Okay, I think we'll get started. So on behalf of the American Society for Surgery of the Hand, I'd like to welcome everyone to the webinar on Innovative Salvage Procedures. I'm Alex Lauder, chairing today's course. Just a few housekeeping notes before we start. The audio will be muted during the presentations. The webinar is being recorded and will be emailed out to all attendees by the end of the week. Please use the question and answer section to submit any questions to our panelists. And you can email any technical difficulties to webinarsupport at ASSH.org. Attendees from the webinar can receive one and a half hours of CME and can claim the CME credits on Wednesday, April 10th by logging into the ASSH website. Further instructions will be emailed after the webinar. With that, we have a great panel talking about kind of the owner side of the wrist and salvage procedures for this. So we are going to kick things off with Dr. Glenn Gaston, and I will let him kind of start the course. Thanks a lot. I'll share my screen over now. So I'll give the lone, non-salvage talk for the group. Hopefully that's showing up right there for you guys. So one second there. So yes, I got charged with talking to you guys about TFCC repair versus ulnar shortening osteotomy to manage DRUJ instability. And I'll tell you, I think those are two critical procedures to be able to do right to manage instability, but they're really not the only two things to know how to do. And to manage instability, those are just two of the pieces of the puzzle. So hopefully I can give you the entire puzzle in the next 10 minutes. Here's my disclosures. None of them are relative for the talk I'm going to give you tonight. So Jeff Niesel, one of our tumor guys, I love one of the things he tells the residents. He says, every single time you see a patient, the first thing you should order is an H&P, and it couldn't be more true. And I think that still holds true with DRUJ instability. And the critical history is pretty simple for this. It's number one, what's the etiology? Is this traumatic DRUJ instability, or is this atraumatic DRUJ instability we're dealing with? And number two is, what's the chronicity? Is this acute or is it chronic? That's the basic thing. And then in terms of the physical exam, I think we're all very comfortable diagnosing somebody with DRUJ instability like this kid right here. And I think the thing that matters then is, what's the direction? Is this volar instability, dorsal instability, or is this combined instability? You can see this kid's really stable in pronation, but as soon as you supinate him at all, he develops volar instability that you can reduce, like you see there with dorsal pressure on his head. And then when we get to managing DRUJ instability, I think these are the three critical questions you have to ask. The most important is probably the first one, which is, are there any bony issues? Because if there's any bony problems and you try to fix the TFCC, or you just try to do an ulnar shortening and there's other bony malalignments, you will fail every single time. If the bony problems have been solved or don't exist, then the next question is, is there repairable TFCC tissue? And then lastly, is there any degenerative change, which will fall in the category of the people to follow me? So there's three primary considerations of bony problems, at least in my eyes. The biggest and most important is, is there any malalignment? And I think as surgeons, we think a lot about that acutely. So if you're fixing a distal radius, you think a lot about the bony alignment at that time. If there's persistent instability at the end of a case, the one that gets overlooked a lot though is just chronic problems. So I see a lot of late teenagers or early 20-year-olds who had a childhood fracture that seemed fairly innocent and was casted, and now they have DREJ instability. And if you don't appreciate that malalignment of the radius and or ulna, you will fail in your soft tissue efforts. There are atraumatic causes of bony malalignment, things like tumors, different congenital issues, I think one we're all familiar with is RA with Caput Ulna Syndrome. And once its malalignment's been ruled out, the other bony considerations would be the presence or absence of an ulnar styloid fracture, particularly the more proximal basilar fractures. And then ulnar variants, are they ulnar positive or are they ulnar negative? So let's dive in a little bit to these bony malalignments, because again, I think this is one of the most overlooked problems people have when they consider DREJ instability. So in the delayed settings, I will tell you that if you fail to recognize radial shaft or just a radial malunion and go on to do surgeries just to address the TFCC, again, you will fail. So failure to recognize is a failure to succeed. Patients need full-length forearm films. And then if you're not sure if there's any bony malalignment, I don't hesitate to get bilateral full-length forearm CT scans and get digital overlays of that. So this is a great case. It highlights that this patient got sent to me for a DREJ reconstruction by another surgeon, because they said it's a procedure that they don't do. And the patient had DREJ instability. He was a 19-year-old plumber, DREJ pain and instability, gross instability on exam. And on further questioning, he says, you know, I didn't have any recent injuries, but I did break my arm about 10 years ago. And these are the x-rays that he got sent with. And this is what it looks like when you get full-length forearm films. So full-length forearm films are absolutely essential as a first step in approaching DREJ instability. And if there are shaft malunions of the radius and or ulna, the treatment of choice is an osteotomy. So these patients need an osteotomy of whatever is malaligned, the distal radius or the proximal radius of the ulna. And then I always can send those same patients for a possible TFCC repair reconstruction. But first you have to get anatomic bony alignment before you can move into soft tissue reconstructions. And here's that patient. All he ended up needing was the osteotomies, even though the fracture was 10 years ago and he had instability. As soon as you get the bony alignment right, you can see he's got great range of motion. He had absolutely no instability and no TFCC repair reconstruction was needed, although he was consented for that as a backup had he not been stable at the conclusion of that case. Now in the acute setting, I think this is one we're all more familiar with, is after we fix a distal radius fracture and someone appears to have DREJ instability, the first step should of course be to compare it to the opposite side. And I don't hesitate to scrub out, put on a new pair of gloves and test the other side and then scrub back in, because sometimes they're just lax bilaterally. So you want to be able to know is this different than their contralateral side. And then the next question I ask myself is if they're stable in one position and not others, or if they're stable just grossly. Because if they're stable in usually pronation, if they're stable in supination but they're unstable in pronation, then sometimes you can simply splint them temporarily in supination and they will regain stability. If they're grossly unstable, the first thing to do is again, make sure your bony alignment's perfect. Two things that can predispose you to missing that would be radial translation of distal fragments, ulnar sigmoid notch malunions, and ulnar styloid or neck fractures. So here's just an example. If the dorsal aspect of the sigmoid notch is off, then the patient's typically going to be unstable in pronation. If the volar aspect of the sigmoid notch is malreduced, the patient would typically be unstable in supination. And Scott Wolf did a great job of highlighting this for us and really bringing this to light, which is if there's radial translation of a distal radius fragment, then that's going to create laxity in the distal oblique band and therefore predispose them to DREJ laxity. So if you can restore anatomic alignment of the radius and correct that radial translation, you will properly tension your distal oblique band and therefore strengthen the stability of the DREJ. If the distal radius and or radial shaft has been anatomically aligned and a patient has persistent instability and they have an ulnar styloid fracture, then that is my next point of attack is I'm going to go fix the ulnar styloid fracture. One little word of caution, there are times where you can have an ulnar styloid fracture that's not a basilar fracture and you go to fix that and the superficial fibers of the TFCC are attached to it, but the deep fibers have been avulsed from the fovea separately. So just be prepared that you may have to fix the styloid and or the deep fibers of the TFCC to regain that stability. And if things just don't feel right and it's still unstable, another consideration is there are case reports of ECU being interposed in the DRUJ and that's something you would want to consider in an acute setting. And then ulnar variance, one of the things I was asked to talk about is when do I just do an ulnar shortening osteotomy and one of the absolute requisites for that being your treatment of choice would be that all the other bony issues are either non-existent or have been corrected. So if someone has perfect radial alignment and ulnar positive variance and DRUJ instability, then I will do an ulnar shortening osteotomy as my first treatment for that. But I'm always prepared to do more because for an ulnar shortening to work, it's a requisite that they have some fibers of their deep radial ulnar ligaments attached. Because if none of them are attaching to ulnar shortening, now you just have a shorter ulnar that's persistently unstable. So oftentimes you don't know that for sure heading into the case. So these cases for me are booked for an ulnar shortening osteotomy and possible additional TFCC repair or reconstruction if instability persists. These are some of the trickiest ones, which is bony malalignment that is atraumatic in nature. And the cases I see this be an issue are things like Madelung's, multiple hereditary exostosis, different tumor cases. We see it in rheumatoid arthritis. And a lot of times these require really creative solutions. Sometimes they're dome osteotomies, lengthening, shortenings. They're a little bit beyond the scope of this talk. And many of these oftentimes require a salvage procedure as well. So let's assume there's absolutely no bony issues. Or there were bony issues such as malalignment that have been dealt with already. But we have persistent DREJ instability. As I said, if they're ulnar positive with no other bony issues, I will typically start with an ulnar shortening, but be prepared to do more. And what do I do? So that's question two that I mentioned earlier. Is there sufficient TFCC to repair or not? And if there is, then of course you would fix the TFCC, specifically the deep radial ulnar ligament or ligamentum subcruentum fibers. The one thing that surprised me in practice is these can be present for months or even years out. Unlike SL repairs, which is like at six to eight weeks, sometimes it's getting questionable if the fibers are still going to be there. You'll see TFCC tears that are a year or more out and still have great tissue for repair. So don't discount it based on chronicity alone until you've looked at it. So most of the time I'm booking these cases for repair versus reconstruction. In terms of whether you do an open or an arthroscopic repair, it's entirely up to you. There's plenty of studies to support both. There's systematic reviews to support both. I personally like an open repair if I have gross DREJ instability. I use arthroscopic repairs if I have stable DREJs that are painful. So that's just a personal preference. And if there's not sufficient tissue for repair, then you have to be prepared to do something more, i.e. a DREJ reconstruction. And for me, that comes down to the simple question of, is this unidirectional or bidirectional instability? If I have unidirectional instability, such as isolated volar or isolated dorsal instability, but they're stable in the other positions, I like a BR wrap. If they have a combined instability, I like an Adams procedure. This is what those look like. So the more common scenario, at least in my practice, is a dorsal DREJ instability, but they'll be stable palmarly when tested. And that's where I like the BR wrap that Amit Gupta taught me. If you look on the left, you can strip BR out of the muscle approximately, but leave it attached to the styloid, and then pass that tendon palmar to the pronator quadratus, go between the radius and ulna from volar to dorsal, as you see on the image on the left, and wrap around. He shows it kind of anchored over there to the side of the ulna. I'll tell you, if you strip it out all the way, a lot of times you have length to get all the way back to itself, where it goes between the radius and ulna, and you can tighten that down, and it pulls the ulna palmarly, or conversely, pulls the radius dorsally, whichever way you like to think of it, and tighten it up. If they have volar instability, instead of going between the radius and ulna there at first, I'll go all the way across the ulna and back around, and then come through from dorsal to volar between the ulna and the radius to achieve the similar goal for isolated instabilities. And then for bidirectional instabilities, the classic Adams procedure with a free tendon graft to reconstruct both the volar and dorsal limbs makes a lot of sense to me. And then lastly, is there degenerative change? And if there is, typically that's going to become a salvage procedure, although I will say there are some very rare cases, I've done two or three of these, where someone has ulnar positive variants, some DREJ arthritis, but their symptoms seem to be more ulnar impaction and or a little bit of instability, and you can get away with an ulnar shortening osteotomy in them, but that's the exception, not the rule. So in summary, for managing DREJ instability, my personal algorithm is kind of three critical questions. Is there any bony issues? And if yes, you have to correct the malalignment first, because again, all soft tissue repairs will fail in the face of bony malalignment. If there are shaft and or distal radius alignment and ulnas are all correct, but there's an ulnar styloid fracture, that tends to be the next thing I go after to repair the ulnar styloid, but be prepared to fix the TFCC simultaneously if it's separately evolved in the deep fibers. And then if those two are correct, and there's still ulnar positive variants, I will typically do an ulnar shortening next, but be prepared for the second question, which is, if I've done all the bony work and they still have instability, is there repairable TFCC tissue? If yes, then fix it. If no, then is it unidirectional or bidirectional instability? If it's unidirectional, I personally ripe a BR wrap. If it's bidirectional, I like an Adams procedure. And lastly, is there any degenerative change? And if yes, then the next five speakers will take you from there. Thank you. That was a great overview. Thank you very much. For the audience, if anyone has questions, please feel free to submit those in the chat boxes, and we can touch base with them on the end. Next topic of discussion is the daradistal ulnar resection, the tried and true. And I will turn the screen over to Dr. Tom Keebaber. Okay, thank you very much. Okay, and here we go. I hit the button, but nothing happened. There we go. All right. I'm stepping in for Peter Stern. He was scheduled to do this, and he unfortunately had another conflict at the last minute. So we've worked together for 38 years, and so he and I think alike, and he trusted me to carry the message to you with some clarity. Neither one of us have any financial concerns. The DARA procedure, like most things in orthopedics, is named after an old dead guy, nothing named after me or Dr. Stern quite yet, and it's over 100 years old. And so the question is, how many procedures that we do have lasted for 100 years? And, you know, in orthopedics, when we're talking to young people, we always say, well, my new favorite operation is this, but the DARA operations hung around for more than 100 years, so there must be something to it. There are good and bad, and there are supporters, and then there are people that just rail against it. And the good news is most studies show you get an improved range of motion and grip strength, 90% good to excellent results. Most patients are satisfied. Is everybody happy? Although some of the other articles talk about the fact you get ulnar impingement, if you do get that, then you get a weaker grip, pronation, supination, and clicking. And then there's one article out there that talks about a 50% poor result. So, you know, where does the truth lie between these two extremes of what the literature has talked about? Well, let's just talk about one of the biggest criticisms, and that's radial ulnar impingement or convergence. And then that can also be associated with some dorsal palmar instability. If that occurs, people hurt, and they have some weakness on forearm rotation. You can get extensor tendon ruptures. And then the biggest criticism that we've had over the years is that a bailout for ulnar impingement, we haven't had a good bailout until recently. And some of the bailouts have been soft tissue stabilization, the Jupiter brain, which doesn't work all the time, implant arthroplasty, which we'll talk about. One bone forearm was one we used a lot a long time ago, allografts and wide resection. My name was on a multicenter study of wide resection, and I will tell you that of the 26 patients, the two major complications were mine, so I don't advocate that. But we have better bailouts now for radial ulnar impingement. And so I think that this criticism needs to be softened a little bit based on the bailouts that some of the other speakers are going to talk about later on. What are the indications for it? Well, inflammatory arthritis is certainly one, as long as you don't have ulnar translocation of the carpus. If the carpus is about to fall off and you take the ulnar head off, well, then you've got a problem. So you need to look and see, well, if I'm going to do a DERA, do I also need to stabilize what's left of the carpus? In this particular case, the carpus has stabilized itself, so no problems. Then after distal radius fracture malunion, and if the patient has loss of forearm rotation, DREJ incongruity, especially in lower demand patients, and this is changing, Dr. Stern put lower demand age plus greater than 50. I would have to say we will kind of up that age these days because most of us stay active past that a little longer. Here's a very dramatic case that he put in for us to see. This is a roofer, fell off a roof, had a monster distal radius fracture, had median nerve involvement, was taken to the operating room that night because it was open, and he had open reduction internal fixation, sort of, with an external fixator. We didn't have bridge plates back at the time. We didn't have quite the sophisticated ORIF that we have now, but he had external fixator applied, and you can see this is a bag of bones treatment. They just sort of got the bones lined up where they sort of should be, and he healed, but his DREJ was a problem, and he had impingement of the ulna into the carpus, and so Dr. Stern felt that he would be best treated with a DERA resection instead of addressing the radiocarpal joint, which he felt was asymptomatic. He did that, saw the patient five years later. He's working full-time as a roofer. He's got good supination and pronation, and he was a very happy camper. So that one case does not make a series, but certainly this is a dramatic example of a good case, and the bottom line is it doesn't matter what the x-rays look like. You've got to look at the patient and look at the function to see how they're doing. So as many things Dr. Stern did, he looked up his patients and he looked up complications that occurred. He was able to get almost a hundred patients. He was able to get a third of them back between six and 20 years. And they had a high rate of satisfaction, normal, nearly full forearm rotation. Now, if you take an X-ray with them holding a weight or a purse and you have them stand up and you hold a weight and then you put the X-ray plate behind them, almost all of them have some form of radial ulnar convergence, but the convergence did not influence the outcome. So, you know, dynamic radial ulnar convergence is common after the DERA procedure, but it's rarely symptomatic. And that was the take home from the paper he published. So Dr. Stern says he remains a fan of the DERA procedure, as do I, with some caveats. And then he threw this quote in, the DERA resection can result in serious disability, especially in younger patients and the patients with lax ligaments. Reoperation in these patients is rarely successful. I disagree with that. I think that now we have salvage procedures that in the rare case where you end up with an unstable ulnar stump and painful radial ulnar impingement, I think we have salvage procedures that work very well. And so I am still a fan of the DERA procedure in the right setting, as is Dr. Stern. Thank you. Great, thank you for the overview on the DERA procedure. Moving on, we're gonna talk about the salve caponge. Dr. Tamar Rosenthal is up next and I will turn the screen over to her. Great, so it's a nice segue, is I've converted to doing more SKs as opposed to DERAs because of some of the issues that you mentioned. So this is a procedure that's very popular in Boston, although I realize it's not as popular in other parts of the country. These are my disclosures. None of them are relevant for this particular talk. So the indications for which I use an SK arthrodesis are several. I use it for instability, and this is in cases of chronic ligamentous instability, but also for Madelung's deformities or for patients who've had a failed soft tissue reconstruction. I commonly use it for arthritis, both primary or post-traumatic and also in inflammatory cases. And it can be useful in patients with tumors as well. The clinical exam as always is really important. So HMP and clinical exam is for most of these patients are gonna have some pain at the DRUJ, they're gonna hurt with palpation. I wanna get a sense of what the pronation and supination is, and also a read on their compression. And if they have a limitation in range of motion, then that's something I obviously want to address. I also like to get a sense of how much instability they have. I mean, is it truly an ulnar head dislocation? Is it just some subtle instability? And I like to assess it in different positions. So pronation, supination, and then also in neutral. In terms of the workup, usually radiographs give you most of the story. I think the most important thing I wanna do is assess their ulnar variance because you can correct that through an SK. So I wanna get a sense of whether that's something I need to do or not. If I'm worried and I wanna compare both wrists, especially in cases of instability, then CAT scans of both wrists can be helpful. And MRI, I tend to use mostly to look at other stuff. So the extent of degenerative changes, if there's other changes in the radiocarpal joint that should be addressed, and then also looking at the extensor tendons to see if there's anything that needs to be done, particularly in cases of inflammatory arthritis. There's a couple of ways to approach this, and I focus this talk a little bit on just technical tricks that I think can make this operation successful. So you can approach it through the ECU-FCU interval. It makes the hardware easier to place, but it does require you to make an osteotomy first in order to visualize the DOUJ and retract, kind of flip the ulnar head up. So I tend to like going through the fifth compartment. I think you visualize the DOUJ very well, as you can see on the photo on the bottom. If you put a Wheatie or a Gilpie in there, usually you can see it well. It does make placement of the screws a little bit more challenging. So you can either lift a soft tissue flap to do that, or you can make a couple of separate stab incisions. For the preparation, if I don't have to do anything about ulnar variance, I will take away and remove the remaining cartilage with a burr. And if the ulnar variance is adequate, I'll usually put my K wires in the ulnar head first, because that just makes it so much easier. And I can advance them into the radius and then perform the osteotomy. And so that's easy. But if you need to change the ulnar variance, then you're gonna make the osteotomy first. And to do this, I like to really make it as distal as I can. So I really make it just at the metaphyseal flare of the ulna. And I think that decreases some of the amount of stump instability that you get, which is one of the main critiques of this operation. So I take exactly a centimeter. And obviously, if I don't have to correct the variance, then your wires are already in, it makes it very simple. It's a quick operation. If you do wanna correct the variance, then this is be when you would usually move the head a little bit more proximal. You may have to take a little bit more bone with the osteotomy. And then advancing the K wires. Many of the reports of this operation complain about hardware prominence along the ulnar side of the wrist. And so I address that by using headless compression screws, which I buried in the bone. And usually it's really not much of an issue. Any headless compression screw really works. I usually use either 2.0s or 2.1 diameter screws. And then just to try and prevent some of the proximal stump instability, I usually like to do a soft tissue repair. And I make it pretty simple. There's a lot of different ones described, but a couple of drill holes in the proximal stump, and I'll suture the peroneal quadratus in there. It helps to prevent reossification, and it also helps to stabilize the ulna. And so this is a case in which the patient had a metal lungs deformity, and I had to address the variance, and so shortened the patient a little bit. And this is just a case where I did it for just more simple DIUG arthritis, where I didn't have to change the variance at all. And so it just made it a little bit easier. This is sort of the more classic one that I tend to see in my practice. So, you know, with just ulnar positive variance with DIUG arthritis, so that's sort of, for me, that's almost the perfect indication because you get to address both things at a time. As I mentioned, that makes the operation a little bit more challenging because you have to make the osteotomy first and change the position of the ulnar head. In terms of outcomes, I tried to really look at some of the more recent literature on this, but there's a couple of studies that I've looked at, series of 100 and so patients. And in most cases, people have good pain relief. As Dr. Kefauver mentioned, there's a lot of radiographic impingement if you get X-rays, but it tends to be asymptomatic. In patients with post-traumatic DJD, the range of motion tends to improve across the board. The reports of complications are relatively high, so 46% in this more recent study, particularly among younger patients. But if you actually look at what the complications were, a lot of them tend to be hardware removals and things that I think are entirely preventable. Comparing the SK and DERA, there's a few studies, not many, but there's one that's 2005 in 61 patients, and they found the pain relief was a little bit better in patients with an SK, and they also had a little bit less instability. A more recent large systematic review showed that the dashcords were actually pretty similar between both groups, but that the DERA had instability in 12% of cases versus 6.8. They also reported more surgery complications with SK, including mostly hardware removals. So we looked at our own experience a few years ago and looked only at patients that had a year follow-up. And in this cohort, we had patients who had post-traumatic changes, inflammatory arthritis, Madelung's, and a couple of tumor cases. And we found that the dashcords really improved over a year from 52 to 28, so pretty significant improvement. The range of motion got much better, and of the 21% of complications, almost all of them were screw removals using old screws with washers, which we've since replaced. Reports of non-unions, we had none, and I really haven't found any others in the literature, so that seems to be less of a concern. And then if you look at the graph of the dashcords improving over the first year, you can see how they get better. And then this is just looking at them in both the OA group, which is a top line, and in patients with inflammatory arthritis. And you can see that they follow a very similar pattern so that the results are predictable in both sets of patients. So this really tends to still be a go-to for me. I use it very frequently. And thank you. Great, thank you. Next up, we have Dr. Marco Rizzo talking about unconstrained distal ulnar arthroplasty. Well, thank you, Alex. Can you see my screen okay? We can, yeah. Okay, great. So my charge is to speak a bit about unconstrained arthroplasty, which really is something that during my fellowship gained a lot of popularity. Dr. Berger, who trained me, had designed some implants that were, we called the U-hood, which is actually no longer available, but there's other implants that are out there. So it's been interesting to watch the progression and some of the lessons we've learned about this option for arthritis, and arguably, maybe to a lesser degree, instability. And I do think this was the precursor for the future talks, especially Dr. Hanel's talk will be, which this is part of the evolution of where we are with some of the constrained arthroplasty at this time, which is quite popular. I have no relevant conflicts. I'll start with a case. This is a 48-year-old female who's a right-handed dominant nurse's aide, and she has pain at the DOEJ. She's quite stable, and she's a petite type person. You can see she has a good amount of osteophytes formation, blunting of the ulnar head, still a little bit of a joint space, but boy, her pain is predominantly at the DOEJ. And we'll come back to her at the end. As Dr. Kiefheber and Dr. Rosenthal nicely stated, these two options are quite commonly utilized for arthritis of the DOEJ. And I'm going to quote Dr. Hanel here, who uses this 8% of patients are unhappy with these procedures. And that's been sort of my clinical experience. Most patients are happy. I'm a big fan of both of these procedures. But most times when patients are unhappy, it's because they've lost that CAM effect. As has been previously stated, they all converge. So this penciling that you're seeing on the slide is expected, and thank God, most of them are not painful. But there are some that are painful, and quite painful even, and some that are unstable, and quite unstable. So having a fallback, a way to manage this problem, much like Lucia is going to be speaking about the interposition stabilization with the Achilles allograft, that is something that is really useful in these cases to be helpful. And having a good sort of bag of tricks on how to manage these unfortunate patients who have trouble after these procedures is going to be an important part of comprehensive management for this condition that's DOEJ. As we mentioned earlier, my charge is to speak on non-constrained arthroplasties. You can have partial or total owner-head arthroplasties, and also a total constrained arthroplasty, which we'll be spoken about a little bit later. The ideal, the goals of owner-head arthroplasty are to, A, relieve pain, try to do a better job than the aforementioned procedures, and restoring the anatomic relationships and the normal use and CAM effect, if you will, of the DRUJ. Hopefully preserve normal biomechanics or as close to normal biomechanics, improve stability and improve ultimately function. And I think the ideal patient is the arthritic patient. A stable patient's much more reassuring. A stable DRUJ in this case is much more reassuring in terms of operating the patient optimizing outcomes. Other indications which are maybe less attractive are failed prior resections. Patients who are quite active are probably the ones that I would consider this on more so, although more and more studies are showing people with DERAs at a young age who've done well, much like Tom's case who showed a very active roofer with a very successful distal one over section. Good bone quality, I think, is essential. I would not consider an ulnar head arthroplasty in a rheumatoid patient. I'll get back to that in a bit. Good soft tissue competence is important in terms of optimizing the stability of the implant. And ideally, no prior infection. There's a myriad of ulnar head arthroplasty options that's becoming less and less. The U-head is no longer on the market. It's been taken off. Some of these, the pyrocarbon as well as the ceramic, they're not readily available in the U.S. There are some folks like creative colleagues and former colleagues of mine, like Dr. Bassam Al-Assan, who would use a pyrocarbon metacarpal head with a, and fashioned a, with a allograft meniscus, a stabilizer and a sigmoid notch and called that the calamari procedure. And I still see some of his patients back and some of them are doing really well. So you can try to be creative if you don't have some of these implants that are readily available in the United States. The total DRUJ was helpful. And again, this is also not readily available, but this was something that was really helpful. And still in some cases can be, in folks who have impingement on the ulnar head or instability issues or pain after an ulnar head implant. I'm going to go over the technique real quick. This is a patient a little bit like what Glenn showed earlier. I was thinking of with the wondering if I could get by with an ulnar shortening, although the slope of his sigmoid notch wasn't really favorable for an ulnar shortening alone. He did have a significant amount of pain at the DRUJ. He was quite active. He worked as a mechanic. And I like that approach from the floor of the fifth compartment that Tamara nicely showed. I do that for my salve componges as well as my darrows. After you retract the fifth compartment tendon out of the way, you can create an L-shaped capsulotomy to expose the ulnar head quite nicely. After you've exposed the ulnar head, you can prepare the ulna. This particular system has cutting jigs that allow you to sort of hook onto the alignment guide. And you can make your cuts based on the size and the fit. This system in particular preserves as much of the ulnar aspect of the ulnar to afford improved stability. And after you've cut and trialed, you can then place the implants in. And let me see if the video is working, okay. And impact it into place. I mean, this is typically what you'd like when you look at the fluoro image on this. Ideally, you want to keep the variance appropriate. There is a learning curve with this, so give yourself extra time as you do it and use the fluoroscopy liberally to make sure that you're in the right alignment when you prepare your cuts. Measure twice, cut once. And here on the side, I've taken a little less bone. You can always take more as you do it. The closure is very important. The interval deep to the fish compartment can be, needs to be re-approximated. I typically do this with the patient in slight supination and sort of a vulgarly directed force if I can on the ulna to maximize the stability. You want to assess rotation after you've closed this interval and then you can either, it's optional to close the extensor retinaculum. I prefer to close it myself, but Brian Adams, for his approaches, for his Adams procedure, leaves it be, or at least he used to. And this is a successful outcome. This is a one-year post-op. He's got full pronosupination. His pain is much better and he's quite satisfied. But they all don't go well, as you might imagine. And complications can occur, and this may be in part why some of these implants have fallen off the market. Pain and stiffness are unfortunately seen in these cases. Sometimes the source of pain is idiopathic. This is a case of a 48-year-old female that I treated years ago who had had a previous DERA procedure that was not successful, and I ended up putting the U-head in. And this is, she had ongoing pain for quite a while. And in my case, I was concerned that she was a little too tight. She had difficulties with pronation supination, and some of the larger implants can be more painful. One of the lessons I learned from this case was maybe tear on the side of a smaller implant, if you're between sizes. And I ended up graduating her to the procedure Lucia is gonna talk about, and the Achilles interposition stabilization. And she is now 10 years out from this and has done fairly well overall. Erosion into the sigmoid notch is an unfortunately all too common finding. Dr. Sanj Kakar helped, you know, look up our series of Mayo for many U-heads and we found that even in non-rheumatoid erosion in sigmoid notch was quite common and unfortunately can be symptomatic. It does afford some improvement in stability as it erodes, but it can be sometimes painful in certain patients. And this was often something we could remedy by a total, but nowadays, I've had to resort to the constrained aptus implant for these patients or removal of the implant and graduation to the soterianus procedure. This is a case of a rheumatoid who had bilateral U-heads years ago and you can see how catastrophic some of these erosions can be. Every year I see this patient back and I'm thinking that her right side is eventually going to fracture. You notice that those implants have a lot of stress shielding. They're hard as heck to remove. So that's another lesson learned. So it's not easy to extract them from the bone. Sometimes you have to split the ulna to get them out. I've used this technique of breaking the bone implant interface with a series of K-wires. You can see I did this on this total wrist, but you can also do them on the U-heads. And that sometimes helps to dislodge them without having to remove too much bone. Loosening can also be a problem. Thankfully, it's not as common as some of the other problems such as erosion into the notch. When they do loosen, you need to consider infection and etiology. And they often need to be removed. You can revise them with cement or graduate them to the total constrained implant as shown in this slide. And if they are unstable, there's a couple things that you need to ask yourself. Is it static or dynamic? How can we stabilize these? You can, a myriad of interpositions have been utilized. Like Glenn showed earlier, I'm a big fan of the BR wrap for some of these as I think it can be quite helpful in affording stability. If they have a bony deficiency in the sigmoid notch, you can create a wedge osteotomy or try to burr a sigmoid notch. With care taken, unfortunately, you're going to maybe potentially invite more erosion into the bone and the sigmoid notch as you create a cavity or create your own acetabulum. So it's a double-edged sword, but it does help provide stability. And maybe the worse, maybe the lesser of the two evils if you can get them to be stable. And of course, the total aptus implant, which Dr. Handel is going to speak about, is often more and more used when you're dealing with issues on this side of the wrist. Being facile with a lot of these conditions, a lot of these options is going to serve you well because you're going to run into problems when you operate on this side of the wrist. This is our original patient. And you can see here she is at about a year out from her surgery, and she had done fairly well at that point. In summary, the ownerhood is important. Implants can preserve the CAM effect that we don't have when we do a resection or an SK procedure. I think these are meticulously technique-dependent procedures, and being meticulous helps optimize outcomes. Be prepared for complications and navigating those complications. And sometimes in the end, resection is the best or only option. And sadly, there's times one-to-one bone form is what these patients will end up with, which is hard to say is really a satisfying procedure, but in some cases can take away the pain, but often leaves the patient with frustrations with regard to function. Thank you for your attention. Well, thank you very much. I think that was a great overview of something that at least I didn't have a lot of exposure to in my training. And so it's nice to see kind of different options for this. So moving forward, we have Dr. Ukiah Papathadourou, I'm probably pronouncing that incorrectly, so I apologize in advance, but she will be kind of going over the Achilles interposition as a salvage option for this as well. Hello to everybody. We're going to talk about the Achilles interposition, and I have nothing to disclose regarding this presentation. So the distal ulnar resection procedures, such as DARAC and NITS modification, are associated with a high failure rate, and this happens mainly because the loss of link between the radius and ulnar following of the distal ulnar resection can result in radial ulnar converges, which can produce the painful impingement of the ulnar stab against the radius with instability of the distal ulnar. The treatment of the symptomatic failed distal ulnar resection remains a difficult reconstructive dilemma. Although numerous procedures have been described, however, none of the procedure has demonstrated clinical superiority. Currently, metallic arthroplasty is used in VOGT, but as we listened already, there are complications associated with implants that have been reported in the literature, and there is especially concern for young active adult patients. In an effort to overcome the symptoms of painful impingement after the failed distal ulnar resection, by maintaining a white space between the resected ulnar and the distal radius, Dr. Dinshutiri-Hantos developed a distal radial ulnar interposition and arthroplasty using an Achilles tendon allograft. To perform this technique, the previous surgical incisions are incorporated into the approach. Dissection through the fifth dorsal compartment provides access to the resected distal ulnar. Then subperiosteal exposure of the distal ulnar is performed approximately 4-6 cm approximate to the distal stub. Then to expose the medial cortex of the distal radius, the ulnar is retracted volatilely using Hohmann retractors over the ulnar and under the radius, as we can see in the photo. Then three 4-mini suture anchors are placed into the medial cortex of the radius at the site of the impeachment, approximate to the sigmoid node. Then three 4-3 holes are made in the distal ulnar approximately across the suture anchors, and free sutures are passed through each hole on the distal ulnar. So we have sutures from the suture anchors on the radius side and sutures through the holes in the ulnar side. The anchors and the holes should be extended approximately 3-4 cm along the medial cortex of the radius and ulnar for the later fixation of the allograft between the two bones. An Achilles allograft tendon is prepared by removing any calcanean bone, and then the allograft is rolled to itself, creating a large interposition pillow. Then all the sutures from the anchors and from the holes should be passed through the allograft. This is a very important step of the technique for optimal outcomes. Each suture from the suture anchors in the distal radius is passed through the allograft along one side of the allograft, mainly it will be the radial side of the graft. And then each suture from the holes in the ulnar is passed through the allograft on the opposition side of the graft from the previous suture. So at the end it looks like we have two lines of sutures, one towards the radius and one towards the ulnar. Then the allograft slides through the suture and finally is interposed between the resected ulnar and the distal radius to act as a soft tissue buffer between the two bones to prevent the radial ulnar impingement. Then the sutures through the graft are tied on the top of the allograft very firmly to secure the graft between the two bones. With the final allograft pillow placement there should be significant padding between the two bones to prevent any crepitus or impeachment during the forearm rotation under compression. If there is crepitus with the passive forearm rotation then the size of the allograft pillow should be increased. At the end of the procedure the wrist is placed in a long-arm splint in neutral rotation and flexion. The splint is converted to a long-arm cast at the first post-operative visit, usually ten days after the procedure, for six weeks. After six weeks the cast is removed and a removable long-arm splint is used. At this time the patient can begin therapy, initially with active assistance and active range of motion exercises, progressing to appropriate strengthening exercises. In 2014 we have published with Dr Sotirianos the outcomes of the first 26 patients with the Achilles allograft interposition. The mean age of the patient at the time of the surgery was 43 years and we found that the mean follow-up of 79 months that there was significant improvement of the pain, the grip strength and the forearm rotation. Post-operative radiographic evaluation demonstrated maintenance of a white space between the resected distal ulna and the radius. The first patient in this clinical serial had persistent pain and crepitus due to insufficient interposed bulk between the two bones and he underwent revision with radio-ulnar arthrodesis 39 months after the Achilles allograft interposition. One of such scalloping was observed in radiographic evaluation in two patients, two and three years post-operatively, however all the patients remain asymptomatic during the follow-up period. This is a patient 47 years old female who had two previous distal ulnar resection procedures presented with severe painful radio-ulnar impingement. She was treated with Achilles allograft interposition arthroplasty and 10-year post-operative radiographs show a maintenance of a white space between the resected ulna and the radius without impingement. Patient had good clinical wrist motion without pain. Allograft dislodgement is a reason for failure and this can happen if the allograft is not firmly secured and sutured between the two bones when interposed between them or if the graft is not large enough in size to prevent the radio-ulnar impingement. For the optimal outcome of this technique the Achilles interposition should be performed in an appropriate way. If you perform the technique like this it's going to be failed. In this case the surgeon did not perform adequate distal ulnar resection and he used the palmaris locus as a graft to interpose between the two bones which is too small in size and cannot prevent the radio-ulnar impingement. Recently in this study Dr. Sin and his colleague report the outcome in 10 patients with Achilles allograft interposition arthroplasty. At the mean follow-up of 77 months they found that 5 patients underwent revision due to persistent pain and instability. As we can see in one of these patients in the x-ray there is a little more extra distal ulnar resection and there is not enough space between the two bones so maybe the graft they used was not large enough in size to prevent the radio-ulnar impingement and this can lead to instability and failure. Regarding the Achilles allograft incorporation in experimental study with thumb CMC joint arthroplasty using Achilles allograft interposition in monkeys, the authors found that the interposed Achilles tendon allograft was vascularized and underwent fibroplasia. The graft adhered to the adjacent bones through the collagen fibers and they found that the graft resulted in maintenance of the space between the base of the first metacarbon escapode. So if these results are applicable to the DRUJ then they potentially exist for a lifetime cure with Achilles allograft interposition technique for the treatment of failed distal ulnar resection. In conclusion, although the Achilles allograft interposition arthroplasty does not restore the normal biomechanics of the DRUJ, it's a safe and reliable alternative technique that can prevent the radio-ulnar impingement in patients with failed distal ulnar resection and can be very useful, especially in patients who may not be candidates for implant arthroplasty because of their young age or high level of activity. Thank you for your attention. Thank you for that great presentation. To kind of wrap us up with the last talk, we have Dr. Hanel talking about the constrained implant for salvaging failed DRUJ reconstruction. Okay, let's see what I've got here. Basic. Here. Here. There. All right. So we're going to talk about salvaging a failed DRUJ reconstruction with a semi-constrained prosthesis, the so-called Aptis or Schecker device. This is all level 345 knowledge. I do have a conflict of interest because I've been a consultant and a speaker regarding the complications of this device and have written on this in our literature. Everything that I'm about to say has been written in a chapter for Marco Rizzo and Graham King. My co-authors on this are Chelsea Boe, who is a fellow and now is my partner, and Abhi Kimbasham, who is my fellow a couple of years ago and is now in Boston at Harvard replacing Jesse Jupiter. So the thing that's really remarkable is I wouldn't have to write this article if everybody did their salve compunges with the same speed, dexterity, and outcome as Tamara Rosenthal. She had no failures in the series that she recently presented, and her complications were, as she stated, were hardware removal type things. So the issue is that, as Marco had pointed out, if you look at all of the studies on all the distal radioulnar joints, everybody did well up to about 92% to 94%, and nobody tells you what to do with that other 6%. And this is just a clinical classic example, this 53-year-old artist that presented to me as a 53-year-old, and her 15-year history, 20-year history, was in treatment for King Box was six procedures listed here. And my practice and my introduction to this device was based on these cases that are shown here, plus another 40 or so. And each of them had the standard of care, and each of them had DASH scores that were high, work modification if they were working, an average of two to three procedures, resting pain at a relatively high level, and pain especially with pronation, supination especially when holding onto anything greater than five pounds. Now, I'll be the first to admit that all resections impinge, and I'll even say that not all impingement is painful, but when it is, it is really a life-changing problem. And so, you know, what do we do about this life-changing problem? Well, when it comes to my office, the first thing I think about is an article that was written by Sanjay Kakkar and Amarkus Elias, which said, you know, why don't we put all this distal radial ulnar joint pain into lenses, four lenses, bony deformity, cartilage defect, triangular fibrocartilage injuries, and an unstable ECU, with the thought that, you know, people will key in on one of the four, think that if they repair it, the patient will get better. But if they happen to have problems with another one of the problem, and you don't address that lens, then you're going to have an unsatisfactory or suboptimal clinical outcome. So, if you have a problem with lens A, lens D, and lens B, you may be able to repair those without having to do a reconstruction. But when you have all of those together, A, B, C, and D, you're going to need something that will address all four lenses. And in my setting, it is that semi-constrained prosthetic. And what does it do? Well, it shares forearm convergent load. It prevents full or dorsal translation. It allows forearm axis of rotation. And it addresses all four of the lenses of the CACAR, Garcia-Elias, Distal Radial Hormone Joint Pathology. So this was introduced to us as a technique in 2008 and introduced to us as a series of patients in 2015, all of which had good follow-up. They had marked improvement in their BAS scores, pronation, supination, grip strength, and their complications. They had one failed and one fractured, and they listed it as 2%, or as 5%, 2046. But if Peter Stern had written this article, then the complication rate would have been 39%. Because he noted that within this article, they had nine patients that had ECU tendinitis, some implant revisions, etc. So that was that 39%. So from left to right, that's Kate Bellevue, Mike Puglio, Mary Kate Thayer, myself, and Jerry Wang. And Kate and Mike looked at all of our cases and looked at our complication rate and found that our complication rate in 54 patients was 29%. And we had marked improvement in those 54%, but we had a lot of complications, or a lot more than had been reported. At the same meeting, the Mayo Clinic result showed a complication rate of 44%. And more recently, Glenn Gaston, who is the lead off today, he and his group, Alan Moore, had 21 patients with 29% matching RS. Now, a couple months ago, in an article from the Netherlands, the complication rate was 64% with this procedure. And if you look at it, 17% of that 64%, nobody needed surgery. And 30%, the surgery was minor surgery for minor problems. And there was really only 12% major problems, excision of severe heterotopic auspication being one, explantation in two cases, and then revision of the defias in three cases. One thing that comes out of this series is that when the procedure was done as the primary procedure in 11 cases, there were no complications. And there's been a number of series in Europe that have demonstrated this again and again, and their explantation rate was 2%. So, you know, this is a great example of, you know, when you consider doing this operation, knowing that you're going to look at your patient and go, I've got a one in four complication rate, and maybe a minor complication, but it's going to be a complication. And you'd ask yourself, you still do this? And I do. And what has changed? And so let's take it one complication at a time getting through this. The first is that of our cases, we had two that had distal synostosis. And the way that we have treated that is to avoid using the short implant. We now use an implant that is at minimum one centimeter of stem length versus two, but we never use this implant. And that decreases that and has kept us from doing that. I'm not going to mention of this absorption right here, other than to mention that you'll see this on a number of your patients, and this hasn't presented a problem. This isn't loosening and it hasn't progressed further. It seems to find its own zone of resorption. And it usually is somewhere around one centimeter to two centimeters when that happens. We had two caps that loosened people that were very, very aggressive. And this was a mechanical error that has now been corrected with the redesign of the head. And the most common head is a so-called 20 millimeter head. And I would bet you that well over 90%, 95% of all the implants that are going in right now are a 20% or a 20 millimeter head. So the cap loosening has been addressed and re-engineered. There were two tendon adhesions, and these were in patients that had tenolysis of their extensor tendons, and then their wrist was immobilized for a couple weeks, because of just the geographic geographic challenges of taking care of patients from Alaska in the Pacific Northwest. And so they were immobilized for a long period of time, a couple weeks. And we address that by following the rules. And then if you read the manual, and you should, if you're going to do this device, then you're going to raise retinacular flap. That retinacular flap is placed underneath your extensor tendons on top of the implant. There's the implant shown here in the, underneath the head. And if you don't have a retinaculum that's left because of previous surgery, then the, Dr. Shecker has recommended that you either use a dermal graft or a fasciae latae allograft. We had three late infections, and not surprising, they're actually at the time. These were, two of these were in patients that had their implants in place for greater than five years, both of whom had dental manipulation within four or five weeks of presenting. In this particular case, this was 20 days after a root canal patient presented. And in these two cases of the dental manipulation and infection, we explanted them, put them on antibiotics for six weeks and then re-implanted their implants successfully. So I recommend antibiotic coverage with dental procedures, even though that isn't what is now being recommended for total hips and total knees. I had one permanent explant that remained an external, I could not sterilize the medullary canal of the ulna. Now it kept growing up the same bug and we could control it. And this was in a patient that 10, 15 years before we put this implant in, had undergone a wrist fusion related to an open fracture as a result of a dune buggy injury. We had three cases that had problems with the distal dorsal continuous branch of the ulnar nerve. Two of whom had been injured because of previous surgeries. And in these cases, we did neuroma excisions and placed the proximal end of the nerve into the muscle belly of the extensor carpi ulnaris. And then we had one case that it was my case that I caused a iatrogenic neuropraxia that resolved after four to six months because of the traction that was placed on the scarred nerve. With increased distal radial ulnar joint pain, I mean with increased distal radial ulnar joint motion, there will be and will reveal problems at the elbow. And so if you were going to do this procedure, I think that it's paramount that you get a full form radiograph as described by Dr. Gaston in his lecture. And in this particular case, this is an example of what we did to salvage this procedure in this patient and continue to do well. We had four stress fractures all related to impact loading. Two of the patients decided that they would demolish their house or their rooms by themselves to save money. One occurred in a guy who insisted on splitting wood even though he was told not to. And one who was racing old cars at a Le Mans. All of these happened within six weeks of the procedure. And so I really, really, really press hard that patients need to follow the rules and avoid impact loading. Are there any contraindications to this procedure? I don't know what too young is, but I think that the mid-20s would be the earliest I'd ever put one of these in. I think that indolent uncontrollable infections, as in that patient with the dune buggy, is a contraindication. An uncorrectable radius and ulnar deformity, you have to have near normal anatomy of the metadiaphyseal radius to do this, to use this procedure. And then an unwillingness on your part, the surgeon, to pay attention to detail. So this isn't an easy operation to do. But when it does well, it does well for a very long time. This is 1995. This patient went from the sylastic implant, then presented to me. I put in a U-head. U-head became painful in 2008. We replaced it. She refuses to come in and see me. And I haven't seen these radiographs are from about 2010. She does send me cards telling me that she's doing fine. And she did take these films from her therapist, who are a couple hundred miles from where we are in Seattle. So what did we do with the 53-year-old artist, educator? We did this. We replaced it. I took down the distal ulna, mostly because this implant fit a lot better when I did. And so that's what I did. This is the implant in place with a four-centimeter stem or a spacer. This is her one-year post result. And so why do we use this procedure? Well, we use this procedure because it shares forearm convergent load. It prevents bolar and dorsal translation. It follows the forearm axis of rotation. It addresses all four of the lenses of the ulnar pathology. But it is demanding. And what's different? I think that the minor complications can be improved. The primary complications have improved. And the salvage procedures are just that. They're salvage procedures, and not every one of them is going to be salvaged by this particular procedure. So thank you very much. All right. Thanks, Dr. Hanel and the rest of the panel today. We did have a couple questions, which I can bring up for some audience questions. And then if we still have time, we have some cases to discuss. So first question is for Dr. Rosenthal. Question about an objection to the salvicopongic procedure, just that it's harder to perform salvage procedures with an implant for existing. For example, when a patient has symptomatic convergence, when you've fused the distal radial ulnar joint, and any comments on how to address that? And I know we just saw a nice example from Dr. Hanel using the Aptis, but any comments on that? Yes, I do think it's harder, but it's not impossible. I'll probably preface it by saying that I think if you perform the SK well, technically, the likelihood of having symptomatic impingement is relatively small. So in the series that we published, I think I had to revise one of them. I think the Achilles allograft is a very good salvage in those cases. And I also think you can do an Aptis, although I agree it's more complicated to do it. I have a question. Do you ever do the Fujita modification to the SK procedure where you rotate the ulnar head about 90 degrees to increase the stability in the wrist? I usually don't. I usually don't. I know one of my partners likes to do ECU stabilization, so taking a slip of ECU to stabilize the proximal stop. There's different variations that you could try for that particular problem. I usually keep it pretty simple, just with Pronator. Can I ask a question, Hannah? You showed a case where it looked like it was an adult Madelung. It was an adult skeleton with a Madelung, so pretty mild, but it was still there. Now, how do you choose where to put the head when you do that in that case? Do you make it ulnar neutral, or do you put it proximal? No, that's a great question. I try and make it either ulnar neutral or proximal, so definitely not positive. And I basically put it where it seats best. Okay. So not too great. I mean, it looks like it just fit right in, and I was wondering, in those Madelung deformities, you don't have to do anything to the sigmoid notch. Usually not. Sometimes you have to burr it a little bit more just to get it to sit nicely. All right. Thank you. Next question is for Dr. Gaston. So how often do you find in the chronic setting that the TFCC and kind of those DRUJ ligaments have good enough tissue to repair, and then when you do repair them in a chronic setting, do you typically use bone tunnels or anchors? Yeah, that's a good question. So the literature would support either in terms of bone tunnels versus anchors. There's, you know, Sotirionis wrote kind of the early papers on anchors. There's tons of papers on bone tunnels. I'm a bone tunnel fan personally. I just like to bring it over and tie it over the side for the grossly unstable ones. So that's just kind of a personal preference. But repairable tissue, I'll admit, I'm curious what the other panelists think. I'm surprised by the number of times I've gone in eight months, nine months, a year, and there still is TFCC that's repairable. I think you should always consent them for both and be ready to do whichever is needed, whether it's an ADAMS, a BR or RAP. Like I said, I'll base that on kind of the direction of instability versus tissue available to repair. But I have been very surprised in practice the number of times a year out, eight months out, I've gone in and there still is good TFCC tissue. You have to debride sort of this fibrinous stuff that's between the good TFCC and in the fovea. But oftentimes there's still repairable tissue very late in my personal experience. You know, I agree with that. Could I ask you a question? When you have, you're going to do a combination of a soft tissue repair and a normal shortening osteotomy. Yep. What do you do first, the osteotomy or the repair? Osteotomy for me always, if I'm going to do it. Now that's again, that's not always the case, but anytime, especially the most common osteotomy is going to be like a radial shaft or disc radius because the number of times I've seen patients and it doesn't take much. I've got a kid going next week that's, she's 15. She had a childhood fracture at five. Now she has deary jane instability and I did bilateral CTs because I wasn't even sure there was a bony malalignment, but a lot of times you get them and it's like 10 degrees, 15 degrees, not much. And you do that osteotomy and they're rock stable. It comes up a lot in my practice personally. I wonder what the other panelists think about that. But I think a lot of times, once you get the bony perfect, the necessity of the DRUJ reconstruction and or TFCC repair is lower than I would have expected once you get the anatomy right. So I always go with the osteotomies first, realign bony alignment, and then reassess. But what's been your experience, Doug and others? Well, my experience is that I think that you need to do your osteotomies first. And to that point, the last one that I did was a patient who was a 17, 18 year old male who had a bent, a plastic deformity of the ulna and a fracture of the radius. I said, oh, it's a Galiazi variant, I guess. If we look at her, Montasia variant, I guess. But where nobody really appreciated the fact that this was a plastic deformity. And once you realign it, you regain 45 degrees of supination. You went from 35 degrees of supination to a near 90 degrees of supination after the osteotomy. Yeah, I agree. It's not uncommon in my experience that you see patients with failed soft tissue procedures that you get bilateral CTs and line it up. And it's that there's a, it's not big, 10 degree, 15 degree malalignment of the radius and soft tissue procedures will continue to fail. And with the ulnar shortening, is everyone doing diaphysial or metaphyseal? What's the thought? I personally do diaphysial in the setting of an instability case. Again, it's predicated on there being some deep radial ulnar ligament attachments maintained. If there's no ligamentum subcruntum attachments, then it doesn't matter which you do. You're just going to have a shorter, but persistently unstable ulna. The problem is there's not an easy way to predict that ahead of time. So that's why to Doug's point, I like doing the osteotomy first, reassessing if it's still unstable and I'm going to reconstruct. All right. Last audience questions for Dr. Rizzo. With the unconstrained dysradial ulnar implant or the ulnar head implant, it seems like a very nice option. Are you doing these more or less as your practice has evolved, just given some of the notching and notching erosion that you've been seeing? Yeah, good question. Less is the theme. The results that Sanj helped us look up from our experience was a little bit less than enthusiastic. We've slowly walked away from some of it. Some of it's beyond our control though. The only implant that I think is out there now is the, I guess, Smith & Nephew owns them now. It used to be Integra had an implant, the one that I showed in my presentation. The U-head's off the market and the total U-head's off the market. So we don't have as much to choose from in terms of options. In Europe, there's still an enthusiasm. The ceramic implant, the Herbert one, is really quite popular. And they don't get as much notching for whatever reason. And it sort of defies logic on some level, because ceramic is much harder than stainless steel, but it doesn't seem to notch as well. Or it doesn't seem to erode into the sigmoid notch as much. And I wish we had that available here. I also wish we had the pyrocarbon implant that was designed by Mark Orsi-Elias. I think that would be a wonderful option, much better fit than what Bossam does with the calamari procedure. So in some ways, our hands are tied in terms of what's available in the U.S. And it's forced us to become more dependent on the non-arthroplasty-based procedures. But if it does come to arthroplasty, more and more I go to the Aptis, which is quite popular. And as Doug nicely showed, our Mayo experience does have similar compatible complication rates, much as like you described, Doug, as well as Glenn and others. But it can really bail you out. As Doug said so nicely, some of these patients, they go down that slippery slope and they are just miserable. And having an implant like the Aptis can bail you out and really give these patients back quality of life, even though there are obviously complications with them. So long-winded answer, Alex, but I hope that answers it. Mark, you hit on something that I couldn't agree more with. And Doug mentioned in his talk too, which is at least for me, when I started doing Aptis, they were always for like the worst patient imaginable, that it had like 10 failed surgeries and all this. And that's where we kind of cut our teeth on it. And we reported ours, like Doug said, our complication rate was similarly around a third, but these weren't patients that had had multiple previous surgeries and were like, you were just trying to hit a double. And several of them did really good. And like, I don't know, if I went back and they had some ECU tendinitis, and then you resolve that with a second surgery, that's several of them really turned out very, very well. And to Doug's point, it's not till I've gotten further along in my career that I've used it as a primary choice, because I always felt like it was wrong to do it out of the gates, because it was considered quota salvage. But it's been a real game changers for me with no conflicts either. And I agree with Doug's sentiments that all the complications I see too, aside from the three you showed Doug of like dental implants, it's like if they get through the first six months, they do great. It's very uncommon to see an Aptis come back five, I've got some that are 15 years out now and five to 15 years, you don't see them come back very much. It's almost always early trouble, or they do well. Yeah, I'd like to echo that I, I'm fortunate to have lived with 100 miles of Dr. Shecker, and he's a good friend of mine. And the first few that I did, he came up and stood behind me and would smack my head if I did something that he thought was incorrect. And so I got good instruction, although a headache at the end of the case. But this is a good procedure. And Dr. Stern, who's, who's passed the mantle to me tonight, was very down on it for a long time. And I would argue with him and I'd say, Peter, what's the worst thing that can happen? You take the implant out, and then you're back to Adara with an unstable ulna, which is what we had for years and years and years. And so I think that the Aptis prosthesis is a wonderful game changer for these very, very difficult situations. And I haven't done a one bone forearm in the last, I don't know, 10 years, probably for this, because the Aptis has kept us from having to do one bone forearms. So, so I'm a believer, even though it's a technically very demanding operation and requires a lot of attention to detail. So with that, I think this will be a nice segue for hopefully a couple cases. We only have a couple of minutes, but just why should you not do your procedure? So here is a case of a crash pilot. He's a 50 year old pilot, former Air Force, flying a small EMS plane. He crashes in Montana, and he's transferred to your care with this. His ulna's on the field and they bring it in, and forearm radiographs and a CT show this. So he's clearly missing quite a bit of ulna, has a segmental radius fracture. And who on the panel will try to reconstruct? So Dr. Rizzo, is an unconstrained implant anywhere in the question for this? No, I don't believe so. I mean, I'm assuming it's an open fracture where the other ulna is, or the rest of the ulna. The proximal ulna is, right? What about if he staged it and did it at a later time? I would still lean on either Soterianus or Naptus once he's healed. I've had complications with both in this setting. I mean, I've had fractures with the Soterianus in one case. I had the suture anchor holes. I drilled too far on the radial side of the radial cortex, and she developed a stress riser and fractured her radius that required me to plate it after I did the Soterianus. And I've had several apti that have gotten loose, and I'm not sure exactly the mechanism of their loosening. I've had patients refer to me from Chicago who've had five different apti that have failed repeatedly. Some of those patients, I don't know if the biomechanics of them is such that they just overdo it, or they just don't sort of settle like you were saying, Doug. You know how they settle, that stress shielding that you showed? Some of them just never settle. The physics of the way they work just develop their own momentum and catastrophize, a little bit like the pyroglybin implants in the PIP joints that Dr. Stern would show with the cutting out. Thankfully, those are rare. But I'm going off topic here, Alex. I would say I would reconstruct the radius, and I would do nothing at the ulna right now. And I would let it heal, and then address the ulna at a later date. And I would sadly throw that ulna in the bucket, I guess. I mean, I suppose you could argue, Marco, why not fix it and see where it goes? And that might be worth considering. You can pin it for a while. But I would worry that it would, I don't know. Go ahead, Tom. Please bail me out. Yeah, well, yeah. This looks a lot like the cases that we did in this paper 25 years ago, about large resections of the ulna. A lot of them have been done for tumors, some of them multiple procedures that had failed. And I would fix this radius. And I will tell you that unless you were me contributing to that multicenter paper, most people do well with an ulna that's that short. And so, I would wait until you had problems before you did anything. Do you think, you know, once you do fix the radius, do you think that convergence might become an issue? Like, would an Achilles interposition be appropriate? Or I think they can also make custom aptus-size implants, right, later to potentially? Yeah, they can. But the convergence wasn't a problem with ulna that short. The complications that I reported were extensor tendon ruptures. And the radius would sag, and the ulna would grind into the musculotendous junction of the extensor tendons. But you can pick that up early. You can see the stenovitis and the pain. So, I would fix this radius and leave it be. And I think he's got a 24 out of 26 chance of doing well with it the way it is. Would anybody fix the radius to the ulna primarily? No, I've done a lot of radial ulnar fusions. And number one, they're hard to get to heal. Number two, it's very limiting. You can always go back and do it. I, you know, I've got some patients that thank me after it, but most patients are not my favorite campers. I agree, Tom. This guy gets ORIF antibiotics left exactly as is. Based on your paper, I've inherited, I don't know, three or four, not many over the last 15 years. But it's all the super-dare, as I call them like this, to your point, they actually usually do okay. And he's got plenty of residual ulna that if I had a bit, I would do that. If they had problems long-term, I would get a custom aptus personally once I ruled out infection with probably bone cultures prior to doing it, to be certain. But I would do ORIF radius, antibiotics, weight, do nothing if necessary, persistent pain, bone cultures to rule out infection, and then a custom aptus for me personally. So Alex, we jumped right to the bone. Yep. So yeah, I think, I think you know where this is going, Dr. Handel. The way that you know it from, from me is that a fracture is a soft tissue injury that involves bone, right? Tell me about the soft tissue set. What's the soft tissue injury we're dealing with here? Well, so just like the images weren't supplied with the patient when they transferred here, or to you, the, this was, this was kind of the presenting film. So it looks, you know, it's a little more than kind of build. You guys can see where this is going. Despite this, the patient needed forearm rotation to maintain FAA licensing and asked that everything be done. So the team taking care of them, just like kind of everyone recommended, fixed the radius, left the ulna. This allowed, you know, the radial capitellar joint was nice and reduced, and the soft tissues were able to be closed because there was pretty extensive bone loss, and so it didn't require a flap. Images at discharge showed a concentric elbow, but we can probably see where this is going. Three weeks later in clinic, dislocates later undergoes annular ligament reconstruction, open reduction, and temporary radial capitellar transfixion. And at 10 weeks is actually doing okay, and this is kind of the last follow-up before he moved back to Germany, but it sounds like might not be the last of the problems, but that's where we're going to leave it. So would anyone, knowing that the radial capitellar joint was unstable, would they do a one bone form from the get-go? I'll tell you, we've got a couple now. It's interesting because you think of the Schecker classically as you're plating the radius and then you're kind of hanging the ulna on it, but I've done two or three now Scheckers where they were absent the proximal radial ulnar joint, either from previous excision or otherwise, and it can be stabilized based on the ulna. So I've got several cases where, like I said, about three now where they're missing the proximal radius and you do a Schecker implant or an Aptis implant, and they regain very good stability. One of them I had to go back and oddly enough do an Achilles interposition, the proximal radius converging on the ulna. So sort of the reverse of what we've classically done it for. So I'm curious other thoughts, but I think you can definitely still maintain forearm rotation. I agree with Tom. I think the role of a one bone form is very much diminished and you can do it for kind of the opposite. Usually we're losing the distal ulna, but you can absolutely do the same procedure for missing the proximal radius in my experience. All right. Louie's coming out with a PRUJR supply state that he's working on, so that might be something that could be utilized in the future for cases like this. And maybe I'm not a liar, but maybe I've done too many one bone forearms, but I've learned to plate them and bond for the ulna so that it's, because like Tom mentioned, they're really hard to get to heal. And if you- Wait a minute, I'm going to interrupt you there. Yes. It's really hard to get a distal, to get a one bone forearm to heal? Well, if you do, well, yeah, like Tom said that just now, it's like they're hard to heal. I don't agree with that. Well, the other option is to do a transposition. No, you don't need to do a transposition. It doesn't feel like gangbusters. Yeah. Actually, so I've written on this and I'm up in the high teens for one bone forearms, but if you take, in this case, if we wanted to create a one bone forearm, taking your screws and passing them from ulna to radius and taking around probably four screws, four 4.5 or 3.5 screws, starting at the tuberosity of the biceps and then going distally along the ulna, that'll heal. Now you need to pack bone. Yeah, Doug, I, okay, great. What I usually do is take a reconstruction plate and I bend it and I put about six screws in the radius and then I bend it so that it goes over to the ulna, put about six screws in the ulna and then try and get the two to heal together. But I can show you multiple pictures of screws between the radius and the ulna and they look great in the operating room, but they come back and the screws have got big halos around them and there's all kinds of troubles. So it's, I've not had as much luck getting them healed in the method that you've described. But then again, like most things, when they don't work, the author of the paper says, well, you don't know how to do the surgery, Dr. Keefe. You know, isn't that true? I mean, that really is. The only person here that could actually say that based on her stuff is, well, I actually, both Lohia and Tamara, the stuff they presented was so elegant. Yeah. I think it's going to be a game changer. A lot of attention should be paid to those papers. So we are over time. We have more, some more cases if people want to keep going, otherwise we can adjourn. Does anyone, do people have a preference? Don't really care. Lot open. Any audience want to chime in? Well, let's do, why don't we do one more? We'll bring it back. Something a little more common. So 56 year old lady with rheumatoid arthritis complaining of finger deformity. That's what she presents to you with. Her main complaints is her fingers, but the classic RA management recommends improving wrist alignment prior to digit correction. Her extensor and flexor tendons are functioning well. She doesn't have any tenosynovitis that you can appreciate. Here are her wrist radiographs. And I'll give it away that she's going to get her wrist fusion, but what should we do with the ulna? Dr. Gaston, any role of just an ulnar shortening? No, I would not do an ulnar shortening. I guess my question for the dysulna would be, is she at all symptomatic with forearm rotation or not? If she wasn't having pain at the dysulna, and she had no advanced extensor tendon ruptures, the majority of time I would say I would just do a DERA for these. That would be my typical go-to. If she truly had no symptoms, there would be times where I'd consider just leaving it alone if she truly didn't have any symptoms and didn't have any evidence of capidulna on the lateral. But if I was going to do something, I would do a DERA. I wouldn't get any more aggressive with a rheumatoid disadvanced. I'd get a wrist straight, go back and deal with her fingers. And I've been very happy with a DERA in this situation. And Dr. Rosenthal, how about an SK? So I would agree that if you're going to fuse a wrist, a DERA is the simplest and easiest thing to do because you don't have to worry about the ulnar translocation of the carpus with the wrist fusion. I have done wrist fusions with SKs at the same time in younger patients, which you think it's a lot of fusion to ask of the body, but it actually works out okay. And I've done a couple of RSL fusions with SKs in patients with post-traumatic arthritis who are also young who have a good bit carpal joint. But in this particular case, I would do wrist fusion and DERA. Awesome. Well, that's what she got. And then in terms of type of interposition, do people typically like PQ, ECU slip, FCU? What's kind of everyone's thoughts? Just take it out and do a good capsule or closure. That's all you need to do in this particular case. DERA described? Say that again? Just like DERA described as opposed to how big, you know, and Tom, because of the constraint of time, the DERA procedure is actually a soft tissue procedure. Part of which is removing the ulnar head. And if you do the soft tissue part of the procedure in this setting, I think they do well. There is a series of rheumatoid DRUJs replaced with Aptis. That's in the European literature. And the bone quality here is bad. This patient's low demand. Get her wrist stabilized and fix her knuckles and be done with it. And that's what we did. And she was pretty happy. Nice result. Way to go. I think we're probably running out of time. So with that, I will say thank you to the panelists and thank you to the attendees. I think this was a great discussion on a lot of topics on the ulnar aspect of the wrist. And we really appreciate everyone's participation.

Achilles Interposition procedure

salvage option

failed distal ulnar resection

painful impingement

instability

radial ulnar convergence

distal ulna stabilization

Achilles tendon interposition

reconstructive dilemma

complications

metallic arthroplasty

functional solution

ulnar pathology

wrist alignment