On behalf of the American Society for Surgery at Hand, I'd like to welcome everyone to this webinar on wrist surgery. I'm Dr. Louis Catalano, chairing today's course. I'm lucky to be joined by four distinguished faculty members, Drs. Grewal, Friedrich, Lauder, and Gottschalk. Just a few housekeeping notes before we start. Your audio is going to be muted during the presentations. The webinar is being recorded and will be emailed out to all attendings by the end of the week. I strongly encourage you to use the question and answer section at the bottom right of the screen here to submit some questions to our panelists. We have about 10 to 15 minutes at the end of webinar to ask the panelists some questions. In case of technical difficulties, contact webinarsupport at assh.org. One last thing. Attendees of this webinar can receive up to 1.5 hours of CME credit. You can claim your credit after Monday, May 30th by logging on to the ASSH website. Our first lecturer is Dr. Ruby Grewal, and she's going to talk about distal radial ulnar joint instability after distal radius fracture, open reduction, and internal fixation. Thank you, Ruby, for joining us. Thank you very much for inviting me to be a part of this seminar. Hopefully everybody can see my screen. I'm from London, Ontario at the Hannon Upper Limb Centre in Canada. There are a lot of different factors that contribute to drudge stability. Disruption of any of these can lead to instability. Recognizing each of these factors and how they interplay with the distal radius fracture is very important if you're going to treat this successfully. The bony anatomy is quite interesting in the drudge. The radius of curvature of the sigmoid notch is much bigger than that of the ulnar seat. It's very shallow, and that's what allows it to have such a large range of motion. The radius actually rotates between 150 and 180 degrees around the ulnar head. The morphology of the sigmoid notch is such that the dorsal and bolar rims do contribute to stability, but inherently it's a relatively unstable joint. That is why the soft tissues are really so critical in this joint. The TFCC is probably the main thing that we think of when we think about drudge stability. It's composed of a lot of different aspects. We have the fibrocartilaginous and the ligamentous structures, and then also the dorsal and palmar radial ulnar ligaments. All of these working together are important to stabilize the dredge. Not only does it stabilize it, but then it also, the disc portion, also acts as a bit of a shock absorber to help address some of the compressive loads that that joint also sees. Within all of these structures, the fovea is probably the most important because all of these soft tissues attach on to this very critical point. These are just some of the things I want you to keep in mind as we go about on our discussion today, just understanding some of that basic anatomy. Beyond that, we also have other soft tissues that contribute to the stability of the dredge. Things like the pronator quadratus, the ECU tendon, also the interosseous membrane, particularly the distal oblique bundle. In general, if we're thinking about causes of distal radial ulnar joint instability in this scenario, it can be caused from the fracture itself, from other problems more proximally in the forearm. It can be related to an associated ulnar styloid injury, or it can be contributed to by the soft tissues. We're going to go through a couple of cases and just talk about a few salient points based on those. The first case I want to review is this is a 17-year-old boy who had a fall while playing football. He's otherwise healthy. He denied any previous problems and he was treated somewhere else, but these are the interoperative films here. You can just see the AP a little bit better on this view. A fairly shallow distal radius fracture. He's a young kid, so it's probably gone through remnants of the growth plate. This treating surgeon performed an ORIF. At first glance, these x-rays look fine. Everything seemed to be going fine. The person was discharged home without any issues and came back at two weeks. At this point, this young man is basically unable to supinate. He has full pronation and he has no problems bringing his palm down, but he's restricted in his supination. The question is really what went wrong? I didn't do this operation, so I don't know what happened at the time of surgery, but the most important thing before you leave the OR when you're treating a distal radius is to assess the drudge. For me, what that means is checking rotation. Make sure that the patient has full pronation, supination, and that the joint is stable in each and every one of those positions. The next thing you want to do is look at x-rays. It's very important, first of all, that you get a true lateral x-ray. These two x-rays here are of a different patient, but it just shows the point here how if the pisiform and the bolar tubercle of the scaphoid are not overlapped, you can make it look like the radius and ulna are in line. The x-ray on the right here, you can see that the x-ray text lined up the forearm bones, but it's actually rotated. This is more of an obliquogram. Once you get the pisiform and the bolar beak of the scaphoid lined up, you can see here that the ulna is actually not in line with the radius. If we look at this case here, once we have an actual true lateral, there's the pisiform, there's the scaphoid, you can see that the ulna is actually sneaking out the back there. Another tool I think that is quite important for evaluating the dredge is a CT scan. We don't have luxury of dynamic CT scans in our facility on a routine basis, but what you can do and what we do very often is we get bilateral dredge CTs and we do them in three positions. We have the patient, we get them scanned in pronation, neutral, and supination. Then we compare each of those films and you can get a really good idea of where the joint is moving in all of those positions. For this guy here, you can see that once we get a true lateral, the dredge is out dorsally and the CT scan certainly confirms this. What went wrong here? Well, this is an example where we have to think about the forearm as a unit. Really, it is a very complex connection between the radius and ulna. You can't really think of them as two independent bones, but they are really an entity in and of themselves. It's very easy at the wrist to think of the radius as the main bone and we think of the ulna as this little bone that's off to the side. If we go back to our elbow anatomy, the ulna humeral joint is really the main articulation. The ulna is rigid and it's actually the radius that's moving around the fixed ulna. While we think that it's the ulna that's mobile, it's actually the ulna that's fixed and the radius that has some interplay. When we go back and talk to this guy again and say, okay, what has been happening to you in the past? He does say that, well, actually, when he was 13, he does remember having an old injury, but he was treated with a cast, the cast came off, and prior to this injury, he reports no issues. He states that he had full rotation, he had no clicking or clunking. The first step we've done here is to get full forearm x-rays. I always get bilateral forearm x-rays. Part of the problem is intra-op when we use a mini fluoro scan, we only see a very small snapshot of what we're working on, but sometimes you need to look back and look at the bigger picture. You can see here, if we compare the x-rays of the left and right forearm, there's a significant bow to the radius. Whether this additional fracture just tipped him over the edge or really how much rotation he had prior to this, I don't know. Certainly, it's just a good example of how these complex forearm deformities can cause issues later on down the road. If we go back to our anatomy, depending on where the forearm is fractured, you're going to have different deforming forces based on the muscular attachments. That will predict whether the piece rotates or which way it angulates. Problems with forearm malunions can lead not only to pain in the drudge, but they can cause instability at the drudge, also the prudge, and they can limit rotation. A lot of these forearm deformities can be quite complex based on all of those deforming forces that we spoke about just moments ago. One of the things we sometimes do for more complex or this is possibly a multi-level deformity, is computer mapping can be your friend here. This is something that our engineering lab does. There are also commercial groups that can do this. Basically, you get two CT scans of both forearms, and then based on their algorithms, they can basically figure out where the deformity is, how significant the deformity is. In this case, we were interested to know how much of it was coming from the old injury versus how much of it was coming from the new injury. It was a subtle deformity, but the main issue was about that mid-shaft of the radius and only about an eight-degree malalignment. Because it was so proximal, it really results in a lot of displacement of the radius distally. Really, those middle third deformities of the radial shaft are probably the worst in that they are most likely to cause problems distally. Really, malalignment of anywhere from 15 to 20 degrees can result in about a third of your loss of rotation. We felt at the end of the day that really the distal radial fracture fixation was probably okay, and we weren't going to go after it. We thought that the deformity more proximal was probably contributing. Based on our computer modeling, we decided to focus our corrective osteotomy at that level. This just shows you how much motion he had intra-op. He really was stuck in rotation. It wasn't just the fact that he was two weeks post-op and had poor pain control or something and couldn't rotate. This is an example of his dredge. It just gives you an idea of how it is sort of unstable. The shock test shows that it is coming out a bit dorsally. We did a multi-planar correction here. We not only performed a dorsal closing wedge osteotomy, but there was also a rotational component to it. We were able to dial both of those in proximally, and we did nothing to the distal radius fracture itself. This young man intraoperatively was actually able to achieve full rotation on the table. I think that's really important to not leave the OR without that. The reason for that second incision at the back is one of our screws was going to be right where the other screw was, so we had to take that hardware out. His osteotomy went on to heal quite nicely, and he's done very well. He has full pronation, full supination, and he's been able to regain full motion and grip strength back to all of his usual activities. The next case I want to talk about is a 61-year-old woman. She had a fall several months ago and has been doing her rehab, but has been complaining of some ulnar-sided wrist pain and clicking. This is actually somebody I just saw in the last couple of weeks, and I think her instability is actually quite remarkable. You can see here with the shuck test that there's really a lot of play on the distal radial ulnar joint in comparison to the contralateral side. Overall, if you look at the forearm, I mean, or if you look at the wrist, there's not a huge deformity. You sometimes think of these distal radius malunions, but you know, she's got a bit of prominence on the ulna, but it's not overly mal-aligned. This is what her x-rays look like, and what I want you to appreciate here is that very subtly, you have a bit of an offset of the radial shaft to the distal aspect of the radius. She also has ulnar styloid fracture, and we're going to talk about both of these issues and how they can contribute to instability. This is an example of her contralateral side, so you can really appreciate the discrepancy here between the malunion and the normal side. So this is what her x-rays looked like during the time of her treatment and her casting. You can see the radial shaft is offset a bit. I don't know if it's, you know, extremely offset to the point where I would have, you know, panicked or anything or thought that it was terrible, but this is a really good example of how unstable you can be when there is that coronal malalignment, and several authors have shown us how important this is, and the reason is that it affects the tension on the distal aspect of that interosseous membrane. So what happens here is you have these fibers that are really considered secondary stabilizers of the dredge. The primary stabilizer is the TFCC, but this band comes into play when you have the TFCC involved or injured. So without that TFCC, we become very dependent on the tension of that distal aspect of the interosseous membrane, and as you have radial translation of the distal fragment, you can see that you lose tension on this structure, and that causes increased laxity. This is an example of a 3D CT, which just depicts that concept for us once again. Now, it's very hard to consider shifting the distal fragment ulnar, but if you can think about moving the proximal fragment radial, that will help to restore the tension on that distal oblique band, and particularly when you have disruption of the ulnar styloid, I think that becomes very important, and I think this is one of the reasons why we see less dredge instability now, that we're more likely to see these fractures being plated more. So if you can make a line along the ulnar aspect of the radial shaft, and if you see that it's offset, that's a good example, a good indication that something needs to be done. So this is something that you need to watch interoperatively during your fluoro, interoperative fluoro images. There's different strategies that you can use to try to correct that. You can hook a homin around the radial shaft and pull that in. Some people put a gelpe into that space. You can put a large retractor like an Army-Navy in there and then rotate it 90 degrees. It's a depiction of a lobster claw clamp used to pivot around that fracture site and help to correct that alignment. I also like to sometimes use a laminar spreader. You can see here there's an offset of the radial shaft. We stuck the laminar spreader here in between the radius and ulna, and you can see here as you spread the prongs apart that it helps to correct that coronal alignment. So this lady, I've actually not treated yet. She interestingly does not want surgery, but it's an interesting one because she's got this coronal shift of the radial shaft, but she also has an ulnar styloid fracture, and particularly basilar ulnar styloid fracture is more likely to cause destruction of the TFCC, and that also contributes to drug instability. Now, the literature is full of conflicting evidence about the relevance of this. There are some authors that show that the ulnar styloid fracture does contribute and others that show that it doesn't. This is an example of a series of about 70 patients. They were all treated with boulder-locked plating, and they concluded that the presence of a styloid fracture, the type, or whether it unites or not, doesn't really seem to affect outcomes at one year, and they concluded that really those fractures should be left untreated. Now, there are other studies that show the opposite, that really drug instability is quite common following distal radius ORIF. In this series, they performed MRI scans on everyone, and not only do they see disruptions of the TFCC, but they actually report over 50% of patients actually having drug instability, so I think it's very hard, based on the literature, to have a good idea of what to do. My personal view is that fixation of the styloid is rarely required, particularly if you've restored an anatomic reduction. If you have an anatomic reduction, the drug is usually stable. I think in my practice, it's been quite unusual to fix the ulnar styloid when I'm doing a boulder-locked plate. With that being said, it's very important to always test that intraoperatively and really make it part of your routine. That's one of the things I stress with my trainees and my fellows, that every time you need to do it, have a little routine so you don't forget, and always include it as part of your dictation. When you do fix the ulnar styloid, there's lots of different options. K-wires, hook plates, some people use screws. In my experience, it's not really necessary to do anything fancy here. Prominent hardware is quite a relatively significant issue here. The hardware at this side of the wrist always bugs people, so I like to keep it simple, and I typically just use K-wires, and they are removed afterwards. When you're testing drug stability intraoperatively, test it in all three positions. If there is stability in one position, maybe unstable in others, it's a reasonable approach to just split them in that position for a couple of weeks. You can consider pinning them in that position if you're concerned about losing alignment. When you are pinning the drudge, it's important that those K-wires go all the way across and you capture all four cortices. The pins can break in between the radius and ulna, so it's important to have them prominent on both sides so you can pull them out radially or ulnarly and you're not stuck. Once you pin it, get a CT scan because it is possible to malalign the drudge when it's pinned. Lastly, we'll talk about the soft tissues. I would say they rarely need to be addressed. This is a little bit of an algorithm that you can go through when you're dealing with drudge instability intraoperatively. If you find a position of stability, splint it in that position. If you don't find a position of stability in that it's unstable in all three positions, then you may have to go after the ulnar styloid. Usually once you fix it, it's stable. If it's still unstable, that's when you'd have to go after the soft tissues and perform a TFCC repair. I'd say in my practice that's extremely rare. So to summarize, check the intraoperative rotation and drudge stability before you leave the OR. Ensure that you've restored a normal anatomy. Look at that coronal shift of the radial shaft. Look at the entire forearm. Sometimes that's contributing. Then look at the ulnar styloid. Really, the soft tissues are the last thing to consider and repair. Thank you. Thanks, Ruby. That was excellent. I would agree with you. I think that having to fix an ulnar styloid fracture is very rare after ORF. I can't believe that one study found 56% of the time they needed to do something. That's pretty amazing. The other thing I'd add is the way I was taught by Dr. Galula at WashU to read a lateral was to have the SPC lateral. I don't know if you've heard that. It's a scaphoid pisiform capitate. So from vulnar to dorsal, the scaphoid is most vulnar, the pisiform's in the middle, and the capitate's next. That's how you know you have a true lateral. Like you said, you can be fooled by not having a true lateral and the DREJ look reduced, but when you get a true lateral, the DREJ is not reduced. So SPC lateral. He used to beat that into our heads. That's excellent. I like that little acronym. And I think it's true. I think that often the techs try to line up the forearm bones, and they don't pay attention to actually what position. Exactly. Right. They're lining up the forearm and not the carpus. Yeah. Yeah. That was great. Thanks. Our next speaker is Dr. Jeff Friedrich. He's going to speak on carpal subluxation after open reduction and internal fixation of distal radius fractures. Everybody's worst nightmare here. So thanks, Jeff. Thanks, Lou. And thanks to all of you for your attention tonight. I'm excited to be talking before you today and excited to share this webinar with some great friends and great panelists here. So I'm going to talk about, as Lou said, can be a nightmare, this vulnar subluxation after distal radius fracture, how it happens, how to hopefully avoid it, and how do you bail yourself out. So what are we talking about here? Well, we're talking about when one or more of the carpus, so the proximal carpal road, translates vulnarly after a fracture. It's sometimes called vulnar escape, sometimes lunate escape, because it is typically the lunate bone that does translate vulnarly or pulmonary with that fracture fragment. The reason why the lunate goes is because this small fracture fragment on the lunate side is not fixed appropriately, which I'll show you here in a minute. Because of the short radial lunate ligament attachment to the lunate, everything goes with it or at least that lunate goes with it. It can be a tummy ache inducing phenomenon when you see it. Let me walk you through a case of mine and talk to you about some of the pitfalls that I encountered. I see this patient here with a distal radius fracture that's an intra-articular type. He also has another fracture on the other side, somewhat similar to this. But you can really see on the lateral, you can argue that it's already escaped, the carpus has already translated and we need to get that back where it came from. But remember that x-ray because that becomes pertinent later. I think you probably all found that once a distal radius fracture is displaced, its tendency or its desire is to re-displace in that same direction. We really have to counteract those forces of that displacement. This is our fixation after that fracture. You could argue that looking at the PA and lateral, that things are okay. On the AP, we've got a relatively good alignment of the radiocarpal joint on the lateral. You can actually see that fracture here at the distal end that escaped lunate piece. You can see the fracture there and it appears that the volar plate is covering that. But I would argue that this x-ray is somewhat deceiving. The other thing that is reassuring is that the capitate is lined up with the volar shaft of the radius bone itself. In terms of the radiographic parameters we look for, I would say this looks pretty good. I would tell you that even during this surgery, we manipulated this under floral and attempted to do volar translation of the carpus because I was worried about this. But I would say probably, I could have used a little bit more vigilance because I'm going to show you what happens next and you probably know where this is going. But the things I would say before I show you what happens is that in being self-critical, I would say that this plate is probably not older enough and it's not distal enough. Now, for a volar locking plate of the distal radius, it is distal enough. It's in the right spot. It's in the watershed region of the distal radius. But I put there because it's not distal enough because it's the wrong plate or the wrong fixation method. I'll get into that here in a minute. This is a diagram from the AO website. You can see the reference there below it showing the watershed region of the distal radius. The red dotted line indicates the watershed line. You can see there that our plates in the watershed region, it's where it should be to prevent flexor tendon rupture. It's where these plates are supposed to be. But what I would point out to you is, let me see if I can go back. If you'll remember, and it's difficult to see on this one, it's a little bit easier to see here. You can see the split between the scaphoid and the lunate facets that goes obliquely here towards the DRUJ, and it's just past the distal end of this plate. That's why I say this plate was not older enough and it was not distal enough because it was probably the wrong implant for this fracture. We got it right with the placement of the plate, but not for the fracture itself. The root cause of this particular patient, and what I'm about to show you is that it's a polytrauma patient. We have a lot of injuries bilaterally that we're working on. Really, I think it was a lack of diligence on my part with this fracture and what came next. What do we do about addressing the volar ulnar corner of the distal radius? Step 1 of that is recognition. I've talked a little bit about the recognition, but we really need to get good at recognizing these fracture patterns. It's typically AO, B, and C fracture patterns. If you're into the AO classification, there's a number of classifications. You have to listen or pay attention to what the radiograph is telling you or what the radius is telling you. As I said, this radius has displaced volarly and proximally. That's where it wants to go and now desires to go back to that position. With a Colley's fracture, its tendency is to move dorsally back to its pre-reduction position. That's just what distal radii do. I think I would consider in retrospect a CT scan, particularly if we have any concerns about where exactly each fracture fragment is, the size of it, and its displacement. Consider the CT scan when you're dealing with these interarticular fractures. Think about the approach to these, really these volar ulnar corner fractures. The common method is a flexor carpi radialis approach to the distal radius that works for 90-95 percent of our distal radius fractures. Potentially, I'm making that number up. But the vast majority of them can be fixed through that approach with a volar locking plate. The more direct approach or the straight shot approach to this volar ulnar corner is barely named the volar ulnar approach or the extended carpal tunnel approach is the name that I was taught for this. This is a great article about that. This is from Journal of Hand Surgery, that volar ulnar approach for fixation of that volar lunate facet. Some of the technical points with it, this is from Journal of Hand Surgery back in 2016. This is an excellent article that I recommend you have a look at. These are the approaches for that volar ulnar corner, that direct shot to it. On the left is the more limited longitudinal incision, and on the right is the extended carpal tunnel incision because it indeed goes into the carpal tunnel, and you can decompress the carpal tunnel through that, and thereby get a little bit better visualization of that volar ulnar corner. This is what it looks like from an axial section. On the left are the flexor tendons, and on the right are the flexor carpi ulnaris, and the ulnar artery and ulnar nerve. That's the interval. We're going in between the ulnar neurovascular bundle and the flexor tendons. And you can see there, once you divide the pronator quadratus, it literally is a direct shot to the volar ulnar corner of the lunate facet. Then appropriate fixation, and once you've gotten past the recognition and the approach to it, is the appropriate fixation, which, as I showed you before, we did not quite have. Kirschner wires are appropriate. Fragment-specific plates are appropriate. Volar rim plates, some plating companies do make a specific volar distal radius rim plate for this problem, and I'll show you some examples of that. Dr. Dennison and Dr. Moore, several years ago, back in 2014, wrote in the Hand Journal about distal radius fracture fixation using K-wires and a volar plate to provide that fixation of the volar lunate facet. And these are diagrams from their article about it, showing the placement of a K-wire from volar distal to dorsal proximal, and then the K-wire is bent along the volar surface and metastasis of the distal radius and then covered with that volar locking plate that you see there on the right side. I would argue that you could even use a K-wire that you drive in from that volar lip and then bring it out the dorsal aspect of the radius. That's also a totally sound way to do that. This is another patient of mine where we did appropriately recognize the combination of volar lip of this articular fracture and recognized that it needed a volar support, volar buttress that goes more distal than our volar locking plates. And so this is a volar rim plate, and several, as I said, vendors make this plate for this type of distal radius fracture. I will tell you that this is a gut-wrenching amount of soft tissue stripping on the volar lip of the radius. Thankfully, the radioscapular captate ligaments and the long and short radial ligaments are a little bit more dorsal than the volar rim of the radius. But still, the entire time I was stripping soft tissue in order to get this plate on, I was anxious about it. And so this is not one that's in my regular repertoire, but it certainly is available for these type of fractures. And then finally, this is an example of a fragment-specific plate, and I have no interest in any of these plates, you know, financially or otherwise, but this is a fragment-specific plate that is available from, these type of fragment-specific plates are available from a number of vendors. This is a volar hook plate. So there's no screws distally, it's sort of akin to the old blade plates that were used early on when we were learning about fixed angle constructs in orthopedic surgery. These blades are placed into that volar lip fragment and then screws placed proximally in the metaphysis to the radius. Also another very good way to hold in these volar lips. So how do we get the horse back in the barn? So this is what happened with the fracture that I showed you earlier, and this is step four. You wanna be able to stop at step three, which I just showed you, which is appropriate fixation, but if God forbid this happens to you, how do we get the horse back in the barn, so to speak? So you can see what's happened here. The volar lip of the distal radius, along with the lunate, and really all of the carpus, has escaped either over the distal end of the plate or around the ulnar side of the plate, most likely around the ulnar side of the plate in our case. The carpus has gone back to, and that volar lip of the distal radius has gone back to where it started before we reduced it, which, as I said to you, is where it wants to go, and all the carpus went with it. We can see that the cap date here, if we draw a plumb line through it, is at least a centimeter volar to the volar shaft to the radius, which is not appropriate alignment of the radiocarpal joint. And then on the AP, you can see an obliteration of the joint space of the radial lunate facet, and some considerable height loss there, what appears to be height loss of the carpus. So the fix, I believe that sooner is better, and this is typically recognized when, quite honestly, the soft tissue envelope is quite hostile in this environment. The scarring is intense. There's still quite a bit of edema, but I think sooner is better, and you have to bite the bullet to go back in. It is a difficult dissection to get back down to this fragment and to get it back into place. And I do think that these need adjunct stabilization, such as an external fixator or a spanning plate. And so here is this in process. We have dissected down to the radius. We're gradually getting these fragments back in. You can see my thumb there on the X-ray on the right is trying like hell to get this fracture back in or that fragment back in, but it's really difficult. The scarring makes this a difficult proposition to get back into place. And here's our fix, and we could quibble with this one too. We've got a pin into the fragment itself going from radial proximal to ulnar distal. We've got the styloid pinned. That styloid in some ways has, the radial styloid needs to get re-displaced so you can kind of unlock this intermediate column. And then we've got a vulnar plate on, and you could argue, well, Jeff, that's what gave you the trouble in the first place, but I would argue that we've remedied it because we've got it a little more distal and we've got it more ulnar to capture this plate. So we've got two methods of capturing the plate, I mean, the fragment. And then finally, the spanning plate, which holds our carpus aligned the way that we need it to as it's healing. And there you can see, as it continues to heal, the lateral there on the right shows a nice curvature of the radius. And most importantly, the captate is well aligned with the vulnar shaft and the radius as it should be. And then there it is with the spanning plate and the pin's removed, and it's maintaining that alignment as it should, albeit, as you might expect, with some significant stiffness of the radial carpal joint. So to wrap up, I would say that for this problem, it's recognition and prevention are the key. You know, really, you should only let this happen to you zero or one time in your career. And that's probably all it will be because you will learn from it and you will remember these kind of perilous issues that you need to be vigilant for. The flexor carpi radialis approach and vulnar locking plate are not panacea for all distal radius fractures, and you really have to tailor your approach to the personality of the fracture. Test that fixation intraoperatively with live fluoroscopy. Really, you should give it a good wrench on the wrist and see if you can make it jump from over or from around your fixation. But also, if you do detect vulnar escape of the radius, aggressively pursue it, even though it's, as I said there in parentheses, it'll make your tummy hurt to do it, to get in there right after this has happened. But I think that's when it needs to happen. And then think about some sort of neutralization device like a spanning plate to go dorsally. So that's what I have, and I really appreciate your attention for this. Thank you. That was great, Jeff. I think one of the hardest things to determine is how honored you really have to be with your plate. And I basically try to get a true AP of the wrist, and I make sure my plate is as honored as it can get without getting into the D or a J. And I also make sure when you're putting that owner screw in that you're in the piece, but not in the D or a J. And I think when you have these vulnar sets, you really owe it to yourself to make sure that plate is almost in the D or a J, and your screws should almost be in the D or a J. And that's how honored you have to be. You showed a picture of a plate, that one that was kind of gut-wrenching to take some ligaments off. Now, that plate was vulnar, and at or distal to the vulnar rim, which is kind of the group two where the plates can rupture the FPL. So what do you tell those patients about FPL ruptures and plate removal? That's a great question, and I talked to this patient extensively about that, and I brought him back in a number of times asking him specifically, what do you do to feel like your tendons crunch when you flex and extend? My partner, Doug Hanel, sometimes talks about tendons that are in impending rupture can feel like wet leather. Sometimes patients will describe that sensation. So I constantly asked him about that. I thought about taking that plate out, and you certainly can make that argument to take it out once it's consolidated. He eventually stopped coming back because I think he got tired of me asking about his tendons, but I didn't really make the argument that you could argue for routine removal of a plate like that, because you're right, it is totally at risk for a flexor tendon rupture. Yeah, I think I would consider even getting an ultrasound and seeing what the FPL is doing under a live ultrasound and see if it's rubbing up against the plate. Do you ever cast people after plating when you're concerned about the fixation? That is a great question. I would say rarely, and the caveat to that is, or the reason is that a lot of you probably know that here at Harborview, just as a local culture, we put a spanning plate on anybody that kind of looks at us wrong or a fracture that looks at us wrong. And that's only sort of a joke. We do that quite a bit because I really feel like that's such an excellent neutralization device. And again, I have no financial or other interest in those plates either. I just think it's a great tool for neutralization, early motion, and even weight bearing. So I rarely cast afterwards, I think probably in part because when there's any sort of tenuous plate fixation, I'll add that dorsal plate. All right, that's great. Again, I just want to reiterate the trick I've learned the hard way, just like Dr. Jeff has. Full AP of the wrist, make sure you get a true AP, look at the DRJ, make sure the plate is ulnar, your screws are ulnar, but not into the DRJ. That's how you buttress that piece. You really have to do that almost every time when you're plating a volar wrist. So our next speaker is Dr. Lauder. He's one of my colleagues here at University of Colorado. And he's going to be talking on revision of scaphoid nonunion when to bale. Thank you, Alex. All right, well, thank you everyone for having me. And it's really an honor to be able to talk to everyone tonight about this. I have no disclosures. We are going to start with a case, 36 year old man presenting the clinic. He's a laborer, he smokes, he came in with hand pain. He was in a bar fight, presented with this metacarpal fracture. Plan was to treat this non-operatively. So he got splinted, sent out. Two weeks after, he had a ground level fall at work, slept on ice and went to the ER. The X-ray was read as negative. But then when he came to clinic about a month later, still had some nagging radial snuff box pain and made the diagnosis of the scaphoid fracture. So he's got a distal pole scaphoid fracture. We took him to the OR, placed a retrograde screw. He's about two weeks post-op. Things are looking reasonable. Six weeks post-op, things are still looking reasonable. And then when he came back at three months, this screw's prominent, still no signs of healing. He's still smoking. And what do you do from here? He was started on a bone stimulator to see if we could get the bone to consolidate prior to taking the screw out. And then what do we do next though? He can't quit smoking, he needs to get back to work. He's frustrated with his outcome. So our options are really either do a revision, try to get the bone to heal or try to salvage it. So we have a big mountain to ski down. This topic is pretty broad. We'll go a little bit in the background, a little bit of the prevalence, and then we'll hit some topics that are a little in the spotlight currently, like about the proximal pole AVN, vascularized versus non-vascularized bone grafting, osteochondral reconstructive options, and then salvage options. So the problem. So scaphoid, the normal function of the scaphoid, it connects the proximal and distal row. It's super essential for carpal wrist kinematics. And fractures of the scaphoid are pretty common, and they account for 60 to 70% of all the carpal fractures. And when you do get a fracture, that's usually at the waist, because this is the point of the thinnest trabeculae and where fractures typically occur. Treatment options, if we can get things to progress, are either if they're non-displaced, non-operative or operative, with the operative having a little faster healing time, or if they're displaced, typically operative intervention is recommended. So the majority of the scaphoid's cartilage, which makes this bone healing a little bit of a challenge, over 80%, and that has implications with the limitations to the vascular supply. It's also intracernobial, so healing does not typically occur with callus. And that has implications on stability with fracture healing. So the ligaments that connect the scaphoid are typically just the scapholunate ligament, and then the radioscaphocapitate ligament in the front can actually serve as a fulcrum in these waist fractures, which can contribute to the humpback deformity. So the vascular supply to the scaphoid is typically retrograde from the dorsal carpal branch, which supplies the majority of the scaphoid, but the bolo tubercle does also have some supply as well. So with non-operative treatment, it's again reserved for non-displaced fractures and immobilization until signs of union. And operative, there's so many ways to fix these. So you can go volar, do percutaneous or open approaches. You can go dorsal with open approaches or many open approaches. And fixation constructs, right? So one screw longitudinally along the long axis or perpendicular to fracture site has shown equivalent biomechanical studies. Two screws is possible, and here's a photograph intraoperative showing that there is space on the kind of dorsal and volar side of the scaphoid to fit two screws. Plating is an option, and even use of staples has been described. So lots of different options, and this should be thought of when we're approaching scaphoid non-unions as well. So most of these do well until they don't. And so how many of these fractures go on to develop non-union? Well, it's not insignificant. So up to 12% of non-displaced fractures, and up to 50% of displaced fractures, and that's even with appropriate treatment. So what are the risk factors for non-union, and can we prevent any of them? So the historical description of risk factors are displacement more than 1 millimeter, tobacco use, or associated carpal instability. This study did a multivariate analysis, though, and found that really delay in treatment more than four weeks and proximal pole fractures were the biggest risk, and these were the only two that were statistically significant to correlate with non-union risk. And does AVN matter? Well, we have to ask ourselves, what exactly is AVN? So there's a very inconsistent definition in the literature. So is it based on histology with bone necrosis? Is it based on radiology, sclerosis, fragmentation, and collapse of the proximal segment? Is it intraoperative findings with punctate root bleeding, or is it MRI? And numerous studies have shown poor sensitivity comparing MRI findings of necrosis or decreased vascularity with intraoperative findings of punctate bleeding. So the initial thoughts on non-unions were that given the fragile vascularity of the proximal pole, that vascularized bone grafting should definitely be considered. This meta-analysis supported the use of vascularized bone grafting over non-vascularized bone grafting, as it showed an 88% of union rate in fractures treated with vascularized grafting compared to non-vascularized bone grafting. More recently, the question has continued, and this group looked at 35 scaphoid non-unions treated with screw fixation in a prospective level IV longitudinal study. Over 50% of the patients they treated demonstrated impaired vascularity, either with MRI, bleeding, or trabecular necrosis. But despite this, using non-vascularized bone grafting, 94% of these healed at 12 weeks. So that led the authors to question, you know, does anyone actually need a vascularized graft? So they performed a review of the literature looking at outcomes of non-vascularized grafting, vascularized grafting, comparative analyses with systematic reviews and prospective randomized studies. And they really found that there's no evidence to show a difference in union rate or time to union between vascularized grafting and non-vascularized grafting. So treatment considers when we're gonna tackle this. So what are the patient factors? What's the duration of non-union? What's the age of the patient? And what are the patient's expectations? Do they need to get back to work? What's their activity level? What's their expectation for recovery? Do they have three months to heal a scaphoid fracture? Do they have any modifiable factors such as smoking, nutrition, or comorbidities that can be optimized? And then fracture factors. So let's look at the non-union. Where is it located? Is there a humpback deformity? Is there comminution? Is there cyst formation? Is there associated carpal instability? Have they had a previous surgery with a big hole in the middle of the scaphoid from a prior fixation? Do they have arthritis? And is the scaphoid actually salvageable? So treatment strategy based on these fracture characteristics are either rigid fixation if it's an early or delayed union and the thought is that you just need stability. But I think if you kind of get to that four week time from considering some type of bone grafting is very reasonable. So if there's a waist non-union with no humpback, either a bowler dorsal approach is reasonable, non-vascularized or vascularized grafting. Once you get to a humpback deformity, we'll talk about this in a little bit, the severity of the deformity, you need to start thinking about using potentially a structural graft. And if there's a proximal pole non-union with fragmentation or collapse and you don't have a reconstructible proximal pole, you start thinking about doing a osteochondral graft, either a proximal hamate, MFT or costochondral. And so what do most surgeons do? Well, here's a study recent looking at a retrospective comparative population study from a national claims database thousands of patients in many years comparing non-vascularized bone grafting to vascularized bone grafting for not scaphoid non-union treatment, revision rates were very similar. Most surgeons, 91% use non-vascularized bone grafting and the revision rate was very similar between the two groups. So let's do some cases to kind of demonstrate some of these points. So 20 year olds right scaphoid non-union presents to clinic on the x-rays we see the non-union here with some cavitation on the proximal and distal aspect. Carpal height is maintained and there's no real DZ deformity on the lateral. This was treated with a non-vascularized bone grafting with the distal radius, two integrated screws, stable fixation, three months, he's a little stiff but working with therapy and you can see that the scaphoid has united no carpal collapse and good alignment. The key points in this case, no humpback deformity, non-vascularized bone grafting was easily obtained with the dorsal approach and this patient didn't have any prior surgeries or fixation. So humpback deformity. Now we start talking about wedge grafting or use of cortical cancellous grafting and that can either be from iliac crest which has been traditionally described or from local distal radius with the roost or modified roost procedure. And typically this is done with a bowler approach but is structural graft actually needed? So recent study 2021, looking at a prospective randomized trial comparing iliac crest bone grafting, structural versus non-structural, looking at time to union, restoration of anatomy and clinical outcomes. And so the union rate was faster with the cancellous only group but at 24 weeks was equivalent. Union rates were very similar. And interestingly, they found that as the scaphoid deformity increased so that lateral intrascaphoid angle as it increased over 70 degrees, the cortical cancellous structural graft had better x-rays, range of motion, DAS scores compared to the cancellous group. And also a lower malunion rate. So the authors concluded really that severity of deformity should be considered when choosing your graft type. But if you don't have a severe deformity, cancellous only grafting gives earlier time to union and equivalent outcomes and patient-reported outcomes. So if we're gonna do a local cortical cancellous graft, a hybrid procedure is a good option. Voller approach. So while you're approaching the scaphoid, make your incision more proximally. You can harvest the cortical cancellous graft from the distal radius, and then wedge it open with a screw, your fixation of choice within the scaphoid. What are the outcomes? Well, here's a recent retrospective review of 20 patients. High union rate, 95%. Improvement of the SL angle, the intrascaphoid angle and the RL angle and good dash scores, patient-reported outcomes and pain. So 95% of the time it works all the time, but sometimes it doesn't work, right? So here's a case where it didn't work. So now what do we do? So now we move on to non-union after prior fixation. And principles are really to look at what type of bone stock do you have? Was the prior surgery appropriate for where the fracture location was? What kind of risk factors did the patient have or the fracture had? Is anything modifiable before moving on to surgery? And here we consider vascularized options or salvage. So lots of different vascularized bone grafting options, either local distal radius or remote. Here's just a picture of all the different arterial pedicles that can be harvested, either volar or dorsal. So the most common volar one is the volar carpal artery harvested off of this branch of the radial artery. Can be used as a cortical pancellus graft, structural graft in the volar distal radius here. Or you can go dorsal, the one-two intercompartmental supraretinacular artery. So here's a intraoperative photo demonstrating the bone graft on the pedicle distally and placement of the graft within the scaphoid with the adjunct fixation of the suture anchor. Or the fourth extensor compartmental artery, dorsal approach, capsular-based retrograde flow through the capsule, and then also placement into the scaphoid here. And x-rays then show a nice healing and a good option dorsally. Or you can go remotely. Options either would be MFC if you want a cortical pancellus graft, and this is based off of the descending genicula artery, the longitudinal branch. Or if you need osteochondrograft, the transverse branch with the medial femoral trochlea. So that brings us to our next topic, which is the, you know, what if the proximal pole is fragmented and not reconstructible? Here's an 18-year-old scaphoid, or 18-year-old skateboarder with a scaphoid nonunion that had been previously fixed. You can see nonunion fragmentation and a little bit of potential status sclerosis of the proximal pole. Here's the CT scan confirming the nonunion. And what are the options? So medial femoral trochlea, proximal hamate, or costal conrografts. We went forward with a proximal hamate reconstruction, removing the old screw, harvesting the proximal pole, flipping it 180, fixing it into the scaphoid, and then providing some adjunct fixation to hopefully prevent some of the deforming forces. Here he is at two weeks post-op. Here he is at three months post-op with adequate healing of the graft here. And here's a CT scan showing the bony bridging across the graft site. So proximal hamate was first described as a case report with three and a half year follow-up. Since then, morphology, biomechanics, and we now have a case series that have all been reported. The pros are that it's a local graft. It doesn't hinder or salvage reconstructive options down the road. It doesn't require microvascular surgery. But the question is, can this non-vascularized bone graft to the proximal pole be reliable? And so technical pearls when you're gonna do this, this is a picture of a right-sided wrist dorsal exposure with the hamate outlined. You take the graft, this volar portion, this is the capital hamate ligament that you try to keep with the graft, then rotates 180 degrees so that it's facing dorsally and then can be placed into the defect here, fixed and then repaired to the remnant of the SL ligament. So morphology has been assessed looking at, is this a good match? And a group out of University of Washington looked at depth, width, and sagittal radius of curvature, and they all found that these were within one millimeter between the proximal pole of the scaphoid and the proximal pole of the hamate. And they basically concluded that the hamate has very similar morphology and size of the scaphoid. What about biomechanics? So if you resect this portion of the hamate, does that cause any carpal instability or altered motion? This fresh frozen cadaver study of eight cadavers looked at flexion extension, radial and altering deviation. They found no differences in the SL or LC axis between an intact specimen or that after the osteotomy and concluded that hamate harvest doesn't really adversely affect wrist kinematics. And what about biomechanics? So if we now take that graft and put it, does that restore the biomechanics after the fracture? So this is also a cadaver study out of Mayo Clinic looking at a native state. So three states, native state, fractured proximal pole, and reconstruction with the hamate. They found the fracture condition had significant changes in the kinematics. And that once we reconstructed with the hamate, the SL kinematics were close to normal, but the LC were close, but there was a decrease. So outcomes. Here's a four patient case series with 14 month average follow-up. They had 100% union and very good pain relief and quick dash scores. However, there was significant decreases in grip strength, range of motion compared to the contralateral side. And the authors concluded that really provided union and pain relief, but moderate objective outcomes. So finally, back to our original patient with the 36 year old that smoked, was a laborer and needs to get back to work and didn't have this heal. So what do we do? We talked about reconstructive options. We talked about salvage options and he elected to go with the distal pole excision. He needed to get back to work. So here are the x-rays after the distal pole excision. And you can see that it went into DC deformity with some extension here, but here's his range of motion at six weeks. And he had started work this week and was able to get back to activity. So the pros of this procedure is that it's a very fast healing time, faster return to activities, no hardware needed. It doesn't eliminate the ability to do a PRC or corporeal infusion later. The cons though, it doesn't restore the native scaphoid architecture and that has implications on DZ, carpal collapse and arthritis. And what are the outcomes of this procedure? Well, 13 patient case series with mean follow-up of five years showed that they had improved inflection extension, improved dash scores, but 50% developed DZ deformity. Here's a 19 patient case series with mean 15-year follow-up. Also had increased grip and range of motion. They had a DZ deformity, a little bit of a carpal collapse. 11% failed and went on to PRC or arthrodesis and 50% showed some mid-carpal arthritic changes even though they weren't symptomatic. And here's a systematic review of six studies with 70 patients. Similar results, improvement in range of motion, grip strength, radial ulnar deviation, dash scores, and 88% had complete satisfaction at six and a half year follow-up was the average follow-up for this study. So that was a lot, but in summary, the principles when we attack these problems, we should consider AVN, but non-vascularized bone grafting does seem to work. Patient factors and fracture characteristics are really important to consider. So timing of non-union, modifiable fractures, and really how much deformities in the scaphoid. There's so many options for treatment with non-vascularized grafting, vascularized grafting, and osteochondral options, but don't forget salvage options because sometimes that'll get your patient back sooner. So thank you very much for the opportunity to present. Great job, Alex. That's a complicated topic. Since I was one of the authors on that distal pole resection arthroplasty with Matt Malarich, what we gleaned from that research was the optimal patient for distal pole excision is someone who's had a chronic scaphoid non-union where the distal pole is really overgrown, so it's not even really fixable. And because of the chronic non-union, they have a chronic DC deformity with mid-carpal collapse. I say that because if you take out the distal pole, you can expect the mid-carpus to collapse and form a DC deformity, and I'm concerned about doing that operation in people who don't have that established yet. So if it's a six-month-old fracture and the distal pole is not overgrown and they have a normal carpal alignment, I think that's a good thing. If it's a normal carpal alignment, I think cutting it out is probably a mistake. But if it's seven years out and they have a DC deformity and their distal pole is overgrown to the point where when you cut it out, sometimes you can't even recognize the fact that it's a distal pole with a scaphoid, I think that's the perfect indication for that operation. I'm gonna remind everybody that at the end of this next lecture, we're gonna get to the Q&As from the audience. So hold your horses on that. We have one last lecture. Charles is gonna talk about persistent pain after basal joint arthroplasty surgery. Mike, thanks for helping out. Okay, hopefully y'all can hear me and see me, and these are my slides. These are my disclosures. I don't have any financial disclosures relevant to this topic, meaning I don't do any research related to what I'm gonna present, but nonetheless, this is what I've got for you. So this is just a brief agenda, and I thought we'd start off with some case presentations, go into maybe a little bit of the epidemiology and causes, talk about the physical exam and workup of what I would typically do, things about cervical options of how to treat painful thumb CMC arthroplasties that have been done, tips and tricks, and then some evidence-based outcomes of what works and what doesn't. So hopefully y'all received the handouts that were part of this. You'll notice that the handout that I gave you actually is not on revision CMC arthroplasty, and that was on purpose. It's a primary CMC talk that I've given before, as well as some references from the treatment of our basal thumb arthritis critical review that Sanj and I did, and I think this just has a good background. I always tell everybody a strong defense is also a good offense, so that means that you have to know how to treat the primary disease that hopefully you don't have any revisions. So this is case number one. So this is a patient, they are, I think he was about 70 years old, it's his non-dominant side. Interestingly enough, we did his contralateral side, and he did well from that, and he was so happy, he wanted his left hand done and couldn't wait to have it. A couple of notes, he's on anticoagulation, so he's on Xarelto on a regular basis, and he's had prior wrist surgery involving the volar aspect of his wrist, and he just wants it fixed. He also is an alcoholic. So we take him to the operating room, and because he's had prior wrist surgery, and I didn't think his FCR was going to be usable, I decided to do this suture button suspensionplasty, and postoperatively at six weeks, he looks good. I typically will splint or cast my patients for a period of time, and I thought this looked quite well. I didn't have any issues with the placements of the buttons or the suture, and ultimately he was doing okay. I don't always get x-rays, but for patients that I have a little bit of concern about compliance, such as this gentleman, I said, I'm going to do it. So between six weeks and three months, he managed to fall multiple times, and at the three-month mark, he was pretty unhappy, and I'm just going to show you, this is where he is now, looks pretty reasonable, and you fast forward, he's now three months out, and he's complaining of more pain, so I got x-rays again, and he's fallen twice, showed up, even though I casted him for a portion of time, and I told him to wear splint on and off, shows up without a splint, and he essentially tells me he's really upset because I didn't do the same surgery I did on the other side, which was an LRTI with a half portion of the SCR. So now he wants something else done. As you can see, there's significant subsidence of the thumb, he's painful in all aspects of motion, and I told him essentially to go to therapy and wait. So we'll discuss the options for this, but this is case one. So I want everybody to think about it, what they would do and discuss. So case two, this is the exact opposite of case one. This is a patient who is a female, she's a little bit younger, she's in her mid 40s to early 50s, if I recall. She's a veteran, so I did this at the VA hospital, and she's actually several years out from her LRTI. She was doing great up until she was in a bike accident, and she fell over her handlebars, she thought she felt a pop and had a significant swelling to the base of the thumb. So we got plain x-rays, and unfortunately, I don't have the preoperative because it's hard to get from the VA, but essentially she had some subsidence and there was concern that there could be a small fracture off of the base of the first metacarpal, and sure enough, she fractured through her tunnel. So she feels a little bit of instability, she can't grip, can't hold anything, and she wants something done. I thought this would also be a great case to discuss of what we would do. So a little bit about the epidemiology about failed CMC arthroplasty. When you go and look up what articles that have been written about this, there's not many, right? So typically you look up CMC arthroplasty, you'll find hundreds and hundreds of articles of what you can read, but about the revisions, there's not many. So revision cases are rare. They're typically the incidence is somewhere around two and a half percent, and these are just a couple of articles. One's a review article at the top, which if you haven't read, I recommend reading, it's in the Journal of Hand Surgery. The bottom one is a case series, essentially also in the Journal of Hand Surgery from the early 2000s, and over 600 cases, incidence was about two and a half percent. You'll see anywhere from two to four percent written in several of the journals. But what are the causes, right? So the causes vary substantially, and that's what you'll see. So the main causes get lumped into essentially three different buckets. One is subsidence. So the mechanism of fixation of what you did didn't hold or pass the test of time. And this could be either from a post-LRTI, post-implant, post-future suspension plasty. I think you name it, you'll see it. The second is failure to diagnose a concomitant problem at the time of your initial surgery or initial plan. And this may be from STT arthritis that you didn't realize from a grade three to a grade four or stage four type arthritis. It could also be that you failed to diagnose the patient's hyperextension deformity as well as a contracture. And then, of course, if there's injury to a neurologic structure at the time of the surgery, such as the SBRN, that's causing a significant amount of pain. So other case scenarios, as I mentioned, there's a couple of things that you may find when patients complain to you about. They come into your office, they've had surgery either by you or someone else, and they say their thumb feels unstable when they're pinching. And oftentimes it will collapse. You'll see that their thumb goes into hyperextension, it's unstable, and they tell you it could be painful. Oftentimes it's just difficult. They feel that they're weak. And I will tell you that almost all arthroplasties of the thumb have a problem recreating the strength of the thumb or the force that you normally need for key pinch, with the exception of some of the implant arthroplasties. And I'm not talking about a suture suspension plasty. I'm talking about the formal total arthroplasties where we replace something in the trapezium and up the metacarpal, which are not as typical these days. Of course, you can also have continued pain, as I mentioned. Oftentimes the site of the pain is a little bit different from the initial CMC joint itself. Now you're thinking this is STT, typically more common in men than you will in women. And then we talk about hypersensitivity of the scar. These patients will tell you anything that touches their scar is exceedingly sensitive. It can be problematic. It's not necessarily towards one type of surgery or the other, whether it be through a volar approach or a dorsal approach to the thumb. One of the problems that I didn't touch on is whether or not the thumb is positioned properly. So you can see patients that have had either hyperpronation or hypersupination of the thumb. And this is often because the surgical tensioning of whichever type of ligament reconstruction was done, was probably done in a poor alignment or poor vector. And then, of course, you get these other things, which typically, luckily, forearm tendonitis doesn't always require anything surgical, but you can see this post LRTI or FCR sling or even APL suspension plasty, et cetera, et cetera. And then first and second metacarpal impingement can happen too, where you fail to release the osteophytes in between the first and the second metacarpal. So which surgery has the significant or most amount of subsidence? So this is an article also from JHS Go, which is a great resource for those maybe not familiar. They're open access articles, so you should be able to get to it online. And the truth is all of them subside. And so when people, specifically hand physicians, including myself, say like, oh, my method of thumb CMC arthroplasty is the best, I would argue that probably all of ours are equally poor. So I don't know that there's one substantially better than the other. I think relatively speaking, most of the studies look for inferiority and they just will tell you one's not inferior to the other. So this was a retrospective case review, looked at 686 cases. And essentially, when you look at that, there's about a 2.9% subsidence requiring reoperation. And it was highest in the resection of arthroplasties with pinning, which I thought was interesting, only in the sense that you would think the ones that weren't pinned would have subsided more, but they didn't. So it just kind of goes to show you. And that could be sampling bias, even though it's 686 cases, it's still a relatively small amount, but it's the best data that we have. So physical exam and workup. So I often like to get new radiographs. I'll often have patients pinch. We're lucky enough now, unfortunately, I don't have a sample. We have dynamic digital radiography at our institution. So essentially, you can get live low-dose x-rays of patients doing certain activities. We find it's most useful in the shoulder, but we're extrapolating it out for carpal instability and CMC arthroplasty. Sometimes electrodiagnostic testing can be good, and that may help you decide whether or not it's truly an aroma. Ultrasound can also be very good for this, as well as selective injections, as I mentioned. We also are lucky to be able to have MRI and neurography, but for those that aren't at an academic center, typically this is something where you can actually just find whether or not they've got a tunnel over the area and inject. I still like a Roberts AP, and that will help you look for MCP arthritis as well, and it's a great x-ray and can help with some pathology if you miss it. So this is a good article by my friend Sanj as well, and you'll see it kind of goes over what are your various salvage options for when one, either the FCR is gone or you're having to do a revision, and essentially what are your options, right? So the graft material that you would normally use is not there. So one, you can use a suture button suspension plasty. Alternatively, you can do an extensor carpal radialis, use that as a graft, and essentially you can use a section of the ECRL, drill a hole from dorsal to volar, and route it through there, and then now you've got the equivalent of where your FCR would normally be, and then do your standard LRTI or revise it. And then, of course, you can use a free graft with an anchor, and that's something also that can be done whether you take a palmaris or use an allograft to reconstruct and do your ligament reconstruction plus minus your interposition if you so choose. As far as our case scenarios, this is case scenario one. So patient originally was reasonably tensioned, didn't have subsidence to start, but then subsequently subsided. Well, so we know that he doesn't have an FCR because he didn't have one, which is why we did the suture button suspension plasty. He did have a palmaris, and so essentially what we did is we did a free graft. So you'll notice there's an anchor in the base of the second. You have to, whenever you're doing a revision in CMC, especially if it was an open procedure, not arthroscopic, you have to go back and essentially free up all the adhesions between the first and second metacarpal to gain your length back. So you'll see there's a freer in between the first and second metacarpal space, and this is done just to help kind of get rid of all the adhesions that I mentioned. We'll pull traction. I put a suture anchor in the base of the second metacarpal. Then you'll essentially tie your graft and set it in there. And then we did essentially the equivalent of a standard LRTI with an interposition as well. And he subsequently did quite well after this type of procedure. This is not an easy procedure. I'll tell you, if you've ever gone in after these, it is a scar ball. So they scar a lot, which is probably why Dr. Meehl's hematoma distraction arthroplasty works to some extent too, is because you do get a lot of scar tissue in between here, but no one really knows why the subsidence happens and why some subsidence is clinically relevant and others is not. So case scenario two, I think this one's a little bit more interesting because this is probably what's more commonly done nowadays in a variety of settings, mainly because it's a little bit easier. So the suture suspension plasty or suture button suspension plasty is a fairly relatively easy technique for, from a revision standpoint. So you'll notice there, this is a lot of people's go-to. If you look at the far left, I think an aiming guide, as far as a tip or trick, an aiming guide can be very helpful. If you're doing it in the primary setting, one of the tips is just not to take out the trapezium at the first get-go and then get your guide in and shoot the wire and put it there. And that will help a lot. In the revision setting, you don't have that luxury. And I always find an ACL guide or any of the guides from any of the companies that make them works just fine. If you'll notice the placement of this can vary substantially. So there's an article on the bottom right that essentially looked at mechanical stability and subsidence based off of if you had a low trajectory, which is what the green is versus a high trajectory, which is closer to what the red is and what the subsidence is. Essentially what they showed is that the subsidence was slightly equal, but the magnitude could be a little bit higher with a higher trajectory. And so they often recommend that you do a slightly lower trajectory. So you'll see this person got a revision. We opened it up and did a suture button suspension plasty, and she subsequently did well. This was also a great option because she had a cortical breach through her tunnel. And therefore all you needed was some sort of a cortical button on the other side and she did well from that. So tensioning of this can be tricky, both in a primary setting and in a revision setting. And typically what we'll do is we'll place our thumb in full AB duction so that you're not going to over-tension. And then at that point I will pull traction and then tie it as hard as I can. I'll throw one knot, take the thumb through a range of motion and see how we do. And then I'll typically tighten after that. Similar to tendon transfers, I find that it's almost impossible to over-tighten these because essentially you still get creep both with this as well as with any tendon reconstruction that you'll do. So this is always the question. I think we see this in orthopedics a lot, right? If one is good, two has to be better. And we always as orthopedics look to see how we can make any device that's in the operating room better than what it is. I think that's just our nature. In this study, this is a biomechanical study that essentially looked at using two buttons into whether or not it was biomechanically sound. And the answer is yes. But as with anything, there's always pros and cons. And the risk of this is you're putting two essentially holes through the second metacarpal with high stress that's holding it in there. And there's a high risk potentially for metacarpal fractures. There's no current evidence to suggest that two clinically is better than one, at least not that I'm aware of, I should say. And so I tell you this only for the sense that yes, theoretically, you could put a second one in for a failed first one. However, I just caution against the risk for metacarpal fracture. So I would caution against it and tell you to see potential other options. So a couple of the other problems, what do you do for hyperextension? Yet again, this is just another article that looked at a series of patients that had CMC arthroplasty with associated hyperextension and looking to see those who did well and those who did not. The algorithm is technically on the left, which I follow, which is less than 30 degrees, you do nothing. 30 to 60 degrees, you can do a capsulodesis and greater than 60, an arthrodesis. I think the mechanism of what you do, any of those three can be variable. This is just a patient of mine who had a pretty substantial CMC deformity. We subsequently did her CMC first and I caution these patients and you can, it's not unreasonable to do one and then the other. But long story short is we did the CMC first and we came back and did her hyperextension deformity second and she was much happier. There's just a sample on the right. Here you can look at the SDT arthritis, what's your go-to. I think the options are SDT fusion versus a proximal trapezoid excision. You can also do ultrasound guided lidocaine injections here. If you're really unsure, you can always get a CT scan. This is just a case example of ours as well where we took out a small portion on the proximal part of the trapezoid. As I mentioned, these are just other SDT surgical options. There's a whole slew of them. My partner, Dr. Wagner is very slick with the arthroscopy and so oftentimes he may do a debridement and do a hemitrapeziectomy and look at the trapezoid and do that as well, all under the scope. But there's a slew of options here. Flail thumb, this is a bale salvage as well. This is just a case from the review and ultimately, you can do a one-two fusion. These obviously have a high incidence of failure and they can be hard to get to fuse because of the stress is important. This is where they use a small little hand plate to get it to fuse. Outcomes of revisions, the problem is not all revisions are the same indication. It's very different for each individual. Not all revisions are the same indication, so it's very hard to compare one versus the option, but essentially, most of them do reasonably okay when I think you have the correct diagnosis. These are two different articles that showed reasonably good to fair results. Yet again, it's hard to know because there's so few that it's hard to get a good answer as to what the correct answer is, but I think there's different options for different indications as we presented so far. In summary, I would say confirm the indication for your revision surgery, not all subsidence require surgery, so give them up to three to six months at the very least before you decide to do a repeat surgery. I often will make them wait at least six months before I do anything. Subsidence, your options are resuspension suture button versus LRTI using FCR, ECRL, or FreeGraft. MCP hyperextension, you've got your options of the capsules versus arthrodesis, and the arthrodesis is also good for MCPOA if that's what they have. Failure to address the STTOA, proximal trapezoid excision versus arthrodesis for 12, one to two impingement. You can always do a revision resection, which is a little different from a flail thumb, which is what I presented as the last case. Then neuroma, those can be difficult no matter where they are, so interpositional graft or burying it. Then SCR tendonitis typically just requires an injection. I would comment just to look at Dr. Hess's review from JHS, that's at Current Concepts. It was a great article, and thank you all for your time. Thanks a lot, Mike. That was great. I have a comment and then a couple of questions of you. I've used the tightrope the past three or four years. I have no relationship with the company, but I do think you can make it too tight. In fact, I've done it once, and I'm going to tell you what I did wrong. I love the fact that you don't take the trapezium out, and I love using the targeting guide because you get one shot at it. Then I put a co-band in the middle, just like you're holding a beer can, and then I tie it before I take the trapezium out. Then I actually take about 95% of all the ligaments off, then tie it, and then to take the last 5% off using my glomerulotractor, just scoop the trapezium out. If you make it too tight, and I've done it once, the thumb metacarpal rides dorsally, and it doesn't hurt the guy yet, but it's definitely dorsal and looks weird. In fact, I did his other side after it, and it looks normal. He's like, why is my one metacarpal really dorsal? That's something to think about. My questions are, how do you diagnose first, second metacarpal impingement? That seems like a tough one to make. That's a great question. I think one, there's three ways, and yet again, we're relatively lucky because we've got a lot of resources here. I think one is you can actually take the thumb and almost like a grind similar, you can push it up against the second metacarpal. Two is a selective injection. Normally, we'll have an ultrasound guide and put a lidocaine amount in between the first and second. Then the third is a CAT scan. You can really see if there's osteophytes that you've really missed. Those are the three methods I use. Another question I have for the whole panel is, Dr. Eaton always talked about the 30-degree MP hyperextension, and you have to treat it beyond that. What I don't know the answer to is, do you base that upon passive hyperextension or active hyperextension, and then based on pinch collapse or not? I can answer first and let someone else from the panel. It's an interesting concept. I've actually gone away from treating both at the same time for that very instance. The reason being is I typically try and see where they're most symptomatic, and more often than not, it's the CMC joint that bothers them. I find that if you correct the adduction deformity of the thumb where the thumb is in the palm, you're able to bring the thumb out. They may not have as much of a symptomatic hyperextension as they used to. Some of that can be also done by imprecating part of the APL and helping it pull out. I oftentimes will wait if it's a borderline hyperextension, but I counsel them extensively saying, listen, if this bothers you, I'm going to come back and do a second surgery for you. Before everybody answers, I will say that a couple times I've been surprised how much the basal joint arthroplasty correction of the thumb deformity has improved the MP joint hyperextension. I'm not exactly sure I quite understand that because it's volar plate laxity, but it definitely does stabilize the thumb MP joint. Anybody else want to comment on whether they use passive or active MP hyperextension to help guide them? I don't have a fixed rule of thumb, and I agree. I've been very surprised. Some patients have significant pinch collapse, but once you address the CMC, they're fine. I think earlier in my career, I used to do a lot of volar capsulodesis because I was worried that they would have that hyperextension, but I'd say now I don't do it as often as I used to because I find it's patients that actually have problems are few and far between, and I've gone now more to a sort of two-stage approach where if they have problems, then I will. Now, the caveat to that is if they have a lot of degenerative change at the first MP, then certainly I will combine a fusion in at the same time, but I find this a very tricky area, and I find the fellows are always looking for an answer. They're like, give me an algorithm. Give me a number so that I know what to do when I see this next time, and I don't think that I have one. Mike, what about you mentioned this, but you didn't pin yourself down, so I'm going to. How do you treat the ST arthritis, the scaphotrapezoid arthritis in the OR? Yeah, so I should have showed pictures, and of course, it's kind of one of those things. Of course, I submit my talk, and I do a case, and I'm like, of course, okay, the talk is there, and I should have said, hey, I want my slides back to add it. So typically at the time of the trapeziectomy, I will actually look at the ST articulation with the frayer, and I will evaluate the distal scaphoid articulation to see if their cartilage has been denuded or not, and I use a small round tip burr, and I will essentially burr out the proximal one-third, which is my go-to. The trapezoid? Yeah. Okay, all right. I want a little trick. As you pull on the index finger, that opens up the joint too, although if you do that after you put the suture button in and tied it down, it makes it a little bit harder to pull traction on it. Do you ever interpose anything into the joint? So I haven't. However, obviously, it certainly has been described that you can. You know, I find that just getting the regular interposition down deep where you want is hard enough. I can imagine that it's fairly difficult to get the interposition between the scaphoid and the trapezoid is pretty difficult, but it has been described. We have a question for the audience for Dr. Friedrich. Jeff, any tips for hostile territory dissection to correct early Verler escape and correct the capitate plumb line? So those two cases that you presented, any helpful hints? Yeah, not really. I mean, you know, it's going to be, you know, a deminiscar. As I said, I like that extended carpal tunnel approach. If you did an FCR approach the first time, I think that's probably reasonable to do, although the skin bridge between them will be somewhat narrow. But I would say go slow because it's going to be a lot of scar tissue there. And it's, you know, but be pretty liberal with removal of scar tissue in the fracture site, like with Rogers and curets and such, because it's really hard to get that fragment to sit back down. It's a lot of picking at it to make it go back in. Ruby, I have a question for you. You had mentioned how you fix your owner stylet fractures. Can you go into a little bit more detail of, do you ever use a wire or fiber wires, kind of like a figure of eight loop? And do you remove the K wires, you bury them? I usually use K wires, just simple K wires, and then I remove them once it's healed. So you bury them? I bury, no, I leave them proud because I'm going to, I know I'm going to remove them in a short while. The only time I bury K wires is if I think I might have to leave them in for an extended period of time. That being said, I can't remember the last time I pinned a styloid. It's going to probably be more than five years, I'd say. I, Brian, I bet we talked about this at the beginning. I bet it's been three years for me. But I do the same thing. I actually make a C-shaped incision over the styloid, find the dorsal sensory branch, reduce it one little bit, and then I'll remove the rest of the styloid. Reduce it. One little trick to find the piece and hold it is using a little single skin hook. You can kind of spear the TFCC, and then this way you have control over it, and you can reduce it to this, to the ulnar head. And then I use two, three, five K wires. I usually put a little figure of eight, uh, 30 fiber wire and tie it down. I think that kind of helps kind of suck it down a little bit better. And then I remove the K wires at six weeks. It can be a tricky thing to find, so that's a really good tip. Yeah, single skin hook, and you like, you spear it, and then you got control of it, because holding it with a pickup, your hand gets fatigued. There is nothing as humbling as percutaneously pinning an ulnar styloid fracture. I will tell you that. What about a screw? Some people put the PERC screw down. I was like, that's a hard shot. I've seen x-rays that look good, and I'm always very impressed. Yeah, that's a tough shot. Well, thanks everybody for, uh, being panelists. This concludes our webinar. I'd like to thank you all for your contributions, and please, for the attendees, don't forget to fill out the evaluation for the webinar. Thanks everybody for attending, and have a great night. Thanks so much for the invitation. That was great. Thank you. Thanks.

scaphoid non-union

complication

scaphoid fractures

risk factors

avascular necrosis

vascularized bone grafting

surgical options

thumb carpometacarpal joint arthritis

failed CMC arthroplasties

diagnosis

surgical technique

revision surgeries