My name is Randy Bindra and my colleague Ritz Mohammed is, we're chairing this session. This ICL was based because last year one of the studies that Ritz ran with me kind of supervising was on temperature inside the wrist joint during dry wrist arthroscopy to look at the temperatures achieved and the safety. So we are thankful to the ASSH for giving us an opportunity to then get together an ICL. And so we thought what better than getting it right the second time, right? So if things don't go well the first time, and this is the real world, it never always does. So how do we get it right the second time and look at common wrist pathology? So we picked five topics that are really common and gotten the best of the best to cover these topics. So the first one would be how to revise a failed TFC repair with Brian Adams from Iowa, can I say, originally Iowa, then Texas, and now maybe Florida. Okay. He's almost moved as much as I have. And then Marion Bernier from Lyon in France will talk about proximal pole scaphoid nonunion, what you can do if a vascularized grafting fails. And then Julie Adams from Chattanooga, right, Chattanooga is going to talk to us about when a tenon graft soft tissue procedures fail after you do a scaphoid nonunion reconstruction. And then Steve Lee from New York is going to talk to us about what happens when you fix a distal radius fracture but it won't stay together. Patients fault always in my book. Brian is going to talk about, you know, we all do the trapezectomy and they work all the time except when they don't work, how to deal with that. And then Ritz has a couple of cases for discussion and obviously we'll have plenty of time for questions. So I'll kick off by getting Brian to come up and kick off. Thank you, Brian. Sure. Well, thanks for having me. I have the, I think the easiest topic of everybody because first of all I'm sure most of you fix your TFCs and they don't fail so you don't even need to listen after this. But it takes a little while to load. But I think the real key here as a preempt is that to get it right the first time is to get the diagnosis right the first time. And there was an ICL that we, a pre-course that we gave, you were a part of it too, Steve, was recognizing that there's a lot of things, I think I have to hit the close thing, okay, that we often don't make the right diagnosis when we look at ulnar-sided wrist pain and then the subtleties kind of evade us. And then when we come back to think about things again we'll find other things that may have been contributing to the problem in the first place. I have nothing to disclose related to this topic. So the TFC is a lot of fun. We all have learned in our fellowships and onward about the disc. It's fun to debride it. It's fun to try to repair it peripherally. But I think what we have to recognize is that TFC injuries are probably not that common in isolation. There's probably something else that was always injured with it. And those other things may heal on their own or they may not. So the very failure that you're blaming on yourself or the patient that it may not stayed anchored, it may have, but other things may have been contributing to the persistent problems or recurrent problems. And I would submit to you the ECU sub-sheath, we often see it like this, has been damaged or the ulnar carpal ligaments, whether that be a split tear or involved with an LT ligament injury are the things you do need to consider that. There's also a lot of other things that may have been contributing to persistent pain and we're all familiar with this. ECU tendinitis or subluxation, those may have been disrupted at the same time as the TFC. Mid-carpal instability, there may be arthritic changes at the mid-carpal joint or in the pisotracheal. And then my favorite reason for ulnar, I'm sorry, TFC failures is probably some degree of ulnar impaction. Another way to look at this concept that I like to is the column issue that we're all familiar with now in terms of fixing distal radius fractures. And I like to think of it as the ulnar column. And by doing so, we sort of focus in on the anatomy rather than specific diagnoses. And we know that injuries to the lunate facet also involve the sigmoid notch and specifically the volar and dorsal corners when we're talking about the TFC. We also know that it involves the radial ulnar ligaments, that's the easy one. And then we have the distal oblique band which we've all heard about for the last 10 years or so. But don't forget about the skeletal anatomy and here's where I think the number one failures occur for under-recognizing its contribution in both the ulna and the radius. And then of course what's involved directly to the anatomy of the DREJ. From a clinical standpoint, when you find somebody that has a failed TFC repair, I think you want to approach it from these three standpoints. Is it a stability problem? Is it a motion problem or is it pain? And in my experience, as you go down this list, it becomes harder and harder to sort out. Stability, we can test that. We can see it. We can feel it. Motion, we can see it and feel it also. But motion usually recurs and if there's decreased motion, it's usually due to pain. And pain is the one that's hard to sort out as we all know. So as I go down the primary cause for failure, I've just talked about other causes. Well, let me go into this ulnar positive variance which I think is our number one reason for these things to fail. If you go back to your previous operative note, figure out whether it be you or somebody else if it really was repaired or if it's simply debrided. There's been substantial literature to suggest that if we just go in and debride TFCs like has been now shown in multiple joints, it actually has very little value for long-term resolution of recalcitrant ulnar wrist pain. So these concepts we go in there and clean up a little bit is probably ill-placed. And maybe it's because of this, at least this is one of my biases, is that there's probably some degree of ulnar impaction whether it be physiologic or acquired. And in this study, here you see repair of the TFC combined with ulnar shortening osteotomy is a reliable for unstable TFC tears in somebody at ulnar positive variance. And that kind of leads us to believe, as I always question, why did the TFC tear in the first place? You know, we're falling on our wrists all the time. Why did this specific one reach to an injury stage? And I think there's probably some setup from the anatomy. And then if we look at this as persistent complaints of ulnar positive variance after TFC surgery can be treated successfully by delayed ulnar shortening osteotomy. And in the back of my mind, that's always been true. So I have a very low threshold for doing an ulnar shortening shaft osteotomy in anybody I'm going back in on to consider a re-repair of the TFC. It actually is going to be a low percentage of mine that do not get an ulnar shortening osteotomy in somebody that's a recurrent problem. So why does it work? I think we all know that. But remember, not only are you reducing the loads, but you're also allowing more, I'm sorry, less tension on the TFC after a re-repair or a primary repair. And then it does have positive influences, excuse me, on both the LT and the ulnar carpal ligaments as well as the DRUJ surfaces. So if we strike that one where we know that there is an ulnar positive variance or neutral and we now move on, the repair did not heal is our next area. Well, if it didn't heal and there's no other reasons for it not to heal, again, I like to consider non-operative management like all of you for a long time. And if you've never used any of these sort of specific DRUJ braces, I would highly recommend you consider it. That's the original wrist widget. I have no financial connection to these. And that's another variety, the bullseye. I've had residents and fellows even wear these after injuries and they swear by these. So I was very much thinking this was not going to be helpful in many of my patients. And now I think they all deserve at least some try with that. So looking at how do you work up these patients, I think an MR scan without contrast is the most helpful. I don't like it with contrast because I think it obscures things in a chronic situation. And what am I looking for? I'm looking at the TFC condition, whether they have ulnar variance, as I mentioned, the articular surfaces, and you can assess volar dorsal instability. So you have lots of surgical options. I can't possibly cover all of that in 10 minutes. But I think every one of you will use one of these procedures at least once, probably a year, and maybe multiple of these. So your options are, again, debride if you think they just have synovitis, repeat the arthroscopic repair, an open repair, ligament reconstruction, as I mentioned before, an osteotomy of the shaft to shorten, or you can do an ablated procedure or maybe a corrective osteotomy if that's really the original reason for your problems. So I think most of these re-repairs should be done, and Randy and his colleagues have looked at dry arthroscopy, assuming you don't burn up the joint. I think this is the best way to reassess because you're likely to do something else and the fluid may obscure what you're trying to accomplish. So most of these patients are going to receive a dry arthroscopy evaluation. Now the question is, should you do a foveal or capsular repair? Well, I have some biases here. I think if you do a capsular repair, you're not really doing an anatomic repair, but you may stabilize the TFC. But it's sort of like a boat at a dock. The concept of tying a boat up is not to have it very tight to the dock, but rather be able to float, if you will, with the moving tide. And when you do a capsular repair, you're probably accomplishing a similar thing, even though it has worked clinically. So be careful if there's actually a recurrent one that you can accomplish this properly. The next one is if you're going to do a trans-osseous foveal repair, my only statement here is be cautious. In fact, I just saw one, not to name names, in a pre-course where they showed an arthroscopic repair. And the trajectory for some of these can be very difficult. And in that repair, there was actually a hole coming out the dome. So you can see your options of doing a trans-osseous repair. It is not technically easy in all patients, because the trajectory can be very difficult. So if you're going to do an arthroscopic trans-osseous, make sure the anatomy is appropriate for that. Some patients, the ulna just isn't going to allow you to do an easy trajectory to get to the fovea. And you're going to end up going through the disc and the dome. So the algorithm I would have for a re-repair is it depends on if there's DREJ instability. If it's mild or moderate, I think an arthroscopic TFCC re-repair would be appropriate. If there's more instability, or your MR scan shows some worse tissue, then I think an open repair is probably going straight away after a dry scope is probably your best option. And then if you don't see much to repair at all on your MR scan, then I would say that your plan would probably be a ligament reconstruction. So going in dorsally through the fifth compartment is probably your easiest to get a good exposure. Here you can see the scope being done first. You get your TFCC and profile. You can assess the tissue. You can clean out the fovea nicely. And you can pull down a transosseous NICE repair. And I think this is one of the most gratifying operations I did and still would consider doing to this day. I think this is really a lot of fun, personally, through a little incision. So I think you're all capable of doing that operation in a very good way. If I can get an advancement on my... There we go. I've never done this operation. Greg Bain described this, where you can augment the TFC. It's intriguing to me if you can find the right patient where somehow the foveal side is not with good tissue, but the rest of it is. So something to consider where you're augmenting it on the ulnar side. And then the last option, if you don't have... If the TFC didn't stay at anchor, there's not good tissue left, then you consider a radial ulnar ligament reconstruction. These are the entry criteria. Skeletal realignment or, I'm sorry, a proper skeletal alignment really is the main entry criteria in addition to insufficient TFCC. And the other one I would caution you is you do not want to do this procedure in somebody with ulnar positive variance. It's likely to fail. So and I haven't really changed this procedure for over two decades. One of the reasons why it works is it does reconstruct to some degree the ulnar carpal ligaments, which I mentioned at the outset is one of the reasons for persistent problems after a TFCC repair that failed. Postoperative management is gradual return of motion with proper immobilization, and you can read that through. The results of that procedure have been generally good at around 85% success rate. Those that fail have typically been because they have not restored stability, sometimes forearm stiffness, and sometimes a recurrent instability due to rupture. And in my experience, those that have failed the most quickly are either a TFC repair or a ligament reconstruction is when there's hyperlaxity in combination with a flat sigmoid notch. So those critical corners that have the fibrocartilaginous rims are very important for stability and to take tension away from the TFC so it is not stressed. This is a procedure that I think is delicate and difficult, but very reliable in restoring stability, and this was originally described by Woolwork and Bain. Like every surgeon, I modified it slightly. But the idea is to augment typically the volar rim of the sigmoid notch with a graft, and then you can see how it changes the slope of the sigmoid notch. So and here's a couple in a cadaver demonstration showing how those cuts are made. So a case where it was applied, you can see a styloid nonunion that was originally pinned but did not heal. We have a widened sigmoid notch, mild distal radius malunion. This patient had a flat sigmoid notch, but had a very juicy repairable TFC. And so a combination of an open TFC repair and a sigmoid notchplasty restored stability for this patient whose TFC did not heal initially. And here's a case of the flat sigmoid notch, a poor TFC, where a combination of the sigmoid notch and the ligament reconstruction restored stability. And here you can see how it just ever so slightly changes the rim of the volar sigmoid notch. And then lastly, I'd like to show this case where a failed TFC repair. Here's the original injury. Sorry, I don't have a PA. We have the original fixation. You can see there's some ulnar variance problems, a big styloid nonunion taken back by a very accomplished hand surgeon, reconstructed. I'm sorry, here you can see the CT scan of that patient. Here this patient was taken back and the dorsal rim of the sigmoid notch was fixed. The TFC and styloid was fixed and the patient was pinned. Here you can see once the pins are removed, there's dorsal subluxation of the ulna. Some of you are probably picking up on what's going on here. Here's the recurrent dislocation of the DREJ dorsally, you can see. The styloid is now well positioned, but it's still unstable. Sigmoid notch, as you notice, looked quite good there. It was a nice captured sigmoid notch. Here's how she was when she presented to me. Some of you are probably seeing what's going on here, if you're catching it. Here's the left and right views. Again, left and right view shows pretty darn good alignment, but the ulna's out dorsally. Here's the full forearm view, which I like to do on anybody with instability and previous surgery for sure. You can see the overall alignment looks pretty good. Now I'm going to draw the lines to let you focus in on it, and you can see how deformed the ulna is relative to the other side. There was the problem. She came in, had been scheduled for an aptus surgery, and I said, well, let's try this. An osteotomy of the ulna, I went in, the TFC was completely nicely healed, and the sigmoid notch was in reasonable shape. This IOM was highly scarred. She's back to being an OBGYN resident and now catching babies. She was being kicked out of her residency prior to coming to see me because she couldn't supinate, and the director said, I can't really use you. You're going to be dangerous. So she came to me in tears and didn't want the aptus, didn't think she could last and did this, and I just got another email from her. She's one year out now saying, you changed my life. So we always like to show hero stories, though. Thank you very much. Thank you. So it takes a little time to download the presentation, so maybe if there is any question for Dr. Adams. I tried before and it took so long. I have a question for you, Dr. Adams. How often do you combine a unar shortening and TFCC repair or reconstruction, but at the one stage, the first procedure? It depends on the preoperative studies. If the TFC is really thick and it's a neutral or negative variance, then I would not do it. If the TFC is thin and it's a ulnar neutral or ulnar positive, then I will shorten at the same time. Most ulnar negatives, I wouldn't. And nearly all ulnar positive, I would. Okay. Thank you very much. Thank you for the invitation. I'm really glad to be here and happy to come back in the U.S. for this meeting. So this is my topic. I was very happy when I received that. It's a challenging one. So to remind us how high is the rate of scaphoid nonunion, especially considering the proximal pole fracture, you can see it's 7.5 higher risk to the usual scaphoid fracture. Why? We know that the great study from the Mayo with the micro CT scan, the fragile vascularity of the proximal pole, and the second challenging point is because of there is so much cartilage on this bone that if we fail, it will evolve to a snag. Vascularized bone graft. Why? First, because we know that increasing vascularity of proximal pole increase the rate of union. Second, because as you see in this study, the nonvascularized bone graft lead to a high rate of nonunion. This is one of the first vascularized bone grafts described. You can see it looks like to have almost 100% of union. What? It's wonderful. But if you look at it more carefully, and especially with this study, you can see there was almost 50% of nonunion if there was an avascular proximal pole. So it looks like it was not so promising, finally. That's why we have seen more and more different vascularized bone grafts described. These are some are pediculed. Other are free vascularized bone grafts. Of course, you know all of them. And if we look at the outcomes, we can achieve between 77 until 95% of union with those vascularized bone grafts. But we identified some risk factors such as the size of the proximal pole, the dizzy deformity. If there was no rigid fixation, there was a higher rate of nonunion and a previous failed surgery. So how to manage now this vascularized bone graft? I think there are two very important questions for that. First, what about the arthritis? Because, of course, you won't rate on the same way the X-ray on the left side and the patient on the right side. And second, how is the proximal pole? Is it reconstructible or not? Considering that, we have three scenarios. Of course, if you are next to or more, we will go to the salvageable procedure. I won't detail it today. And if you have no arthritis or stuck in one with a reconstructible proximal pole, we believe you can consider two different options. The free medial femoral condyle graft or an arthroscopic scaphoid bone graft. First, we know this graft described a long time ago by Dione Eastin. This is a great study from the Mayo. The description of the technical points. But also a great series of about 50 patients with scaphoid nonunion and previous surgery. You can see that it achieved almost 85% of union. But you see that one of the main criteria was a sufficient bone stock of the proximal pole. We know the advantages of this graft, especially because of the larger bone stock, you better restore the scaphoid length and collapse. And we know from different series that this leads to a better rate of union. Then Jones and colleagues significantly demonstrate the superiority of this medial femoral graft to the 1.2 ECSRI graft. The inconvenience, of course, it's a technically demanding procedure with usually two teams. And there is donor site morbidity. Then, okay, arthroscopy. I know that it's not so famous here. But we used to practice this technique, especially from the proximal pole. You can see the different step of the surgery. First, you start your K-wire preparation under fluoroscopy. And then the curettage under arthroscopy through your mid-capital portal. The graft interposition either from the radius or from the iliac crest. And then graft amputation and fixation with K-wire. This technique, as we all know, was described a long time ago by Dr. P.C. Ho from Hong Kong. And you can see in this study about 124 patients. They achieve almost, they achieve actually 95% of union. And most important, they show that there was no impact of the vascularity of the proximal pole considering the rate of union. Second scenario, non-reconstructible proximal pole. Of course, we can still use the free MFC graft. But there is also some other options to consider. The pyrocarbon implant, which can be introduced through a mini-dorsal approach. Was described by a French team. You can see this series with 10 years follow-up. They decrease the pain. The range of motion was acceptable. And also the myo-risk. But pay attention. Because there was almost one-third re-operation. We analyzed this series. There was two big kind of re-operation. Early failure with implant dislocation. And radioscapheid pain. And you can see in almost 77% they performed at a secondary stage or radiostylectomy. And the late failure that they observed a carpal degenerative progression. Even with the APSI. The same degeneration than if you didn't perform any procedure. Another option can be the chondrocostal graft. Described at front from Australia and from France. From the ninth rib. You can replace the proximal pole as in this example. And it is a smaller series. But with a mean follow-up of four years. They analyze with MRI. And they achieve 100% of healing. Which can promising. A more recent technique described by our friend from Mayo Clinic. With Dr. Bassamel Hassan and Sonj Kakar. They harvest the proximal hemate. You flip it at 180 degrees. And you can see it can fit the size and the shape of the proximal pole of the scaphoid. And you can harvest also the volar capitol hemate ligament. Which is a good opportunity to repair the scapholinate ligament at the same time. They show considering the biomechanics that there was no impact of removing this proximal pole of the hemate. This series, this study about CT scan show a high rate of correlation between the proximal pole and the proximal hemate. But of course it is important to introduce this into your workup. Because it's not all the patients. But 70%. And we performed this study at Mayo Clinic. Showing that you can replace the proximal pole of the scaphoid by the proximal hemate. And you can achieve a normal carpal kinematics. This is an ongoing clinical series. Thanks to Sonj Kakar for sharing with me this example. You can see you can use the new technology and reproduce a 3D reconstruction of the wrist. So you can match very well how much of the proximal hemate you have to harvest. Harvest to reconstruct your proximal pole. It was fixed with K wire and screw. And it healed. Then we compared those three techniques of reconstruction of the proximal pole. Biomechanically speaking at the lab of Mayo. And what we observed, there was no statistical differences between those three technique in reconstructing the carpal kinematics. So they are equivalent at least on the biomechanical point of view. In summary of course, we have to remind it's always better to succeed first. And then considering the arthritis and the reconstructability of the proximal pole, you can have those different options. Thank you very much. Thank you. Thanks for including me. My task is to talk about failed scapholunate reconstruction, which is easy, of course, right? Testing me. So the task is when tendon grafts cannot hold bones together. And I think that the issue really sort of philosophically if you sort of sit back is say that is there a compelling and now solved and solvable reason for failure? Did you do a procedure that was too little? So just pinning the scaphalonate when you really should have done a reconstruction and you can now solve that procedure? Or do you have the options for sort of throwing in the towel and addressing it in another way? Either continuing non-operative care, pain relieving measures, or salvage procedures. Certainly again sitting back and saying why did it fail or did it really fail? Is there something else going on? Sometimes it's a radiographic dental luma where you look at the contralateral wrist and you'll find surprisingly that there's a bilateral diastasis. So this is a patient who was actually sent to me for do something following a quote unquote failed scaphalonate reconstruction. Here's her plain film radiographs and her exam is remarkable for really quite good motion. And if you look at her contralateral films. And is this a failure of surgery? I don't know. She was completely asymptomatic on the other side. So being aware that sometimes stopping, taking the time to take another look and figure out what's really going on with the patient. What about doing something rather than doing nothing? I think that my task was to talk about I've already done my reconstruction and it failed for whatever reason. So understanding why it failed, did I underestimate what was going on with the wrist? And did the patient have pre-existing arthritis? Did it fail because the patient is stiff? And then having an armaterium of options. So I like this procedure. Sometimes I'll augment it with the Vuller Capsulodesis that Steve Moran described. But there's a variety of different techniques. I like this technique because it's sort of biology. I don't like putting big holes for suture anchors. Although arguably there's a giant big hole in the scaphoid. Which as you heard from the previous talk, sometimes breaks and sometimes fails to heal. And you sometimes end up with a problem. But really the failures I think of are failure to realign the bones. Failure of them to stay there. Failure to recognize issues associated with the patient. Whether pre-existing arthritis or underestimating the power or overestimating the power of the wrist to sort of regenerate. And then new problems which can be substantial infection, iatrogenic problems. So this is a patient with a so-called failed scapholunate reconstruction. And this patient was actually made worse. So if you look carefully, there is now a free-floating suture anchor in the mid-carpal joint. And there's a non-free-floating suture anchor over here in the mid-carpal joint as well. So being aware of what issues. And so my revision surgery for this patient was to take out the suture anchors, inject his carpus and see how he did. And he actually did quite well with that sort of minimalistic approach. What about salvage treatment? There's a reason to consider this. If the patient and you sort of shared decision-making, what's the likelihood of success with a revision reconstruction versus shall we move on to something else? Then continued non-preventative care has a role. Certainly that patient I showed previously, I simply took out his suture anchors, did a corticosteroid injection and said, let's see how you do. It allows the patient to potentially regress to the mean, but also to readjust their expectations. Medical options, we talk about pain-relieving measures that don't address the carpal instability. And I think there's a number of them that are quite reasonable to pursue. Neurectomy, I tell patients this is sort of a salve. This is not necessarily a long-term solution. So I choose my patients carefully, make sure that their expectations are aligned. This isn't going to solve all of your problems, but it might provide some relief. I do the pre-op block like Dick Berger described, and I look for a difference in grip strength as well as symptoms. And the procedure itself is quite easy. I tell the patient that it's a low investment, but a potentially low reward, excise a portion of the PIN and AIN. I have zero personal experience with the more involved global neurectomy, so I'd be interested to see if any of the other speakers have that. But as Dick Berger said, this procedure is not curative, and it's not necessarily a long-term success. Radial styloidectomy, some of our speakers and individuals in the audience have written beautifully about this, particularly as an arthroscopic procedure. I think this is great as a pain-relieving measure, particularly those patients who have reproducible radial-sided impingement. And Guillaume and his colleagues have described a beautiful technique using the Dorsal 3-4, the 1-2, and a VOLAR portal. And he actually reported on 34 patients with slack or snack wrist, did an arthroscopic styloidectomy in 24, and nothing else, and only one patient went on to another procedure. So I think this is something that I consider in my patients, and I really like arthroscopy for visualization. What about proximal rotor pectomy and four-corner fusions? Well, the meta-analysis suggests that the range of motion is better in PRC, and although you'll get radiographic evidence of arthritis, it certainly wins in ease. It wins in sort of the cost analysis. The cost analysis is substantially cheaper because of predominantly the supplies, the implants, but also operative time. I sort of favor the limited wrist fusion in the younger or middle-age, high-demand patients with an anticipated higher complication rate, poor motion, and a higher re-operation rate. There is some discussion about which joints, which bones to fuse in limited wrist fusion, and I think the principles are really correcting the alignment and correcting the DC to make sure that you achieve a reasonable range of motion. The nonunion rate, depending on who you read, can be quite high. I think the pendulum often swings back and forth about fixation from K-wires to staples and screws or circular plates. Statistically speaking, in the literature, it suggests that some sort of compression device may be better. Beware that the radiographs are underestimating the arthritis, and certainly there is some vascular safe zones for fixation of the lunate, which I think can be important both in scapholunate reconstruction when you're drilling those very big holes sometimes for some techniques, but also for limited wrist arthrodesis. I really like this technique. If you have a chance to look at Del Penal's article, he used a dry scope and puts his screws from distal to proximal so that you avoid injuring to the lunate fossa. The issues, of course, nonunion, overtime, implant costs, malreduction, which is easy to do, but hard for the patient to recover from. Proximal rocurpectomy, they fail if they do. Usually within three years, they all get arthritis that may not be problematic for them. And I've used this technique particularly in patients who have keen box who have a little bit of changes at the capitate, but resurfacing with capsular interposition, and some folks do this on almost every case, which I'm a little scared to do, but if you have a very beat capitate like you see here, it's a very good technique to limit that contact forces. Complete wrist fusion is sort of the one and done, sacrifice motion for pain relief in a definitive procedure, and many different options in terms of fixation and in terms of alignment. Replacement arthroplasty, I really love this procedure, but only in low demand patients, and I will caution you that there's an issue with the literature saying the evidence doesn't support it, and I'm always cautious about that. So again, reasons to consider sort of giving up. You have an unsolvable problem, or you and the patient feel that the low chances of success exist for a high investment of time and effort, and I think that that's reasonable to say the patient and you have had enough. Thank you. I was told by the IT people that they send these talks over through Wi-Fi, so this is probably not the best way to do it at meetings like this. We have double-clicked it, Warren, and it's not doing it. Yeah, it just takes a while to load up. All right, good morning, everybody. Thank you for coming, and great session so far. It's a really potpourri of problems, and so Randy asked me to talk about just radius fractures that fail. You know, you see or you see radius fractures all the time, right, and many of them can be fixed just by a roller plate, but there's a subset that can't be, and also, there's fragments that are sometimes missed. So, roller plate works every time. Of course, it does not. Here's a case where it does not, did not work, and I think we know about the roller marginal fragment as being one of the big keys for not working, but also, interarticular hardware is not well-tolerated usually in this case or this case, and, you know, a lot of these cases that I'm going to show are, you know, done elsewhere, so I don't always know exactly what it looks like when they leave. I have a, you know, I think that some of them have been kind of like left like that, which is a problem, obviously. So, I'm just going to go through. This is really cases. You know, I look through, you know, a lot of literature, and there's not a ton on, you know, revising these, but how would you fix this one? You know, would this just be a voller lock plate? This is actually a case of mine that came in, and I think, you know, this audience probably knows that you don't always just do a voller lock plate. You have to look at all the pieces, all the fragments, and think what you're going to do. In this case, I added a radial column plate. I think it's really valuable to do that, and the approach that I do is I just do a hockey stick type incision over this way, and then raise a flap and get to the radial side, rather than a separate window from the usual window vollerly, but then on the other side of the artery, you can have a really good look at the radial column and get excellent fixation there. I don't hesitate to put one over there if I need. And when you're post-op, this was an, that was an open fracture that she came in with, totally dusted. I think we know about this paper, one of the landmark papers that talked about the voller marginal fragments is something that can be a bad actor. A person comes in like this, and this is the case from the paper. It was fixed here. Voller marginal fragment was missed, and five weeks post-op, you see this, and you lose your lunch. I think we've all been there, or you want to see a door on the side of the room, just crawl out, you know, and, but you can't. So in their paper, they revised it and, you know, had a reasonable result, but not awesome. So these are cases that came in that I've seen. This patient came in and had pain in minimal range motion for months post-op, fixed elsewhere, and you can see that subluxation of the carpus, and you have a hint of some, maybe some hardware in the way. I get CTs on all these, and this indeed is subluxated, and there's a step-off, intraarticular hardware has been confirmed. This patient comes in, can barely move the wrist, and it hurts a lot. So I think, you know, these are just cases I think most people do, a similar type situation is what I did here, and, you know, if we have time at the end, it'd be nice to hear other thoughts, but. Remove the hardware, these are tough because they're intra and extraarticular osteotomies, very challenging, and, you know, you really have to lay the crate, you know, because this may not heal, and also discussing them that you might have to do more, including full wrist fusions or some of the other potpourri that Julie went through. I find that when you need large pieces to really fill the gaps, crest is really valuable because it's much bigger, and it's more robust to lift up and raft those fragments. The subluxation part, you know, spanning plate, always need that as a, you know, as a backup, and then potentially pinning. So here's the case, so osteotomy extraarticular, and also he needed intraarticular osteotomies. I like to put a K wire in the joint, and then when you jack it up, you can actually see what your tilt is going to be. And fixed dorsally too, because those fragments are just like falling out the dorsal side. So that's a buttress over there, and then radiolunate pinning. This is a, this case, very memorable one. She comes in, and she has this radius fracture is fixed, and they pinned it as well, and I, you know, if you can get the trauma film, it's very valuable because this one was, you know, did not look that unstable from the DRJ perspective and the trauma films, and she could barely move her wrist inflection extension. She couldn't rotate it, but she couldn't move her digits either, and it hurt a lot. And you know when those patients come in, and they're acting like that, you don't know if they're crazy or if they have like a real problem. Like why can't she move her digits? You wouldn't think that, you know, digits would be involved with this as much. But, you know, I had suspicion that there might be something going on there from maybe the dorsal hardware that you can't see in these images. She had severe dorsal wrist pain and ulnar-sided pain. Once again, couldn't move her fingers, which is, you know, a little bit strange. But if you, and once again, you know, like I was saying, get CTs on all of them. You really understand. Make sure you get good sagittal kernels and axial cuts, and what you see here, and my colleague Scott Wolf has talked about this, is this coronal shift that happens. And if you coronally shift, and then you don't have a good relationship with the DROJ, not, you know, aside from the pinning of it, which is obviously that it can't rotate. But if the DROJ is not reduced, and Brian showed some really good images of the DROJ, you know, that should be a congruent joint when you get films. And I'll rotate to make sure I can see that DROJ in radius fractures. But the DROJ is obviously not congruent, and it's, you know, pinned in that way. But this was very significant too. Axial cuts show the pins that were between the radius and the lunate went out the dorsal side of the radius. You know, there's, they're talked about like they should stick out some, but not so dorsally. And so those pins were in her extensor tendons. That's why she had pain there and couldn't move her digits. So I think, you know, this is kind of leading in a path where people would do a sensible thing, is to remove that hardware and reduce the fracture, reduce the coronal shift, and then refix it. And this is one where it's kind of like an opposite of what I just said. Like, you don't have to do, or volar plates don't work every time. But I think if you do it well, then it does work. You know, you don't want a hardware sticking out the dorsal side either. Because like dorsal pins coming out can also mess up with the, mess the extensor tendons and give them pain and decrease range of motion. Here she was. Pandemic times, this is a Zoom telemedicine. But I asked her to, you know, come back and show. But this is, I mean, if you saw her pre-op, it was, it was widely different. You know, couldn't move and tears and everything. But she was extremely happy. What do you do in these cases where, you know, you have, once again, they all present the same. Like, they have a lot of pain. They can't move. And then you get x-rays, and you're like, hmm, something's going on there. You get CT, and you have, you know, screws in the joint. Obviously, you know, you have to do something for those. So in these cases, you know, take these out. And there was bone-on-bone arthritis there. So I think you're, you know, knowing the path where it's going to go. But these are ones where, obviously, if the right carpal joint is completely trashed, in my mind, you have to fuse that. It's a good operation for the right person. I was talking to some people about, you know, how you do it. Is it screws? Is it a plate? You know, I've done it every which way. As a disclosure, I do consult for Synthes. I was involved with a design team when it was BME, and Synthes bought BME. But the Nitenol staples, you can use any other company as well. But they've been very good for partial risk fusions. Now, that was an earlier case of mine. I do, now I've gone to two. This is a different case for a different reason. But I just want to show that I go with two per joint. And some people have been like, whoa, how much does that cost then? But these work really well. They fuse really fast. It's not a simple operation. You have to, it's very technically demanding. But the results and the reliability for me has been extremely good. And this is, once again, another indication, but just to show, you know, the person with, you know, a decent functional result. So, you know, somebody has hardware in the joint, bone on bone, this is the option that I would choose. I'm going to put a couple in here where you're just, you know, the person comes in and they're, once again, you're like, are they crazy or do they have a real problem? And this person actually left the OR somewhere else like this. And I think the important thing is to look at the subtleties of it. You know, if you look at that, if you look at the scaphoid fossa and lunate fossa are different. But you shouldn't see this kind of double wing sign there. You should see a nice kind of a bowl shape. And if you get CTs, once again, there's a theme here, you'll see that what's going on here. I mean, this is not reduced. And this person comes in saying it hurts a lot, they can't move. They see people in therapy next to them like being able to move after a radius fracture and they're wondering like why am I like this and I'd seem, you know, my other surgeon said just, I'm fine, just keep doing therapy. You know, you've heard that story before. So, you know, this is kind of common themes here. But you're really trying to get a good facet view when you fix and make sure that you can see a nice U shape to that, you know, so the facet view, very important to get where you get, you know, come down the inclination of the radius so you can see the joint better and know that it's reduced. And she was improved from this. So take home points would be each fracture is unique, you know, probably 90% you can fix with roller plate but the others you need to really think about, you know. And so I get CTs. If I'm going to fix it, I'm going to go to the length. I actually get CTs on all because I do not want to have like a fragment that I miss. A whole other section of like augmentary fixation but I think that, you know, every fracture is one that you have to think about separately and then salvage if arthritic. Thank you. OK. We finally have an easy one to load up finally. We have the computer system figured out now at the end. So my charge is to talk about patients that have persistent pain after trapeziectomy. So as opposed to scapholunate reconstructions where there's a variety of techniques, then none of them do perfectly. Many of the trapeziectomies or thumb arthritis surgeries do well. So most of the time, this is not an issue but when you do have problems, we want to figure out how do you manage it if they're still symptomatic. So no disclosures related to this. So let's make this a case-based discussion. Fifty-four-year-old lady, dominant thumb. She's had two previous procedures. The first one was an APL-FCR suspension, had persistent symptoms and then she had a revision to more of a standard LRTI as Burton and Pellegrini have described using the FCR through the metacarpal base. So she's got collapse with pain. She's got pain. She's got weakness. So how are we going to go through, figure out what her problem is and manage this? So in general, as I said, trapezial resection arthroplasties provide excellent results for patients. There's a high incidence of people returning to have the other side treated. So we know that those generally do pretty well. But you need to try to figure out what in the prior surgery happened that didn't go well or is there something that was missed that's causing the patient to have persistent pain. You think about pan-trapezial arthritis, you know, is there a problem with the ST joint? I think STT arthritis with CMC arthritis is different than CMC arthritis with little STT arthritis. So figuring out your initial diagnosis can come into play as well. Thumb MP joint instability, part of it is teaching the patient how to pinch and making sure that that MCP joint is stable. So when they pinch, it's not collapsing. It's not hyperextending or they don't have ulnar collateral or radiocollateral ligament insufficiency. So pinch creates a problem at the MCP joint that's subsequently going to be manifested at the CMC joint, particularly if the trapezium has been resected previously. So what does the literature show? There's some, there's not a lot, but there is some literature. If you look at this paper from the Mayo Clinic, 2006 Journal of Hand Surgery, looked at 654 procedures over 12 years, only had 17 revisions. But what they did was look at the pain relief, the motion and strength. And in the revision surgeries, 13 out of 17 produced good results. Two were fair, two were poor. The procedures that they did looked at interposition silicone, which we wouldn't do now, to replace the trapezium. Another paper here in Archives of Orthopedic Trauma Surgery from 2011. They looked at, this was out of Germany, but they had a revision rate of 2.9 percent, 343 primary arthroplasty, 16 revisions. They had 12 that they were able to follow up and see how they were doing. Often had pain due to crepitus, radial sensory nerve, neuropathy or injury, or scapho-trapezoid arthritis. And in their revisions, 12 patients, 2 did good, 5 did fair, 5 did poor. So not quite as promising as Dr. Cooney's paper. So why are the patients symptomatic? What went wrong initially? Well, it could have been a wrong diagnosis. There are situations where you have incomplete trapezial resection. You know, you have that beak that often extends between the base of the index and the base of the thumb metacarpal and that can sometimes be missed when you're taking it out. Could be persistent STT arthritis, thumb MP arthritis or instability, radial sur, radial sensory nerve irritation, subsidence. You know, most of the papers would suggest that subsidence doesn't matter, but maybe sometimes it does. And then mid-carpal arthritis or carpal instability in patients that have predominantly STT arthritis. I think they often will have extension of their proximal row and if you get wrist x-rays and you look at their lateral view, you'll often see extension of the proximal row and when you take out the trapezium, that could be manifested and they may have kind of more dorsal central pain. And then tendinopathy, de Quervain's can cause persistent radial-sided symptoms occasionally. Implants are not commonly done in the U.S., but there are a group of patients that have implants and there's certainly a high risk of revision if you have implant or plastium thumb. So subsidence, as I said, is common, but what's the clinical relevance? I think if you look at most of the papers that look at outcomes of thumb CMC arthritis surgery, it'll show that once the trapezium is rejected to some degree, you're going to have subsidence. This is a paper from the Rothman Group. Looking at 112 patients, they compared the standard LRTI to suture button suspension and what they found that the LRTI had more subsidence early, but long-term, by 12 months, they both had similar amounts of subsidence. But there's no difference in their pain scores, their pinch or reoperation between the two cohorts. Suture button seemed to do better quicker or earlier in terms of quick dash and had better quick dash scores throughout the entire time frame. If you look at this paper by Jean Del Senor with her technique essentially tethering the APL and the FCR together, patients did pretty well at long-term follow-up, but 35% of them had some degree of radiographic subsidence. So I think if you take the trapezium out, you know it's going to collapse. Fortunately, most of the time it doesn't seem to correlate with outcomes. So revision options. Once the trapezium is out, what are you going to do to try to revise them if you think they have persistent symptoms? Well, obviously, in part that depends on what the primary procedure was and what the options are as far as tendons that are left. There's really no evidence-based decision, so it comes down to surgeon's preference. Suspension options, really tendon transfer, tendon graft or suture button suspension and then arthrodesis. What you don't want to do in a patient that has subsidence is try to fuse the thumb metacarpal to the scaphoid. That generally doesn't work. So if you're going to do an arthrodesis, you want to fuse it to the index metacarpal, and that can create a stable joint, particularly in someone that's very ligamentously lax or soft tissue issues such as Ehlers-Danlos Syndrome. So if you look at this paper by Bobby Charbera in the group, it's actually very good, worth looking at. And four years ago now in the Journal of Hand Surgery, but a current concepts article, and it went over the different options and techniques. And this is something that I really like for the patients. It's using the ECRL when the FCR has been taken before. And essentially what you do is you take the ECRL, do a drill hole through the base of the index metacarpal. So you've got a slip of that ECRL. Now it comes out. Now it's almost like a standard FCR LRTI suspension. So if the FCR is gone, this I think is a great way to reconstruct this. So if you look at the outcomes for some of these things, this is one of the earlier papers, Connolly and Rath, the Journal of Hand Surgery, British edition, now European, but British at that time, 1993. They looked at 17 revision procedures. Nine of those did pretty well with complete relief of pain. Three were fair and five were poor. So not great, not what you would think of as far as primary. If you look at this paper by Dean Citerionis and Gary Lurie from Atlanta and Pittsburgh, 32 revisions over an eight-year period. Pain they felt was predominantly due to subsidence. And so their treatment, a mean time of 41 months, which is kind of late for revision when you think about this. There's a variety of procedures, but the key I think is they all had six weeks of pinning and they all had interposition material placed with either tendon autograft or allograft. And they demonstrated significant improvement in pain, grip, and pin strength. And 29 of the 32 were very satisfied and the other three were satisfied. So this would lead you to believe, at least in their series, it can do well. And I think the key is these six weeks of pinning. So you can't move these patients nearly as quick when you're doing a revision surgery. If you look at this group from Washington University, they looked at 10 revisions and compared them to 20 primary CMC arthroplasties. What they found is that the revisions ended up having better objective outcomes than subjective outcomes. So the patients still didn't seem like that they were doing well. When you look at MHQ total pain, but their pin strength and grip strength were pretty similar. So some of it probably has to do with the psychological state and they found that there was a higher incidence of depression in these patients that had revision surgery. So the mental side of things, I think, as we're starting to understand, plays a role in patient outcomes as well. There's a paper where they looked at 83 patients over 20 years, complication rate, so radial sensory nerve irritation, CMC instability, pain. They looked at 25 PROMs, 10 had good, seven had failed, and 10 were poor. Trapezial space ratio and subsidence, though, didn't seem to correlate with outcomes. So most of the literature would suggest that subsidence is not necessarily important in terms of subjective outcomes. Paper out of Australia here, 25 thumbs, five and a half years after revision surgery, subsidence was the most common reason for revision. Nine patients had a second revision and two patients had a third revision. And so they treated it with resection of the base of the metacarpal plus interposition. And two thirds were better than prior to their primary pre-surgery, but not as good as primary outcomes for arthroplasty. So suspension arthroplasty for revision thumb and other papers, 18 suture button suspensions, 18 LRTIs, comparing those. And there is the similarities between them and outcomes. So I think the decision that you have to make if you're thinking about revision surgery here, is it gonna be a soft tissue reconstruction or is it gonna be a bony reconstruction? And I think the bony reconstructions are maybe more helpful in patients that have substantial laxity. You know, all thumb arthritis is not created equal and the person that has collapse of the metacarpal, high MP joint hyperextension, is different than the person that's pretty stiff and you're gonna manage those a little bit differently. So back to our case, or here's another case, a 58 year old prior APL based suspension, postal worker, pain at the base of the left thumb, had previous arthroplasty, worsening pain at six months, or suture removed from the base of the second metacarpal, still has symptoms at two years, continued pain after the second surgery. And so here are the radiographs, you can see a little bit of subsidence at two years, you can see now the scaphoid is, or the metacarpal is impinging upon the scaphoid, so persistent symptoms from this. So subsidence to this level probably is problematic, some degree of subsidence, as long as it's not impinging is not. And so these were the examination findings, pain with metacarpal to scaphoid grind, compression and pain between the base of the thumb and base of the index metacarpal. And so in this situation, this is a case that Peter Rhee gave me, one of the things when you move is you realize you don't have x-rays, or you don't have access to your x-rays before, and so it can become challenging putting things together. But basically the technique here, as I said, is to fuse the thumb metacarpal to the index metacarpal. You can see things brought together here, a combination of screw and pins, and there you can see the CT scan demonstrating healing. Back to the case that I talked about, this is an example of using the ECRL as a strip, again, there's thumb impingement instability as well. So we're gonna take a portion of the ECL, drill through the base of the thumb metacarpal, now we can bring it out on the volar side, just like the FCR, and use this as more of a standard LRTI type of arthroplasty. There you can see the MP arthrodesis just with tension bands and a K-wire. Again, I keep these immobilized longer, so I generally pin them for about six weeks, and then remove the pin and start the therapy program. So in summary, I think most patients do well. You need to identify the source of pain, determine if the soft tissue reconstructions are likely to work the second time, and in general, plan B should be different than plan A. So if something didn't work, repeating that most of the time is not gonna work the second time. Make sure you address the MP joint if there's instability, and if there's really substantial laxity or substantial collapse, that's when I'd consider arthrodesis of the thumb metacarpal to the index metacarpal. Thank you very much. Thank you. Can I invite the faculty up here? We can go through a few cases very quickly, and then we'll take some questions from the audience. Just one question, Dr. Hammer. What are your indications and what do you do for amputee instability? So I don't have anything that I love. I try to avoid fusing it, unless it's really arthritic or unstable, even if they hyperextend more than 30 or 40 degrees, because I think just an easier recovery. So I do a vular capsulodesis. I've done a variety of techniques over the years, and I don't have one that I say this is perfect, this is the way I do it every time. But basically, what I try to do is advance the vular plate and reattach it into the recess on the metacarpal. Are you using suture anchors, or what do you use to reattach it? Yeah, so I will take a ronger and roughen it up, and then put an anchor in there, and then just try to tack it down, and then I pin the MP joint for six weeks as well. Thank you. So first of all, I'm from Australia, so the cases I'm presenting have got a bit of a local twist to them. So the first patient is a 46-year-old male patient, right hand dominant. He's a road train driver. So these road trains are used in the outback in Australia. They're basically trucks with multiple trailers behind them. And the work that these drivers do is actually quite heavy work. Sometimes when they deal with obstacles, they actually have to stop, detach every single trailer, and then take them across the obstacle one by one, and then reattach them. So he injured himself. Now, this is the kind of guy that works and parties hard. He injured himself in December, New Year's Eve. He was a bit drunk, and he fell, injuring his left hand. And these are the initial x-rays. Anyone want to comment on them? Maybe we'll start with you, Steve. Yeah, concerned about the vulnar marginal fragment. Careful when we go to CT. Yeah, so this is the CT scan. Now, this was fixed by one of the trainees, one of the residents at the hospital I work at. And this is what he did. Now, this patient then, he missed some of his follow-up appointments. He lives two hours away from the hospital. Because of geography, it's difficult for him to get in. No one to drive him in. But his local doctor did the initial management for him. And then, at six weeks, I get a knock at my door, and the resident comes in and says, this is what's happened to him. Yeah, they missed that fragment. And so, you know that, you show that one cut, and it looked like it had a long enough proximal area. That's right. But that, you don't always, like, I really look at all of it. Yeah, that little lip there. Yeah, that's what I was concerned about. And so, I would, you know, and that plate was a little proximal, or at least there wasn't anything capturing distal ulnar in the original one. Yeah, I think what happens is, you get the plate, and the plate's kind of right over the fracture line. So, the plate's covering the fracture line, but there's not a screw in that vulvar fragment. And so, it looks good initially. And then, at four to six weeks, they start to move, and it just becomes more noticeable. Yeah, and the fracture's probably right at the edge of the plate. I think most of us have had similar cases that we think we've captured the fragment, and unfortunately, have not adequately done so. So, in terms of revising this, what would you do? So, in my hands, I take off the vulvar plate, reduce the fracture, and I am a big fan of the spanning internal fixator plate. I like that a lot, because that will neutralize some of those forces, plus or minus revising the vulvar fixation. A lot of sort of fragment-specific devices, or other devices, that go very, very distal, that allow one to fixate that fragment. Yeah, what about you, Steve? Yeah, similar. Similar thoughts. So, this is what I end up doing for him. The fragment-specific type fixation, and I put a neutralization plate on, and took it off at about 10 weeks. So, this is three months post-op. Now, the one thing I've noticed, even I've noticed in some of your photographs of your patients, is that patients lack flexion of the wrist. My question is, at what stage would you intervene, and what would you do for them, if it becomes a problem for them, or has there not been much of an issue? No, no. And, you know, I tell them that, I tell them about the functional amount that they need to move, and it's usually not exactly what they had before. Yeah. And I also, you know, I tell them, I warn them, that if you go to the therapist, and they, don't let them think you're a failure, because you're not doing, you're not symmetrical, because I don't expect you to be. But the range you're gonna get is functional. Right. Okay. So, was that patient immobilized in a cast or not? So, after the first surgery, yes, he was. He was placed in a cast. For how long? Until he came back to see us, so six weeks. Yeah, my experience is these patients will move before their first post-op visit, whether or not they're immobilized. So I think it's the fact that the carpus is coming down like a big battering ram and displacing everything vulnerably. So I'm not sure that immobilization is adequate. My immobilization depends on my security and the fixation of the fragment. So if I have a very old patient with fragile bone, then I will tend to immobilize a bit longer than if I have a younger patient, and I'm quite satisfied with my fixation. So it sort of varies on what I find at the time of surgery, but generally speaking, I try to immobilize quickly. I'm not sure it makes a difference, but... I personally cast everybody for five weeks, and if I put a bullet point on, and you know... And I'm not... Stiffness is not going to... Yeah, I can't argue with that. I mean, I think that... Yeah, David Ring had a paper some years ago where it didn't matter if you do it. Yeah. I know some people, like, I don't know, it almost seems like they're bragging. I get them moving in like, you know, in three days. It's like, you don't need to. I agree with you. I mean, it's okay. I think we're out of time, so I'm going to skip the second case. Are there any other questions from the audience about any of the presentations before this? I mean, I think if the sagittal tilt is at least neutral, then I would go after the ulna instead. It's a simpler operation for me. Yeah, it's kind of dealer's choice, and I cater to the patient, and it's very tempting to go off through the radius because that's where the abnormality is, but it really depends on what I'm addressing and how much distance I need to make up. Just a bit on that. Is there an amount of abnormality where you consider that, actually, I've got to address the radius now instead of the ulna? Any degree of malunion? In terms of... The radius malunion. In terms of an extra-articular malunion. You know, I think that, really, if you're looking at the ulnar variance, if you're going to have to really take a large amount, then you may need to address both at the same setting. I have no personal experience with distraction, but I know that sometimes patients who have a very large lengthening will have quite a lot of pain because you are stretching the soft tissues, including the median nerve, and so I'm a little bit cautious about that. I think it depends if it's just a short, like, mostly just a shortening issue, and the ulnar sinusoidal pain because of impaction, versus if there's something off on the other planes. Like a sagittal, you know, dorsal malunion that's 20-plus degrees, I would go after the radius instead. Right. Okay. Any other questions from anyone else in the audience? No? All right. Well, thank you very much. All right, Rez.

orthopedic surgery

replacement arthroplasty

wrist fractures

radius fracture

vulvar marginal fragment

persistent pain

trapeziectomy

soft tissue reconstruction

bony reconstruction

thumb MP joint instability

post-operative immobilization