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Name:
Arthroscopic Foveal TFCC Repair
Description:
Arthroscopic Foveal TFCC Repair
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T00H17M53S
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Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
SANJ KAKAR: Hello, my name is Sanj Kakar. It's a privilege to be with you today and to go over Arthroscopic Foveal TFCC repair. My disclosures are on the ASSH website. Start off with a case of this 25-year-old gentleman who sustained this heavy twisting injury to his left wrist at work. On clinical examination, he was tender over his phobia and his DRUJ was unstable.
SANJ KAKAR: It's important to examine the whole wrist and he was also tender over the lunar triquetral joint and the triquetrohamate joint. We initially treated him non-operatively with splinting and injections, which did help to a degree, but he continued to have pain failing non-operative treatment. If you look at the MRI here, what you'll see is that on the left side you'll see there's a coronal view of the wrist and you'll see the TFCC
SANJ KAKAR: but his insertion, the foveal fibers you can see, looks rather scant. When you look at the axial view on the top right, you can also see that there's some volar subluxation of the distal ulnar in relation to the distal radius. So before we dive into the surgical treatment, let's look at the soft tissue anatomy of the ulnar side of the wrist.
SANJ KAKAR: You can see here my mnemonic here is Rupert. R stands for the sigmoid notch of the distal radius, which gives you 20% of stability of the DRUJ. U is the ulnocarpal ligaments. P is the deep head of the pronator quadratus. E is the ECU, which is a dynamic stabiliser of the DRUJ. R are the radioulnar ligaments which confluence into the TFCC. When you look at this histological image from Toshi Nakamura, you will see that the TFCC is divided into the superficial fibers which insert into the ulnar styloid
SANJ KAKAR: and it's this deep foveal fibers which are important in terms of DRUJ stability. So in terms of managing ulnar wrist pain, Dr. Berger taught us that there were three main questions that you want to ask when managing these patients. This was a nice article written by David Brogan, who goes into this in detail. But essentially the three key questions to ask is, does the patient just have pain,
SANJ KAKAR: do they have pain with instability such as this patient, or do they have pain with prono supination suggestive of arthritis of the sigmoid notch because the treatment is very different based on what's causing the pain. It's also important to realize that in terms of the pathology of the ulnar side of the wrist, these are not mutually exclusive. They're multifactorial in nature,
SANJ KAKAR: and if you treat these as mutually exclusive events, when there's multiple pathologies going on at the same time, and this is when you get into trouble. So is there an easier way to figure this out in terms of working classification? There's many systems out there, but I'd like to share with you the four leaf clover algorithm that was described by Marc Garcia-Elias.
SANJ KAKAR: Essentially, you ask four key questions. What's the nature of the bony architecture of the DRUJ? Is there, for example, a distal radius malunion? Is the cartilage normal or is it arthritic? What's the quality like of the static stabilizers of the DRUJ, for example the TFCC? And what about the dynamic stabilizers? Here I've put the ECU in and you go through these questions, yes or no
SANJ KAKAR: and you sequentially address these. And if there's more than one, it's critically important that you address both or 3 or 4 of these if these are indeed causing the problem, patients problems. So back to this patient. This is his x rays, which look relatively unremarkable. So going through this checklist, in my mind, he had a TFCC problem which would fit with his clinical examination and also the MRI that I showed you.
SANJ KAKAR: I'm going to show a technique that was described by Wei Chen in terms of how to manage this arthroscopically. So in terms of the indications for an arthroscopic foveal repair of the TFCC, these patients that have failed conservative treatment have gross DRUJ instability, and when you feel that the TFCC is repairable with the foveal disruption, though, obviously the main contraindications here is where the TFCC is irreparable
SANJ KAKAR: for example, you have poor soft tissue and you need to do a DRUJ reconstruction, or if they also have concomitant DRUJ arthritis because this will need to be addressed as well at the same time. So here you can see we're marking out the portals. I've already done an examination under anesthesia compared to the uninjured side and confirmed that he indeed has DRUJ instability. So here we've marked out the 3-4, the 6-R portal as well as the ulnar midcarpal portal and the radial midcarpal portals.
SANJ KAKAR: So once we've established this, this is under tourniquet control. The needle comes in and the 3-4 portals so once we pop through the skin, we then can mark where our 3-4 portal is. The needle is then withdrawn. We make a small skin incision through the 3-4 portal and then take our tenotomy scissors and spread down between the extensor tendons until we pop into the wrist.
SANJ KAKAR: So now the camera is coming in. You can see the scaphoid above the scaphoid facet below. You can now, you can see the lunate. You can see as we're coming into the ulnar carpal joint. We're then coming in and now we're getting a look at the TFCC and now the TFCC is coming into view and you can see the synovitis in the ulnar gutter and when I do the foveal sign, you can see as I'm pushing, you can see I'm able to push the TFCC up.
SANJ KAKAR: So once we've come into this side, now we take the needle, we come through the 6R, we make sure that we're happy with our needle position, the needle is then withdrawn and then we make a skin incision. It's important just to make a skin incision, and then we'll take the tenotomies and spread radial to the ECU tendon to make our 6R portal.
SANJ KAKAR: And there we're now taking the trocar just to open this space up. Sometimes it's rather tight because of the synovitis and we're just opening this area up, which will allow us to now use this as a working portal. So now here comes the shaver and this is an important part because there's synovitis in the ulnar gutter and you really need to take your time to debride the ulnar carpal capsule to ensure, for example, that there's not an underlying UT ligament split tear.
SANJ KAKAR: And so here we're debriding, but because there some blood in the joint, we're now doing the automatic washout technique where we take a 10 cc syringe and then we're just turning on the shaver just to lavage the joint and this will get us a better view cleaning out the joint. So here you can see we've levaged the joint, we're now debriding the synovitis in the ulnar gutter and just, just taking our time to remove the synovitis so we get a good working picture because for repair, we want to get a good arthroscopic view of this.
SANJ KAKAR: And so here you can see we're debriding and as you can see, as I come underneath the TFCC, you can see how it's relatively unstable and I can lift this up. So here you can see we're removing the synovitis so we get a good dorsal view and now we're doing the trampoline sign, bringing in the probe and there's the hook test. Look how easily I can lift up the TFCC,
SANJ KAKAR: that is not normal and I shouldn't be able to displace the TFCC from ulnar to radial. We'll also confirm this with the suction test where we put the sucker on and lift this up. Now we're making an ulnar midcarpal portal because remember, he had some tenderness over the lunotriquetral joint and the triquetrum hamate joint. So we basically spread through, we've popped into the ulnar carpal joint, and then the camera goes in.
SANJ KAKAR: So now under direct arthroscopic visualization we'll then make the radial midcarpal portal. So here we've incised the skin, we've spread down, we've opened up the joint, and then this will be our working portal with instruments. So here you can see the shavers coming in, but also the probe can come in here as well at the same time. So now you can see there's a step off between the scaphoid and the lunate,
SANJ KAKAR: you can see. Patient wasn't complaining of any symptoms, but it's important to do a good diagnostic exam. So you can see that there's some insufficiency of the scapholunate joint as well, but again, was not clinically symptomatic. Now we're debriding, remember, he did have tenderness of the triquetrum hamate joint and you can see he has synovitis in the triquetrum gutter so we're debriding this with the arthroscopic shaver.
SANJ KAKAR: Now we're taking a probe because he also was tender over the LT joint and we're getting a feel here of what the LT joint feels like. Remember, it was unstable on the SL, but was asymptomatic and you can see here that the LT looks relatively stable as we're probing this. Cartilage isn't perfect, but otherwise the joint, however, looks relatively stable. So here we're finishing the debridement of the triquetra hamate joint and taking out that synovitis for where he was clinically symptomatic.
SANJ KAKAR: So once we've done our work here, the attention will now be moving to the fixing the DRUJ and you can look at the instability as I shuck the DRUJ back and forth. And this was in keeping with the foveal disruption that we found arthroscopically. And you can also do a DRUJ arthroscopy here. Now we're making an ulnar incision from the hamate body going proximally, which will allow us to do our arthroscopic repair.
SANJ KAKAR: So once the skin is incised, it's critical that you then dissect out the dorsal sensory branch of the ulnar nerve so once we're through the skin, we'll then retract the skin flaps out of harm's way and spread, finding the dorsal sensory branch of the ulnar nerve. So here you'll see that the skin flaps are retracted and we're spreading, looking for that branch of the nerve that goes from volar to dorsal.
SANJ KAKAR: Little trick here is to find the basilic vein and just adjacent to the vein, you can see there is a dorsal sensory branch of the ulnar nerve. So once we've found this, a vessiloop will go around this to retract this out of harm's way. Little surgical trick is once you've found one branch, keep spreading because sometimes it will bifurcate or trifurcate
SANJ KAKAR: and so you want to get all of the branches of the nerve within the vessiloop, and now we're incising the retinaculum that runs from dorsal to volar incising onto the pisiform and so we're incising the retinaculum and now once we've done this, you'll see that the camera is in the 3-4 portal and you'll see that the needle is underneath the TFCC. You can either do DRUJ arthroscopy or you can open this area up, make a small little hole underneath the TFCC and taking a curette to debride the scar tissue where the fovea is.
SANJ KAKAR: This is a critically important part because we want the TFCC to heal back down to bone and is oftentimes a lot of scar tissue in this area that we're debriding out with the curette. Once we've done this, we'll now take a 0.06 2 k wire, place this under oscillate mode going through the distal ulnar but not popping through the TFCC. So we do this and we confirm this under fluoroscopic guidance and also with the camera in the 3-4 portal.
SANJ KAKAR: And so here you can see we're coming up and just underneath the TFCC and then we confirm this with fluoroscopy. And here you can see the fluoroscopic imaging. The wire is coming slightly radial to the fovea because I want to get a good bite of the TFCC when we're passing our sutures. And so here now watch? We've taken the k-wire out.
SANJ KAKAR: We've taken an 18 gauge needle with a looped 2-0 PDS and we're popping through the TFCC. You can see the cameras in 3-4 portal. And then, once the needle has popped through, you can see the looped 2-0 PDS, so we'll pop through into the TFCC. There you can see the needle and the loop to 2-0 PDS. So a grasper comes from the 6-R portal and we'll grab this loop
SANJ KAKAR: so here you can see the grasp is grabbing this, pull the needle back and this is a 2-0 PDS. Now the 0.062 k-wire hole is large enough that you can take another 18 gauge needle, and here you can see we're pushing the needle slightly volar through that hole, and then we're grasping that loop of 2-0 PDS so we basically have four limbs of suture now passing through the ulnar tunnel, coming out of the TFCC.
SANJ KAKAR: So there's another loop 2-0 PDS. And now what we'll do is cut one of the limbs and so we'll see which end runs with which and put a snap here. And we'll then now use a suture shuttle to shuttle these sutures back through the TFCC or the ulnar carpal capsule. So here we're knowing which suture runs with which and tagging this, and now we're taking a needle with a looped 2-0 PDS.
SANJ KAKAR: You can see the camera is already in the wrist and you can see here the needle comes through the ulnar carpal capsule. We'll grab this with the grasper in the 6-R portal and this will grab that suture loop, we'll pull this out of the 6-R portal, we'll pull the needle back, and this will be our suture shuttle. So there you can see we have a loop 2-0 PDS
SANJ KAKAR: and we'll take one free limb of the PDS now pulling this through and now as we're pulling this through, this limb of suture has gone through distal ulnar, through the TFCC, through the ulnar carpal capsule and back on itself. So you can see now here's one passage of that suture, and we'll do this three more times. Here again, needles coming in. The sensory nerve is retracted out of harm's way.
SANJ KAKAR: We're going through the ulnar carpal capsule. You can see there's the loop of the 2-0 PDS. The grasper comes in through the 6R portal and we'll now grab that limb, we'll pull that limb of 2- PDS back out of the 6R portal. Remember, this is our suture shuttle, and we'll take another free limb and then shuttle this back by pulling on the loop. And so you can see as we pull on the loop, once we've passed this suture end through, this will then be shuttled out of the ulnar, ulnar incision.
SANJ KAKAR: So now we have two sutures holding the TFCC down. We'll now come in again with the needle. You can see coming in just dorsal to the other sutures, again, acting as a suture shuttle to suture now, the other limb of the 20 PDS. Remember we had that clear limb and so here we're pulling out that suture shuttle. We'll have cut the loop. Here we're cutting the loop of that clear 2-0 PDS and we'll ensure we know which end runs with which
SANJ KAKAR: and then shuttle one limb back out. So this is the third passage, and we'll do this one more time. So then comes in the suture. There's the 2-0 PDS and this will be our final suture shuttle through. So now you can see with this technique, we have four strands of suture through the distal ulna, through the TFC three, through the ulnar carpal capsule.
SANJ KAKAR: So this will give us a robust repair. And you can see now we're bringing the probe in, I haven't even tied this down now. Now you can see that hook test is less positive than before. It's critical when we tie this that we take the wrist out of traction. So what we'll do is release the traction and then make sure that the nerve is retracted out of harm's way
SANJ KAKAR: and we simply tie this down snugly on the ulnar carpal capsule. So here you can see that there's really no soft tissue between the capsule and the sutures. The nerve is retracted volarly. So here we're tying this down and again, remember, this is done out of traction. And here's all the sutures tied
SANJ KAKAR: and then here you can see there's no traction on the wrist. And now we'll check the stability of the DRUJ. So remember how unstable it was before? There you can see immediate stability with just tying these four sutures down and good prono supination. Now to cover the suture ends,
SANJ KAKAR: what we'll now do is with a monocryl, you can see now we'll close the extensor retinaculum so the suture ends are not palpable for the patient. So here you can see we're closing the extensor retinaculum with the nerve retracted out of harm's way. So in terms of the post operative plan, patient is placed in the sugar-tong splint for two weeks. He then transitioned into a munster cast for an additional four weeks.
SANJ KAKAR: And at six weeks the patient goes into a munster splint and then we start a TFCC protocol. Because this is a foveal repair, I'll leave him in the munster splint for an additional six weeks so he has in total three months of post operative immobilization above the elbow but at six weeks after surgery, the patient is working on elbow flexion and extension prono supination
SANJ KAKAR: but also it's critically important that the therapists are working from proximal to distal so they're working on the scapulothoracic joint, the arm and the forearm in terms of wrist conditioning and strengthening and proprioceptive training. Here you can see the post operative radiographs and if you look at the post operative MRI, remember the preoperative MRI he had at volar subluxation, here you can see how we've restored the congruency of the DRUJ.
SANJ KAKAR: And this you can now see is the post operative range of motion. Remember, the wrist that we operated on was on the left side. So you can see he has good supination, good pronation may be slightly lax, terminal supination compared to the uninjured side, but the DRUJ is now stable in terms of his functional range of motion. So in terms of outcomes, I could have picked many articles. This is one article showing favorable results of a trans osseous arthroscopic foveal repair.
SANJ KAKAR: This is another article with follow up showing again good restoration of a range of motion and stability when one is doing this arthroscopically. Thank you very much for the pleasure of your time.
Segment:0 .
SANJ KAKAR: Hello, my name is Sanj Kakar. It's a privilege to be with you today and to go over Arthroscopic Foveal TFCC repair. My disclosures are on the ASSH website. Start off with a case of this 25-year-old gentleman who sustained this heavy twisting injury to his left wrist at work. On clinical examination, he was tender over his phobia and his DRUJ was unstable.
SANJ KAKAR: It's important to examine the whole wrist and he was also tender over the lunar triquetral joint and the triquetrohamate joint. We initially treated him non-operatively with splinting and injections, which did help to a degree, but he continued to have pain failing non-operative treatment. If you look at the MRI here, what you'll see is that on the left side you'll see there's a coronal view of the wrist and you'll see the TFCC
SANJ KAKAR: but his insertion, the foveal fibers you can see, looks rather scant. When you look at the axial view on the top right, you can also see that there's some volar subluxation of the distal ulnar in relation to the distal radius. So before we dive into the surgical treatment, let's look at the soft tissue anatomy of the ulnar side of the wrist.
SANJ KAKAR: You can see here my mnemonic here is Rupert. R stands for the sigmoid notch of the distal radius, which gives you 20% of stability of the DRUJ. U is the ulnocarpal ligaments. P is the deep head of the pronator quadratus. E is the ECU, which is a dynamic stabiliser of the DRUJ. R are the radioulnar ligaments which confluence into the TFCC. When you look at this histological image from Toshi Nakamura, you will see that the TFCC is divided into the superficial fibers which insert into the ulnar styloid
SANJ KAKAR: and it's this deep foveal fibers which are important in terms of DRUJ stability. So in terms of managing ulnar wrist pain, Dr. Berger taught us that there were three main questions that you want to ask when managing these patients. This was a nice article written by David Brogan, who goes into this in detail. But essentially the three key questions to ask is, does the patient just have pain,
SANJ KAKAR: do they have pain with instability such as this patient, or do they have pain with prono supination suggestive of arthritis of the sigmoid notch because the treatment is very different based on what's causing the pain. It's also important to realize that in terms of the pathology of the ulnar side of the wrist, these are not mutually exclusive. They're multifactorial in nature,
SANJ KAKAR: and if you treat these as mutually exclusive events, when there's multiple pathologies going on at the same time, and this is when you get into trouble. So is there an easier way to figure this out in terms of working classification? There's many systems out there, but I'd like to share with you the four leaf clover algorithm that was described by Marc Garcia-Elias.
SANJ KAKAR: Essentially, you ask four key questions. What's the nature of the bony architecture of the DRUJ? Is there, for example, a distal radius malunion? Is the cartilage normal or is it arthritic? What's the quality like of the static stabilizers of the DRUJ, for example the TFCC? And what about the dynamic stabilizers? Here I've put the ECU in and you go through these questions, yes or no
SANJ KAKAR: and you sequentially address these. And if there's more than one, it's critically important that you address both or 3 or 4 of these if these are indeed causing the problem, patients problems. So back to this patient. This is his x rays, which look relatively unremarkable. So going through this checklist, in my mind, he had a TFCC problem which would fit with his clinical examination and also the MRI that I showed you.
SANJ KAKAR: I'm going to show a technique that was described by Wei Chen in terms of how to manage this arthroscopically. So in terms of the indications for an arthroscopic foveal repair of the TFCC, these patients that have failed conservative treatment have gross DRUJ instability, and when you feel that the TFCC is repairable with the foveal disruption, though, obviously the main contraindications here is where the TFCC is irreparable
SANJ KAKAR: for example, you have poor soft tissue and you need to do a DRUJ reconstruction, or if they also have concomitant DRUJ arthritis because this will need to be addressed as well at the same time. So here you can see we're marking out the portals. I've already done an examination under anesthesia compared to the uninjured side and confirmed that he indeed has DRUJ instability. So here we've marked out the 3-4, the 6-R portal as well as the ulnar midcarpal portal and the radial midcarpal portals.
SANJ KAKAR: So once we've established this, this is under tourniquet control. The needle comes in and the 3-4 portals so once we pop through the skin, we then can mark where our 3-4 portal is. The needle is then withdrawn. We make a small skin incision through the 3-4 portal and then take our tenotomy scissors and spread down between the extensor tendons until we pop into the wrist.
SANJ KAKAR: So now the camera is coming in. You can see the scaphoid above the scaphoid facet below. You can now, you can see the lunate. You can see as we're coming into the ulnar carpal joint. We're then coming in and now we're getting a look at the TFCC and now the TFCC is coming into view and you can see the synovitis in the ulnar gutter and when I do the foveal sign, you can see as I'm pushing, you can see I'm able to push the TFCC up.
SANJ KAKAR: So once we've come into this side, now we take the needle, we come through the 6R, we make sure that we're happy with our needle position, the needle is then withdrawn and then we make a skin incision. It's important just to make a skin incision, and then we'll take the tenotomies and spread radial to the ECU tendon to make our 6R portal.
SANJ KAKAR: And there we're now taking the trocar just to open this space up. Sometimes it's rather tight because of the synovitis and we're just opening this area up, which will allow us to now use this as a working portal. So now here comes the shaver and this is an important part because there's synovitis in the ulnar gutter and you really need to take your time to debride the ulnar carpal capsule to ensure, for example, that there's not an underlying UT ligament split tear.
SANJ KAKAR: And so here we're debriding, but because there some blood in the joint, we're now doing the automatic washout technique where we take a 10 cc syringe and then we're just turning on the shaver just to lavage the joint and this will get us a better view cleaning out the joint. So here you can see we've levaged the joint, we're now debriding the synovitis in the ulnar gutter and just, just taking our time to remove the synovitis so we get a good working picture because for repair, we want to get a good arthroscopic view of this.
SANJ KAKAR: And so here you can see we're debriding and as you can see, as I come underneath the TFCC, you can see how it's relatively unstable and I can lift this up. So here you can see we're removing the synovitis so we get a good dorsal view and now we're doing the trampoline sign, bringing in the probe and there's the hook test. Look how easily I can lift up the TFCC,
SANJ KAKAR: that is not normal and I shouldn't be able to displace the TFCC from ulnar to radial. We'll also confirm this with the suction test where we put the sucker on and lift this up. Now we're making an ulnar midcarpal portal because remember, he had some tenderness over the lunotriquetral joint and the triquetrum hamate joint. So we basically spread through, we've popped into the ulnar carpal joint, and then the camera goes in.
SANJ KAKAR: So now under direct arthroscopic visualization we'll then make the radial midcarpal portal. So here we've incised the skin, we've spread down, we've opened up the joint, and then this will be our working portal with instruments. So here you can see the shavers coming in, but also the probe can come in here as well at the same time. So now you can see there's a step off between the scaphoid and the lunate,
SANJ KAKAR: you can see. Patient wasn't complaining of any symptoms, but it's important to do a good diagnostic exam. So you can see that there's some insufficiency of the scapholunate joint as well, but again, was not clinically symptomatic. Now we're debriding, remember, he did have tenderness of the triquetrum hamate joint and you can see he has synovitis in the triquetrum gutter so we're debriding this with the arthroscopic shaver.
SANJ KAKAR: Now we're taking a probe because he also was tender over the LT joint and we're getting a feel here of what the LT joint feels like. Remember, it was unstable on the SL, but was asymptomatic and you can see here that the LT looks relatively stable as we're probing this. Cartilage isn't perfect, but otherwise the joint, however, looks relatively stable. So here we're finishing the debridement of the triquetra hamate joint and taking out that synovitis for where he was clinically symptomatic.
SANJ KAKAR: So once we've done our work here, the attention will now be moving to the fixing the DRUJ and you can look at the instability as I shuck the DRUJ back and forth. And this was in keeping with the foveal disruption that we found arthroscopically. And you can also do a DRUJ arthroscopy here. Now we're making an ulnar incision from the hamate body going proximally, which will allow us to do our arthroscopic repair.
SANJ KAKAR: So once the skin is incised, it's critical that you then dissect out the dorsal sensory branch of the ulnar nerve so once we're through the skin, we'll then retract the skin flaps out of harm's way and spread, finding the dorsal sensory branch of the ulnar nerve. So here you'll see that the skin flaps are retracted and we're spreading, looking for that branch of the nerve that goes from volar to dorsal.
SANJ KAKAR: Little trick here is to find the basilic vein and just adjacent to the vein, you can see there is a dorsal sensory branch of the ulnar nerve. So once we've found this, a vessiloop will go around this to retract this out of harm's way. Little surgical trick is once you've found one branch, keep spreading because sometimes it will bifurcate or trifurcate
SANJ KAKAR: and so you want to get all of the branches of the nerve within the vessiloop, and now we're incising the retinaculum that runs from dorsal to volar incising onto the pisiform and so we're incising the retinaculum and now once we've done this, you'll see that the camera is in the 3-4 portal and you'll see that the needle is underneath the TFCC. You can either do DRUJ arthroscopy or you can open this area up, make a small little hole underneath the TFCC and taking a curette to debride the scar tissue where the fovea is.
SANJ KAKAR: This is a critically important part because we want the TFCC to heal back down to bone and is oftentimes a lot of scar tissue in this area that we're debriding out with the curette. Once we've done this, we'll now take a 0.06 2 k wire, place this under oscillate mode going through the distal ulnar but not popping through the TFCC. So we do this and we confirm this under fluoroscopic guidance and also with the camera in the 3-4 portal.
SANJ KAKAR: And so here you can see we're coming up and just underneath the TFCC and then we confirm this with fluoroscopy. And here you can see the fluoroscopic imaging. The wire is coming slightly radial to the fovea because I want to get a good bite of the TFCC when we're passing our sutures. And so here now watch? We've taken the k-wire out.
SANJ KAKAR: We've taken an 18 gauge needle with a looped 2-0 PDS and we're popping through the TFCC. You can see the cameras in 3-4 portal. And then, once the needle has popped through, you can see the looped 2-0 PDS, so we'll pop through into the TFCC. There you can see the needle and the loop to 2-0 PDS. So a grasper comes from the 6-R portal and we'll grab this loop
SANJ KAKAR: so here you can see the grasp is grabbing this, pull the needle back and this is a 2-0 PDS. Now the 0.062 k-wire hole is large enough that you can take another 18 gauge needle, and here you can see we're pushing the needle slightly volar through that hole, and then we're grasping that loop of 2-0 PDS so we basically have four limbs of suture now passing through the ulnar tunnel, coming out of the TFCC.
SANJ KAKAR: So there's another loop 2-0 PDS. And now what we'll do is cut one of the limbs and so we'll see which end runs with which and put a snap here. And we'll then now use a suture shuttle to shuttle these sutures back through the TFCC or the ulnar carpal capsule. So here we're knowing which suture runs with which and tagging this, and now we're taking a needle with a looped 2-0 PDS.
SANJ KAKAR: You can see the camera is already in the wrist and you can see here the needle comes through the ulnar carpal capsule. We'll grab this with the grasper in the 6-R portal and this will grab that suture loop, we'll pull this out of the 6-R portal, we'll pull the needle back, and this will be our suture shuttle. So there you can see we have a loop 2-0 PDS
SANJ KAKAR: and we'll take one free limb of the PDS now pulling this through and now as we're pulling this through, this limb of suture has gone through distal ulnar, through the TFCC, through the ulnar carpal capsule and back on itself. So you can see now here's one passage of that suture, and we'll do this three more times. Here again, needles coming in. The sensory nerve is retracted out of harm's way.
SANJ KAKAR: We're going through the ulnar carpal capsule. You can see there's the loop of the 2-0 PDS. The grasper comes in through the 6R portal and we'll now grab that limb, we'll pull that limb of 2- PDS back out of the 6R portal. Remember, this is our suture shuttle, and we'll take another free limb and then shuttle this back by pulling on the loop. And so you can see as we pull on the loop, once we've passed this suture end through, this will then be shuttled out of the ulnar, ulnar incision.
SANJ KAKAR: So now we have two sutures holding the TFCC down. We'll now come in again with the needle. You can see coming in just dorsal to the other sutures, again, acting as a suture shuttle to suture now, the other limb of the 20 PDS. Remember we had that clear limb and so here we're pulling out that suture shuttle. We'll have cut the loop. Here we're cutting the loop of that clear 2-0 PDS and we'll ensure we know which end runs with which
SANJ KAKAR: and then shuttle one limb back out. So this is the third passage, and we'll do this one more time. So then comes in the suture. There's the 2-0 PDS and this will be our final suture shuttle through. So now you can see with this technique, we have four strands of suture through the distal ulna, through the TFC three, through the ulnar carpal capsule.
SANJ KAKAR: So this will give us a robust repair. And you can see now we're bringing the probe in, I haven't even tied this down now. Now you can see that hook test is less positive than before. It's critical when we tie this that we take the wrist out of traction. So what we'll do is release the traction and then make sure that the nerve is retracted out of harm's way
SANJ KAKAR: and we simply tie this down snugly on the ulnar carpal capsule. So here you can see that there's really no soft tissue between the capsule and the sutures. The nerve is retracted volarly. So here we're tying this down and again, remember, this is done out of traction. And here's all the sutures tied
SANJ KAKAR: and then here you can see there's no traction on the wrist. And now we'll check the stability of the DRUJ. So remember how unstable it was before? There you can see immediate stability with just tying these four sutures down and good prono supination. Now to cover the suture ends,
SANJ KAKAR: what we'll now do is with a monocryl, you can see now we'll close the extensor retinaculum so the suture ends are not palpable for the patient. So here you can see we're closing the extensor retinaculum with the nerve retracted out of harm's way. So in terms of the post operative plan, patient is placed in the sugar-tong splint for two weeks. He then transitioned into a munster cast for an additional four weeks.
SANJ KAKAR: And at six weeks the patient goes into a munster splint and then we start a TFCC protocol. Because this is a foveal repair, I'll leave him in the munster splint for an additional six weeks so he has in total three months of post operative immobilization above the elbow but at six weeks after surgery, the patient is working on elbow flexion and extension prono supination
SANJ KAKAR: but also it's critically important that the therapists are working from proximal to distal so they're working on the scapulothoracic joint, the arm and the forearm in terms of wrist conditioning and strengthening and proprioceptive training. Here you can see the post operative radiographs and if you look at the post operative MRI, remember the preoperative MRI he had at volar subluxation, here you can see how we've restored the congruency of the DRUJ.
SANJ KAKAR: And this you can now see is the post operative range of motion. Remember, the wrist that we operated on was on the left side. So you can see he has good supination, good pronation may be slightly lax, terminal supination compared to the uninjured side, but the DRUJ is now stable in terms of his functional range of motion. So in terms of outcomes, I could have picked many articles. This is one article showing favorable results of a trans osseous arthroscopic foveal repair.
SANJ KAKAR: This is another article with follow up showing again good restoration of a range of motion and stability when one is doing this arthroscopically. Thank you very much for the pleasure of your time.
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