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Scapholunate Ligament Injury: Fellowship Lecture Series Debate
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Scapholunate Ligament Injury: Fellowship Lecture Series Debate
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Segment:0 .
JERRY HUANG: Welcome back, everybody. Jerry Huang from University of Washington. Welcome, everybody back to Controversies in Hand Surgery and Fellowship, virtual debate. And really one of the things Dr. Hammer and Dr. Leversedge last week for an excellent job not that we joined but was able to watch recording and another great job are the Fellows, the moderator as well as the mentors.
JERRY HUANG: So I think what's been great about this, I think everybody is hopefully able to return back about clinic and but I certainly really enjoyed this opportunity to learn from faculty from across the country and learn different perspectives. I think collegiality has been kind of unbelievable across the board. I think every week I'm amazed at how great a job the Fellows do. Certainly an amazing job on presentation, the content and the delivery.
JERRY HUANG: The mentors and moderators can't do this without you guys so thank you so much. And then last couple of weeks, we switched to a new format, so kind of a longer overview by the moderator and also introduction and also allowed for a lot more time for discussion. And Dr. Yao today is going to be adding a participant poll today to try and kind of gauge what people will do. So as we kind of get ready for the face off between the different institutions, I think this week is more like a cage match with five different institutions in the cage, very, very strong believers in their technique,
JERRY HUANG: and this is going to be moderated by Dr. Yao out of Stanford, and it's going to be University of Colorado versus Columbia versus the Mayo Clinic, Philadelphia Cancer Center and HSS. From there, I'm going to pass it off to Jeff Yao.
JEFFREY YAO: Thanks, Jerry. Cool thanks, Jerry, and thanks, Jerry and Warren for continuing to set up these great educational opportunities during this crisis.
JEFFREY YAO: I hope everyone and their loved ones are staying safe and well. So I've been tasked to be the moderator for this discussion/debate. We'll talk about the chronic scapholunate ligament injury: The debate rages on. So what are we talking about here? We're talking about the chronic scapholunate ligament injury where the ligament is no longer repairable so we're outside of that 6 to 8 to 10 week window where the ligament is still repairable.
JEFFREY YAO: But, it's not to the point where the patients develop SLAC arthritis and unfortunately, we get a fair number of patients who show up in this space and this stage. So here's our case. So this may or may not be based on true events. We have a 31-year-old hand fellow fell off her bicycle on the way to the hospital to go in for a replant.
JEFFREY YAO: She thought she just, quote unquote, sprained her right dominant wrist. She had dorsal central wrist pain, this persisted for months but she was afraid to get it checked out, out of fear of scorn from her fellowship director. Six months later, she told her highly supportive hand fellowship director, who urged her to get some film
JEFFREY YAO: and this is what she got. So now this is six months after her injury.
JEFFREY YAO: similar results. So she wanted to continue with fellowship with minimal time off, so she elected to have a wrist arthroscopy debridement and denervation procedure. Upon wrist arthroscopy showed a wide scaffolding interval, drive-through sign the capitated view through viewed the radiocarpal joint.
JEFFREY YAO: So if you look at Will Geissler, there's arthroscopic classification, this would be a stage four tear or the IWAS classification, a stage four tear as well. So suffice it to say that denervation failed, we couldn't operate. She'd just signed a deal to become a new hand surgeon at a prominent academic center. She was hired to be the new hotshot risk specialist and she, quote unquote, needs a wrist to be able to operate.
JEFFREY YAO: In case you're considering a salvage, she had family members that had both a scaphoid excision four corner fusion and PRC with dismal results so she wasn't interested in either of those options. So we're talking about Mark RC Elias stage three/four. This is where the ligaments disrupted. This is where the scaphoid is still normally aligned, and most importantly, the carpel malalignment is easily reducible.
JEFFREY YAO: And the cartilages of both the radial carpal and MC joints are normal. So this is before the scaphoids and lunate has fallen into the fixed, easy deformity. The joint is still reducible. So what are your options in this situation? We already spoke about denervation. Historically, capsulodeses were popular, and then as you can see, there's a number of different scapholunate ligament reconstruction procedures that have been described.
JEFFREY YAO: This is not even an exhaustive list. And as the saying goes, when there's multiple ways to treat one problem, either they all work as in the case for thumb CMC arthritis or they all don't work and unfortunately in this situation, none of these procedures in my mind has definitively distinguished itself from the others as being the true gold standard
JEFFREY YAO: but maybe we'll be convinced of other otherwise today. So we'll be talking about these five techniques, so what do we do now in this situation? So get ready for the Battle of the acronyms and let's meet our combatants. And please forgive me if I had a little bit of fun with this. It's been a long time of quarantine with my family so I took a little time to have a little fun with this. So the first group will be from Colombia.
JEFFREY YAO: We'll be talking about the RAZL. This is Dr. Kelly Esposito and Mel "The Gladiator, Rosenwasser. Sorry no, I had to do something with the facial hair, I think. What about the 3LT? That, that'll be Christopher Chen and Alex "The Marauder" Lauder from the University of Colorado. The Swivelock SL Reconstruction with Remy Rabinovich and Mark "The Ravager" Rekant from the Philadelphia Hand to Shoulder Center.
JEFFREY YAO: More acronyms. The SLITT procedure. Dr. Lauren Dutton and Sanj "The Centaur" Kakar. Nice ads there Sanj, from the Mayo Clinic. And last the ANAFAB with Genevieve Rambau and Scott. this was too easy, "The Wear" Wolfe.
JEFFREY YAO: From HSS. Probably the friendliest werewolf you'll see. After the presentation, Jerry is going to put up a poll and I request all the participants to answer two short questions at the end of the presentations. And so with that, hopefully the audio plays. All right. So I think our first speaker will be Dr. Esposito from Columbia, if you want to go ahead and share your screen.
KELLY ESPOSITO: All right. All right.
KELLY ESPOSITO: Can you see that? Yes great. OK, so Mills gone. OK, so up first, we will be making the case for the RASL procedure.
KELLY ESPOSITO: I'm Kelly Esposito. I'm the fellow at Columbia, and my mentor is Dr. Rosenwasser, who I'd like to thank for his help with this presentation and his help in mentoring me for this entire year. So, as was already mentioned, this is clearly the Battle of the Acronyms. And I think the one acronym that we're really going for here is the GOAT.
KELLY ESPOSITO: And seen here a goat is shooting the illest album of 2020 and we're here to argue that the GOAT in this situation is the RASL. So a similar case is the one that was presented. This is a 40-year-old young person, chronic cell instability causing pain, weakness and functional limitation. I won't belabor any of the anatomical points about this as obviously this audience is very well familiar with this problem.
KELLY ESPOSITO: However, I will point out one salient point, which is that there are 20 degrees of relative motion between the scaphoid and the lunate. The scaphoid continues to flex after the lunate stops, and so it's important to be able to replicate this physiological motion and if you tie the two bones together too tightly, you will lose that. So there's many options, most of which are interesting acronyms
KELLY ESPOSITO: and we'll hear about five of them today and our preferred treatment is the RASL. So to frame this debate, we like to harken back to a well known surgeon of yesteryear, Dr. Codman, who essentially invented the idea of follow up. And so on that vein, what kind of follow up do we have for today's contenders? And a quick review of the literature. The three-LT has some medium term, short term follow up available.
KELLY ESPOSITO: The NFAB has some preliminary outcome available in the literature and the other two procedures today have some biomechanical studies and technical guides, but no published cohorts of follow up yet. Here's a summary of the literature in descending order of the amount of follow up that's published in the literature at this time. And we would be very interested in having this debate perhaps again in 10 years when we had more long term follow up
KELLY ESPOSITO: but alas, we're doing this now and we have 20 plus years of follow up on the RASL procedure. This was first described in 1997, and we've been following the patients since. So to go over the RASL procedure, the concept is like an axle. And as I mentioned, it's important to preserve some of the physiologic motion between the scaphoid and the lunate,
KELLY ESPOSITO: and as you will hear from no doubt my colleagues today, it's important to preserve both the dorsal and the volar components as this is a really strong, this is quite a lot of force that goes through this joint. The RASL achieves this by going through the center and creating an axle. And so it actually supports both dorsally and volarly. I'll quickly go over the technique and then I'll go over this step by step.
KELLY ESPOSITO: So this is done through two incisions, a longitudinal dorsal incision in addition to a radial styloid incision over the first dorsal compartment. We do a capsular or a ligament sparing capsular approach, and we work through two windows, use joysticks to reduce the scapholunate interval and then place a screw down the axis, and the trajectory of the screw is paramount to the success of this procedure
KELLY ESPOSITO: as I will go into. So you start with your dorsal incision, make sure to preserve the dorsal ligaments and Dr. Wolfe has actually done great biomechanical research emphasizing the importance of maintaining these attachments. The other incision is over the radial styloid, and it's imperative that you perform a radial styloidectomy to get the correct starting point and I'll go into that a bit in a moment, but this is a key point to this procedure.
KELLY ESPOSITO: You then perform reduction association with the scaphoid and lunate by placing K wires into the respective bones, reducing the lunate under the capitate and making sure these K wires are out of the trajectory of your screw, which is a little tricky at first but practiced hand surgeons can certainly get the hang of it. It's important to not skip this step, either the burring of the subchondral or to the subchondral surfaces of the two bones to be able to get a fibrous neoligament scar response.
KELLY ESPOSITO: Again, this is not a fusion procedure, so we want some physiological motion, but it's important to get a healing response. This is an important step. You then use a Kocher clamp to maintain your reduction and after your radial styloidectomy as you can see what's done here, you place your guidewire in the correct axis and the correct axis of the screw is exactly parallel to the inclination of the distal radius, as you can see here on the P X-ray, and then in the sagittal plane, you want to aim right at the center of the lunate or aim slightly lower.
KELLY ESPOSITO: It's very important to not place the screw dorsal. So again, to recap, the critical technical points of this procedure are perform a radial styloidectomy or it's not possible to get the correct starting point for the screw. The correct starting point for the screw is at or proximal to the dorsal lateral ridge of the scaphoid. And in the example that was shown at the very beginning, actually that starting point was a bit distal.
KELLY ESPOSITO: The axis of the screw is directed toward the center of the lunate, as I mentioned, and you never want to place the screw to dorsal. Screw placement is fundamental to the success of this procedure and we would argue that that's fundamental, that correct technique and adherence to rigorous standards is important to the success of any orthopedic procedure, and we aren't the only people saying this.
KELLY ESPOSITO: Dr. Hausman published on the placement and the importance of the starting point and with a distal starting point that that's associated with failure. So what this means is if the screw is in the wrong place or steps are skipped, you're not doing a RASL. Maybe you're doing some sort of modification, but it's not the RASL as we're describing it here. And so to take a page out of the Book of B Rabbit seen here on the left in the finale of the movie Eight Mile, he was also selected to go first, and his strategy was to anticipate the critiques that his opponent, Papa Doc, would be leveraging at him.
KELLY ESPOSITO: And so in that vein, I have a few papers I'd like to clarify here. The first is this paper by Dr. Stern, which concluded that the RASL procedure was ineffective in providing stability about the FL interval. However, you can see, there were no radial styloidectomies performed in this, there were no lateral x-rays included
KELLY ESPOSITO: so we don't know where the screw was in the sagittal plane and the starting point is too distal. So we would argue this was not the RASL procedure that was performed here. Similarly, Dr. Aibinder et al concluded that this procedure has a high rate of early failure and reoperation. However, there is a tremendous amount of variation in the types of screws, lengths of screws and placement of the screws, whether or not a styloidectomy was performed,
KELLY ESPOSITO: so there is sort of a heterogeneous mix of things that were done. And actually, to quote the article itself, they believe that the failures may have been due to the challenges of the screw placement as opposed to a problem with the procedure itself, if done, if done in the described way. So let's say we followed the steps and put the screws, put the screw in the correct place.
KELLY ESPOSITO: How do these do? Well, at that point, the proof is really in the pudding. We have the longest published follow up of chronic static SL instability at an average of about 10 and 1/2 years, 35 patients ranging from 1 to 24 years. They maintained 80% of their motion and grip strength and the reduction was maintained over that time as well. Here are a couple of case examples.
KELLY ESPOSITO: This is a patient at almost 19 years. This is one at 20 years, and here he is in the office and you can see his range of motion. And then, as Dr. Sandel mentioned, the gold standard is really the ability to do a push Upup and you can see this patient would do as many push ups as we wanted him to in the office.
KELLY ESPOSITO: So back to our case. We were very careful to place the screw in the ideal position. As described earlier, radius styloidectomy was done, subchondral brain was done to create the neo ligament healing response and you can notice that the starting point is in the correct position proximal to the dorsal lateral ridge of the scaphoid. Three months post op screw is in the same place,
KELLY ESPOSITO: and I will note it's actually it's expected to have a little bit of lutency due to the physiologic motion, this stays stable and does not regress. Here he is in the office and then here's the patient at 9 years with essentially equal grip strength bilaterally. At this point, I yhank you for your attention and I would like to pass the mic to my colleagues.
JEFFREY YAO: Wow with the mic drop and everything, that's impressive. Thank you, Kelly. All right, so we'll move on. Our next speaker will be Chris Chen from the University of Colorado. Chris, there you go.
CHRIS CHEN: All right, guys, can you hear me? Yep cool. What? My name is Chris Chen and I'm one of the hand fellows at the University of Colorado. And I'll be talking to you about the three-LT technique for SL dissociation. And I don't actually have any conflicts of interest in this case because I've never actually seen one before because this isn't actually performed in our institution routinely.
CHRIS CHEN: All right, so we all know the basics of SL ligaments. The proximal rows and intercalated segment doesn't have any musculotendinous attachments, and lunate is held balanced in the neutral position because of the flexion of the scaphoid and the extension of the triquetrum. And of course, if you disrupt the SL ligament, it's a crucial link between the scapholunate,
CHRIS CHEN: and when it gets disrupted, you get slac wrist, right? Well, it's actually not that simple because we often forget about the secondary stabilisers, such as the STT ligament and the dorsal radial carpal ligament, which also play an important role in stabilizing the proximal role. A more complete way to think about this injury is that complete SL injury, in addition to the failure of the secondary stabilizers, leads to abnormal kinematics and then eventually slac wrist.
CHRIS CHEN: So as Dr. Yao mentioned, these injuries often present chronic, and they're often at six to greater than six to eight weeks out from their injury, and at that point, repair isn't a good option. Unfortunately, there's no gold standard technique. However, there are a lot of non gold standard techniques, and this is a small sampling of the main techniques out there, and we're running out of acronyms for all the treatment options.
CHRIS CHEN: Props to RASL dazzle crew. That's a pretty cool one. The SLITT technique is also a pretty cute name too. So the three-LT technique was first published by Garcia-Eias in general hand surgery in 2006. It's indicated for complete injuries with non repairable ligaments where the deformity is still reducible and ideally there's minimal or no arthritis. The technique has three goals in mind. So the first is to reconstruct the dorsal SL ligament.
CHRIS CHEN: The second goal is to augment the palmar distal connections to the scaphoid, that is the palmar-STT ligaments, and the third goal is to reduce ulnar translation of the lunate. So the technique actually incorporates elements of three previously described techniques, and we are trying to compare these techniques. It's kind of like playing spot the difference. So I made it easy for you in red.
CHRIS CHEN: So in red are the elements from each of these methods that are incorporated into the three-LT technique. So the original Brunelli technique, we use a slip of the FDR through a hole of the distal scaphoid and tenodesis across the radial carpal joint, which theoretically could lead to some wrist stiffness. The Linscheid technique is similar, it uses the ECRB, however, it's different in that it uses the dorsal radial triquetral ligament as a pulley and it does not cross the radial
CHRIS CHEN: carpal joint. The Van Den Abbelle technique also uses the FCR and it incorporates the pulley described by Linscheid so it doesn't cross the radial carpal joints. So the three-LT technique takes the best elements of each of these techniques and we use the FCR down the long axis of the scaphoid and this helps to augment the SCT segment as well as the dorsal radial triquetral ligament.
CHRIS CHEN: And it doesn't cross the radiocarpal joint. So to perform the technique, you begin with the standard dorsal approach. You do a berger ligament spearing capsulotomy and you want to make sure you leave enough of the dorsal radial triquetral ligament such that you can make a pulley in the later steps. Next through a separate incision, you harvest a 8 centimeter distally based strip of FCR, you then weave it through a drill hole in the long axis of the scaphoid.
CHRIS CHEN: And this is a crucial step because this is the step that augments the volar SCT ligament. You then create a trough in the lunate with a burr, you drop a suture anchor in there and this is going to help the tendon heal to the bone. When you localize your dorsal radial triquetral ligament, you create a slit. You pass the tendon through, reduce the proximal row, lock it down with K wires from the scaphoid to capitate to the scaphoid lunate and you tighten everything down, including the suture anchoring,
CHRIS CHEN: sew the ligament back on itself. So it's the best technique because it reconstructs the dorsal SL-ligament, it augments the palmar STT-ligament and it doesn't cross the radiocarpal joint. And theoretically, this creates normal carpal kinematics and theoretically, it prevents SLAC wrist. So that's the theory but how does it actually do in real life? So this is a compilation of eight different studies and it includes both a three LT technique as well as the Van Dem Abbeele technique, which is very, very similar.
CHRIS CHEN: And the original series by Garcia-Elias was, followed 38 patients for four years. 74% of them had no pain at rest, 21% had some pain with loading and 5% in chronic pain. Well, we'll just ignore those 5%. Two patients experienced recurrence of carpal collapse and 24% progressed to arthritis, however, most of it was mild in 18% of cases, and there were very few complications and no cases of avascular necrosis.
CHRIS CHEN: Overall, other studies have been able to replicate the success, which is important. Other case series range from 8 patients to 117 patients, with follow up anywhere between 10 months to 14 years. And most series demonstrate that pain improvement can be achieved pretty consistently, and the incidence of chronic pain or unchanged pain is between 5 to 27%. With regard to radiographic parameters, the SL angle is typically improved to somewhere between 54 to 68 degrees.
CHRIS CHEN: However, loss of reduction and increased SL gap at the final follow up is not uncommon. Range of motion and grip strength are also reasonable, with 75% to 85% of the pre-op motion being reserved and grip strength approaching 65% to 85% of the contralateral side. So overall the incidence of progression of arthritis is relatively low and actually the highest rate of progression, as reported in the original series by Garcia-Elias.
CHRIS CHEN: And complication rates are very low. So you all remember, first do no harm, right? In conclusion, the three LT technique is a reasonable technique. Like every other technique, 60% of the time it works every time. It has a theoretical, anatomic benefit. It also has a long track record, unlike a lot of the other techniques we'll be hearing about today. It has a low complication rate,
CHRIS CHEN: unlike certain screws, which may loosen over time. And whether or not you like the technique or not, it's a classic technique to know about and it's been used as a benchmark, and it's commonly cited in pretty much every subsequent article about the topic. So for our young hotshot hand fellow hoping to become a wrist specialist, I think it's a good option because it's going to help or preserve some range of motion.
CHRIS CHEN: It's going to help or preserve pain and hopefully it's going to slow the progression of SLAC wrist until at least you can get your hands on some good disability insurance. Thank you.
JEFFREY YAO: Very nicely done, Chris. So let's move on to Philadelphia.
JEFFREY YAO: Dr. Rabinovich, will discuss this All-Block SLL reconstruction. All right.
REMY RABINOVICH: All right. Can everyone see my screen? Yes, we can. All right. So my name is Remy Rabinovich, and I'm from the Philadelphia Hand Center.
REMY RABINOVICH: And I, along with my mentor, Mark Rekant, will be defending the All-Dorsal SL Reconstruction with an Internal Brace. So the treatment of stage 3 and 4 SL instability has led to the development of a vast arsenal of treatment options. As Kelly and Chris nicely talked about, the RASL and the three-LT are just two of the many ways to tackle this problem, none of which has proven to be the gold standard.
REMY RABINOVICH: The RASL, which was introduced in the late nineties, really has not stood the test of time. It's been associated with several complications, including revision surgery for painful progressive screw lucency, the inability to maintain initial deformity correction, the development and progression of degenerative changes and AVN of the scaphoid has also been reported. This has led to several institutions, including Peter Stern's group out of Cincinnati, as well as an institution out of France, to acknowledge that they've stopped using this technique altogether for SL dissociation.
REMY RABINOVICH: The three-LT, along with the earlier modifications of the Brunelli procedure, have overall demonstrated variable short term clinical outcomes. Marc Garcia-Elias noted that 18% of the patients develop progressive degenerative changes. In a more recent report out of France, the authors also noted that 20% of patients developed arthritis, along with diminished post-operative range of motion and the inability to hold that reduced SL interval and SL angle, as well as a 35% incidence of palmar pain but likely related to that anterior posterior approach required for this technique.
REMY RABINOVICH: The newer techniques out there, such as the 360 tenodesis and the anatomic front and back repair, have sparse published clinical outcomes. They're technically pretty complicated and they require multiple incisions and front and back approaches, which, as just alluded to in the previous slide, is not necessarily benign. So moving forward, what can we learn from the literature, as well as our experience with the RASL,
REMY RABINOVICH: three-LT and numerous other tendon ligament reconstructions available? Well, firstly, reconstructing the torn ligament solely with a tendon autograph does not match the native ligaments fiscal less properties and this leads to creep and delayed elongation. On the other extreme, placing the screw across the SL interval may create too rigid of a construct, which eventually leads to ecentric loading on that screw and possible lucency.
REMY RABINOVICH: The all dorsal SL reconstruction with internal brace provides that balance between not being too rigid or too elastic to restore stability. This technique has gained popularity while still in its infancy and aims to reconstruct that thicker dorsal portion of the SL ligament while stabilizing the scaphoid out of flexion, pronation and the lunate out of extension.
REMY RABINOVICH: A proposed advantage is that it's a biologic reconstruction, using a two to three millimeter slip of ECRL or ECRB that's reinforced with a robust one three millimeter suture, which basically acts as a brace while the tendon heals into the bone so this helps preserve that near physiologic motion between the scaphoid and the lunate while not being too elastic given the strong static suture tape.
REMY RABINOVICH: This technique is quick. It's simple, only utilizing a single dorsal incision, as opposed to the four other techniques discussed today, which not only require multiple incisions, but most of them require you to drill completely across one or more carpal bones and show the graft through numerous bony tunnels and/or ligaments. In a recent review on various cell reconstruction techniques, the authors noted that this was the preferred technique at their respective institutions.
REMY RABINOVICH: They illustrated a case of a former NFL player with painful SL instability. You can see the wide gap on the clenched, clenched fist views all the way to the right. At two years post-op, the patient was pain free and demonstrated an excellent wrist range of motion. His grip strength on the operative side was 170 kilograms, and on the contralateral side it was 160. These are his films at two years post-op, and you can appreciate the maintenance of a reduced ASL interval and no progression of degenerative changes.
REMY RABINOVICH: So in summary, the all dorsal reconstruction when the eternal brace is a simple and quick biologic reconstruction aim to restore the stronger dorsal portion of a state ballooning ligament while stabilizing the corpus out of a flexible deformity. It provides a satisfactory balance between not being too rigid or too elastic, which has limited earlier reconstruction attempts. So I got to Thank doctors mark Kent, David Zulu and Steve Lee for helping me out.
JEFFREY YAO: Thank you, Remi. Nice job. OK let's move on to the Mayo Clinic with Lauren Dutton, who will discuss the SLITT procedure.
LAUREN DUTTON: Good evening from Rochester, Minnesota, where it has finally stopped snowing. My name is Lauren Dutton. I am a hand fellow at Mayo Clinic and I will be discussing the SL 360 procedure as described by my mentor, Dr. Kakar.
LAUREN DUTTON: Dr. Kakar would like to acknowledge several individuals whose work led to the development of this procedure, including Dr's Berger, Garcia-Elias and Ho. We would also like to thank Dr. Huang, Dr. Hammad and Dr. Yao for all they have done to put together these fellowship cross country Zoom debates which have been educational as well as entertaining. Now quite a bit has changed over the past year, but some things have remained the same.
LAUREN DUTTON: As hand surgeons, our charge remains to attempt to prevent the X-ray from this case presented to us by Dr. Yao from evolving into this one. Doing so can be easier said than done, as reflected by the wide variety of techniques that have been employed over the years to address the problem of scaphoid lunate dissociation. So where do we begin when we approach a case of scaphoid lunate instability?
LAUREN DUTTON: Dr. Garcia Elias and colleagues have provided us with a useful roadmap in taking stock of SL injuries and planning treatment. To remember these factors, Dr. Kakar has created the mnemonic SCARCE, a term that took on a whole new meaning during the early days of the COVID 19 pandemic. The S stands for the integrity of the secondary stabilisers, as per Dr. Wolfe's recent work.
LAUREN DUTTON: The, in order to create a adhesive deformity more than just the SL ligament must be disrupted. The C is for cartilage status, as this will influence our decision of whether to reconstruct the SL ligament versus consider other options. A is for alignment of the carpus and specifically the position of the lunate and whether it is located within the lunate set or ulnarly translocated. The R is for reducibility of the SL interval, which can be judged arthroscopically after debridement of scar tissue and use of a probe to visualize the reduction.
LAUREN DUTTON: C is for chronicity of the injury, which provides a surrogate, surrogate indicator of the quality of the ligament and its ability to be repaired. And finally, E is for the extent of the ligament injury that is whether it is partial versus complete. So once these factors are assessed, our next task is to come up with an appropriate treatment plan. One common method for addressing SL ligament reconstruction is to focus solely on the dorsal SL ligament.
LAUREN DUTTON: And indeed, the work of Dr. Berger has shown us that the breaking strength of the dorsal SL ligament is close to 300 newtons, whereas the palmar ligament provides 120 Newtons. It's important to remember that while less than the dorsal ligament, this is still a substantial component of stability. Furthermore, if we only reconstruct the dorsal ligament and the presence of a complete ligament tear, not only will we only be halfway there, but we are also at risk of gapping open the volar SL interval.
LAUREN DUTTON: This is akin to fixing a fracture dorsally that then gaps open volarly. Dr. Ho and others have contributed significantly to the evolution of a combined dorsal and volar reconstruction by describing their techniques of reducing the SL interval and performing a box type reconstruction with a free tendon graft, followed by pinning. And these authors have shown favorable results. So the question becomes, can we take this concept of addressing both the dorsal and volar ligament disruption and at the same time improve upon it by eliminating K-wires, minimizing post-operative immobilization and addressing the secondary stabilizers that we know to be critical.
LAUREN DUTTON: So let's return to our case of this patient with a complete, irreparable SL tear and a reducible SL interval. How can we help fix her wrists so that she can go back to fixing other people's wrists? Our approach would be to perform an SL 360 reconstruction as follows. We begin by approaching the dorsal wrist via a ligament sparing capsularotomy as described by Dr. Berger.
LAUREN DUTTON: K-wires are inserted into the scaphoid and lunate and used to assess the reduced ability of the SL interval. Once this is confirmed, the wrist is flipped volarly and approached via an extended carpal tunnel incision. If present, a palmaris longus autograft is harvested, if not a plantaris allograft tendon is recommended. The graft is whipped stitched to each end with a four braided non absorbable suture.
LAUREN DUTTON: If there is no disi present, four or five K wires are placed parallel to each other through the scaphoid and lunate from dorsal to palmar and the presence of a disi deformity, the trajectory of the scaphoid pin is from dorsal distal to palmar proximal in order to correct the deformity. A three millimeter drill hole is created in the lunate and a 2.5 millimeter hole is made in the scaphoid to permit a single passage of the graft through the scaphoid with the larger hole placed in the lunate to eventually accommodate the second passage of the graft.
LAUREN DUTTON: A suture passer is used to first pass the graft from dorsal to volar through the lunate, then volar to dorsal through the scaphoid. And finally, from dorsal to volar back through the lunate, thereby completing the 360 tenodesis. The graft is tensioned and the wrist is cycled through a passive range of motion to decrease creep.
LAUREN DUTTON: The graft is then secured within both the scaphoid and the lunate, with bioabsorbable interference screws placed from dorsal to vollar. Through the tenodesis screw holes, a 1.3 millimeter diameter synthetic tape is passed from dorsal to volar through the scaphoid and the lunate and then type palmarly. The passage of the tape through the screws rather than directly over the bone, prevents the tape from cutting out through the carpus.
LAUREN DUTTON: All K-wires are removed. To control flexion of the scaphoid, the dorsal limb of the graft can be tethered to the distal pole of the scaphoid. In the case of this patient, who also had ulnar translocation of the lunate, the extra tail passed volarly through the lunate was used to reconstruct the long radiolunate ligament via a suture anchor placed into the distal radius. The capsule is closed with 2.0 non absorbable suture with great care taken to repair the dorsal radial carpal ligament back down to the carpus.
LAUREN DUTTON: The patient is immobilized in a short arm splint postoperatively, and rehab has begun at three or four weeks. This MRI was obtained at the three year follow up mark for a patient who underwent an SL 360 reconstruction. A recent biomechanical study compared the stiffness and maximum load to failure of a 360 tenodesis alone, as compared to one augmented with tape and found a two-fold increase in the maximum load to failure of reconstruction when augmented with tape, thereby rendering it nearly the same as that of the native dorsal SL ligament.
LAUREN DUTTON: Mark Twain told us that to a person with a hammer, every problem looks like a nail. Accordingly, we would submit that, as per Dr. Garcia-Elias's work, not every SL injury is the same. And thus we need a variety of tools in our armamentarium to address them. We propose the SL 360 as one such tool. Thank you very much for your time.
JEFFREY YAO: Thank you, Lauren. A very, much more diplomatic presentation. Thank you very much, that was great. OK so we'll round it out from New York again at HHS. Dr. Rambau. You have the floor.
GENEVIEVE RAMBAU: All right. So good evening, everybody.
KELLY ESPOSITO: I'm Genevieve Rambau, I'm from Hospital for Special Surgery. Thank you, everyone, for the chance to present and a special thank you to my mentor, Dr. Scott Wolfe for his help with putting this together. So I'm going to talk about the anatomical front and back repair, which is a new technique for chronic SL dissociation. This was pioneered by Dr. Michael Sandow in Australia and we've been starting to do this at HSS. So the impetus for this technique was to address the other deformities incumbent with chronic ACL injuries.
GENEVIEVE RAMBAU: I think the focus is often on the obvious SL diastasis, which often drives the treatments that we're discussing tonight with the focus on just reapproximating the scaphoid ameliorate {?}. But that may not address the other issues such as EC, scaphoid rotatory subluxation. And lastly, and perhaps most importantly, the dorsal gateway translation, which is the only radiographic parameter that correlates with post-operative pain.
GENEVIEVE RAMBAU: So we know that it takes more than the division of SL alone to lead to DISI and other main contributors for the wrist stability are the dorsal scaphoid and interosseous ligament, STT the long lunate, the DIC and the DRC. So when thinking about a repair technique, ideally the goal of surgery would be to perform a true anatomic repair and to restore all the ligaments involved.
GENEVIEVE RAMBAU: Many of the procedures, like the first three focus on reapproximation of the scaphoidolunate. The TLT adds one more step in restoration of the STT ligament arguably, plus or minus the DIC, however, the new technique the NFAB, additionally restores the critical long radial lunate ligament as well as the other three elements. So this technique is one of multiple reconstructive procedures previously described reconstructing those four important stabilizers of the wrist.
GENEVIEVE RAMBAU: It's indicated for SL diastasis and SLAC wrists or Garcia-Elias stage 4 and 5. The contraindications are fixed deformity, advanced arthritis, osteoporosis and inflammatory arthritis. This is a transition technique, beginning with the dorsal approach to the wrist, a longitudinal incision through the third dorsal compartment. A window capsulotomy is performed, preserving the DIC and the DRC.
GENEVIEVE RAMBAU: A volar FDR approach is performed and the trapezium is exposed and an anchor with suture tape is placed as shown in the schematics into the lower trapezium. The palmar carpus is exposed for the radial lunate tunnel along with the radial styloid if a styloidectomy is to be performed in conjunction. And I have access to the volar and dorsal wrist. The scaphoid tunnel is then drilled from dorsal to volar with your index finger on the tubercle and the volar structure is well, well protected as seen in the image on the right.
GENEVIEVE RAMBAU: K-Wire placement is confirmed on fluoroscopy and then using a 3 millimeter accumulator drill over k-wire, you create this scaphoid tunnel as shown here. The lunate tunnel has been drilled also from dorsal to volar, again careful to protect the volar structures. And lastly, the radial tunnel is drilled from volar to dorsal, aiming to exit at the radial and proximal margins of Lister's tubercle. A 3 millimeter radial strip of the FCR tendon is harvested and dissected distally and load of the trapezium for accurate line of pull.
GENEVIEVE RAMBAU: The tendon and suture taped together, then pass sequentially through the tunnels and secured with interference screws at each segment. The first materials are passed from volar to dorsal through the scaphoid to recreate the STP while holding tension. It is secured volarly in the scaphoid with an interference screw. A small trough is made in the dorsal scaphoid to allow tendon growth and the tendon to taper, then pass from the dorsal scaphoid through the dorsal lunate.
GENEVIEVE RAMBAU: Prior to tensioning, a knotted suture iss placed in the dorsal lunate to allow for laser reapproximation of the DIC and the tendon suture tape and knotted suture are secure with an interference screw in the dorsal lunate. They're then passed from volar to dorsal through the distal radius to recreate the long radial lunate ligament and tension and secured in a similar fashion.
GENEVIEVE RAMBAU: A new modification to this is augmenting the repair with an additional suture boning or dorsally approximately to the long radial lunate tunnel. This is a critical stabilizer to resist any pull out and act as a ripstop should failure occur along the way. Closure begins first with reapproximation of the dorsal ligaments and a pants over vest repair, using that knotted for suture that was dumped into the lunate.
GENEVIEVE RAMBAU: As an intraoperative fluroscopy showing reduction of the ethyl gas, restoration of scaphoidolunate angle and the radial lunate angle and an improvement of the dorsal scaphoid translation. And an important pre and post op imaging showing again the importance of correction of that dorsal scaphoid translation. Oops. Sorry about that. So post-op patients are placed into a cast immobilization for six weeks.
GENEVIEVE RAMBAU: Thumb spica optional. There are no k-wires needed for stabilization. I'm not sure. But this is one of my patients. So stop being able to do that. So this, I mentioned before. There's not a lot of literature about this technique yet. It's relatively new.
GENEVIEVE RAMBAU: Dr. Sandow has published a small cohort 10 patients with a minimum two year follow up, showing excellent return of grip, strength and motion. One patient was revised with an ulnar shortening osteotomy, but had no further issues at the time of publication. Our own series hereat HSS, we've done 14 patients with an average six month follow up, arguably very short, but so far have shown a modest decrease in wrist range of motion and grip strength at early follow up, although grip strength is not statistically significant.
GENEVIEVE RAMBAU: There was an improvement in the radiographic assessment of the SL angle, the gap and dorsal scaphoid translation. We did have two complications, one was a patient with earlier fixation distally, and that was the impetus for adding that additional zone anchor. And the patient was converted to PSC and one patient's osteogenesis imperfecta ended up with a VISI deformity but had an improved scaphoidolunate angle.
GENEVIEVE RAMBAU: So in summary, yes, it's a very new technique. We don't have long term data, but our preliminary studies are somewhat promising so it'll be interesting to follow this technique as it continues to develop and as modifications are made and I think hopefully it can offer one option for a very difficult problem, in the wrist that we still have not totally figured out. Thank you guys for your time.
JEFFREY YAO: Great. Thank you very much and thank you to all of our Fellows. Those were great presentations. I applaud you all and thank you to the mentors. The, all the Fellows were clearly well coached, so thank you very much. What I'd like to do is to know, I guess, Jerry, can you launch the poll or I guess the pole is already launched?
JERRY HUANG: It's a matter of. Wait, wait, now, hold on. Can anybody see the poll on there? So yep, it's there.
JEFFREY YAO: So we'll take about 30 seconds to just answer these two questions. Again there are no losers here. There's only one winner, and I'm just joking.
JEFFREY YAO: Everyone's a winner here. But I'd love to see how the group feels in terms of these procedures, which are all very promising. But the question is, has one distinguished itself as being more promising than any of the others.
JERRY HUANG: Score, about 50% voting so far. So I'm going to give another few more seconds.
JERRY HUANG: It's looking close. Very close.
REMY RABINOVICH: Sanj, for a second, I thought that scarce was referring to my golf shot hitting the green.
JERRY HUANG: I'm going to go ahead and end the poll right now here Jeff (OK) so the poll is ending. I'm going to go ahead and share the results.
JEFFREY YAO: Oh, there you go.
REMY RABINOVICH: I'm glad we have a consensus. That's great. Yeah.
JERRY HUANG: Can anybody see the results from both questions on the poll on their screen?
JEFFREY YAO: I can see them. Hopefully everyone can see them. So it looks like.
REMY RABINOVICH: Yeah, you know, one, Jeff, come on, you can say it.
JEFFREY YAO: So for those of you, if you can't see, it looks like in terms of the most compelling argument, it looks like long term follow up trumps all, and then the which procedure people would want done. Looks like the swivel lock reconstruction if it were your own wrist. Interesting in hearing what the other options would have been, whether that be denervation or a salvage procedure.
JEFFREY YAO: I purposely sort of massaged the case a little bit such that the denervation and the salvage procedure was not an option but obviously, I don't want to make the point. I want to make the point that those clearly are good options as well. OK well, great. Thank you for your participation in the poll. We're down to 10 minutes, but I'd like to take a moment to ask our mentors, Dr Rosenwasser, Dr.
JEFFREY YAO: Lauder, Dr Rekant, Dr Kakar and Dr Wolfe two quite simple questions. Number one, do you ever see a case of scaphoidolunate dissociation, which is still reducible and still reconstructable where you would not use your advocated technique and why? And number two, is there ever a situation when you would use one of the other proposed techniques? So, Mel, what do you think?
JEFFREY YAO: Is there ever a case where you would not use a RASL?
MEL ROSENWASSER: Yeah I think, you know, I pushed the envelope in some cases early on and they were patients that had some arthritis in the midcarpal joint. And those were always mistakes because those patients, even though they had better alignment, they had more discomfort, more pain, and they were actually probably made worse.
MEL ROSENWASSER: But I think if the right if you have the right indication, I think it's doable. I think your question is, if there's ligaments still there, would you just do a repair, even if it was late? Because I'm not quite sure that 8 to 12 week limit to repairs, because sometimes a ligament is still there, and I don't mean just the avulsion from the scaphoid, but, but actually there's ligament there and I never when I do this procedure debride any of the dorsal ligament structures, even if they don't look great, I mean, I use it as just part of a scar formation and I always leave it there.
MEL ROSENWASSER: But what's interesting to me is that a lot of these techniques, no matter what they're done, they could still benefit from a stabilization. And when I first started doing RASL's, people kept saying, when do you want to take them out? So some people like to put these in and take them out after they've had sufficient biologic healing. So I don't have any, I don't take any issue with people that said, I want to take it out, although I've not done it because I haven't seen a lot of trouble with issues in the screw long term.
MEL ROSENWASSER: I know everybody sort of harps on the lucency, but, you know, every one of these cases and techniques we saw, there's giant holes in the bone. I mean, what more lutency do you want if there's three to 4 millimeter holes in the bone. So if you have a half a millimeter lutency around the threads of a screw, is that worse than a 4 millimeter hole in the bone? I don't think so, but I don't think that's the issue.
MEL ROSENWASSER: The issue is maintaining alignment. And I think the critical issue and I agree with Scott Wolfe, keeping the scaphoid proximal pole from dorsally subluxing and getting a lunate reduction. However you do it, I think that's the key to getting long term results. I've continued to do it and I follow the patients very carefully and I'm satisfied with the outcomes.
JEFFREY YAO: Great, Alex.
ALEX LAUDER: So I think the first question you had was if it's reducible, is there a technique that you would use in a different way? Would you change the technique based on the patient? And so our patient population is a tertiary County Hospital and in a large city and for the labor who can't take time off of work, for the homeless patient what not, it's not going to have good follow up or it doesn't have resources or the patient that can't participate in the adequate rehab that you need to truly kind of repair, you know, have a good repair of that biology, you know, something like injections, non operative treatment.
ALEX LAUDER: Those things are definitely something to keep in mind. Other situations when you might have to think outside the box a little bit is the patient with FCR tendonosis? If you're going to use that SCR as a reconstructive model for your tendon and keep it attached to its insertion, that's really something you have to think about looking at and really examining the patient ahead of time, because if you're going to use that and it ruptures, that might compromise your fixation.
ALEX LAUDER: Other times you have to think outside the box or use a different method is patients with a failed RASL, a failed swivelock or a failed implant, or you have to take that out and they have huge holes in the bone and you might have to do something differently as well.
ALEX LAUDER: So those are all things to keep in mind and obviously all the kind of key learning points that were mentioned before is having a flexible, reducible deformity, making sure you don't have any concomitant arthritic changes in the mid carpal joint or ST joint. Things to, those are all things to that might sway your choices as well.
JEFFREY YAO: Great. Thanks.
JEFFREY YAO: Thanks for those comments, Mark?
MARK REKANT: Yeah, I would just echo what Alex was saying and now is I think it's helpful to have many tools in the toolbox. This technique doesn't burn any bridges. It's not harvesting a tendon, it's not destroying a cartilage with a Burr but certainly I think the evidence, as it was demonstrated with excellent speakers, so thank you, is that if a patient had a strong inkling whether a family member advised them or a previous surgeon advised them of another technique that was described today, I don't think there's enough evidence that I would try to talk them out of that procedure.
MARK REKANT: Given that, I think there's some placebo effect with any of these procedures in believing if the patient thinks that particular technique is best for them, then it's helpful to have other tools in your toolbox, so to speak.
JEFFREY YAO: OK. Sanj?
SANJ KAKAR: So I think there's a couple of thoughts. Number one, I think from tonight, as Lauren and all the speakers have shown, when you see a gap, a gap is not just the gap.
SANJ KAKAR: There's many factors that you have to consider and Scott and Steve's work in New York has really shown a lot of what the ligaments have injured and what needs to be done. I think to answer your question, though, there are occasions and we did one two days ago where the patient, we scoped him, volarly he was stable and dorsally was gapping open and so we did the Christophe Mathlow [?] in arthroscopic SL capsulardesis.
SANJ KAKAR: And you know what, I saw his patients and his patients actually did really well with minimal morbidity and great motion. Now, yes, they gapped a little bit, but they were pain free, so I think that is a very useful technique. And I tell the patients, I'll scope you and if there's a big gap and I think you need a front back, we'll do it another time. I think it's a big operation that they have to get through. But if it's like we had the other day, volarly he's intact, dorsally open.
SANJ KAKAR: I think that's minimal morbidity operation, and if it fails, you can always do one of the things that we discussed.
JEFFREY YAO: I think that's a great point and not to beat a dead horse, but Scott and Steve from New York, they're work on the dorsal translation of the proximal pole, the scaphoid, if that's controlled, I think that's clearly more important than closing the gap with the scaphoid lunate interval
JEFFREY YAO: and that's why the capsulardesis tend to work as well, albeit limiting range of motion. Thanks for those comments. All right, Scott, what do you think?
SCOTT WOLFE: Thanks, Jeff. First of all, I think it's tremendously exciting that we've got a conference like this going. We for years have kind of treated this the same way and I think there's a whole array of different ways to look at this now.
KELLY ESPOSITO: And the challenge is for us to not just sort of pick what sounds best, but the challenge is really to study this now in large numbers and the only way we can do that is to look at these stratified by the type of injury. Pick your classification. I like Marc Garcia-Elias and pick that classification and then look at how these repairs pan out over the years going forward at one year, two year, 5 years and 10.
SCOTT WOLFE: So we can really see the differences that these different repairs will have on long term outcomes. So that's just a plug. I mean, I'm really excited about all the work that's being done now. I think we have a chance at finally making a real dent in this problem that Ron Lynchard and Jim Dobbins brought to our attention 50 years ago.
SCOTT WOLFE: I mean, you could almost say that we haven't really advanced that far. And to answer your questions, yes, I think that from what I've learned is that in a patient with severe osteoporosis, I wouldn't do this. It's so dependent on getting a bite on those different bones that you don't want to put synthetic tape and implants into soft bone. In that one case, it failed.
SCOTT WOLFE: And also, it's so good this antegrade repair, it's so good at bringing back your DISI that if you do have a lax wrist that tends to fall into DISI it may convert you to a VISI, which I don't think is the end of the world and that particular patient that went into VISI some is doing quite well. That's the thing. It'll tip the balance more towards VISI in a very lax patient I think.
SCOTT WOLFE: And when would I do something else? Yeah, like Mel said, if you've got a good strong repair or a strong ligament that you can repair and it's an early case, I would try to do that. I like I still like that. But I think the advantage of this repair is it really does cover all the bases. It gets your lower and dorsal contributors to eliminate and your natural stability that you really do have to address.
SCOTT WOLFE: One thing I would just throw in an element of caution with the swivelock repair, is we're now looking at a series of patients who've had osteolisis and extrusion of these implants from the scaphoidolunate and just clear cut fractures and destruction of their proximal carpal growth. So we're looking at that histologically, we're trying to figure out what it is, but I would just inject an element of caution.
SCOTT WOLFE: That's a lot of material to be putting in these very small bones, so just something to think about.
MARK REKANT: Scott that brings up a great point and maybe similar to the CMC stabilization, perhaps there have been some surgeons putting them in beyond the biomechanical tighteners, so I think as Remy said, you can certainly over tighten these as was been done with the mini tightrope.
MARK REKANT: And maybe that may be the cause that you're seeing, or could.
JEFFREY YAO: Oh, don't bring the mini tight rope into this Mark.
MARK REKANT: I'm sorry.
SCOTT WOLFE: One last thing. One one very interesting thing that we're going to publish shortly is that the traditional capsular split,
SCOTT WOLFE: we're concerned because that really does take down these ligament attachments of both the dorsal rator carpal and the dorsal hook carpal and a lunate and be very careful if you do that, you're adding what is really angiogenic instability on top of what's already a bad situation. So if you have to do that approach and I did that for years, decades, but if you have to do that approach, make sure you hammer it back down with some good anchors and make sure you reattach those ligaments.
SCOTT WOLFE: Very important.
JEFFREY YAO: Very good points, everyone. Unfortunately, we could go on forever. Unfortunately it's 6:00 our time,
JEFFREY YAO: I guess 9:00 on the East Coast. I'd really again, like to thank all of our Fellows for outstanding presentations. I'd like totThank the mentors for their comments. Jerry, do you want to take us home?
JERRY HUANG: Yeah, sure.
JERRY HUANG: Yeah, sure. Yeah Jeff, thank you so much for the moderation, introduction to overview. I agree all five Fellows and thank you for all five mentors for excellent coaching and presentations, I think.
JERRY HUANG: Great learning points and hopefully get to keep this going for a while and folks are getting busy. As I mentioned, it's going to be every other week and going on to every month kind of going forward the academic year but thank you all for joining us. So in two weeks, it's going to be on another very non-controversial topic on arthritis in terms of what's going to be best treatment for that for a 25 year old, 50-year-old and potentially a 75-year-old rheumatoid,
JERRY HUANG: so hopefully you could join us and everybody stay safe and healthy out there. And I thank you for joining us.
MEL ROSENWASSER: And I want to make one point. These, these conferences go much better when you're drinking wine. So I'm so I'm surprised to not see any other wine glasses there. Sanj, what do you have one hidden down below the desk or something?
SANJ KAKAR: I've got. I've got milk.
KELLY ESPOSITO: You're not clocking in or something at the Mayo Clinic right now, are you?
KELLY ESPOSITO: Mark's got a whole vineyard behind him, so.
MARK REKANT: Oh, Yeah.
SANJ KAKAR: We have to be sharp Mel, with you and Scott coming at us, you know what I mean?
MEL ROSENWASSER: Oh, it was benign tonight. It was very benign. We're among friends. Of course, we are. Yes, we are.
SCOTT WOLFE: Good job, Jeff. Good job, Jerry.
MEL ROSENWASSER: Yeah thanks a lot, Jeff and Jerry for putting it on.
SANJ KAKAR: Cheers, guys.
SANJ KAKAR: Thanks for. Thanks, Jeff. Thanks, Jerry. Three top guys. Take it easy, Take care.
Segment:0 .
JERRY HUANG: Welcome back, everybody. Jerry Huang from University of Washington. Welcome, everybody back to Controversies in Hand Surgery and Fellowship, virtual debate. And really one of the things Dr. Hammer and Dr. Leversedge last week for an excellent job not that we joined but was able to watch recording and another great job are the Fellows, the moderator as well as the mentors.
JERRY HUANG: So I think what's been great about this, I think everybody is hopefully able to return back about clinic and but I certainly really enjoyed this opportunity to learn from faculty from across the country and learn different perspectives. I think collegiality has been kind of unbelievable across the board. I think every week I'm amazed at how great a job the Fellows do. Certainly an amazing job on presentation, the content and the delivery.
JERRY HUANG: The mentors and moderators can't do this without you guys so thank you so much. And then last couple of weeks, we switched to a new format, so kind of a longer overview by the moderator and also introduction and also allowed for a lot more time for discussion. And Dr. Yao today is going to be adding a participant poll today to try and kind of gauge what people will do. So as we kind of get ready for the face off between the different institutions, I think this week is more like a cage match with five different institutions in the cage, very, very strong believers in their technique,
JERRY HUANG: and this is going to be moderated by Dr. Yao out of Stanford, and it's going to be University of Colorado versus Columbia versus the Mayo Clinic, Philadelphia Cancer Center and HSS. From there, I'm going to pass it off to Jeff Yao.
JEFFREY YAO: Thanks, Jerry. Cool thanks, Jerry, and thanks, Jerry and Warren for continuing to set up these great educational opportunities during this crisis.
JEFFREY YAO: I hope everyone and their loved ones are staying safe and well. So I've been tasked to be the moderator for this discussion/debate. We'll talk about the chronic scapholunate ligament injury: The debate rages on. So what are we talking about here? We're talking about the chronic scapholunate ligament injury where the ligament is no longer repairable so we're outside of that 6 to 8 to 10 week window where the ligament is still repairable.
JEFFREY YAO: But, it's not to the point where the patients develop SLAC arthritis and unfortunately, we get a fair number of patients who show up in this space and this stage. So here's our case. So this may or may not be based on true events. We have a 31-year-old hand fellow fell off her bicycle on the way to the hospital to go in for a replant.
JEFFREY YAO: She thought she just, quote unquote, sprained her right dominant wrist. She had dorsal central wrist pain, this persisted for months but she was afraid to get it checked out, out of fear of scorn from her fellowship director. Six months later, she told her highly supportive hand fellowship director, who urged her to get some film
JEFFREY YAO: and this is what she got. So now this is six months after her injury.
JEFFREY YAO: similar results. So she wanted to continue with fellowship with minimal time off, so she elected to have a wrist arthroscopy debridement and denervation procedure. Upon wrist arthroscopy showed a wide scaffolding interval, drive-through sign the capitated view through viewed the radiocarpal joint.
JEFFREY YAO: So if you look at Will Geissler, there's arthroscopic classification, this would be a stage four tear or the IWAS classification, a stage four tear as well. So suffice it to say that denervation failed, we couldn't operate. She'd just signed a deal to become a new hand surgeon at a prominent academic center. She was hired to be the new hotshot risk specialist and she, quote unquote, needs a wrist to be able to operate.
JEFFREY YAO: In case you're considering a salvage, she had family members that had both a scaphoid excision four corner fusion and PRC with dismal results so she wasn't interested in either of those options. So we're talking about Mark RC Elias stage three/four. This is where the ligaments disrupted. This is where the scaphoid is still normally aligned, and most importantly, the carpel malalignment is easily reducible.
JEFFREY YAO: And the cartilages of both the radial carpal and MC joints are normal. So this is before the scaphoids and lunate has fallen into the fixed, easy deformity. The joint is still reducible. So what are your options in this situation? We already spoke about denervation. Historically, capsulodeses were popular, and then as you can see, there's a number of different scapholunate ligament reconstruction procedures that have been described.
JEFFREY YAO: This is not even an exhaustive list. And as the saying goes, when there's multiple ways to treat one problem, either they all work as in the case for thumb CMC arthritis or they all don't work and unfortunately in this situation, none of these procedures in my mind has definitively distinguished itself from the others as being the true gold standard
JEFFREY YAO: but maybe we'll be convinced of other otherwise today. So we'll be talking about these five techniques, so what do we do now in this situation? So get ready for the Battle of the acronyms and let's meet our combatants. And please forgive me if I had a little bit of fun with this. It's been a long time of quarantine with my family so I took a little time to have a little fun with this. So the first group will be from Colombia.
JEFFREY YAO: We'll be talking about the RAZL. This is Dr. Kelly Esposito and Mel "The Gladiator, Rosenwasser. Sorry no, I had to do something with the facial hair, I think. What about the 3LT? That, that'll be Christopher Chen and Alex "The Marauder" Lauder from the University of Colorado. The Swivelock SL Reconstruction with Remy Rabinovich and Mark "The Ravager" Rekant from the Philadelphia Hand to Shoulder Center.
JEFFREY YAO: More acronyms. The SLITT procedure. Dr. Lauren Dutton and Sanj "The Centaur" Kakar. Nice ads there Sanj, from the Mayo Clinic. And last the ANAFAB with Genevieve Rambau and Scott. this was too easy, "The Wear" Wolfe.
JEFFREY YAO: From HSS. Probably the friendliest werewolf you'll see. After the presentation, Jerry is going to put up a poll and I request all the participants to answer two short questions at the end of the presentations. And so with that, hopefully the audio plays. All right. So I think our first speaker will be Dr. Esposito from Columbia, if you want to go ahead and share your screen.
KELLY ESPOSITO: All right. All right.
KELLY ESPOSITO: Can you see that? Yes great. OK, so Mills gone. OK, so up first, we will be making the case for the RASL procedure.
KELLY ESPOSITO: I'm Kelly Esposito. I'm the fellow at Columbia, and my mentor is Dr. Rosenwasser, who I'd like to thank for his help with this presentation and his help in mentoring me for this entire year. So, as was already mentioned, this is clearly the Battle of the Acronyms. And I think the one acronym that we're really going for here is the GOAT.
KELLY ESPOSITO: And seen here a goat is shooting the illest album of 2020 and we're here to argue that the GOAT in this situation is the RASL. So a similar case is the one that was presented. This is a 40-year-old young person, chronic cell instability causing pain, weakness and functional limitation. I won't belabor any of the anatomical points about this as obviously this audience is very well familiar with this problem.
KELLY ESPOSITO: However, I will point out one salient point, which is that there are 20 degrees of relative motion between the scaphoid and the lunate. The scaphoid continues to flex after the lunate stops, and so it's important to be able to replicate this physiological motion and if you tie the two bones together too tightly, you will lose that. So there's many options, most of which are interesting acronyms
KELLY ESPOSITO: and we'll hear about five of them today and our preferred treatment is the RASL. So to frame this debate, we like to harken back to a well known surgeon of yesteryear, Dr. Codman, who essentially invented the idea of follow up. And so on that vein, what kind of follow up do we have for today's contenders? And a quick review of the literature. The three-LT has some medium term, short term follow up available.
KELLY ESPOSITO: The NFAB has some preliminary outcome available in the literature and the other two procedures today have some biomechanical studies and technical guides, but no published cohorts of follow up yet. Here's a summary of the literature in descending order of the amount of follow up that's published in the literature at this time. And we would be very interested in having this debate perhaps again in 10 years when we had more long term follow up
KELLY ESPOSITO: but alas, we're doing this now and we have 20 plus years of follow up on the RASL procedure. This was first described in 1997, and we've been following the patients since. So to go over the RASL procedure, the concept is like an axle. And as I mentioned, it's important to preserve some of the physiologic motion between the scaphoid and the lunate,
KELLY ESPOSITO: and as you will hear from no doubt my colleagues today, it's important to preserve both the dorsal and the volar components as this is a really strong, this is quite a lot of force that goes through this joint. The RASL achieves this by going through the center and creating an axle. And so it actually supports both dorsally and volarly. I'll quickly go over the technique and then I'll go over this step by step.
KELLY ESPOSITO: So this is done through two incisions, a longitudinal dorsal incision in addition to a radial styloid incision over the first dorsal compartment. We do a capsular or a ligament sparing capsular approach, and we work through two windows, use joysticks to reduce the scapholunate interval and then place a screw down the axis, and the trajectory of the screw is paramount to the success of this procedure
KELLY ESPOSITO: as I will go into. So you start with your dorsal incision, make sure to preserve the dorsal ligaments and Dr. Wolfe has actually done great biomechanical research emphasizing the importance of maintaining these attachments. The other incision is over the radial styloid, and it's imperative that you perform a radial styloidectomy to get the correct starting point and I'll go into that a bit in a moment, but this is a key point to this procedure.
KELLY ESPOSITO: You then perform reduction association with the scaphoid and lunate by placing K wires into the respective bones, reducing the lunate under the capitate and making sure these K wires are out of the trajectory of your screw, which is a little tricky at first but practiced hand surgeons can certainly get the hang of it. It's important to not skip this step, either the burring of the subchondral or to the subchondral surfaces of the two bones to be able to get a fibrous neoligament scar response.
KELLY ESPOSITO: Again, this is not a fusion procedure, so we want some physiological motion, but it's important to get a healing response. This is an important step. You then use a Kocher clamp to maintain your reduction and after your radial styloidectomy as you can see what's done here, you place your guidewire in the correct axis and the correct axis of the screw is exactly parallel to the inclination of the distal radius, as you can see here on the P X-ray, and then in the sagittal plane, you want to aim right at the center of the lunate or aim slightly lower.
KELLY ESPOSITO: It's very important to not place the screw dorsal. So again, to recap, the critical technical points of this procedure are perform a radial styloidectomy or it's not possible to get the correct starting point for the screw. The correct starting point for the screw is at or proximal to the dorsal lateral ridge of the scaphoid. And in the example that was shown at the very beginning, actually that starting point was a bit distal.
KELLY ESPOSITO: The axis of the screw is directed toward the center of the lunate, as I mentioned, and you never want to place the screw to dorsal. Screw placement is fundamental to the success of this procedure and we would argue that that's fundamental, that correct technique and adherence to rigorous standards is important to the success of any orthopedic procedure, and we aren't the only people saying this.
KELLY ESPOSITO: Dr. Hausman published on the placement and the importance of the starting point and with a distal starting point that that's associated with failure. So what this means is if the screw is in the wrong place or steps are skipped, you're not doing a RASL. Maybe you're doing some sort of modification, but it's not the RASL as we're describing it here. And so to take a page out of the Book of B Rabbit seen here on the left in the finale of the movie Eight Mile, he was also selected to go first, and his strategy was to anticipate the critiques that his opponent, Papa Doc, would be leveraging at him.
KELLY ESPOSITO: And so in that vein, I have a few papers I'd like to clarify here. The first is this paper by Dr. Stern, which concluded that the RASL procedure was ineffective in providing stability about the FL interval. However, you can see, there were no radial styloidectomies performed in this, there were no lateral x-rays included
KELLY ESPOSITO: so we don't know where the screw was in the sagittal plane and the starting point is too distal. So we would argue this was not the RASL procedure that was performed here. Similarly, Dr. Aibinder et al concluded that this procedure has a high rate of early failure and reoperation. However, there is a tremendous amount of variation in the types of screws, lengths of screws and placement of the screws, whether or not a styloidectomy was performed,
KELLY ESPOSITO: so there is sort of a heterogeneous mix of things that were done. And actually, to quote the article itself, they believe that the failures may have been due to the challenges of the screw placement as opposed to a problem with the procedure itself, if done, if done in the described way. So let's say we followed the steps and put the screws, put the screw in the correct place.
KELLY ESPOSITO: How do these do? Well, at that point, the proof is really in the pudding. We have the longest published follow up of chronic static SL instability at an average of about 10 and 1/2 years, 35 patients ranging from 1 to 24 years. They maintained 80% of their motion and grip strength and the reduction was maintained over that time as well. Here are a couple of case examples.
KELLY ESPOSITO: This is a patient at almost 19 years. This is one at 20 years, and here he is in the office and you can see his range of motion. And then, as Dr. Sandel mentioned, the gold standard is really the ability to do a push Upup and you can see this patient would do as many push ups as we wanted him to in the office.
KELLY ESPOSITO: So back to our case. We were very careful to place the screw in the ideal position. As described earlier, radius styloidectomy was done, subchondral brain was done to create the neo ligament healing response and you can notice that the starting point is in the correct position proximal to the dorsal lateral ridge of the scaphoid. Three months post op screw is in the same place,
KELLY ESPOSITO: and I will note it's actually it's expected to have a little bit of lutency due to the physiologic motion, this stays stable and does not regress. Here he is in the office and then here's the patient at 9 years with essentially equal grip strength bilaterally. At this point, I yhank you for your attention and I would like to pass the mic to my colleagues.
JEFFREY YAO: Wow with the mic drop and everything, that's impressive. Thank you, Kelly. All right, so we'll move on. Our next speaker will be Chris Chen from the University of Colorado. Chris, there you go.
CHRIS CHEN: All right, guys, can you hear me? Yep cool. What? My name is Chris Chen and I'm one of the hand fellows at the University of Colorado. And I'll be talking to you about the three-LT technique for SL dissociation. And I don't actually have any conflicts of interest in this case because I've never actually seen one before because this isn't actually performed in our institution routinely.
CHRIS CHEN: All right, so we all know the basics of SL ligaments. The proximal rows and intercalated segment doesn't have any musculotendinous attachments, and lunate is held balanced in the neutral position because of the flexion of the scaphoid and the extension of the triquetrum. And of course, if you disrupt the SL ligament, it's a crucial link between the scapholunate,
CHRIS CHEN: and when it gets disrupted, you get slac wrist, right? Well, it's actually not that simple because we often forget about the secondary stabilisers, such as the STT ligament and the dorsal radial carpal ligament, which also play an important role in stabilizing the proximal role. A more complete way to think about this injury is that complete SL injury, in addition to the failure of the secondary stabilizers, leads to abnormal kinematics and then eventually slac wrist.
CHRIS CHEN: So as Dr. Yao mentioned, these injuries often present chronic, and they're often at six to greater than six to eight weeks out from their injury, and at that point, repair isn't a good option. Unfortunately, there's no gold standard technique. However, there are a lot of non gold standard techniques, and this is a small sampling of the main techniques out there, and we're running out of acronyms for all the treatment options.
CHRIS CHEN: Props to RASL dazzle crew. That's a pretty cool one. The SLITT technique is also a pretty cute name too. So the three-LT technique was first published by Garcia-Eias in general hand surgery in 2006. It's indicated for complete injuries with non repairable ligaments where the deformity is still reducible and ideally there's minimal or no arthritis. The technique has three goals in mind. So the first is to reconstruct the dorsal SL ligament.
CHRIS CHEN: The second goal is to augment the palmar distal connections to the scaphoid, that is the palmar-STT ligaments, and the third goal is to reduce ulnar translation of the lunate. So the technique actually incorporates elements of three previously described techniques, and we are trying to compare these techniques. It's kind of like playing spot the difference. So I made it easy for you in red.
CHRIS CHEN: So in red are the elements from each of these methods that are incorporated into the three-LT technique. So the original Brunelli technique, we use a slip of the FDR through a hole of the distal scaphoid and tenodesis across the radial carpal joint, which theoretically could lead to some wrist stiffness. The Linscheid technique is similar, it uses the ECRB, however, it's different in that it uses the dorsal radial triquetral ligament as a pulley and it does not cross the radial
CHRIS CHEN: carpal joint. The Van Den Abbelle technique also uses the FCR and it incorporates the pulley described by Linscheid so it doesn't cross the radial carpal joints. So the three-LT technique takes the best elements of each of these techniques and we use the FCR down the long axis of the scaphoid and this helps to augment the SCT segment as well as the dorsal radial triquetral ligament.
CHRIS CHEN: And it doesn't cross the radiocarpal joint. So to perform the technique, you begin with the standard dorsal approach. You do a berger ligament spearing capsulotomy and you want to make sure you leave enough of the dorsal radial triquetral ligament such that you can make a pulley in the later steps. Next through a separate incision, you harvest a 8 centimeter distally based strip of FCR, you then weave it through a drill hole in the long axis of the scaphoid.
CHRIS CHEN: And this is a crucial step because this is the step that augments the volar SCT ligament. You then create a trough in the lunate with a burr, you drop a suture anchor in there and this is going to help the tendon heal to the bone. When you localize your dorsal radial triquetral ligament, you create a slit. You pass the tendon through, reduce the proximal row, lock it down with K wires from the scaphoid to capitate to the scaphoid lunate and you tighten everything down, including the suture anchoring,
CHRIS CHEN: sew the ligament back on itself. So it's the best technique because it reconstructs the dorsal SL-ligament, it augments the palmar STT-ligament and it doesn't cross the radiocarpal joint. And theoretically, this creates normal carpal kinematics and theoretically, it prevents SLAC wrist. So that's the theory but how does it actually do in real life? So this is a compilation of eight different studies and it includes both a three LT technique as well as the Van Dem Abbeele technique, which is very, very similar.
CHRIS CHEN: And the original series by Garcia-Elias was, followed 38 patients for four years. 74% of them had no pain at rest, 21% had some pain with loading and 5% in chronic pain. Well, we'll just ignore those 5%. Two patients experienced recurrence of carpal collapse and 24% progressed to arthritis, however, most of it was mild in 18% of cases, and there were very few complications and no cases of avascular necrosis.
CHRIS CHEN: Overall, other studies have been able to replicate the success, which is important. Other case series range from 8 patients to 117 patients, with follow up anywhere between 10 months to 14 years. And most series demonstrate that pain improvement can be achieved pretty consistently, and the incidence of chronic pain or unchanged pain is between 5 to 27%. With regard to radiographic parameters, the SL angle is typically improved to somewhere between 54 to 68 degrees.
CHRIS CHEN: However, loss of reduction and increased SL gap at the final follow up is not uncommon. Range of motion and grip strength are also reasonable, with 75% to 85% of the pre-op motion being reserved and grip strength approaching 65% to 85% of the contralateral side. So overall the incidence of progression of arthritis is relatively low and actually the highest rate of progression, as reported in the original series by Garcia-Elias.
CHRIS CHEN: And complication rates are very low. So you all remember, first do no harm, right? In conclusion, the three LT technique is a reasonable technique. Like every other technique, 60% of the time it works every time. It has a theoretical, anatomic benefit. It also has a long track record, unlike a lot of the other techniques we'll be hearing about today. It has a low complication rate,
CHRIS CHEN: unlike certain screws, which may loosen over time. And whether or not you like the technique or not, it's a classic technique to know about and it's been used as a benchmark, and it's commonly cited in pretty much every subsequent article about the topic. So for our young hotshot hand fellow hoping to become a wrist specialist, I think it's a good option because it's going to help or preserve some range of motion.
CHRIS CHEN: It's going to help or preserve pain and hopefully it's going to slow the progression of SLAC wrist until at least you can get your hands on some good disability insurance. Thank you.
JEFFREY YAO: Very nicely done, Chris. So let's move on to Philadelphia.
JEFFREY YAO: Dr. Rabinovich, will discuss this All-Block SLL reconstruction. All right.
REMY RABINOVICH: All right. Can everyone see my screen? Yes, we can. All right. So my name is Remy Rabinovich, and I'm from the Philadelphia Hand Center.
REMY RABINOVICH: And I, along with my mentor, Mark Rekant, will be defending the All-Dorsal SL Reconstruction with an Internal Brace. So the treatment of stage 3 and 4 SL instability has led to the development of a vast arsenal of treatment options. As Kelly and Chris nicely talked about, the RASL and the three-LT are just two of the many ways to tackle this problem, none of which has proven to be the gold standard.
REMY RABINOVICH: The RASL, which was introduced in the late nineties, really has not stood the test of time. It's been associated with several complications, including revision surgery for painful progressive screw lucency, the inability to maintain initial deformity correction, the development and progression of degenerative changes and AVN of the scaphoid has also been reported. This has led to several institutions, including Peter Stern's group out of Cincinnati, as well as an institution out of France, to acknowledge that they've stopped using this technique altogether for SL dissociation.
REMY RABINOVICH: The three-LT, along with the earlier modifications of the Brunelli procedure, have overall demonstrated variable short term clinical outcomes. Marc Garcia-Elias noted that 18% of the patients develop progressive degenerative changes. In a more recent report out of France, the authors also noted that 20% of patients developed arthritis, along with diminished post-operative range of motion and the inability to hold that reduced SL interval and SL angle, as well as a 35% incidence of palmar pain but likely related to that anterior posterior approach required for this technique.
REMY RABINOVICH: The newer techniques out there, such as the 360 tenodesis and the anatomic front and back repair, have sparse published clinical outcomes. They're technically pretty complicated and they require multiple incisions and front and back approaches, which, as just alluded to in the previous slide, is not necessarily benign. So moving forward, what can we learn from the literature, as well as our experience with the RASL,
REMY RABINOVICH: three-LT and numerous other tendon ligament reconstructions available? Well, firstly, reconstructing the torn ligament solely with a tendon autograph does not match the native ligaments fiscal less properties and this leads to creep and delayed elongation. On the other extreme, placing the screw across the SL interval may create too rigid of a construct, which eventually leads to ecentric loading on that screw and possible lucency.
REMY RABINOVICH: The all dorsal SL reconstruction with internal brace provides that balance between not being too rigid or too elastic to restore stability. This technique has gained popularity while still in its infancy and aims to reconstruct that thicker dorsal portion of the SL ligament while stabilizing the scaphoid out of flexion, pronation and the lunate out of extension.
REMY RABINOVICH: A proposed advantage is that it's a biologic reconstruction, using a two to three millimeter slip of ECRL or ECRB that's reinforced with a robust one three millimeter suture, which basically acts as a brace while the tendon heals into the bone so this helps preserve that near physiologic motion between the scaphoid and the lunate while not being too elastic given the strong static suture tape.
REMY RABINOVICH: This technique is quick. It's simple, only utilizing a single dorsal incision, as opposed to the four other techniques discussed today, which not only require multiple incisions, but most of them require you to drill completely across one or more carpal bones and show the graft through numerous bony tunnels and/or ligaments. In a recent review on various cell reconstruction techniques, the authors noted that this was the preferred technique at their respective institutions.
REMY RABINOVICH: They illustrated a case of a former NFL player with painful SL instability. You can see the wide gap on the clenched, clenched fist views all the way to the right. At two years post-op, the patient was pain free and demonstrated an excellent wrist range of motion. His grip strength on the operative side was 170 kilograms, and on the contralateral side it was 160. These are his films at two years post-op, and you can appreciate the maintenance of a reduced ASL interval and no progression of degenerative changes.
REMY RABINOVICH: So in summary, the all dorsal reconstruction when the eternal brace is a simple and quick biologic reconstruction aim to restore the stronger dorsal portion of a state ballooning ligament while stabilizing the corpus out of a flexible deformity. It provides a satisfactory balance between not being too rigid or too elastic, which has limited earlier reconstruction attempts. So I got to Thank doctors mark Kent, David Zulu and Steve Lee for helping me out.
JEFFREY YAO: Thank you, Remi. Nice job. OK let's move on to the Mayo Clinic with Lauren Dutton, who will discuss the SLITT procedure.
LAUREN DUTTON: Good evening from Rochester, Minnesota, where it has finally stopped snowing. My name is Lauren Dutton. I am a hand fellow at Mayo Clinic and I will be discussing the SL 360 procedure as described by my mentor, Dr. Kakar.
LAUREN DUTTON: Dr. Kakar would like to acknowledge several individuals whose work led to the development of this procedure, including Dr's Berger, Garcia-Elias and Ho. We would also like to thank Dr. Huang, Dr. Hammad and Dr. Yao for all they have done to put together these fellowship cross country Zoom debates which have been educational as well as entertaining. Now quite a bit has changed over the past year, but some things have remained the same.
LAUREN DUTTON: As hand surgeons, our charge remains to attempt to prevent the X-ray from this case presented to us by Dr. Yao from evolving into this one. Doing so can be easier said than done, as reflected by the wide variety of techniques that have been employed over the years to address the problem of scaphoid lunate dissociation. So where do we begin when we approach a case of scaphoid lunate instability?
LAUREN DUTTON: Dr. Garcia Elias and colleagues have provided us with a useful roadmap in taking stock of SL injuries and planning treatment. To remember these factors, Dr. Kakar has created the mnemonic SCARCE, a term that took on a whole new meaning during the early days of the COVID 19 pandemic. The S stands for the integrity of the secondary stabilisers, as per Dr. Wolfe's recent work.
LAUREN DUTTON: The, in order to create a adhesive deformity more than just the SL ligament must be disrupted. The C is for cartilage status, as this will influence our decision of whether to reconstruct the SL ligament versus consider other options. A is for alignment of the carpus and specifically the position of the lunate and whether it is located within the lunate set or ulnarly translocated. The R is for reducibility of the SL interval, which can be judged arthroscopically after debridement of scar tissue and use of a probe to visualize the reduction.
LAUREN DUTTON: C is for chronicity of the injury, which provides a surrogate, surrogate indicator of the quality of the ligament and its ability to be repaired. And finally, E is for the extent of the ligament injury that is whether it is partial versus complete. So once these factors are assessed, our next task is to come up with an appropriate treatment plan. One common method for addressing SL ligament reconstruction is to focus solely on the dorsal SL ligament.
LAUREN DUTTON: And indeed, the work of Dr. Berger has shown us that the breaking strength of the dorsal SL ligament is close to 300 newtons, whereas the palmar ligament provides 120 Newtons. It's important to remember that while less than the dorsal ligament, this is still a substantial component of stability. Furthermore, if we only reconstruct the dorsal ligament and the presence of a complete ligament tear, not only will we only be halfway there, but we are also at risk of gapping open the volar SL interval.
LAUREN DUTTON: This is akin to fixing a fracture dorsally that then gaps open volarly. Dr. Ho and others have contributed significantly to the evolution of a combined dorsal and volar reconstruction by describing their techniques of reducing the SL interval and performing a box type reconstruction with a free tendon graft, followed by pinning. And these authors have shown favorable results. So the question becomes, can we take this concept of addressing both the dorsal and volar ligament disruption and at the same time improve upon it by eliminating K-wires, minimizing post-operative immobilization and addressing the secondary stabilizers that we know to be critical.
LAUREN DUTTON: So let's return to our case of this patient with a complete, irreparable SL tear and a reducible SL interval. How can we help fix her wrists so that she can go back to fixing other people's wrists? Our approach would be to perform an SL 360 reconstruction as follows. We begin by approaching the dorsal wrist via a ligament sparing capsularotomy as described by Dr. Berger.
LAUREN DUTTON: K-wires are inserted into the scaphoid and lunate and used to assess the reduced ability of the SL interval. Once this is confirmed, the wrist is flipped volarly and approached via an extended carpal tunnel incision. If present, a palmaris longus autograft is harvested, if not a plantaris allograft tendon is recommended. The graft is whipped stitched to each end with a four braided non absorbable suture.
LAUREN DUTTON: If there is no disi present, four or five K wires are placed parallel to each other through the scaphoid and lunate from dorsal to palmar and the presence of a disi deformity, the trajectory of the scaphoid pin is from dorsal distal to palmar proximal in order to correct the deformity. A three millimeter drill hole is created in the lunate and a 2.5 millimeter hole is made in the scaphoid to permit a single passage of the graft through the scaphoid with the larger hole placed in the lunate to eventually accommodate the second passage of the graft.
LAUREN DUTTON: A suture passer is used to first pass the graft from dorsal to volar through the lunate, then volar to dorsal through the scaphoid. And finally, from dorsal to volar back through the lunate, thereby completing the 360 tenodesis. The graft is tensioned and the wrist is cycled through a passive range of motion to decrease creep.
LAUREN DUTTON: The graft is then secured within both the scaphoid and the lunate, with bioabsorbable interference screws placed from dorsal to vollar. Through the tenodesis screw holes, a 1.3 millimeter diameter synthetic tape is passed from dorsal to volar through the scaphoid and the lunate and then type palmarly. The passage of the tape through the screws rather than directly over the bone, prevents the tape from cutting out through the carpus.
LAUREN DUTTON: All K-wires are removed. To control flexion of the scaphoid, the dorsal limb of the graft can be tethered to the distal pole of the scaphoid. In the case of this patient, who also had ulnar translocation of the lunate, the extra tail passed volarly through the lunate was used to reconstruct the long radiolunate ligament via a suture anchor placed into the distal radius. The capsule is closed with 2.0 non absorbable suture with great care taken to repair the dorsal radial carpal ligament back down to the carpus.
LAUREN DUTTON: The patient is immobilized in a short arm splint postoperatively, and rehab has begun at three or four weeks. This MRI was obtained at the three year follow up mark for a patient who underwent an SL 360 reconstruction. A recent biomechanical study compared the stiffness and maximum load to failure of a 360 tenodesis alone, as compared to one augmented with tape and found a two-fold increase in the maximum load to failure of reconstruction when augmented with tape, thereby rendering it nearly the same as that of the native dorsal SL ligament.
LAUREN DUTTON: Mark Twain told us that to a person with a hammer, every problem looks like a nail. Accordingly, we would submit that, as per Dr. Garcia-Elias's work, not every SL injury is the same. And thus we need a variety of tools in our armamentarium to address them. We propose the SL 360 as one such tool. Thank you very much for your time.
JEFFREY YAO: Thank you, Lauren. A very, much more diplomatic presentation. Thank you very much, that was great. OK so we'll round it out from New York again at HHS. Dr. Rambau. You have the floor.
GENEVIEVE RAMBAU: All right. So good evening, everybody.
KELLY ESPOSITO: I'm Genevieve Rambau, I'm from Hospital for Special Surgery. Thank you, everyone, for the chance to present and a special thank you to my mentor, Dr. Scott Wolfe for his help with putting this together. So I'm going to talk about the anatomical front and back repair, which is a new technique for chronic SL dissociation. This was pioneered by Dr. Michael Sandow in Australia and we've been starting to do this at HSS. So the impetus for this technique was to address the other deformities incumbent with chronic ACL injuries.
GENEVIEVE RAMBAU: I think the focus is often on the obvious SL diastasis, which often drives the treatments that we're discussing tonight with the focus on just reapproximating the scaphoid ameliorate {?}. But that may not address the other issues such as EC, scaphoid rotatory subluxation. And lastly, and perhaps most importantly, the dorsal gateway translation, which is the only radiographic parameter that correlates with post-operative pain.
GENEVIEVE RAMBAU: So we know that it takes more than the division of SL alone to lead to DISI and other main contributors for the wrist stability are the dorsal scaphoid and interosseous ligament, STT the long lunate, the DIC and the DRC. So when thinking about a repair technique, ideally the goal of surgery would be to perform a true anatomic repair and to restore all the ligaments involved.
GENEVIEVE RAMBAU: Many of the procedures, like the first three focus on reapproximation of the scaphoidolunate. The TLT adds one more step in restoration of the STT ligament arguably, plus or minus the DIC, however, the new technique the NFAB, additionally restores the critical long radial lunate ligament as well as the other three elements. So this technique is one of multiple reconstructive procedures previously described reconstructing those four important stabilizers of the wrist.
GENEVIEVE RAMBAU: It's indicated for SL diastasis and SLAC wrists or Garcia-Elias stage 4 and 5. The contraindications are fixed deformity, advanced arthritis, osteoporosis and inflammatory arthritis. This is a transition technique, beginning with the dorsal approach to the wrist, a longitudinal incision through the third dorsal compartment. A window capsulotomy is performed, preserving the DIC and the DRC.
GENEVIEVE RAMBAU: A volar FDR approach is performed and the trapezium is exposed and an anchor with suture tape is placed as shown in the schematics into the lower trapezium. The palmar carpus is exposed for the radial lunate tunnel along with the radial styloid if a styloidectomy is to be performed in conjunction. And I have access to the volar and dorsal wrist. The scaphoid tunnel is then drilled from dorsal to volar with your index finger on the tubercle and the volar structure is well, well protected as seen in the image on the right.
GENEVIEVE RAMBAU: K-Wire placement is confirmed on fluoroscopy and then using a 3 millimeter accumulator drill over k-wire, you create this scaphoid tunnel as shown here. The lunate tunnel has been drilled also from dorsal to volar, again careful to protect the volar structures. And lastly, the radial tunnel is drilled from volar to dorsal, aiming to exit at the radial and proximal margins of Lister's tubercle. A 3 millimeter radial strip of the FCR tendon is harvested and dissected distally and load of the trapezium for accurate line of pull.
GENEVIEVE RAMBAU: The tendon and suture taped together, then pass sequentially through the tunnels and secured with interference screws at each segment. The first materials are passed from volar to dorsal through the scaphoid to recreate the STP while holding tension. It is secured volarly in the scaphoid with an interference screw. A small trough is made in the dorsal scaphoid to allow tendon growth and the tendon to taper, then pass from the dorsal scaphoid through the dorsal lunate.
GENEVIEVE RAMBAU: Prior to tensioning, a knotted suture iss placed in the dorsal lunate to allow for laser reapproximation of the DIC and the tendon suture tape and knotted suture are secure with an interference screw in the dorsal lunate. They're then passed from volar to dorsal through the distal radius to recreate the long radial lunate ligament and tension and secured in a similar fashion.
GENEVIEVE RAMBAU: A new modification to this is augmenting the repair with an additional suture boning or dorsally approximately to the long radial lunate tunnel. This is a critical stabilizer to resist any pull out and act as a ripstop should failure occur along the way. Closure begins first with reapproximation of the dorsal ligaments and a pants over vest repair, using that knotted for suture that was dumped into the lunate.
GENEVIEVE RAMBAU: As an intraoperative fluroscopy showing reduction of the ethyl gas, restoration of scaphoidolunate angle and the radial lunate angle and an improvement of the dorsal scaphoid translation. And an important pre and post op imaging showing again the importance of correction of that dorsal scaphoid translation. Oops. Sorry about that. So post-op patients are placed into a cast immobilization for six weeks.
GENEVIEVE RAMBAU: Thumb spica optional. There are no k-wires needed for stabilization. I'm not sure. But this is one of my patients. So stop being able to do that. So this, I mentioned before. There's not a lot of literature about this technique yet. It's relatively new.
GENEVIEVE RAMBAU: Dr. Sandow has published a small cohort 10 patients with a minimum two year follow up, showing excellent return of grip, strength and motion. One patient was revised with an ulnar shortening osteotomy, but had no further issues at the time of publication. Our own series hereat HSS, we've done 14 patients with an average six month follow up, arguably very short, but so far have shown a modest decrease in wrist range of motion and grip strength at early follow up, although grip strength is not statistically significant.
GENEVIEVE RAMBAU: There was an improvement in the radiographic assessment of the SL angle, the gap and dorsal scaphoid translation. We did have two complications, one was a patient with earlier fixation distally, and that was the impetus for adding that additional zone anchor. And the patient was converted to PSC and one patient's osteogenesis imperfecta ended up with a VISI deformity but had an improved scaphoidolunate angle.
GENEVIEVE RAMBAU: So in summary, yes, it's a very new technique. We don't have long term data, but our preliminary studies are somewhat promising so it'll be interesting to follow this technique as it continues to develop and as modifications are made and I think hopefully it can offer one option for a very difficult problem, in the wrist that we still have not totally figured out. Thank you guys for your time.
JEFFREY YAO: Great. Thank you very much and thank you to all of our Fellows. Those were great presentations. I applaud you all and thank you to the mentors. The, all the Fellows were clearly well coached, so thank you very much. What I'd like to do is to know, I guess, Jerry, can you launch the poll or I guess the pole is already launched?
JERRY HUANG: It's a matter of. Wait, wait, now, hold on. Can anybody see the poll on there? So yep, it's there.
JEFFREY YAO: So we'll take about 30 seconds to just answer these two questions. Again there are no losers here. There's only one winner, and I'm just joking.
JEFFREY YAO: Everyone's a winner here. But I'd love to see how the group feels in terms of these procedures, which are all very promising. But the question is, has one distinguished itself as being more promising than any of the others.
JERRY HUANG: Score, about 50% voting so far. So I'm going to give another few more seconds.
JERRY HUANG: It's looking close. Very close.
REMY RABINOVICH: Sanj, for a second, I thought that scarce was referring to my golf shot hitting the green.
JERRY HUANG: I'm going to go ahead and end the poll right now here Jeff (OK) so the poll is ending. I'm going to go ahead and share the results.
JEFFREY YAO: Oh, there you go.
REMY RABINOVICH: I'm glad we have a consensus. That's great. Yeah.
JERRY HUANG: Can anybody see the results from both questions on the poll on their screen?
JEFFREY YAO: I can see them. Hopefully everyone can see them. So it looks like.
REMY RABINOVICH: Yeah, you know, one, Jeff, come on, you can say it.
JEFFREY YAO: So for those of you, if you can't see, it looks like in terms of the most compelling argument, it looks like long term follow up trumps all, and then the which procedure people would want done. Looks like the swivel lock reconstruction if it were your own wrist. Interesting in hearing what the other options would have been, whether that be denervation or a salvage procedure.
JEFFREY YAO: I purposely sort of massaged the case a little bit such that the denervation and the salvage procedure was not an option but obviously, I don't want to make the point. I want to make the point that those clearly are good options as well. OK well, great. Thank you for your participation in the poll. We're down to 10 minutes, but I'd like to take a moment to ask our mentors, Dr Rosenwasser, Dr.
JEFFREY YAO: Lauder, Dr Rekant, Dr Kakar and Dr Wolfe two quite simple questions. Number one, do you ever see a case of scaphoidolunate dissociation, which is still reducible and still reconstructable where you would not use your advocated technique and why? And number two, is there ever a situation when you would use one of the other proposed techniques? So, Mel, what do you think?
JEFFREY YAO: Is there ever a case where you would not use a RASL?
MEL ROSENWASSER: Yeah I think, you know, I pushed the envelope in some cases early on and they were patients that had some arthritis in the midcarpal joint. And those were always mistakes because those patients, even though they had better alignment, they had more discomfort, more pain, and they were actually probably made worse.
MEL ROSENWASSER: But I think if the right if you have the right indication, I think it's doable. I think your question is, if there's ligaments still there, would you just do a repair, even if it was late? Because I'm not quite sure that 8 to 12 week limit to repairs, because sometimes a ligament is still there, and I don't mean just the avulsion from the scaphoid, but, but actually there's ligament there and I never when I do this procedure debride any of the dorsal ligament structures, even if they don't look great, I mean, I use it as just part of a scar formation and I always leave it there.
MEL ROSENWASSER: But what's interesting to me is that a lot of these techniques, no matter what they're done, they could still benefit from a stabilization. And when I first started doing RASL's, people kept saying, when do you want to take them out? So some people like to put these in and take them out after they've had sufficient biologic healing. So I don't have any, I don't take any issue with people that said, I want to take it out, although I've not done it because I haven't seen a lot of trouble with issues in the screw long term.
MEL ROSENWASSER: I know everybody sort of harps on the lucency, but, you know, every one of these cases and techniques we saw, there's giant holes in the bone. I mean, what more lutency do you want if there's three to 4 millimeter holes in the bone. So if you have a half a millimeter lutency around the threads of a screw, is that worse than a 4 millimeter hole in the bone? I don't think so, but I don't think that's the issue.
MEL ROSENWASSER: The issue is maintaining alignment. And I think the critical issue and I agree with Scott Wolfe, keeping the scaphoid proximal pole from dorsally subluxing and getting a lunate reduction. However you do it, I think that's the key to getting long term results. I've continued to do it and I follow the patients very carefully and I'm satisfied with the outcomes.
JEFFREY YAO: Great, Alex.
ALEX LAUDER: So I think the first question you had was if it's reducible, is there a technique that you would use in a different way? Would you change the technique based on the patient? And so our patient population is a tertiary County Hospital and in a large city and for the labor who can't take time off of work, for the homeless patient what not, it's not going to have good follow up or it doesn't have resources or the patient that can't participate in the adequate rehab that you need to truly kind of repair, you know, have a good repair of that biology, you know, something like injections, non operative treatment.
ALEX LAUDER: Those things are definitely something to keep in mind. Other situations when you might have to think outside the box a little bit is the patient with FCR tendonosis? If you're going to use that SCR as a reconstructive model for your tendon and keep it attached to its insertion, that's really something you have to think about looking at and really examining the patient ahead of time, because if you're going to use that and it ruptures, that might compromise your fixation.
ALEX LAUDER: Other times you have to think outside the box or use a different method is patients with a failed RASL, a failed swivelock or a failed implant, or you have to take that out and they have huge holes in the bone and you might have to do something differently as well.
ALEX LAUDER: So those are all things to keep in mind and obviously all the kind of key learning points that were mentioned before is having a flexible, reducible deformity, making sure you don't have any concomitant arthritic changes in the mid carpal joint or ST joint. Things to, those are all things to that might sway your choices as well.
JEFFREY YAO: Great. Thanks.
JEFFREY YAO: Thanks for those comments, Mark?
MARK REKANT: Yeah, I would just echo what Alex was saying and now is I think it's helpful to have many tools in the toolbox. This technique doesn't burn any bridges. It's not harvesting a tendon, it's not destroying a cartilage with a Burr but certainly I think the evidence, as it was demonstrated with excellent speakers, so thank you, is that if a patient had a strong inkling whether a family member advised them or a previous surgeon advised them of another technique that was described today, I don't think there's enough evidence that I would try to talk them out of that procedure.
MARK REKANT: Given that, I think there's some placebo effect with any of these procedures in believing if the patient thinks that particular technique is best for them, then it's helpful to have other tools in your toolbox, so to speak.
JEFFREY YAO: OK. Sanj?
SANJ KAKAR: So I think there's a couple of thoughts. Number one, I think from tonight, as Lauren and all the speakers have shown, when you see a gap, a gap is not just the gap.
SANJ KAKAR: There's many factors that you have to consider and Scott and Steve's work in New York has really shown a lot of what the ligaments have injured and what needs to be done. I think to answer your question, though, there are occasions and we did one two days ago where the patient, we scoped him, volarly he was stable and dorsally was gapping open and so we did the Christophe Mathlow [?] in arthroscopic SL capsulardesis.
SANJ KAKAR: And you know what, I saw his patients and his patients actually did really well with minimal morbidity and great motion. Now, yes, they gapped a little bit, but they were pain free, so I think that is a very useful technique. And I tell the patients, I'll scope you and if there's a big gap and I think you need a front back, we'll do it another time. I think it's a big operation that they have to get through. But if it's like we had the other day, volarly he's intact, dorsally open.
SANJ KAKAR: I think that's minimal morbidity operation, and if it fails, you can always do one of the things that we discussed.
JEFFREY YAO: I think that's a great point and not to beat a dead horse, but Scott and Steve from New York, they're work on the dorsal translation of the proximal pole, the scaphoid, if that's controlled, I think that's clearly more important than closing the gap with the scaphoid lunate interval
JEFFREY YAO: and that's why the capsulardesis tend to work as well, albeit limiting range of motion. Thanks for those comments. All right, Scott, what do you think?
SCOTT WOLFE: Thanks, Jeff. First of all, I think it's tremendously exciting that we've got a conference like this going. We for years have kind of treated this the same way and I think there's a whole array of different ways to look at this now.
KELLY ESPOSITO: And the challenge is for us to not just sort of pick what sounds best, but the challenge is really to study this now in large numbers and the only way we can do that is to look at these stratified by the type of injury. Pick your classification. I like Marc Garcia-Elias and pick that classification and then look at how these repairs pan out over the years going forward at one year, two year, 5 years and 10.
SCOTT WOLFE: So we can really see the differences that these different repairs will have on long term outcomes. So that's just a plug. I mean, I'm really excited about all the work that's being done now. I think we have a chance at finally making a real dent in this problem that Ron Lynchard and Jim Dobbins brought to our attention 50 years ago.
SCOTT WOLFE: I mean, you could almost say that we haven't really advanced that far. And to answer your questions, yes, I think that from what I've learned is that in a patient with severe osteoporosis, I wouldn't do this. It's so dependent on getting a bite on those different bones that you don't want to put synthetic tape and implants into soft bone. In that one case, it failed.
SCOTT WOLFE: And also, it's so good this antegrade repair, it's so good at bringing back your DISI that if you do have a lax wrist that tends to fall into DISI it may convert you to a VISI, which I don't think is the end of the world and that particular patient that went into VISI some is doing quite well. That's the thing. It'll tip the balance more towards VISI in a very lax patient I think.
SCOTT WOLFE: And when would I do something else? Yeah, like Mel said, if you've got a good strong repair or a strong ligament that you can repair and it's an early case, I would try to do that. I like I still like that. But I think the advantage of this repair is it really does cover all the bases. It gets your lower and dorsal contributors to eliminate and your natural stability that you really do have to address.
SCOTT WOLFE: One thing I would just throw in an element of caution with the swivelock repair, is we're now looking at a series of patients who've had osteolisis and extrusion of these implants from the scaphoidolunate and just clear cut fractures and destruction of their proximal carpal growth. So we're looking at that histologically, we're trying to figure out what it is, but I would just inject an element of caution.
SCOTT WOLFE: That's a lot of material to be putting in these very small bones, so just something to think about.
MARK REKANT: Scott that brings up a great point and maybe similar to the CMC stabilization, perhaps there have been some surgeons putting them in beyond the biomechanical tighteners, so I think as Remy said, you can certainly over tighten these as was been done with the mini tightrope.
MARK REKANT: And maybe that may be the cause that you're seeing, or could.
JEFFREY YAO: Oh, don't bring the mini tight rope into this Mark.
MARK REKANT: I'm sorry.
SCOTT WOLFE: One last thing. One one very interesting thing that we're going to publish shortly is that the traditional capsular split,
SCOTT WOLFE: we're concerned because that really does take down these ligament attachments of both the dorsal rator carpal and the dorsal hook carpal and a lunate and be very careful if you do that, you're adding what is really angiogenic instability on top of what's already a bad situation. So if you have to do that approach and I did that for years, decades, but if you have to do that approach, make sure you hammer it back down with some good anchors and make sure you reattach those ligaments.
SCOTT WOLFE: Very important.
JEFFREY YAO: Very good points, everyone. Unfortunately, we could go on forever. Unfortunately it's 6:00 our time,
JEFFREY YAO: I guess 9:00 on the East Coast. I'd really again, like to thank all of our Fellows for outstanding presentations. I'd like totThank the mentors for their comments. Jerry, do you want to take us home?
JERRY HUANG: Yeah, sure.
JERRY HUANG: Yeah, sure. Yeah Jeff, thank you so much for the moderation, introduction to overview. I agree all five Fellows and thank you for all five mentors for excellent coaching and presentations, I think.
JERRY HUANG: Great learning points and hopefully get to keep this going for a while and folks are getting busy. As I mentioned, it's going to be every other week and going on to every month kind of going forward the academic year but thank you all for joining us. So in two weeks, it's going to be on another very non-controversial topic on arthritis in terms of what's going to be best treatment for that for a 25 year old, 50-year-old and potentially a 75-year-old rheumatoid,
JERRY HUANG: so hopefully you could join us and everybody stay safe and healthy out there. And I thank you for joining us.
MEL ROSENWASSER: And I want to make one point. These, these conferences go much better when you're drinking wine. So I'm so I'm surprised to not see any other wine glasses there. Sanj, what do you have one hidden down below the desk or something?
SANJ KAKAR: I've got. I've got milk.
KELLY ESPOSITO: You're not clocking in or something at the Mayo Clinic right now, are you?
KELLY ESPOSITO: Mark's got a whole vineyard behind him, so.
MARK REKANT: Oh, Yeah.
SANJ KAKAR: We have to be sharp Mel, with you and Scott coming at us, you know what I mean?
MEL ROSENWASSER: Oh, it was benign tonight. It was very benign. We're among friends. Of course, we are. Yes, we are.
SCOTT WOLFE: Good job, Jeff. Good job, Jerry.
MEL ROSENWASSER: Yeah thanks a lot, Jeff and Jerry for putting it on.
SANJ KAKAR: Cheers, guys.
SANJ KAKAR: Thanks for. Thanks, Jeff. Thanks, Jerry. Three top guys. Take it easy, Take care.
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