Good evening. My name is Bruce Leslie. Over 20 years ago, I hosted a seminar at the Hand Society in which we invited Drs. Kleiner, Naliboff, Eaton, Blatt, Bowers, and Agee to give a 20 to 40-year perspective on their classic papers. Tonight, we're going to try and recreate that seminar with some of the giants in modern hand surgery who are going to give us the benefit of their years of experience. We have a number of moderators. Nikki Leung will be introducing Peter Stern who will be speaking about PIP arthroplasty. David Ruckelsman will be introducing Drs. Paul Feldman and Lee Osterman who will be speaking about the wafer excision as well as ulnar-sided wrist pain. And Samir Puri will be introducing Scott Wolf who will be speaking about scaphoid non-unions. First, I have to do some housekeeping. One, your audio is going to be muted during the presentations. The webinar is being recorded and will be emailed to all attendees at the end of this week. We'd like you to submit questions in the chat box at the bottom of your screen. If you just type in your questions, one of the moderators will introduce the question to the speaker at the end of their talk. Most importantly, if you have any technical issues, we need you to contact webinarsupport at assh.org. Finally, this webinar is eligible for 1.75 hours of credit which will be available at the ASSH next week. Thank you very much. And now I'm going to introduce Nikki Leung. Hey. Thank you very much, Bruce. My name is Nikki Leung and I am a hand surgeon with Tufts University School of Medicine and Newton Wellesley Hospital in Massachusetts. And I have no relevant financial relationships to disclose. I have the pleasure and honor of introducing our first speaker of the evening, Dr. Samir Puri. I have no relevant financial relationships to disclose. I have the pleasure and honor of introducing our first speaker of the evening and that is Peter Stern, a man who needs no introduction. His written works on the subject of small joint arthroplasties are extensive. In looking over the many articles that you've written on this subject, I came across one not directly related to fingers but it was actually your 2001 presidential address which its title was very apropos to this evening's talk. Your presidential address in 2001 was on generational differences. So tonight I believe you'll be speaking on generational differences of a different sort. I suppose you could be talking about the differences in the generations of finger joint arthroplasties and I look very much forward to hearing you talk about your experiences with pyrocarbon arthroplasty and your return to silicone arthroplasty after that experience. So without further ado, Peter Stern. Oh, thank you, Nicky. Okay. Well, the suggested title that Bruce assigned me was Return to Silicone PIP Arthroplasty After Poor Experience with Pyrocarbon PIP Arthroplasty. My preferred title, however, is silicone is the gold standard for PIP joint replacement. So that's kind of obnoxious. Why silicone? So I'm going to do a comparison for the next five or two minutes on different aspects of PIP joint arthroplasty. So we'll start off with why I think silicone arthroplasty is preferred to pyrocarbon. Silicone is definitely more versatile. It's really a spacer and it can be used despite lack of soft tissue, which doesn't apply to pyrocarbon, and it has much broader implications. In general, for pyrocarbon arthroplasty, you need a decent soft tissue sleeve. The ligaments, collateral ligaments must be intact and its stability is achieved by the tongue and groove confirmation of the implant. There is no literature with pyrocarbon for the use of it in rheumatoids at the PIP joint, and it has fairly poor results as reported by Drs. Nunley and Boyer with the result of trauma. In terms of expense, and again, silicone gets the gold star, about $300 per implant for silicone for surface replacement arthroplasty, about $2,000 per finger joint. How about range of motion? In this domain, it's a tie. In general, whether you do silicone or pyrocarbon, I think you can tell your patients that it's unlikely that range of motion is going to improve. With silicone, it stays about the same, at least in the series we've written. With pyrocarbon, it's better at a year, but after that, there's a decline in active range of motion. The bottom line is that neither arthroplasty reliably improves range of motion, and that should be explained to your patients. Pain relief. So, both silicone and pyrocarbon arthroplasty provide reliable pain relief. In terms of coronal plane correction, this is something that particularly women will notice. If a finger is crooked in the coronal plane, they don't like it, and there's no question that pyrocarbon wins in this category. As I mentioned before, it's a tongue and groove articulation. The collateral ligaments are preserved, and you'll end up with a much straighter finger. There is very little you can do, in my experience, with silicone to correct coronal plane angulation, and the index finger is particularly problematic, because when you pinch, you tend to ulnarly deviate at the PIP joint of the index finger. Squeaking. Silicone, of course, does not squeak. Pyrocarbon occasionally squeaks. It's not that common, and different patients have different reactions to it. Some people kind of think it's neat. They can show it to their grandchildren. I was involved in one case where the patient claimed that no informed consent about squeaking occurred, and litigation ensued. I do not know the outcome. Going down to things that I think are much more important is that you've got to remember that we're discussing a PIP joint. This is one finger and a ten-fingered hand, and I think revision arthroplasty is fairly unacceptable for the finger. So, if you look at silicone, I think it wins the battle heads and tails over pyrocarbon. Swanson, of course, who always had great results with any and everything he did, 2% revision rate. We presented this series. We had a 12% revision rate with silicone. A British series, 13%. Another series that we did in 2014 with a minimum of 10-year follow-up, 90% survival rate. Contrasting to pyrocarbon, Mayo Clinic, bravo, 31%. Watts, 23%. Wagner, again, from Mayo Clinic, 1 in 5, and that was a very good paper out of the Journal of Hand Surgery. I just don't think the 20% revision rate at 5 years is acceptable. Selig, I'm not sure where he or she is from, 23% revision rate. The Brigham, 23% at 6.4 years. So, I think it's important, a firm consent that you explain to the patient that with pyrocarbon, which has a much, much higher revision rate compared to the silicone implant, and I personally think pyrocarbon is unacceptable in this day and age. So then, in this very busy slide, you look at a literature review comparing PIP joint surface replacement versus silicone. Van Nuff reported pyrocarbon has a higher cost, which I mentioned, and it has a higher complication rate. Foster in a meta-analysis comparing the two. These are all comparison studies. Reoperation rate in their series for silicone, 1%, pyrocarbon, 7%, and metal on poly, 10%. Again, silicone wins out on reoperation. Helder et al., 2021 series, reoperation 5.4% versus 0.5% for silicone. Again, also a higher complication rate, 20% for surface replacement and 11% for silicone. Mayo Clinic article, Eric Wagner, revision of silicone, pyrocarbon, and metal on poly. Silicone and metal on poly had lower rates of implant failure and complications. So, even from Mayo Clinic, where Dr. Beckenbaugh, who was the originator of pyrocarbon arthroplasty, admits that there's a higher revision rate in the pyrocarbon group. And here's a quote from Steve Morgan, our ASSH president, Marco Rizzo, who is impeccably honest. Quote, pyrocarbon has become the major alternative to silicone and offers the potential for long-term implant survival. However, these implants require intact soft tissue constraints. Postoperative instability and dislocation can be managed with revision surgery that focus on stabilization of the soft tissues or conversion to silicone. So, silicone is the bailout for pyrocarbon before considering a joint fusion. So, in their article, although they favor, seem to favor pyrocarbon, they bail out with silicone. Some case examples. These are all my cases. So, this is kind of an interesting case. This is a nice lady in her mid-50s. I did PIP arthroplasties a year apart on all eight of her PIP joints. And this is her preoperative x-rays, which show a loss of cartilage space of the PIP joints. At that time, she was 47 years old. Here she is at about 10 years follow-up. You can see that from a radiographic standpoint, there's not perfect alignment in her fingers. In fact, and there's some loss of space in the PIP joint, but she's got reasonably good range of motion, and she's working as a full-time nurse. At 20 years follow-up, the arthroplasties have fallen apart. She's now in her 60s, late 60s. She actually was still working part-time. She has excellent range of motion, very crooked fingers, doesn't want any more surgery. She's very happy. So, now we look at another series that I did looking at pyrocarbon arthroplasties. The strengths of the study were that there were, well, the weakness was there weren't a great deal of joints, 31 joints, one surgeon. We had 100% follow-up. The person, the author of this named Tommy Sweets, he was a medical student. I said, Tommy, if you're going to write this up, you need to find every single patient. So, he went to West Virginia, Indiana, Kentucky, et cetera. So, that's a strength. We had 100% follow-up. 56 months, motion decreased significantly over time from 65 degrees to 35 degrees, variable patient satisfaction, unacceptably high complication rate, 90%. Here's an example of a patient who had a good-looking radiograph immediately post-op. She was from West Virginia, silicone implants broken. The interesting thing was she didn't even know it. Here's another patient immediately pre-op, and then at five-year follow-up, a severe dislocated swan neck deformity. Another case at just under a two-and-a-half-year follow-up, the implant was completely dislocated. So, I would conclude that silicone arthroplasty, PIP silicone arthroplasty, has stood the test of time. It was introduced in the late 60s by Dr. Swanson, and it's still around. There are not a lot of implant designs that have been around for 60, 70 years. No implant has been around longer. They're less costly. They're more versatile. They can be used, as I mentioned in the first slide, for the treatment of rheumatoid, osteo, and post-traumatic arthritis, and they have, I think, most important, a much, much lower revision rate. Thank you. Thank you very much, Dr. Stern. That was a fantastic point-by-point comparison of the pyrocarbon PIP arthroplasties and the silicone arthroplasties. I have a question of my own, and there appears to be a question in the chat box. We'll start with the question that's in the chat box. That's coming from Dr. Smitana, and the question is, Dr. Stern, do you think the difference in complications seen in these studies between pyrocarbon slash SR versus silicone is due to selection bias as to who receives each implant, age, activity, finger, central versus border, and comorbidities? I'm not sure I have a good answer for that. There's no question there's selection bias, but I think in general, interestingly, at least in my selection, I use pyrocarbon for less deformed fingers. Silicone you can use for almost any degree of deformity. There are definitely issues with silicone if you try to do coronal plane correction. I've never been able to do that. Maybe someone on the conference call has that, but sure, I think selection bias is a possibility, but given so many series from so many different countries and authors, it's hard for me to believe that pyrocarbon is still being done with the frequency that it is. I know that's a fairly bold outlandish statement, which I try to avoid, but that's my story. Thank you very much. I have a question. After looking at that statement that was put out in summary in Marco Rizzo and Steve Moran's paper, if you have the proper conditions and have meticulous soft tissue balancing, could you have a situation where it is preferable to use pyrocarbon, such as for an index finger where coronal plane forces are best? I sometimes like to use the baseball analogy. Is this like hitting a home run? Is the pyrocarbon like potentially hitting a home run where you could potentially have a complication, but if it works, it works better than a silicone in that situation in an index finger? That's a very good question. I think that in an index finger where there's collateral ligament integrity and you educate the patient to buttress her finger against the middle finger when she pinches, I think that pyrocarbon probably still has a place, but with caution. So, I think that in that circumstance where the biology is such that you have integrity of collateral ligaments and it's a radial digit, which you might be pinching with, I think you would be better off with pyro, might be better off with pyrocarbon, assuming there are no technical mistakes. But geez, from Mayo Clinic where you have, you know, tremendous surgeons who have great experience, 20% revision rate at five years, that to me is just not acceptable for her little PIP joint. Sorry to be so obnoxious. I myself do not have a lot of experience with this, but in theory, is this a procedure where with a long enough of a learning curve, do you think this would be something where a surgeon could become more proficient at this and produce results that rival those of silicone arthroplasties? Well, there's certainly no question that the more you do, the more you practice, the better you are. But I think the forces of nature plus the fact that you're operating on an already damaged joint is a strike against you or perhaps two strikes against you. And technically, arthroplasties are not difficult procedures to do. I'd say it's just not technically difficult. There's no question there's a learning curve. There can be intraoperative complications. You can fracture when you're putting the implant in. You can put an implant through the cortex of the bone. You can have permanent or you can not be able to correct dislocation, et cetera. But I don't think a longstanding technical proficiency would change things. I have one more question coming at us from the chat box that is from Bruce Leslie. And he asks, is there a difference between arthroplasties performed for osteoarthritis and traumatic PIP arthritis? Yeah, I think that's kind of a broad question, but I think for traumatic PIP arthritis, in general, there's more injury than just the hyaline cartilage. There's generally cartilage may be missing, extensor tendon or dorsal apparatus may be missing or adherent. Collateral ligaments may be insufficient. So, I think in general, at least in my case, if I'm going to do an arthroplasty for post-traumatic arthritis, I would much prefer silicone. And oftentimes, at least in the destroyed PIP joints post-traumatic that I've taken care of. Arthrodesis, a dreaded thing, is very effective. People do pretty well with PIP. People do fairly well with PIP arthrodesis if they have a decent MP joint and some motion at the DIP joint. Most of these patients do have some loss of terminal joint motion in addition to the fused PIP joint. Okay. Great, well, thank you very much, Dr. Stern. Thank you. Thank you, Bruce, for putting this together in the ASSH. I see there is one more question in the Q&A, but we may be running short on time. So perhaps, should I come back with that? No, you have time. I do, okay. All right, well, then I will give you one final question here, and that's from the chat box, and that is from Dan Ebert. I switched 20 years ago away from pyrocarbon and favor a metal poly implant. I have a very low revision rate, but currently have a MP joint dislocation. I assume you're asking about a specific case. Should I consider a silicone bailout? So we're talking about MP joint now. Okay, yeah, I think if you, yeah, I think that's a reasonable thing to do. I've also written on salvage of silicone. So let's say you have a rheumatoid patient, I'll try to be very brief, and the silicone MCP arthroplasty breaks. So what do you do? And they're symptomatic, because most broken silicone implants are not terribly symptomatic. They may, they're not symptomatic in terms of pain. So you can do a revision arthroplasty, but by that time, the soft tissue restraints, the dorsal apparatus, collateral ligaments are gone. Rather than using a plate and bone graft, we've published on using an intermediary rod and then a cerclage or two cerclages between the proximal phalanx and the metacarpal, and that actually works pretty well in rheumatoids. But I would probably revise the silicone if possible, but be prepared to do an arthrodesis with or without bone graft. Okay, fantastic. Thank you very much. Welcome. Thank you, Nicky. Next, we're gonna have Dave Roglesman introducing Paul Feldman. Good evening, everybody. No disclosures here. Like Nick Leung, I'm a hand surgeon up here in the Boston area. And I had the good fortune to spend several years with Dr. Feldman while he was up here. And of course, the talent of his career became a close mentor and friend. And I think about him all the time, especially when doing ulnar-sided wrist surgery. Dr. Feldman is a professor of orthopedics. He's one of the giants of hand surgery here in the Boston area, and made a huge name for himself at the New England Baptist Hospital in the field of rheumatoid hand surgery. And as you know, on the ulnar side of the wrist. And when I was asked to introduce Paul, I recalled an article I had read by Terry Whipple over a decade ago when he was given his perspective on wrist surgery. And he made a comment about the fact that significant contribution to the field of hand and wrist surgery come only from a few ventures into the unknown. And Paul has certainly done that with regard to the wafer. And Whipple had said something to the effect that he had done a wafer through a central TFC injury and tear. And when he came back and scoped the wrist several months later, it made him think that the hematoma from the wafer resection allowed the central TFC deficiency to heal with a cartilaginous patch. Paul, I'm gonna turn the slides over to you and you can explain to us how this all came to be. Okay, thank you, David. Let me see if I can get my slides up here. Okay, no disclosures on my end. Ruth, thank you very much for inviting me out of retirement to do yet one last lecture, but no more. The wafer procedure paper came out in 1992. And I have to say, we didn't start in 1992, obviously it started about 1985. What I'd like to do is just give you some of the backstory on how it came about. And then at the end, tell you how I think it's transitioned and whether or not it's still viable. Of course, my story is gonna be more true confessions and sausage making than a prospective rational progression. Prospective rational progression. So I think we're all familiar with Ulnar Impaction Syndrome. I'm not gonna go over all of the fine points with you, but there were several findings that I would like to point out, mostly on the x-ray. On the right-hand side, this cystic change in the lunate as a result of chronic ulnar side compression. And that came to play a part, which I'll get to later in the progression of developing the wafer procedure. The other thing that was of interest to me is that with an arthroscope, you can see this is the distal surface of the TFC. And in this case, open, there's some granulation tissue here, but had a central perforation, but the cartilage looks pretty much intact. And that's what you see if you look inside the space with a scope, but you can't, or at least I couldn't get a scope between the ulna and the TFC. On this side, this is the TFC pulled backwards, and so you're, or distally, so you can see the undersurface. This is the side that abuts against the lung, and the tissue is just torn up. There's granulation tissue and fragmentation. I had not, and I was not aware of how much damage was actually being done to the TFC until I looked at it from the perspective of doing the wafer. So I'd like to tell you that this idea came to me in a dream, and then I, like a very proper clinical researcher, progressed to the lab, and then IRB, and all of the other things from that. But that didn't happen. What I had was an index patient followed by a case series, and so I'll tell you what happened with that. I'd like to acknowledge the key contributors, which I'll list here. All of these people were very helpful in getting to the end point with the wafer. I also want to set the stage. So it was 1985, that's a long time ago, and this was the current state-of-the-art cell phone. This was the state-of-the-art laptop, only floppy disk drive. This thing is called a light box, and some of you may remember it. We used to look at x-rays with this. Arthroscopy was in its infancy, maybe a little bit beyond looking directly in the telescope, but if you can see on the right-hand side of the image, even with the camera and screen, it's still pretty fuzzy. This is where we were tactically. The index patient was DW. She was a 25-year-old woman who had an elbow injury several years prior to my seeing her. She had had two operations. She had had a radial head fracture that was resected. She developed mild ulnar impaction syndrome because of proximal migration of the radius, and so her elbow was revised with a silicone implant. No metal was available at that time, and of course the silicone fractured after a while, and she again developed ulnar impaction with increasing ulnar-sided wrist pain and had a lot of trouble with daily activities as well as sports activities. This was her elbow x-ray, and the silicone implant is here, but it's broken at its stem, and her wrist x-ray shows just how much proximal migration of the radius there was. I told her not to worry. We had a great operation. I had done a number of these. I extolled its virtues. It was simple, reliable. It's also fun to do. It's like being in the workshop. You cut something in half, and then you put it back together with hardware. It was a great operation from my point of view. Its advantages, of course, simple, effective, reliable, and a relatively rapid recovery, but there were some disadvantages, risk of nonunion, and the need for plate removal because the plate was usually in a subcutaneous area, and eventually it was very irritating to the overlying skin. However, her reaction was not exactly what I expected. And that's how I remember she had blue eyes. She was not having any of this. And the quote, which I also remember, was, well, let me get this straight. You want to take my bone, which is fine, cut it in half, put a plate on it, hope it heals, and then take the plate off? I'm not doing that. So that was a problem. She absolutely refused to consider anything else, and I didn't have any other good answer for her problem. So as we both sat staring at the light box with the X-ray on it, and I'm not really sure if she said, can't you take a little bit of bone off of the end of the ulna, or I said, why don't we try taking a little bit of bone off the end of the ulna? But regardless of who said it, that was where the idea occurred. And with trepidation and a lot of informed consent, that's what we did. So the turning point was her post-operative course. In those days, we admitted patients for pain control after surgery, so she was admitted, and I came back to see her the next morning, and she was gone. I asked the resident where she went, and he said she was doing fine. She wanted to go home. She said she had to leave, and so I discharged her. No problem. I'm sure she'll be back for her post-operative visit in a few days. She disappeared. She didn't come back for any post-ops. We couldn't track her down. No cell phones in those days, but she did show up on my schedule, pardon me, schedule about six weeks later. And again, with a lot of trepidation, I walked into the exam room expecting the worst, and I said, how's your wrist doing? And she said, it's great. I said, well, that's nice. Why didn't you come back? And she said, well, I had to leave right away because I'm in the Army National Guard, and the day after surgery, I had a report for my annual two-week training. And if I didn't go, they would either kick me out or I would lose credit for that. I said, oh, well, who took care of your dressings and removed your sutures? She said, oh, the Army medic did that. I said, no, this was a two-week training program. I knew a little bit about this. I said, would that include obstacle courses and pull-ups and push-ups? And she said, yeah. And your wrist, did it OK with that? And she said, yeah, great, no problems. So I figured after, with a sigh of relief, they said, I think we're maybe onto something. And that's when my associate at that time, Mark Belsky, and I started our series, which turned into 13 patients. The second turning point was a middle-aged woman who had less severe length discrepancy, but nonetheless had all of the symptoms of, sorry, who had all the symptoms of ulna impaction. And interestingly, her x-ray showed the cysts. So I didn't think much of that, did the procedure. And she did very well also. But I was sort of shocked to see that in six weeks, even though I didn't do the neatest job on that wafer resection, in six weeks, the cyst in her lunate had completely resolved. I don't have the view that shows that the tributary cyst also resolved. This one has the pisiform overlying it. But both sets of cysts resolved completely in six weeks. So then that was confirmation, for me at least, that this really was an effective decompressive procedure. So we continued with our study. We had a total of 20 patients, but we only had 13 that didn't have, that had purely a wafer done. The other patients had some other thing done, like a carpal tunnel. And we figured we didn't want to include those for potential confounding reasons. So why do we call it the wafer? Well, being a young surgeon about five years into practice and being prudent, I thought it might be a wise idea to use a substitute for partial distal ulna resection that might distance the procedure from its authors, just in case things didn't work out as we wanted. So I was calling it the notch procedure because I thought I was making a notch in the ulna. And as we were sitting around the dining room table with our medical illustrator discussing this, Mark said, it's not a notch. You're taking out a wafer. And we should call it the wafer procedure. And I said, great idea. We'll call it the wafer procedure. And that's where we got the name. So going to the original results back in 1992, they were pretty good. No loss of motion of the wrist or forearm, no loss of grip strength, no instability of the DREJ or arthritis, and the symptoms of clicking, crepitus, and pain associated with activity or load resolved. Using the DERO classification, everyone in that study had either excellent or good results and essentially double the number of excellent to good results. So we were happy with that. A subsequent study in the European literature in 2014 showed comparative patient satisfaction and outcome results. And you can see that all three procedures, wafer, arthroscopic wafer, and only shortening osteotomy, all had about the same patient satisfaction ratings, although note that in their study, arthroscopic wafer was 100%. And the outcomes were either good or excellent in a high percentage of cases in all three groups. So what about the evolution of the wafer? Well, it's become an arthroscopic procedure. I was a self-taught arthroscopist, and probably not a very good one at that, as were most of my peers. It just was not a standard procedure in our training. And as I pointed out earlier, the techniques and the technology were not particularly good. We didn't have small scopes, so wrist arthroscopy was difficult. However, that's changed dramatically. And I'm sure now every resident is well-trained in arthroscopy. We have great equipment, much better than before. I actually learned how to do it eventually and could repair a TFC. But I continued on with a modified wafer procedure. But these days, I think arthroscopy is taken over, and it's become the arthroscopic wafer procedure. So what's the current status of the procedure? Well, I went through the literature. And since 1992, there have been about 54 papers written, nearly half of those just in the past 10 years. 34 addressed arthroscopic wafer procedure rather than open. The procedure is indexed in Green's textbook. I was sort of shocked to find that the wafer was used as an answer choice in a recent ASSH self-assessment exam. You can easily find it on the internet. And it's pretty much become part of the hand surgery lexicon. I think all of our audience, if we talk about wafer procedure, pretty much everyone knows what we're talking about. My conclusions are arthroscopic wafer has become a standard hand surgery procedure and there's no need to retract the wafer concept. Thank you for allowing me to present this and now you know something about its evolution. Paul, thanks for that and we'll hopefully have some audience questions that pop up in the question and answer box. In the meantime, I know in your first index case, you talk about how the patient came back at six weeks feeling wonderful. Was that a uniform experience or was it more, sometimes it could be a fairly protracted course that requires some patience on both the surgeon and patient side? That's an excellent point because she was very unusual. I didn't have any other patient that recovered that rapidly or was able to take on the activity that she took on right away. She was very motivated, obviously. The problem with open wafer procedure has been very prolonged recovery time compared to only shortening osteotomy. I think this in both my patients and subsequent papers have confirmed that recovery is prolonged. Thank you for bringing that up. I think things have changed somewhat with the arthroscopic. I think it's less invasive and probably the recovery time is much faster. I would defer to any of those on the faculty or in the audience that are doing arthroscopic procedures to comment. I think for the audience and some of the panel members here, I'll put some thoughts down here that I'll read for the benefit of the audience. How would you define contraindications to the procedure or are there any cases where you prefer osteotomy first? As a follow-up to that, if in the case of a failed wafer, what are your options? Is only shortening contraindicated if the wafer fails? I'm throwing a lot at you here, but does the orientation and anatomy of the sigmoid notch play a role in your decision-making? Yeah, I didn't go through the contraindications, but number 1, if there's a significant ulnar length discrepancy and that index patient was right on the borderline of that, and I took four millimeters as the maximum that I would consider doing a wafer on, because it leaves just a small rim of articular cartilage at the DRUJ, so that was one contraindication. In that case, I would prefer an ulnar shortening osteotomy. I didn't have any failures of the wafer, but I don't recall having to revise any of the ones I did, but I think my fallback procedure probably would be an ulnar shortening osteotomy if there were enough articular cartilage left to preserve the DRUJ. I think you just preempted a question, I think, from your former fellow, Dr. Eugene Tsai, who said, in your mind, Paul, how do you decide wafer versus ulnar shortening in the index procedure? I guess I would add to that, is there a place for a wafer in the setting of the need for concomitant TFC repair, whether you're doing it arthroscopically or open? The original paper, to answer the last point, I thought it was very effective for being able to repair TFCC because again, before arthroscopy had matured, and I was comfortable doing arthroscopic TFC repairs, the wafer was an excellent way to see the whole TFC and be able to repair it very easily. I thought it was a great procedure for isolated TFC repair, if one were not inclined to do an arthroscopy for any specific reason. I'm sorry, the first part of the question was? In your mind, decision-making factors, are there any besides the limit of the resection that help you decide wafer versus shortening osteotomy? As I said, I love doing shortening osteotomies, but patients seem to prefer a less invasive procedure, and certainly now that it's become primarily an arthroscopic procedure. I think only shortening osteotomy would be the choice that would be second, almost always. All right. Thank you, Paul. I think our time is about up and we'll move on to the next lecture. All right. I'm going to share my screen here. I'm Samir Pari from the Indiana Hanson Shoulder Center, and I'm introducing Dr. Wolfe. Dr. Wolfe was going to give us a talk about about scapoid non-unions. Rehashing Dr. Wolfe's CV in about two minutes would be harder than fixing a scapoid non-union, so I'm not going to try and do that. On a personal note, I had the distinct pleasure and honor of training with Dr. Wolfe about nine years ago when I was a fellow at the Hospital for Special Surgery. Since that time, I've had a really great opportunity to work with wonderful hand surgeons at Loyola, where I used to work, and at the Indiana Hanson Shoulder Center now. It's rare that Dr. Wolfe's voice is not in my head when I'm doing a wrist operation on a scapoid or a scapular ligament, certainly, so certainly his contributions to the literature and speaking about, you know, teaching us about these things over many, many years, and as the editor of the Green's Hand Surgery, he's one of the great surgeon educators of our any generation, so I thought it'd be a great choice to guide us through the evolution of treatment for scapoid non-unions. I have no disclosures, sorry, nothing relevant. I have disclosures, but nothing relevant to this talk, I think. Thanks, Dr. Wolfe. All right. It's a great pleasure to join my esteemed panelists in tonight's webinar, and I'd like to thank Samir for that wonderful introduction. Sorry to hear that I'm in your head when you're operating now, and also my longtime friend and colleague, Bruce Leslie, for inviting me to be part of this. I have no relevant disclosures, and I'll speak to you tonight about my journey to scapoid nirvana. It's been a long and sometimes winding road. I think I've done just about every operation tried for scapoid non-unions. It's always been interesting and challenging, and of course, great thanks to the many mentors and colleagues and collaborators who've helped me along the way. As we cue the Star Wars music, let's take a trip down memory lane to the beginning, a long time ago in a university far, far away. In 1990, I stepped foot on the Yale campus for the first time as a young attending in hand surgery, and I was the sole hand surgeon at the university at the time. It was a lonely place, but a lot of fun, and I carved my niche out there. But at the time, scapoids had a very fearsome reputation. They were said to have an extremely poor blood supply, frequently went on to non-union. It was a small, strange-shaped deformed peanut, as it was called. We had inadequate fixation techniques. We had poor imaging, no mini-fluoroscopy, and there was really no dominant technique for scapoid non-union at the time. There were two prevailing techniques, that of the Rousset bone graft, which was repopularized by David Green, and the trapezoidal bone graft, it was eloquently described and illustrated by Diego Fernandez. Both were largely successful, but the results dropped precipitously off in scapoids with diminished blood supply, and then were completely unsuccessful in those with no bleeding bone. So with these hopeless results in these small avascular proximal poles, the scapoid earned the name of polecat, coined by Pete Carter. What, you ask, is a polecat? Well, it's essentially another name for a European carnivorous mammal of the weasel family, also related to the American skunk or the ferret. Like the scapoid proximal pole fractures and non-unions, they have a nasty reputation. They're aggressive, territorial, and fierce. But as the only hand surgeon at Yale, and faced with several daunting scapoid challenges, I girded for battle. As the young Padawan at Yale, I did the best I could to fight the fearsome scapoid fractures and the humpback scapoid non-unions with all the tools I had at the time. I used predominantly autogenous cancellous bone wedge grafting and K-wire fixation, and had my share of delayed non-unions, which I could always conveniently attribute to poor vascularity. And what today we realize were crucial advantages in the surgical treatment of scapoid fractures and non-unions were in the late 1980s, widely viewed with skepticism and even poor results, as you see here by this paper by Brian Adams, with the scapoid failing to heal in seven to nine cases, inaccurate jig placement, improper screw lengths, et cetera. So it wasn't immediately accepted, but the early adopters were ultimately rewarded with improved technology in both fluoroscopy and cannulated implants, which really were a big change and tremendously improved the scapoid fixation techniques and our aim and our length. And who can forget the scapoid allograft, again, of Pete Carter. But as we all know, nothing ruined good follow-up like long-term follow-up. And while the allografts did not work out so well, they may well have been a prelude to the hemihemate, the costal chondrographs, and even the medial femoral trochlear graphs of today. These were heady times indeed. So for the remainder of the 1990s, we were all putting in cannulated screws for every scapoid fracture non-union we could find, some with better results than others, unfortunately. But in 1995, Pete Carter again waved in with a seminal paper demonstrating that despite all prior results to the contrary, entirely avascular proximal poles were very capable of healing, as long as we used corticocancellous bone graft, good carpentry, and appropriate postoperative immobilization. Not long after, a bright young Yale orthopedic resident named Greg Merrill wrote up an enormous systematic review of over a thousand articles on scapoid non-unions with me and Mr. Scapoid himself, Joe Slade. Joe and I, I had the immense pleasure of honoring, I'm sorry, much pleasure and honor of hiring Joe Slade and working with him for almost a decade. There in the background is another bright surgical resident by the name of Seth Dodds, who continues to push the boundaries of scapoid surgery. And our paper showed that screw fixation and graft was much more successful than K-wires and graft. And the new kid in town, vascular grafting, was actually better than screw fixation and graft. Vascular grafting can be traced to a paper by Hori et al in Japan in 1979, wherein canine vascular bundles were transplanted into the canine proximal tibia in several situations. One intact, the second was isolated bone segments that were cut, removed, and put back in. And the third was a necrotized bone where the bone was killed. And then successful revascularization was documented histologically in almost every specimen, interestingly. The authors went on to demonstrate the success in several cases of Kienbach and vascular grafting of the scapoid. Fernandez and Egli published this paper showing success of this technique in 10 of 12 patients using the second intermetacarpal dorsal artery, which they transplanted into a hole in the proximal scapoid. And some of us call this the fire hose technique. It actually is an artery and a vein, to be honest, and it's tied at the end. And this, like Hori's model, was successful. In many, and I used it actually in many cases. Carlos Zydenberg's technique of rotation of the 1,2-ICSRA, the intercompartmental supraretinacular artery, ignited a firestorm of clinical and research activity when it was presented at the Henn Society in the early 90s. This was followed shortly thereafter by the Boller graft technique of Christoph Mathelin, and excellent results there, as well as a very practical rotation technique from Dean Citerionis, using basically a capsular flap and corticansis bone from the fourth dorsal compartment floor. Vascular techniques proliferated in the 2000, reports have dramatically improved union rates over non-vascularized autograft, shorter healing intervals. The Mayo Clinic compared Constantin Doria's technique of free vascular medial femoral condylar graft to the Zydenberg technique, all with favorable results. When I left Yale and returned to HSS in 2000, I rode the wave of vascular bone grafting and tried virtually every vascular graft for what we presume were a vascular escape for non-unions and with varying degrees of success. And here's a couple of the 1,2-ICSRAs and their results. Another patient where I did a Citerionis graft and its results. And a patient of using Fernandez and Egley's technique with the dorsal intermetacarpal artery, harvesting it, plugging it in. And there you can see over time, but it wasn't long before the contrary papers started coming out. And this from Washington U with Marty Boyer as a young surgeon showing that these vascular grafts had a questionable union rate, six out of 10 at two years. And Joe Dias and Tim Davis showing six out of 22 at three years made some of us start to question the utility of vascular grafting and even asked the question, were the 2000s an error of vascular grafts? What were we missing? The game changer for me was when I hired Steve Lee who brought with him a surprisingly simple and highly effective modification of the Rousset technique for scapoid non-union surgery, wherein we cavitate out any necrotic or fibrotic material from the proximal distal poles. We restore length of the cortical strut. We pack it full of cancellous graft fresh from the distal radius and fix it with a cannulated screw. The lunate is pinned to neutral extension which reliably corrects DZ and rotates the proximal pole into anatomic alignment. Patients are casted for above the elbow for four weeks to protect that pin. The pin's then removed and they're put in a short arm cast for four more weeks. And a CT is always done at 10 weeks, reliably showing union in just about every patient. The first series are 17 patients we demonstrated 100% healing rates at an average of 15 weeks with full correction of the inner scapoid angle, humpback deformity and DZ. With these results, we were emboldened to utilize that technique on virtually all scapoid non-unions, including small avascular proximal poles. A typical case is shown above and a 20 year old college student who fell from a balcony at 2 a.m. and severely fractured both scapoids, presenting at 14 months following the injury. Autogenous bone, corticocancellous bone grafting and rigid internal fixation enable complete healing through creeping substitution as promulgated by Pete Carter nearly two decades earlier. And in both of these, I think you can see the cortical strut alongside the cannulated screw. So when are vascular grafts for scapoid non-union necessary? Well, how about never? In the next five minutes, I hope to demonstrate that there's no consensus to support the routine use of vascular grafts for scapoid non-unions, that our vascular assessment techniques are woefully inadequate and that true infarction of the scapoid proximal pole is decidedly rare. With one exception, the fragmented proximal pole. So that is a truly infarcted but rare situation. I utilize all these different techniques as needed. My preferred solutions are the medial femoral trochlear graft, which I do with my esteemed colleague, Doretti Fufa. And here you can see just one of those cases. We pin the lunate, use the scapoid screw. The costoconal graft, which was popularized by Mike Sandow early in the 1900s, 1990s. And you can see another one of these grafts and this is the technique. I love this, but it's a little bit fiddly and you're working on the pleura of the lung and there's some complication potential, but it does work very nicely. And finally, the hemihemate graft popularized by Sanj Kakar and Elsa Sahn at the Mayo Clinic, where you take a portion of the hemate, you flip it and use it for the proximal pole, use a scapoid screw. Nice, brand new, fresh corticocancellous articular graft. Again, pinning the lunate. Very successful as long as you can get the hemate to appropriately fit the scapoid. For those of you who haven't read a book called Sapiens, and this is probably two decades old by now, but Noah Harari proposes that it's myths that bind us, that common beliefs enable large groups of us to work together towards common goals, something that no other animal species can do. At least we don't know of any. As hand surgeons, tens of thousands for us for decades have operated on the myth that proximal scapoids are avascular. What if this isn't true? Let's examine the science behind the myths. I'm gonna show you that proximal poles are almost never actually dead. Furthermore, we have no consensus on even the definition of AVM. Punctate bleeding, we all know, does not adequately predict capacity to heal. There are no standards for preoperative MRI. Histologic avascular acrosis does not predict healing capacity. Vascular graphing is not always effective. To illustrate this, Dr. Pinder and colleagues examined 48 studies of 1600 patients with a 90% union rate and concluded that there's no evidence favoring a particular technique. They further concluded that there's no statistical advantage favoring vascular graphs in the treatment of scapoid nonunion. In an exhaustive meta-analysis of nearly every paper ever written about scapegoat nonunions, and 12,618 scapegoats, Schneider, Ranci, and Grenot-Schmidl, excuse me, from Austria, again demonstrated there was no evidence to show differences in rate or time of union between vascularized and nonvascularized grafts. Why is this? Well, five years ago, Schneider, Ranci, and I set out to bust the myth of proximal pole avascularity. Schneider was a pre-medical student, actually, it's more like 10 years ago now. Schneider was a pre-medical student when he wrote the paper, and he's now a resident of New York's Mount Sinai Surgical Program. The purpose of our study was to determine if scapegoat proximal pole avascularity correlates with the likelihood of healing or the time to union. Our hypothesis was the proximal pole avascularity would correlate with increased union rates and shorter time to union in nonvascularized grafts for scapegoat nonunion. We enrolled 35 consecutive patients with scapegoat nonunion in an IRB-approved longitudinal registry at an average of 32 months from injury. We assessed vascular supply of the proximal pole using MRI in 25 of 32 patients, presence of interoperative bleeding in all, and preoperative postoperative histology in all 35 as measured by two independent histologists, internationally known bone histologists. The entire hand service at HSS treated virtually every proximal pole with avascular grafting. We did vigorous curatage of the proximal distal poles. We used nonvascularized autogenous cortical cancellous grafting from the distal radius with a correction of DZ and rigid internal fixation with a cannulated scapegoat screw. We studied nine proximal poles, 21 waste, and five distal nonunions. MRI demonstrated no entirely infarcted, but 39% ischemic proximal poles. Bleeding bone was assessed as fair or poor in three quarters of our patients, and histologically, nearly half demonstrated greater than 50% trabecular necrosis, and three patients demonstrated zero remodeling potential. By 12 weeks from surgery, 33 of the 35 consecutive patients were healed by CT scan. We had two delayed nonunions, but ultimately, all 35 patients healed without further bone graft. We identified no significant associations between time union and any measure of vascularity. Similarly, there was no correlation between MRI or bleeding points or histologic evidence of osteonecrosis. Importantly, there was a significant association between all histologic measures of osteonecrosis. Our study was limited by a relatively small number of patients. This was not randomized. We used non-contrast MRI scans, and complete histologic sampling was not possible of the entire proximal distal row poles. In summary, despite a relatively high incidence of proximal pole ischemia as demonstrated by accepted measures of vascularity, we confirmed rapid healing in 94% and union in all 35 patients. We truly believe that avascular necrosis to proximal pole is decidedly rare, that vascularized bone graft is rarely necessary, and that vigorous curatage, dense packing with fresh autogenous bone and rigid fixation leads to healing, regardless of the vascular status of the proximal pole. When we look at this from a national perspective, and assuming there's a conservative 5% nonunion rate and also a conservative 30% rate of osteonecrosis, non-vascular grafting would lead to a cost savings of $403 million in the United States alone. This even includes a 5% autograft failure rate requiring vascular grafting. Interestingly, the cost would not equalize until the non-vascular failures climbed to 57%. These studies have the potential to change not only our understanding of scapeloid nonunions, but also their treatment. Based on this study, we believe that histopathology is the only accurate way to measure scapeloid vascularity. Further, non-vascular grafting simplifies the treatment of scapeloid nonunions, and it also creates a substantial healthcare cost saving. More importantly, these data might stimulate larger trials to identify which scapeloids might benefit from vascular grafting. So, as we ponder scapeloid reconstruction, we have an obligation to look beyond the myth and re-examine this foundational belief of our specialty. To answer the question, do avascular proximal poles require vascular grafts? I think the pole cats of the world would answer a resounding no. Thank you for your attention, and I'm happy to take a question or two if we have time. Dr. Bull, thank you so much. That was an incredible overview of some of the underpinnings of what led the hand surgery world to head down this road, and maybe some thoughts on where maybe it needs to settle out. I don't see any questions from the audience, so I'll ask a couple here to maybe spark some conversation. Could you comment a little bit maybe about your thoughts on approach and how that maybe affects the vascularity of the scapeloid? I remember whether you think a dorsal approach or a volar approach or a scapeloid in a revision setting that's been operated on from one side should be approached from the other side, or if that affects any of these things in your opinion? Maybe I was too close to Kirk up in Hartford, but Kirk Watson said it really doesn't matter that you can operate from either side. Having done enough of these now, I would tend to believe him that the scapeloid is a very resilient bone, that creeping substitution is a very powerful rule in our specialty, and even with a dead proximal pole, you can bring it back to life with creeping substitution. Dr. Leslie asked a question also that may be helpful. Why in the hybrid Rousset technique do you feel the cortical graft may be necessary for rigidly fixing the scapeloid? Two reasons. One, after you generally have the humpback nonunion that Peter Amadeo coined decades ago, and that means that the two poles have collapsed on each other, so you've got a large, really that wedge defect that Fernandez talked about years ago. So you've got this giant defect, and despite what Mark Cohen and Jesse Jupiter showed that you can get it to heal with cancellous graft alone, we both believe that putting that cortical strut in there brings the two poles right out to their appropriate anatomic length. Then you can pack in all your cancellous graft, and then putting that scapeloid screw right next to that, it gives both centripetal and centripetal forces to both compress and expand all of that cancellous graft into all the interstices of your cavitated bones. Do you feel that there are any cases where there is a volumetric defect that needs to be addressed that that technique might not be perfectly applicable to? Like after a very cystic nonunion where you have to take out a lot of bone, you don't have any opposing bone, and it's an intercalary segment that you might want to replace. Are those situations where you might consider a vascularized graft, or do you stick with this technique? I mean, those who've studied malunions show that really it doesn't matter if you get a malunion. So I mean, if I truly had a missing waist of a scaphoid, I'd probably try to butt that together and accept a shortened scaphoid, which will undoubtedly go into a little bit of dizzy. But honestly, Pete Carter showed us a long time ago that that dorsal rim is almost always intact. And that's been my finding as well, that when you prop it open, you're propping it open against an intact dorsal wall. So I really haven't run across a completely absent waist of a scaphoid. We do curette out, you know, the proximal and distal poles completely. Scott, great talk. Sorry. Sorry. Go ahead. Go ahead, David. It was a great talk. And, you know, the longer I've been at it, I think, you know, one of the keys is teaching our residents and not to be shy about aggressively debriding the non-union site. And you can always backfill it as you outline. You know, one thing that was a little bit absent, and I think it says something, I haven't gone to the crest, you know, in over 10 or 12 years. And I think if you plan use of the distal radius correctly, and Garcia Eliza talked about the interlateral wedge, which I, you know, which I favor when I need some, you know, additional structural support in addition to the Kinn-Sells bone. So is there a role still in your practice for a crest or have you gone to that less and less? No, I actually haven't used a crest in a long time. I had to do a different, I had to do a humeral case the other day, I would use crest, but but not for scaphoid. You know, there's the Argentinian technique of Keenbach, treating Keenbach, and just with an osteotomy in the radius and stimulating vascular graft. And I think that's actually what you're doing when you take bone graft out of the radius, is you're actually stimulating a vascular milieu, if you will, around the scaphoid. I have no way to prove that though. Another question that came through here is regarding the hybrid roosay technique. If you could comment about the specifics or maybe some technical tips when you're dealing with a very small proximal pole fracture in that setting. You know, many people prefer to approach those very proximal pole scaphoid screws from the dorsal approach, just given the ability to target it adequately. Do you run into any technical challenges with those very small proximal fractures from the Ebola approach and the hybrid roosay technique? Yeah, that's a great question. I use, I'll go down to approximately a third, maybe even a quarter of length of the scaphoid in terms of the smallest proximal pole. I would treat that way. I'll cavitate it out less aggressively. I'll leave some cancellous bone in there to put a screw in. And importantly, even though I do the whole thing from the bowler side, I make a small incision and put a dorsal screw right down the middle, just as Joe Slade showed us so long ago. So I do put that one in dorsally, dorsal to palmar. Thank you. I think we're out of time. That was a great overview. I really appreciate that. And thank you. Thank you, Samir. All right, we're going to move on to Dr. Lee Osterman's talk on wrist arthroscopy. As you know, Lee is the consummate world-class clinician and surgeon and professor of orthopedics at Thomas Jefferson. He's a prolific author. He's a current founding member and a president of the Philly Hanson Shoulder Center, and a real expert in the field of advanced wrist arthroscopy. Lee, it's a pleasure to have you talk about the ulnar side of the wrist again and issues beyond the TFC. So thanks for taking the time. I'm good. So my love affair with wrist arthroscopy, started about 35 years ago when I was a resident. And at that time, when you had ulnar wrist pain, it was like the back pain of the wrist. Nobody wanted to be faced with it in clinic because there were a lot of potential diagnoses. And the surgery, at least the open surgery, was almost more morbidity than the problem that they were presenting you with. We then began to think about, because arthroscopy was becoming the darling of the knee and the darling of the shoulder, that maybe with smaller scopes we could begin to look at things. And so this was one of the first conferences in 1986 with Gary Poehling in the area. There's a young surgeon, yours truly, and many people went on to become leaders of arthroscopy. This early arthroscopy, we took knee scopes and shoulder scopes and essentially put them in the wrist and move the wrist around the scope, not the scope around the wrist. Bill Borah, who was my mentor and a close friend for a better part of my young practice, and I began to say, why can't we design a smaller scope? And so we came up and published this as the first sort of publication, the Journal of Hand Surgery, about the use of a smaller scope. We made a little more ergonomic, making a kind of ball, which was what was being used on computers at that time, and it was a small 1.5 millimeter scope. Not long after that, Jim Roth, a Canadian hand surgeon, he was a good arthroscopist of all joints, but using the larger scopes, the 4.0 and 4.5, again published that it was helpful to look at a TFC lesion in using that arthroscope. Finally, in the Hand Society meeting in 1987, yours truly presented the first paper, which then was published in the Journal of Arthroscopy on the arthroscopic treatment of tears of the triangular fiber cartilage, with good to excellent results in the majority of patients. Nowadays, if you do an internet search on arthroscopic TFC treatment, you'll get 66,000 plus hits in 0.51 seconds, so it's become part of the understanding of treating the ulnar side of the wrist. In fact, wrist arthroscopy became considered the diagnosis, the gold standard, if you will, in the treatment of TFC lesions. Terry Whipple, in 1992, came out with the first book on arthroscopic surgery at risk, talking with four or five chapters on what to do with the TFC, and then began to push the envelope a little bit further. Well, what have four decades of small joint arthroscopy taught us? I think they've enhanced the dimensions of surgical anatomy. They really have opened us to see some of these 45 so-named ligaments of the wrist. They've allowed us to have a very accurate diagnosis, and of course, they've given us a therapeutic tool to treat patients. In fact, today, wrist arthroscopy is still the fastest-growing arthroscopy. Obviously, much more knee and shoulder is done, but we're the fastest growing by numbers in terms of what joints are being scoped. For me, the critical point is it's improved understanding of wrist anatomy. What's changing in the game? Well, if we look at the tools of the trade, one thing that's changed is we're now going to iPad kinds of things instead of this giant tower that you can see. Instead of having this room set up and large things, you can almost do it in a small procedure room if you want. We then have continued to shrink the scope. You still need traction to open the space so you don't scar it up by banging around, but where scopes are getting smaller and smaller and smaller, Sajka Kaur has talked about this scope, which is a flexible scope, which allows us almost to go out to the PIP joint overall. Furthermore, one of the things that always used to bother people, these small scopes are very fragile. If you're a teaching institution, it would seem like every week we'd have a scope out on repair or another scope, or we get a matching piece that didn't fit this scope or the wrong cord or the wrong light source, et cetera, et cetera. Well, now I think the future is going to be disposable scopes for small arthroscopy where everything comes prepackaged for you. That decreases sterilization costs, so there's some saving there. Scope repair, as I mentioned. You also need tools, and you obviously can't reach inside a joint, and so the probe becomes your finger, and we now have smaller instruments. The probes, the shuts, the suction punches have all been miniaturized to allow us to do things. Whether you believe it or not, at least some of the synovectomy tools and heat probes allow us to do capsular shrinkage, and in the wrist, unlike other large joints, we immobilize for a few weeks, and so that allows us to potentially use this as a tool. One of the problems in the wrist with some of the larger synovectomy motorized shavers, they sort of gum the tissue, and you really can't excise it well. The other thing that's moved along is I learned arthroscopy, as do most of the large joints, on what we call wet arthroscopy. We had pumps in the room, and now we're learning particularly that dry arthroscopy gives you a lot more chance to be in the wrist without getting a soggy bag of fluid. It may allow better visualization, particularly if you're doing scaphoid bone grafting, which we do for scaphoid non-unions using cancellous bone, as Scott just suggested to us, for repairing ligaments in the joint and for articular reduction so you don't get the leakage that you might get. The other thing we started off with just essentially pretty much radiocarpal portals, the 3-4 portals, all named because of their intervals between the extensor tendons. We kind of had a radiocarpal portal, a 6-R portal, just radial to the ECU, and one mid-carpal portal. Well, now we've expanded. We have volar portals, we have triscaphe portals, 1-2 portals, and each allows us to see other dimensions of the wrist. We have just a radial ulnar joint portals. So, this is kinds of things. With the volar portal, basically, you can see what you see here, the scaphoid coming through that workhorse 3-4 portal. When we establish a volar portal, which a lot of people don't use, we usually do it in an in-and-out fashion, as you see here, coming between the ligaments, establishing the portal. Well, this has given us another diagnosis that popularized by David Slutsky, that you can see the dorsal radiocarpal ligament. You can look at dorsal rim fractures. It's good for contracture release and ganglion excision. And so, here is one of a case where we're repairing a torn dorsal radiocarpal ligament. Most of us probably think I haven't seen one of those, but these are people who have variations on dorsal wrist pain, no ganglion in place, who've had some sort of fall. And if you think about it, every ligament in a wrist that is subjected to abnormal forces is potentially torn. And so, you can see this on your MRI. There's the torn off dorsal capsule. The lunate hasn't yet collapsed in a deformity. You can now see it, and you can repair it through that thing. One plea that I always like to make before you go into any arthroscopy is when you have ulnar wrist pain, don't just say, well, I'm going to schedule you for a scope or I'm going to get an MRI. Make a diagnosis at least tentatively. Only the National Hockey League gets away with calling any injury an upper body or a lower body injury. You need to have a specific thing. So, I never go into an arthroscopy saying, well, I'll see what I see. I have a game plan and thought, and that game plan is developed by doing what I think is the algorithm you should use in any ulnar wrist pain workup, the usual things that we know about from history inspection. I happen to like grip strength for a lot of things before you get to arthroscopy. And so, for that physical examination, look for points of asymmetry and tenors. Ask the patient to put a dime where it hurts most. If they can't put a dime on it and they put a dollar bill over their whole hand and wrist, you're going to have a hard time trying to help that patient overall. In a study we did of 50 patients, our clinical diagnosis was about 68% agreeing with the final arthroscopic diagnosis. MRI wasn't any better and not statistically different, being about 74%. Also, remember that 90% of ulnar wrist pain is ulnar wrist based, where only 50% of radial wrist pain is radially based and often has an ulnar origin. Furthermore, when you're doing diagnostics, don't think every ulnar wrist pain is the TFC, as we'll see. Therapeutic indications have expanded. Obviously, synovectomies and loose bodies are one of the early stages of arthroscopy, but ganglion resection was one of my favorites because I hated the dorsal ganglion with a big incision, some stiffness in the wrist, and the inability to see what lesion in the wrist might be associated with that ganglion. We now address a certain percentage of interarticular radial fractures, articular fractures of the scaphoid, certainly ligament injuries, contracture release, and for arthritis, if you so choose, and more so in Europe than in our country, proximal rocarpectomies. I do all my pisiformectomies arthroscopically, and if you're Dr. Ho in Hong Kong, he does all his fusions, at least partial ones, arthroscopically. Now, the problem is that arthroscopy is, for the most part, a little bit of elevated anecdote and class IV studies. We don't have good BSE for the most part, but you can, as you see, easily debride a central TFC tear. You can do a sinovectomy. You can resect the dorsal ganglion, which you can see looking from the operative portal, and you can fix a distal radius. Well, the prevalence of TFC injuries is high because as we get older, it's one of those wear areas in our body, and particularly our wrist, and depending on what study you look at, almost per age, at 50, 50% of people will have an MRI evidence of a TFC tear, at 60, 60%, etc. They're not all symptomatic, and so here you see the classic MRI central tear, but here is a classic German textbook talking about real anatomy with one of the first ways to open the wrist like a book, and they call this normal. Well, this has a large TFC tear, which is a central tear, so they saw it almost as a normal lesion. So, remember that. When this is a patient who was sent to us with a diagnosis of ulnar wrist pain with a big central TFC tear, that was the cause of their pain, but their examination didn't hit completely with a TFC tear. They hurt more when examining the ulna, and so when you scope this, what we saw with the scope now in the 3-4, as we followed this wrist around and the radiocarpal portals, we found that the real issue going on was a large, here's the TFC tear, there was one, but there's no reaction around it. It's a stable tear. You don't see a lot of sinusitis. When you come in the ulnar side of the wrist, suddenly the problem becomes obvious with a large, completely shredded ulnar half of the lunate with no articular cartilage on it, not from an impaction lesion, but similar to what you might see with an impaction lesion. Andy Palmer back in the day gave us TFC identities that we had the central lesion, the peripheral lesion, what he called the 1C, which is really an ulnar extrinsic problem, and then the 1A, which was torn off the radius. In one study, when we looked at chronic wrist pain, who had, this is an early study when arthrography was felt to be the thing, and Lou Galula was saying you got to do all three compartments. These were people that had normal studies. The only abnormal study in the group was some had a positive bone scan. Well, if you broke down, there were 23 people, about a third of the group who we couldn't find anything wrong, probably because we weren't smart enough, but certainly we couldn't find anything wrong. But you can see that ulnar extrinsic tears and peripheral TFC tears were the most common things that you didn't know other than chondromalacia. We often talk about it as being the gold standard, but I'm not sure it truly is because, again, there's a lot in the eye of the beholder. Everybody can identify a central TFC tear. When you get into the more subtle diagnoses, peripheral TFC tears, ulnar extrinsic tears, it can be a challenge, and so we did a study where we sent 10 identical full stem to stern wrist arthroscopies to seven arthroscopy mavens and wanted to see if we all came up with the same diagnosis. The inner observer from seven people who you would recognize, including yours truly, our agreement across the board was only 83%. So, the gold standard is a little tarnished when we start to talk about wrist arthroscopy. When we look at the wrist, you should do a systematic examination. Here we are in the three-quarter portal. There's your proximal scaphoid, your radial extrinsic ligaments. You're now looking at what used to be called ligament test tube, but it's just a vascular mechanofibral leash. Now we're looking at the lunate, and as we come over, we come into the triangular fiber cartilage, and when you'll see an arthroscopic TFC like this with a central almost bucket handle tear, it's easy enough to make and to breathe that without destabilizing the wrist because the central portion of the TFC is not part of the stabilization associated with the edges of the triangular fiber cartilage. You need at least to look at an ulnar portal. You cannot look up at the LT, which we just passed, nor can you go in the piso-toqueto joint, which you can get in in about 85% of wrists. It's a very easy scope, and the piso-toqueto is the second most common site of arthritis in the wrist after a slack wrist. Ulnar extrinsic ligament injuries, I would venture to say most people have never seen one or don't think they've seen one. This was really Palmer's 1C injury, and it's this combination of tears. Dick Berger was one of the early people to popularize this, and in 300 and some scopes that he did at the Mayo Clinic, he felt it was present and the main cause of the pain in 20% of people. The basic concept is you have a torque injury, particularly if you're in a racket sport, be it a golf club or a baseball bat, and you get a torque injury which separates the ulna luna and ulnar toqueto ligaments from each other or pulls them off of the attachment to the TFC. Always when you're looking at an ulnar wrist pain, make sure you don't have a subluxing ECU tendon because of its intimate association with the peripheral TFC. Here's a 22-year-old professional hockey player, twisted his wrist during a slap shot, ulnar pain but able to play. Over the next few months, however, his power shot just wasn't there. He had tolerable pain, but he couldn't land a shot. His exam showed that he was tender on the ulnar side of his wrist, more volarly in the area of what we call the fovea sign, which is you put your finger right on the pisiform and slide it slightly dorsally. Most TFC injuries will hurt more on the dorsal side of the wrist, and so this fovea sign has a great level of accuracy. You'll also see a carpal sag sign where the carpus will supinate off a bit of the distal ulna, and that's a very obvious sign where you see sort of slouching, if you will, on the ulnar side of the wrist. It has nothing to do with distal radial ulnar joint instability. The distal radial ulnar joint is stable. Often MRIs are not sophisticated enough to read them. You'll often just see a lot of fluid, as we see on this area. They don't often call it, but it's fairly obvious when you scope the wrist. Here's the intact floor with the probe in the LT above, ulnar extremities below, TFC in the foreground, and when there is a tear, you can put your probe along this split tear, and you can go, because this covers the pisotequetral joint, you can go in that joint almost like falling in it. You don't have to look for it, and this is kind of what it looks like. It's a very subtle injury initially, but your physical examination correlates with this. The TFC is just off the field. We're putting the probe in this kind of synovitic sort of open tear, and you can then repair it arthroscopically in an out-thin fashion. People that have looked at this, this is a paper that Randy Culp and I did way back in 2012, looking at ulnar extrinsic tears only. Again, professional athletes being high on the list. The other thing is we now can look in the midcarpal joint. I have proselytized forever that if you do a wrist arthroscopy and don't go in the midcarpal joint, I think it's less than complete arthroscopy, because the midcarpal joint lets us define what's going on often with our scapholunate and LT ligaments, because if you have a ligament tear that's important and decompensating to the wrist, you should see synovitis at the reaction site. For the SL, the triscaphy, and for the LT, with the proximal pole of the hamate. It also is where you're going to do scaphoid reduction, and that allows you, for example, to see normal bare spots. It allows you to see the ulnar midcarpal ligaments, and you get a nice look at the capitate to evaluate the capitate. Should you be deciding, what should I do? And say someone who has a scapholunate dissociation, you're not quite sure of the age or the quality of the cartilage in trying to make a decision as to what to do. So here we have a young professional pitcher for the Phillies, who fell on the dugout when he was in AAA, called up to the majors, started pitching, pitched with wrist pain, but was fairly effective. And here were his plane films, waist scaphoid fracture. One would argue that there's minimal displacement, though I believe if you see any displacement, it has an element of instability. CAT scan, as we can see, MRI. Again, Scott wouldn't say that this was ischemic, and nor did we. But here's what you see on wrist arthroscopy. We're in the midcarpal joint, looking in the ulnar midcarpal portal. There's our scaphoid, and you can see the amount of play that you have just with a portal. You can then reduce it, and now you can then percutaneously put a screw, so that most of my acute scaphoids will be done in some sort of arthroscopic fashion that Joe Slade, who Scott mentioned, was a high person. I do believe that CAT scanning, particularly in high-end athletes, to make sure you're healed before allowing to return to full unrestricted play, and he did go back. And so when we looked at arthroscopic role in professionals with this, we had a return to sport fairly early. The other thing that I find extremely relevant for ulnar wrist pain is the concept of the type 1 and type 2 lunates. Most of us, 76%, will have that extra facet of the hammock, which can vary in size from 1 to 6 millimeters. When you have a large interface, you tend to get loading in this area, and loading, particularly if you're playing golf and racquet sports, leads to shear, and you can get what we call hammate impingement. And so when you look in the midcarpal joint, there's the LT, capitate above. Probe is in the ulnar midcarpal portal. You can begin to sneak around to the proximal pole of the hammate. Vegas and his crew in a number of studies proved the association of type 2 lunate with hammate arthritis. And when you look at an MRI, you can see it. Andy Palmer coined the HALT lesion, which is hammate arthrosis, when you have LT instability. The HAH lesion, which is hammate arthrosis, associated with a type 2 lunate. So here we have a professional golfer, acute ulnar wrist pain after a miss hit, unable to play effectively. As he traveled the circuit, he saw a bunch of different sports medicine mavens, was told he had a TFC injury, but his pain was not there. His pain was only on ulnar deviation, and it was midcarpal pain. And if you look, this was an early thing. His arthrography, which was done somewhere, was normal, but he has that large type 2 lunate. And here you go, when you look in there, he's ebernated all of that cartilage where it's impacting. And so you have an easy treatment for that. You bring in your burr, and you take down that ulnar cartilage. And you can see it on the thing you're taking about two to three millimeters away. Not unlike what you do for an arthroscopic wafer that Paul Felden alluded to earlier. Our results in the HAH lesion, where we have LT instability, are not as great as we would like, and I don't necessarily favor arthroscopy for isolated or unstable LT injuries. But certainly for the HAH lesion, where there's no LT instability, the results in a seven-year follow-up were excellent. Finally, remember that when you're doing fractures, the goal of arthroscopy is to allow you to get a congruent joint surface. And I think the final thing that I will say is that what has changed my treatment in a biggest way recently is all of my perilunates now with those, unless they have an obvious carpal tunnel situation, I will do arthroscopically. This has become the treatment of choice almost in many hand centers in Europe. So here we have a professional hockey player again, wrist slams into the board. Here's his locker room x-rays with a classic perilunate dislocation. Here you are scoping, and you see hemorrhage. You can drive through the scapholunate area. You can drive through the LT area. There is some cartilage damage, which you see, which you don't appreciate on the area. Ligament, this is the instability looking at the mid-carpal joint. Treated with anatomic reduction, and here we're using shrinkage. I'm not sure how important that is, but then this is an early case which we treated with pinning. Nowadays I would use screws across the radiocarpal joint, and back to playing at about three months with good grip strength, as you can see, no secondary collapse, and reasonable motion. Most of us, when we have perilunates or transcaphoid perilunates, say we want a stable wrist with 30-30, not everybody gets that. And so, in our one-year follow-up, we saw 70% of wrist motion, no re-ops, and two-thirds had totally normal x-ray parameters. At three years, it continued to be held up. So, it can be used, this is Kim's paper in 2015, again showing a fairly complex wrist injury treated arthroscopically with reductions. It's less invasive, and I think it has the same results, and you get less stiffness overall. In conclusion, the wrist arthroscopy is not harmless. Larry Schneider, who unfortunately passed about a month ago, used to say, Lee, whenever you put a scope in the wrist, if it was normal, it doesn't come out normal. But I would caution you, if you can't see something, don't shave it. You shouldn't be four hours on a wrist arthroscopy. If you can't do it in an hour to an hour and 15 minutes, I think in general, you ought to open it up instead of this. Now that we're dry, you could argue for a little bit longer, but still. And I think one of the greatest things is arthroscopy or procedures, when you have open ones, which you don't look so cool at, now using arthroscopy, you're much closer to, as the palmists say, the area of the wrist, which really gives us the secrets of life. So thank you. Well, Lee, thank you. Wonderful, nuanced approach to the ulnar side of the wrist and hand, and exactly right. I think we would all agree, it's not always a TFC, and you have to be nuanced. If we were to have this talk and project 10 years from now, the state of ulnar wrist pain and diagnostics and therapeutics, do you foresee in-office chip-on-tip technology like nanoscopes replacing MR as a staged approach to potentially the operating room and the advanced arthroscopic techniques? Well, if I was a rheumatologist, I might argue that. The rheumatologists are trying, because they like synovial biopsies, et cetera. So the problem is, I think no matter how small the scope is, you're going to have some, you have to know your anatomy. Scoping has obviously become kind of a Nintendo game, and some of our younger surgeons are much more facile than I was at their stage of the game. I'm not quite sure if it will replace MR, but I think as we get to, for example, we have several contracts where we're given a certain amount for treating a wrist problem. And do I want to spend it on an MRI and get less? So if my package deal is X, I may not want to spend a lot of time. We found that for the MRI, while we all get them, we looked at ulnar wrist pain in 50 patients with MRIs which were ordered by their family physician or by a general orthopedist. In only two of those MRIs did the MRI change what you would have done. One was an early Keenbox disease, which you couldn't see, and one was a small osteoid osteoma of the capitate. Other than those two, out of 50 wrist pain things. So I think, you know, the MRI has gotten better, but I don't think it replaces things. And I think as we get better, certainly the use of the arthroscope, whether you do it in a small procedure room, things. We have done some under local. In fact, Greg Bain and his crew have gone to local for scoping a lot of their wrists with less traction, so they don't use a lot of traction. And they've shown that they can do many, not all, but many of the things, certainly in TFC land, that we would do with the traction device, etc. Thank you. I want to thank everybody. We've come to the end of our allotted time, and I want to thank all the participants, the speakers, the moderators, and also the people who have signed up for this course. And I want to remind all the participants that you will receive an electronic copy of this webinar sometime in the next week or so. I also want to make a pitch here, and I'm going to I also want to make a pitch here for the benefit of clinical experience. There's no question that randomized controlled trials have advanced our knowledge base. But there's still a place for clinical experience, and this was underscored by one of my favorite papers, the tongue-in-cheek parachute study in the British Medical Journal in 2018. If you're not aware of it, you should look it up, in which they did a tongue-in-cheek randomized controlled study of patients who jumped out of the airplane with and without parachutes. If there's interest in this format that we generated tonight, where you have experienced people looking at their years of practice and commenting on what works and what doesn't work, then please let the Hand Society know, and we'll try and run another webinar like this, or perhaps have a podium presentation at the upcoming Hand Society. Thank you, everybody, for participating. If there's any questions, if there are not any questions, we're going to sign off.

Dr. Wolf

scaphoid non-unions

bone grafting

vascularized bone grafts

pioneers

vascular grafting techniques

Dr. Osterman

wrist arthroscopy

ulnar-sided wrist pain

arthroscopy

specific injuries

chip-on-tip technology

personalized approaches

evolving landscape