnar radiocarpal portal. Here we're looking at the ulnar extrinsic ligaments, the LT interval.
LEE OSTERMAN: As we advance in further, we'll be able to see a normal pisotriquetral joint, as you can see here, as we come back, you'll see the ulnar extrinsics again and our LT. And then we can look back radially, seeing the scapholunate ligament going up to the dorsal capsule where ganglions originate. One thing that I teach is you should always scope the midcarpal joint.
LEE OSTERMAN: It would be like doing a knee scope without looking at the patellofemoral joint. I think it is the key to defining carpal instability, which is the subject of another talk. But there are also the ability to look at stability of the wrist, there are conditions in the midcarpal joins, such as ulnar impaction or triscaphe arthritis, which are causes of wrist pain and can be identified there. As we enter the sort of radial midcarpal joint.
LEE OSTERMAN: You can see the lunate below, the classic lunate, the classic capitate. We come up the scaphoid, which is where you would define a scaphoid fracture. And as we fight through a little bit of synovitis and air bubbles, we can generally pop in to a very nice trapezium and trapezoid view of the triscaphe joint. Using an arm and looking ulnarly, we can again define this as a type 2 lunate, our probe is in the ulnar midcarpal joint.
LEE OSTERMAN: We have the capitate to the left. We have the lunate at the base. The probe is in the LT interval, which is stable, there is a small type 2 lunate. We see that little triangular area, which is the ulnar fat pad. And as we move, ordinarily we'd be able to see the proximal pole of the hamate. In interests of time, I'm going to move on.
LEE OSTERMAN: When we're doing diagnostic arthroscopy, we can look at the type and size and shape of the defect, whether it's traumatic, whether it's fibrillated, like a degenerative change. We can in fact, look at the amount of synovitis, which is a thing, so often is because of the commonness of a TFC. It may not be the cause of pain so look for the synovitis and look for the chondromalacia.
LEE OSTERMAN: We also again using our probe evaluate when the LT is intact and when it's not, and when the ulnar extrinsic ligaments are intact. Andy Palmer I've mentioned several times, early on did a very nice division of TFC injuries dividing into traumatic and degenerative. Relative to the traumatic, he defined essentially four types; one a central perforation which can be both degenerative and/or traumatic, a 1B, which is an avulsion from either superficial fibers or from the deep foveal area.
LEE OSTERMAN: A distal 1C, which we now tend to think of as anulnar extrinsic lesion and a radial avulsion. If we look at these here, you can define each one will have a different treatment. I should emphasize that there's still a place for non-operative treatment of traumatic injuries. You can do a mobilization, usually a sort, a short arm splint for me or a long, short arm splint.
LEE OSTERMAN: A Munster. Rarely a cortisone injection and restriction of activity. After three to four months however, I think that that strategy falls by the wayside. So the surgical indications are symptomatic and impairing ulnar wrist pain that is failed months of non-operative care and a valid wrist examination. If we look at the 1C or excuse me, the 1A, it's going to be in the central portion.
LEE OSTERMAN: Here's our MRI. And here looking from the 3-4 portal ulnar right wrist, our radial extrinsics again, so you've noticed that, there's our proximal volar hamate again, as we start to move the ligament of Testut to the kind of humping end of the SL, the lunate, the lunate facet. Our probe is from the 6-R portal. We're now going to see the TFC, which has that sort of bucket handle tear.
LEE OSTERMAN: You'll notice that if it were intact, you would have to use your probe to define where the TFC ends and where the articular surface begins. We can now then come in with a suction punch blade and begin just like you do a peripheral meniscus tear in the knee to debride this back to a smooth edge. Some people have questioned why does making a smaller hole bigger seem to work? The current theory is that the lesion catches and puts traction on the peripheral portions which are well innervated of the TFC.
LEE OSTERMAN: But doing this you can see the underlying negative distal ulnar, we have not changed the mechanics of the wrist. The outcome of central TFC debridement about 85% in our series that we followed for 7.5 years for traumatic 1A lesions. When we come to the peripheral TFC, there are really two types that we're not really emphasized in Andy's classification as well, but one essentially is a superficial avulsion from the ECU subsheath and surrounding capsule and the other is the foveal insertion, which is often associated with significant instability.
LEE OSTERMAN: Lindau and Etsai and others have defined these two and it is absolutely important to tell because if you do a capsular repair in a foveal avulsion, you will have a failed surgery. I think it is absolutely important to remember that the peripheral TFC is in intimate contact with the ECU subsheath. And therefore, I think it is absolutely important to remember something that Charlie Melone taught us, again almost 20 years ago.
LEE OSTERMAN: He decided and proved in cadaver models that there is a sequential injury on the ulnar side of the wrist. You first start with an ECU sheath tear, you then have a peripheral TFC tear, you then have the ulnar extrinsic tears and finally an LT tear. And it often is sequential when you fall on the wrist and I always think of that,
LEE OSTERMAN: so whenever I have a peripheral TFC tear, first thing I want to do is to rule out a subluxing ECU subluxation. And that's one of the most common diagnoses that gets sent into me for somebody who's failed at TFC surgery. It's a fairly easy diagnosis to make, popping is fairly obvious. Peripheral TFC tears, as I mentioned, are not so obvious on an MRI, often with a good high Tesla magnet
LEE OSTERMAN: you may in fact get some increased signal in the area of repair but they don't leave a big hole like the central thing. You do when you explore them, often you will find that using your probe, you will sink into it like you're sinking into a feather duster or a cover on a bed, you'll be able to hide your probe. That's one clue that the tension in this TFC is not appropriate, and then you can follow it back to where the tear is.
LEE OSTERMAN: And so here we're looking from the 3-4, the probe is in the 6-R, the central portion of the TFC and it's juncture to the lunate fossa is intact. As we begin to move ulnarly, however in this patient with wrist pain, we start to see there's a little loss of trampoline. But as we move ulnarly, we can flip this TFC up and hide it. This is a superficial peripheral tear. It enlarges on the pre styloid recess, which is below.
LEE OSTERMAN: Remember that this lesion, unlike the central lesion, can repair itself because it has a great vascular supply. In a study we did looking in ganglions done arthroscopically but measuring using an internal Doppler, we showed and confirmed this data that Mike Bednar showed that the central portion is poor vascularization, the radial portion is poor. vascularization because the cartilage interface, but the periphery is well supported
LEE OSTERMAN: vascularly. There are a number of types for peripheral TFC repair that can be Out to In, they can be In to Out and classically we'll use some type of meniscal repair kit, similar to the knee using portals where we'll come through, grab the capsule, we'll bring sutures of 2-0 PDs and then restore the tension by tying using a wagon wheel fashion anywhere from 2 to 4 sutures,
LEE OSTERMAN: whatever it takes. The outcomes of peripheral TFC are 75% to 80%, good to excellent in a number of studies. One of the nicest studies was done by Estrella in 2007 and his results showed excellent in essentially 80% and failure rates in 20%. And as I sign off, our next speaker is going to address why we have such a failure rate. And so we now call in the cavalry of Dr. Goldfarb and Dr. Kakar.
LEE OSTERMAN: Thank you all.
CHARLES GOLDFARB: My assignment was to discuss central tears, radial tears impaction and open repair and I'll do that in a succinct way. Let me start with the case. Consider an 18-year-old male, left wrist pain for nine months. He's a high school senior and he's playing College baseball next year.
CHARLES GOLDFARB: Symptoms began with one swing of the bat. Pains ulnar sided, no mechanical symptoms. A steroid injection completely relieved his symptoms for about three months. And then when he went back and started playing baseball again, his symptoms returned. He has foveal pain on exam and we'll talk a little bit more about that. He has positive compression testing, his ECU and DRUJ are not part of the problem.
CHARLES GOLDFARB: His MRI, which, as Lee said, might be helpful, especially with central tears, suggests something going on along the radial side of the TFCC as you can see here, foveal insertion looks good, which is not always apparent and so we felt he had a central TFCC tear with a stable DRUJ and due to his failure of non-operative care, we scoped his wrist. And to keep it very simple, I don't have any video for this.
CHARLES GOLDFARB: He did have a central tear. It was debrided as Lee said, and it's not clear why this works, but it does seem to work for most patients. And there was no secondary tear. A lot of times in this young patient population, a central tear can be associated with a secondary 1-B tear. Not in this case. So examination is crucial and it does provide a lot of information.
CHARLES GOLDFARB: The ulnar wrist is still considered a Black box, but the more you see, the more you examine with your attendings, I think the more clear it will become, although not always completely clear. So localization of pain. And this description of the fovea, which is just volar to the ulnar styloid is super helpful. We always test the DRUJ in all positions. Provocative tests for the TFCC are important, ruling out the ECU tendon both for tendinitis and for instability, and assessing the LT ligament are a key part of all of our examinations.
CHARLES GOLDFARB: MRI might be helpful, but it's not nearly as sensitive as arthroscopy. I don't perform many diagnostic wrist scopes, but they do play a part in most of our practices. Corticosteroid injections, I believe, are really reasonable, both for information gathering and occasionally they provide a long lasting answer if synovitis is the primary issue. Ultrasound helps for some as a diagnostic tool,
CHARLES GOLDFARB: not really in my practice. So Lee mentioned the Palmer classification, which has stood the test of time to a limited degree. There are more complex classifications which exist which actually provide more information, but I share this mainly because of what I'm going to discuss, which is the 1-A tear, which is the central tear and the 1-D tear, which is the radial tear, as well as classic degenerative tears.
CHARLES GOLDFARB: So this photograph, I hope, is helpful. So this is volar and this is dorsal and you can see the scaphoid facet of the distal radius, the lunate facet of the distal radius and this is the TFCC. So these are the ulnar carpal ligaments here and here and we are focused on really two types of tears for this part of the presentation this evening.
CHARLES GOLDFARB: A central acute tear and a radial sided tear and a degenerative tear, which is typically central as well. So the Palmer 1A tear, that is, the central tear can be acute more often is degenerative and as Lee suggested, debridement to a stable base is the treatment of choice. And trying to confirm this is the source of the discomfort is really important because you, as Lee said, up to 50% of people, once we get a bit older, will have a tear
CHARLES GOLDFARB: and it may not be the source of the symptoms. It's key to maintain the dorsal and volar contributions to stability, which really doesn't take much so debridement makes a lot of sense and here's another example of a debridement. The Palmer 1-D tear is something completely different. So this is the tear of the TFC off its radius insertion, and it has a poor vascular component, although probably has a bit of vascularity potentially
CHARLES GOLDFARB: so that makes it a little bit different from a central tear. And treatment is either debridement alone or repair and the repair techniques are not straightforward, and I think if you ask anyone, we would prefer to avoid repairing these, although certainly that is an option. There are different techniques and these include suture repair or suture anchor repair and this next depiction, which is actually taken from the Hand Surgeries recently released Pediatric Hand Trauma book, Kevin Little wrote a great chapter depicting Walter Short's technique of repairing radial side of TFCC tears.
CHARLES GOLDFARB: My problem with the repair of these, and I'd be interested to hear the panelists later if we have time, is I have a difficult time bringing the TFCC back to bone because typically it has retracted. So more conversation and these are rare, honestly. And so it's not a huge problem that we see on a daily basis, at least in my practice.
CHARLES GOLDFARB: Central degenerative tears are potentially a bigger issue in an aging population and so they don't always look as bad as I have depicted here. So this is a large central tear and you can see the head of the ulnar and you can also see a kissing lesion or really a massive lesion on the proximal lunate as well. So what do the radiographs look like and what does the MRI look like?
CHARLES GOLDFARB: Well, they can be subtle, even more subtle than this but this is a classic appearing proximal, ulnar aspect of the lunate with a long ulnar. So the radiographs need to be taken in a zero rotation configuration so shoulder abducted 90 degrees and you want to avoid pronation or supination because pronation and supination change the relative length of the ulnar.
CHARLES GOLDFARB: All MRIs are done in pronation, so the ulnar always looks a little bit longer. But you can see on this MRI depiction, the lucency or the edema within the volar and ulnar aspect of the lunate is a strong indication of impaction. So this is perhaps the most impressive ulnocarpal impaction that I've seen and you can see the rim of the TFCC. And this is before any surgery, any intervention was done on my part other than looking.
CHARLES GOLDFARB: And you can see the worn away head of the ulnar and you can see the complete absence of cartilage on the proximal lunate. So consider patient two. This is a 58-year-old right hand dominant male with ulnar sided wrist pain on the right, worse with activity, worse with playing hockey, and even bothersome with daily activities, including desk work.
CHARLES GOLDFARB: Radiocarpal injection helped him temporarily as well, so he had reasonable range of motion of the wrist. He had pretty much entire ulnar sided wrist pain with pain at the fovea as well as dorsal ulnar pain but again, the ECU did not seem to be the source of his symptoms and the DRUJ was stable. His radiographs demonstrated slight ulnar positive variance. In his MRI demonstrates again, a bit of edema in the proximal lunate and a TFCC tear.
CHARLES GOLDFARB: So again, I'm not going to play the video, but there was a large central tear, which was debrided and you can see this is looking from radial to ulnar. Dorsal is to the right, volar is to the left and you can see that despite the debridement, the TFCC is not tensioned. I didn't identify another specific tear because I don't mind debriefing the central tear and repairing a dorsal ulnar tear because I do believe it can be beneficial as long as the foveal insertion is not disrupted.
CHARLES GOLDFARB: So what do you do now? So you've debrided a large central tear. Is that enough? And you can also see the irregularity on the proximal ulnar aspect of the lunate. So what's next? So arthroscopic debridement in my mind is likely insufficient and so you have two options; an open ulnar shortening osteotomy, which will decompress the ulnar wrist.
CHARLES GOLDFARB: It also tensions the TFCC assuming the foveal insertion is intact and it can provide additional stability to the DRUJ. I really like this operation. I think it's one of the best and most satisfying operations that I do. And we can bring Warren into this conversation later because he's described an alternative method of shortening the ulnar.
CHARLES GOLDFARB: And then you have the wafer procedure, which can be done open or arthroscopic, which removes the distal aspect of the ulnar, which can decompress the ulnar wrist, but does not tension the TFCC and does not stabilize the DRUJ. So for me, nine times out of ten, I perform an open ulnar shortening osteotomy. I believe it serves my purposes and the needs of my patient well.
CHARLES GOLDFARB: I believe it heals in a reliable fashion. And while plate removal is a problem, probably only about one out of five patients requires plate removal from irritation, maybe even less than that. I would throw in a plug, especially in the adolescent patient. So in adolescent patients that have neutral to positive any positivity in the variance, I would strongly recommend considering ulnar shortening osteotomy at the same time. It's pretty interesting,
CHARLES GOLDFARB: there was really nothing in the literature three years ago and then the last three years, there's been three publications and one of these is ours, looking at adolescents and with TFCC repairs and looking at what happens and the requirement for secondary surgery, which is ulnar shortening. And the bottom line is it's quite common to need a secondary surgery in this population to shorten the ulnar because TFCC repair alone is often insufficient.
CHARLES GOLDFARB: Finally, a few slides on Open TFCC repair. So my question is, what's its role in 2020? And in my practice, its role is really limited and I'll show you why. So this is a classic paper, as Lee shared, Dr. Kleinman really did a lot to advance our understanding of the ulnar wrist. And this paper is a classic and really one of the better papers or the best paper describing positive results with open TFCC reconstruction with DRUJ instability.
CHARLES GOLDFARB: And so here's what it looks like and these are from one of my partners, Dr. Gelberman, who preferred and really was quite facile at open TFCC repair. So first of all, the approach is dorsal ulnar from the floor of the fifth and the exposure is wide. And so this is unbelievable everything that we can see, right? So you can see the TFCC, you can see the lunate and the triquetrum in a way that, you know, typically you don't see this.
CHARLES GOLDFARB: And then what we're demonstrating here is that there is no foveal insertion, the head of the ulnar is bare and so debridement and then drilling of a pathway and a suture repair of the TFCC down to the bone. And this really can be effective in stabilizing the DRUJ. But this is not a small surgery and Sanj is going to go over arthroscopic techniques to accomplish this same goal.
CHARLES GOLDFARB: So in my hands, open TFCC repair or reconstruction or I should say repair is not a big part of my practice. So I'll close by saying that for me, the main thing to focus on during your fellowship is understanding what a good clinical examination looks like and how it helps to focus your treatment. What I learned in my first few years of practice after my fellowship was to truly understand the arthroscopic anatomy.
CHARLES GOLDFARB: Also focus on that because there are subtleties to the arthroscopic anatomy that you won't pick up in a talk like this that are really important. Understand the benefits of ulnar shortening. I think it is a fantastic procedure that really deserves an important place in all of our practices. And the adolescent population may be somewhat different than patients as we age.
CHARLES GOLDFARB: So thanks to Jerry for organizing this and to Lee and Sanj for including me as well.
SANJ KAKAR: Thanks. Thanks Charles. So my role here is to talk about arthroscopic treatments. And just like Chuck did, and Lee will give you some case based examples and hopefully some nuggets of information. a big thank you, really, to Marty Boyer during his presidential year.
SANJ KAKAR: As many of you know, you know, he had planned a Fellows Boot Camp and so we were planning on doing a wrist arthroscopy course, but sadly, that got canceled. Thank you to Warren and Jerry for doing this and also thanks to chuck, Marc and Jeff Yao. A bunch of these videos that will show you and Chuck has shown is on HandE for your education if you don't get everything tonight.
SANJ KAKAR: So this is a patient that comes in to see me, avid tennis player, his whole part of retirement is to play tennis and he's 70. You may say, well, you know, choose something else, but this is what he wanted to do. So we treated him non-operatively, he had pain in the foveal region. His DRUJ was stable. The injection, I think, is a powerful tool for diagnostic and therapeutic purposes and also prognostic purposes.
SANJ KAKAR: So he got well, treated non-operatively, but the symptoms returned. So one of the things I think to pick up from on today's discussion is your clinical exam is key. If you look at a TFCC MRI, as Lee showed us, many patients have tears but are clinically asymptomatic. He was point tender over the ulnar and extrinsic ligaments. So in terms of ulnar wrist pain, we're not going to spend too much time on this
SANJ KAKAR: but there's a couple of real sort of mentors that I'd like to share their thought processes. One was Dick Berger, who spent really an incredible career talking about ulnar wrist pain, and he broke it into three concepts. Is there just pain? Is there pain with instability for example, a foveal tear, for example, or pain with arthritis such as DRUJ arthritis?
SANJ KAKAR: And it's important, I know these sound just pain, pain, pain, but they all have their subtle nuances and you have to delineate that with your history and physical examination. And Marc Garcia-Elias, who basically taught us about this four leaf clover algorithm that we'll talk about a little bit, breaking it down into key segments. So this patient, how did we treat this patient?
SANJ KAKAR: So there was no bony problem. His cartilage looked OK. Clinically, he was tender over the foveas so suggestive of a UT ligament split tear with a stable DRUJ. And as Lee mentioned, TFCC tears go hand in hand with the ECU, so you have to rule that out, he had a stable ECU. So this is his wrist arthroscopy. We'll spend a few minutes just going through the technical details.
SANJ KAKAR: So one of the things I think in doing your fellowship is to challenge do you do this wet or do you do this dry? There's many, many advantages of both, and I think you should be facile in doing both and make your own mind up. So for me, this is doing it dry. You can see the needle goes in the 3-4 portal, no need to insufflate the joint and then I tend to make transverse incisions.
SANJ KAKAR: I feel that they heal more cosmetically and you can just close these portals with steristrips, you don't need sutures. So 3-4 portal is made, wrist scope goes in and as Lee mentioned, you can see there's four marks for the midcarpal joint as well and I think that's critical, especially for instability issues.
SANJ KAKAR: So here we're making the 6-R portal and we're going to look to the ulnar side. This is the automatic washout technique. You can see there's a 10-CC syringe attached to the scope. This was really taught to us by Paco Del Penau, so you don't need fluid, but sometimes when you get in there, there's hematoma in the joint. And you can put a shaver in there and it makes a closed loop system and it irrigates the joint.
SANJ KAKAR: So for example, for distal radius fractures, it's very useful. So here you can see at a central TFCC tear, which we know about, but that was not the cause of his problem. For me, when I'm doing this arthroscopically, I look where the synovitis is, that's your key. So he had a central tear that we debrided at a loose little body
SANJ KAKAR: but the mistake is to stop here. That's not where his pathology is. And you have to go with your clinical examination and you'll see that there's this synovitis here. And so we're debriding the synovitis to really get to this ulnar extrinsic split tear. And Lee showed a nice picture showing there's a natural confluence between the ulnar lunate and the ulnar triquetral ligament.
SANJ KAKAR: But you can see as we're debriding the synovitis, there's that split tear and we, before we started, this was a little discussion we were having amongst ourselves is, is this a tear that has seen us more than we've seen it, seen it? And so here you can see we're debriding away and now you can see the extent between that split between the ulnar lunate and the ulnar triquetral ligament. And I think if you look for it, you'll find it more often than not, especially if they have tenderness there.
SANJ KAKAR: So now we'll make an incision to the volar aspect to the ECU from the mid hamate body to the ulnar styloid. And a little trick that Dick Berger taught me was when you spread, look for this little vein. There's a basilic vein there. And just deep to that is the dorsal sensory branch of the ulnar nerve so you can see I've got the pickups are holding the vein. And as I spread, there you can see one of the branches of the dorsal sensory branch of the ulnar nerve.
SANJ KAKAR: Once you found one branch, my experience is that there's often other branches and so you can see as I open up the pickup, there's an aberrant branch running from dorsal to volar. That's not the normal anatomy of the dorsal sensory branch of the ulnar nerve, but nevertheless, it's there. So here you can see I'm taking one branch of that nerve with the vein, and we'll put a vessiloop around there.
SANJ KAKAR: But the mistake here is now to stop and say you've got all the nerve. Spend a couple of minutes just looking and as I showed you and we'll grab it in this case, you'll see that there's a branch of the dorsal sensory branch of the ulnar nerve going, running in the wrong direction there but it's there. And the mistake is, if you catch that with your sutures, your patient will never be very happy.
SANJ KAKAR: So there's the nerve retracted out of harm's way, and this we're going to show is a simple outside to inside repair, just using meniscal mending needles. This is available to you on HandE so if you don't get it all tonight, you can still see it. So essentially, we're going to put the needles straddling that tear, so one goes to the radial side and one goes to the ulnar side and you're looking at directly with your scope.
SANJ KAKAR: And so now what you'll do is put a wire loop through one of the meniscal mended needles, and then essentially you put the what, the other needle into the wire loop. So there you can see the wire loop and the other needle comes into it, OK, and then you pull that wire loop taut. So now you have a system to shuttle your sutures. So now what we'll do is take the stylet out, that pink stylet, you'll see we'll remove from one of the meniscal menders needles.
SANJ KAKAR: And through that, you can pass a suture. I think it's dealer's choice, to be honest what type of suture you want to use? I use 2-0 PDS. Sometimes the knots can be a little bit proud but you do know with 2-0 PDS that eventually it will absorb and so it's reassuring that this is not a non-absorbable suture. So there you can see the suture comes in and then through your 6-R portal, you pass a grasper, essentially pull it out of your 6-R portal.
SANJ KAKAR: So we'll pull it out, we'll pull the needle out so you don't cut the suture and then we'll just pull that out, and then you'll just pull back on the other needle with the wire loop, and that'll be your suture. So this is a relatively straightforward outside to inside passage and you can see it's closing the tear.
SANJ KAKAR: But this patient actually needed two other sutures to close that down. In the interest of time, we'll just move on. Post-operatively they're managed for two weeks in a Sugar-tong splint and then a Munster cast for four weeks. And our therapy protocol is to start mobilization but start from the shoulder down. Most of our patients with ulnar nerve wrist pain have poor scapulothoracic conditioning and control
SANJ KAKAR: so we really work on the big muscles as well as the smaller ones. And this was a study out of our institution of just under 100 patients. Patients did well. Some did have some numbness of the dorsal central branch of the ulnar nerve which got better, so routinely I tell the patients it'll take about three months before that settles down.
SANJ KAKAR: One of the things I wanted to challenge today again with the Fellows is we're often taught that if an injury is acute, i.e. less than perhaps six weeks, it's repairable. Anything chronic, you should be thinking about a reconstruction and I actually don't think that's necessarily true. I think you have to judge the quality of the tissue. So if the tissue is like wet tissue paper, sure, it won't stand a repair, but if it is more robust, you can repair it.
SANJ KAKAR: And Lee showed the Palmer classification. This is a classification by Andrea Atzei that I urge you all to look at. It basically breaks it down into those that have excellent and poor healing potential from types 1 to 5. But it also shows you where your ligament injury is. So how do you test for foveal attachments? There's different tests that we'll go through very quickly.
SANJ KAKAR: So this is a hook test. So you'll see that the probe is coming from the 6-R portal and I can easily get it underneath the TFCC and lift it off the fovea so that that's a positive hook test. In terms of the trampoline sign, there's a natural buoyancy of the TFCC so when you push it down, it springs back up so that is normal trampoline sign
SANJ KAKAR: and you saw some cases earlier from Lee and Chuck how it was rather lax when you pressed down. The next one is the suction test and what this is doing is you turn on the suction and you can see how you can lift it off. And this is useful for not only foveal pathology, but also if there's a peripheral tear and it's scarred in. And so what you need to do now is take it down and then there's a natural laxity of the TFCC
SANJ KAKAR: but by using the suction test, you can grade if you've actually tried to restore some of that tension. And finally, DRUJ arthroscopy and I'm just going to spend a couple of minutes showing the power of DRUJ arthroscopy. This is how I used to do it and this is something I would not do anymore. I'm showing a proximal and distal DRUJ portal. There's a direct foveal portal.
SANJ KAKAR: And so here the needle has gone in the proximal DRUJ and this is blind. You're basically going in, you think you know where you're at. And this is when I used to do it wet. The problem with doing it wet is all that synovial hyperplasia just engorges and it blocks your view. Now this is the distal DRUJ portal which is proximal to the 4-5 portal,
SANJ KAKAR: but you'll see when the camera goes in, you're now trying to get your working portal and you're sort of sword fighting. There's not much room between your hands and the camera, so this is not something I would do. This is a much easier way where you keep your scope in the 3-4 portal. You put your needle underneath the TFCC and so you keep your scope in the 3-4 portal,
SANJ KAKAR: you see the needle under the TFCC. You then spread and then stick your scope in. So here you can see I'm laying the 3-4 portal. Oh, did that play? Let's just see when the 3-4 portal and the needle is underneath it so I know I'm exactly in the right spot. And so here you'll see this is just for demonstration purposes,
SANJ KAKAR: yes there's a central test, sonyou could scope through that. But once you put your needle in, you make an incision, you spread down on the ulnar head underneath the TFCC so you know you're exactly in the right spot and then you just take your cannula out and you stick it right there. So 100% of the time, you know you're in the right position. And so and that takes some of the guesswork out because sometimes you're in the right position, but you don't quite know it,
SANJ KAKAR: so you pull back, you can see the ulnar head below you. The foveal is on the right and the TFCC is above you. And then you can come from the volar side with a switching tack stick technique to bring in your shaver to debride underneath the TFCC. So you may say, OK, what's the clinical relevance of that? Is this truly Hocus Pocus? So look at this case.
SANJ KAKAR: So this is a child who comes in with a distal radius and ulnar fracture, either displaced. And our pediatric orthopedic colleagues did a great job. They reduced it, they pinned him and I think that looks pretty anatomic. So four months later, he's healed and he's getting on with life, and then 10 months I see him. So remember 10 months, a year out.
SANJ KAKAR: So he has gross instability of the DRUJ in neutral, pronation and supination. OK, so he's clearly unstable. This is his MRI. And look at the fovea. So too many eyes, the fovea actually looks pretty good and this is the MRI read saying that he may have had a small ulnar triquetral ligament tear,
SANJ KAKAR: well that's not going to cause that instability in the TFCC is otherwise intact. So going through that four leaf clover, four leaf clover algorithm, the bone looks good. There's no arthritis. The ECU is stable. Clinically, he probably has a foveal tear although remember the MRI was normal, so he had a negative trampoline sign and a hook test.
SANJ KAKAR: And so here the needle is now underneath the TFCC, remember, the camera is still in the 3-4 portal and now I'm underneath the TFCC. And as I come ulnarly, look at that, the foveal insertion is completely detached, it's not down there. And so you get a perfect view doing this dry. You don't need fluid insufflation. So now I make a little working portal just with a needle and then spreading.
SANJ KAKAR: And so now what we're doing is taking a curette to debris the footprint of where that foveal insertion needs to be. And then you shave this away because the key here is now you have to get this tissue to heal down to bone. Now, this is a different patient, but I just wanted to show you how you do a foveal repair. So there's the dorsal sensory branch of the ulnar nerve. You can see it trifurcate, find that nerve, a vessiloop goes around it, and now you make an incision volar to the ECU,
SANJ KAKAR: so the extensor retinaculum we're incising and we're volar to the ECU. We don't need to destabilize the ECU. This is a technique described by Wai Chen in Taiwan and works very well. And so now what we're doing is taking the shaver. This is the DRUJ portal, but you can work between the DRUJ and the 6-R portal, debriding all that scar tissue on the foveal insertion because we want that to heal down to bone.
SANJ KAKAR: So once I'm happy with the debridement, here we're doing an 0-6-2 k wire under oscillate mode and critically when you look at that, that is slightly dorsal. So the beauty of arthroscopy as Chuck mentioned is you can exactly see where that foveal insertion is. So you just back out the pin, lift your hand and the wire is going slightly more volar so it's a little bit moreanatomic and you can see it's just a few millimeters
SANJ KAKAR: but that makes a lot of difference when you're trying to get this anatomically reduced. So there it comes out slightly volar at its footprint. So now what I'll do is I'll take a probe and I'll make sure that I can move and mobilize the TFCC so that again, challenging that dogma, that at 10 months you cannot repair this. So here you can see we're pulling it, moving it to over. And then there's an 18 gauge needle with a 2-0 PDS looped, goes through the foveal tunnel.
SANJ KAKAR: You pull this out through the 6-R portal so you've got one loop of 2-0 PDs and that hole is big enough that actually you can put a second 18 gauge needle through with a looped 20 PDS, push it through and then grab that 2-0 PDS as it comes out through bone. So there we are, we're pushing it through. There's the needle and then we'll pull it out.
SANJ KAKAR: So now we have two loops of 2-0 PDS being pulled out through the 6-R portal. And so we'll cut one of he loops like there, and then you want to check which end goes with which. So we're just checking which end goes with which, and then what we'll do is take a 20 gauge needle with a 3-0 suture as a suture shuttle going through the capsule or the peripheral aspect of the TFCC. There you can see it comes through.
SANJ KAKAR: And then what we're going to do is use that suture to shuttle the other sutures through. So now what we'll do is grab the 6-R portal, grab that loop of 300 PDS, just pull that out and use that now to shuttle one of the limbs of the 2-0 PDS back through the capsule. So there you can see we're going to take one of the limbs of the 2-0 PDS, pull it through. So this stitch has gone through bone, through the fovea, through the TFCC and back out.
SANJ KAKAR: And in the interest of time, we'll just move on but this will be available to you and HandE. And so in that patient, we'll go back to that one, that kid who had that foveal disruption. You can see there, there's the sutures and this is him on the table. OK, I've taken the traction off and you can see just by tying the sutures, immediate stability has been restored. In terms of the literature, this just a couple of papers showing patients doing well with this technique.
SANJ KAKAR: This is up to four years follow up without any instability. So I think for me, in summary, the clinical exam is critical. The examination under anesthesia is key for me to really ensure that there's no foveal disruption. And if you're suspicious scope the DRUJ, it will tell you much more than an MRI would. Thank you very much.
JEFF YAO: Uh, Thank you so much, Lee, Sanj and
JEFF YAO: Chuck, that was phenomenal. Kind of a whirlwind tour through a wrist arthroscopy and TFCC. So a lot of great pearls for the Fellows and faculty. This is going to be on HandE for everybody who's on the conference right now on the webinar so we'll have a chance to view this later on. Any kind of last comments? Maybe one pearl from each faculty and for the interest of time, we'll kind of end the webinar just for the Fellows throughout the year.
JEFF YAO: Lee, Chuck and Sanj. As far as one pearl for Fellows going into arthroscopy this year.
LEE OSTERMAN: I'll start. I mean, I think in this year of your fellowship, one thing defines a hand surgeon from an orthopedic surgeon is in fact your ability to do wrist arthroscopy. In other words, when you go in your communities, when you're trained, it's often nobody can do wrist arthroscopy.
LEE OSTERMAN: So learning this technique this year will stand and put you above your peers who say, well, I can do carpal tunnel triggers, et cetera, but they can't do wrist arthroscopy with all its variations. And so I would spend time learning this technique. This year there are courses that will be offered in 2021 by the Hand Society so please take advantage of that.
CHARLES GOLDFARB: Yeah, that's exactly right. And I would add that, you know, the most important thing for me well, two things. One is correlate the MRI with your arthroscopic findings. Make it a habit to spend time with the MRI before a wrist arthroscopy and then after the wrist arthroscopy, go back to the MRI and make sure you understand what you saw. So that is just incredibly important and do it with your attending if you can convince them to do it.
CHARLES GOLDFARB: But if they don't want to do it with you, do it on your own. And then you just have to see a lot of wrist arthroscopies to get the subtleties of the anatomy. So just stay at it and you won't be done learning wrist arthroscopy when your fellowship is over.
JEFF YAO: That's such a great pearl Chuck. I think the MRI arthroscopy correlation, that's such a great kind of point to really try and do throughout the year and also throughout your practice.
SANJ KAKAR: Um, I would just say I would challenge your faculty to move from wet to dry. That's just my bias. And I can see Lee and Chuck and Warren and Jerry chuckling away and they may not want to, so go and do it in the lab. As Lee said, there will be courses next year and we will teach you this and you'll be amazed what you can do, doing it dry.
SANJ KAKAR: It will open up other avenues that you initially couldn't do, doing it wet so that would be my only sort of pearl to after this webinar.
LEE OSTERMAN: Again, just in closing, Sanj mentioned it a couple of times, but you all have access to HandE. Warren and his team have put many of the videos that you saw, many of the instructional lectures that you saw, and you can go and review those and see those.
LEE OSTERMAN: It is an absolute treasure trove of information. So every fellow, even more important than these monthly seminars should go to HandE. It's an absolute goal that you should do.
JEFF YAO: Right, any kind of comments? Warren? So Dr. Hammert's done a phenomenal job with both the videos and also the 50 lectures as well, the Hand 50. Any kind of closing remarks for the Fellows on board here Warren?
WARREN HAMMERT: I think just as they've said, you know, I'm the editor, so I'm biased with this, but I think there's a bunch of really good educational resources, not just on arthroscopy, but on hand surgery in general. So if you haven't spent some time looking at it, look at the Hand 50 lectures. I think that's one of the key series that was really developed for the Fellows. And there's a Fellow Shoe, which is a weekly email that comes out on with different topics.
WARREN HAMMERT: So sign up for those and take advantage of them.
JEFF YAO: All right. Well, hank you. Everybody stay safe and healthy out there. Again, we'll send a more complete schedule for the upcoming academic year to everybody and really appreciate your participation and all your great lectures. Thank you so much.
JEFF YAO:
Segment:0 .
JEFF YAO: I want to welcome everybody back to Hand Fellowship Virtual Debates. We have a brand new fellowship class 2020, 2021. Hope you're all doing well.
JEFF YAO: And this is something we started back in March during the middle of COVID to try and look for ways of enhancing the fellowship education and also really just increasing collaboration and education across institutions and really trying to create a platform for us to share ideas and also for the Fellows to really build that collegiality.
JEFF YAO: I really want to thank everybody for supporting us, and for all the faculty, for making this happen. So traditionally the format has been really a fellow versus fellow, more of a face off. We had a couple of cage matches with four different programs going at it. And I think it's been a great way to a little bit of playful banter and also learn off of each other.
JEFF YAO: And the Fellows last year certainly did a phenomenal job and set the bar very high. But as this is the beginning of the year, we thought it might be a little bit tough to throw them back into the ring right away and kind of get their feet wet and get used to their fellowship and give some knowledge of training under their belt before going into the cage match. So instead, we're very excited to welcome the professors who are going to be educating the forum today on wrist arthroscopy.
JEFF YAO: We're going to be starting off with Dr. Osterman from the Philadelphia Hand center, followed by Dr. Goldfarb from Wash U, Saint Louis, and the anchor will be Dr. Kakar from the Mayo Clinic. So they're going to give us kind of a tour of wrist arthroscopy and looking at TFCC and offering the Fellows tour some pearls for both their fellowship and also as they go to practice a year from now. So as far as the format for the virtual debate middle of Covid, we're doing a once a week and everybody's going to be busy clinically.
JEFF YAO: We're going to be looking at the fourth Thursday of every month. Once we get a more firm schedule in place, we'll email this out to all the programs and program directors across the country. So the next one will also be more of a didactic session by the faculty in September just to get the Fellows used to it. And the virtual debates will be starting back up at the end of October
JEFF YAO: as far as a fellow versus fellow format and really, you know, please share this with your colleagues at other institutions as well and also other Hand Fellows. Really encourage participation from as many programs as possible to really make this successful. And we're going to be hopefully going back to the cage match in a couple of months again. As far as wrist arthroscopy, I think this has really come a long way.
JEFF YAO: It was first really popularized by Terry Whipple, his paper in arthroscopy in 1986, talking about wrist arthroscopy as a very promising new technique for evaluation of wrist pain and dysfunction is really a diagnostic tool. Back then, not a lot of techniques for repair or reconstruction, and these words by Dr. Whipple with further miniaturization of precision equipment and refinement of techniques, we expect those modalities to emerge as an important clinical tool for treatment as well as diagnosis of wrist disorders.
JEFF YAO: And certainly our faculty panel will be able to discuss some of the pearls they have and also how they expand the wrist arthroscopy into their clinical practice. As far as initial indications of wrist arthroscopy that most of our Fellows will learn to do throughout the year is looking at a diagnostic wrist arthroscopy, looking at TFCC pathology, scapholunate, lunotriquetral and also looking at articular cartilage defects, looking at the best treatment option for various conditions and also arthroscopic TFCC techniques
JEFF YAO: and Dr. Osterman will be going over. As you become more and more advanced throughout your training also practice, you'll venture into disarray and scaphoid fracture fixation and potentially looking at scaphoid non-union, doing everything arthroscopically, including bone grafting. I know Doctor Kakar has looked at doing arthroscopy for scapholunate as well.
JEFF YAO: And then potentially doing a intercarpal fusion with arthroscopic guidance. So certainly a huge growth across the world, looking at wrist arthroscopy as a community and as a society. This is a course by Dr. Atzei and also Lucchetti these passed about a year ago, from zero to hero, looking at arthroscopy and the powers and potential techniques, and innovations of wrist arthroscopy. So now I'm going to pass it off to our esteemed faculty going over wrist arthroscopy portals, anatomy, arthroscopic peripheral TFCC repair techniques, looking at central and radial tears, open techniques, foveal repair arthroscopically and also look into split tear.
LEE OSTERMAN: So my charge really is to talk about anatomy, arthroscopy and ulnar wrist pain. I really don't have anything that's relevant to the topics tonight. Well, when I was starting fellow in resident, ulnar wrist pain was one reason people didn't go into hand Surgery. It was considered the low back pain and you didn't have much action. It was right up there with global warming in terms of controversy about what we do.
LEE OSTERMAN: And part of the problem with the wrist is it's a complex joint with all the carpal bones, articulations and ligaments that you see in a complex space with nerves and tendons and arteries surrounding it. And when we look at the wrist, it has to be both mobile, it has to provide stability and it has to be able to transfer the loads across that area. When I think about the wrist, I think in a sense, divide it into the radial side of the wrist and the ulnar side of the wrist.
LEE OSTERMAN: Not being too sexist. The radial side of the wrist, I think, is the power. It basically bears 80% of the load and it's relatively simple. Now, that doesn't mean that scapholunate repair is a simple or predictable result, but at least we understand it. We may not be able to solve it. By contrast, the ulnar side of the wrist is involved with balance and versatility and is complex.
LEE OSTERMAN: In fact, if we look at our inheritance genetically, we always talk about the opposable thumb as differentiating lower species from man and ape. But in fact, the ulnar wrist liberation, where essentially the wrist has receded from the carpus, which has allowed us 180 degrees of rotation, it's improved the versatile motions that we have, and that may be as defining an achievement of evolution as, in fact, we have.
LEE OSTERMAN: If we look at the ulnar side of the wrist, there are 112 diagnoses that often challenge us. We can look at mechanical problems, soft tissue problems, which range from certain arthritis, to certain ligament lesions. Tonight we're really going to spend time on the TFC, ulnar extrinsics and ulnar impaction. Well, the TFC is a classic structure that defines the radiocarpal joint, separating it from the distal radioulnar joint.
LEE OSTERMAN: It has its origin in the foveal base of the ulnar styloid and a superficial insertion to move towards the radius, inserting it the articular margin. If we look at the TFC proper, it's thin in the center and volarly and dorsally it's defined by dorsal and volar, radial ulnar ligaments. If we look mechanically, the center portion of the ligament has no nerves and very few vessels and therefore very little healing potential.
LEE OSTERMAN: By contrast, the peripheral more ligamentous portion has nerve fibers proprioceptors etc. Michael Bednar, when he was a fellow, did an elegant study as seen here looking at the vascularity of the TFC and showed the peripheral portions were well vascularized. The central and radial portions were not. We also now understand that the TFC has two insertions, one superficial and the deep fibers which insert at the foveal area.
LEE OSTERMAN: Dick Berger and the Mayo Clinic defined what happens when you section this. It gives its instability, whereas superficial TFC tears very seldom result in instability and changes occur when we lose that foveal connection. Again, this was an area of controversy which I think Bill Kleinman really helped define by showing that the TFC and its fibers really divide into superficial and deep fibers.
LEE OSTERMAN: The deep fibers have a much more obtuse insertion such that they cover more of the stability of the edges of the distal radioulnar joint. The superficial fibers come in more of an acute angle for this. He had this wonderful illustration of thinking of the deep so-called ligamentum subquantum fibers as really being the outrigger guides for your team of horses and the TFC superficial fibers as helping to guide the central portion, keeping everybody on track.
LEE OSTERMAN: Andy Palmer defined the triangular fibrocartilage really is a complex and in that he included the ulnocarpal ligaments. These are the ulno, lunate and ulnar triquetral ligaments which we can see arthroscopically and are easily defined. The key point is that they are stabilizers of the ulnar carpus from supination, they are not stabilizers of the distal radioulnar joint, but they can clearly be seen here in a normal thing with the TFCC in the lower portion, the two ulno lunate and ulno triquetral and the posterior and the prestyloid recess.
LEE OSTERMAN: The function of the TFC. It extends the gliding surface of the radiocarpal joint. It acts as a cushion and helps stabilize with its attachment through the ulnar extrinsic the ulnar carpus and stabilizes the distal radioulnar joint. Again, Palmer and crew defined that if you can take out the central two thirds of the CFC, you have no change in mechanical bearing at the distal radioulnar joint.
LEE OSTERMAN: The mechanism of injury is usually a fall on the outstretched hand with the wrist extended and the forearm pronated, but it isn't as obvious as this obvious open dislocation is. So when you're doing your ulnar wrist pain workup for the TFC remember history, remember a physical examination? Remember provocative, provocative maneuvers. I always test grip strength and find that helpful.
LEE OSTERMAN: Sometimes trial injection and then imaging and arthroscopy. Certainly physical examination is the key to, I think, a lot of understanding the wrist. Make sure that you look for asymmetry and tenderness between the two wrists, perform a TFC test et cetera. So if you're looking, you want to be able to isolate distal radioulnar joint pain from TFC pain which is dorsal, from foveal pain which is just over the pisiform.
LEE OSTERMAN: You can also do a TFC stress test where you're going to take the wrist and ulnar deviation and either rotate the wrist or move the ulnar up and down, generating a click, which if it is symptomatic and produces the pain of the patient, will tell you that you're probably in the right neighborhood. When it comes to imaging, plain X-rays should include comparison views, grip loaded views, and often you will see something like positive ulnar variance with the so-called lunate impaction lesion.
LEE OSTERMAN: Arthrography has gone by the boards, but it was often a good way to find the tear. And certainly wrist MRI became the standard which we all use. And MRI is sensitive to central tears. It is less sensitive, however, to peripheral TFC tears, both superficial, both superficial and foveal and ulnar extrinsic tears. One pearl, I would say, is that 90% of ulnar wrist pain is ulnar.
LEE OSTERMAN: 50% of radial wrist pain has an ulnar origin. And third, not all ulnar wrist pain is caused by the TFC. Remember that as we age, we get a wear related perforation in the TFC, in fact, in this illustration from a German textbook on normal anatomy shows a classic TFC tear, and when you get to my age, i.e. past 50, 50% of us have an asymptomatic TFC tear. So here is a patient sent to me with a positive MRI for a central TFC tear.
LEE OSTERMAN: And when you scope it, there certainly was a central TFC tear. But as we use that ulnar wrist arthroscopy portal, we find the real problem is the lunate chondral lesion where there's been a shear across the lunate. So wrist arthroscopy has come into its own. It basically allows us to look both diagnostically and therapeutically. It augments the MRI, some would argue replaces it.
LEE OSTERMAN: It certainly replaces arthrography. It allows us not only to evaluate joint reaction, which I believe gives us clinical relevance for what we're seeing, but also to treat it therapeutically. It is, however, become the diagnosis and treatment of TFC lesions and a gold standard way. If you in fact hit an internet search and arthroscopic TFC treatment, in about half a second, you get 60,000 references on the treatment of TFC's.
LEE OSTERMAN: Arthroscopy using small scopes.
LEE OSTERMAN: My favorites are the 2.7 and a 1.9, and traction is needed to separate the carpal bones. You then need a probe which acts as your finger to look at ligament stability to elevate the TFC tear. And we have a number of instruments very similar, just downsized from knee and shoulder arthroscopy. We have probes which allow us to do synovectomies and clear the area.
LEE OSTERMAN: We have shavers, we have shrinkage devices which work in the wrist because of immobilization, where they didn't work in other joints. In looking into the wrist, most of the portals and gateways to the wrist are defined dorsally. We have essentially the workhorse, which is defined between the extensor tendon compartments and here the third, fourth between the EPL and the common extensors defines the workhorse portal.
LEE OSTERMAN: We then have accessory portals, be it the excuse me, the 6-R interval, the 4-5 interval, 1-2 and we even have a volar portal when necessary. We can also scope the radial, the midcarpal joint through radial and ulnar midcarpal portals classically, but we have accessory portals there and when necessary, though often not used, we can look in the distal radioulnar joint.
LEE OSTERMAN: So here we have a relatively normal 3-4 view. You see the radial extrinsic ligaments, the RSL, SL and the long radial lunate ligament, scaphoid above. As we look at the scapholunate, you see the ligament of Testu,t the lunate is now in phase. We see the short radial lunate ligament as we come on the ulnar side, the probe coming in from the 6-R, we do have a very thin degenerative TFC tear with a positive ulnar variant in this a patient.
LEE OSTERMAN: And you get a fairly good view, as you can see, of the radiocarpal joint, but because of its c-shaped nature, you do need for complete accuracy to do an ulnar portal because you can't look directly at the pisotriquetral joint, the LT ligament. For that you need an ulnar radiocarpal portal. Here we're looking at the ulnar extrinsic ligaments, the LT interval.
LEE OSTERMAN: As we advance in further, we'll be able to see a normal pisotriquetral joint, as you can see here, as we come back, you'll see the ulnar extrinsics again and our LT. And then we can look back radially, seeing the scapholunate ligament going up to the dorsal capsule where ganglions originate. One thing that I teach is you should always scope the midcarpal joint.
LEE OSTERMAN: It would be like doing a knee scope without looking at the patellofemoral joint. I think it is the key to defining carpal instability, which is the subject of another talk. But there are also the ability to look at stability of the wrist, there are conditions in the midcarpal joins, such as ulnar impaction or triscaphe arthritis, which are causes of wrist pain and can be identified there. As we enter the sort of radial midcarpal joint.
LEE OSTERMAN: You can see the lunate below, the classic lunate, the classic capitate. We come up the scaphoid, which is where you would define a scaphoid fracture. And as we fight through a little bit of synovitis and air bubbles, we can generally pop in to a very nice trapezium and trapezoid view of the triscaphe joint. Using an arm and looking ulnarly, we can again define this as a type 2 lunate, our probe is in the ulnar midcarpal joint.
LEE OSTERMAN: We have the capitate to the left. We have the lunate at the base. The probe is in the LT interval, which is stable, there is a small type 2 lunate. We see that little triangular area, which is the ulnar fat pad. And as we move, ordinarily we'd be able to see the proximal pole of the hamate. In interests of time, I'm going to move on.
LEE OSTERMAN: When we're doing diagnostic arthroscopy, we can look at the type and size and shape of the defect, whether it's traumatic, whether it's fibrillated, like a degenerative change. We can in fact, look at the amount of synovitis, which is a thing, so often is because of the commonness of a TFC. It may not be the cause of pain so look for the synovitis and look for the chondromalacia.
LEE OSTERMAN: We also again using our probe evaluate when the LT is intact and when it's not, and when the ulnar extrinsic ligaments are intact. Andy Palmer I've mentioned several times, early on did a very nice division of TFC injuries dividing into traumatic and degenerative. Relative to the traumatic, he defined essentially four types; one a central perforation which can be both degenerative and/or traumatic, a 1B, which is an avulsion from either superficial fibers or from the deep foveal area.
LEE OSTERMAN: A distal 1C, which we now tend to think of as anulnar extrinsic lesion and a radial avulsion. If we look at these here, you can define each one will have a different treatment. I should emphasize that there's still a place for non-operative treatment of traumatic injuries. You can do a mobilization, usually a sort, a short arm splint for me or a long, short arm splint.
LEE OSTERMAN: A Munster. Rarely a cortisone injection and restriction of activity. After three to four months however, I think that that strategy falls by the wayside. So the surgical indications are symptomatic and impairing ulnar wrist pain that is failed months of non-operative care and a valid wrist examination. If we look at the 1C or excuse me, the 1A, it's going to be in the central portion.
LEE OSTERMAN: Here's our MRI. And here looking from the 3-4 portal ulnar right wrist, our radial extrinsics again, so you've noticed that, there's our proximal volar hamate again, as we start to move the ligament of Testut to the kind of humping end of the SL, the lunate, the lunate facet. Our probe is from the 6-R portal. We're now going to see the TFC, which has that sort of bucket handle tear.
LEE OSTERMAN: You'll notice that if it were intact, you would have to use your probe to define where the TFC ends and where the articular surface begins. We can now then come in with a suction punch blade and begin just like you do a peripheral meniscus tear in the knee to debride this back to a smooth edge. Some people have questioned why does making a smaller hole bigger seem to work? The current theory is that the lesion catches and puts traction on the peripheral portions which are well innervated of the TFC.
LEE OSTERMAN: But doing this you can see the underlying negative distal ulnar, we have not changed the mechanics of the wrist. The outcome of central TFC debridement about 85% in our series that we followed for 7.5 years for traumatic 1A lesions. When we come to the peripheral TFC, there are really two types that we're not really emphasized in Andy's classification as well, but one essentially is a superficial avulsion from the ECU subsheath and surrounding capsule and the other is the foveal insertion, which is often associated with significant instability.
LEE OSTERMAN: Lindau and Etsai and others have defined these two and it is absolutely important to tell because if you do a capsular repair in a foveal avulsion, you will have a failed surgery. I think it is absolutely important to remember that the peripheral TFC is in intimate contact with the ECU subsheath. And therefore, I think it is absolutely important to remember something that Charlie Melone taught us, again almost 20 years ago.
LEE OSTERMAN: He decided and proved in cadaver models that there is a sequential injury on the ulnar side of the wrist. You first start with an ECU sheath tear, you then have a peripheral TFC tear, you then have the ulnar extrinsic tears and finally an LT tear. And it often is sequential when you fall on the wrist and I always think of that,
LEE OSTERMAN: so whenever I have a peripheral TFC tear, first thing I want to do is to rule out a subluxing ECU subluxation. And that's one of the most common diagnoses that gets sent into me for somebody who's failed at TFC surgery. It's a fairly easy diagnosis to make, popping is fairly obvious. Peripheral TFC tears, as I mentioned, are not so obvious on an MRI, often with a good high Tesla magnet
LEE OSTERMAN: you may in fact get some increased signal in the area of repair but they don't leave a big hole like the central thing. You do when you explore them, often you will find that using your probe, you will sink into it like you're sinking into a feather duster or a cover on a bed, you'll be able to hide your probe. That's one clue that the tension in this TFC is not appropriate, and then you can follow it back to where the tear is.
LEE OSTERMAN: And so here we're looking from the 3-4, the probe is in the 6-R, the central portion of the TFC and it's juncture to the lunate fossa is intact. As we begin to move ulnarly, however in this patient with wrist pain, we start to see there's a little loss of trampoline. But as we move ulnarly, we can flip this TFC up and hide it. This is a superficial peripheral tear. It enlarges on the pre styloid recess, which is below.
LEE OSTERMAN: Remember that this lesion, unlike the central lesion, can repair itself because it has a great vascular supply. In a study we did looking in ganglions done arthroscopically but measuring using an internal Doppler, we showed and confirmed this data that Mike Bednar showed that the central portion is poor vascularization, the radial portion is poor. vascularization because the cartilage interface, but the periphery is well supported
LEE OSTERMAN: vascularly. There are a number of types for peripheral TFC repair that can be Out to In, they can be In to Out and classically we'll use some type of meniscal repair kit, similar to the knee using portals where we'll come through, grab the capsule, we'll bring sutures of 2-0 PDs and then restore the tension by tying using a wagon wheel fashion anywhere from 2 to 4 sutures,
LEE OSTERMAN: whatever it takes. The outcomes of peripheral TFC are 75% to 80%, good to excellent in a number of studies. One of the nicest studies was done by Estrella in 2007 and his results showed excellent in essentially 80% and failure rates in 20%. And as I sign off, our next speaker is going to address why we have such a failure rate. And so we now call in the cavalry of Dr. Goldfarb and Dr. Kakar.
LEE OSTERMAN: Thank you all.
CHARLES GOLDFARB: My assignment was to discuss central tears, radial tears impaction and open repair and I'll do that in a succinct way. Let me start with the case. Consider an 18-year-old male, left wrist pain for nine months. He's a high school senior and he's playing College baseball next year.
CHARLES GOLDFARB: Symptoms began with one swing of the bat. Pains ulnar sided, no mechanical symptoms. A steroid injection completely relieved his symptoms for about three months. And then when he went back and started playing baseball again, his symptoms returned. He has foveal pain on exam and we'll talk a little bit more about that. He has positive compression testing, his ECU and DRUJ are not part of the problem.
CHARLES GOLDFARB: His MRI, which, as Lee said, might be helpful, especially with central tears, suggests something going on along the radial side of the TFCC as you can see here, foveal insertion looks good, which is not always apparent and so we felt he had a central TFCC tear with a stable DRUJ and due to his failure of non-operative care, we scoped his wrist. And to keep it very simple, I don't have any video for this.
CHARLES GOLDFARB: He did have a central tear. It was debrided as Lee said, and it's not clear why this works, but it does seem to work for most patients. And there was no secondary tear. A lot of times in this young patient population, a central tear can be associated with a secondary 1-B tear. Not in this case. So examination is crucial and it does provide a lot of information.
CHARLES GOLDFARB: The ulnar wrist is still considered a Black box, but the more you see, the more you examine with your attendings, I think the more clear it will become, although not always completely clear. So localization of pain. And this description of the fovea, which is just volar to the ulnar styloid is super helpful. We always test the DRUJ in all positions. Provocative tests for the TFCC are important, ruling out the ECU tendon both for tendinitis and for instability, and assessing the LT ligament are a key part of all of our examinations.
CHARLES GOLDFARB: MRI might be helpful, but it's not nearly as sensitive as arthroscopy. I don't perform many diagnostic wrist scopes, but they do play a part in most of our practices. Corticosteroid injections, I believe, are really reasonable, both for information gathering and occasionally they provide a long lasting answer if synovitis is the primary issue. Ultrasound helps for some as a diagnostic tool,
CHARLES GOLDFARB: not really in my practice. So Lee mentioned the Palmer classification, which has stood the test of time to a limited degree. There are more complex classifications which exist which actually provide more information, but I share this mainly because of what I'm going to discuss, which is the 1-A tear, which is the central tear and the 1-D tear, which is the radial tear, as well as classic degenerative tears.
CHARLES GOLDFARB: So this photograph, I hope, is helpful. So this is volar and this is dorsal and you can see the scaphoid facet of the distal radius, the lunate facet of the distal radius and this is the TFCC. So these are the ulnar carpal ligaments here and here and we are focused on really two types of tears for this part of the presentation this evening.
CHARLES GOLDFARB: A central acute tear and a radial sided tear and a degenerative tear, which is typically central as well. So the Palmer 1A tear, that is, the central tear can be acute more often is degenerative and as Lee suggested, debridement to a stable base is the treatment of choice. And trying to confirm this is the source of the discomfort is really important because you, as Lee said, up to 50% of people, once we get a bit older, will have a tear
CHARLES GOLDFARB: and it may not be the source of the symptoms. It's key to maintain the dorsal and volar contributions to stability, which really doesn't take much so debridement makes a lot of sense and here's another example of a debridement. The Palmer 1-D tear is something completely different. So this is the tear of the TFC off its radius insertion, and it has a poor vascular component, although probably has a bit of vascularity potentially
CHARLES GOLDFARB: so that makes it a little bit different from a central tear. And treatment is either debridement alone or repair and the repair techniques are not straightforward, and I think if you ask anyone, we would prefer to avoid repairing these, although certainly that is an option. There are different techniques and these include suture repair or suture anchor repair and this next depiction, which is actually taken from the Hand Surgeries recently released Pediatric Hand Trauma book, Kevin Little wrote a great chapter depicting Walter Short's technique of repairing radial side of TFCC tears.
CHARLES GOLDFARB: My problem with the repair of these, and I'd be interested to hear the panelists later if we have time, is I have a difficult time bringing the TFCC back to bone because typically it has retracted. So more conversation and these are rare, honestly. And so it's not a huge problem that we see on a daily basis, at least in my practice.
CHARLES GOLDFARB: Central degenerative tears are potentially a bigger issue in an aging population and so they don't always look as bad as I have depicted here. So this is a large central tear and you can see the head of the ulnar and you can also see a kissing lesion or really a massive lesion on the proximal lunate as well. So what do the radiographs look like and what does the MRI look like?
CHARLES GOLDFARB: Well, they can be subtle, even more subtle than this but this is a classic appearing proximal, ulnar aspect of the lunate with a long ulnar. So the radiographs need to be taken in a zero rotation configuration so shoulder abducted 90 degrees and you want to avoid pronation or supination because pronation and supination change the relative length of the ulnar.
CHARLES GOLDFARB: All MRIs are done in pronation, so the ulnar always looks a little bit longer. But you can see on this MRI depiction, the lucency or the edema within the volar and ulnar aspect of the lunate is a strong indication of impaction. So this is perhaps the most impressive ulnocarpal impaction that I've seen and you can see the rim of the TFCC. And this is before any surgery, any intervention was done on my part other than looking.
CHARLES GOLDFARB: And you can see the worn away head of the ulnar and you can see the complete absence of cartilage on the proximal lunate. So consider patient two. This is a 58-year-old right hand dominant male with ulnar sided wrist pain on the right, worse with activity, worse with playing hockey, and even bothersome with daily activities, including desk work.
CHARLES GOLDFARB: Radiocarpal injection helped him temporarily as well, so he had reasonable range of motion of the wrist. He had pretty much entire ulnar sided wrist pain with pain at the fovea as well as dorsal ulnar pain but again, the ECU did not seem to be the source of his symptoms and the DRUJ was stable. His radiographs demonstrated slight ulnar positive variance. In his MRI demonstrates again, a bit of edema in the proximal lunate and a TFCC tear.
CHARLES GOLDFARB: So again, I'm not going to play the video, but there was a large central tear, which was debrided and you can see this is looking from radial to ulnar. Dorsal is to the right, volar is to the left and you can see that despite the debridement, the TFCC is not tensioned. I didn't identify another specific tear because I don't mind debriefing the central tear and repairing a dorsal ulnar tear because I do believe it can be beneficial as long as the foveal insertion is not disrupted.
CHARLES GOLDFARB: So what do you do now? So you've debrided a large central tear. Is that enough? And you can also see the irregularity on the proximal ulnar aspect of the lunate. So what's next? So arthroscopic debridement in my mind is likely insufficient and so you have two options; an open ulnar shortening osteotomy, which will decompress the ulnar wrist.
CHARLES GOLDFARB: It also tensions the TFCC assuming the foveal insertion is intact and it can provide additional stability to the DRUJ. I really like this operation. I think it's one of the best and most satisfying operations that I do. And we can bring Warren into this conversation later because he's described an alternative method of shortening the ulnar.
CHARLES GOLDFARB: And then you have the wafer procedure, which can be done open or arthroscopic, which removes the distal aspect of the ulnar, which can decompress the ulnar wrist, but does not tension the TFCC and does not stabilize the DRUJ. So for me, nine times out of ten, I perform an open ulnar shortening osteotomy. I believe it serves my purposes and the needs of my patient well.
CHARLES GOLDFARB: I believe it heals in a reliable fashion. And while plate removal is a problem, probably only about one out of five patients requires plate removal from irritation, maybe even less than that. I would throw in a plug, especially in the adolescent patient. So in adolescent patients that have neutral to positive any positivity in the variance, I would strongly recommend considering ulnar shortening osteotomy at the same time. It's pretty interesting,
CHARLES GOLDFARB: there was really nothing in the literature three years ago and then the last three years, there's been three publications and one of these is ours, looking at adolescents and with TFCC repairs and looking at what happens and the requirement for secondary surgery, which is ulnar shortening. And the bottom line is it's quite common to need a secondary surgery in this population to shorten the ulnar because TFCC repair alone is often insufficient.
CHARLES GOLDFARB: Finally, a few slides on Open TFCC repair. So my question is, what's its role in 2020? And in my practice, its role is really limited and I'll show you why. So this is a classic paper, as Lee shared, Dr. Kleinman really did a lot to advance our understanding of the ulnar wrist. And this paper is a classic and really one of the better papers or the best paper describing positive results with open TFCC reconstruction with DRUJ instability.
CHARLES GOLDFARB: And so here's what it looks like and these are from one of my partners, Dr. Gelberman, who preferred and really was quite facile at open TFCC repair. So first of all, the approach is dorsal ulnar from the floor of the fifth and the exposure is wide. And so this is unbelievable everything that we can see, right? So you can see the TFCC, you can see the lunate and the triquetrum in a way that, you know, typically you don't see this.
CHARLES GOLDFARB: And then what we're demonstrating here is that there is no foveal insertion, the head of the ulnar is bare and so debridement and then drilling of a pathway and a suture repair of the TFCC down to the bone. And this really can be effective in stabilizing the DRUJ. But this is not a small surgery and Sanj is going to go over arthroscopic techniques to accomplish this same goal.
CHARLES GOLDFARB: So in my hands, open TFCC repair or reconstruction or I should say repair is not a big part of my practice. So I'll close by saying that for me, the main thing to focus on during your fellowship is understanding what a good clinical examination looks like and how it helps to focus your treatment. What I learned in my first few years of practice after my fellowship was to truly understand the arthroscopic anatomy.
CHARLES GOLDFARB: Also focus on that because there are subtleties to the arthroscopic anatomy that you won't pick up in a talk like this that are really important. Understand the benefits of ulnar shortening. I think it is a fantastic procedure that really deserves an important place in all of our practices. And the adolescent population may be somewhat different than patients as we age.
CHARLES GOLDFARB: So thanks to Jerry for organizing this and to Lee and Sanj for including me as well.
SANJ KAKAR: Thanks. Thanks Charles. So my role here is to talk about arthroscopic treatments. And just like Chuck did, and Lee will give you some case based examples and hopefully some nuggets of information. a big thank you, really, to Marty Boyer during his presidential year.
SANJ KAKAR: As many of you know, you know, he had planned a Fellows Boot Camp and so we were planning on doing a wrist arthroscopy course, but sadly, that got canceled. Thank you to Warren and Jerry for doing this and also thanks to chuck, Marc and Jeff Yao. A bunch of these videos that will show you and Chuck has shown is on HandE for your education if you don't get everything tonight.
SANJ KAKAR: So this is a patient that comes in to see me, avid tennis player, his whole part of retirement is to play tennis and he's 70. You may say, well, you know, choose something else, but this is what he wanted to do. So we treated him non-operatively, he had pain in the foveal region. His DRUJ was stable. The injection, I think, is a powerful tool for diagnostic and therapeutic purposes and also prognostic purposes.
SANJ KAKAR: So he got well, treated non-operatively, but the symptoms returned. So one of the things I think to pick up from on today's discussion is your clinical exam is key. If you look at a TFCC MRI, as Lee showed us, many patients have tears but are clinically asymptomatic. He was point tender over the ulnar and extrinsic ligaments. So in terms of ulnar wrist pain, we're not going to spend too much time on this
SANJ KAKAR: but there's a couple of real sort of mentors that I'd like to share their thought processes. One was Dick Berger, who spent really an incredible career talking about ulnar wrist pain, and he broke it into three concepts. Is there just pain? Is there pain with instability for example, a foveal tear, for example, or pain with arthritis such as DRUJ arthritis?
SANJ KAKAR: And it's important, I know these sound just pain, pain, pain, but they all have their subtle nuances and you have to delineate that with your history and physical examination. And Marc Garcia-Elias, who basically taught us about this four leaf clover algorithm that we'll talk about a little bit, breaking it down into key segments. So this patient, how did we treat this patient?
SANJ KAKAR: So there was no bony problem. His cartilage looked OK. Clinically, he was tender over the foveas so suggestive of a UT ligament split tear with a stable DRUJ. And as Lee mentioned, TFCC tears go hand in hand with the ECU, so you have to rule that out, he had a stable ECU. So this is his wrist arthroscopy. We'll spend a few minutes just going through the technical details.
SANJ KAKAR: So one of the things I think in doing your fellowship is to challenge do you do this wet or do you do this dry? There's many, many advantages of both, and I think you should be facile in doing both and make your own mind up. So for me, this is doing it dry. You can see the needle goes in the 3-4 portal, no need to insufflate the joint and then I tend to make transverse incisions.
SANJ KAKAR: I feel that they heal more cosmetically and you can just close these portals with steristrips, you don't need sutures. So 3-4 portal is made, wrist scope goes in and as Lee mentioned, you can see there's four marks for the midcarpal joint as well and I think that's critical, especially for instability issues.
SANJ KAKAR: So here we're making the 6-R portal and we're going to look to the ulnar side. This is the automatic washout technique. You can see there's a 10-CC syringe attached to the scope. This was really taught to us by Paco Del Penau, so you don't need fluid, but sometimes when you get in there, there's hematoma in the joint. And you can put a shaver in there and it makes a closed loop system and it irrigates the joint.
SANJ KAKAR: So for example, for distal radius fractures, it's very useful. So here you can see at a central TFCC tear, which we know about, but that was not the cause of his problem. For me, when I'm doing this arthroscopically, I look where the synovitis is, that's your key. So he had a central tear that we debrided at a loose little body
SANJ KAKAR: but the mistake is to stop here. That's not where his pathology is. And you have to go with your clinical examination and you'll see that there's this synovitis here. And so we're debriding the synovitis to really get to this ulnar extrinsic split tear. And Lee showed a nice picture showing there's a natural confluence between the ulnar lunate and the ulnar triquetral ligament.
SANJ KAKAR: But you can see as we're debriding the synovitis, there's that split tear and we, before we started, this was a little discussion we were having amongst ourselves is, is this a tear that has seen us more than we've seen it, seen it? And so here you can see we're debriding away and now you can see the extent between that split between the ulnar lunate and the ulnar triquetral ligament. And I think if you look for it, you'll find it more often than not, especially if they have tenderness there.
SANJ KAKAR: So now we'll make an incision to the volar aspect to the ECU from the mid hamate body to the ulnar styloid. And a little trick that Dick Berger taught me was when you spread, look for this little vein. There's a basilic vein there. And just deep to that is the dorsal sensory branch of the ulnar nerve so you can see I've got the pickups are holding the vein. And as I spread, there you can see one of the branches of the dorsal sensory branch of the ulnar nerve.
SANJ KAKAR: Once you found one branch, my experience is that there's often other branches and so you can see as I open up the pickup, there's an aberrant branch running from dorsal to volar. That's not the normal anatomy of the dorsal sensory branch of the ulnar nerve, but nevertheless, it's there. So here you can see I'm taking one branch of that nerve with the vein, and we'll put a vessiloop around there.
SANJ KAKAR: But the mistake here is now to stop and say you've got all the nerve. Spend a couple of minutes just looking and as I showed you and we'll grab it in this case, you'll see that there's a branch of the dorsal sensory branch of the ulnar nerve going, running in the wrong direction there but it's there. And the mistake is, if you catch that with your sutures, your patient will never be very happy.
SANJ KAKAR: So there's the nerve retracted out of harm's way, and this we're going to show is a simple outside to inside repair, just using meniscal mending needles. This is available to you on HandE so if you don't get it all tonight, you can still see it. So essentially, we're going to put the needles straddling that tear, so one goes to the radial side and one goes to the ulnar side and you're looking at directly with your scope.
SANJ KAKAR: And so now what you'll do is put a wire loop through one of the meniscal mended needles, and then essentially you put the what, the other needle into the wire loop. So there you can see the wire loop and the other needle comes into it, OK, and then you pull that wire loop taut. So now you have a system to shuttle your sutures. So now what we'll do is take the stylet out, that pink stylet, you'll see we'll remove from one of the meniscal menders needles.
SANJ KAKAR: And through that, you can pass a suture. I think it's dealer's choice, to be honest what type of suture you want to use? I use 2-0 PDS. Sometimes the knots can be a little bit proud but you do know with 2-0 PDS that eventually it will absorb and so it's reassuring that this is not a non-absorbable suture. So there you can see the suture comes in and then through your 6-R portal, you pass a grasper, essentially pull it out of your 6-R portal.
SANJ KAKAR: So we'll pull it out, we'll pull the needle out so you don't cut the suture and then we'll just pull that out, and then you'll just pull back on the other needle with the wire loop, and that'll be your suture. So this is a relatively straightforward outside to inside passage and you can see it's closing the tear.
SANJ KAKAR: But this patient actually needed two other sutures to close that down. In the interest of time, we'll just move on. Post-operatively they're managed for two weeks in a Sugar-tong splint and then a Munster cast for four weeks. And our therapy protocol is to start mobilization but start from the shoulder down. Most of our patients with ulnar nerve wrist pain have poor scapulothoracic conditioning and control
SANJ KAKAR: so we really work on the big muscles as well as the smaller ones. And this was a study out of our institution of just under 100 patients. Patients did well. Some did have some numbness of the dorsal central branch of the ulnar nerve which got better, so routinely I tell the patients it'll take about three months before that settles down.
SANJ KAKAR: One of the things I wanted to challenge today again with the Fellows is we're often taught that if an injury is acute, i.e. less than perhaps six weeks, it's repairable. Anything chronic, you should be thinking about a reconstruction and I actually don't think that's necessarily true. I think you have to judge the quality of the tissue. So if the tissue is like wet tissue paper, sure, it won't stand a repair, but if it is more robust, you can repair it.
SANJ KAKAR: And Lee showed the Palmer classification. This is a classification by Andrea Atzei that I urge you all to look at. It basically breaks it down into those that have excellent and poor healing potential from types 1 to 5. But it also shows you where your ligament injury is. So how do you test for foveal attachments? There's different tests that we'll go through very quickly.
SANJ KAKAR: So this is a hook test. So you'll see that the probe is coming from the 6-R portal and I can easily get it underneath the TFCC and lift it off the fovea so that that's a positive hook test. In terms of the trampoline sign, there's a natural buoyancy of the TFCC so when you push it down, it springs back up so that is normal trampoline sign
SANJ KAKAR: and you saw some cases earlier from Lee and Chuck how it was rather lax when you pressed down. The next one is the suction test and what this is doing is you turn on the suction and you can see how you can lift it off. And this is useful for not only foveal pathology, but also if there's a peripheral tear and it's scarred in. And so what you need to do now is take it down and then there's a natural laxity of the TFCC
SANJ KAKAR: but by using the suction test, you can grade if you've actually tried to restore some of that tension. And finally, DRUJ arthroscopy and I'm just going to spend a couple of minutes showing the power of DRUJ arthroscopy. This is how I used to do it and this is something I would not do anymore. I'm showing a proximal and distal DRUJ portal. There's a direct foveal portal.
SANJ KAKAR: And so here the needle has gone in the proximal DRUJ and this is blind. You're basically going in, you think you know where you're at. And this is when I used to do it wet. The problem with doing it wet is all that synovial hyperplasia just engorges and it blocks your view. Now this is the distal DRUJ portal which is proximal to the 4-5 portal,
SANJ KAKAR: but you'll see when the camera goes in, you're now trying to get your working portal and you're sort of sword fighting. There's not much room between your hands and the camera, so this is not something I would do. This is a much easier way where you keep your scope in the 3-4 portal. You put your needle underneath the TFCC and so you keep your scope in the 3-4 portal,
SANJ KAKAR: you see the needle under the TFCC. You then spread and then stick your scope in. So here you can see I'm laying the 3-4 portal. Oh, did that play? Let's just see when the 3-4 portal and the needle is underneath it so I know I'm exactly in the right spot. And so here you'll see this is just for demonstration purposes,
SANJ KAKAR: yes there's a central test, sonyou could scope through that. But once you put your needle in, you make an incision, you spread down on the ulnar head underneath the TFCC so you know you're exactly in the right spot and then you just take your cannula out and you stick it right there. So 100% of the time, you know you're in the right position. And so and that takes some of the guesswork out because sometimes you're in the right position, but you don't quite know it,
SANJ KAKAR: so you pull back, you can see the ulnar head below you. The foveal is on the right and the TFCC is above you. And then you can come from the volar side with a switching tack stick technique to bring in your shaver to debride underneath the TFCC. So you may say, OK, what's the clinical relevance of that? Is this truly Hocus Pocus? So look at this case.
SANJ KAKAR: So this is a child who comes in with a distal radius and ulnar fracture, either displaced. And our pediatric orthopedic colleagues did a great job. They reduced it, they pinned him and I think that looks pretty anatomic. So four months later, he's healed and he's getting on with life, and then 10 months I see him. So remember 10 months, a year out.
SANJ KAKAR: So he has gross instability of the DRUJ in neutral, pronation and supination. OK, so he's clearly unstable. This is his MRI. And look at the fovea. So too many eyes, the fovea actually looks pretty good and this is the MRI read saying that he may have had a small ulnar triquetral ligament tear,
SANJ KAKAR: well that's not going to cause that instability in the TFCC is otherwise intact. So going through that four leaf clover, four leaf clover algorithm, the bone looks good. There's no arthritis. The ECU is stable. Clinically, he probably has a foveal tear although remember the MRI was normal, so he had a negative trampoline sign and a hook test.
SANJ KAKAR: And so here the needle is now underneath the TFCC, remember, the camera is still in the 3-4 portal and now I'm underneath the TFCC. And as I come ulnarly, look at that, the foveal insertion is completely detached, it's not down there. And so you get a perfect view doing this dry. You don't need fluid insufflation. So now I make a little working portal just with a needle and then spreading.
SANJ KAKAR: And so now what we're doing is taking a curette to debris the footprint of where that foveal insertion needs to be. And then you shave this away because the key here is now you have to get this tissue to heal down to bone. Now, this is a different patient, but I just wanted to show you how you do a foveal repair. So there's the dorsal sensory branch of the ulnar nerve. You can see it trifurcate, find that nerve, a vessiloop goes around it, and now you make an incision volar to the ECU,
SANJ KAKAR: so the extensor retinaculum we're incising and we're volar to the ECU. We don't need to destabilize the ECU. This is a technique described by Wai Chen in Taiwan and works very well. And so now what we're doing is taking the shaver. This is the DRUJ portal, but you can work between the DRUJ and the 6-R portal, debriding all that scar tissue on the foveal insertion because we want that to heal down to bone.
SANJ KAKAR: So once I'm happy with the debridement, here we're doing an 0-6-2 k wire under oscillate mode and critically when you look at that, that is slightly dorsal. So the beauty of arthroscopy as Chuck mentioned is you can exactly see where that foveal insertion is. So you just back out the pin, lift your hand and the wire is going slightly more volar so it's a little bit moreanatomic and you can see it's just a few millimeters
SANJ KAKAR: but that makes a lot of difference when you're trying to get this anatomically reduced. So there it comes out slightly volar at its footprint. So now what I'll do is I'll take a probe and I'll make sure that I can move and mobilize the TFCC so that again, challenging that dogma, that at 10 months you cannot repair this. So here you can see we're pulling it, moving it to over. And then there's an 18 gauge needle with a 2-0 PDS looped, goes through the foveal tunnel.
SANJ KAKAR: You pull this out through the 6-R portal so you've got one loop of 2-0 PDs and that hole is big enough that actually you can put a second 18 gauge needle through with a looped 20 PDS, push it through and then grab that 2-0 PDS as it comes out through bone. So there we are, we're pushing it through. There's the needle and then we'll pull it out.
SANJ KAKAR: So now we have two loops of 2-0 PDS being pulled out through the 6-R portal. And so we'll cut one of he loops like there, and then you want to check which end goes with which. So we're just checking which end goes with which, and then what we'll do is take a 20 gauge needle with a 3-0 suture as a suture shuttle going through the capsule or the peripheral aspect of the TFCC. There you can see it comes through.
SANJ KAKAR: And then what we're going to do is use that suture to shuttle the other sutures through. So now what we'll do is grab the 6-R portal, grab that loop of 300 PDS, just pull that out and use that now to shuttle one of the limbs of the 2-0 PDS back through the capsule. So there you can see we're going to take one of the limbs of the 2-0 PDS, pull it through. So this stitch has gone through bone, through the fovea, through the TFCC and back out.
SANJ KAKAR: And in the interest of time, we'll just move on but this will be available to you and HandE. And so in that patient, we'll go back to that one, that kid who had that foveal disruption. You can see there, there's the sutures and this is him on the table. OK, I've taken the traction off and you can see just by tying the sutures, immediate stability has been restored. In terms of the literature, this just a couple of papers showing patients doing well with this technique.
SANJ KAKAR: This is up to four years follow up without any instability. So I think for me, in summary, the clinical exam is critical. The examination under anesthesia is key for me to really ensure that there's no foveal disruption. And if you're suspicious scope the DRUJ, it will tell you much more than an MRI would. Thank you very much.
JEFF YAO: Uh, Thank you so much, Lee, Sanj and
JEFF YAO: Chuck, that was phenomenal. Kind of a whirlwind tour through a wrist arthroscopy and TFCC. So a lot of great pearls for the Fellows and faculty. This is going to be on HandE for everybody who's on the conference right now on the webinar so we'll have a chance to view this later on. Any kind of last comments? Maybe one pearl from each faculty and for the interest of time, we'll kind of end the webinar just for the Fellows throughout the year.
JEFF YAO: Lee, Chuck and Sanj. As far as one pearl for Fellows going into arthroscopy this year.
LEE OSTERMAN: I'll start. I mean, I think in this year of your fellowship, one thing defines a hand surgeon from an orthopedic surgeon is in fact your ability to do wrist arthroscopy. In other words, when you go in your communities, when you're trained, it's often nobody can do wrist arthroscopy.
LEE OSTERMAN: So learning this technique this year will stand and put you above your peers who say, well, I can do carpal tunnel triggers, et cetera, but they can't do wrist arthroscopy with all its variations. And so I would spend time learning this technique. This year there are courses that will be offered in 2021 by the Hand Society so please take advantage of that.
CHARLES GOLDFARB: Yeah, that's exactly right. And I would add that, you know, the most important thing for me well, two things. One is correlate the MRI with your arthroscopic findings. Make it a habit to spend time with the MRI before a wrist arthroscopy and then after the wrist arthroscopy, go back to the MRI and make sure you understand what you saw. So that is just incredibly important and do it with your attending if you can convince them to do it.
CHARLES GOLDFARB: But if they don't want to do it with you, do it on your own. And then you just have to see a lot of wrist arthroscopies to get the subtleties of the anatomy. So just stay at it and you won't be done learning wrist arthroscopy when your fellowship is over.
JEFF YAO: That's such a great pearl Chuck. I think the MRI arthroscopy correlation, that's such a great kind of point to really try and do throughout the year and also throughout your practice.
SANJ KAKAR: Um, I would just say I would challenge your faculty to move from wet to dry. That's just my bias. And I can see Lee and Chuck and Warren and Jerry chuckling away and they may not want to, so go and do it in the lab. As Lee said, there will be courses next year and we will teach you this and you'll be amazed what you can do, doing it dry.
SANJ KAKAR: It will open up other avenues that you initially couldn't do, doing it wet so that would be my only sort of pearl to after this webinar.
LEE OSTERMAN: Again, just in closing, Sanj mentioned it a couple of times, but you all have access to HandE. Warren and his team have put many of the videos that you saw, many of the instructional lectures that you saw, and you can go and review those and see those.
LEE OSTERMAN: It is an absolute treasure trove of information. So every fellow, even more important than these monthly seminars should go to HandE. It's an absolute goal that you should do.
JEFF YAO: Right, any kind of comments? Warren? So Dr. Hammert's done a phenomenal job with both the videos and also the 50 lectures as well, the Hand 50. Any kind of closing remarks for the Fellows on board here Warren?
WARREN HAMMERT: I think just as they've said, you know, I'm the editor, so I'm biased with this, but I think there's a bunch of really good educational resources, not just on arthroscopy, but on hand surgery in general. So if you haven't spent some time looking at it, look at the Hand 50 lectures. I think that's one of the key series that was really developed for the Fellows. And there's a Fellow Shoe, which is a weekly email that comes out on with different topics.
WARREN HAMMERT: So sign up for those and take advantage of them.
JEFF YAO: All right. Well, hank you. Everybody stay safe and healthy out there. Again, we'll send a more complete schedule for the upcoming academic year to everybody and really appreciate your participation and all your great lectures. Thank you so much.
JEFF YAO:
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