The Role of Arthroscopy

OnDemand Precourse 09: Fundamental to Cutting Edge: The Role of Arthroscopy

Co-Chairs: Charles A. Goldfarb, MD, Pak-cheong Ho, MD, and Francisco del Piñal, MD

Program Syllabus

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]

OnDemand Precourse 09: Fundamental to Cutting Edge: The Role of Arthroscopy Please note that in order to receive CME for this session, you will need to view this in the ASSH Learning Management System.

This Precourse is designed to explore the arthroscopic treatment of wrist pathology, specifically focused on the athlete. We will explore arthroscopic treatment of wrist fractures, ligament injuries, TFCC tears, and dislocations of the wrist and hand. We will include videos of clinical findings and wrist arthroscopic findings/ treatments. Experts from around the world will share new perspectives and cutting-edge treatments.

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

• Describe the arthroscopic anatomy of the wrist joint. • Understand classification systems affecting wrist arthroscopy and patient outcomes. • View and incorporate into your practice advanced arthroscopic techniques for fractures and ligament injuries.

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

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. 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 Claim: By viewing on-demand content in the LMS and completing the test questions when prompted, you will automatically be awarded your CME credit and have the ability to download your certificate immediately. No additional steps are needed.

Physicians should claim only the credit commensurate with the extent of their participation in the activity. *Please note that ASSH does not provide Continuing Education for physical therapists. Visit the APTA website for more information.

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 Charles A. Goldfarb, MD ● Non-CME Services: Acumed

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

Francisco del Piñal, MD No relevant conflicts of interest to disclose

Faculty Keiji Fujio, MD No relevant conflicts of interest to disclose

David Hargreaves, MBBS No relevant conflicts of interest to disclose

Jan-Ragnar Haugstvedt, MD ● Consulting Fees: Arthrex, Medartis ● Non-CME Services: Arthrex

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

Sanjeev Kakar, MD, FAOA ● Royalty: Arthrex ● Consulting Fees: Arthrex ● Ownership Interests: Sonex

Toshiyasu Nakamura, MD, PhD No relevant conflicts of interest to disclose

Juitien Shih, MD No relevant conflicts of interest to disclose Steven S. Shin, MD ● Royalty: Arthrex Hely & Weber ● Consulting Fees: Arthrex ● Speakers Bureau: Arthrex

David J. Slutsky, MD No relevant conflicts of interest to disclose

Clara W. Wong, FRCS No relevant conflicts of interest to disclose

Jeffrey Yao, MD ● Royalty: Arthrex ● Intellectual Property: Arthrex, Elevate Braces ● Speakers Bureau: Depuy-Synthes, Trice/Segway, Exsomed ● Ownership Interests: Elevate Braces, 3D Systems OnDemand Precourse 09: Fundamental to Cutting Edge: The Role of Arthroscopy Co-Chairs: Charles A. Goldfarb, MD, Pak-cheong Ho, MD, and Francisco del Piñal, MD

Description

Please note that in order to receive CME for this session, you will need to view this in the ASSH Learning Management System.

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

Program

Session Chair(s) Charles A. Goldfarb, MD | Pak-cheong Ho, MD | Francisco del Piñal, MD

5 Minutes Welcome and Introduction Charles A. Goldfarb, MD | Pak-cheong Ho, MD | Francisco del Piñal, MD

10 Minutes Anatomy, Portals David J. Slutsky, MD

15 Minutes Distal radius fractures Francisco del Piñal, MD

15 Minutes Scaphoid fracture and non-unions Clara W. Wong, FRCS

15 Minutes Acute and Subacute SL Injury Juitien Shih, MD

15 Minutes Chronic S-L dissociation Pak-cheong Ho, MD

15 Minutes Acute and Chronic LT Injury Jan-Ragnar Haugstvedt, MD

12 Minutes Perilunate fracture- dislocations Guillaume Herzberg, MD, PhD

7 Minutes Dorsal Impingement Jeffrey Yao, MD

16 Minutes Cases/Questions/Discussion/Break All Faculty

15 Minutes Ulnocarpal impaction and arthroscopic wafer Sanjeev Kakar, MD, FAOA

15 Minutes TFCC: Diagnosis (exam, imaging) and Classification Toshiyasu Nakamura, MD, PhD

15 Minutes TFCC injury without instability Charles A. Goldfarb, MD

15 Minutes TFCC injury with instability Keiji Fujio, MD

12 Minutes Midcarpal Instability David Hargreaves, MBBS

5 Minutes CMC fracturedislocation, Small Joint Arthroscopy Steven S. Shin, MD

18 Minutes Cases/Questions/Closing Comments All Faculty

OnDemand Precourse 09: Fundamental to Cutting Edge: The Role of Arthroscopy

10 Minutes

Anatomy, Portals

David J. Slutsky, MD No relevant conflicts of interest to disclose

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

7/27/2020

OnDemand Precourse 09: Fundamental to Cutting Edge: The Role of Arthroscopy

Course Chairs: Charles A. Goldfarb, MD, Pak-cheong Ho, MD and Francisco del Piñal, MD Faculty: Keiji Fujio, MD, David Hargreaves, MBBS, Jan-Ragnar Haugstv edt, MD, Guillaume Herzberg, MD, PhD, Toshiyasu Nakamura, MD, PhD, Juitien Shih, MD, Steven S. Shin, MD, David J. Slutsky, MD, Sanjeev Kakar, MD, FAOA, Clara W. Wong, FRCS and Jeffrey Yao, MD

DISCLOSURES

David J. Slutsky, MD

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

ASSH PRECOURSE 09 FUNDAMENTAL TO CUTTING EDGE: ROLE OF ARTHROSCOPY

WRIST ARTHROSCOPY PORTALS

David J. Slutsky MD

The Hand & Wrist Institute Torrance, CA

1 7/27/2020

David J . Slutsky M.D.

I have no potential conflicts with this presentation

2 7/27/2020

4,5

Midcarpal portals

3 7/27/2020

Midcarpal portals

STT portal

4 7/27/2020

1,2 Portal

Volar Radial (VR)

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7 7/27/2020

DRUJ OA

8 OnDemand Precourse 09: Fundamental to Cutting Edge: The Role of Arthroscopy

15 Minutes

Distal radius fractures

Francisco del Piñal, MD No relevant conflicts of interest to disclose

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

Speaker has not provided a handout for

this presentation OnDemand Precourse 09: Fundamental to Cutting Edge: The Role of Arthroscopy

15 Minutes

Scaphoid fracture and non-unions

Clara W. Wong, FRCS No relevant conflicts of interest to disclose

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

Speaker has not provided a handout for

this presentation

OnDemand Precourse 09: Fundamental to Cutting Edge: The Role of Arthroscopy

15 Minutes

Acute and Subacute SL Injury

Juitien Shih, MD No relevant conflicts of interest to disclose

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

Speaker has not provided a handout for

this presentation OnDemand Precourse 09: Fundamental to Cutting Edge: The Role of Arthroscopy

15 Minutes

Chronic S-L dissociation

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

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

Speaker has not provided a handout for

this presentation OnDemand Precourse 09: Fundamental to Cutting Edge: The Role of Arthroscopy

15 Minutes

Acute and Chronic LT Injury

Jan-Ragnar Haugstvedt, MD ● Consulting Fees: Arthrex, Medartis ● Non-CME Services: Arthrex

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

7/27/2020

75th ASSH Virtual Annual Meeting, September 29-October 3, 2020

Acute and Chronic LT Jan Ragnar Haugstvedt, MD, PhD injury Østfold Hospital Trust, Moss, Norway

Acute and Chronic LT injury

LT tears is 15-20 % as common as SL injuries

Part of a more extensive injury, often missed diagnosis; true incidence is unknown...

1 7/27/2020

Acute and Chronic LT injury

Martin Langer

Acute and Chronic LT injury

J Hand Surg Am. 1999 Sept;24(5):953-62. Constraint and material properties of the subregions of the scapholunate interosseous ligament. Berger RA, Imeada T, Berglund L, An KM

J Hand Surg Am. 1998 May;23(3):425-31. Lunotriquetral ligament properties: a comparison of three anatomic subregions. Ritt MJ, Bishop AT, Berger RA, Linscheid RL, Berglund LJ, An KN.

Acute and Chronic LT injury Mechanism of injury

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Acute and Chronic LT injury Symptoms

Be suspicious when you hear about the history of injury

Symptoms often intermittent

Prominent in special positions (ulnar deviation or pronation)

“Clunk” https://www.dinside.no/bilder/luftig-svev/62323484

Foto: All Over Press/Cameron Spencer

Acute and Chronic LT injury Examination

LT tests

Acute and Chronic LT injury Examination

LT Ballottement

From “Arthroscopic Management of Ulnar Pain”, Springer, 2012 9

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LT ballottement Reagan Linscheid

Acute and Chronic LT injury Examination

LT Shear test

From “Arthroscopic Management of Ulnar Pain”, Springer, 2012 11

LT Shear test (Kleinman)

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Acute and Chronic LT injury Examination

Proximal Row Compression test

From “Arthroscopic Management of Ulnar Pain”, Springer, 2012 13

Acute and Chronic LT injury Examination

Proximal Row Compression test

From “Arthroscopic Management of Ulnar Pain”, Springer, 2012 14

Proximal Row Compression test

5 7/27/2020

Acute and Chronic LT injury Examination

Derby test

Courtesy: Marc Garcia-Elias 16

Acute and Chronic LT injury Examination

Derby test

Courtesy: Marc Garcia-Elias 17

Derby test Support Pisiform. Test LT

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Acute and Chronic LT injury Examination

Radiological examination

MRI

Arthrography

Video

Arthroscopy

Acute and Chronic LT injury

Gilula’s lines

From “Arthroscopic Management of Ulnar Pain”, Springer, 2012 20

Acute and Chronic LT injury

Gilula’s lines

From “Arthroscopic Management of Ulnar Pain”, Springer, 2012 21

7 7/27/2020

Acute and Chronic LT injury

Courtesy: Toshi Nakamura 22

Acute and Chronic LT injury

Courtesy: Jörg von Schoonhoven 23

Acute and Chronic LT injury

Courtesy: Jörg von Schoonhoven 24

8 7/27/2020

Acute and Chronic LT injury

Arthroscopy has become a new standard for diagnosing and treatment

Acute and Chronic LT injury

From “Arthroscopic Management of From “Arthroscopic Management of Ulnar Pain”, Springer, 2012 Ulnar Pain”, Springer, 2012

T T L L

Capitate

Scaphoid

Lunate Triquetrum

Acute and Chronic LT injury Staging

•Stage I: interosseous lig

•Stage II: interosseous lig and palmar LT lig

•Stage III: Complete disruption

9 7/27/2020

Acute and Chronic LT injury

J Hand Surg Am. 1990 Mar;15(2):268-78. Ulnar-sided perilunate instability: an anatomic and biomechanic study. Viegas SF, Patterson RM, Peterson PD, Pogue DJ, Jenkins DK, Sweo TD, Hokanson JA.

•Stage I: interosseous lig

•Stage II: interosseous lig and palmar LT lig

•Stage III: Complete disruption

Most LT lig injuries are found to be dynamic 28

Acute and Chronic LT injury Treatment

The goal is to reestablish normal alignment and stability

From a brace to an advanced surgical procedure

The type of treatment could depend on time from injury, the extent of injury, the patient’s needs, available equipment and/or the skill of the surgeon

Arthroscopically assisted surgery or Open surgery

There are (to my knowledge) no randomised prospective studies evaluating different treatment options (evidence based)

Recommendations are based on studies, case reports, retrospective studies, and my own experience

Acute and Chronic LT injury Treatment

An acute injury;

well-molded cast, immobilization for 8 weeks, prevent forearm rotation at least the first 4 weeks

https://www.google.com/search?q=forearm+in+a+cast&client=firefox-b-d&source=lnms&tbm=isch&sa=X&ved=2ahUKEwj PgJDP1M_qAh Xiw8Q BHU3ECFAQ_AUoAXo ECAwQAw#imgrc=ar8R8DtyEo9TsM

https://www.google.com/search?q=long+arm+cast&client=firefox -b-d&source=lnms&tbm=isch&sa=X&ved=2ahUKEwi0vseX1c_qAhWF4aYKHbLJDDMQ_AUoAXoEC AwQAw &biw=1280&bih=677#i mgrc=3BGSu MS0zzREKM 30

10 7/27/2020

Acute and Chronic LT injury Treatment

An Acute injury; less An acute injury; than 6 (-12) weeks

In the literature; injuries older than 5 yrs have been treated as an acute injury

Acute and Chronic LT injury

ACUTE INJURIES…

Acute and Chronic LT injury

From “Arthroscopic Management of Ulnar Pain”, Springer, 2012 33

11 7/27/2020

Acute and Chronic LT injury

From “Arthroscopic Management of Ulnar Pain”, Springer, 2012 35

Acute and Chronic LT injury

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Acute and Chronic LT injury

Make a skin incision. Debride. Use a drill guide for K-wires

Acute and Chronic LT injury

Create a fibrodesis 39

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Acute and Chronic LT injury

OLD INJURIES…

ARTRODESIS or… 40

Acute and Chronic LT injury

OLD INJURIES…

… or LIG RECONSTRUCTION 41

Acute and Chronic LT injury

J Bone Joint Surg Br. 2001 Sep;83(7):1023-8. Treatment of isolated injuries of the lunotriquetral ligament. A comparison of arthrodesis, ligament reconstruction and ligament repair. Shin AY, Weinstein LP, Berger RA, Bishop AT.

Lig repair (27)

Ligament reconstruction (8)

Arthrodesis (22)

15,4-53,5 yrs, subacute or chronic in 98,2 %, FU 2-22 yrs 42

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Acute and Chronic LT injury

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Acute and Chronic LT injury

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Acute and Chronic LT injury

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Acute and Chronic LT injury

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Acute and Chronic LT injury

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Palmar side

Lunate

Triquetrum

Acute and Chronic LT injury

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Acute and Chronic LT injury

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Acute and Chronic LT injury

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Acute and Chronic LT injury

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Acute and Chronic LT injury

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Acute and Chronic LT injury

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Acute and Chronic LT injury

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Acute and Chronic LT injury

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Acute and Chronic LT injury

Before… After…

Acute and Chronic LT injury

Arthroscopic assisted LT lig reconstruction

We’ve been able to do only two cases with more than 30 months FU

Man born 1993 Man born 1961

Manual heavy worker White collar

Surgery Sept 2017 Surgery Nov 2017

Preop Q-DASH: Rest Work Preop Q-DASH: Rest Work 31 100 61 75

Postop Q-DASH: 6.8 0 Postop Q-DASH: 23 0 83

Acute and Chronic LT injury

Arthroscopic assisted LT lig reconstruction

We’ve been able to do only two cases with more than 30 months FU

Man born 1993 Man born 1961

Manual heavy worker White collar

Surgery Sept 2017 Surgery Nov 2017

Preop Q-DASH: Rest Work Preop Q-DASH: Rest Work 31 100 61 75

Postop Q-DASH: 6.8 0 Postop Q-DASH: 23 0 84

28 7/27/2020

Acute and Chronic LT injury

Arthroscopic assisted LT lig reconstruction

We’ve been able to do only two cases with more than 30 months FU

Man born 1993 Man born 1961

Manual heavy worker White collar

Surgery Sept 2017 Surgery Nov 2017

Preop Q-DASH: Rest Work Preop Q-DASH: Rest Work 31 100 61 75

Postop Q-DASH: 6.8 0 Postop Q-DASH: 23 0 85

Acute and Chronic LT injury Summary

LT injuries are difficult to diagnose

Arthroscopy is the gold standard for diagnosing ligament injuries

Treatment of acute injuries: K-wires and immobilization

Treatment of chronic injuries; reconstruction (or arthrodesis)

Thank you

29 OnDemand Precourse 09: Fundamental to Cutting Edge: The Role of Arthroscopy

12 Minutes

Perilunate fracture- dislocations

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

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

DISCLOSURES

Guillaume Herzberg, MD

Royalty: Groupe Lepine Company

Arthroscopic Treatment of Perilunate Injuries

Guillaume Herzberg, Marion Burnier, Lyon, France

ASSH Precourse 09 – Fundamental to Cutting Edge: The Role of Arthroscopyy- 2020 – No Conflicts 2

Arthroscopic Treatment of Perilunate Injuries

Definitions

Why ?

When ?

Results ?

1 Acute Prerilunate Injuries: Definitions

Floating Lunate Transosseous PLIND

2 Why ?

Arthroscopy for Perilunate Injuries

When ?

3 Provide an ID To Perilunate Injuries

I.D. 1

Immediate Mid- Carpal Closed Reduction Perilunate ID-1

Relieves Median Nerve

4 Immediate Mid- Carpal Closed Reduction

CTS +++

OZIER

Immediate Mid- Carpal Closed Reduction

Perilunate ID-1

24/48h Surgical Repair

ORIF AARIF ARIF

Scaphoid Intact ORIF Trans-Scapho

5 16

Dry Arthroscopy (Del Pinal) + Automatic Wash-Outs

6 Dry Arthroscopy (Del Pinal) + Automatic Wash-Outs

AARIF CR

OZIER

I.D.

dorsal TS PLFD stage 1 (Greater Arc ) 20

OZIER Radial Ulnar

7 AARIF

OZIER

8 ARIF

Toubal

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

Toubal

I.D.

9 ARIF

Radial Ulnar

Toubal

I.D. ARIF

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

10 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

romieu

I.D. tisserand koudry 2

11 romieu

I.D. tisserand koudry 2

Closed Reduction Not Indicated

Immediate ORIF tisserand

tisserand

Dorsal

Salvage Procedure

ROMIEU romieu

12 Irreparable / Free Carpal Bone(s)

romieu

I.D. 2

Emergency Informed Consent

Summary

« Be Prepared to Any Perilunate Variant»

13 « Include Arthroscopy in your PLI Management »

I.D. I.D. 1 2

Arthroscopy No Arthroscopy

14 Arthroscopic Treatment of Perilunate Injuries

Guillaume Herzberg, Marion Burnier, Lyon, France Thank You 43

15 OnDemand Precourse 09: Fundamental to Cutting Edge: The Role of Arthroscopy

7 Minutes

Dorsal Impingement

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

6/30/20

Introduction

• Dorsal Wrist Syndrome aka Dorsal Wrist Impingement Syndrome • Kirk Watson, 1993 • Pain in dorsal central wrist Dorsal Wrist Impingement • Exacerbated with wrist hyperextension Jeffrey Yao, MD • Yoga, pushups, gymnastics Professor of Orthopaedic Surgery Stanford University Medical Center

1 2

Anatomy Dorsal Capsuloscapholunate Septum (DCSS)

• Mathoulin C (Hand Surg and Rehab 2016)

3 4

Scapholunate Stability A Spectrum of Disease

C C DIC/DST DCSS L S DSL

R R

Prominent role of dorsal radiocarpal ligaments: DIC/DRC Dorsal Scapholunate Ligament Thanks, Abhijeet Dorsal Capsulo-Scapholunate Septum (DCSS) Wahegaonkar, MD Watson HK and Sorelle J from Slutsky’s Principles and Practice of Wrist Surgery, 2010

5 6

1 6/30/20

Classic Symptoms Physical Examination

• T

Thanks, Martin Caloia, MD Thanks, Martin Caloia, MD

7 8

Imaging Treatment of Dorsal Wrist Impingement

• Xrays and MRI are often normal • Activity Modification • Avoidance of wrist hyperextension and axial loading • Pushups, yoga • Immobilization • 4 weeks • Corticosteroid injection • Surgery… Wrist Arthroscopy!

9 10

Left Wrist 3-4 portal looking ulnar Left Wrist 4-5 portal looking radial

11 12

2 6/30/20

Debridement of Synovitis and Frayed Capsule

13 14

Following Debridement Thermal Treatment of dSLIL, DCSS

15 16

Denervation Effect Clinical Outcomes

Pirolo and Yao, Arthroscopy 2016

17 18

3 6/30/20

Clinical Outcomes Spectrum of Disease: Ganglion

• Martin Caloia, MD (Buenos Aires) • 17 cases DCSS • Quick DASH: 44.1 to 5 • MWS: 50 to 87.9 • VAS: 6.8 to 1.2 • Grip Strength: 85% contralateral wrist • Complications: 2 (loss of flexion, Ganglion transient DRSN) Stalk

19 20

Arthroscopic Excision Conclusion

• Dorsal Wrist Syndrome aka Dorsal Wrist Impingement Syndrome • Pain in dorsal central wrist • Exacerbated with wrist hyperextension • Immobilization, steroid injections • Arthroscopic debridement works!

21 22

Thank You!

4 OnDemand Precourse 09: Fundamental to Cutting Edge: The Role of Arthroscopy

15 Minutes

Ulnocarpal impaction and arthroscopic wafer

Sanjeev Kakar, MD, FAOA ● Royalty: Arthrex ● Consulting Fees: Arthrex ● Ownership Interests: Sonex

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

Ulnar Impaction Arthroscopic Wafer Procedure

Surgical Tips and Tricks In a Case Based Approach

Sanj Kakar MD, FAOA Professor of Orthopaedic Surgery Mayo Clinic Rochester, MN USA Three Key Questions To Ask Yourself When Managing Ulnar Wrist Pain? Categorization Of Ulnar Wrist Pain

• Pain

• Pain with instability

• Pain with arthritis Distal Radioulnar Joint Pathology A Difficult Problem To Treat !!!! . LOW BACK PAIN OF THE WRIST . Multifactorial pathology • Bony Deformity • Cartilage injury • TFCC disorders • Soft tissue injury e.g. ECU instability

. These are NOT mutually exclusive • Failure to recognize this → suboptimal results

Four Important Questions To Ask

Bone deformity

Unstable Cartilage  Bone deformity ? YES / NO ECU defect Cartilage damage ? YES / NO   TFCC injury ? YES / NO

TFCC  Unstable ECU tendon ? YES / NO injury

.Arthroscopic assessment • Hook test Ruch et al. • Trampoline test Hermansdorfer & Kleinman • DRUJ arthroscopy Nakamura

– But what if it’s scarred down peripherally?

Hook Test

Myriad of Causes of Ulnar Impaction Syndrome . Idiopathic . Malunited distal radius fracture . Post-shortening of radius . Madelung’s deformity . Epiphyseal arrest . Radial head excision . Essex-Lopresti injury . Non-traumatic Natural History of Ulnar Impaction Syndrome

. Chondromalacia •Lunate •Ulnar head . TFCC degeneration . LT disruption . DRUJ arthritis •20-38% incidence at 2 years

• Ulnar wrist pain with extension & UD****

– True PA xrays (elbow & shoulder at 900)

– MRI, arthroscopy

ΔΔ Kienbock’s Dx Diffuse lunate oedema Stylocarpal impaction Pain with wrist extension and supination

. Nonsurgical . Wafer resection • Splint • Arthroscopic • NSAIDS • Activity modification • Open • Steroid injections . Ulnar shortening . Surgical osteotomy • TFCC debridement • Metaphyseal • Lunate microfracture • Diaphyseal

. 36 articles re: arthroscopic wafer, open wafer or USO . Satisfaction rates • 100% - arthroscopic wafer • 89% - open wafer • 84% - USO . Excellent/good outcome • 82% - arthroscopic wafer • 87% - open wafer • 75% - USO . Complications • 21% - arthroscopic wafer • 8.8% - open wafer • 30% - USO e.g. symptomatic hardware, nonunion, DRUJ DJD . Could not establish clinical superiority Situations where ulnar shortening is favored over wafer

. Marked ulnar positive variance (>4mm resection needed) . Stylocarpal impaction . Dorsal ulna subluxation . Possibly LT injury . DRUJ Instability . Non smokers . Tolat 1 & 2 Wafer Procedure

Arthroscopic Wafer . Less invasive than open . Needs a central TFCC defect • or create a central TFCC defect will need to be created . Can do via DRUJ arthroscopy • Limited to < 3-4 mm shortening • Smokers

. Risk: inadequate resection, destabilization of DRUJ, pain Summary: Arthroscopic Wafer . Can do via radiocarpal or DRUJ arthroscopy

. Ensure resection through full pronosupination • Limited to < 3-4 mm shortening • Smokers

. Address all pathologies (four leaf clover)

. Takes time for patient to recover***

Sanj Kakar 2020

Thank You For The Privilege Of Your Time

Email: [email protected]

OnDemand Precourse 09: Fundamental to Cutting Edge: The Role of Arthroscopy

15 Minutes

TFCC: Diagnosis (exam, imaging) and Classification

Toshiyasu Nakamura, MD, PhD No relevant conflicts of interest to disclose

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

2020/8/1

OnDemand Precourse 09: Fundamental to Cutting Edge: Role of Arthroscopy DISCLOSURES 2020 ASSH TFCC: Diagnosis (exam, imaging) and Classification DISCLOSURES Toshiyasu Nakamura, MD, PhD Toshiyasu Nakamura, MD, PhD Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Tokyo, Japan Speaker has no relevant financial relationships with commercial interest to disclose.

Histological findings Triangular Fibrocartilage Complex - TFCC - Palmer AK., JHS 1981 T MH: meniscus homologue AD: articular disc L UCL: ulnar collateral lig. RUL: radioulnar lig. TFC • stabilizer of the ulnocarpal joint RUL • stabilizer of the distal radioulnar joint U R • load distributor • smooth wrist and forearm motion Nakamura T, Annals Anat 2000, JHS 26B, 2001

Tenderness point, ulnocarpal stress test Diagnosis of TFCC tear

Stress maneuver: ulnocarpal stress test ballottement test Image diagnosis: Arthrography MRI Arthroscopy

1 2020/8/1

Ballottement test Multiple directional DRUJ instability with complete fovea avulsion

Radiographs useful to diagnose ulnocarpal abutment syndrome Radiographs DRUJ dislocation

Arthrogram sequential images can be obtained Arthrogram

• Invasive • Use radiographic dye

Initial neutral ulnar deviation radial deviation

2 2020/8/1

AG TFCC ulnar tear (Palmer 1B) Arthrography

complete fovea avulsion

MRI MRI serial sections

Non invasive Screening coronal, sagittal, axial views

TFCC fovea avulsion: easy to diagnose (arrow)

dorsal volar

Ulnocarpal abutment syndrome Staticodynamic MRI

neutral

supination pronation

3 2020/8/1

Comparison of MRI and arthrogram AG and MRI  1B tear MRI ＋ − AG ＋ − AS AS ＋ 42 65 ＋ 93 14 − 2 31 − 10 23 Sensitivity : 39% Sensitivity : 86% Specificity : 93% Specificity : 69% Accuracy : 52% Accuracy : 82% • Fovea avulsion MRI AG AS ＋ − AS ＋ − ＋ 26 6 ＋ 18 14 − 58 50 − 26 82

Sensitivity : 81% Sensitivity : 56% Specificity : 46% Specificity : 75% Accuracy : 54% Accuracy : 71%

CT arthrogram Precise diagnosis with multiple slice Arthroscopy is gold standard for diagnosis of TFCC lesions after arthrogram STT

MCR MCU MCJ RCJ 6U 1-2 2-3 6R

3-4 DRUJd 4-5 DRUJp

TFCC: radiocarpal view 3-4 portal DRUJ arthroscopy

lunate

TFCC TFCC

radius sigmoid fovea notch ulnar head

4 2020/8/1

DRUJ arthroscopy DRUJ arthroscopy: direct vision to the ulnar lesion

DRUJ AS probing Severe DRUJ instability: right wrist

Palmer classification of traumatic tear Atzei classification of ulnar TFCC tears

Palmer AK, JHS-A 1989 Atzei A, Luchetti R. JHS-E 2008

New Classification Materials and Methods Traumatic-degenerative/ RCJ

• July 2014 to Sept 2015 (1 y 3m), Single surgeon Class 0 intact • 213 wrists of 211 patients, who underwent treatment of TFCC injuries, were Class 1 intra-disc a. slit, b. flap, c. double studied transverse slit, d. coronal, • Second look surgeries or secondary surgeries were excluded e. oblique, d. bucket handle • All cases had the RCJ and DRUJ arthroscopic findings Class 2 radial border a. disc, b. rim, c. complete Class 3 peripheral a. ulnar (classic Palmer 1B) • Male 123, Female 88 b. dorsal • Right 116, Left 93, Bilateral 2 c. palmar • Average age at the surgery 39.1 years (range 13-72) d. distal • Diagnosis of TFCC injury was based on MRI, arthrogram and arthroscopy e: horizontal Class 4 degenerative a. wear, b. perforation, c. massive Nakamura T. JWS in submitting Nakamura et al. JWS in submitting

5 2020/8/1

New Classification Surgical treatments of TFCC lesion based on classification

Traumatic-degenerative/ DRUJ RCJ Class 1 AS partial resection According to DRUJ arthroscopic findings: Class 2 AS partial resection or repair Class 3 AS capsular repair Stage 0 intact Class 4 ulnar shortening Stage 1 slit tear on the RUL surface Stage 2 partial RUL tear (dorsal or palmar) DRUJ Stage 1 AS debridement Stage 3 complete RUL tear Stage 2 AS transosseous repair or open repair Stage 4 relaxed RUL Stage 3 AS transosseous repair or open repair Stage 5 degenerative findings in the DRUJ TFCC reconstruction a. wear on proximal TFC surface, b. cartilage damage Stage 4 ulnar shortening Stage 5 ulnar shortening, Sauvé-Kapandji • Covers all TFCC injuries Nakamura et al. JWS in submitting Nakamura et al. JWS in submitting

DRUJ Stage 2 or 3: trans-osseous arthroscopic repair Reconstruction of the TFCC ECU half-slip

TFCC

Foveal detach Interference screw

TFCC tear with DRUJ instability Nakamura et al., JWS 2015, HaMiPla 2016, J Hand Surg E 2017

In summary: TFCC diagnosis and classification Thank you for your attention!

• DRUJ Ballottement test is the most useful test to diagnose TFCC lesions

• Arthrogram and MRI is excellent image modality to diagnose TFCC lesions

• Arthroscopy is gold standard for precise diagnosis of TFCC lesions

• Classification system should be based on RCJ and DRUJ arthroscopic findings

• Original classification system based on RCJ and DRUJ findings worked well for diagnosis of TFCC lesions as well as for determination of surgical treatment options

6 OnDemand Precourse 09: Fundamental to Cutting Edge: The Role of Arthroscopy

15 Minutes

TFCC injury without instability

Charles A. Goldfarb, MD ● Non-CME Services: Acumed

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

7/30/20

37 yo male

TFCC Injury without Instability • Fall on outstretched dominant right hand, supinated • Persistent ulnar sided pain for 2.5 months • Has failed NASAIDs, off the shelf brace, & activity modification

Charles A. Goldfarb, MD Professor and Executive Vice Chair Department of Orthopaedic Surgery

Washington University Orthopedics | Barnes Jewish Hospital Washington University Orthopedics | Barnes Jewish Hospital 1 2

Key Examination Points TFCC Additional information

• Localize pain • MRI • Test DRUJ stability in sup, pron, neutral • 80+% sensitive for central tears • Peripheral tear sensitivity less but increased w/ arthrogram • Provocative tests for TFCC • Negative MRI does not rule out tear • Rule out ECU • Corticosteroid injection- diagnostic/ therapeutic • Rule out LT ligament • Ultrasound

Hand Clinics 2010

Washington University Orthopedics | Barnes Jewish Hospital Washington University Orthopedics | Barnes Jewish Hospital 3 4

1 7/30/20

Next step

• 37 yo male with 2.5 months of ulnar sided wrist pain w/o instability • Has failed conservative treatment including steroid injection • 72 patients • Continued nonoperative care vs wrist arthroscopy • Based on PRWE <20, complete recovery in • 32 of 72 (44%) at 34 weeks • 45 of 72 (63%) had at least a 14- point improvement

Washington University Orthopedics | Barnes Jewish Hospital Washington University Orthopedics | Barnes Jewish Hospital 5 6

Wrist Arthroscopy Palmer Classification, JHS 1989

• Acute Tears • A- Central • B- Ulnar (+ dorsal- ulnar) • C- Volar (UC ligaments) • D- Radial

Washington University Orthopedics | Barnes Jewish Hospital Washington University Orthopedics | Barnes Jewish Hospital 7 8

2 7/30/20

TFCC Lunate Scaphoid Facet Facet

Primus Manus: A Pocketbook Manual of Hand and Upper Extremity Anatomy Primus Manus: A Pocketbook Manual of Hand and Upper Extremity Anatomy

9 10

Kleinman, JHS 2007

Primus Manus: A Pocketbook Manual of Hand and Upper Extremity Anatomy

11 12

3 7/30/20

Palmar 1A Palmar 1A

• Central tears- poor blood supply (Bednar, 1991 JHS) • Debridement to stable base • Maintain dorsal and volar ligaments

Washington University Orthopedics | Barnes Jewish Hospital Washington University Orthopedics | Barnes Jewish Hospital 13 14

Palmar 1B Palmar 1B

• Peripheral tears, straight ulnar or dorsal/ ulnar 1. Outside in repair to ECU subsheath (Whipple and Geissler, • Critical to understand DRUJ stability Ortho 1993) • Debridement with or without repair 2. Inside out repairs to capsule (De Araujo, Arthroscopy, 1996) 3. All arthroscopic anchor repairs • Yao, 2011 • Geissler, 2015

Washington University Orthopedics | Barnes Jewish Hospital Washington University Orthopedics | Barnes Jewish Hospital 15 16

4 7/30/20

Palmar 1B Palmar 1B

Washington University Orthopedics | Barnes Jewish Hospital Washington University Orthopedics | Barnes Jewish Hospital 17 18

Palmar 1B Outside In Repair

Washington University Orthopedics | Barnes Jewish Hospital Washington University Orthopedics | Barnes Jewish Hospital 19 20

5 7/30/20

Partial

Washington University Orthopedics | Barnes Jewish Hospital Washington University Orthopedics | Barnes Jewish Hospital 21 22

Palmar 1C Palmar 1D

• Attachment of ulnocarpal ligament • May be isolated or associated with fracture • Ligament avulsion • Poor vascularity • Split tear b/w UT and UL ligaments 1. Debridement (Trumble Hand Clinics, 2011) • May be associated with LT instability 2. Repair 1. Debridement 1. Arthroscopically assisted 2. Heat Shrinkage 2. All arthroscopic 3. Open repair, outside- in Ho, Lee, Sin Hand Surgery, 2012

Washington University Orthopedics | Barnes Jewish Hospital Washington University Orthopedics | Barnes Jewish Hospital 23 24

6 7/30/20

Outcomes

65% good or excellent

Washington University Orthopedics | Barnes Jewish Hospital Washington University Orthopedics | Barnes Jewish Hospital 25 26

Peripheral TFCC Tear in Adolescent

Washington University Orthopedics | Barnes Jewish Hospital Washington University Orthopedics | Barnes Jewish Hospital 27 28

7 7/30/20

Thank you Pearls

1. Careful clinical examination 2. Understand arthroscopic anatomy 3. Multiple surgical techniques yield satisfactory results 4. Adolescent population

Washington University Orthopedics | Barnes Jewish Hospital Washington University Orthopedics | Barnes Jewish Hospital 29 30

Charles A. Goldfarb, MD

[email protected]

Blog: congenitalhand.wustl.edu Twitter: @congenitalhand Podcast: The Upper Hand: Chuck & Chris Talk Hand Surgery

Washington University Orthopedics | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis 31

8 OnDemand Precourse 09: Fundamental to Cutting Edge: The Role of Arthroscopy

15 Minutes

TFCC injury with instability

Keiji Fujio, MD No relevant conflicts of interest to disclose

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

Speaker has not provided a handout for

this presentation OnDemand Precourse 09: Fundamental to Cutting Edge: The Role of Arthroscopy

12 Minutes

Midcarpal Instability

David Hargreaves, MBBS No relevant conflicts of interest to disclose

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

8/3/2020

DISCLOSURES

David Hargreaves, MBBS

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

The Role of Arthroscopy : Midcarpal Instability

David G Hargreaves Southampton , UK.

What is Midcarpal Instability?

• Misnomer: Not “Instability of the Midcarpal joint”

• Instability of the Proximal row: R-C & MC

• Lack of Proprioceptive control in a lax wrist

1 8/3/2020

“Catch Up” Clunk

From Radial to Ulnar deviation :

Sudden transition of proximal row from flexed position to neutral

Ulnar Sag

Pathophysiology

• Role of Forearm rotation :

• Instability in Pronation • Stable in Supination

2 8/3/2020

Spectrum of Palmar M/C Instability

Grade 0 Pre-symptomatic No symptoms. Voluntary clunking only Grade 1 Dynamic Giving way . No passive sag / voluntary clunk

Grade 2 Voluntary dynamic Symptomatic giving way Voluntary clunking

Grade 3 Static reducible VISI at rest. Passively reduced

Grade 4 Static Irreducible Fixed VISI. Not reducible

Hargreaves. J Hand Surg(Eu) Jan 2016.

Role of Arthroscopy

• Diagnostic: Exclude other Pathology (L-T rupture)

• Treatment: Thermal Capsular Shrinkage Partial wrist fusion

Grade 1 and 2 : Arthroscopic Capsular Shrinkage

Palmar Dorsal

Post Op: Immobilisation 6w

3 8/3/2020

Tips and Tricks

• Avoid extensive burning

• temperature  : • Spotting • Water flow • Temp regulated probes

Long Term results: FU 10-14yrs: Instability Symptoms

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pre op 2yrs 10yrs

none Occasional Frequent

>10Yr FU : DASH

0 Pre op 2yr 10 yr

4 8/3/2020

Objective stability

• Anterior drawer test : Stable : 12/14 wrists

Movement

• > 95% Arc

Treatment Options 0 Pre- No symptoms. No treatment symptomatic Voluntary clunking only

1 Dynamic Giving way . Soft tissue stabilization No passive sag / voluntary or clunk arthroscopic capsular shrinkage

2 Voluntary Symptomatic giving way Soft tissue stabilization dynamic and voluntary clunking or arthroscopic capsular shrinkage 3 Static VISI at rest. Easily reduced Soft tissue stabilization reducible or Bone procedure (R-L Fusion) 4 Static Fixed VISI. Not reducible Bone procedure (R-L Fusion) Irreducible

5 8/3/2020

Grade 3 and 4: Arthroscopic Radio-Lunate Fusion

Conclusion

• Long term results : improvement maintained 80% : Immobilization 6w.

• Avoidance of Complications : Meticulous care !

• Dynamic instability: Arthroscopic Capsular Shrinkage

• Static Deformity: Radio-lunate fusion

6 OnDemand Precourse 09: Fundamental to Cutting Edge: The Role of Arthroscopy

15 Minutes

CMC fracturedislocation, Small Joint Arthroscopy

Steven S. Shin, MD ● Royalty: Arthrex Hely & Weber ● Consulting Fees: Arthrex ● Speakers Bureau: Arthrex

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

If it can fit a scope, we should scope it…right?

CMC Fracture-Dislocations and • Radiocarpal, midcarpal Small Joint Arthroscopy • CMC, MCP, PIP, DIP, DRUJ

• ~ 2 mm (larger with sheath or cannula)

Steven S. Shin, MD, MMSc

Associate Professor and Executive Vice Chair

Department of Orthopaedics, Cedars-Sinai Health System

cedars-sinai.org

2 1 2

Thumb CMC Arthroscopy Thumb CMC Arthroscopy for Bennett Fractures

• General or regional anesthesia (local?)

• Finger traps on thumb/index finger, traction tower (5-10 lbs) J Hand Surg Am. 2010 Jan;35(1):137-40. • Portals: 1-R, 1-U, dorsal, trans-thenar • Benefits • Instruments ~ 2 mm • Can directly view and assess articular reduction • Ensure wires or screws are not intra-articular • Things you can do • Synovectomy, chondroplasty, thermal • Understand deforming forces shrinkage, loose body removal, • APL: dorsal, radial, proximal; supination microfracture, bony resection • Adductor pollicis

3 4 3 4

Case: Bennett Fracture Thumb CMC Arthroscopy: Insufflation and Scope Insertion

30 yo RHD MMA fighter

Injured right thumb during UFC match 5 days prior

5 6 5 6

1 Case: Arthroscopic Visualization and Diagnosis Arthroscopic Debridement

7 8 7 8

Using Arthroscopy and Fluoroscopy at the same time I’m not that good: Fluoroscopy-only Reduction and Fixation

Culp R and Johnson J. Arthroscopically Assisted Percutaneous Fixation of Bennett Fractures. J Hand Surg Am. 2010 Jan;35(1):137-40. 10 9 9 10

Maybe better without the scope! Post Op

Pins/cast for 4 weeks

Return to impact/grappling: 3 months

4 weeks post op

11 12 11 12

2 5th CMC Joint Arthroscopy (courtesy of David Slutsky, MD) 5th CMC Fracture-Dislocation (courtesy of David Slutsky, MD)

• Finger traps on RF/SF

• Portals (Slutsky, Hand Clin 2011): • Ulnar or 5-MH (between EDM and 5th MC ulnar base-hamate ligament) • Radial or 4-MH (between 4th MC ulnar base-hamate ligament and extensor tendon)

• Structure at risk: DUSN

Slutsky D. July 21, 2011. Retrieved from https://www.vumedi.com/video/5th-cmc-joint-arthroscopy-for-a-fracturedislocation/ 13 Slutsky D. July 21, 2011. Retrieved from https://www.vumedi.com/video/5th-cmc-joint-arthroscopy-for-a-fracturedislocation/ 14 13 14

Arthroscopic Visualization Arthroscopic Reduction

Volar articular fragment attached to 4th MC base Displaced fracture of 5th MC base through intact intermetacarpal ligament

From Slutsky D. Arthroscopic Reduction and Percutaneous Fixation of Fifth Carpometacarpal Fracture-Dislocations. From Slutsky D. Arthroscopic Reduction and Percutaneous Fixation of Fifth Carpometacarpal Fracture-Dislocations. Hand Clin 27 (2011) 361–367 15 Hand Clin 27 (2011) 361–367 16 15 16

K-wire Fixation MCP Joint Arthroscopy

• First reported thumb MCP scope (Andrews 1985, AJSM)

• Indications similar to other small joints • Thumb: reduction of Stener lesions, artho- assisted repair of UCL tears, thermal shrinkage of volar plate for instability (PC Ho 2019, JHS Asia Pacific)

• Long-term results: unknown

From Slutsky D. Arthroscopic Reduction and Percutaneous Fixation of Fifth Carpometacarpal Fracture-Dislocations. From Badia A. Arthroscopy of the trapezoimetacapral and metacarpophalangeal joints. J Hand Surg Am. 17 18 Hand Clin 27 (2011) 361–367 May-Jun 2007;32(5):707-24 17 18

3 MCP Joint Arthroscopy RCL Avulsion Fracture at 5th MCP Joint

• Radial and ulnar MCP portals

From Cobb TK, Berner SH, Badia A. New frontiers in hand arthroscopy. Hand Clin. 2011 Aug;27(3):383-94. 19 Cobb TK, Berner SH, Badia A. New frontiers in hand arthroscopy. Hand Clin. 2011 Aug;27(3):383-94. 20 19 20

PIP Joint Arthroscopy DIP Joint Arthroscopy: WOW

PIP joint: portals between lateral bands and collateral ligaments

DIP joint: high risk of scope damage, technically difficult

Cobb TK, Berner SH, Badia A.New frontiers in hand arthroscopy. Hand Clin. 2011 Aug;27(3):383-94. 21 Cobb TK, Berner SH, Badia A.New frontiers in hand arthroscopy. Hand Clin. 2011 Aug;27(3):383-94. 22 21 22

Keep pushing the envelope…THANK YOU

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