Okay, well, good afternoon. I think we'll go ahead and get started. I'm Warren Hammert from Durham, North Carolina at Duke University, and this is How to Approach Ulnar Sighted Wrist Pain. We have an excellent group of faculty that are going to be presenting, including Dr. Yao, Dr. Bernier, Dr. Richard, and Dr. Kakar, and so I'll introduce them as they get ready for their portion. But to start off with, I'm going to talk about really how to, some keys with examination and imaging of the ulnar side of the wrist. So when you think about the biomechanics, the exam, and imaging of the ulnar wrist, there are several things to think about. I have no disclosures related to this presentation. So when you think about the anatomy and the biomechanics of the DRUJ, which you must understand, you have to remember that the ulna is the stable bone of the form. And so when we talk about the mechanics, everything that happens at the DRUJ or ulnar carpal joint has to do with the radius and its position related to the ulna and the carpus and its position to the radius and the ulna. And when you talk about, people often describe a dorsal dislocation of the DRUJ, but it's actually a vulvar dislocation of the radius, because remember, the ulna doesn't move. And often in our literature, that's described incorrectly. So always keep that in the back of your mind, that the ulna is a stable bone and it doesn't move. So when you think about the axis of forearm rotation, you can draw a line from the radial head into the ulna fovea. And as we go into supination, the two bones become more parallel. As we go into pronation, the radius crosses over the ulna. The anatomy of the DRUJ, from a bony standpoint, there's a shallow concavity in the sigmoid notch of the radius. The ulnar head articulates about 220 degrees of its portion, and it's covered with articular cartilage. And forearm rotation, or pronosupination, is a combination of the rotation and at the extremes, translation of the radius in a dorsal or vulva direction to get the final extent of pronation or supination. And so more recently, one of the concepts popularized by this group here, Dr. Garcia Elias and colleagues, talked about the ligaments and muscles that stabilize, and they refer to it more as the radial ulnar carpal joint rather than distal radial ulnar joint, trying to highlight the key components of the ulnar carpal ligaments that also act around the distal radial ulnar joint. So again, with forearm rotation, this is a schematic from their article about how the radius rotates around the ulna to become parallel or cross over, and that's going to affect the relative length of the distal radial ulnar joint. When you think about the restraints, there are primary stabilizers and secondary stabilizers. There are portions that are intrinsic to the wrist and extrinsic to the wrist, and what they've described as passive and active stabilizers. And then when you think about the load that's transmitted, remember there's a load across the ulnar carpal joint as well as the radial carpal joint, and then there's a transverse load across the distal radial ulnar joint, so that's often forgotten when you think about the load as well. And so this forearm rotation is a combination of shear stresses, of compression, together they equal the total force along the distal radial ulnar joint. So this is from Bill Kleiman's article in 2007, if you haven't read this, it's definitely worth reading. It's one of the classic articles, and it really puts a lot of things together. It's entitled, I think, Lessons We've Learned Over 25 Years. But the TFC, which is the important portion that we're going to talk about a lot here, is depicted with the green and the blue fibers, and there's two components of this. And initially, if you read some of the older literature, it would talk about the TFC and the portions that are tight in pronation and supination, and there's some contradictory articles, and I think it's because we didn't really understand what we were talking about and the difference in the superficial and the deep components. And then the ulnar carpal ligaments are important for stability as well. And so when we think about the foveal insertion, that's the blue, it really has a different or a more broad angle of attack to help with stability. The superficial portion, which is depicted here in green, is a more narrow or more acute angle. But the foveal fibers or the deep insertion, which is depicted here in blue, is really the key for stability at the distal radial ulnar joint. And we think about passive stabilizers. We also have the ECU and its sub-sheath, the inner osseous ligament, and the ulnar carpal ligaments, as depicted here. And then when you think about the active or the dynamic stabilizers, we have the brachioradialis, the APL and the EPB. In supination, the pronator quadratus contracts, and so that compresses the DRUJ. And in pronation, the ECU is really an ulnar deviator, it doesn't extend the wrist in pronation, but it provides a compressive force against, resistance against the distal radial ulnar joint. And when we think about the load, the load will vary depending on the position of the form and the length of the form. So normally, the load across the radial carpal joint, normally the load is across the radial carpal joint in an ulnar neutral or ulnar negative variance. But as we shift and rotate the form into pronation, or you have an ulnar positive variance, it's either static or dynamic as you shift, the radius shortens so the ulnar becomes relatively longer. And that increases the shift in the load across the ulnar carpal joint. And so when you think about form rotation, you try to put this all together. As we go into pronation, the dorsal deep fibers and the palmar superficial fibers of the radial ulnar ligament contract. And that's the primary stabilizer. And then the secondary stabilizers are the pronator quadratus and the vulnar capsule. When we go back into, I'm sorry, that was in supination. When we go into pronation, the vulnar radial ulnar ligaments are important from a primary stability standpoint with the vulnar deep fibers tightening and the dorsal superficial fibers tightening. And the secondary stabilizers are the ECU and the dorsal capsule. So when you think about an examination of the ulnar-sided wrist, thinking about the biomechanics first, there's certain things that you have to understand. And the surface anatomy is the key to being able to understand what's going on or try to get a sense. So the pronator, excuse me, the pisotricoetral joint, the hook of the hamate, lunar tricoetral ligament and interval, and then the DRUJ and the TFC. And once you understand the anatomy, surface anatomy, you can palpate and often have a sense of what's going on. These are pictures from Glenn Gaston, but did a phenomenal job of outlining this and depicting what the surface anatomy is. And particularly with trainees, they often, if you ask them to palpate the ulnar head or the radiocarpal joint, they're often way off because superficial surface anatomy is often underappreciated. I think from a standpoint of positioning to examine the wrist, it's very helpful to be across from the patient. It's hard to do it without a wrist table, but if you have a table to have the patients put their elbows to examine their wrist on, I think you can do it very well in this position sitting across from the patient. So things to consider as you're going through the exam. Think about the age of the patient and any history of trauma. You're probably looking for something different in a 20-year-old than you are in a 65-year-old or a 70-year-old just by the nature of degenerative conditions that occur. You want really a systematic approach, and so when you talk about the ulnar aspect of the wrist, when I do this, I start with the pisotricuitral joint region with direct palpation, compress the pisiform against the tricuitrum, and you can grind and compress radial and ulnarly, see if that causes symptoms or reproduces symptoms because I think pisotricuitral arthritis is one of the underappreciated causes of ulnar-sided wrist pain. It's often there, particularly as we become a little bit more experienced in life, and one of the sources that is often forgotten about. Remember the hook of the hemate. This is something that I think you're more likely to see in someone that has a history of trauma, either recently or remote trauma. Common to have hook of hemate fractures in athletes that swing, such as a tennis racket, a golf club, a baseball bat, a softball bat. They're often going to have pain with direct palpation and pain with resisted flexion of the ring and small fingers and ulnar deviation. That will irritate the flexor tendons and often get a little bit of tinnitus and vitis around that. And so here you can see the picture on the bottom right. This is a plane radiograph, the carpal tunnel view, I think is very helpful for looking at this. You don't always see it. A lot of times that carpal tunnel view is normal because the fracture is at the base and there's enough overlap that you can't actually see. So CT scan is generally very helpful for defining a hook of the hemate fracture or identifying a hook of the hemate fracture. Then we think about the lunar tricuitral ligament. I think this is hard to visualize on MRI. For all the good things about MRI and the advance and better magnets and coils dedicated to the wrist, I think it still doesn't do a great job of the lunar tricuitral ligament. And you like to get a sense, at least on your exam, what you're going to potentially find. So the Blotman test is described by Linscheid. The compression of lunar tricuitral ligament, the shuck test and the shear test are all things that have subtle differences. So in the Reagan shuck test, as you're doing the examination, you're going to put your thumb on the pisiform and your finger on the tricuitrum and then your other hand on the lunar tricuitrum and you'll shuck them back and forth. In Kleinman shear test, thumb on the pisiform, finger actually on the lunate and you're going to elicit a smaller amount of force. But Bill Kleinman feels that's very specific and sensitive in looking at lunar tricuitral ligament problems. ECU tendinopathy and subluxation, conditions that can cause discomfort along the ulnar side of the wrist. It's a picture of the ECU synergy maneuver with the forearm rotated like this. You compress the thumb and either the index or middle finger together. To resist that, you have to tighten the ECU and stabilize the ulnar side of the wrist. So if that reproduces their pain, it's indicative of something outside of the ulnar carpal joint such as the ECU tendon. And then to look for subluxation, the ice cream scoop maneuver, where you only deviate and go into supination and pronation, you'll often feel a clunk that's reproducible and that's indicative of subluxation. A lot of people have subluxation that's asymptomatic, so just because they haven't doesn't necessarily mean that it needs to be treated, but you want to identify this on exam. And then palpation over the TFCC. As Dick Berger described, the foveal region being very sensitive and specific, this is pretty easy to identify. You feel the pisiform and the FCU in that level, and then you go into the soft spot, just dorsal to that, and put pressure there. I think if you push hard enough on most people, you can elicit some discomfort in that area. But if that's the localized area of their pain, then you can at least have a good sense that there's possibly something going on with the ulnar TFCC insertion. Ulnar carpal stress maneuver, as described by Nakamura, essentially axial load to the wrist. So, again, your elbow's going to be in flexion, your wrist is going to be on only deviation, and then you passively rotate through pronation and supination to see if this reproduces the ulnar-sided wrist pain that they have. Depressed maneuver, getting up off the table, or getting up off a chair, putting your hand on the table. If someone has instability that's pretty substantial at the DRUJ, you'll often see a depression, or you'll feel or hear a clunk, depending on the severity of that. And so when you think about the DRUJ, if they have arthritis at that level, compression and forearm rotation will often elicit their symptoms, as opposed to instability, which may exist without arthritis, where you stabilize the radius and ulna, and then translate them back and forth, both with the forearm supinated and pronated. And you may always want to compare to the opposite side, because many times patient symptoms are on one side. You may feel like that the DRUJ is pretty lax, and then you check the asymptomatic side and you notice it's the same. So it's a good comparison for most patients that only have symptoms on one side. And so after your exam, the next thing you're going to do is go through the imaging. I think zero rotation views are very important, because that'll tell us the true length of the ulna and the radius, and you'll understand, do they have a ulnar positive variance that is static, or with pronation and grip, because as I said, with pronation, the radius crosses over, the ulna's going to become relatively longer, and you'll generally get about two to three millimeters difference with pronation in the length of the forearm. So there are patients that have symptoms from dynamic impaction that's only in pronation. That's why a lot of times patients will say, I can't do pushups, it hurts when I do this, much less so with the forearm supinated. And then if there's any history of trauma, I think full-length x-rays of the forearm can be very helpful. One thing that you may notice is a child will have both bone forearm fracture when they're eight, when they're ten, and then that fracture that was at the distal aspect of the radius as they grow is now a mid-shaft forearm malunion, and they'll have instability or problems at the DRUJ that you can't pick up on the plain wrist x-rays because you don't go far enough, but looking at the length of the forearm can be very helpful. And then the MRI, we often will look at the coronal views of the MRI to see the TFC, and you can see the insertion on that, but I think these axial views are very helpful as well to look at the position of the radius relative to the ulna and whether there is subluxation associated with this. So as I try to stress the importance of always reading the MRIs yourself, I think it's very helpful because some radiologists are really good, and other radiologists maybe are less experienced. And so these are two examples of patients that have TFC tears. I think it's fairly obvious in this one here that you can see the disruption of the ulnar insertion. But what's less obvious here, the superficial fibers are actually intact, but the foveal insertion is disrupted. So this is something that when you look at it on the MRI, your radiologist may not say, they may say the TFC is intact, and part of it is, but the most important part of it is not. This is also a reason I find that MRIs can be helpful prior to wrist arthroscopy because if you look at the radiocarpal joint here, you wouldn't notice that there's a disruption of the TFC probably without some additional maneuvers. This paper from the Mayo Clinic, now over 10 years ago, I think has been very helpful. What they did is they looked at a series of MRIs and then they scoped the wrist to determine how much subluxation you needed to see in those views that were predictive of the foveal detachment. And as much as you'd think, there's a 16% plus or minus four, or 16 degrees plus or minus four degrees with the amount of translation that you have that was consistent with a foveal detachment as opposed to 5% in the patients that did not have a foveal detachment. So when you look at those views and see where the radius is in relation to the ulna, that can be very helpful in determining is there a foveal detachment of the TFC. Here you can see the difference, the one on the left is normal, the one on the right is indicative of potential foveal TFC tear. So then when you think about all these things and put them together, you want to look at the conditions that are affecting the ulnar aspect of the wrist. You can have TFCC injuries, you can have other soft tissue conditions such as the ECU tendinopathy or ECU subluxation. You can have osseous problems such as instability from a previous radius fracture or ulna fracture. You can have problems with the cartilage such as arthritis at the distal radial ulnar joint and all of these can cause ulnar-sided wrist pain. And so this is something I've learned from Dr. Kakar that I think is very helpful. The questions you want to ask, this is I think a Dr. Berger thing, but do they have pain in isolation, it just hurts, do they have pain with instability or do they have pain with arthritis? And all of these are going to lead to different treatment algorithms for this. And so this is put together nicely in an article they published about six years ago called The Four Leaf Clover, Practical Approach to Management of Disorders of the Distal Radial Ulnar Joint. And the way that they've highlighted things is looking at each of these individually so you can have a bone deformity, you can have an unstable ECU, you can have a TFCC injury, you can have a cartilage defect. These may occur in isolation and that's the best case scenario because if only one of these is affected then it becomes more straightforward to treat. But sometimes you have combinations of these things and so you have instability of the DRUJ because the TFC is torn and you have a radius malunion so you need to correct both of them. Or you have arthritis as well as other problems you may need to consider about DRUJ arthroplasty. So I think this is another excellent article to review ulnar-sided wrist pathology in coming up with treatment. So that is the end of this talk, I appreciate your attention. Next we're going to have Dr. Yao from Stanford talk to us about arthroscopic evaluation and treatment of the triangular fibrocartilage. Thanks Warren. Good afternoon everyone. Sorry for the projection. Can everyone see okay? I know it's a little bit of a small projection. There's plenty of seats in the front if anyone wants to move up. I promise I won't call on anyone. I also apologize for the temperature in here, it's a little bit chilly but I guess that's to keep everybody awake. All right so thank you Warren, that was a great introduction to the topic. A shameless plug, Dr. Kakar is walking in right now, he and I co-edited a textbook for the Hand Society. Thanks to Dr. Hammer for the opportunity to do so which will talk about everything in this ICL and much more about the ulnar side of the wrist so please feel free to check that out. Okay so I'm just going to focus on the TFCC. Thank you Warren for not going too far into that, it's my disclosure slide. So we know that tears of the TFCC are a very common cause of ulnar side wrist pain and traumatic tears usually occur with a fall, axillary load, extension and rotation. Patients typically have pain with ulnar deviation and gripping activities, opening a jar, doorknob, etc. These injuries are more common in patients who are ulnar positive or neutral and less common in ulnar negative patients that have a compensatory larger or thicker articular disc. Andy Palmer helped us classify these tears back in 1989. He classified them based on whether they are traumatic or degenerative. For the purpose of this discussion I'll focus on the traumatic injuries. And for me, my algorithm is I take a good history, clinical findings and use studies as needed to formulate a plan. Always start with non-operative treatment. We published a study a few years ago which showed that about 57 percent, not a huge number but 57 percent of people got better with just immobilization alone for these injuries. And so I always start with that and the benefit of that is it reduces any synovitis that's in that area and potentially some tears, particularly the peripheral tears can heal given their vascularity. Often I'll offer corticostero injections if that's not effective and ultimately if that all fails in surgical intervention whether it be debridement or repair is the treatment of choice and that's based on the location of tear as I'll go into in a moment. So for the 1A tears or the central perforations, these are the common degenerative as well as the traumatic tears in the center of the articular disc. These are unlikely to heal because the center of the disc is avascular and so these can be debrided. Studies have shown that up to two-thirds of the disc can be removed as long as the periphery is still intact and that doesn't affect load transfer. You'll typically again see this in ulnar positive variants. In that situation we may consider an ulnar shortening osteotomy or wafer procedure and I think Mark is going to talk about that shortly. Debridement, I don't think this video is going to play. I had trouble with this. Oh, maybe it will. Okay. Not rocket science. I think anybody who's done a wrist arthroscopy, this is probably wrist arthroscopy 101, the first procedural you'll do. You'll see it often encounter a tear in the center. Just debride it, remove the pain generating flap of tissue and that should resolve the problem. In fact, studies have shown very good results with just debridement alone of these tears. I'd like to use thermal treatment on the articular disc occasionally. I do think that this makes it cleaner, number one, but also we found in our lab that there's a denervation effect of these tissues by the use of thermal treatment with obliteration of neuronal markers in that area and I do think that contributes to pain relief. That's what it typically would look like after you've debrided your central tear. One C tear or volar, I'm going to skip the 1B and come back with those at the end because I think we have the most to talk about them at the end. The 1C tears are the distal or volar avulsions. For the most part, we debride those, although if you have an ulnar extrinsic split tear as Dr. Berger and Dr. Kakar and others have really helped elucidate for us, those can be repaired. Remember, if you do repair these, the ulnar nerve vessel bundle is in that area so you need to make sure that you're visualizing and protecting that before you do your repair. What about 1D repairs? 1D repairs historically was relatively controversial, whether or not these needed to be debrided or repaired. The thought is that they're, again, avascular in that area because at the insertion of the sigmoid notch, as long as there's no DRJ instability, studies have shown that just debridement is sufficient. You don't need to repair these and with repair, the complication rates are much higher. Let's focus on the 1B tear because this is where we can do the most or we can apply the most in terms of intervention. These are the peripheral tears and these have the best vascularity. It's important to note that as good as a classification scheme, as Palmer's classification was, it's not comprehensive completely. Not all tears are the same. As Warren showed, there's really two segments of the peripheral attachment, the deep attachment which goes down to the sigmoid notch, I'm sorry, down to the fovea and the superficial portion which inserts onto the ulnar styloid. So Leuketian ATSA has a nice new classification based purely on the severity of the injury at that level, whether it's a deep tear, a superficial tear, or both of the periphery. And so for the most part, you'll see these class I tears, which is just the distal or superficial portion of the periphery that's disrupted. The DRJ in these cases are generally, is stable. In that case, there's a number of different options, outside in, inside out, open repairs, all arthroscopic repairs that have been described. I tend to favor this technique of using a pre-tied suture device, which was designed for knee meniscal repairs, which we've developed for the use in peripheral TFC tears in the type I, where the deep foveal portion is intact. This is how it's done. This is what the device looks like. I have no financial relationship with this company, but basically it's an implant that has a pre-tied suture that goes into the 3-4 portal here. Your viewing portal is a 6-R portal. Here actually the arthroscope is in the 4-5 portal. You could do the 6-R or the 4-5. And you can see there's a cannula that allows you to introduce the instrument into the joint. That's removed, and you'll see the introducer needle there. And this has been developed for meniscal injuries, but we figured that the TFC is a similar structure as the meniscus in the knee, and so we thought that this could be applicable to the TFC. So we find our tear. We march back about 2 millimeters. This is essentially unedited video. The needle is placed through the articular disc and out through the ulnar capsule. You'll see the tenting of the skin on the outside, on the ulnar side. We deploy our first block. There's a PLLA block with the pre-tied suture, two PLLA blocks with the pre-tied suture in between. Then the second block is deposited ulnar to the peripheral tear. Then you have a vertical mattress suture. You deploy your second block. Pre-tied suture, so you just pull on the suture, it addresses the knot, tightens it, and then you just cut it. In the interest of time, I'll just move forward. So after the repair, you can see the amount of tension that's been restored to the articular disc with a good trampoline effect. This is what it looked like before. You can see it's really kind of soggy, and you can see the amount of tension on that repair. No knots are tied. It's a pre-tied suture. What about a foveal versus capsule repair? So occasionally, you'll get in there, and you'll see that the foveal attachment is disturbed, disrupted. Here's the hook test, where you can get your probe underneath the articular disc and lift it up. You can see that I shouldn't be able to get my probe underneath there. This is the so-called ghost sign, where you also put your probe underneath and lift the articular disc up. I shouldn't be able to get my probe all the way underneath there. DRJ arthroscopy is very useful for this. It's a small space, and I recommend doing this dry. Going up, you can see the ulnar head below. The TFC is above. Often it is a very small space, and often it's very difficult to see. But you'll see in a moment, as I push past this synovitis here, overall it looks OK. But in a moment, you'll see there's a tear underneath. So there's a foveal detachment, and that can be indicative of a potentially unstable DRJ. There's a tear. So in this situation, there's a class 2 or class 3, where the deep fibers are disrupted. And in that situation, a capsule repair is not appropriate, as the DRJ may be unstable. In this case, any foveal repair can be employed, repairing the TFC back down to the fovea of the ulna. I favor what's called the ulnar tunnel technique. We make a small incision on the ulna. I like to use a C-clamp targeting guide to put a guide wire from the ulnar shaft about 1.5 centimeters proximal to the ulnar styloid, insert the tip of the C-clamp right to the articular disc, where I want that wire to exit. So this wire is going through the ulnar shaft, through the ulnar head, and up to the articular disc, out through the fovea. And you can see that's what the guide wire looks like as it's advanced. Then there's a 3.0 millimeter drill that goes over that guide wire to drill your tunnel. And you insert a suture. Here you can see this is a non-absorbable suture that's passed first. And through the same tunnel, we passed a night-nod loop. So the night-nod loop captures the suture, pulls the suture back through in a horizontal mattress configuration. And then you have both your limbs out through the same tunnel on the ulnar cortex. Here you can see a shuttling of the suture. You can see what it looks like once it's settled down. It's like a nice mattress suture. Then we insert our anchor onto the ulna. You tension your sutures, and then you use a knotless anchor that's embedded into the ulna right there. This is what your final repair would look like. Again, it's back down to the fovea. You can see my probe's in there. I'm pulling on that suture. You can see it's nice and tight. You can see the hook test has been resolved. The trampoline test is restored. Trampoline effect is restored. Obviously, test your GREJ stability after the repair to confirm good stability. The GREJ has been restored. When do we reconstruct? This is when you have an unstable GREJ. The timing, whether or not it's chronic, is a little less important. Whether it's three months, six months, even a year. Sometimes it's just based on the quality of the tissue. I've repaired TFCCs out to a year, so I don't think the timing is that important. It's more the quality of the tissue. If it's that soft, fluffy tissue paper type quality of tissue, it's going to be repairable, so then we reconstruct that. This is the class four injury. And I still do favor a Brian Adams, Dick Berger ligament reconstruction. And P.C. Ho has described this arthroscopically. So to summarize, I think it's clear that central volar and radial tears should be pretty much debrided, unless you have an ulnar extrinsic split tear. Peripheral tears should be repaired, but not all peripheral tears are the same. Be familiar with the Atzai and Lucchetti classification. It's based on DRJ stability. If the DRJ's stable, any repair technique is fine. If the DRJ's unstable, then you need to do a foveal or boner repair, either open or arthroscopic. If the ligament's irreparable, you should reconstruct. And the failed treatment, if that all fails, then I think Mark's going to talk about ulnar shortening osteotomy. So, thank you very much. That was great, yeah, thanks. So next, we'll introduce, let's move slower than I'd like. Dr. Marion Brunet from Lyon, France. Perfect, okay. Good afternoon, and thank you again for the opportunity to participate to this great session. So this is my topic. I am very glad to be here, and especially to speak about this topic, because, so here we are speaking about the non-reparable tear, just as mentioned by Dr. Yao. So this is patient with severe chronic DRUG instability, and an irreparable TFCC foveal tear. You can know that this is irreparable, because there was a previous repair which failed. Some MRI can help, but of course, as you can see here, the arthroscopy is the best way to assess this is irreparable. Different anatomic reconstruction was described, first the open techniques. So one of the first actually was described by a French, Professor Mansa, a long time ago. And then, of course, the great reconstruction by Professor Adams and Berger, that we all know. There is also this technique, it's almost the same that the Adams-Berger reconstruction. But with one skin incision, this could be questionable, because it could put more destabilization. And of course, there are recent description with arthroscopy. And of course, as I am French, I will focus on this arthroscopy reconstruction. But also because we really believe it can be even more easier to perform with the arthroscopy technique compared to the open technique. First of all, the technique described by our friends from Hong Kong, with Professor PC Ho and Dr. Tse. They use a 3-4 and 4-5 radiocarpal portal. They perform the usual radial and ulnar tunnel with a small incision. Actually, this is assisted arthroscopic. Of course, it's not all arthroscopic. And then they pass the graft through the radial tunnel. And then you take the both limbs and took them through the ulnar tunnel from the articulation to the external side of the ulnar. And in this technique, they tie around the ulnar neck, as you can see with a new transverse tunnel. There is a slight variation from the Italian team with a passage between the volar ulnocarpal ligament. So it can stabilize a little bit more this reconstruction between the ulnolunate ligament and the ulnocarpal ligament. And the second difference is that they fix the graft with an interference screw. This is an example of the patient from Guillaume Herzberg. And this was an unstable DRUG. As you can see, there was a previous surgery. This was the knot from the previous repair, which failed because, of course, it's rare, but it happens. This is the ulnar bone tunnel, the passage. You can make it either with the device from Dr. Nakamura or with an EK wire. And then you retrieve the limb, the lime from the volar side between the ulnocarpal ligaments. And then you have to pass both limes through your ulnar tunnel. So you need to perform a 3.5 ulnar tunnel to be able to pass the two limes. And in this technique, in this patient, the technique we use in the unit is the technique with the transverse fixation. And this is the stabilization, the intra-articular view of the stabilization at the end of the procedure. And of course, you can see that the stabilization was good enough in this example. And this is the final X-ray view. What can we expect from this procedure? This is the outcomes from both open and arthroscopic. Complications, they are almost the same. We already have, we know that, but we already have to pay attention to the dorsal sensory branch of the ulnar nerve. There is not so much recurrence, some, but this is not the main complication. The mobility, it's not a concern. As you can see, it's a little bit better in the arthroscopic series, but no significant differences. And considering the outcomes about the DRUG, this is an accurate and reliable surgery between 80 to 90% of stabilized DRUG with the arthroscopic procedure. So we can believe in this surgery as we know. But when does it fail? The same that for the TFCC tear, be aware of a positive ulnar variance. It has been shown by Dr. Nakamura a long time ago for the TFCC repair. And this is, of course, the same for the reconstruction. This example showed this to us. You can see that this patient has a previous non-reconstructible TFCC with DRUG instability, severe and chronic. You can see that there is a huge ulnar variance. The sigmoid notch was OK because, of course, we always have to pay attention to the bone. And we will see it later with Dr. Yao with the reconstruction of the bone. And you can see the TFCC tear non-reconstructible on the MRI and the arthro CT scan. So in this patient, after performing the ulnar shortening osteotomy, there was still a stable DRUG. So we decided to perform TFCC reconstruction as shown here. And then the DRUG was finally stable. So sometimes you have to associate those two procedures. And, of course, don't forget that there is an inherent stability of the DRUG because of the bone's configuration. And we know from Tola the different configuration of the sigmoid notch. And this could be another failure of the TFCC repair. So we are ready to be aware of that. And if needed, to perform either an open wedge osteotomy, as described by Dr. Bain, or a closed wedge osteotomy, as described by Dr. Sheng in 2008. In conclusion, we can say that the arthroscopic TFCC reconstruction is a reliable procedure. But even if we are speaking about soft tissue reconstruction, as always, we do not have to forget the bone, either for the positive ulnar violence or the pathologic sigmoid notch. Thank you very much. Thank you very much. We're going to need to flip the order here, because Dr. Kakar is actually supposed to be in another place at the same time. So I'm going to let him go, if that's OK with you, Dr. Richard. And then we will bounce back. So I'll introduce, if I can make this work, Dr. Sanj Kakar from the Mayo Clinic in Rochester, Minnesota. He's going to talk to us about ulnar head and DRUJ arthroplasty. Thanks, Warren, and to the esteemed faculty, and to you for the privilege of your time. My charge is to talk to you about ulnar head replacement. Be remiss of me not to acknowledge two people here have been integral in my learning of the ulnar side of the wrist, Mark Garcia-Lias and Dick Berger, who sadly we lost earlier on this year. So let's start off with a case. So this is a 64-year-old active physician who comes to an ulnar side of the wrist pain, treated non-operatively elsewhere, comes in for a second opinion. She was offered a linked prosthesis for her primary DREJ arthritis, and we'll come back to her in a minute. So I think when you're thinking about DREJ arthritis, I think there's many summary slides I could give you. If there's one pearl that I would take away from this talk, it's this one here, especially in the younger, active individual, in that the ulnar head is critical for forearm pronosupination. And if you take the ulnar head away, there may be issues down the road. So if you are going to do that, think about down the road what potential repercussions this may have. Because we know that the forearm, in terms of the radius, rotates around the ulnar with the carpus. And when you remove this, you get this radial ulnar joint convergence. Now, this happens in most patients, although not symptomatic in everybody. And this was a biomechanical study that was done several, several years ago, but I think the principles still hold true today, where they looked at dynamic forearm rotation with a mirror at a different forearm conditions ranging from the intact to the ulnar head resection. And they looked at radial ulnar joint convergence. And the take home point with this was when you do a DARA procedure, you get this convergence. The only way to really cure this, to restore ulnar head, sorry, DIJ stability, is by an ulnar head prosthesis. So when we're thinking of ulnar head preserving procedures, well, sacrificing is not really the scope of this today. Some of the top tips in thinking that maybe can help you. So again, what Mark Garcia-Elias said, but this is a common quote by Dick Berger, in that this should always be preserved, namely the ulnar head, in terms of forearm pronosupination. Because it's not just a mobile joint, it's a load-bearing joint. And for me, I think things that I've sort of taken now over the last decade, especially when it comes to DIJ arthritis, is start thinking small and build up. And think to yourself, if what I'm doing is gonna fail, what's my procedure down the road? What's my salvage gonna be? And once you excise the ulnar head, the salvages get a little bit harder down the road. And this was a recent study that was published in the Journal of Hand Surgery from excellent surgeons, technically very gifted. And one of the conclusions at the end of their paper, this was basically salvaging the implants with a linked prosthesis, is that removal of the ulnar head prosthesis is technically challenging, okay? If we look at some of the series of ulnar head replacements, this is the Eclipse prosthesis, which is a pyrocarbon implant that I don't think, that's not available, I don't think, anymore. Certainly can't get it in the US, this is in Europe. The outcomes actually were not too bad in terms of pain improvement. This is a study out of our colleagues in Wrightington in England, and the summary of this was that substantial disability still remained in all groups with post-traumatic, other, and revision groups faring worse. And so patients should be counseled about the expectations when you're doing this prosthesis. We looked at this in our series several years ago, 47 patients, and what we noticed was improvement in terms of pain score. If you look at the mayor risk score, it went up significantly, but 69 is still not great. Implant survivalship was good, but there was no improvement in terms of forearm rotation. But the real sort of alarm bells to me was that, what was the complication rate? There was a 30%, so one in three, secondary surgery rate, which is actually very high, and the biggest problems were twofold. Number one was instability, and number two was sigmoid notch erosion. Metal on the cortical bone of the sigmoid notch, there was only one winner. And when you look at this reaction of the sigmoid notch, there was essentially a five-stage classification. And look at the bottom right, how the ulnar head is driving into the sigmoid notch, causing wear. And this was not uncommon in this series. And when we looked at the failure rate, when we look at the sigmoid notch on the axial view, there was a much higher failure rate when you have that flat-faced sigmoid notch. So remember, instability and wearing of the sigmoid notch with the metal. So as we've seen, there are complications with ulnar head replacements. So let's take this case. This is a patient with a distal radius malunion treated elsewhere, who comes in, we've managed him non-operatively as long as we can. He has instability and crepitus at the DIUJ with post-traumatic arthritis. And so if we go through this, for me, I wanted to address the cartilage and the instability. And so I learned that apparently there's Rhode Island calamari today from my colleague Mark Richard, which is apparently you have hot peppers. This is the regular calamari. It's funny what you learn in an ICL. But this is really the brainchild of my good friend Bassamel Hassan, taking principles of the shoulder, putting them into the wrist. And so what are we doing here? We're taking a lateral meniscal allograft and putting it in the sigmoid notch. So remember, the biggest problems with ulnar head replacement was instability and wear of the sigmoid notch. So what we're trying to do here is take this tissue and deepen the concavity of the sigmoid notch. So we've got this sort of labrum, as you were, in the sigmoid notch. And you'll see it's sort of designed here to accept that implant. And this is what it looks like. We had a small series of just several patients. And what we noticed is that there was no revisions and we'd improved their pain and function. But again, I remember I mentioned instability and wear of the sigmoid notch. Metal and bone, there's only one winner. Now, we don't have this implant in the US, which is a pyrocarbon. So let's go back to that patient that we took care of that I mentioned earlier. So here we are. We believe the calamari procedure, but this is a metacarpal head. So this is off-label, so you have to explain to the patient. And you're just using this as a spacer for the sigmoid notch. And this is her two years post-operatively. And this is her clinical exam. We operated on the one on the right. So remember, she was offered a linked prosthesis. And so in terms of a forearm pronosupination, it was pretty good, as well as wrist flexion and extension. What about this patient? This is a 44-year-old right-hand dominant manual worker, okay, in the oil wells. Comes in with ulnar wrist pain, primary DIEJ arthritis. And so a linked prosthesis in this patient has lifelong lifting restrictions. And again, if that fails, how am I gonna revise this down the road? So this is him four years post-operatively. And so the one that we operated on was on the left, not the right, okay? So you'll see his motion is pretty good. He's still active, he's still a manual worker doing what he does. And so I think the telltale sign for me was not his motion, but actually his strength. So he's gonna grab the dynamometer here in a second. And you'll see the one we operated on was the left wrist, this one. So you can see he's got good strength. And we'll now look at the right side. Remember, he's right-hand dominant, so you expect the right side to be stronger, which he is. This is our series of patients that we did this on. It was limited follow-up, but so far, we're doing okay. But again, it's not all rosy with the calorimarium. Remember I told you, if you start going down this path, we have to anticipate complications. What about this patient? This is a lady who comes in to see me, had this hip prosthesis done elsewhere. She's very well read, has read all the literature, comes in. This is her sort of checker view, and you can see she's got this impingement. So what do you do now? Do you do a DARA procedure, linked prosthesis, do a tissue interposition? She's only 44, right-hand dominant. And so she wanted the calamari, actually came in asking for it. And we had a long conversation. This is the biggest prosthesis we could put in it, which is actually a small one. Two years later, she's not happy, okay? And so this is somebody that I'm actively managing at the moment. So again, it's not a panacea for every patient. What about this patient here, comes in with a complete, when you think of the DRUJ, think of it actually as a forearm, as a joint. What we do proximally can affect distally, and distally can affect proximally. So everything's been violated here, the radial head, the DRUJ. And so for me, this was a combination of multiple factors. How are we gonna address the bone, the cartilage, the instability? And so this was a linked prosthesis. Now when you look at the history and the outcomes of the linked prosthesis, this was a series out of Boston, 13 patients. You can see many of them had multiple surgeries beforehand. The typical patients, the outcomes were actually pretty good. But again, there's still some complications, but the majority of patients were satisfied and would have this again. And I think many of us who've used this prosthesis have a similar type of tale to tell. This was a series out of our institutions, and the biggest complications here were wound healing complications, especially in those patients with rheumatoid arthritis or on immunosuppression. Back to that original study that I showed you about salvage of these with a semi-constrained prosthesis. You can see the types of ulnar heads that were placed, and they were revised to this. And again, when you look at the Mayo Risk scores, they went up. They went up from 50 to 65, but if we bring critical, that's actually not that great. But they did go up, their range of motion didn't really improve. But again, the take home point from this, conversion from an ulnar head to this type of prosthesis is technically challenging, and the outcomes are okay, not great. This was a final systematic review in the literature by Greg Giddings. Again, when you look at this, complications are there whenever you're putting this type of implant in. So I think in summary, for me, when I'm thinking of DIAJ arthritis, especially in the younger patient, I am very respectful of the ulnar head. If you do take the ulnar head out in the younger patient, beware of problems down the road. But even if you are doing implant arthroplasty, anticipate the complications because they will happen eventually when you do enough. Thank you very much. That was great, Sanj. Thank you. So next I'll introduce Dr. Mark Richard from Duke University. He's gonna talk to us about ulnar impaction and TFCC injuries or conditions associated with it. All right. Thank you, Warren. Thank you, everybody, for being here. It is cold in here. So even Rhode Island style calamari with hot peppers or anything hot right now sounds good. I'm gonna talk about TFCC injuries with ulnar impaction and the role of ulnar shortening osteotomy. So a little bit of a twist on the standard ulnar shortening, and I'll give my thoughts about how ulnar shortening osteotomy has kept me humble in my practice. So the problem, both TFCC tear and ulnar impaction, so presumably an ulnar positive variance, and we'll talk about that. We'll talk about the solution, both the review of the literature and the types of procedures, and some tips and tricks. So what flavors, there's a lot of different avenues for us to take this. What flavors of TFCC do we have, and does it matter? The answer is it does. So with ulnar positive variance, we can get central degenerative tears, which are probably most common, but you can get peripheral TFCC tears as well. And they're different. And then you can get peripheral superficial tears or deep foveal tears that have either no instability or an associated instability. So you can see, we've got a lot of roads to cover here. So I'll try and move through relatively quickly. The first question is, is the role of arthroscopy when you do ulnar shortening? And I've learned over time to make this a part of the procedure. What you do find, you can see here from this paper, kind of the classic find is you get those flap degenerative tears of the TFCC. You can get flap osteochondral lesions from the lunate and the impaction. All that can be debrided. You can see on the right there is a flap tear of the LT ligament. So there is other pathology that you can address, even though you're not technically gonna be doing a TFCC repair like Jeff was talking about. So what about that peripheral TFCC tear in the setting of ulnar positive variance? We've got a couple of papers to go through. This is ulnar shortening for TFCC tears associated with ulnar positive variance. They had shortenings that ranged from one to eight millimeters, but a mean of 3.5, and had appropriate results with ulnar shortening for these tears. I do think it probably matters how big of a shortening you end up doing. We looked at it in our own group as well. We had a comparative cohort group looking at management of, these were 1B. So these were superficial tears only, no instability. But did it matter if you did the TFCC repair arthroscopically or an ulnar shortening, and was there any difference? And in our series, we did not find any difference between the two groups. You could do, if it was within two millimeters of ulnar positive variance, you could do whichever your favorite procedure was. For me, I know that we often think of the ulnar shortening as a panacea. I have seen more non-unions than I care to admit. So I usually like to start with an arthroscopic repair of these and save the ulnar shortening if I need it later. Other authors have had similar findings. A mean, this is ulnar positive group, mean of 1.8 millimeters of shortening, 1 to 4.2 in their series. Ulnar positive areas did not significantly affect the outcomes of arthroscopic repair in those peripheral tears that did not have instability. But if they had an associated central flap tear, those did worse. Again, another vote for arthroscopy at the same time, even if you're planning on doing the shortening. Actually, this paper will come up later, and hopefully it has the title on it. So we'll cross our fingers and see if it comes up. Getting into ulnar shortening, which is really the meat of this, wafer procedures, metaphyseal ulnar shortenings, the distal ones as Warren has taught us about, and the classic diaphyseal. I'm not gonna speak very much on the wafer procedure. I'll give you my two lines here. It does seem to be very regional. Boston is actually a popular place for it, it seems. And if it's zero to two millimeters, you can take off that distal end of the ulna, either arthroscopically or open. My experience with it just from residency was that those patients did seem to hurt for longer than some of these other procedures. So I have not made it a big part of my practice, but it's got literature. And at a year, these patients all do the same. So I think it's a very reasonable one to consider. So again, looking at ulnar shortening osteotomy, how much do we shorten? And then how do we translate that templating from pre-op to intra-op? So this is one of the things I like to do. I like to template off that ulna as long as it is when you're in that fully abducted shoulder position with the wrist in neutral position. But we're looking at it volarly, cuz we're doing this usually in a supine position when the patient is now supinated. So what I do is, whatever my template is, let's say here I wanted three millimeters of shortening. I take my depth gauge and I get this view where I set it to three millimeters. And I know that that is where my ulnar head is gonna be if I shorten three millimeters. And I just make sure that that makes sense to me and passes the eye test. So that's before I actually do my shortening, I do do a little intra-operative check. And I found that to be pretty helpful. There's debate over whether or not you need to truly make them ulnar neutral or negative. I feel bad leaving the operating room and not making them ulnar negative. So that's my bias, is to get to at least there. I know Dean Soterianos has some good literature and his experience that you just need to shorten them a couple millimeters. And that is, seemed to bore out in his group. If you're doing a diaphysial shortening, most of us use a jig system, but there's a number of different ways to do it. There's an appropriate shortening. We got the ulnar negative variance we were looking for. So this is actually good, it showed up on this one. I'm glad it stayed in there twice. This is outcomes of arthroscopic repair versus debridement for chronic unstable TFCCs in patients that are also undergoing ulnar shortening. They had 16 in the debridement group 15 in the repair group, and the repair group, if they had unstable DRUJs, they got 11 out of 12 to improve, whereas if it was just a debridement, four out of 11 improved. So if there is instability, a repair is better than a debridement, I don't think there's a surprise there. Let's just talk a little bit about the distal interosseous membrane, and specifically that distal oblique bundle. A lot of this literature comes from Japan. This is a paper looking at the contribution of ulnar shortening on tightening the DRUJ complex and re-providing stability there. They section just the palmar, just the dorsal, and then both, and if you section both and take away both the contributors to the foveal attachment, you do not get that same effect of tightening the DRUJ, so you need at least one of those ligaments to be intact. And that's what they demonstrated in this biomechanical study. Moritomo has showed us and taught us the most about the anatomy there. The short version of this is that there's a lot of variation in the stoutness and even the presence or absence of that. They found in their series, these were small series, usually something like 10 cadavers where only 40% of them had a distal oblique bundle, and that does make a challenge in our decision making if we don't know who has one and who doesn't and how stout it is and what to expect of shortening through that distal oblique bundle. But they looked at location of osteotomy relative to the anatomy of the distal oblique bundle, and what they studied is distal to the attachment on the ulna or proximal to the attachment, and I think this is where you have to think about your indication for the procedure. Are you trying to get some tightening of the DRUJ or are you simply trying to unload the ulnar carpal joint with a shortening because of impaction? Again, they found the presence of a DOB confer stability to the DRUJ, but it was only present in four of the 10 specimens. The DOB origin, if you wanna call it that, or its attachment under the ulna, was about 5.4 centimeters proximal to the ulnar styloid. So if you're gonna be doing a diaphysial shortening and expect it to be tightening the DRUJ, you better be at least 5.4 centimeters proximal to the tip of the styloid in order to be achieving that. They looked at one, two, three, and four millimeter shortenings, then evaluated volar dorsal instability in pronation, neutral, and supination, and found that in the group that had the distal oblique bundle, they were able to confer stability at each of those with those diaphysial shortenings. So in conclusion from their study, proximal ulnar shortening in the setting of DOB conferred more stability than when it wasn't present. No surprise. It only took one millimeter of shortening proximal to the origin of the DOB in order to provide that stability and if you did it distal or metaphyseal, you needed at least four millimeters of shortening to increase stability in that patient group, which is probably not attainable. Longitudinal resistance to shortening was greater in the proximal ones that had a stout ulnar shortening and that may affect our non-union rates that we see and it's something I think we have to start thinking about. And this is just a summary from the paper that if you did have a thick distal oblique bundle, it may contribute to ulnar shortening non-unions and that may be what we're seeing. So we've seen a couple of cases. 59-year-old woman, distal radius fracture, persistent ulnar side of wrist pain. So an acquired ulnar positivity, which I think is different. We did four millimeters of shortening in this case, got her short, she came in at eight weeks and despite something that looks technically done, good apposition, nothing crazy intraoperatively and four millimeters of shortening, she was very happy with this. She thought she was never gonna see me again and she saw me many more times because we had to revise this and do a separate plate and some orthogonal fixation. In this case, we used a nitinol staple and ultimately got her to heal. But I looked through the literature. It's generally reported to be about 6% but you certainly find literature up to 16, 17% of ulnar shortening non-unions and that's been my anecdotal experience. So we looked at our own series and Greg Pereira, who's one of our chief residents now, did a very nice study taking smoking out because we're in North Carolina and there's a lot of smoking. But when you take that out, the resection length did correlate with non-union. And if the resection length was greater than or equal to 5.5 millimeters, which is admittedly a large resection, had 20 times the increased odds of developing a non-union as compared to the smaller resection length. So you are probably finding some of those patients with that stout DOB that you're pulling through and it's fighting your compression with these diaphysial shortenings. So what else do we have available? 62-year-old woman, left wrist pain for years, failed immobilization, a couple of appropriate non-operative modalities. Big central degenerative TFCC tear with chondral lesions, which we're able to address through the scope and get her back to a stable edge like Jeff showed. And then we do a metaphyseal ulnar shortening because of her two millimeters of positivity through the dorsal side and it's just a closing wedge osteotomy with headless compression screw to be able to close that down. And I think these do really well if you're not trying to gain any stability at the DRUJ. So putting this all together, the last couple slides here, you have to ask why are you doing the ulnar shortening? Is there instability? You would probably fix the TFCC if there's instability related to a TFCC tear, that if you do add an ulnar shortening, you have to be at least six centimeters proximal to the ulnar head in order to be pulling through that DOB. If it's just ulnar abutment, you can consider a distal ulnar shortening. And if you are gonna do a proximal one because that's what you do, you're releasing the DOB if there's no instability. So next directions, we need to figure out better ways to know who has a DOB and how stout it is. Maybe it's MRI, maybe it's ultrasound. I would argue that ultrasound probably has a lot more cost effectiveness in our practices, especially with the direction ultrasound is going. And if present and no instability, should we be releasing it for a certain size ulnar shortening? I think we're starting to get a sense of its contribution to non-union with that 16, 17% rate that we see. Thank you. That was great, Mark. Thank you. So next, Dr. Yao is gonna come back and talk about instability related to bony problems. All right, so somehow the time got away from us a little bit. It's almost six o'clock. I totally understand if you guys have other stuff to do and you wanna leave, it wouldn't be the first time someone walked out on one of my talks. So I won't hold it against you. I'm gonna try to go as quickly as possible. I'm gonna try to really hit on the major, there's really three main concepts here for bony causes of DRG instability. I'm gonna try to hit on those. I wanna thank Mark Recant, Scott Edwards, and Lee Osterman for some of these slides. So causes of DRG instability, we already talked about kind of the soft tissue stuff, congenital causes, incompetent sigmoid notch. We talked about that flat face sigmoid notch that came up in Marion's talk and Mark's talk as well, Sanja's talk as well. Hyperlaxity, I'm not gonna focus on those. I'm gonna focus on the traumatic. We already talked about the TFCC. But what about bony injuries? Isolated bony injuries or combined, sorry, isolated DRG disruption from a bony issue or combined with a dysradiated fracture. Important to discuss an assessment. Remember, you wanna test the DRG in multiple positions. Usually in the mid position, the form, the DRG is somewhat lax, but in pronation, supination should be stable. Obviously, you always wanna compare to the other side. You know, you can get some signs from radiographs of instability, basilar stylide fracture, and then the lateral view, sorry, on the AP view or PA view, widening of the DRG, and then the lateral view, obviously, dorsal or volar subluxation of the ulna. Again, the ulna is not the bone that's moving, so that's a misstatement. It's the radius relative to the ulna. CT scans can be useful, particularly looking at the sigmoid notch. When you're talking about dysradiated fractures, you wanna assess the competence of the sigmoid notch. Here on the right, you can see the sigmoid notch is competent despite the metaphyseal combination of the dysradiated fracture versus on the right-hand side, it's a different animal. Obviously, with any fracture, and I'm not here to talk about dysradiated fractures, that's a different topic altogether, but obviously, anatomic reduction of not only the radiocarpal joint, but the dysradiated ulnar joint is of utmost importance. So again, I think there's really three main situations, maybe four, where we're talking about bony disruptions of the DREJ. Commonly, we see ulnar stylite fractures. We already talked about TFCC injuries, so I'm gonna skip past this. And we talked about foveal repairs, but what about ulnar stylite fractures, particularly in the face of radial dysradiated fractures? Used to be somewhat controversial. I think the controversy's pretty much resolved at this point. This is the Palmer 1B tears with the ulnar stylite fracture. We do know that basilar stylite fracture potentially destabilized the foveal TFC insertion. And so, and we do know that the ulnar stylite fractures are more likely to lead to DREJ instability if it's at the base, or more than 100% of the stylite is fractured. There have been a number of studies, and I know this pendulum's gone back and forth over the years. When I was training, we fixed every ulnar stylite fracture, and then we found out later that that probably was not necessary, based on studies, including this one by David Ringen, showing that there was no difference with a non-union or a union of the ulnar stylite at the base. So what do I currently do? We do know that they're a high non-union rate. You always have to tell your patients about that because they always look at that, and they say, oh, the other bone looks fine, but why is it that floating bone over there? Always tell your patients. There's limited evidence for fixing these. After every fixing of this raised fracture, you always examine the DREJ. I can't stress that enough. And marked DREJ instability is typically rare. If you do encounter it, my algorithm is first to fix the ulnar stylite fracture if it's at the level of the base. If that's not possible, if it's a small fragment, then I do do an open TFCC repair. You can also splinted supination if it's mild instability. And my last line of treatment is pinning the DREJ. I think that's an option, but it can cause other issues. If you do do that, like you can see on the bottom right photo, you wanna make sure that your K-wire goes all the way through to the opposite side, the radial side, leaving enough K-wire on the radial side to retrieve if somehow that pin breaks, which it can do. So that's my algorithm. Here's a typical patient with this raised fracture, ulnar stylite fixation. The DREJ was unstable, so we made an open incision. Watch out for the dorsal branch of the ulnar nerve. And there's many ways that you can fix the ulnar stylite, whether it be with a tension band. I like to use cannulated screws, as you can see here. What about Galeazzi fractures? This is a, you know, the quote-unquote fracture of necessity. We know it's a foreign fracture with a unstable dysadrenal ulnar joint. Historically, non-operative treatment has been shown to be ineffective with a greater than 90% treatment failure of the non-op group. And this is a landmark study by Raskin and Reddick, which shows that fractures within 7.5 centimeters of the articular surface are more likely to be unstable. So have a high index of suspicion. If you have a radial shaft fracture within 7.5 centimeters of the joint. More approximately, it tends to be more stable. There's a patient of mine that was, fell off their bike. You can see, again, a fracture within about 7.5 centimeters. We fixed the radius fracture, identified instability of the DREJ intraoperatively. Look, Aaron. See the amount of laxity. I'll skip this poll, but essentially skip to the punchline. We just basically did an open TFC repair in this situation, putting a anchor into the fovea and repairing the TFC. Postoperatively, I splint them in supination for about a week. I don't use pins. Then switch them over to a Munster cast in supination for another three weeks to keep the position of safety and then start mobilizing them. What about the incompetent sigmoid notch? Marion introduced this topic very nicely. Again, we talked about in the fracture setting, you can encounter this, but what about in the kind of the non-traumatic or at least a soft tissue combined injury? Here's a 15-year-old female patient, Scott Edwards, who shared this with me. Ulnar side risk pain and DREJ instability after a fall. Had a history of a failed TFCC repair. CT scan showed the flattened sigmoid notch as we've been talking about. So he performed a dorsal anvil or sigmoid notch osteoplasty to create that concavity of the sigmoid notch to provide inherent bony stability. So here's a dorsal approach. Again, opening wedge osteotomies with the dorsal plate. And then similarly on the vulnar side, again, an opening wedge osteotomy to recreate that concavity or that cup, if you will, for the ulnar head. Lastly, I wanted to highlight the Essex lopressi or IOM injury. Mark did a really nice job introducing the disoblique bundle of the interosseous membrane. Remember, the interosseous membrane does act as a secondary stabilizer of the disarray ulnar joint, particularly this disoblique bundle. And something that I've been doing more recently is actually for any of my disarray fractures now, I actually preferentially lengthen the fracture. So this solves two problems. Number one, how often do you get your anatomic disarray reduction? You're high-fiving. Three months later, it settles. Even with your locked vulnar plate and they're ulnar positive, patient has ulnar side wrist pain, they're not happy with you. It happens all the time. So what I do now, intraoperatively, is I purposely lengthen. You can see, compared from the left to the right, you can see there's a gap at the metaphyseal bone. I lengthen. You can see where the screw in the oblong hole translates from the mid portion to the proximal portion. So I preferentially lengthen. So now this patient's ulnar negative, about two millimeters. That tightens that disoblique bundle. And if there's later shortening, then they shorten back down to neutral as opposed to ulnar positive. And so you can see that I restored it to an anatomic in that position first, and then I subsequently lengthened the patient. You can see the gapping of the metaphyseal bone. So you can see the disoblique bundle is lax here, and then tight there. Here's a video showing that maneuver. So you can see it's about neutral here, and then as I lengthen the radius, then I lock it in. And I purposely keep it lengthened. And as we know from malunion surgery, you can leave a gap in the metaphyseal bone at the radius, you know that's gonna heal very well. So to conclude, again, TFC injury we talked about earlier. This can occur with or without a bony injury. You wanna carefully assess before and after treatment of concomitant injuries, particularly intraoperatively. Obviously instability requires a restoration of the stability. The technique depends on the injury pattern. Obviously with soft tissues, you repair bony. You can perform percutaneous fixation or stabilization with the techniques I just showed. And I do think that there's predictable outcomes in the acute setting. So thank you very much. I'm going to finish things off talking about the role of resection arthroplasty in 2022. So resection arthroplasty, is there a role at this point in time? Nothing to disclose related to this presentation. So remember we talked about what happens at the DRUJ as the forearm rotates into pronation and supination. And so procedures for DRUJ arthritis that are involving resection, generally are the hemi resection or the matched ulnar resection, the DERA, the SAVE-CAPANJE, and then plus or minus interposition. And then what happens when these tend to fail? Ulnar head implants, DRUJ implants can salvage this, or proximal resection in a one bone form or kind of the ultimate bailouts. So remember the ulnar head is the distal link to a stable form. So I'm always concerned about taking that out or what will happen with resection arthroplasty. And so when you see something that's grossly unstable like this, or grossly unstable like this, it's pretty clear. Instability is probably not an all, it's definitely not an all or none phenomenon and it can be subjective and up to the interpretation of the surgeon. But these are pretty clear. There's not a lot of question about that, I don't think. So anything about the hemi resection, you're removing a portion of the arctic or surface of the distal ulna while retaining the TFC attachments. These have the same indications for a DERA or a SAVE-CAPANJE. Reasons you wouldn't want to do this are an ulnar positive variance. If you have ulnar translocation of the carpus such as rheumatoid arthritis, or if you have gross instability in a non-functional TFC, then there's not really an advantage to maintaining the distal portion of this. The idea behind this, you're resecting the articulating portion of the ulnar head so you're gonna leave the ulnar aspect of the distal ulna's attachment and the styloid and the TFC. And then you're often gonna do some sort of a soft tissue interposition. Either dorsal retinacular flap, allograft or autograft can be used to try to create a space. So here's an example of this. You can see the capsular flap. We've resected a portion of the ulna. You can see this interposition here. And this has bigger, that's the palmaris, but I also put some additional tissue in there. And you can see the space between the radius and ulna distally. And here she is at 12 months. So even though this is a younger patient, did pretty well with the resection arthroplasty. If you look at the outcomes for these types of resections, they're all pretty good, but most of them are in lower demand patients. The papers generally describe patients with rheumatoid arthritis. Here's a paper from 11 years ago now, 51 patients with rheumatoid arthritis. Pretty good follow-up and improvement. Another paper in the European Journal of Hand Surgery, 62 patients, 68 risks. Again, rheumatoid arthritis. So we're generally doing these resection arthroplasties at this level in lower outcome, lower demand patients. Another paper from Hian, 2021, from here in Boston. They looked at 66 patients that did the procedure. They had data for follow-up on 31 at an average of 8.6 years. Quickdash was 31, plus or minus 20. And satisfaction was actually pretty high in this group. Conditions were predominantly inflammatory arthritis. So again, something more consistent with a lower demand type of patient. The DARA has historically been used for a variety of things. You resect the ulnar head, can be done post-traumatic, and that was the initial kind of description of this. You can do a variety of things to stabilize this. So descriptions of the ECU, the FCU, or both, as well as the peroneal quadratus. And each of these have advocates. If you look at the long-term results of this, again, a paper from now 10 years ago. 13-year follow-up, though, in their patients. They had 27 at final follow-up. But 25% of these had additional surgery. One had DUJ arthroplasty, and six had radiocarpal fusions. You can surmise the radiocarpal fusions were probably related to something other than their DUJ problems. And so, as I said, there's a variety of different tendon weaves and reconstructions. The problem with these is they're good from a standpoint of dorsal volar instability, but none of them prevent radial ulnar convergence or impingement, and that's really the problem when you take the ulnar head out. The savicopongy is essentially a arthrodesis of the distal radial ulnar joint. Concept behind this is if you have someone that has potential to have ulnar translocation of carpus, you'll still provide support across the ulnar carpal joint. Thing that's somewhat problematic is the proximal resection is essentially the same as a DERIS. You're in a convergence of your proximal stump of the ulna into the radius. If you look at outcomes comparing the DERIC and the savicopongy, systematic review here from earlier this year, looked at 44 articles that had risk per study between eight and 95. Huge variation of age, 14 to 86, and a follow-up dramatic difference in some of the studies. But they all had similar outcomes. So in these papers, when you combine the data, the DERIC and the savicopongy were similar. Stump instability was more common in the DERIC, and savicopongy had more complications with nonunion and reoperation. And so what all these patients get, if you look at them, is the convergence and you get notching. So here you can see early on, everything looks good, but by 12 months, you have notching where the ulna and the radius converge. Anytime you lift, we've lost that stable length and so you're in the convergence and impingement. And so when these fail, it is really just because of this. So this is generally the problem with the DERIC and why you don't wanna do it in a higher demand person without having at least some reservation. And this has been known for a while. The first paper that I could find with this was by Bell in the British Journal of Bone and Joint Surgery in 1985. And another paper a decade later talking about dynamic radial ulnar convergence after distal ulnar resection. So when you have instability of the stump, again, as depicted here, this becomes pretty clear that it's unstable and there's not a lot of question about that. So in this situation, if you have this much instability and either the DRUJ is incongruent and you're gonna take out the distal ulna, or the ulna's already been removed, the procedure described by Dean Soterianos is actually a reasonable procedure. It's Achilles-allograft interposition. Essentially what you're doing is just creating a big soft tissue bumper between the radius and ulna. So you're gonna have the pillow between the two bones preventing the impingement. And so you have to anchor this into the radius as well as then drill holes through the ulna to hold this in place. And if you ask Dean about it, I always ask him, how much can you do? Can you make it too big? And he says, no, he's never made one too big. I've done one of these that actually did impinge on the median nerve and the patient had symptoms. So I had to go and shave it off on the vular side. So you can make it too big. But in general, the problem with this and the reason that this doesn't work is there's not enough tissue interposed there. There's several papers on this. They all relate back to Dean's original description in 2002 in the British Journal of Hand Surgery. But he has four publications. Most recently, seven years ago, looked at 26 patients with a follow-up of 79 months. So that's pretty good long-term follow-up. They had significant improvements in all parameters including pain, patient satisfaction. Mayor risk scores were good but not great. Improvement in supination and pronation, but again, not normal or what you would want ideally. And grip strength, 72%. So better than they were before but not great. So when you look at salvage for this, if it doesn't work, you have the advantage or the possibility of doing a prosthetic arthroplasty, a more proximal resection or a one-bone form. I'll just briefly go through the other two last ones. The wide excision of the distal ulna. There's really not a lot talked about. This is one paper from Scott Wolf and his group in 1998, or a group of surgeons that were with Scott, not with him institutionally, but put together a series. And so they had 12 patients overall. And the concept is, if you keep resecting far enough proximally, the radius and ulna will not impinge or will be not enough bone. The results that they reported, nine of the 12 actually did very well. And then three of the 12 were converted to a one-bone form. Their indications were across the board, a combination of a failed derricks tumor, osteomyelitis, congenital pseudarthrosis. So hard to make much out of this other than it's something that can be done. But this is a clinical example of a further proximal resection. And I think the one-bone form is the ultimate salvage for this. I think it's pretty debilitating. You can do pretty well with the wrist fusion and loss of motion in the radiocarpal plane. It's very hard to function if we don't have form rotation. I think that's really a much more important motion. If you're gonna do this because all else has failed, generally you're going to try to figure out the best position for the patient. And it's predominantly in pronation, particularly with computers and the things that we do at this point in time. Probably worth a trial of casting before you do this type of procedure. But a couple different ways to do it. One is to kind of rotate the form into pronation and converge the radius and ulna together. And the other is actually to resect and create a single bone through the form. So this is an example from one of my former colleagues in Rochester created a one-bone form with this. You can see the plating there. And so it's an ultimate bailout. If you look at the literature on this, it shows that the complication rates are still pretty high. They had 38% non-union. Median pain score of seven at follow-up and final quick dash of 77. So I think these patients were better, but they're still not very good overall. This more recent paper in hand from the Mayo Clinic, they looked at 20 years of patients, a 20-year period. They had eight patients, 84-month follow-up. Five of the eight had soft tissue complications, but they did all heal. And then finally, a paper from 2019, outcomes of patients with single-bone form surgery. They had three children and one adult. So again, a very small series. Took them a longer time to complete tasks, but they actually were pretty functional. And then just one more clinics from Doug Hanel's group. So in summary, is there a role for resection arthroplasty in 2022? I think there is. Remember, it doesn't restore normal kinematics. It's probably much better in a lower-demand patient. I think currently, people that do a lot of this would say that the implants tend to restore much better forearm function and are probably better overall, but there's a risk with implants and complication rates are pretty high, or revision operation rates are pretty high even with skilled surgeons. So I appreciate your attention. It is later than we thought. We got started a little bit later, and so we've gone over. So I hope everybody has a safe evening, and if anybody has questions, certainly feel free to come up here and ask us. Thank you.

ulnar-sided wrist pain

anatomy

biomechanics

examination

imaging

TFCC tears

DRUJ arthritis

debridement

ulnar head replacement

ulnar shortening osteotomy

DRUJ instability

resection arthroplasty