and recovering from handapalooza the night before. So hopefully, well, thank you for coming to this ICL. We have an action-packed hour for you. We have a tremendous faculty that'll be help educating us and demystifying the illness side of the wrist. We have Rob Kamal from Stanford University. We have Mark Richard from Duke University. And we have Tamara Rosenthal, who's from Beth Israel Deaconess and also was elected to the presidential line, and so we're honored to have such a great team here today. We're sort of going to run through this. This is a lot of information to sort of pack into an hour, but we're sort of going to go through the gamut of TFCC or when it's reported as being normal and it's not. We're going to address ECU instability, ulnar impaction, okay, should we be shortening, what should we be doing here, and then finally, DIEJ arthritis. If we have time, we will have a case discussion. I logged on to the app, and apparently there's a code for the moderator, which I don't know the code. So if there's questions, please just come up and ask us through the microphone. So without further ado, I'll kick it off and talking about TFCC. And the title of this talk is essentially when you think it's a TFCC injury and the MRI is normal or reported as normal and you're not quite sure what to do with that information. And so the three takeaways, I think one of the key things in terms of ulnar wrist pain is 90 to 95% of this is the history and the physical examination. I think imaging is important, but over time you realize that how it sort of supplements your diagnosis but doesn't confirm it. And I want to introduce DIEJ arthroscopy. There's nothing new here, but I think this is one of those things that we were sort of talked about but didn't really know how to do it. So hopefully I can give you some technical pearls of how to do this. So we'll start off with a case. This is an active gentleman who comes in, retired early, very sporty, loves to play tennis five days a week. So this was a big deal for him. And comes in with ulnar wrist pain, is tender in the fovea, DIEJ is stable, and we treated him nonoperatively with injections, did well with therapy, but it came back. This is his MRI, and his MRI was basically read as having a central tear. And we all know as you get older, it's common to have central tears and be asymptomatic. But he was read as having a central tear that's causing his problem. So just briefly before we go into the nuances of treatment, I think it's always important to think about the soft tissues and the bony stabilizers on the ulnar side of the wrist. My acronym here is RUPERT. There's a lot to remember here. So R stands for the sigmoid notch, which gives you 20% stability. And then we have the rest of the soft tissue stabilizers. And the most important soft tissue stabilizer is the TFCC. And this is a nice histologic section from Toshi Nakamura. And I want to draw your attention to the bottom left, because when you're scoping, if there's no central tear, that's what you're going to be seeing. You're going to be seeing the TFCC and the superficial limb of the TFCC. And the critical part for DRUJ stability is this foveal attachment. And you will not see this unless there's a central tear and you can come underneath it, or you scope the DRUJ. In terms of the fovea sign, this is Dr. Berger's classic sign. And I think it's a useful pearl to have in terms of the high sensitivity and specificity for diagnosing. For me, it's either a TFCC tear or a UT ligament split tear. I think it's hard to determine the difference until you pop the camera in. So what about the role of MRI? How useful is this? Well, I think it's useful for central tears. But in terms of peripheral tears, it's actually pretty poor. And I think one of the caveats or take-home messages is that a negative MRI does not rule out a tear, especially peripheral or foveal tears. This is a useful paper by Kim Amrami and her team. When you're looking at an MRI, people ask, well, what sequences do I look at? For me, routinely, it's the axial view and the coronal view. And when I'm looking at the axial view, the bottom left is what a normal sort of view should look like. The right is when you have a foveal tear where you get some subluxation. And I would remember this image because you can have subtle partial tears where there's some slight dorsal subluxation, and it will give you a clue that there's a foveal injury. But as I'll show you some of the cases, that doesn't always happen. In terms of arthroscopy, I want to try and introduce the concept of moving away from just sticking the camera in for a diagnostic, and then we just do an open procedure. How can we use arthroscopy for a therapeutic modality? And we're all aware of Dr. Palmer's classification. We're not going to go through this in a lot of detail, but type 1 being a traumatic injury and type 2 being a more degenerative type of ulnar impaction. We're going to hear a little bit about that later on. And I think the problem with the ulnar side of the wrist is this, and this is Mark Arce Elias' sort of concept, in that we think of everything as mutually separate. But they're not. They all have an interplay. And when you think of them as independent entities and just treat one when they have multiple pathologies, that's when we get into trouble. So in this sort of classification, what we're thinking about is four key questions. So when you see a patient with ulnar wrist pain, there's many classifications. This is one of them. What's the bone like? So for example, is there a sigmoid notch malunion? And we need to address this. What is the quality of the cartilage like? Is this arthritic or not? Is the TFCC normal or abnormal? And finally, I put EECU because that's the most important dynamic stabilizer of the ulnar side of the wrist. And Rob Kamal will be teaching us about the ECU. So back to that patient. So this patient was treated. He had a UT split tear and was fixed and went on to doing well. And a lot of these surgical videos that I'm going to share are on handy. So obviously, in the limited time, we can't go through them in detail. But these are all on handy. So the other thing that I want to get across about TFCC problems is that we were always taught if it was less than three months, you can fix. Over three months or six months, you're thinking you have to do a reconstruction. I think the only way to determine that really is in the operating room. So when you're operating and you're putting your sutures through, if it's like wet tissue paper, then clearly you can't fix that. But I think it's impossible to determine that preoperatively unless the patient's had a previous surgery. I highlighted the Palmer classification. This is another classification, the Atzi and Lucchetti classification, that you may not be aware of. And what this is helpful for in that it tells you, number one, where the injury is in the TFCC. Is it foveal? Is it the superficial limb that you see in the radiocarpal joint? Or is it through and through? But it also tells you what type of tears you can fix or you need to do a reconstruction. So if you're not aware of this, this is a useful classification. So how do you test the foveal attachment? So there's basically four tests that you can do in the operating room. So the hook test. So the camera is in the 3-4 portal and we're taking a probe here and we're really lifting that TFCC up, pulling it from ulnar to radial. So you can see I can really lift and get underneath that. And that is a foveal tear. A trampoline test. So this is a normal trampoline. So you can see when you push down on the TFCC, there's a natural buoyancy for this to spring up. And in some of the cases I'll show you, the TFCC feels a little bit loose. It's not as taut as this. It's a very subjective test. But as you're scoping, I would urge you to do all of these four to build up what normal is in your mind. What about the suction test? So here this patient, here you put the suction on and it lifts right up. So there's two diagnoses with the suction test. Either you've got a peripheral tear that's healed in by scar, so it's loose, or you've got a foveal tear and it lifts it up. But the suction test is useful because sometimes you put your stitches and you go, well, have I put enough in? Is that normal restoration? So in this patient, you'll see I actually put two sutures in and it was still lifting way up. And it's that third big bite that actually restored normal tension. So that's how you can use a suction test. And finally, DREJ arthroscopy. So let's look at a case. This is a young gentleman who comes in who has a pretty distal, distal radius and distal ulnar styloid fracture and was treated by our pediatric orthopedic colleagues and had a pretty good reduction in pinning, I thought, of his distal radius. This is his x-rays at four months later. And I talked about the acuity, like don't worry about timeline. So I see him 10 months later. And this is his clinical examination. OK, so you can see he's grossly unstable at 10 months. And that's when I first see him. If you look at the MRI, the MRI was reported as normal. It was basically reported as an ulnar tricuteral split tear. Now a UT split tear does not give you DIJ instability. And so what I highlighted here in that sort of circle is if you look at the normal, if you look at the TFCC to the left, it's thick and black. As you come to the right, you'll see it's more gray. It doesn't look as black as the TFCC on the left. So to me, that was scar tissue. But this was reported as normal. And remember I told you about that dorsal subluxation on the axial view? I mean, that looks pretty normal to me. So this was the read by our MSK radiologist, world-class MSK radiologist, but basically saying the TFCC is intact. So now what do you do with that information? Clearly the history in the physical exam is telling you it's a TFCC and foveal injury, but the TFCC is normal. So this is where MRI can be misleading. So going through that checklist, I thought, well, was there a distal radius malunion? I think the reduction was pretty good. I didn't think he needed a corrective osteotomy. So to me, this was a foveal injury. So I put the camera in. He had a negative trampoline sign and hook test. It's completely normal. So this is how you do DIJ arthroscopy, or one easy way to do this. So you have the camera in the 3-4 portal, and you put a needle underneath the TFCC. So you're looking directly where that needle is underneath the TFCC. You make a small incision spread, and then pop the camera in. So you know you're in 100% the right spot. I'm a big advocate of doing this dry, because when you put fluid in, all the scarring on the underside of the TFCC becomes like crab meat, and you cannot see. And so this is what he looks like. So underneath the TFCC, I come all the way ulnar, and you can see that TFCC is inserted, but it's totally delaminated off, healing with scar tissue. So this is what he looked like. So now I make an ulnar incision and make a portal underneath this. You can supinate the forearm, taking the dorsal sensory branch of the ulnar nerve out of harm's way, and then here now I'm putting a curette in, debriding that footprint. And this is why I say do this dry. You can see, it's hard to see. Now you put fluid in, all that red tissue just gets engorged, and it's even harder to navigate that. And so then I make a little drill hole, and I'll show you a case in a minute of technically how to do this. And there's a suture. So it's four sutures, and you remember how unstable he was. You don't have to wait for six weeks for healing. So this is the patient on the table. You can see he's rock solid. And I've taken the traction off in a minute. You'll see I'm not cheating by pulling traction on this and making him stable. And so you can see here, there's no traction. So he's rock solid. And then this is him at three months. So this is the uninjured side. Okay, so this is his normal side. And now we're going to show you the injured or the repaired side. So he's good passive range of motion, good active range of motion. And again, here now you can see how he's stable. So that was a relatively straightforward case of DREJ instability, even though the MRI was normal. But not every patient presents with DREJ instability. And I contest to you that there's a spectrum. You have gross instability and stability. And most patients I've seen recently fall in that in-between category. So look at this patient. So this is a healthy, active lady who comes in with chronic ulnar wrist pain over the TFCC and the ECU. So not just the TFCC here. Here's the MRI. Okay, she was tender, foveal. TFCC was tender. The DREJ was not unstable. And she had a positive ECU synergy test. And we'll hear about this. That was the MRI. You can look in the axial view. There's no dorsal subluxation. It's concentric. And so for me, this patient had two pathologies, the TFCC and the ECU. The mistake here is just addressing one. This is the trampoline test. So you can see I'm pushing down. It's a little bit loose. But I think some people would say that's normal, perhaps. And now I'm going to do the hook test. And you'll see as I come under with the probe, I'm trying to get underneath it, and I slip out. So to me, this was equivocal, not grossly positive. Here's the suction test. I'm turning the suction on. It lifts up a little bit. But some people would say that's probably normal for a 27-year-old. Now I'm scoping the DREJ, and you can see I'm underneath this. There's a tremendous amount of scar tissue. So it's hard to see. So this is why that little trick that I showed you can hopefully help you. So again, here, we're basically debriding the scar tissue, getting down a healthy, bony bed, and we're putting the shaver in just to curet that out. This is a different patient, but this is a way of doing this. So it's an ulnar incision. You find the dorsal sensory branch of the ulnar nerve. You can see it trifocates. Don't worry, this is all unhandy again, because we are in the interest of time. We have to speed through this. You now make an incision through the extensor retinaculum, cheating as volar as you can. And in this patient, again, it's a different patient, I'm preparing that bony bed that you saw when I bring the shaver in. So I'm just cleaning that out, making sure that we've got bone for that TFCC to adhere to. Now here I am using an 062-KY, and the beauty of doing this under arthroscopy is I'm actually a little dorsal there. And remember, the fovea is more midline. So here you can just raise your hand up, and then drop your hand, and look at this under direct vision. So now you can see, instead of being dorsal, we're a little bit more volar. Remember I said to you, judge the repairability of the TFCC in the operating room. I think the next stage will show me pulling the probe and saying, yep, I can get that TFCC back down. So this patient doesn't need a reconstruction. Take an 18-gauge needle, put it through the drill hole. This is a looped suture. I've moved away from PDS because they're not stacked. Sometimes can bother patients. And you can actually put the needle through twice. So you push this through. It's a little bit tight, but you push this through, so you have two loops of suture coming through there. So basically, you can see here, now we have two loops of 2O-PDS, and you cut the loop. So now you have four sutures running through that drill hole. So I cut one of the loops. And now it's a question of now taking another needle. This next needle will be a 20-gauge needle with a 3O nylon. And now we're simply going to sequentially work our way around the TFCC. So I come through the TFCC, first treating volar. And then I come through the 6R portal with a suture grasper, grab that loop, pull it out of the 6R portal, and use that as a suture shuttle to shuttle one of those 2O-PDSs that I passed through the fovea back across. And you do this working your way around from volar to dorsal. So this is back to that patient. This is the repair. You can see I actually had a UT split tear that I fixed as well at the same time. I stabilized the ECU, right? The mistake is stopping there. You have to fix the ECU. This is just some literature showing that arthroscopic repair through the fovea does pretty well. So I think in summary, in ulnar wrist pain, clinical exam is everything. And I've shown you some MRIs reported as normal. I think if you're suspecting this, I think this is where arthroscopy can really help you in the operating room to treat these patients. Thank you very much. Okay, next talk is Dr. Kamal in treating the ECU. And this is what we spent the last 30 minutes fixing. I know all our faculty have put their talks on because we went through this. All right, Marwin. No. No, it worked. It was weird. When I clicked on this and then clicked on this, it came up. All right, while we're waiting for the AV to be sorted out again, any questions there? Oh, that's pretty easy. Yeah, no, we – yeah, no, I'm just – yeah, we – this happened this morning. I went through everyone's talks, and this happened, and they came and fixed it. Did you – I mean, maybe they can hang out in this room. No, no, no, it's all uploaded. I think Marwin's called them. Well, nobody's comes up tomorrow, so it doesn't come up, Marks doesn't come up, no. So apparently too many people are logging on at the same time to just be patient. Got an ICL going, and then after 9 o'clock, somebody else is coming on. Okay. I'll try that. Thank you. All right. Bye. Ah, thanks, Christy. Was this one that you were trying to open? Yep. Do you have it on a thumb drive, Rob? Yeah, what are they doing? So they told me to just pretty much refrain. OK, Dr. Kamal. I think you have 45 minutes, Rob, because you've been through all the other talks. All right, good morning. So I'm going to talk about ECU instability. And I know Dr. Kakar had some complex acronyms, like RUPERT and things like that, very British things. I have very simple things for you to remember that hopefully will help guide how you approach these to, in my opinion, somewhat complex patients. Because I'm always a little bit troubled for what's best for these patients. So here's my disclosures. So we often see ECU instability in patients that are active athletes, stick bat, racket sports. And the reason we do is that the ECU is sort of anatomically made to be a little bit unstable. It always wants to be unstable, especially when you're getting into supination, ulnar deviation, and flexion. So it starts from the lateral epicondyle to the base of the fifth metacarpal. It has an angular path. Even in somewhat neutral wrist position, the ECU has a little bit of an angle to it. But that angle is obviously increased as you go more into ulnar deviation. And then as you go into supination, then as you go into wrist flexion. So your active athlete will or may have issues with this, depending on their level instability, and to some degree, their level of inflammatory response to that instability. So you can see here pictures of the ECU as you go into ulnar deviation, and then even more supination. The body, in my opinion, is obviously incredibly smart in the way it's designed. So there are a number of anatomical structures made, understanding that this can be a concern. And so here's one anatomical study just evaluating the ECU within the compartment. And in this study, 84% of specimens had an extra septum that was present, located ulnarly to the ECU tendon. But not everybody has that septum, and presumably that can impart some risk of instability. On the right, you can see the stabilizing structures around the ECU tendon as you go from supination and pronation. So you can see in pronation how tight those structures are around the ECU tendon, stabilizing it within its groove. But as you go into supination, some of the laxity you see in the stabilizing structures and how that may allow for some instability. But you might ask, and I'm sure everybody in this room has seen patients with asymptomatic ECU instability. And it always, I always find it challenging when they have asymptomatic on one side and symptomatic on the other. And I really, I say, well, I wanna get you to look like that side. It's like, I don't care about the instability, it's just the fact that you hurt. That's the only reason you're in my office. And so to some degree, a lot of our initial treatment is guided towards what can we do to presumably blunt the inflammatory response that that person has on their symptomatic side so that they can just continue to have asymptomatic ECU instability. And this is one study that confirmed, I think, what we all see in clinic, which is that there's some amount of tendon dislocation even in asymptomatic patients. So this is MRI of the wrist in pronation, neutral, and supination. And you can see the amount of dislocation percents you see from the groove as you go from pronation, neutral, and supination. And so, at least in this study, generally in pronation, the ECU always sat in the groove. Around 10% of the population had some dislocation in neutral, and then 30% had in supination. And so these numbers may seem a little exaggerated, but I think we've all seen it in clinic where we see bilateral instability and just one symptomatic side. So here's my patient that we'll take from pronation and slowly go into supination. You'll see it pop over there. And so it seems somewhat subtle, but it is amazing how symptomatic some of these patients can be. And it can be obviously frustrating in the active patient. So I do like Sanja's four-leaf clover as a framework in terms of how I approach ulnar-sided wrist pain. And so here you can see the unstable ECU, but at the same time I'm confirming sort of the other aspects of ulnar-sided wrist pain on the bone side, the cartilage side, and the TFCC side. We already reviewed some of the anatomy of the ECU, but dorsally on the ECU at the roof is the extensor retinaculum, and then deep to that as the ceiling is the ECU sub-sheath. Radially the sub-sheath is relatively thin, which is okay, that's not a problem. Clinically, volarly it's the sulcus of the ulna, and then ulnarly is really the thickest aspect of the sub-sheath and the linea jugata. And this is, again, sort of anatomically designed because this is the position in which the ECU can subluxate out of the ulnar groove. Here's some descriptions of the linea jugata, which are longitudinally oriented fibers reinforcing the ulnar attachment of the sub-sheath. And you can think about it like a labrum. And so you can imagine as that labrum begins to either peel off and create more and more room within the sub-sheath, or if you have an injury to the sub-sheath and the ECU can sort of pop out of the sub-sheath, you can begin having some problems with symptomatic instability. So here's some figures that can describe that where you have an injury to the sheath, and you can have ECU tendon just dislocation. You can have it dislocate and then not try to reduce, but have some interposed tissue, or you can see more tears in the linea jugata and opening up of the sub-sheath, and the ECU tendon sort of sliding in and out. And perhaps these are the patients that on some sides are asymptomatic as long as this doesn't trigger some inflammatory reaction. Imaging always comes up. Typically, it is something that we get, but the diagnosis is often clinical. And this just sort of reinforces what we're thinking clinically in terms of how much of inflammatory reaction are we dealing with around the ECU, and how unstable is our ECU. So treatment, non-operative versus operative. So I have not seen any literature on the timing of reconstruction for this condition, and so at least in my practice, we're sort of babying these along for a while in terms of trying a number of different modalities, oftentimes saying, well, let's try to get it to look like the other wrist where it pops, but it doesn't hurt you. And so we try that first. Some very standard things are mobilization and pronation for four to six weeks, where we know the ECU is quite stable. And then we watch for mechanical symptoms without pain or loss of function really being the goal. Steroid injection I think has some purpose here. Again, we're trying to address the inflammatory and pain-generating aspect of the instability, and so certainly should be an option as well for patients. External support's been studied to some degree and can be helpful, and there's a number of ways in which you can do that. I usually send my patients to the hand therapist. You can do taping, you can get this wrist widget or some sort of prefab brace that helps stabilize the ulnar wrist and minimize the motion of the ECU tendon during supination, so here's some examples of that. Lastly, if you end up getting to surgery, there's a number of different options, and the literature's a little bit mixed in terms of what to do, and so in those cases, for me, I stay very principle-based and use sort of the clinical series as guidance as to what makes sense. So ulnar groove deepening has been described. I think there's not a lot out there in the literature. There's actually more contemporary evidence saying that it probably doesn't make a difference, but historically, it's been done similarly what you would do for peroneal tendons for peroneal instability in the foot and ankle. And so conceptually, it does make sense to deepen the groove and create a bigger sulcus for the tendon to sit in. Clinically, I'm not sure that has borne out to make a difference, and at least biomechanically, in one paper, it hasn't. ECU subsheath repair has been described, but generally is abandoned because by the time you're doing this procedure, the tissue's not great, and it's not something you're gonna rely on for stability when leaving the operating room. And so lastly, the majority of what you see in the literature is ECU subsheath reconstruction. Typically, with the extensor retinaculum, either radially-based or ulnarly-based, and really, that's dealer's choice in terms of what you wanna do as long as the ulna, or the ECU tendon stays reduced both in pronation and supination. So that's really the test at the end of your procedure is can I put this wrist in extreme supination, ulnar deviation, flexion, and does my ECU stay stable and not subluxate ulnarly? Here's one anatomical and biomechanical study from Carlson evaluating ECU subluxation in cadavers. They had intact, and they did a reconstruction, and they did ulnar groove deepening and didn't find any value add from the ulnar groove deepening. And Mel Rosenwasser, similarly, has a paper that came out this year that confirms that as well. In terms of reconstructions and stabilization of the ECU subsheath, again, you can use either a radially-based or ulnarly-based retinaculum flap, oftentimes using the septum, so the 4-5 septum, for example. You do wanna check ECU excursion through the range of motion after your reconstruction, so whether that means putting a pediatric feeding tube or something there around the tendon just to make sure it's not too tight, but at the same time not allowing for the tendon to subluxate through range of motion. Here's some examples on the bottom right here, which is just a free extensor retinaculum graph that you can wrap around the tendon. There's techniques where you can place anchors both on the radial side of the groove and use that as a way to attach your reconstruction and prevent the ECU from sliding. There's other techniques where you put anchors on the ulnar side of the groove and then tie those to your reconstruction. You really use the sutures then and the anchor to stop your tendon from subluxating ulnarly. Again, dealer's choice in terms of what you wanna do. There's not really any difference that's been shown in the literature. And so here's one example of radially-based extensor retinaculum flap. You can see pulling the ECU tendon radially in pronation and all the way through supination. So thanks again. Thank you. Thank you, Rob. Okay, next, Tamara Rosenthal will be teaching us on ulnar impaction. And should I always shorten the ulnar? Yes. Not yes to that. Yes, the slides are working. Thank you. So the question I was asked to answer is when is it appropriate to shorten the ulnar and when you should be thinking about something else? I tend to think about ulnar impaction like most other people as a progression. So you start with impaction. It progresses to having a central TFCC tear. You eventually get chondral lesions in the lunate and the triquetrum that can eventually lead to LT instability and over time to mid-carpal changes which you'll see with handmade impingement. So at the beginning, when you're thinking about ulnar carpal impaction, the first thing for me is to consider what the etiology is. And I usually put it in two big buckets. It's either congenital or it's usually the case of a distal radius malunion. Not to say that those are the only ones, but this is the most common. And as Sanj said earlier, physical exam is pretty key. So typically patients will have pain over the dorsal side of the lunate. They'll complain that they have pain with load bearing and rotation and they also have a positive ulnar grind test. I also like to make sure to examine their DRGJ stability because that's gonna be important in figuring the appropriate treatment algorithm. For imaging, for plane radiographs to assess ulnar variance, usually you want the shoulder abducted at 90 and the elbow at 90. I think in reality, I don't know how many people actually do this in their office. So we're usually judging it based on a regular PA view. You can get clenched fist views for dynamic injuries and I often like to image the contralateral wrist because in many cases, it may actually be the same. One side may be symptomatic or neither may be symptomatic and so you obviously don't wanna just treat the x-ray. And then MRI is helpful in terms of defining where the patterns of edema are and in particular, you wanna differentiate it from Keenbox disease. So this is what a typical image would look like in a patient with an impaction. So if you look at the x-ray on the left, you can see their ulnar positive, you can see some cysts along the ulnar most corner of the lunate and on the MRI, you'll see on the T2 sequence that they have edema in the lunate but it's really just the corner on their side as opposed to the whole bone which is what you would typically see with Keenbox. And then on the MRI sequence on the right, you start to see the TFCC changes with a central tear. So this is a very classic picture for ulnar impaction. So how do you treat it? So for me, number one, I wanna know, are they ulnar positive? I wanna think about whether there's a dystoritis malunion that needs to be addressed and then I wanna think about the DRUJ. Are they stable? Do they have impingement? Do they have arthritis? Because all of that's gonna change my algorithm. If it's a congenital case, so basically not a dystoritis malunion, you can consider doing an arthroscopic wafer. The indications for this is usually a fairly pronounced TFCC tear because you're gonna put your instruments through the hole of the TFCC to get to the ulna. So if the TFCC's intact, you don't wanna create a tear to do this. And typically, variance of less than three millimeters is a good indication. Some authors will say that low demand is also, this procedure's best used on low demand individuals. I have to say, it's not my favorite, so I don't tend to use it a lot, but it's definitely a technique to consider. For most cases, this is where we're thinking about ulnar shortening osteotomy. So if you have an intact TFCC, you're not gonna wanna make a hole in it, as I mentioned. If you have a bigger number for your positive variance, so bigger than three millimeters, but you do have to make sure that the DRUJ is congruent because when you shorten the bone, if it's incongruent for any reason, you're gonna create another problem. The techniques for this have been widely described. So you use an osteotomy that you can be, it can be transverse, it can be oblique, it could be a step cut. Many companies have now developed compression plates, which is what I typically use. I like to put the plate volar to reduce hardware rotation and to hopefully avoid hardware removals. And then there's a question of what you should do with the TFCC and whether you should debride it or not, and I'll go through some of that literature. It's pretty mixed in terms of what you should do. The complications from ulnar shortening osteotomy are not insignificant. So nonunion has been reported to be up to 17%, and then I think hardware irritation is the other one. And hardware irritation is fairly easy to address. Nonunion's a little bit hard. So if you see on this case, this is a patient who had radiocarpal arthritis as well as ulnar impaction, and I treated him with an ulnar shortening osteotomy, and six months later, he's still somewhat symptomatic. And despite use of a compression plate with a lag screw, he still does not have a lot of healing. So when I went back to do his radiocarpal fusion, I bone grafted the osteotomy site, and he went on to unite. But nonunion is real and something to consider. So the second bucket is what if they have a distal radius malunion? Should you do an ulnar shortening or should you do a radial lengthening? And to me, this depends on what else you need to address. So in this case you see on the left where the patient is basically ulnar positive, a lot ulnar positive. But the angulation of the radius is adequate. This is a perfect indication in my eyes if the DRUJ is congruent and they don't have arthritis for an ulnar shortening osteotomy. On the other hand, if it's like this case where they were ulnar positive, but there's also angulation of the radius that you would like to address, I prefer to address it with a radial lengthening because that allows me to correct the angulation of the radius as well as the length. Technically more challenging, but I think it's a better operation. And then just lastly to talk about the DRUJ. So DRUJ instability. So when they're unstable, you can do an ulnar shortening osteotomy as well as a TFCC repair. I think that typically goes together. And if they're arthritic, I usually prefer either a salvicopongy, arthrodesis, or a DERA resection. I like the SK in my younger, more active patients because it also allows you to correct the ulnar positive nature. So if you see on this case, this is a patient who's got DRUJ arthritis. They're ulnar positive. I can bring the ulnar head down to a more neutral position and then address the arthritis with a fusion. So you can deal with both things at once. Additional things to consider. Lesions of the tip of the hamate. So that's an extension of the impaction forces. Some authors advocate to breeding this arthroscopically. It's really not very clear what the significance is. So I typically don't worry too much about it. And then there are cases of styloid impaction where it's really the styloid that is impacting on the triquetrum. And this typically will be with extension and supination. And you'll see a styloid that's a little bit larger than six millimeters in length. And often on x-ray, you'll see kissing cysts between the triquetrum and the styloid. And this can be treated whether you're an open or an arthroscopic styloidectomy. So just briefly reviewing what's out there in terms of outcomes. This study looked at 100 plus patients with ulnar-shortening osteotomies. About half of them had distal radius malunion and half did not. And they all seemed to improve just about the same, regardless of etiology. So I think that's what you see on the graph at the bottom, that the improvement was very similar, whether it was a distal radius malunion or not. They had a complication rate of 64%. One third required hardware removal, 6% non-union. In this study, it was all distal radius malunions and they were split between ulnar shortenings and radial lengthenings. And they found that the dash scores were just a little bit better in the radial lengthenings. The complications were more frequent with the ulnar shortenings. And again, I think it's the hardware removal that typically increases the complication rate in most papers. Once you start to look at the types of DRUJ, some of the studies, like the first one I listed there, don't seem to think that the DRUJ morphology impacts your clinical results in terms of what the shape is. I do think that if it's arthritic, you have to consider it more. And comparing a wafer versus a regular shortening osteotomy, they seem to be pretty similar, although obviously the complication rate's gonna be higher with an ulnar shortening osteotomy. This study looked specifically at what to do with the TFCC. So they either did an ulnar shortening or they did that with a debridement or they just did a debridement. And they didn't really find much of a difference between groups, but the ones who just had a debridement alone had more persistent symptoms. So it just means that if they have ulnar positive variance, you probably need to address that and the TFCC debridement by itself is not sufficient. In this paper, they present an algorithm, which I thought was quite nice, so I put it there for your reference. So they performed arthroscopy in all of the cases and they only repaired the TFCC if the DRUJ was unstable. And they didn't seem to think that the TFCC had much of an influence on the overall outcome. So this argues against addressing the TFCC at the time of ulnar shortening. And that's the approach that I typically take. I address the ulna, I shorten them. I don't really scope the wrist in addition to it, unless there's a different symptomatology. So here's a, you know, I like to think in boxes, so this is how I look at it. Congenital cases, if it's under three millimeters, they get either a wafer or an ulnar shortening. If it's over three millimeters in my hands, they'll get an ulnar shortening. If they have a dystereitis malunion, if there's angulation to correct, I'll lengthen the radius. If not, I'll do an ulnar shortening. And if they have arthritis at the DREJ, I usually will do an SK-Fusion or a DARA in a lower demand individual. And if they're unstable, I'll repair their TFCC. Thank you. Beautiful. Thank you, Tamara. Okay, and another treatment for DREJ arthritis is potentially ulnar head replacement. And so Mark Richard will be talking about is prosthetic joint replacement the best option? Go ahead. Good morning. So some great talks this morning and I'm gonna share thoughts about DREJ arthritis as we work our way around the wrist hanging out on the ulnar side. So we're gonna talk about arthritis at the DREJ specifically. There's a number of available treatment options, resection, fusion with the SK, arthroplasty. And we're gonna be focused on arthroplasty and specifically ulnar head arthroplasty in the next 10 minutes. And then we will go through the literature and share a case at the end. So just as a review, a couple of good papers out there. The first one from University of Washington reviewing DREJ and its options. I like how they talk about balancing that functional demand and the bony resection that you're gonna make. And that's a good way to think about this as you think about your patients with DREJ arthritis. And then the second from Zimmerman, Kim and Jupiter that was in the Yellow Journal about 10 years ago. Both very good references. So looking on the left there, one of the things that you notice is how close everything is to each other at the ulnar side of the wrist and at the wrist in general. And as Sanj has done a lot of work on this and a lot of these structures are incredibly close on physical exam. And I couldn't agree more that physical exam and history really lead you to the diagnosis. And keep in mind the help of diagnostic injections. So an injection intra-articulately versus the ECU sub-sheath versus the DRUJ can all be very helpful in helping you piece together those final bits of history and physical exam and make sure you're thinking about things clearly. They also have this nice little chart from their paper looking at increasing demand and increasing bone loss and putting you on the spectrum of what your surgical options may be and where your comfort level is with risk reward and probably more importantly your patient's comfort level. So some thoughts on selecting a procedure to match your patient's demands and expectations which is really the hard part of this. We already talked about imaging and I totally agree that especially with TFCC that MRI does not really help make a change for me in my decision making very often. But for pre-op planning with arthritis at the DRUJ I do think that good imaging, both plain x-ray and CT scan are helpful. I do try to make that point that Tamara was making about getting them to get that true neutral variance because some of your surgical options will depend on ulnar variance and being able to think about it clearly is helpful. So when a patient gets back to the room from x-ray I go in and I say, so when you had your wrist out there how did they do it? Did they have your arm up at the side? Did they have you like this? And if they didn't I'm a little suspect of my judgment of their variance. CT scan is helpful to evaluate the magnitude and location of arthritic change as well as the volume of bone loss and the bony anatomy to guide surgical options. If you look at the obliquity of the DRUJ and the sigmoid notch, the TOLA classification, you know if you have a type two and it's that reverse oblique you, or sorry oblique you may be considering an ulnar shortening with a little bit of arthritis depending on where those osteophytes are or are not. And you would likely not be considering that if it was a type three. So think about it in both the coronal plane and the axial plane with the described sigmoid notch shapes because as you start to think about arthrodesis or implant arthroplasty, those things will come to bear and matter. So just other thoughts. I think as you choose your operation, type of arthritis, osteo versus rheumatoid probably matters. Age certainly matters and functional physiologic age. Bone loss matters. Their demand, their vocation and their avocations will both have an effect. And managing expectations is always difficult with this problem. And your goal should be to eliminate pain, preserve function and stability, and hopefully to minimize the need for future operations. So I like to do this in a very stepwise way and not jump to the end of the line at the beginning of the clinical care. So just one more look at this slide, which I do think is helpful. But if you look at where arthroplasty is, it's in the upper right. So this is really a high risk, high reward operation. And hopefully we have some time for some discussion about where these other procedures will fit into our algorithm. So this is just a little bit of the history of implant arthroplasty. Started in the early 70s with silicone implants. And we all know the history of silicone implants. They had reactive silicone synovitis and a high breakage and migration rate. But you got away with it in the fingers with the amount of silicone synovitis you got, but you did not in the wrist. And that fell victim to that problem. Then in the mid 90s, Herbert had a ceramic ulnar head that seemed to do pretty favorably over time. There's an 11 year follow up that's reasonably favorable. And then a number of implants hit the market, both total ulnar head and then a partial ulnar head that we'll talk about a little bit more specifically. So what implant arthroplasties are available? This is a Brian Adams review paper that looks at that. And to think of it, there are two options for the partial or the HEMI and I should say HEMI and two for the total. There's a total ulnar head and a partial ulnar head that you see there. The concern being on the left that there are, these implants do have little holes and points of attachment for the soft tissues. We all, I think, pretend like soft tissue heals the metal. Our partners who do a lot of shoulder think the same thing, but that never really resonated well with me. The partial ulnar head is a little bit more respective of that ulnar sleeve and the soft tissue attachments and you see that on the right. And then for the DRUJ, there's an unlinked total DRUJ and then the linked DRUJ or the Schecker prosthesis that I think we know best. So going through decision making, one of the big things is whether or not you have significant bone loss and stability on the ulnar side of the wrist. And the instability does not have to come from just a previous DARA and an unstable stump. It can be just a simple unstable DRUJ that you saw in many of the other talks before. And that's something to think about. If you have a stable ulnar stump or ulnar head at the DRUJ, you do want to preserve the soft tissue restraints. You want to evaluate your bone loss. And I do think you want to be minimalists as you start to resect bone because these are annuities for an orthopedic or a plastic surgeon that takes care of these. And I think you'll be seeing these patients for a while. If you have primary DRUJ arthritis or a failed partial resection, consider a partial ulnar head arthroplasty and go with the least bony resecting operation first. So just a quick note on the approach. It's the floor of the fifth compartment, which is the window to the DRUJ, C-shaped capsulotomy, preserving a little cuff at the notch for closure later. You're gonna try and preserve the dorsal radial ulnar ligament in the ECU sheath because of their importance and stability, as Rob talked about before. Release the deeper portion of the foveal attachment. You've got to be able to dorsally translate the ulnar head to do your arthroplasty. You're gonna size the ulnar head to appropriately tension the DRUJ within the sigmoid notch. So how do these do? This is one of the largest series that's out there. 79 implants in 74 patients that had more than two-year follow-up. 47 of them were included in the study. The mean follow-up was actually seven years, and survivorship did not change from the short to the intermediate term results at 90% for five to 15 years, but that's not the entire story. They achieved a functional range of motion and about two-thirds of the grip strength as compared to the contralateral side. There was high patient satisfaction, but there was residual disability in the majority of patients when you looked at patient-reported outcomes. Primary did better than previous prior surgery. So if you get these patients with primary DRUJ arthritis and do this operation, they do better than the person who's had multiple operations or are post-traumatic. They had the lowest satisfaction scores in this series. So you do have to counsel your patients. The ulnar head arthroplasty does not result in a normal wrist, though it should improve their overall function and decrease their pain. So we'll finish with a case that was shared by Sanj in his wisdom with the ulnar side of the wrist. This is a patient that is a 68-year-old active male, and that matters. We talked about patients' demands and expectations. They had a chronic distal radius malunion, and we were just talking about the malunions, and if it's a significant malunion, volar dorsal, you have to correct that before you do an implant. Arthroplasty, this had overall good alignment, so Sanj was comfortable moving forward with the plan that he enacted. Over the last several years, he had increasing wrist pain specific to the DRUJ, refractory to appropriate non-operative treatment, and he had the appropriate physical exam to go along with it. What you'll note in physical exam is that he had mild DRUJ instability and all the other findings that you'd expect with DRUJ arthritis. So again, looking at Sanj's four-leaf clover, which is really helpful in trying to compartmentalize your thinking of the ulnar side of the wrist, he had both cartilage damage with that DRUJ arthritis and TFCC injury. So this is what Sanj and Basimil Hasan described as a calamari procedure. My only edit to this slide was I switched out Sanj's picture of calamari for Rhode Island-style calamari from Rhode Island, and they put hot peppers in their calamari, and they have it in Boston, so I recommend it. I'll take my five seconds and my 10 minutes to recommend it if you're in Boston and you've not had it before. It is a good way to go. So this is a meniscal allograft that they used to increase the stability of the DRUJ implant, and I believe Sanj had a paper, probably the better part of a decade ago, showing that these partial ulnar head or ulnar head arthroplasties, about a third of them still had some degree of instability. So this is a augment to the procedure to try and increase the stability of the DRUJ, and they use a meniscal allograft that goes into the sigmoid notch and deepens it to essentially create a labral effect, and I don't do shoulder arthroplasty, but this is very analogous to a shoulder arthroplasty. You're looking at the sigmoid notch. You have to take off those marginal osteophytes, and that's what I think these arrows are showing. You do have to ream a little bit through the sigmoid notch to get down to some bleeding bone, but you want to be very careful not to over-ream and soften that bone and allow the contact pressures to wear away over time, and then he puts a series of anchors in at 12, three, six, and nine o'clock, and I love when Sanj invents new operations because he makes it very user-friendly as far as his descriptive techniques, but you can see the anchors in place there, and then they take the calamari, or the meniscal allograft, and they do not bread it, but they put it into place and create that labrum, and he's already prepared the proximal, or the distal ulna, sorry, for this, and then once they have that in place and secure it, you can see that 30,000-foot view just looking out the dorsal approach through the fifth compartment there, what that looks like in place to essentially try and deepen the labrum and recreate in some way, shape, or form the radial ulnar ligaments, so there's the depth of that, and you can see the ulnar stump right there, and then the partial ulnar head prosthesis in place underneath the calamari, and then appropriate closure over the back with the dorsal capsule, and that is what it looks like radiographically. So they have reported on this four patients, maybe more now, but primary DRJ arthritis, remember we talked about those are the patients that do the best with an ulnar head implant, follow-up is over a year in all of these, and they've had no revisions in really good range of motion, and you notice increased function, decreased pain. So in summary, with all of these procedures we've talked about this morning, you have to understand your patient, you have to know their expectations, you have to know their demands, and you have to help manage those, that's a big part of the clinical care of this. If you're gonna do arthroplasty, less is more, try and preserve bone, one of those papers, I think it was a UW paper, described bone as a commodity, and I like that way of thinking, so try and preserve the bone and the soft tissues, because this is gonna be an iterative problem for you over time, more likely, especially if you're in the younger end of your career, and remember that primary cases of DRJ arthritis to be better than secondary cases. Thank you. Yeah. Okay, we have five minutes, sorry, with the AV snafu, so maybe if there's any questions in the audience, I can maybe ask our panel, I don't think we have too much time, really, for a case discussion. Tamara, do you wanna come up? So, Rob, you mentioned about non-operative treatment for the ECU, and I'm totally with you on that. What is your non-operative treatment, and what do you think your success is, especially in the athletes? Yeah, so it's tough to get an athlete to wear an above-the-elbow splint and pronation for six weeks. So you do splint or cast? I do splint, and I let them come out of it for elbow range of motion in pronation. Obviously tougher in the athlete, easier to do in the weekend warrior. I just saw a patient last week, we went two years of kind of babying his instability along. He did fine, was a little bit limited, and then it got re-aggravated, and he sort of came to see me frustrated again, and we sort of talked about it. I don't rush to operate on these patients, I kind of make them make the decision as to how quickly to move, and the young athlete will be quicker to move to want something done. Do you inject them? I always try to inject them, just because of what I mentioned, and certainly borne out in the literature, how often we see instability that's asymptomatic. And so if you can get them to have asymptomatic instability, that's a win-win for everybody. And you also mentioned the role, sorry, there's a question. No, it's just a question. You showed about ultrasound, and I totally agree with you. I mean, I send out to my partners who use ultrasound in practice. Do you have ultrasound in the clinic? Do you send them, what do you do? Yeah, I have partners that do ultrasound and are very good at dynamic ultrasound injections via ultrasound, et cetera, so I don't do them myself. Okay. Question from the floor. Not a question, but a comment with Dr. Rosenthal with regard to the ulnar infection. I've been mistaken with MRI, so on all these patients, I usually scope them for their symptoms, and I shorten their ulna because I always wanna know what they have going on on that ulnar wrist, so if they come back with continued ulnar wrist pain, I at least can show them a picture of whether they have an LT problem or lots of arthritis that might not be fully addressed. So Tamara, I wanna pick up on one of the papers that you showed because I've fallen into this camp. When I started practice, I would do a lot of shortenings or wafers, but you always learn from your patients, and that study, I think, by Kim that you showed, three of the eight went on to needing shortening, but five of the eight didn't, so, and I've become into that five of the eight camp, so I've become more minimally invasive and maybe debride and address the TFCC unless it's grossly positive. Thoughts on that? I mean, I don't, is this on? I don't think there's a right or wrong on it, and I think to some extent, it depends on your philosophy if you prefer one operation or multiple operations and how you think about that. I tend to be on the one operation camp, so I think if I'm going to, if I think the TFCC's an issue, I will do an arthroscopy, but I'll probably also plan on doing an ulnar shortening unless I see something at arthroscopy that changes my mind. In response to your comment, I haven't had that happen as much that I've had to change my plan based on what I've seen, but if I think it's really true ulnar impaction, I'll just do the ulnar shortening. Okay, question. Thank you, I appreciate it. In the situation of the subacute or, you know, going on chronic foveal tear with instability that's symptomatic, you mentioned a couple times in your talk and right at the end especially that you're often addressing the ECU at the same time as you're dealing with that foveal tear. How do you make that decision over whether that needs to be done, that add-on procedure? Yeah, so I'll address the ECU if clinically they're symptomatic like I picked up ahead of time, but I don't routinely address the ECU with every foveal repair. So that second case I showed, she had both pathologies, but typically, no, I just addressed the TFCC, but I address whatever's going on at the same time. In that video, the reason why I showed making that incision on the retinaculum cheating as vulva as possible is because if they have symptomatic ECU pathology like Rob Kamal showed at the same time after I pass my foveal stitches, but before tying them, okay, because I tie them last because when you then take the arm out and pronate to address the ECU, you're pulling on your repair. Then I'll address the linea jugata, probably put anchors in as Rob mentioned. If the tissue is good, I would just sew it up. If it's not, I'll use that radially based extensor retinaculum to reconstruct that sort of ECU sub-sheath. And then the last thing I'll do is then tie the foveal stitches in neutral. Thank you. Pleasure. What, Mark, you didn't get off. 60 second, 45 second answer on this question. Man, young, forget about manual labor, but us in the audience, right? So, and I would say we're manual laborers. DIJ arthritis primary, what are you doing? Good bone stock, people in the audience. Yeah, totally putting me on the spot because there's no good answer. But I have to say for my younger, more active patients, I agree with Tamara that I prefer an SK. I've had good luck with SK and I do more of those than anything else for that subgroup. Okay. I'm guessing you're doing partial ulnar. No, you know, it's interesting. We had a IWIW meeting the other day and an old procedure that was revamped was ulnar shortening for primary DIJ arthritis because you're offloading the arthritic area. And I've not done it for that. Yeah. But some people, especially in the younger patients, had talked about that in a way of buying time, but prefacing the fact that you are loading now another area. So, no, that was the way I asked the question. And to your point too, that's where the TOLAP classification is really helpful because if you have that type two and it's engaged, but you're gonna disengage it by shortening, that's a good option. Yes. All right, I'd like to thank you and our speakers for a great hour. Thank you very much. Thank you.

wrist conditions

TFCC injuries

ECU instability

ulnar impaction

DRUJ arthritis

diagnosis

treatment

arthroscopy

ulnar shortening osteotomy

patient expectations