Carpal Instability: Around the Wrist from Around the World Co-Chairs: Melvin P

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Live Precourse 06: Carpal Instability: Around the Wrist from Around the World Co-Chairs: Melvin P. Rosenwasser, MD and Jeffrey Yao, MD

Program Syllabus

Octobber 1, 2020

75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 – 3, 2020

822 West Washington Blvd Chicago, IL 60607 Phone: (312) 880-1900 Web: www.assh.org Email: [email protected]

All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain.

Live Precourse 06: Carpal Instability: Around the Wrist from Around the World

This pre-course will cover all the relevant topics regarding carpal instability. Our international faculty will include some of the world’s leading experts regarding the wrist. During this comprehensive pre-course, we will cover the basic anatomy and carpal kinematics as well as illustrate pathology and the myriad of current treatment options. The format will be conducive to audience participation with case presentations and panel discussions.

LEARNING OBJECTIVES At the conclusion of this program, the attendee will:

• Understand the relevant anatomy and kinematics of the carpus. • Incorporate recent advances in understanding of carpal pathology. • Understand the most recent treatment options from around the world for these pathologies. • Discuss innovative surgical treatment options to incorporate into one’s practice.

CME CREDIT HOURS

The ASSH designates this live activity for a maximum of 4.00 AMA PRA Category 1 Credits TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The ASSH is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

PRE/POST EVENT – Learner Assessment The Pre-event Assessment was sent electronically to the email you have on file. The Post-event notification will be sent using the same method. Please check your email 24 hours after this course for a message from ASSH with access instructions and information.

You are encouraged to complete the post-event assessment even if you did not participate in the pre-event assessment. If you experience difficulty completing the post-event assessment online please email [email protected] or call (312) 880-1900.

According to standards established by the Accreditation Council for Continuing Medical Education (ACCME), the ASSH is required to assess learning from participation in Continuing Medical Education events. To address these standards, the Hand Society uses pre-and post-tests for all of its courses. These questions are used to evaluate the knowledge of course participants before attending a program and again after the course to see if improvements were made.

DISCLAIMER The material presented in this continuing medical education program is being made available by the American Society for Surgery of the Hand for educational purposes only. This material is not intended to represent the best or only methods or procedures appropriate for the medical situation discussed; rather the material is intended to present an approach, view, statement or opinion of the authors or presenters, which may be helpful, or of interest to other practitioners.

The attendees agree to participate in this medical education program, sponsored by ASSH with full knowledge and awareness that they waive any claim they may have against ASSH for reliance on any information presented in this educational program. In addition, the attendees also waive any claim they have against the ASSH for injury or other damage that may result in any way from their participation in this program.

All of the proceedings of the 75th Annual Meeting, including the presentation of scientific papers, are intended for limited publication only, and all property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain. Any sound reproduction, transcript or other use of the material presented at this course without the permission of the speaker or the ASSH is prohibited to the full extent of common-law copyright in such material.

The ASSH is not responsible for expenses incurred by an individual who is not confirmed and for whom space is not available at the meeting. Costs incurred by the registrant such as airline or hotel fees or penalties are the responsibility of the registrant.

The approval of the U.S. Food and Drug Administration is required for procedures and drugs that are considered experimental. Instrumentation systems discussed and/or demonstrated in or at ASSH educational programs may not yet have received FDA approval.

Claim your CME hours through www.ASSH.org

• How to Earn: Attend the live virtual meeting, October 1-3. The sessions included in your registration can earn you 20.25 AMA PRA Category 1 Credits™ of which 5.50 are patient safety hours. This includes scientific sessions, keynotes, symposia and ICLs. Additional-fee sessions, including precourses and the Residents/Fellows Conference, can earn you an additional 9 credits. • How to Claim: You can claim your CME for attending the live event in the same way you've claimed CME at previous ASSH Annual Meetings. Simply login to your ASSH account, choose the 75th Annual Meeting of the ASSH, and indicate which sessions you attended.

Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Questions? Problems? Contact the American Society for Surgery of the Hand at (312) 880-1900 or by email at [email protected].

Conflict of Interest Disclosures for 2020 Program Committee and Course Faculty

Program Faculty & Disclosures The American Society for Surgery of the Hand gratefully acknowledges those who have generously volunteered considerable time and effort to plan, organize and present this CME course. The ASSH appreciates the faculty’s dedication to teaching, their support of the ASSH mission, and their significant contribution to the educational success of this program. The following is a list of disclosures for all participating faculty and program staff.

CONFLICT OF INTEREST POLICY According to the ASSH conflict of interest policy, individuals involved in continuing medical education activities are required to complete a disclosure statement. The ASSH acknowledges this fact solely for the information of the listener. Non-conflicted reviewers have examined, documented and resolved financial relationship disclosures for this course content.

Financial Disclosure – represented by ● Instructors, planners, content reviewers and managers who affect the content of a CME/CE activity are required to disclose financial relationships they have with commercial interests (i.e. any entity producing, marketing, pre-selling, or distribution health care goods or services consumed by, or used on, patients) associated with this activity.

FDA Disclosure – represented by ▲ Some drugs or medical devices demonstrated at this course may have not been cleared by the FDA or have been cleared by the FDA for specific purposes only. The FDA has stated that it is the responsibility of the physician to determine the FDA clearance status of each drug or medical device he or she wishes to use in clinical practice.

The ASSH policy provides that “off label” uses of a drug or medical device may be described in the ASSH CME activities so long as the “off label” use of the drug or medical device is also specifically disclosed (i.e., it must be disclosed that the FDA has not cleared the drug or device for the described purpose). Any drug or medical device is being used “off label” if the described use is not set forth on the product’s approval label.

Planners 2020 Annual Meeting Program Chairs Dawn M. LaPorte, MD No relevant conflicts of interest to disclose

Ryan P. Calfee, MD, MSc No relevant conflicts of interest to disclose

Session Co-Chairs/Moderators Melvin P. Rosenwasser, MD ● Royalty: NewClip, AlloSource ● Receipt of Intellectual Property Rights: Radicle Orthopedics ● Consulting Fee: Stryker, Acumed, ZeroCast ● Speakers Bureau: Stryker, Acumed ● Contracted Research: Acumed, ZeroCast ● Ownership Interest: Radicle Orthopedics

Jeffrey Yao, MD ● Royalty: Arthrex ● Intellectual Property: Arthrex, Elevate Braces ● Speakers Bureau: Depuy-Synthes, Trice/Segway, Exsomed ● Ownership Interests: Elevate Braces, 3D Systems

Faculty Randip R. Bindra, FRACS, MCh Orth ● Royalty: Acumed LLC ● Consulting Fees: Acumed LLc, Tissium ● Speakers Bureau: Acumed Llc, Integra Life Sciences, Medartis ● Contracted Research: MTP connect

Diego L. Fernandez, MD No relevant conflicts of interest to disclose

Guillaume Herzberg, MD, PhD ● Royalty: Groupe Lepine Company

Pak-cheong Ho, MD No relevant conflicts of interest to disclose

Steven J. Lee, MD ● Royalty: Arthrex ● Consulting Fee: Arthrex ● Speakers Bureau: Arthrex ● Contracted Research: Arthrex

David M. Lichtman, MD No relevant conflicts of interest to disclose

Jane Christiane Messina, MD, PhD No relevant conflicts of interest to disclose

Mark Ross, FRACS ● Royalty: Integra, NewClip ● Consulting Fee: Integra, Newclip, Depuy Synthes ● Speakers Bureau: Integra, NewClip ● Contracted Research: Integra

Michael J. Sandow, BMBS, FRACS, FAOrthA ● Royalty: Signature Orthopaedics ● Intellectual Property: US patent - Animation Technology ● Ownership Interests: Stock in True Life Anatomy Pty Ltd, Macropace Products Pty Ltd, RuBaMAS Pty Ltd

Alexander Y. Shin, MD ● Royalty: TriMed Orthopedics/Mayo Medical Venture ● Consulting Fees: Hologic

Peter Tang, MD, MPH ● Consulting Fees: Globus Medical, Inc ● Speakers Bureau: AxoGen, Inc, Depuy Johnson & Johnson

Abhijeet L. Wahegaonkar, MD No relevant conflicts of interest to disclose

Scott W. Wolfe, MD ● Royalty: Trimmed, Inc, Extremity Medical, Elsevier ● Consulting Fes: Extremity Medical ● Speakers Bureau: Trimmed, Inc

Live Precourse 06: Carpal Instability: Around the Wrist from Around the World Co-Chairs: Melvin P. Rosenwasser, MD and Jeffrey Yao, MD

Description

Learning Objectives At the conclusion of this program, the attendee will:

Program

Session Chair(s) Jeffrey Yao, MD | Melvin P. Rosenwasser, MD

7:00 AM - 7:10 AM Introductions Jeffrey Yao, MD | Melvin P. Rosenwasser, MD

7:10 AM - 8:06 AM Moderator Jeffrey Yao, MD

7:10 AM - 7:22 AM Carpal Anatomy, Kinematics and Classification Martin Franz Langer, MD

7:22 AM - 7:34 AM Examination of the Carpus Pak-cheong Ho, MD

7:34 AM - 7:46 AM Augmenting the Examination with Imaging Studies Abhijeet L. Wahegaonkar, MD

7:46 AM - 7:54 AM Role of Arthroscopy in Diagnosis Jane Christiane Messina, MD, PhD

7:54 AM - 8:06 AM Roundtable Discussion Martin Franz Langer, MD | Jane Christiane Messina, MD, PhD | Abhijeet L. Wahegaonkar, MD | Pak-cheong Ho, MD

8:06 AM - 9:42 AM Moderator Melvin P. Rosenwasser, MD

8:06 AM - 8:18 AM Review of 2018-2019's Pertinent Carpal Instability Literature Scott W. Wolfe, MD

8:18 AM - 8:30 AM Radiofrequency Capsular Shrinkage in Pre-Dynamic SL Tears (With Video Demo) Randip R. Bindra, FRACS, MCh Orth

8:30 AM - 8:42 AM Why I Do It This Way and How I Do It (With Technique Video): Arthroscopic SL Reconstruction Pak-cheong Ho, MD

8:42 AM - 8:54 AM Why I Do It This Way and How I Do It (With Technique Video): Internal Brace Repair/Reconstruction with Fibertape Steven J. Lee, MD

8:54 AM - 9:06 AM Why I Do It This Way and How I Do It (With Technique Video): Rasl Technique, Long Term Outcomes and Tips and Tricks Melvin P. Rosenwasser, MD

9:06 AM - 9:18 AM Why I Do It This Way and How I Do It (With Technique Video): Scapholunotriquetral Tenodesis Reconstruction Mark Ross, FRACS

9:18 AM - 9:30 AM Why I Do It This Way and How I Do It (With Technique Video): Anafab Reconstruction Michael J. Sandow, BMBS, FRACS, FAOrthA

9:42 AM - 9:47 AM Break All Faculty

9:47 AM - 11:00 AM Moderator Jeffrey Yao, MD

9:47 AM - 9:59 AM Lunotriquetral Injuries Alexander Y. Shin, MD

9:59 AM - 10:11 AM Midcarpal Instability: Who Needs Treatment David M. Lichtman, MD

10:11 AM - 10:23 AM Perilunate Injuries Guillaume Herzberg, MD, PhD

10:23 AM - 10:35 AM CIND Following DRF Diego L. Fernandez, MD

10:35 AM - 10:47 AM SLAC Wrist: Salvage for 45 y.o. M, 75 y.o. M Peter Tang, MD, MPH

10:47 AM - 11:01 AM Roundtable Discussion Alexander Y. Shin, MD | David M. Lichtman, MD | Guillaume Herzberg, MD, PhD | Diego L. Fernandez, MD | Peter Tang, MD, MPH

Live Precourse 06: Carpal Instability: Around the Wrist from Around the World

7:30 AM - 7:40 AM

Introductions

Jeffrey Yao, MD | Melvin P. Rosenwasser, MD

Melvin P. Rosenwasser, MD ● Royalty: NewClip, AlloSource ● Receipt of Intellectual Property Rights: Radicle Orthopedics ● Consulting Fee: Stryker, Acumed, ZeroCast ● Speakers Bureau: Stryker, Acumed ● Contracted Research: Acumed, ZeroCast ● Ownership Interest: Radicle Orthopedics

Jeffrey Yao, MD ● Royalty: Arthrex ● Intellectual Property: Arthrex, Elevate Braces ● Speakers Bureau: Depuy-Synthes, Trice/Segway, Exsomed ● Ownership Interests: Elevate Braces, 3D Systems

75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

8/31/2020

Precourse 6: Around the Wrist from Around the World Course Chairs: Jeffrey Yao, MD (Stanford University) and Melvin Rosenwasser, MD (Columbia University)

Faculty: Randip R. Bindra, FRCS, MCh Orth, Diego L. Fernandez, MD, Guillaume Herzberg, MD, PhD, Pak-cheong Ho, MD, Steven J. Lee, MD, David M. Lichtman, MD, Jane Christiane Messina, MD, PhD, Mark Ross, FRACS, Michael J. Sandow, BMBS, FRACS, FAOrthA, Alexander Y. Shin, MD, Peter Tang, MD, MPH, Abhijeet L. Wahegaonkar, MD and Scott W. Wolfe, MD

• Please engage with us! • CHAT function

• Please submit your course evaluations

1 Live Precourse 06: Carpal Instability: Around the Wrist from Around the World

7:40 AM - 7:52 AM

Carpal Anatomy, Kinematics and Classification

Peter Tang, MD, MPH ● Consulting Fees: Globus Medical, Inc ● Speakers Bureau: AxoGen, Inc, Depuy Johnson & Johnson

75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

Slide 1 ______Carpal Anatomy, Kinematics and Classification ______

Pre-Course 06: Carpal Instability October 1, 2020 ______Peter Tang, MD, MPH, FAOA Associate Professor Drexel University College of Medicine Program Director ______Hand, Upper Extremity & Microvascular Surgery Fellowship Director Center for Brachial Plexus and Nerve Injury Allegheny General Hospital [email protected] ______

Slide 2 ______Disclosures

• Course Instruction: • AxoGen, Inc ______• Depuy Johnson & Johnson • Consultant: • Globus Medical, Inc ______• Previous research funding from the: • AxoGen, Inc • Orthopaedic Research Education Foundation (OREF) • Orthopaedic Scientific Research Foundation (OSRF) • American Association for Hand Surgery (AAHS) ______• American Foundation for Surgery of the Hand (AFSH) ______

Slide 3 ______Osseous Anatomy ______Slide 4 Extrinsic Ligaments ______• 3 main groups • Palmar radiocarpal • Palmar ulnocarpal • Dorsal radiocarpal ______

Slide 5 Extrinsic Ligaments ______• 3 main groups • Palmar radiocarpal • Palmar ulnocarpal • Dorsal radiocarpal ______

Slide 6 Intrinsic Ligaments ______Slide 7 ______Carpal Kinematics

• Wrist motion depends on ______pull of extrinsic tendons compared to center of rotation • No tendon connections to ______proximal carpal row – Rotation begins in distal row – Proximal row follows ______passively • Distal carpal row functionally one unit ______

Slide 8 ______Overview

Carpal Carpal Carpal ______Instability Instability Instability Dissociative Nondissociative Complex (CID) (CIND) (CID) ______Between the bones of the Instability of entire Perilunate injuries, proximal carpal row proximal row Axial fx- dislocations, Isolated carpal ______Scapholunate Lunotriquetral Extrinsic Intrinsic dislocations

Distal radius fracture ______malunion ______

Slide 9 ______CIND – Extrinsic (Adaptive)

• Most common cause is distal radius malunion with dorsal angulation ______• Palmar midcarpal ligaments slack • Instability, clunking similar to midcarpal instability • Load bearing also altered with malunion ______• In most cases, corrective osteotomy corrects carpal malalignment ______Slide 10 ______CIND Intrinsic

CIND ______Extrinsic Intrinsic ______

Palmar Dorsal Combined Radiocarpal ______

Anterolateral Anteromedial Palmar RSC, LRL, SRL (Radial (STT) (triquetrum- radioscaphoid- ligaments) hamate- capitate ______capitate ligament and ligament) DIC ______

Slide 11 ______Palmar CIND

• Anterolateral (Radial (STT) ligaments) or ______Anteromedial (triquetrum-hamate-capitate ligament) • On lateral xray, lunate is VISI ______• Catch-up clunk with ulnar deviation as proximal row suddenly goes from flexion to extension ______Wolfe, JAAOS 2012 ______

Slide 12 ______Slide 13 ______

Slide 14 ______Dorsal CIND

• On lateral xray, lunate is neutral ______

• With dorsal directed force the capitate subluxes dorsal from capitate ______Wolfe, JAAOS 2012 ______

Slide 15 ______Combined CIND

• Patients have hyperlaxity ______

• Demonstrate signs of palmar and dorsal CIND

• With dorsal capitate displacement test ______(traction, mild flexion and dorsally applied pressure to scaphoid tubercle) capitate and proximal row sublux dorsally ______

Wolfe, JAAOS 2012 ______Slide 16 ______Radiocarpal CIND

• Ulnar translocation ______

• Radial translocation

• Radiocarpal dislocation • Type I – purely ligamentous ______• Type II – radial styloid avulsion fracture Green’s, 6th Ed ______

Slide 17 Carpal Instability Complex (CIC) ______

• Dorsal Perilunate Dislocations (lesser arc injuries) ______• Dorsal Perilunate Fracture-Dislocations (greater arc injuries) • Palmar Perilunate Dislocations • Axial Fracture-Dislocations • Isolated carpal bone Dislocations ______

Slide 18 ______Summary

Carpal Carpal Carpal ______Instability Instability Instability Dissociative Nondissociative Complex (CID) (CIND) (CID) ______Between the bones of the Instability of entire proximal carpal row proximal row Perilunate injuries, Axial fx- dislocations, Isolated carpal ______Scapholunate Lunotriquetral Extrinsic Intrinsic dislocations

Palmar Distal radius Dorsal fracture Combined ______malunion Radiocarpal ______Slide 19 Thank You! ______

Live Precourse 06: Carpal Instability: Around the Wrist from Around the World

7:52 AM - 8:04 AM

Examination of the Carpus

Pak-cheong Ho, MD No relevant conflicts of interest to disclose

75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

9/3/2020

Wrist Examination for Chronic Wrist Pain “5 Level Approach”

PC Ho

Chief of Service Department of Orthopaedics & Traumatology Prince of Wales Hospital Clinical Professor (honorary) Chinese University of Hong Kong Founding President Asia Pacific Wrist Association S

Approach to Wrist Pain

S Radial S Central S Ulnar S Circumferential

1 9/3/2020

Systematic Assessment

The Basic Rules always apply S Look S Feel S Move S Provocative tests S Lignocaine injection

Feel

S Single most important step in all wrist conditions

S Anatomical components S Tendon S Bone S Ligament S Nerve

Tender Spots

❖ Radial to ulnar ❖ Proximal to distal ❖ Dorsal to volar ❖ Non-painful to painful site ❖ Palpated structures change with wrist position

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Provocative Test

S Beware of generalized laxity

S Compared to unaffected side

S Grip measurement

S Resistive movement S Resisted pronation/ supination

5- level Approach for Ulnar Wrist Pain Examination

Articular Causes of Ulnar Wrist Pain

3 9/3/2020

Forced Prono-supination

S Well supported elbow, fully relaxed wrist

S Rotate forearm (pure DRUJ)

rather than hand (multi-linked)

S Pain pinpointed to ulnar wrist

DRUJ Ballottement

S Hand and distal radius as single unit S Test in neutral, pronation and supination S Apply anterior and posterior stress S Note translation, pain & clicks S Compare with unaffected wrist

Omokawa , JWS 2017 11

Radio-Ulnar Ligament Behavior

S Hagert 1994, Kleinman 2007 S Pronation S Superficial dorsal & Deep palmar taut

S Supination S Superficial palmar & Deep dorsal taut

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DRUJ stability increased with wrist in extension and radial deviation due to tightening of :

S Ulno-carpal ligament

S ECU Floor

Ulnocarpal Ligament Injury

5 9/3/2020

DRUJ Loading Test

Squeezing of 2 forearm bones well proximal to DRUJ Passive P/S +/- pain CompressingVarying forearm position in various of prono angle-supination of P/S Pain pinpoint to DRUJ

Ulno-Carpal Grinding Test (UCG)

S Relaxed wrist, free fingers S Ulnar deviation + varying degree of flexion /extension S Pain /crepitus S Note site of pain S Ulnar column pathology S Ulnar head / styloid S Central TFCC S Triquetrum / lunate S Triquetro - hamate

Piso-Triquetral Shear

S Wrist start at RD S Thumb pressing on ulnar aspect of pisiform S Followed by passive ulnar deviation S Indirect stress to TFCC

S Highly suggestive of TFCC lesion if PT grinding test -ve

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Piso-Triquetral Ballottement & Grinding

S Direct rocking of pisiform against triquetrum

S Varying degree of wrist flexion / extension

S Note pain, crepitus and degree of instability

Luno-Triquetral Ballottement

S Indirect (Kleinman) S Direct (Reagan)

S +ve laxity of ulnar column

S -ve LT direct ballottement

7 9/3/2020

Shuck Test & Mid-carpal Clunk

ECU Synergy (Stress) Test

5th CMCJ Disorders

8 9/3/2020

Resisted Prono-supination

S Ultimate confrontation test

S Testing DRUJ stability

S Testing mid-carpal stability

S Effect of manual stabilization

5 –Level Examination Approach

V – CMCJ CMCJ grinding / ECU ECU Stress IV – Inter CJ i. Shuck ii. MC clunk iii. Ulnar column

III – Intra CJ i. PT – PT ballotte ii. LT – LT ballotte

i. UCG II - UCJ ii. PT shear iii. UCL Stress

i. P/S I - DRUJ ii. DRUJ ballotte iii. DRUJ loading

Radial Wrist Pain

S Eichhoff / Finkelstein

S WHAT Test

S Radio-carpal Grinding

S Scaphoid Shift (Watson)

S SL Ballottement

S Finger extension test

S 1st CMCJ Grinding

S Thumb Hyperextension Stress

9 9/3/2020

WHAT Test

S Goubou JF et al. The wrist hyperflexion and abduction of the thumb (WHAT) test: a more specific and sensitive test to diagnose de Quervain tenosynovitis than the Eichhoff's Test. J Hand Surg Eur Vol. 2014 Mar :39(3):286-92

Radio-carpal Grinding

S Relaxed wrist, free thumb S Radial deviation + varying degree of flexion / extension S Pain / Crepitus S Beware of site of pain

S Radial column pathology S Radius S Scaphoid S TT 30

10 9/3/2020

Radio-carpal Grinding

Watson’s test (Scaphoid Shift)

S SL instability S pain over dorsal SL junction S click / clunk

S Scaphoid pathology S Pain over scaphoid tubercle S No click/clunk

SL Ballottement

11 9/3/2020

Finger Extension Test

S Forced extension of I/F and/or M/F against resistance with wrist in flexion

S Occult ganglion

S SL instability

S Dorsal synovitis

1st CMCJ Grinding Test / Hyperextension Stress

S Grinding of 1st MC against

trapezium

S Pain, crepitus and instability

S Forced hyperextension

of adducted thumb

5 –Level Examination Approach

CMCJ grind Hyper-E Stress V. CMCJ

STT tender IV. Inter CJ + grinding - STTJ

Watson SL ballotte III. Intra CJ Finger extension - SL

Radiocarpal Grinding II. RCJ 1st DC tenderness Eichhoff/ Finkelstein I. DeQuervain WHAT test 36

12 9/3/2020

13 Live Precourse 06: Carpal Instability: Around the Wrist from Around the World

8:04 AM - 8:16 AM

Augmenting the Examination with Imaging Studies

Abhijeet L. Wahegaonkar, MD No relevant conflicts of interest to disclose

75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

8/31/2020

Live Pre-course 06: Carpal Instability: Around the Wrist from Around the World

Augmenting the Examination with Imaging Studies

75th Annual Meeting of the ASSH October 1-3, 2020

Abhijeet L. Wahegaonkar Adjunct Professor of Hand Surgery Distinguished Clinical Tutor of Orthopedic Surgery Director- Upper Limb, Hand & Microsurgery Fellowship Program Consultant & Head Department of Upper Extremity, Hand & Microvascular Reconstructive Surgery Sancheti Institute for Orthopaedics & Rehabilitation Jehangir Hospital Pune, INDIA

www.thehandsurgeryclinics.com 2

COI/ Disclosures

• No disclosures

1 8/31/2020

• P/E Rt Lt DF 30 76 PF 60 65 RD 20 25 UD 15 30

- Point tenderness of SL region dorsally and anatomic snuff box - Pain with scaphoid shift test - Non tender fovea, LT - Stable DRUJ

Differentials

• 1) # Scaphoid • 2) Wrist sprain • 3) SL injury

X-rays

• The initial study is complete radiographic assessment with six views of the wrist (posteroanterior, lateral, radial deviation, ulnar deviation, clenched fist).

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PA radiograph

“Gilula’s lines”

Lateral Plain Radiograph

capitate

pisiform scaphoid

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What do the radiographs tell us?

Radiological Evaluation for Suspected SL Injury

• Ask 3 Questions to Yourself • Is the PCR intact? • What is the position of the lunate? • Is the abnormal position constant or intermittent?

11 11

Radiological Evaluation for Suspected Carpal Instability

• Ask 3 Imaging Questions

• x-ray at rest: is there deformity? If not,

• Stress x-ray: is there deformity now?

12 12

4 8/31/2020

PA radiograph

Cortical ring with flexion of scaphoid

Quadrilateral appearance of lunate 20 extension SL gap

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Lateral radiograph

DISI > 60o

Predynamic SL membrane partially ruptured or attenuated

Normal x-rays (plain & stress) Arthroscopy → grade I or II

6 8/31/2020

• Dynamic • Tear of volar or dorsal aspect of the SL

• Normal plain xrays (abnormal stress) • Arthroscopy → grade III or IV

• Static (without DISI) • SL gap ≥ 3mm IIM • Disruption of SL ligaments Tp • Injury or attenuation of secondary stabilizers

• Static (with DISI) • Chronic rupture of SL & extrinsic ligaments • ↑SL gap, ↑SL & RL angles

7 8/31/2020

• SLAC wrist

Fluoroscopy

Normal PCR moves as a unit

WRIST MOTION PCR Flex Flex Extend Extend RD Flex UD Extend

Fluoroscopy

8 8/31/2020

Motion Series

ulnar deviation radial deviation

Arthrography

Dye leaks into the midcarpal joint

SLD normal

Do we need any further investigations?

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CT Scan

Dynamic CT Scan

• MRI

10 8/31/2020

1.5T 3T 31

MRI

L S

Sensitivity 63% Specificity 86% Schadel-Hopfner et al. 2001

• MRI

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• Arthroscopy

• Imaging method of choice

• Staging the severity of an SLIL tear can be performed best by radiocarpal and midcarpal arthroscopy.

Cooney WP: Evaluation of chronic wrist pain by arthrography, arthroscopy, and arthrotomy. J Hand Surg[Am] 1993;18:815-822.

Cooney WP, Dobyns JH, Linscheid RL: Arthroscopy of the wrist: Anatomy and classification of carpal instability. Arthroscopy 1990;6:133-140.

• Arthroscopy

Arthroscopic Dorsal Capsuloligamentous Repair ADCLR

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Summary

• Imaging studies are meant to “augment” a sound & thorough history taking & clinical exam

• Investigations/ Imaging studies should not be a “eureka” moment!

• Best to speak to your radiologist

• Arthroscopy is currently the “gold standard” in the diagnosis and management of SL injuries

Question

Which of the following radiographic stress views best demonstrates dynamic scapholunate (SL) instability?

A. Clenched pencil view B. Posteroanterior clenched fist in neutral position C. Posteroanterior clenched fist in radial deviation D. Anteroposterior (AP) clenched fist in neutral position E. Anteroposterior clenched

Preferred response: A

Question

In scapholunate advanced collapse (SLAC), which joint is spared arthritic changes?

A. Scapho-trapezial-trapezoid B. Scaphocapitate C. Lunocapitate D. Radioscaphoid E. Radiolunate

Preferred response: E

13 8/31/2020

Thank you!

www.thehandsurgeryclinics.com 40

14 Live Precourse 06: Carpal Instability: Around the Wrist from Around the World

8:16 AM - 8:24 AM

Role of Arthroscopy in Diagnosis

Jane Christiane Messina, MD, PhD No relevant conflicts of interest to disclose

75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

75rd ASSH Annual Virtual Meeting

Pre-Course 06: Carpal Instability

October 1st, 2020

CARPAL INSTABILITY: ROLE OF ARTHROSCOPY IN DIAGNOSIS

Jane C. Messina

First Orthopaedic Clinic University of Milan

Gaetano Pini Orthopaedic Institute- CTO, Milan, Italy

For correspondence: [email protected]

Goals At the conclusion the attendee should

• Understand the role of Arthroscopy in detection of intra-carpal injuries • Identify intracarpal ligament tears and cartilage damage • Understand that intracarpal ligaments have different anatomical portions • Extrinsic ligaments may also be involved (as secondary stabilizers) associated to intrinsic ligament damage • Be able to stage them with Arthroscopic EWAS Classification

Main Points

• Wrist pain after a trauma can be related to scapho-lunate or luno-triquetral tear , that may not be detected by diagnostic imaging, expecially in partial injuries (XRays, MRI) • These injuries can develop in several steps according to Mayfield • The scapho-lunate instability is a spectrum of injuries that can lead to the development of osteo- arthritis • Treatment of chronic cases is still a challenge for the surgeon • Non arthroscopic (Garcia Elias Staging System) and arthroscopic Classification are the key points to understand the anatomo-pathological injury

Pearls & Pitfalls

• It is Important to try to distinguish the acute from chronic injuries • Haemorrhage of the ligament generally means acute trauma • Look for extrinsic ligament involvement and damage

Principal Mechanism of Trauma (radial side)

• Fall on outstretched hand • Begins on radial side in extension , ulnar deviation, intercarpal supination • Starts with SL, RC, RTL, DRCL • Leading to perilunar instability

Other traumatic mechanism (ulnar side)

• Fall outstreched hand , radial deviation • Pronation • Compression+ extension

Spectrum of injuries

• Multiple ligament injuries can develop • Differents degrees of intrinsic and extrinsic ligament damage that can be found

Arthroscopic EWAS Classification (9) • The European Wrist Arthroscopy Classification (EWAS) , is based on this anatomical study (9) • It helps to understand the anatomo-pathological damage to the intrinsic and extrinsic ligaments • The Classification is based on the localization of damage at the different portions of intrinsic ligaments (SL or LT) • It can be a guide to plan the repair of ligaments

STAGE LESIONS RC: radiocarpal MC: midcarpal

I SPRAIN RC, MC: haemorrhage ACUTE ONLY

II SPRAIN – membranous portion RC, MC: central passage of probe . Absence of widening of SL space at instability test ACUTE / CHRONIC

III A - PARTIAL ANTERIOR SL TEAR MC: partial anterior SL widening at dynamic (+LRL, RSC) instability test (anterior laxity ) ACUTE/CHRONIC

III B – PARTIAL POSTERIOR SL TEAR MC: incongruency SL, probe passage with (+ DIC, DCSS) partial dorsal SL widening at instability dynamic (posterior laxity) ACUTE/CHRONIC

III C - COMPLETE SL MC: incongruency SL, complete widening of (+ DIC/LRL, RSC) SL space only at dynamic test ACUTE/CHRONIC

IV - COMPLETE SL + GAP RC e MC: obvious SL gap, intability (DIC, LRL, RSC) passage of arthroscope through SL space Injury of DIC,RSC, LRL, ACUTE/CHRONIC

V – COMPLETE SL TEAR+ GAP + XRAYS RC, MC: OBVIOUS GAP, laxity of other ABNORMALITIES extrinsic ligaments, instabily, rotation of scaphoid (Reducible) Mainly CHRONIC (Additional other extrinsic ligaments involved compared to stage IV)

Repair Techniques

• Several non-arthroscopic and arthroscopic repair techniques have been described to repair the different portions of SL ligament • Arthroscopic techniques of repair are developing to treat cases at an early stage • More advanced stages can be treated with open techniques and Arthroscopy helps to define which ligaments are involved and need to be repair and identify the possibile cartilage damage

Conclusions

 Classification is evolving and this allows a better analysis of the ligamentous damage

 The Arthroscopic Classification can be used in intracarpal interosseous ligament injuries (SL and LT), acute or chronic , in order to define the anatomo-pathological damage

 The aim is to treat them early and appropriately in the different stages with minimally invasive techniques and less immobilisation time

 Arthroscopy help in diagnosis and planning of arthroscopic or open repair

References

1) Linsheid RL, Dobyns JH, Beabout JW, Bryan RS. Traumatic instability of the wrist. Diagnosis, classification and pathomechanics. J Bone Joint Surg 1972; 54A:1612-1632. 2) Dautel G, Goudot B, Merle M. Arthroscopic diagnosis of scapho-lunate instability in the absence of XRay abnormalities. J Hand Surg 1993; 18B: 213-218. 3) Garcia Elias M, Lluch AL, Stanley JK. Three ligament tenodesis for the treatment of scpho-lunate dissociation: indications and surgical technique. J Hand Surg 2006; 31A: 125-134. 4) Garcia Elias M, A Lluch. Wrist instabilities, misalignment and dislocations. In “Green’s Operative Hand Surgery” 7th Edition. Editors: Wolfe, Hotchkiss, Pederson, Kozin, Cohen. Elsevier , Phildelphia 2017; Ch 13: 418- 478. 5) Luchetti R, Papini Zorli I, Atzei A, Fairplay T. Dorsal intercarpal ligament capsulodesis for predynamic and dynamic scapholunate instability. J Hand Surg 2010; 35E (1): 32-37. 6) Mathoulin CL, Dauphin N, Wahegaonkar AL. Arthroscopic dorsal capsule-ligamentous repair in chronic scapholunate ligament tears. Hand Clin 2011;27:563-572 7) Dautel G, Merle M. Tests dynamiques arthroscopiques pour le diagnostic des instabilities scapho-lunaires. Ann Hand Surg 1993 ; 12:206-209 8) Berger RA. The ligaments of the wrist. Hand Clinics 199 ; 13 (1): 63-82. 9) JC Messina, L Van Overstraeten, R Luchetti, T Fairplay, C Mathoulin. The EWAS Classification for scapho-lunate tears: an anatomical arthroscopic study. Journal of wrist Surgery 2013; 2: 105- 109 10) Mathoulin C, Messina J. Traitement des lésions aigues du ligament scapholunaire par simple brochage avec assistance arthroscopique. Chir Main 2010; 29 : 72-77 11) L Van Overstraeten, EJ Camus, A Wahegaonkar, J Messina, AA Tandara, A Cambon Binder, CL Mathoulin. Anatomical Description of the Dorsal Capsulo-Scapholunate Septum (DCSS)— Arthroscopic Staging of Scapholunate Instability after DCSS sectioning. J Wrist Surgery 2013; 2: 149-154. 12) Del Pinal F, Studer A, Thams C, Glasberg A. An all inside technique for arthroscopic suturing of the volar scapholunate ligament. J Hand Surg 2011; 36A: 2044-2046 13) Herzberg G. Perilunate non dislocated: PLIND injuries. J Wrist Surgery 2013; 2 (4): 337-45 14) Chin A, Garcia Elias M. Combined reverse perilunate and axial-ulnar dislocation of the wrist: a case report. J Hand Surg Eur 2008; 33 (5) 672-6.

Live Precourse 06: Carpal Instability: Around the Wrist from Around the World

8:24 AM - 8:36 AM

Roundtable Discussion

Peter Tang, MD, MPH | Jane Christiane Messina, MD, PhD | Abhijeet L. Wahegaonkar, MD | Pak-cheong Ho, MD

Peter Tang, MD, MPH ● Consulting Fees: Globus Medical, Inc ● Speakers Bureau: AxoGen, Inc, Depuy Johnson & Johnson

Jane Christiane Messina, MD, PhD No relevant conflicts of interest to disclose

Abhijeet L. Wahegaonkar, MD No relevant conflicts of interest to disclose

Pak-cheong Ho, MD No relevant conflicts of interest to disclose

75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

9/5/2020

Roundtable Discussion

Faculty: Pak-cheong Ho, MD, Abhijeet L. Wahegaonkar, MD, Jane Christiane Messina, MD, PhD and Peter Tang, MD, MPH

DISCLOSURES

Abhijeet L. Wahegaonkar, MD

Speaker has no relevant financial relationship to disclose.

Case history

• 34 year male, software professional • Right hand dominant • Weekend sports enthusiast • C/C Pain (R) wrist of 6-7 months duration • Insidious onset of pain, gradually increased in severity over past couple of months • No H/O trauma recalled, (may have sprained the wrist while playing cricket) • Pain increases with strenuous activities, moderate to severe • Not associated with clicks/clunks • Past medical history: Not significant

1 9/5/2020

Clinical examination

• Inspection: No obvious swelling, deformity, skin (n) • ROM: Wrist extension/flexion painful at terminal range, else all movements free • Palpation: Tenderness over the dorsal aspect of wrist, over SL region, tenderness in the anat. snuff box, finger extension against resistance painful • Special tests: Watson’s maneuver -ve

Radiographs

Differentials?

• What next?

2 9/5/2020

MRI

What next?

3 9/5/2020

Arthroscopy

Ganglion cyst stalk

Arthroscopy – Ganglion excision and ADCLR

Courtesy: Martin Caloia 1) Binder AC, Kerfant N, Wahegaonkar AL, Tandara AA, Mathoulin CL. Dorsal wrist capsular tears in association with scapholunate instability: results of an arthroscopic dorsal capsuloplasty. J Wrist Surg. 2013 May;2(2):160-7.

2) Overstraeten LV, Camus EJ, Wahegaonkar A, Messina J, Tandara AA, Binder AC, Mathoulin CL. Anatomical Description of the Dorsal Capsulo-Scapholunate Septum (DCSS)-Arthroscopic Staging of Scapholunate Instability after DCSS Sectioning. J Wrist Surg. 2013 May;2(2):149-54.

3) Wahegaonkar AL, Mathoulin CL. Arthroscopic dorsal capsulo-ligamentous repair in the treatment of chronic scapho-lunate ligament tears. J Wrist Surg. 2013 May;2(2):141-8.

4 9/5/2020

Thank you!

www.thehandsurgeryclinics.com 13

DISCLOSURES

Jane Christiane Messina, MD, PhD

Speaker has no relevant financial relationships with commercial interest to disclose.

Clinical Case

Jane C Messina First Orthoapedic Clinic University of Milan Gaetano Pini- CTO Orthopaedic Institute Milan, Italy

5 9/5/2020

SD 45 yo

 Profession: Manager. Sports: fishing, weigh lifting, biking - right handed  Wrist pain since many years, diagnosis of SL tear  2018 arthroscopy and shrinkage (other surgeon)  Lifting a table with reappearance of pain, expecialy under load and taking even small weights like a little backback for computer  Objective examination: pain on SL, Ballottment test pos, Watson neg but painful, pain at maximal extension of the wrist  MRI: disomogeneity of dorsal SL and of TFCC

SD 45 yo

Arthroscopy: SL tear 3B TFCC tear: LT tear: 3B

6 9/5/2020

What would you do?

 Diagnosic Arthroscopy and discuss with patient for surgical option of open repair.  Which type of open repair?  Arthroscopic repair of TFCC and shrinkage of SL and LT  Arthroscopic repair of TFCC and SL ligament  Arthroscopic repair of TFCC, SL and LT ligaments

What we did: arthroscopic repair of TFCC, SL and LT

7 Live Precourse 06: Carpal Instability: Around the Wrist from Around the World

8:51 AM - 9:03 AM

Review of 2018-2019's Pertinent Carpal Instability Literature

Scott W. Wolfe, MD ● Royalty: Trimmed, Inc, Extremity Medical, Elsevier ● Consulting Fes: Extremity Medical ● Speakers Bureau: Trimmed, Inc

75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

8/31/2020

Scott W Wolfe, MD

Royalty: Trimed, Extremity Medical, Elsevier Consulting Fees: Extremity Medical Speakers Bureau: Trimed Precourse #06: Carpal Instability Around the Wrist from Around the World None relevant to this talk SCOTT W. WOLFE, M.D.

75th Annual Meeting of the ASSH PreCourse 06: Carpal Instability: Around the Wrist from Around the World September 30, 2020 Carpal Instability Literature Review: PUBMED SEARCH 2018-9 2018-2019 “Carpal Instability” “Scapholunate Dissociation” “Wrist Injury" • 15754 manuscripts • 1324 in 2018-9, titles reviewed • 72 selected, papers reviewed and scored • 18 (upper quartile) selected for presentation • Papers fell into four categories

Scott W. Wolfe, M.D. 34

1 8/31/2020

PUBMED SEARCH 2018-9 “Carpal Instability” “Scapholunate Dissociation” “Wrist Injury"

Dissociative Instability: Biomechanical SLIL Reconstruction Studies

Midcarpal Imaging, Modeling, Instability and Virtual Analysis

Dissociative Instability: SLIL Reconstruction TRENDS • Search for new reconstructive methods • Increasing attention to posture > than gap • Ligaments other than SLIL addressed • Two directions: – Addressing dorsal and volar SLIL – SLIL plus “critical ligaments” vs. • Synthetic augmentation

2 8/31/2020

Biomechanics

TRENDS ANAFAB • Mechanical studies essential • Addresses STT, dSLIL, LRL • Carpal instability related to: – Distal radius fracture malunion • Modification repairs DIC – Lunate fractures • Augmented with synthetic tape • Models for DISI and midcarpal instability • No K-wires, 6 wk postop cast • Kinetic and kinematic properties of SL joint • 10 patients, 2y reduction SLG • “Critical ligaments” of the proximal row and SLA, 100% “pushup test” 910

SCAPHOLUNATE INSTABILITY DISTAL RADIUS

11 12

3 8/31/2020

MIDCARPAL INSTABILITY Midcarpal Instability

TRENDS • Still poorly understood, treatment algorithms vary widely • Non-operative exercise regimens • Mechanical simulation, testing • Ligament plication • Traumatic midcarpal instability patterns

13 14

Imaging, Modeling, & Virtual Analysis

TRENDS • Advances in imaging technology  “4D” • Resolution increasing, acquisition time • Combine MBR with real-time 3D CT • Open source digital library of carpal kinematics • Finite element models for virtual surgery

15 16

4 8/31/2020

17 18

75th Annual Meeting of the ASSH PreCourse 06: Carpal Instability: Around the Wrist from Around the World September 30, 2020 THANK YOU!!

Scott W. Wolfe, M.D. 19

5 Live Precourse 06: Carpal Instability: Around the Wrist from Around the World

9:03 AM - 9:15 AM

Radiofrequency Capsular Shrinkage in Pre- Dynamic SL Tears (With Video Demo)

Randip R. Bindra, FRACS, MCh Orth ● Royalty: Acumed LLC ● Consulting Fees: Acumed LLc, Tissium ● Speakers Bureau: Acumed Llc, Integra Life Sciences, Medartis ● Contracted Research: MTP connect

75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

ASSH 2018 Precourse 02 30/08/2020

DISCLOSURES Randip R. Bindra, FRCS, MCh Orth

Royalty: Acumed LLC Consulting Fees: Acumed LLc, Tissium Speakers Bureau: Acumed Llc, Integra Life Sciences, Medartis Contracted Research: MTP connect

Radiofrequency Capsular Shrinkage

in Pre-Dynamic SL Tears ) Randy Bindra MD FRACS Gold Coast, Australia

DISCLOSURES

Randip R. Bindra, FRCS, MCh Orth

Royalty: Acumed LLC Consulting Fees: Acumed LLc, Tissium Speakers Bureau: Acumed Llc, Integra Life Sciences, Medartis Contracted Research: MTP connect

Randy Bindra 1 ASSH 2018 Precourse 02 30/08/2020

Randy Bindra 2 ASSH 2018 Precourse 02 30/08/2020

Randy Bindra 3 ASSH 2018 Precourse 02 30/08/2020

Randy Bindra 4 ASSH 2018 Precourse 02 30/08/2020

Randy Bindra 5 ASSH 2018 Precourse 02 30/08/2020

24 yr old female- right wrist pain after car accident 6 months earlier

Randy Bindra 6 ASSH 2018 Precourse 02 30/08/2020

Left wrist

Randy Bindra 7 ASSH 2018 Precourse 02 30/08/2020

6R portal

RF thermal capsulorraphy Probe in 3/4- scope in 6R

Before After

Randy Bindra 8 ASSH 2018 Precourse 02 30/08/2020

Randy Bindra 9 ASSH 2018 Precourse 02 30/08/2020

Belyea et al, 2019 JHS GO

Problems with current evidence

Randy Bindra 10 ASSH 2018 Precourse 02 30/08/2020

Take home message

Randy Bindra 11 Live Precourse 06: Carpal Instability: Around the Wrist from Around the World

9:15 AM - 9:27 AM

Why I Do It This Way and How I Do It (With Technique Video): Arthroscopic SL Reconstruction

Pak-cheong Ho, MD No relevant conflicts of interest to disclose

75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

9/4/2020

PC Ho

Chief of Service Department of Orthopaedics & Traumatology Prince of Wales Hospital Clinical Professor (honorary) Chinese University of Hong Kong Founding President, APWA 2015-17 Past President, EWAS 2015

Problems of Conventional SL Reconstruction

 Does not address volar component of SL ligament  Infringe blood supply

 Does not correct diastasis (Slater 1999)

 Recurrent diastasis (Viegas 1994)

 Limited motion & grip strength (Deshmukh 1999, Dagum 1997)

1 9/4/2020

Repair of dorsal SL ligament not improve SL angle

Dunn MJ, Johnson C. Static scapholunate dissociation: a new reconstruction technique using a volar and dorsal approach in a cadaver model. J Hand Surg Am. 2001;26(4):749-754.

Repair dorsal SL alone not restore carpal kinematics, unable to stabilize SL

Short WH, Werner FW, Sutton LG. Dynamic biomechanical evaluation of the dorsal intercarpal ligament repair for scapholunate instability. J Hand Surg Am. 2009;34(4):652-659.

Both dorsal & volar SL of same strength Veigas SF, Yamaguchi S, Boyd NL, Patterson RM. The dorsal ligaments of the wrist: anatomy, mechanical properties, and function. J Hand Surg Am . 1999;24:456-468. Mean max load to failure of dorsal SL: 83 N; volar SL 86N

Fotios VN, Emmanuel PA, Apostolos DP, Panayiotis JP, Aristides VZ, Vassilios AK. Biomechanical properties of the scapholunate ligament and the importance of its portions in the capitate intrusion injury.Clin Biomech . 2011;26:819-823. Volar SL higher strength than dorsal SL

Logan SE, Nowak MD, Gould PL. Biomechanical behavior of the scapholunate ligament. Biomed. Sci.instrum . 1986;22:81-85.

 Cadaveric study (n=4)  Single bone tunnel, PL graft  SL diastasis effectively reduced and SL contact with radius

Zdero R, Olsen M. Linear and Torsional Mechanical Characteristics of Intact and Reconstructed Scapholunate Ligaments J Biomech Eng

Combined Dorsal & Volar Ligament “BOX” Reconstruction

2 9/4/2020

24 Dec 2002

 11 May 2018  9 week post injury & 5 week post-op elsewhere

Right wrist for reference

3 9/4/2020

Right wrist for reference

Passive RD fails to close SL gap

Arthroscopic Assessment

25 May 2018 12

4 9/4/2020

Pre-Arthrolysis Post-Arthrolysis

Dorsal Volar Box Reconstruction of SL Ligament with Tendon Graft

Proximal wrist crease

¾ portal

FCR PL

Landmark for Scaphoid Tunnel

between ECRL & ECRB

ECRB ECRL

EPL

5 9/4/2020

Landmark for Lunate Tunnel

Retract EDC ulnarly or through EDCs

Volar incision for PL graft harvesting

Palmar cutaneous branch of median nerve

Retract Median nerve & flexor tendons

Deep volar SL region

Retract FCR & Palmar branch of MN

6 9/4/2020

Scaphoid Tunnel 2.5mm

Lunate Tunnel (2.5mm)

Dorsal Proximal ------Volar Distal

2mm Mini-grasper

Protect Median Nerve

7 9/4/2020

Volar Part of SL Reconstruction

Tendon Tying (shoe-lacing x 2)

2’0 Ethibond Braided Non-cutting

8 9/4/2020

8 weeks PO (20 Jul 2018)

8 months PO 15 Feb 2019 Scaphoid cast/ brace x 6-8 weeks Active mob 8 weeks Passive mob 10 weeks Strengthening 12 weeks

Clinical Outcome

 Oct 2002 - May 2018 30 cases  Improvement of s/s : 17

 Current study on 1st 17 patients  Pain score : 8.3  1.7 /20  M 15 F 2  Wrist score : 28  37.8 /40

 Av Age : 42 (26 - 60)  Grip power : 74%  84%

 s/s duration : 9.5 months (1.5 - 28)  SL interval : 2.9mm (1.6-5.5mm)

 Geissler Grade : III 3 IV 14  Improved ROM : Ext 13% Flex 16%

 Av SL interval : 4.9mm (3 - 9mm) RD 13% UD 27% (c.f. preop)

 Av FU : 48.3 months (11-132 m)  Complication : proximal pole ischaemia in 1

9 9/4/2020

5 yrs 8 months PO

9.5 yrs PO 17 Sep 2019 30

10 9/4/2020

Ensure Reducibility

3.5mm hole 14.3.2006 14.9.2010

May 2012

Sep 2017

11 9/4/2020

21 May 2002

3 Oct 2002 13 May 2003

Indications

 Complete SL  Complete SL ligament injury, non- ligament injury, non- reparable reparable  Complete SL  No DISI ligament injury, non-  DISI +ve,  Mid-substance reparable  Non-reducible, but tear retracted / rendered reducible fibrotic  DISI +ve, reducible by arthroscopy  Secondary  Secondary stabilizers intact stabilizers disrupted  Cartilage normal

12 Live Precourse 06: Carpal Instability: Around the Wrist from Around the World

9:27 AM - 9:39 AM

Why I Do It This Way and How I Do It (With Technique Video): Internal Brace Repair/Reconstruction with Fibertape

Steven J. Lee, MD ● Royalty: Arthrex ● Consulting Fee: Arthrex ● Speakers Bureau: Arthrex ● Contracted Research: Arthrex

75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

9/4/2020

DISCLOSURES

Steven J. Lee, MD

Royalty: Arthrex Consulting Fee: Arthrex Speakers Bureau: Arthrex Contracted Research: Arthrex

Steven J. Lee, M.D. Chief, Surgery of the Hand and Upper Extremity Lenox Hill Hospital Associate Director, NISMAT New York, NY

Disclosures

 Royalties/Consultant from Arthrex

1 9/4/2020

Scapholunate Injuries: What is the Gold Standard???

 Repair sutures/suture anchors  Capsulodesis  BTB  Brunelli  Modified Brunelli  Garcia-Elias 3 Ligament Tenodesis (3LT)  RASL/SLIC  SLAM  I just tell my pts to expect a gap  I just wait and do a salvage

S-L Spectrum of Injury

 Sprain  Partial  Repairable  Irreparable  Dorsal  Central  Volar  Tear of all 3 components  Acute or chronic  Dynamic or fixed  Arthritis

Repair

 If repairable, repair it!  Capsulodesis, AIN and/or PIN Neurectomy?

2 9/4/2020

Acute Repair  3.5 SL loaded with 2-0 Fiberloop and Suturetape  Use 3.0 SILVER drill

3 9/4/2020

Reconstruction Thoughts…

 S-L Repairs/Recons fail A LOT  Connect the Scaphoid to the Lunate  Control Scaphoid flexion/Lunate extension  Current fixation methods are not strong  Tendon graft recon tend to stretch out  Current treatments suboptimal  Current reconstructions are a pain in the butt

Ideally…

 Reconstruct with a tendon graft  Connect Scaphoid to Lunate  Keep Scaphoid from flexing, Lunate extending  Come up with a strong fixation  Internally brace recon to prevent stretching  I’d like to not tell my pts that the gapping is expected  Simple surgery

Decision process

 Arthritis?  Fixed or Flexible?  Partial Tear  Dorsal portion only torn?  Central tear?  Completely torn

4 9/4/2020

42 y.o male 5 months s/p “wrist sprain”

Harvest 2 mm of ECRB/L

Graft

 Make it THINNER than you think!  2 mm in width best  At least 10 cm in length

5 9/4/2020

Reduce with Joysticks

2-0 Fiberloop ends of tendon

3.5 mm DX Swivelock SL

 PEEK  3.5 x 8.5 mm

6 9/4/2020

3.5mm Drill holes  Proximal scaphoid, lunate, distal scaphoid  Put guidewires in 1st, check xray!

3.5mm Gold Drill  Proximal scaphoid, lunate, distal scaphoid

Clamp joysticks together  Pin S-C

7 9/4/2020

Attach graft and Suturetape to Swivelock

Insert 1st Swivelock

 Into prox pole of Scaphoid

2nd Swivelock dunk

 Dunk the tendon AND Internal Brace together  It will self tension

8 9/4/2020

Final SL Dunk  Distal pole of Scaphoid  Again, both tendon and IB  Cut off excess

Final Reconstruction

Surgical Pearls

 Use if there is still some Volar S-L intact!  Learn how the 3.5 DX Swivelock SL works  Make your graft thinner than you think: 2 mm perfect!  Avoid the temptation to use a thicker graft!  Graft needs to fit inside pitchfork!  Use the guidewires first and check on Xray before drilling  3.5 mm Gold drill for Grafts  Keep graft moist when dunking SL  Firm but steady pressure when dunking SL in before screwing in anchor body  Pin the S-C: Secondary stabilizer?  Have your rep there!

9 9/4/2020

Stronger than your current sx

 Biomechanical strength:  Recon fails at 82.0 N  Repair fails at 41.7 N

 Stiffness: • Recon stiffness: 30 N/mm  Repair stiffness: 14.0 n/mm

Truly Live Fluoro

SURGICAL PEARLS

 Learn how a 3.5 Swivelock SL works. Take it apart!  Open book it – detach any little strands if you need to  2mm width graft enough!  Make your drills in cannulated fashion  3.5 mm drill for Scaphoid, 3.0 mm for Lunate  Inside out, Outside in for Lunate  Put a Kwire into Inside out Lunate hole for aiming  Suturetape for Internal Brace  Let SL sink into hole before screwing in anchor body  Pin S-C joint x 6-8 wks 30

10 9/4/2020

Latest f/u

 18 pts > 2 yr f/u (Avg 3.8 yrs)  Gapping: 4.14 (Preop) -> 3.03 (Postop)  S-L Angle: 68.07 (Preop) -> 56.04 (Postop)  DASH 55 to 19.25  Likert Scale 1.47  Grip 85% of opposite side  Pinch 100% of opp side  D/P 94%/85% of opp side  2 AVN Lunate (1 became nonsymptomatic, 1 lost to f/u)  Both had preop Lunate edema  2 Failures: Gapping > Preop

THANK YOU

11 Live Precourse 06: Carpal Instability: Around the Wrist from Around the World

9:39 AM - 9:51 AM

Why I Do It This Way and How I Do It (With Technique Video): Rasl Technique, Long Term Outcomes and Tips and Tricks

75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

9/1/2020

Melvin P. Rosenwasser, MD

Royalty: NewClip, AlloSource Receipt of Intellectual Property Rights: Radicle Orthopedics Consulting Fee: Stryker, Acumed, ZeroCast Speakers Bureau: Stryker, Acumed Contracted Research: Acumed, ZeroCast Ownership Interest: Radicle Orthopedics

Acumed Upper Extremity Surgical Skills Course: Miami, FL 2

RASL Technique: Long Term Outcomes Tips and Tricks Melvin P. Rosenwasser, MD Robert E. Carroll Professor of Orthopedic Surgery Professor of General Surgery Director Orthopaedic Hand and Trauma Services Director Trauma Training Center Columbia University Medical Center

Why do we treat? DISI leads to SLAC arthritis

1 9/1/2020

Forces are too great for K wires or tenodesis fixation alone OBLIGATORY SL physiologic intercarpal rotation of 25 degrees

Scaphoid continues to flex after the lunate stops SL screw strong enough To neutralize forces

RASL is my solution to a difficult and not uncommon problem Static DISI, prior to onset of Stage 3 SLAC, can be treated with a motion sparing RASL procedure

Others are reporting their results treating Chronic DISI with various soft tissue reconstructions AND a trans-osseous SL screw

First Report published 1997

2 9/1/2020

CONTRAINDICATION to RASL is SLAC 2 and 3

Watson, JHS 1984 Images from www.emedicine.com

SLAC 1 OK for RASL SLAC 1 RADIOSCAPHOID IMPINGEMENT and CHONDRAL WEAR

Radial styloidectomy removes contact and pain

3 9/1/2020

10 RASL Procedure: Reduction and Association of the Scaphoid and Lunate 2 camps: • It works beautifully • It doesn’t work

Why the discrepancy? • Technique and Indications • Name 1 orthopedic procedure that does not require adherence to a rigorous technique

What causes the RASL to fail? • Is it the screw itself? • Is it the reduction? • Is it the orientation of the screw axis? • Is it the stage of SLAC?

Reduction and screw axis are keys to the success of the RASL • Targeting and screw positioning have been extensively discussed in a variety of orthopedic procedures • SCREW positioning is CRUCIAL TO SUCCESS • RASL is no different • Correctly placed screw = successful outcome

4 9/1/2020

RASL Concept is Like an Axle

Allows motion around the axis of rotation

RASL concept is like an Axle

Allows motion VIDEO around the axis of rotation

RASL procedure Do NOT Use a fully threaded screw ▪ It will break This is not a fusion SL screw maintains reduction during soft tissue healing All screws demonstrate some non progressive lucency around the lunate threads Screws in appropriate axis have minimal bone lucency and RASL NOT A FUSION do not migrate

5 9/1/2020

Technique

• Longitudinal dorsal incision • Radial styloid incision- 1st DC • Transverse capsular incision preserves dorsal capsular ligaments (DIC- secondary restraint) • Work through 2 windows • K wire joy sticks placed distally in both S and L o Avoid wire placement in axis of intended screw path

RASL Operative Video: Obligatory physiologic SL intercarpal rotation after RASL procedure

VIDEO

Dorsal Incision

6 9/1/2020

Insert Footer Text Here 9/1/2020 19

Dorsal Ligaments- DIC preserved During Dorsal Capsulotomy

Radial Incision- Styloidectomy Necessary to get correct starting point

Reduction & Association of the Scaphoid & Lunate (RASL)

Fluoro 20s no fade.wmv

VIDEO

7 9/1/2020

Subchondral burring creates bleeding Promotes neoligamant scar response

Kocher Clamp maintains reduction

Guide wire must target the central lunate axis

8 9/1/2020

Reduction K wires avoid the central axis of screw

Critical Technical Points ▪ Radial styloidectomy ▪ Starting point must be at or prox to dorsal lateral ridge of scaphoid ▪ Axis of screw directed towards medial corner of the reduced lunate on coronal view ▪ Saggittal Axis central to slightly palmar on lateral view ▪ This closely approximates the center of rotation of the SL joint ▪ NEVER PLACE THE SCREW DORSAL

Case 1: screw distal Case 2: screw prox to ridge to ridge

▪ Screw placement in the RASL procedure is highly predictive of long- term subjective and objective outcomes

9 9/1/2020

Starting point must be proximal to dorsal lateral ridge of scaphoid

Radial styloidectomy facilitates getting starting point proximal

Saggittal targeting center or volar to mid lunate axis

Case 1: Postop Films Case 2: Postop Films

19 year FU DASH=11.6 Failure

10 9/1/2020

Insert Footer Text Here 9/1/2020 31

MUST DO!

Starting point of the screw proximal to the dorsal lateral ridge of the scaphoid

To do that you need to do a limited radial styloidectomy

Don’t forget the dechondrification of the SL interval to generate a vascular healing response

Properly positioned screw doesn’t restrict movement

Insert Footer Text Here 9/1/2020 33

Results: Screw placement distal to the lateral aspect of the dorsal scaphoid ridge was significantly associated with failure when examined manually, radiographically (1.8 vs. 0.5mm) and using real-time motion capture.

11 9/1/2020

Insert Footer Text Here 9/1/2020 34

Proximal

Distal

Insert Footer Text Here 9/1/2020 35

Conclusion: The lateral aspect of the dorsal ridge is a reliable radiographic landmark on the scaphoid and provides surgeons with a convenient starting point to achieve the most biomechanically stable RASL construct, and, therefore, enhances the potential for an optimal clinical outcome.

The 1 illustration shows a poor insertion site distal to the lateral dorsal ridge of the scaphoid No radial styloidectomy performed Off axis screw placement leads to oscillation of the screw and bony cavitation No lateral x rays shown to demonstrate position of screw 1 Patient had failed primary SL repair surgery Immediately Post-Op 4 months post-op 9 months post-op

12 9/1/2020

Dr. Stern’s article did not report • If radial styloidectomies were done the 1 case example did not show it • No LATERAL XRAYS were shown demonstrating sagittal screw placement • The accuracy of the lunate reduction not shown or discussed • AND in the 1 case shown the critical starting point not obtained • Starting point for screw( ? S) was distal to the dorsal lateral ridge of the scaphoid • Despite all of the variation in the published RASL technique • None of his cases had secondary surgery and at 38 months F/U all had low DASH disability scores • His study’s conclusion, in only 7 patients, focused on x -ray alignment alone Insufficient data to support his strong conclusion about the RASL procedure

• Pain improvement in 10/12 patients • Grip strength 70% contralateral side • Range of motion decreased from pre-op • DASH: 12.6 in 8 patients, 4 did not have DASH scores • 10 had reoperations, 8 of which were for screw removal

39 Dr. Elhassan’s article: • Used four different screws in their 12 patients • Had screw placement that they noted “varied significantly in their cohort” • Three underwent the arthroscopically assisted technique • Only reported three radial styloidectomies out of their 12 patients • 4/8 of the complications had screws that were too short • 2/8 had poor screw trajectories • 4 patients that had dorsal screw placement in saggital plane of lunate

13 9/1/2020

Insert Footer Text Here 9/1/2020 40

• Short screw • Poor fixation • No radial styloidectomy

Insert Footer Text Here 9/1/2020 41 Dr. Elhassan’s article: “The technical failures in this study may be related to the challenges of precise screw placement and expertise required to perform the RASL procedure rather than failures of the procedure itself.”

Case: 40 y/o male with SLIL injury on 01/16/1997

14 9/1/2020

1 year F/U Stable reduction Minimal and non progressive lucency at screw threads

20 year follow-up No SLAC progression

20 year follow-up

DASH score = 5

Grip strength 40/40

15 9/1/2020

RASL Outcome Study- 35 Patients 10.89 Years Longest follow up for any published report of Chronic Static SL instability

DASH 14.96 VAS active 2.7 Patient based outcomes: N = 35, Age = 50.5 (31.0 – 66.8) ▪10.89 years follow up (1.14 to 24.23) Table 1: Patient Based Outcomes Outcome Value Range DASH 14.96 ± 15.2 0-50.83 SF-36 75.13 ± 21.68 12 – 98.8 VAS - rest 0.5 ± 0.83 0 - 3.0 VAS - active 2.7 ± 2.7 0 - 7.3

Legend: All values presented were collected at the final follow-up visit for all 35 included patients and signify averages ± standard deviations. DASH, Disabilities of the Arm, Shoulder, and Hand Questionnaire. SF-36, Short-form 36 Survey. VAS, visual analog pain scale. May 2018

>80% motion and grip strength Physical Exam: N = 26 9.82 years follow-up (1.4 to 24.2)

Table 2: Physical Exam Parameters at Final Follow-Up Parameter Injured Side Contralateral Side % p- CL Value Range Value Range value Flexion/Extension Arc 86 102° ± 29° 55-160° 118° ± 32° 60-170° 0.1 Radial Deviation 82 19° ± 8.0° 10-35° 23° ± 8.9° 5-40° 0.2 Ulnar Deviation 81 25° ± 11° 10-47° 31° ± 8.8° 15-45° 0.2 Grip Strength 83 66 lb ± 19 lb 18-99 lb 79 lb ± 23 lb 44-123 >0.005 lb Legend: Values signify averages ± standard deviations. %CL (contralateral ligament) represents the share of motion/strength in the injured side compared to the uninjured side. P-values represent the results of t-tests comparing values of the injuredMay side 2018 to the contralateral side for each variable.

16 9/1/2020

SL Reduction maintained

Radiographs • N = 20 (complete set of radiographs before and after surgery) • Avg. Radiographic f/u 36.6 months (1.4 – 225.5 months)

Pre-Operative Post-Operative

Value Value p-value

SL-Gap 4.5 mm ± 2.6 mm 2.1 mm ± 1.0 mm < 0.001

SL-Angle 77° ± 19° 55° ± 13° < 0.001

February 2017

It matters where you place the screw- Immediate post op

Screw positioning is fundamental to RASL success AP View ▪ Screw must be placed parallel to dorso-radial inclination ▪ Proximal to dorsal lateral ridge Lateral View ▪ Axis of screw should be central to slightly palmar

14 year follow-up- SL still reduced DASH: 12.5 VAS rest: 0 / VAS active: 3

17 9/1/2020

52 And here he is now 19 years out DASH: 6.67 VIDEO

To continue the Martial Arts Theme

• 57 y/o LHD man who practices judo • Injured when blocking a kick: pain, swelling, splinted for several months • DISI deformity • DOS: 1/13/2017

1 year later Lunate reduced- screw axis ideal

18 9/1/2020

1 year later

Dart throwers’ Motion Preserved Radial and Ulnar deviation

Gold Standard Push Up

VIDEO

Insert Footer Text Here 9/1/2020 57 @ 2 years

DASH: 5.8 Grip: L 98 lbs R 100 lbs

19 9/1/2020

Insert Footer Text Here 9/1/2020 58 @ 2 years

VIDEO 58

RASL 9 year Follow Up

DASH: 5.8 Grip: 92.4 Contralateral Grip: 90.2

Insert Footer Text Here 9/1/2020 60 RASL 9 year Follow Up

VIDEO

20 9/1/2020

Insert Footer Text Here 9/1/2020 61 Comments from patient w/ 6 year FU:

DASH: 11.7

Insert Footer Text Here 9/1/2020 62

Thank You

[email protected]

21 Live Precourse 06: Carpal Instability: Around the Wrist from Around the World

9:51 AM - 10:03 AM

Why I Do It This Way and How I Do It (With Technique Video): Scapholunotriquetral Tenodesis Reconstruction

Mark Ross, FRACS ● Royalty: Integra, NewClip ● Consulting Fee: Integra, Newclip, Depuy Synthes ● Speakers Bureau: Integra, NewClip ● Contracted Research: Integra

75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

P a g e | 1

SLT Tenodesis for SLL reconstruction

Mark Ross Professor of Orthopaedic Surgery University of Queensland Brisbane Hand and Upper Limb Clinic

Greg Couzens Brisbane Hand and Upper Limb Clinic

Brisbane,Queensland, Australia

• “Chronic” SL Dissociation

• Cartilage Acceptable

• Reducible (operative)

• Ligament unlikely to heal

• Dynamic or Static Reversible – Geissler 4 - EWAS IV/V

→Reconstruction ……….

Approach

• Perhaps “ligament splitting” approach divides the extrinsic stabilizer connection to proximal row?

• Arthroscopic techniques and Capsular Window Approach

o Preserve extrinsic ligaments o Preserve proprioception

P a g e | 2

Ligaments

➢ “Secondary” Stabilisers → ?primary stabilisers

• vSTTJ , • DICL/DRCL • LRL

• Excessive focus on intrinsic ligaments • Perhaps we should dispense with the term Secondary stabilisers • Perhaps extrinsic ligaments are the PRIMARY stabilisers

Personal View

• The most important EXTRINSIC stabilisers are DIC-l and vSTT

• Proximal portion of DIC is most important - DSLT – Dorsal Scapho-luno-triquetral Lig

• Probably in most cases the LRL stretches with time as a secondary phenomenon

Isolated Dorsal SLIL Surgery is not predictable in Chronic SLD

Options to overcome this shortcoming

• Combine Dorsal and Volar

• Target Central Sagittal rotation Axis

• Augment “Secondary” Stabilisers

P a g e | 3

SLT Tenodesis

• Modification of 3LT ( “mod Brunelli” ) o Stanley , Garcia-Elias

• Augment secondary PRIMARY EXTRINSIC stabilisers • Capsular window approach • Graft passed through proximal row

• 3mm graft – 3mm tunnel- 3mm interference screw • Reinforced with labral tape in parallel to graft o Anchored in volar trapezium to augment vSTT ligs o Secured in capitate ( robust bone for labral tape anchoring)

SUMMARY SLT • Graft Volar to STT restrains scaphoid flexion (Brunelli) • Preserve dorsal lig attachments to proximal row and repair any observed avulsion back to lunate bare area • Reinforce DSLT ligament • Reduction of rotary subluxation through graft tensioning- NO JOYSTICKS! o The graft does the reduction

Summary

• Extrinsic Stabilisers → PRIMARY stabilisers • vSTTJ , • DICL/DRCL • LRL

Summary

• Perhaps “ligament splitting” approach divides the extrinsic stabilizer connection to proximal row (esp Lunate)? • Capsular Windows and Arthroscopic techniques o Preserve extrinsic ligaments o Preserve proprioception • Tailor operative management to the patient’s specific kinematic problem P a g e | 4 o Different patterns ( dorsal translation of proximal pole , gapping, DISI, ulnar tranlocation ) represent differing EXTRINSIC ligament issues combined with the SLL ligament injury and the chosen reconstruction should address the specific extrinsic pathology

Live Precourse 06: Carpal Instability: Around the Wrist from Around the World

10:03 AM - 10:15 AM

Why I Do It This Way and How I Do It (With Technique Video): Anafab Reconstruction

75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

29-Aug-20

Disclosure Anatomical Volar and Dorsal •M J Sandow may receive a benefit from a Reconstruction for commercial party (True Life Anatomy) Scapho-Lunate Dissociation related to the content of this study - ANAFAB -  Developing interactive 3D imaging since 1997. Michael Sandow FRACS Orthopaedic Surgeon

Wakefield Orthopaedic Clinic

Centre for Ortho. and Trauma Research 1998 1999 2001 University of Adelaide AUSTRALIA

VOLAR May 2014 L-Tq Unifying model of carpal mechanics based on computationally LongR-L derived isometric constraints and rules-based motion Sc-Tm – the stable central column theory M. J. Sandow, T. J. Fisher, C. Q. Howard, S. Papas

DORSAL

Sc-L

DORSAL Scapho-lunate dissociation Injury spectrum:  Scapho-lunate diastasis  Scaphoid dorsal subluxation  Scaphoid flexion  Lunate extension / translation Characterized by: Critical 3 Scapho-lunate diastasis Dorsal scaphoid subluxation  STT Scaphoid flexion  dSLIL Lunate extension

 LRL VOLAR Volar Dorsal

1 29-Aug-20

ANAFAB Dorsal Surgical Technique

Dorsal Longitudinal incision through 3rd compartment, EPL left out and 4th Dorsal Scapho-lunate ligament attachments identified compartment elevated but left intact - marked with 2.5mm drill

Volar K-wire inserted along scaphoid axis using Longitudinal incision along line of FCR targeting jig or Imaging and through sheath to volar capsule and radius

Scaphoid-trapezium ligament attachments identified - marked with 2.5mm drill

3mm cannulated drill over k-wire to create scaphoid tunnel. Drill dorsal to volar to ensure the proximal scaphoid drill hole is correctly positioned

2.5mm wide 15cm long distally based strip of FCR - passing pin, and No.2 Nylon to strip, distal to proximal

2 29-Aug-20

2.5mm wide 15cm long distally based strip of FCR Volar

Double loop of 1.5mm synthetic tape secured to Trapezium (lateral facet) using 3.5mm suture anchor

FCR strip 1.5mm 36” Synthetic tape (doubled) Using tendon passing device, FCR strip and synthetic tape passed volar to dorsal through scaphoid

volar

Using a tendon passing device, FCR strip and synthetic tape passed volar to dorsal through scaphoid to dorsal wound Scapho-trapezium ligament restored

3 29-Aug-20

K-wire inserted to (just) exit on volar-ulnar lunate surface ** Care to avoid mid-carpal joint and volar structures **

Curved smooth instrument through Midcarpal joint protects and guides. Check with imaging.

dorsal

Extend the volar FCR 3mm drill to create lunate tunnel wound and blunt dissect across the volar capsule and under the carpal tunnel contents.

Locate and retrieve the Advance drill just to tendon passing device as it breach volar cortex. exits the volar lunate. Ensure k-wire does not advance!!! Tendon and synthetic tape are then loaded into the tendon passing device….

Dorsal Scapho-lunate ligament restored. … and advanced through lunate to volar wound.

4 29-Aug-20

Using imaging, locate radial drill hole in FCR can sometimes central radial styloid be a bit short. – aim to exit adjacent Add suture extension if needed. to lister’s tubercle

Tendon passing device used to advance hybrid tendon tape volar to dorsal through radial styloid.

Apply adequate tension to FCR tendon and labral tape to reduce carpal bones, and secure dorsally with (3mm or 4 mm) interference screw

Determine screw size with Volar Long Radio-lunate ligament restored. Stepped Sound device

The interference screw fixation of the FCR tendon and Add an additional suture to local tissue, or in larger patients, labral tape is augmented by an additional suture a small interference screw, to secure the FCR/labral tape to anchor more proximally on the dorsal radius. the dorsal lunate to prevent in-line slippage.

5 29-Aug-20

Sutures are inserted “ANAFAB” – between the dorsal lunate Anatomical Front And Back reconstruction and DIC as part of dorsal capsular closure

Splint 5 days then Cast 6 weeks

“ANAFAB” – Anatomical Front And Back reconstruction

32 y.o. male Splint 5 days heavy FOOSH at football then Cast 6 weeks 34

Sca-Lun 400

Cap-Lun 950

6 months post ANAFAB

Pre-repair 3 months Post repair

6 29-Aug-20

Scapho-Lunate Dissociation

•dSLIL •STT CARPAL TRIFECTA •LRL }

Apply injury based repair strategy ➢Repair is directed to the deficits - Logic and Theory based ➢ANAFAB repair appears to achieve this

37 Long term outcomes are needed

[email protected]

www.woc.com.au/ANAFAB

YouTube.com >> “ANAFAB” + “Wolfe”

No funding or support was received from any commercial entity

7 Live Precourse 06: Carpal Instability: Around the Wrist from Around the World

10:15 AM - 10:27 AM

Round Table Discussion With Case Presentations: Emphasize Longest Term Follow UPS and Failure Analysis

Pak-cheong Ho, MD No relevant conflicts of interest to disclose

Scott W. Wolfe, MD ● Royalty: Trimmed, Inc, Extremity Medical, Elsevier ● Consulting Fes: Extremity Medical ● Speakers Bureau: Trimmed, Inc

Steven J. Lee, MD ● Royalty: Arthrex ● Consulting Fee: Arthrex ● Speakers Bureau: Arthrex ● Contracted Research: Arthrex

75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

Mark Ross, FRACS ● Royalty: Integra, NewClip ● Consulting Fee: Integra, Newclip, Depuy Synthes ● Speakers Bureau: Integra, NewClip ● Contracted Research: Integra

75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

9/5/2020

Scott W Wolfe, MD

Royalty: Trimmed, Inc, Extremity Medical, Elsevier Consulting Fes: Extremity Medical Speakers Bureau: Trimmed, Inc

16th Annual UE Tutorial Snowmass, CO DEBATES, Pt I Thursday Feb. 13, 2020 CHRONIC SCAPHOLUNATE INSTABILITY: Repair, Reconstruct or Retreat?

SCOTT W. WOLFE, M.D. 3

1 9/5/2020

9y reducible right scapholunate ligament injury in a 40 year old engineer, RHD 4

PROBLEM LIST • Chronic SLIL dissociation, deficient ligament

• Rotary subluxation of the scaphoid (3D)

• Dorsal intercalated segment instability • SLAC

• Dorsal scaphoid translation 5

GRADE I+ SLAC!?

2 9/5/2020

INSURMOUNTABLENO! OBSTACLES?

HOW?

• SLIL repair/tenodesis • Arthroscopic: Corella • 3-ligament tenodesis • Arthroscopic: DCSS • RASL • Spiral tenodesis • SLAM • SLITT repair • “Axis” repair • SLICL repair • “Box” repair • ANAFAB repair

THE ANAFAB TECHNIQUE

3 9/5/2020

WINDOWS

Wessel, L. et al: The dSLIL Complex: An Anatomic and Histologic Study. JHS (A) 2020, submitted INCISIONS 10

3.0mm Bone Tunnels 11

Passage of construct through lunate hole to palmar side, preparation for passage of tendon through radius to recreate LRL 12

4 9/5/2020

Passage of construct through lunate hole to palmar side, preparation for passage of tendon through radius to recreate LRL 13

Finals. Retained wire in lunate interference screw. 14

Postop: s/p Right SLIL repair with ANAFAB graft on 5/2/19. Radiographs on 5/14/19 x 12 days p/o

5 9/5/2020

6m post reconstruction

PROBLEM LIST • Chronic SLIL dissociation, deficient ligament

• Rotary subluxation of the scaphoid (3D)

• Dorsal intercalated segment instability

• Dorsal scaphoid translation 18

6 9/5/2020

ANATOMIC FRONT AND BACK

• DIASTASIS • DISSOCIATION • DISI • DORSAL TRANSLATION

6 months postop: R wrist ANAFAB 19

THANK YOU!

SCOTT W. WOLFE, M.D. 20

DISCLOSURES Randip R. Bindra, FRCS, MCh Orth

Royalty: Acumed LLC Consulting Fees: Acumed LLc, Tissium Speakers Bureau: Acumed Llc, Integra Life Sciences, Medartis Contracted Research: MTP connect

7 9/5/2020

• 20 yr male, transferred from outside hospital Motorcycle accident

Pelvic fracture Bilateral wrist injuries Right wrist ORIF done left wrist untreated

Right wrist

8 9/5/2020

At presentation

Injury Xrays- right wrist

Current position

9 9/5/2020

Next steps?

• Further imaging • Cast for 6 weeks • Realign index metacarpal

10 9/5/2020

11 9/5/2020

12 9/5/2020

Left wrist

13 9/5/2020

Mark Ross, FRACS

Royalty: Integra, NewClip Consulting Fee: Integra, Newclip, Depuy Synthes Speakers Bureau: Integra, NewClip Contracted Research: Integra

14 9/5/2020

Pre Course 6 Case Discussion M Ross • 34yo male police officer LHD

• Fall 3 metres onto Left hand • Also fractures jaw • Delayed presentation due to other injuries and personal reasons

• No history of prior wrist injury or any wrist symptoms

5 months post injury

• EWAS V

Proximal Scaphoid at A/S 5 months post injury

15 9/5/2020

Assessment?

SLL Dissociation PLUS progressive ulnar translocation

16 9/5/2020

Management?

• Partial Fusion • Total Fusion • Reconstruction?? – If so what recon?

Modified SLT including DRC recon

5 year f/u back on full duties flex 50 ; ext 60 ; grip 42 vs 47kg

17 9/5/2020

Michael J. Sandow, BMBS, FRACS, FAOrthA, PhD

Royalty: Signature Orthopaedics Intellectual Property: US patent - Animation Technology Ownership Interests: Stock in True Life Anatomy Pty Ltd, Macropace Products Pty Ltd, RuBaMAS Pty Ltd

Case Presentation: 2 stage ANAFAB

Case Presentation Pre-course 6 Failed ANAFAB provides a lesson

Michael J. SANDOW BMBS, FRACS, PhD Wakefield Orthopaedic Clinic & Centre for Orthopaedic and Trauma Research University of Adelaide Adelaide, Australia

18 9/5/2020

Scapho-lunate dissociation 42 y.o. Fireman Forceful twisting of right wrist 3 months previously – unrolling fire hose. Immediate pain which settled, but never regained power or comfort. Grip reduced - 30 vs 50Kg F/E 80/80 Positive scaphoid shift

19 9/5/2020

Anatomical Front and Back Reconstruction

FCR strip Labral tape (anchor)

Splint 5 day Cast 6 weeks Removable brace 6/52

Dx – SLD > ANAFAB repair SL widely displaced Procedure technically satisfactory Wrist stable and mobile Splint 5 days Cast 6 weeks

1 week post op – in cast 6 week post op

20 9/5/2020

“If you know what you XXXXed-up, then do it again!”

Tendon mushy Tape let go at last anchor Redo went well.

21 9/5/2020

Lessons: 1. ANAFAB restores stability 2. Tendon is mushy at 8 weeks / validity as a restraint in medium term? 3. Tendon may not be the best repair material 2 years post redo: 4. If it was the right plan, and No pain you know what you XXXX- 100% grip , 65/65 F/E ed up – then do it again Full duties 5. Patient still talks to me 64

Melvin P. Rosenwasser, MD

Insert Footer Text Here 9/5/2020 66

Case Presentation

Illustration of technique Tips and Tricks Reviewed

22 9/5/2020

Insert Footer Text Here 9/5/2020 67 Case: 40 y/o RHD male SLIL instability, + Watson sign

DASH: 50.9 67

Insert Footer Text Here+Positive Positive Watson’s Sign- Gross instability 9/5/2020 68

Insert Footer Text Here 9/5/2020 69 Intra-Op

23 9/5/2020

Insert Footer Text Here 9/5/2020 70 Ideal placement of screw

Insert Footer Text Here 9/5/2020 71

Post-Op Note screw Proximal to dorsal lateral ridge

Insert Footer Text Here 9/5/2020 72 3 Months Post Op

24 9/5/2020

Insert Footer Text Here 9/5/2020 73 3 Months Post Op

VAS: 0/10

Insert Footer Text Here 9/5/2020 74 No Instability 3 mos P.O.VIDEO

25 Live Precourse 06: Carpal Instability: Around the Wrist from Around the World

10:27 AM - 10:39 AM

Lunotriquetral Injuries

Alexander Y. Shin, MD ● Royalty: TriMed Orthopedics/Mayo Medical Venture ● Consulting Fees: Hologic

75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

ASSH Precourse 6: Lunotriquetral October 2020 Injuries

Lunotriquetral Instability Carpal Instability Precourse 6 Alexander Y. Shin, MD Mayo Clinic Rochester, Minnesota

DISCLOSURES Lunotriquetral Ligament Instability Alexander Y. Shin, MD

Royalty: TriMed Orthopedics/Mayo Medical Venture Consulting Fees: Hologic Alexander Y. Shin, MD Professor & Consultant Department of Orthopaedic Surgery Mayo Clinic, USA

History Wrist Instability 1972: Linscheid & Dobyns •Era of Enlightenment •Traumatic Instability of the Wrist •1972-1990 •“DISI” and “VISI” defined

Ronald Linscheid James Dobyns J Bone Joint Surg 54-A, 1972

Alexander Y. Shin, MD 1 ASSH Precourse 6: Lunotriquetral October 2020 Injuries

Lunotriquetral Instability Lunotriquetral Instability

•Reagan, Linscheid, Dobyns • Less common •Introduced the concept of LT injuries • Subtle presentation Examination and Treatment • • Often overlooked • Majority present as chronic injuries

J Hand Surg, Am Vol 9, 1984

Anatomy Lunotriquetral Injury Mechanism of Injury

• Similar to SLIL •Perilunate injury • Dorsal •LT instability as remnant • Palmar after healed SL ligament or • Membranous scaphoid fracture (Mayfield stage III)

Ritt et al 1998 JHS

Lunotriquetral Injury Lunotriquetral Injuries Mechanism of Injury Mechanism of Injury

Isolated LT injury •reverse perilunate •Ulnar plus variant pattern with impingement •loading in dorsiflexion, •attritional tear radial deviation and •TFCC tear intercarpal pronation

Murray, Palmer, Shin JHS A 2012

Alexander Y. Shin, MD 2 ASSH Precourse 6: Lunotriquetral October 2020 Injuries

Lunotriquetral Injury Progressive VISI Pathomechanics •A LT disruption alone is not sufficient to result in a static VISI deformity

Horii et al. JHS 1990

Lunotriquetral Injury Clinical Examination Clinical Presentation •Ulnar sided wrist pain •Stance of wrist •Intermittent pain •Forklike deformity •Static VISI •Feeling of instability • extremes of motion

Lunotriquetral Injury Video: LT Exam Clinical Presentation •¯ ROM •Weakness •Instability •New Wrist Clunk

Alexander Y. Shin, MD 3 ASSH Precourse 6: Lunotriquetral October 2020 Injuries

Radiographs Radiographs

•Often normal • No gaps, VISI •Subtle changes •Breaks in Gilula’s arcs

MRI Radionuclide Scan Technecium 99 MDP

• Poor specificity and sensitivity •Helpful when radiographs normal 52% and 32% •Localization of contrast • With direct arthrography improved sensitivity to 90% and 87% • Requirements 1.5-3 T

Arthrography Diagnostic Injections

•Midcarpal injection of Three phase • lidocaine •Radiocarpal •Midcarpal •Improvement of grip and pain •DRUJ

Alexander Y. Shin, MD 4 ASSH Precourse 6: Lunotriquetral October 2020 Injuries

Arthroscopy Arthroscopy - Midcarpal

• Diagnostic and therapeutic •Direct inspection •Midcarpal assessment •Associated pathology •Possible Treatment

Treatment Goals of Surgical Treatment • Realignment of capitolunate • Acute and chronic tears (without instability) Trial of injection axis & Immobilization • Reestablishment of rotational • Chronic tears unresponsive to integrity of proximal carpal immobilization row Operative • Acute and chronic Intervention • Reduction of abnormal dissociations intercarpal motion

Role of Arthroscopy Ulnar Shortening

• Limited role •Debridement membranous portion ligament Particularly •Plication volar ulnar arcuate effective with ligaments degenerative LT with associated •Reduction/Pinning acute injury ulnar impaction •Grade I-II

Mirza et al, JHS 2013

Alexander Y. Shin, MD 5 ASSH Precourse 6: Lunotriquetral October 2020 Injuries

LT Arthrodesis: Rationale Arthrodesis: Advocates

• Congenital LT Coalition Simmon & McKenzie, JHS 10A, 1985 •“Less technically demanding compared to reconstruction or repair”

LT Arthrodesis LT Arthrodesis Nonunion rates Ulnocarpal Impingement

• 9% to 57% reported nonunion rate • 14.7% rate of ulnocarpal impingement • Sennwald, et al, JHS 20B, 1995 • Favero, Bishop, Linscheid, ASSH Annual Meeting, Orlando, 1991 • McAuliffe, et al, JHS 18A, 1993 • Nelson, et al, JHS 18A, 1993

Lunotriquetral Ligament Injury Treatment Methods: LT Ligament

A Comparative Study of Treatment Methods Alexander Y. Shin, MD Loryn P. Weinstein, MD Richard A. Berger, MD, PhD Allen T. Bishop, MD

JBJS 83B 2001 Arthrodesis Direct Ligament Ligament Repair Reconstruction

Alexander Y. Shin, MD 6 ASSH Precourse 6: Lunotriquetral October 2020 Injuries

Complications Subsequent Surgeries

10 0 100

80 80 81.8% 60 60 % % 40 40 64%

20 40.7% 20 25% 22% 25% 0 0 Repair Recons Arthrodesis Repair Recons Arthrodesis p<0.001 p<0.001

Recommendations Recommendations

• LT ligament reconstruction •LT Arthrodesis or repair •Unacceptably high •Pain relief •Complication rates • Functional improvement •Re-operation rates •Patient dissatisfaction • Patient satisfaction •Treatment of choice

Our Current Recommendations Ligament Repair

•Ligament repair when possible •Reconstruction when unable to repair

Drill Holes Through Triquetrum or Suture Anchors

Alexander Y. Shin, MD 7 ASSH Precourse 6: Lunotriquetral October 2020 Injuries

Ligament Repair Ligament Repair

K wire fixation after reduction if needed Anatomic Closure of Capsular Flap – Reconstruction of DRC Ligament

Ligament Reconstruction Examination LT

•Grade IV LT

Gross laxity Preparation of Bone Tunnels

Alexander Y. Shin, MD 8 ASSH Precourse 6: Lunotriquetral October 2020 Injuries

Passage of Wire Harvest Radial ½ ECU tendon

Passage of Tendon Passage of Tendon

Reduction/K wire Fixation Fixation of Remnant LT

Alexander Y. Shin, MD 9 ASSH Precourse 6: Lunotriquetral October 2020 Injuries

Completion Repair/Reconstruction Tensioning of graft

Capsular Closure Post-op Radiographs

10 years Post op Outcomes Update

Extension 60 Flexion 70

• 28 years of studies • Unable to make comparisons • All studies retrospective • 1 described good outcome for conservative treatment and poor outcome for fixed VISI

Alexander Y. Shin, MD 10 ASSH Precourse 6: Lunotriquetral October 2020 Injuries

Outcome Updates Summary

•Recommendation: LT repair or •Lunotriquetral ligament injuries reconstruction •Broad spectrum of complaints •Caveat: arthrodesis in their hands is •Diagnosis, imaging successful as is ulnar shortening for •Treatment options degenerative LT •Current recommendations •Repair or reconstruction superior to arthrodesis

Thank You

Alexander Y. Shin, MD 11 Live Precourse 06: Carpal Instability: Around the Wrist from Around the World

10:39 AM - 10:51 AM

Midcarpal Instability: Who Needs Treatment

David M. Lichtman, MD No relevant conflicts of interest to disclose

75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

MCI: Who needs treatment 8/28/2020

DISCLOSURES

David M. Lichtman, MD

Speaker has no relevant financial relationships with commercial interest to disclose.

…who needs treatment?

David M. Lichtman, MD ASSH Virtual Pre-course #6 October 1st 2020

Hypermobility of the proximal row caused by lax ligaments resulting in a painful catch-up clunk with UD

?!#!#$!

1 MCI: Who needs treatment 8/28/2020

1..Midcarpal Shift Test

2. Spontaneous “clunk”

At first, they didn’t connect the dots

Intrinsic Palmar Dorsal -CLIP (Louis) -CCI (Johnson) Combined Extrinsic Distal radius malunion

Let’s make it simple… • Normal mechanics

• Pathologic anatomy

• Pathomechanics (i.e-why the clunk!)

2 MCI: Who needs treatment 8/28/2020

PR = mobile intercalary link

TH ext Jt. reaction forces → PR motion • Flexion/pronation moment at STT STT • Extension/supination moment at TH flex Intact Ligaments → PR Stable

Ligament laxity 1. Dorsal radiotriquetral 2. Ulnar arm of arcuate? 3. Periscaphoid? DRT PR=Unstable

Neutral Deviation: • Flexion proximal row (DRT laxity) • Capitate and dorsal row sublux palmarward • Normal joint reaction forces disengaged!

3 MCI: Who needs treatment 8/28/2020

Ulnar Deviation:

• Proximal row stays flexed most of way

• Sudden flip (VISI to DISI) when TH re-engaged

• Capitate reduction follows

• Congenital (most common) • Acquired (crutches) • Trauma (loss of proprioception?)

• Young adult or adolescent (F > M) • Palmar sag on ulnar side of carpus • Painful wrist clunk with ulnar deviation • Variable history of trauma • VISI on lateral x-ray (neutral deviation)

4 MCI: Who needs treatment 8/28/2020

• Visible and audible “clunk” pathognomonic* • Midcarpal shift test pathognomonic* • Video fluoroscopy pathognomonic *

* Therefore it’s hard to mistake the diagnosis… -once you’ve seen it !

Lateral view: • VISI deformity • May be normal • Do not support wrist

5 MCI: Who needs treatment 8/28/2020

Abrupt shift from VISI to DISI with ulnar deviation of the wrist.

“Catch-up clunk”

……everyone!

Non-Operative: Surgical: • Teenagers (esp. w. • Symptomatic adults parent complaining) who have failed non- • Habitual clunkers (as in operative Rx recurrent shoulder) • Traumatic MCI, esp. • All others, at first following DRF

• Explanation • Activity modification • NSAIDs • Splint • Proprioceptive retraining

6 MCI: Who needs treatment 8/28/2020

Push and hold pisiform dorsally

O.T. and patient design their own...

Terry Skirven, OTR

7 MCI: Who needs treatment 8/28/2020

Proprioceptive Retraining

Muscle contraction (e.g.-ECU, FCU, hypothenars) can compensate for mild ligament laxity by preloading (correcting) the subluxation of MCI.

Loss of proprioception can undermine the automatic contraction of these dynamic stabilizers.

Biofeedback can retrain these muscle units to “fire-up” automatically prior to pt. initiating ulnar deviation.

Mild to Moderate (soft tissue): • Tendon weave (FCU) • Arthroscopic thermal shrinkage preferred • Dorsal capsular reefing Recurrent or Severe (bone): preferred • Four corner fusion • RSL or RL fusion…(theoretical) preserves dart thrower motion)

8 MCI: Who needs treatment 8/28/2020

9 MCI: Who needs treatment 8/28/2020

So far, so good!?

Volar approach using switching sticks

Dorsal capsule cauterized

Clunk resolved: 28/30 cases (93%)

Develop computer model to map specific ligament deficit(s).

Devise precise ligament(s) to reconstruct or target based on identified deficit(s)

Define exact role of proprioception and apply to rehabilitation of MCI (and other wrist instabilities)

10 MCI: Who needs treatment 8/28/2020

Thanks, Dudes.

Clunk! 31

11 Live Precourse 06: Carpal Instability: Around the Wrist from Around the World

10:51 AM - 11:03 AM

Perilunate Injuries

Guillaume Herzberg, MD, PhD ● Royalty: Groupe Lepine Company

75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

Guillaume Herzberg, MD

Royalty: Groupe Lepine Company

Perilunate Injuries

ASSH 2020 - Precourse 06: Carpal Instability Perilunate Injuries: New Concepts

P.L.I.N.D.

Guillaume Herzberg, Marion Burnier, LYON, FRANCE 3

1 Introduction

Current Algorythm

Results

Herzberg 2013 5

Floating Lunate Transosseous PLIND

2 PLIND Equivalents

« Be Prepared to Any Perilunate Variant»

Fresh Injury Repair PLI Principles

GH 9

3 « Do it Right at First Place»

« Role for Arthroscopy »

4 I.D. I.D. 1 2

I.D. ➢ Immediate Mid-Carpal Closed Reduction 1 (Unless PLIND)

Relieves Median Nerve

I.D. tisserand 2

Closed Reduction or Arthroscopy Not Indicated

5 or PLIND

CTS +++

OZIER

or PLIND 24/48h Surgical Repair CTS +++ ORIF AARIF OZIER ARIF

Scaphoid Intact ORIF Trans-Scapho

6 ARIF - AARIF

Dry Arthroscopy (Del Pinal) + Automatic Wash-Outs

7 AARIF CR

OZIER

I.D.

dorsal TS PLFD stage 1 (Greater Arc ) 22

OZIER Radial Ulnar

AARIF

OZIER

8 OZIER

OZIER

ARIF

9 Toubal

I.D. dorsal TS-PLFD stage I (Greater Arc)

Toubal

I.D.

ARIF

Radial Ulnar

10 CR

Toubal

I.D. ARIF

I.D. tisserand 2

Closed Reduction or Arthroscopy Not Indicated

I.D. tisserand 2

Closed Reduction or Arthroscopy Not Indicated

ORIF Salvage

11 tisserand tisserand Immediate ORIF

Single Dorsal Approach

ROMIEU

Emergency PRC + Distal Radius ORIF

Introduction

Current Algorythm

Results (ID 1)

12 ORIF (So Far Gold Standard)

Lesser Arc Greater Arc

Trumble 2004: Knoll-Trumble 2005:

22 dorsal PLD 25 TS Dorsal -PLFD

Combined Approaches ORIF Dorsal Approach 4 years F-Up 4 years F-Up

No Pain No Pain Flex-Ext 106° Flex-Ext 113° Grip 77% Grip 77%

« Almost normal » 100% Scaphoid Union SL Relationships No Carpal Malalignment No Carpal Collapse, no DISI

All-Arthroscopic RIF (ARIF)

Wong 2008 Kim 2015 Liu 2015

21 TS Dorsal -PLFD, 15 TS Dorsal -PLFD, 20 TS Dorsal -PLFD, 5 Dorsal PLD IIA 4 Dorsal PLD IIA 3 year F-Up Mean 31 Months F-Up Mean 15 Months F-Up Mayo avg 80 Mayo avg 79 Mayo avg 86 1/21 Scaphoid non Union 1/21 Carpal Malalignment 2/15 Scaphoid non Union 1/20 Scaphoid non Union

AARIF / ARIF

Our Series 2015:

10 Dorsal PLD 4 TS Dorsal –PLFD 4 PLIND

Mean 27 Months F-Up 12 AARIF Flex-Ext 80° Grip 69% 6 Pure ARIF Mayo avg 71

Normal Carpal Alignment 100% Scaphoid non Union in TS

13 Summary

« Be Prepared to Any Perilunate Variant Including PLIND Equivalents» 40

Summary

« Include Arthroscopy in your PLI Management »

« Use of Arthroscopy = A Major Improvement in Perilunate Injuries Management »

14 I.D. I.D. 1 2

Arthroscopy No Arthroscopy

ASSH 2020 - Precourse 06: Carpal Instability Perilunate Injuries: New Concepts

ThankP.L.I.N.D.You

Guillaume Herzberg, Marion Burnier, LYON, FRANCE 44

15 Live Precourse 06: Carpal Instability: Around the Wrist from Around the World

11:03 AM - 11:15 AM

CIND Following DRF

Diego L. Fernandez, MD No relevant conflicts of interest to disclose

75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

8/31/2020

DISCLOSURES

Diego L. Fernandez, MD

Speaker has no relevant financial relationships with commercial interest to disclose.

ASSH , 2020 Carpal Instability Non Dissociative following Distal Radius Fractures

Diego L. Fernandez MD, Professor of Orthopedic Surgery, University of Bern www.diegofernandez.ch

Carpal malalignment following intra-articular wrist fractures has been reported, but without a clear description of the ligament injury leading to the radiographic appearance

O’Flanagan SJ, IP FK, Roberts CJ, Chow SP. Carpal malalignment following intra-articular fractures of the distal radius in a working population. Injury. 1995:26(4)231-235 Lee S, Yu JH, Jeon SH. Fixed lunate flexion deformity in distal radius fractures. Clinics in Orthop Surg. 2016;8:228-231. doi/10.4055/cios.2016.2.228

This study presents a series of patients that developed carpal instability non-dissociative (CIND) following acute wrist fractures.

The mechanism of injury and ligament disruption was reproduced in a cadaveric laboratory investigation.

1 8/31/2020

CLINICAL MATERIAL 2013-2019 INITIAL TREATMENT 14 patients with CIND following wrist fractures were identified 1 closed reduction and cast 1 closed reduction, 12 CIND-VISI, 2 CIND- DISI malalignment percutaneous pins and cast

1 dorsal plate - 10 intra-articular fractures 2 screws (radial styloid) - 3 radiocarpal fracture-dislocations 2 external fixators - 1 extra-articular fracture (Colles type) 7 volar plates

6 wks

9 wks 5

X rays 14 months following injury… practically stiff, athrophic painful wrist 6

2 8/31/2020

1 year post-op

28 year old man motorbike accident post-reduction CT x rays after palmar capsular repair

4 weeks after : practically stiff wrist

radiotriquetral ligament deficiency

3 8/31/2020

6 weeks

4 months

PATHOMECHANICS and MECHANISM OF INJURY

Kauer J M G The interdependence of carpal articulation chains. Acta anat. 88 (1974):481-501 11

PATHOMECHANICS and MECHANISM OF INJURY of CIND-palmar: laboratory findings

4 8/31/2020

intact intrinsic ligaments

T S L

section of volar radiocarpal ligaments short RL lig. section of RT ligament

sensor in lunate RSC + long RL ligaments

palmar

dorsal 14

Fok MWM, Fernandez DL, Maniglio M Carpal Instability Non-disssociative following Acute Wrist Fractures.

J Hand Surg Am. 2020; 45(7): 662.e1-e10

5 8/31/2020

PATHOMECHANICS and MECHANISM OF INJURY of CIND-palmar: laboratory results

sequential section of the dorsal and palmar extrinsic ligaments increased flexion of the proximal carpal row attaining its maximum when the volar ulnocarpal ligaments were also sectioned.

Palmar rotation of the proximal carpal row was also consistently reproduced by applying an axial force manually in cadaveric specimens after sectioning the radiotriquetral ligament radial origin of short radiolunate ligament was elevated with a bony fragment of the volar rim of the radius.

axial loading and dorsally directed shearing force

bony avulsion of the radio-triquetral ligament

3 weeks post-op

6 8/31/2020

MANAGEMENT number of cases: 14

6 Radio-scapho-lunate fusions: Cases 1, 2, 3, 6 ,9,14 (fixed deformity, cartilage damage or incongruency)

3 Open reduction, radiolunate K-wire fixation capsular repair: Cases 7, 8, 10 (reducible malalignment, no cartilage damage)

5 No further treatment : Cases 4, 5, 11, 12,13 (asymptomatic patient, adequate function)

Comon fracture pattern: radial styloid 24 years old construction worker dorsal rim and volar rim fall from ladder

Initial treatment: closed reduction and external fixation

4weeks post-op

post-op Xrays CIND (palmar)and dorsal radio-carpal subluxation

7 8/31/2020

pre-op wrist motion

6 weeks 1 year post op post-op

SUMMARY Radiocarpal fracture dislocations, extra-articular and intra- articular distal radius fractures may develop nondissociative carpal instability (CIND) due to extrinsic ligament injuries that remain mechanically incompetent despite adequate initial fracture reductions and immobilisation.

CIND following acute wrist fractures is much less frequent than associated intrinsic lesions (CID)

8 8/31/2020

In the VISI type there is an extrinsic dorsal and volar radiocarpal capsulo-ligamentous lesion and was commonly seen in the sub-acute period typically when external fixation or initial cast fixation is discontinued

In the DISI type there is a volar radiocarpal capsulo-ligamentous lesion and in both cases there was an intra-articular malunion the scaphoid fossa and the malalignment was present in the initial radiographs.

14 cases of CIND following wrist fractures were identified. Radiographs and arthroscopy confirmed the diagnosis of CIND: malalignment of the proximal carpal row without intercarpal ligament disruption

the most common fracture pattern (11 out of 14) involved the radial styloid and the dorsal rim. These also include the three radiocarpal fracture dislocations that had additional volar rim avulsions

All had severe initial displacement, therefore with greater probability of significant associated ligament lesions

Arthroscopic assisted reduction is the only diagnostic tool to assess the presence of extrinsic (capsular lesion) with residual radiocarpal instability following fracture fixation

For this scenario capsular repair and temporary radio-carpal pinning would be recommendable to prevent secondary malalignment of the first carpal row

This type of CIND should be classified as traumatic following acute wrist fractures and added to the Wolfe and García Elias classification

9 8/31/2020

Traumatic CIND-T (VISI-DISI)

Surgical management a) reducible b) fixed Repair or Salvage

Wolfe S W, Garcia Elias M, Kitay A: Carpal Instability Non-dissociative J Am Acad Orthop Surg 2012; 20: 575-585 28

Thank you

10 Live Precourse 06: Carpal Instability: Around the Wrist from Around the World

11:15 AM - 11:27 AM

SLAC Wrist: Salvage for 45 y.o. M, 75 y.o. M

Peter Tang, MD, MPH ● Consulting Fees: Globus Medical, Inc ● Speakers Bureau: AxoGen, Inc, Depuy Johnson & Johnson

75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

Slide 1 ______SLAC Wrist: Salvage for 45 yo M, 75 yo M ______

Slide 2 ______Disclosures

• Course Instruction: • Axogen, Corporation ______• Depuy Johnson & Johnson • Consultant: • Globus Medical, Inc ______• Previous research funding from the: • Axogen, Corporation • Orthopaedic Research Education Foundation (OREF) • Orthopaedic Scientific Research Foundation (OSRF) • American Association for Hand Surgery (AAHS) ______• American Foundation for Surgery of the Hand (AFSH) ______

Slide 3 ______Benefits

FBF PRC ______• Pain relief • Motion preservation ______• Grip strength improvement ______Slide 4 ______Contact Biomechanics ______

Slide 5 Material and Methods ______• Cadaveric limbs were prepared (intact, FBF, PRC) and affixed on a customized jig • Fuji film was prepared and placed in the radiocarpal joint ______• 200 N was applied to the wrist joint via the tendons in the positions of neutral, 45 deg of flexion, and 45 deg of extension ______Extensor tendons ______Fuji Film Spring scales Low Pressure sensitive to 2.5-10 MPa ______

Flexor tendons ______

Slide 6 Avg Pressure: Intact vs FBF vs PRC ______

• Contact pressure in the PRC wrist was 26% greater compared to FBF wrist • Contact pressure in the FBF was 163% greater ______compared to the intact wrist • * Significant differences for all wrist positions (p<0.05) ______Slide 7 Avg Area: Intact vs FBF vs PRC ______

• Contact area in the PRC wrist was 42% less than the contact area in the FBF wrist. ______• Contact area in the FBF wrist was 52% less than the contact area in the intact wrist. ______

Slide 8 ______PRC Kinematics CAPITATE KINEMATICS ______

7.0

5.0 Flexion 3.1*†, 2.2*† ______3.0 Extension Neutral 1.0 Neutral Flexion

MOVEMENT -4.0 -2.0 -1.00.0 2.0 4.0 6.0 -3.0 ______

VOLAR (-) / DORSAL (+) Extension † † - 0.9 , - 2.4* -5.0 ULNAR (-) / RADIAL (+) MOVEMENT (* p<0.05 compared to neutral, † p<0.05 compared to flex/ext) ______• In flexion, capitate contact significantly moves radial and dorsal • In extension, contact significantly moves ulnar and volar ______

Slide 9 ______Contact Biomechanics ______Slide 10 ______Contact Biomechanics TRANSLATIONAL MOTION - INTACT VS PRC ______10 9 8 7.3 7.5* 7 6 5.6* Scaphoid ______5 Lunate 4 PRC 3 MOTION (mm) MOTION 2 1 ______0 Scaphoid Lunate PRC (*p=0.09) ______The capitate contact translated 34% more than did the scaphoid contact and had about equal translation to that of the lunate ______

Slide 11 Contact Biomechanics ______5.5 mm Flexion FBF PRC ______Extension ______• InForNo the the difference position PRCFBF wrist,wrist, of was flexion, fromfrom found thethe the in positionposition thelunate total ofofcontact average flexionflexion in toto the FBFextension,translation wrist was capitatelunate of found thecontact FBFcontact to wristbe movedlocated moved (6.6mm) significantly 5.5 significantly comparedmm ulnar to dorsal to volar (p=0.005) thethe• capitate dorsalPRC wrist toin volar (7.4mm)the PRC (p=0.01) wrist (p=0.63) ) ______• radial to ulnar (p=0.03) ______

Slide 12 ______Conclusions • The PRC capitate translates a fair amount on the radius ______• The scaphoid in the intact wrist does not translate as much

• The lunate in the intact and FBF wrist translates as much as the ______PRC wrist • The lunate in the FBF wrist maintains its intact wrist kinematics ______Slide 13 ______Key Literature ______• systematic review, 50 papers • few studies used DASH or Mayo Wrist Score • 85% of both PRC and FBF pts rate their post-op pain “good” or “better” • better ROM in PRC; with both procedures pts lose 10 deg compared to preop • grip strength 80% for both ______• equal rates of infection and RSD • PRC lacked potential complications of nonunion (5.5% in FBF), hardware issues (3.3%), dorsal impingement (2.6%) • risk of OA significantly higher in PRC, despite majority being asymptomatic ______• need for arthrodesis 5% for both ______

Slide 14 ______Key Literature ______

• 12 pts (14 wrist) with PRC vs 8 pts (8 wrists) with FBF ______• AROM slightly better in PRC • No differences in grip strength and pt-reported outcomes • No difference in degenerative changes • FBF had more post-op complications ______

Slide 15 ______Key Literature ______

• 51 pts with 4CA (9.5 yr f/u) vs 38 pts with PRC (18 yrs f/u) ______• No differences in need for revision surgery • No difference in reports of moderate or severe pain • ROM: 54 deg after 4CA vs 73 deg after PRC • Grip Strength: 65% 4CA vs 54% PRC • DASH: 19 4CA vs 32 PRC ______• 10 yr interval free of moderate/severe arthritis: 70% PRC vs 71% 4CA ______Slide 16 ______Summary

• Multiple studies have shown that FBF and PRC yield excellent ______clinical results

• Grip strength equal but PRC gives slightly better ROM (approximately 10 degrees more) ______

• PRC is a simpler procedure and avoids complication such as hardware problems and nonunion ______

• In terms of failure as defined by need for arthrodesis, both have a failure rate of approximately 0 - 17% ______

Slide 17 ______Summary

• Based on biomechanical studies FBF has less contact pressure and larger ______contact area when compared to the PRC wrist which I interpret as a more biomechanically sound joint

• In the past, for younger patients I would favor FBF while for older patients ______with less demand I would favor PRC

• I used to find it difficult to resolve why the differences in the biomechanics did not translate into clinical differences ______

Slide 18 ______Summary

• Now I believe that even though the FBF is better than the PRC ______biomechanically, BOTH FBF and PRC have such an increase in contact pressure and such a decrease in contact area compared to intact, that they have equal failure rates ______• Thus, if PRC and FBF have similar outcomes potentially in all age groups, why not choose the simpler procedure that has less complications, namely PRC • So, I may just do PRCs in all patients and not perform FBFs. If there is capitate ______chondrosis with a SLAC 3 or SNAC 3 wrist, I may resurface the capitate with an implant. ______Slide 19 Thank You! ______

Live Precourse 06: Carpal Instability: Around the Wrist from Around the World

11:27 AM - 11:41 AM

Roundtable Discussion

Alexander Y. Shin, MD | David M. Lichtman, MD | Guillaume Herzberg, MD, PhD | Diego L. Fernandez, MD | Peter Tang, MD, MPH

Alexander Y. Shin, MD ● Royalty: TriMed Orthopedics/Mayo Medical Venture ● Consulting Fees: Hologic

David M. Lichtman, MD No relevant conflicts of interest to disclose

Guillaume Herzberg, MD, PhD ● Royalty: Groupe Lepine Company

Diego L. Fernandez, MD No relevant conflicts of interest to disclose

Peter Tang, MD, MPH ● Consulting Fees: Globus Medical, Inc ● Speakers Bureau: AxoGen, Inc, Depuy Johnson & Johnson

75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

9/5/2020

Roundtable Discussion

Alexander Y. Shin, MD | David M. Lichtman, MD | Guillaume Herzberg, MD, PhD | Diego L. Fernandez, MD | Peter Tang, MD, MPH

DISCLOSURES

Diego L. Fernandez, MD

Speaker has no relevant financial relationships with commercial interest to disclose.

CARPAL INSTABILITY NON-DISSOCIATIVE AFTER ACUTE WRIST FRACTURES Diego L. Fernandez M.D. Professor of Orthopaedic Surgery University of Berne www.diegofernandez.ch Case for Round Table Discussion

1 9/5/2020

31-year-old female, X-rays 6 days after a skiing injury closed reduction of a Radio-Carpal fracture-dislocation

CT : 15 days after injury

ORIF performed 3 weeks after injury ( SL intact intra-operatively)

1 week post-op L

2 9/5/2020

How would you manage the carpal malalignment (CIND-T VISI) 4 weeks after the initial injury A. Radiolunate fusion

B. Reduction, radiolunate K-wire fixation, external fixation

C. Proximal row carpectomy

D. Reduction, radiolunate K-wire fixation,cast immobilization

E. Capitolunate fusion

K-wire radiocarpal transfixation (dorsal approach) and forearm cast for 8 weeks

2 months after carpal transfixation, before K-wire removal

1 week after K-wire removal

3 9/5/2020

9 months after CIND-T VISI correction; no pain, normal wrist extension 20° limited wrist flexion, normal pro/supination