ICL on Common Complications. I think we're gonna have a fun hour and a bit, hour and a quarter, I think. So we have a great faculty here with Julie Adams, Bobby Chabra, and Chuck Goldfarb. And so the order of play is that we're gonna go through a myriad of different areas in the hand and wrist, starting from ulnar wrist pain all the way to lumps and bumps. I think the app should be working. If there's questions that you wanna send through, if I can figure out how to use it, we'll try and answer them, or I think we have a small intimate room. If you feel comfortable, come to the microphone. And so I will see. Yes, are there any questions before we start? This is, here we go. Okay, that's first Herculean effort. Let's see if the videos work as well. Okay, ulnar wrist pain, a topic that we truly love and I think it'll be remiss of me not to acknowledge my mentors. For anything ulnar wrist pain, Mark Garcia-Liaison and Dick Berger. We lost him this year and I want to share some of the principles that they've taught me. Hopefully we can share with you to make this easier. So this is an active patient that comes in to see me. History of ulnar-sided wrist pain. Volleyball was a big deal for her. She was an elite athlete training actually for the Olympics for volleyball. Was tender in the fovea. Had some DIJ instability. I think what the key thing with ulnar wrist pain is how important the history in the exam is. I'd say 90 to 95% is a history in the examination. She had a positive synergy test and was tender over the ECU. So what does that mean? So if you look at the x-rays, the x-rays are relatively normal but I think the clue was in her history and physical exam because the MRI, if you look at this, was suggestive of possibly a ulnar extrinsic tear but it wasn't classic. And when you look at the axial view of the MRI, the yellow arrow is where the ECU is normally and you can see that hers was only subluxated but I think diagnosing ECU pathology based on a static MRI is actually probably not the way that we should do it. It's a dynamic method. So typically I get an ultrasound of bilateral ECUs comparing the normal to the abnormal side. So this was her clinical examination. So you can see if we range her wrist, you can see that she has gross DIUJ instability. So a problem with the TFCC and the problem with the ECU. So just in terms of the anatomy before we tackle how to treat these things, I think it's important to remember that everything rotates around the ulna. So the radius, the carpus, and the hand. And in terms of bony stability, 20% is by the sigmoid notch but 80% is soft tissue related. There's a number of factors here. The most important soft tissue stabilizer is the foveal insertion of the TFCC. This was something actually taught to me by Dick Berger in terms of thinking of the forearm as a joint. We tend to think of the forearm and the DIUJ in isolation distally but we tend to forget that it's actually linked proximally as well. And if you do something proximally, it can affect you distally and vice versa. And if you think of this as a joint or another analogy is like a knee, essentially what you have here is that the proximal stabilizers are the annular ligaments, the TFCC distally, and the introsus membrane. So that's the static stabilizers. The dynamic stabilizers are the muscles and the most important are the pronator teres and quadratus. And they give a natural convergence force at the DIUJ. And so one of the key take-home points here, especially in a younger patient, is if you violate that forearm joint, especially distally, for example excise the distal ulna, you do worry about getting radial ulnar convergence. Now it may not necessarily be symptomatic but in a younger patient this can be a problem because it's much harder to solve this. And this sort of alludes to what the forearm is. The forearm is a mobile joint. It's important in terms of pronosupination but also load-bearing. So for example if you're opening a jar or opening a door or pouring a glass of wine, there's load being imparted at the DIUJ. And so I think the problem with ulnar-sided wrist pain is because of the myriad of different factors coming in, anatomic, soft tissue, bony, it becomes complicated because many of these patients don't have one problem. And if you just treat one problem and they have multiple, that's when you get into a problem. You do a good operation, you think you've solved the problem, but there's other factors going on giving you poor results. So the three questions I would always hear Dick Berger sort of ask patients in clinic every time with ulnar wrist pain is he would boil it down to these three key questions. Is there pain? Is there pain with instability? So is there rotating or they're feeling a clunking or is there a crepitus going on? And when the patients come in and they say everything is hurting, he would point out, he would say take your finger and stick it where it hurts, 90 to 95 percent of the time. And because there's really not much soft tissue in that area in terms of skin, you really can hone down your diagnosis based on those key principles. In terms of Mark Garcia Elias, he would teach us this. So when a patient comes in with this, obvious DIUJ instability, is this a bony problem? Is it a soft tissue problem? Is it both? And if we're not thinking like that, that's how we can get ourselves into onto a sticky wicket. And so in terms of using the four-leaf clover algorithm, he would advocate asking four key questions. So is there a bony problem? Yes or no? Is there a distal radius malunion, for example? And we have to address the malunion. What is the quality like of the cartilage? Is it arthritic or not? Because if it's arthritic and we ignore that, that's going to still lead to that pain with crepitus, the pain with arthritis. What is the quality like of the static stabilizer, the DIUJ? And I've listed here the TFCC, the foveal insertion is the key static stabilizer, soft tissue-wise. And what about, is this a dynamic problem of the soft tissue? So static stabilizers and dynamic stabilizers. And the most important dynamic stabilizer of the DIUJ is the ECU. So patient comes in, isolated TFCC problem, straightforward. Hone in on fixing the TFCC. If there's a distal radius malunion, again, if that's all the problem is, do a corrective osteotomy. Target your treatment based on the pathology. If there's arthritis in the DIUJ, many, many types of treatment for this, you can do an ulnar head replacement. I think you're getting the point. If it's an ECU problem, address just the ECU. But many times, and this is the issue with ulnar wrist pain, it's two or three problems. So if we go back to our case, so this is that patient who has a TFCC problem and an ECU problem. And so if we go back to this, and this is not the only classifications, many out there, it's just a simple one that I use in clinic on a daily basis. So for me, the goals here were to address the TFCC or the ulnar extrinsic ligament tear and the ECU. And so here you can see in the operating room, we're turning on the suction, you can see how it lifts right up off the fovea. There's a foveal injury here. And so now I put a foveal stitch in, turn it back on, and so we haven't finished here. So we've addressed the foveal disruption of the TFCC, and now we have to address the ECU. Closing up now and leaving will lead to a suboptimal outcome. And so now you can see, you remember the instability, we've addressed the ECU and the fovea, and you can see that she's rock-solid. And we got her back to playing to the level that she wanted to. You can see her outcomes is not bad. She loses a little bit of wrist extension, but the main thing in terms of pronosupination, we've restored that, and she's able to do what she wants to do. What about this patient? This patient of mine, straightforward extra-articular dysthoradias fracture that I fixed, and she comes back about eight months later, and she's not happy. She's got ulnar wrist pain, she's tender. When she's pronosupinating, she feels this sort of clicking sensation. And so at first I thought I fixed her short, and so she's ulnar positive, but she's ulnar positive on the uninjured side as well. So is this ulnar impaction as well as something else going on? She's got that little ulnar styloid fracture, and this is her clinical exam. Okay, so she's unstable, and you can see the instability. So now going back to this, this is a bony problem. She's ulnar positive. I thought the sigmoid notch was actually okay, so I need to address the impaction, but I also need to address the foveal problem as well. Different ways of doing this. How did I do this? So here you can see how we can lift this TFCC way off the foveal insertion. So she has a central tear with a foveal injury, and what we're doing here is making sure we've got good pronosupination, can see the ulnar head through all its arcs of motion here. And now what we're doing here is taking a shaver, debriding the top, so we're doing an arthroscopic wafer. Anybody who's done this, the key thing is to do this through a constant pronosupination arc, because you'll go dorsal and not take the volar lip. You'll take an x-ray, and it looks like you've left everything still there. So here you can see we're burring away, taking this down. So here you can see through that full sort of arc, we've got a level resection. So again, this is what she looks like. And the mistake now is to say we're done. Remember she has DIEG instability. We have to address that. So how do we technically do this? And so this is this patient, yeah. And so we make an ulnar incision. You find the dorsal sensory branch of the ulnar nerve. It usually trifocates, so look for that trifocation. Make an incision in the extensor retinaculum, cheating volarly. And now here what I'm doing is I'm taking the shaver, and I'm looking at right under the scope, and I'm debriding that DIEG footprint, because I want to get that TFCC back down to the fovea. You saw how it completely lifted off. And so the beauty of doing this under arthroscopic guidance is because here I'm taking 062 KY for the ulnar tunnel, and I'm slightly dorsal. But you're looking directly at it, so I can basically lift my hand and then just advance that KY looking directly, making sure that that ulnar foveal tunnel is placed in the correct spot. And so you can see it's slightly more volar. Now the next thing that I want to do is make sure I can mobilize that TFCC tissue. So I think when you determine if you can repair this, I determine this in the operating room. So here I can mobilize that TFCC and get it back down to its footprint. So I take an 18-gauge needle with a looped suture, pass it through this, and now I can pull this loop out of the 6R portal. I'll take another needle loaded with another 2-0 loop suture, again push this through. It's a little bit snug, but you can actually get this through there. This is PDS. I've now moved to using a more of a 2-0 fiber wire. I find the PDS knots actually do stick up and don't lie as flat. So now I've got two loops of 2-0 suture through that, and I cut the suture. And all these videos are on Handy, so don't worry if it's, you know, you're not getting all the nuances here. It's on Handy. So now I take a 20-gauge needle with a 3-0 nylon, and I push this through, and I'm going to march my way from volar to dorsal, slowly getting more stability of that foveal footprint back. So now I'll pull out that 3-0 loop suture, again through the 6R, and then use this to shuttle one of those sutures back. And so basically what we're going to do now is shuttle this through. So that stitch, that blue stitch, has gone through ulnar tunnel, through TFCC, and through the capsule. And I repeat this just four times. In the interest of time, we'll move along. But you can see I've already put three stitches there. What about an acute situation? Those are chronic problems. What about this patient? Comes in with a distal radius fracture, but there's DIEJ diastasis. And so you can see the dorsal subluxation. So we get a CT scan, and you can see she has a small dorsal on the corner. So her problem of DIEJ instability is not just related to the distal radius fracture. There's something going on else here. So there's a bony problem. She's got a fracture, but she's also got a TFCC injury. Again, bringing back the principles of fixing multiple things at the same time. So I went volar here, and I kept my volar ulnar screw short to allow me to reduce the dorsal ulnar corner. Reduce that down, and you can see that's been reduced. But she also had a TFCC problem at the same time. And so I fixed this with a simple anchor. Again, not recognizing it can lead to problems down the road. Remember where I started off with that forearm analogy, that forearm joint? Well, here's a clear violation of those principles of a forearm joint. You can see it's had a radial head excision, a distal ulnar excision. So there's a bony problem here. We've got arthritis. We've got instability. It's a TFCC problem. Again, how are we going to address all of those problems? And so there's different ways of doing this, and this LINC prosthesis has been a good salvage for these type of problems. So I think just in summary, when you're thinking of ulnar-sided wrist pain, try and think of the different areas that are causing it, from bony to soft tissue, and if possible, try and correct all of them in one go, hopefully to prevent any problems down the road. Thank you very much. Okay, next up is Bobby Chhabra, who will be talking about distal radius mal unions, and what should you do now. I'm being patient. Your talk was fantastic. You always seem to simplify a very complicated problem. So, and thank you for including me in this great ICL. So, I'm gonna talk about disarray as malunions and what should I do now. So nothing to disclose. So let's just start off by saying that many of these malunions will never need surgery. They can be managed with symptomatic treatment, depends on the age and activity level of the individual and their expectations as well. So while disarray fractures comprise 12 to 70% of all fractures, malunions of the disarray have been calculated to be approximately 11%. So a large number of these patients go on to a malunion, but the question is whether they're functionally limiting or not. So there's some discrepancy on how to describe or define a malunion, and these two articles, I think, really give us guidelines on what is truly a malunion in terms of radial inclination, boulder tilt, radial height, ulnar variance and inter-articular step off. And you can see that there's consistency here, but I think this is a reasonable way to define a distal radius malunion. Now what happens if you have a malunion and biomechanically you have an issue because loss of radial inclination leads to hand weakness. There's a change in the vector of the flexor tendons when there's loss of radial inclination and it leads to weakness of grip. Loss of boulder tilt leads to incongruity of the distal radial ulnar joint, and that ends up leading to decreased form of motion, which is very problematic from a functional standpoint for many people. And radial shortening leads to increased forces on the ulnar carpal joint, and 2.5 centimeters of radial shortening can lead significantly to ulnar carpal impaction or ulnar carpal, 2.5 millimeters, sorry, of radial shortening can lead to significant ulnar carpal impaction or ulnar carpal symptoms or TFCC pathology. And there's two types of malalignment that you see with the distal radius malunions, dorsal radiocarpal subluxation, which with maintenance of mid-carpal alignment, as you see in B, and then adaptive mid-carpal dorsal intercalated segmental instability or DC deformity. So there's motion through the mid-carpal joint. And both of these lead to excessive wear, either at the radiocarpal joint or the mid-carpal joint, and it leads to increases chances of arthritis over time. So obviously a big problem for younger individuals who have malunions. Most distal radius fractures managed with closed reduction and casting have some loss of reduction. We've seen this every day, and we should be able to counsel patients appropriately. The majority of the loss of reduction occurs in the first three weeks, and it's correlated with increased age and osteoporosis. But the question is, is what happens when you do lose reduction? And there's several studies that have looked at non-operative treatment of distal radius fractures with resulting malunion. There may be worse radiographic parameters, but there's not always a difference in functional outcome compared to surgery. So this is where the problem lies, is that just because the X-ray doesn't look great doesn't mean there's gonna be a functional problem. So it really depends on the individual's activity level, their age, and their occupational demands or hobby demands, and their expectations. So you don't need to treat every malunion. But there are some surgical indications that you should consider if you see a distal radius malunion. So interarticular malunion with greater than two millimeters of displacement, onocarpal abutment can be a very painful situation, particularly in young, active individuals. Radiocarpal subluxation, and that leads to limited wrist motion, but it also leads to early arthritis, post-traumatic arthritis. And then incongruity of the dysradiated ulnar joint will lead to loss of forearm rotation. So these are the surgical indications if you're going to consider treating a malunion. So what do you do when you have a malunion? So corrective osteotomy is the answer, but of course there's different ways to do this. You can do it early versus a late reconstruction. You can go volar versus dorsal, and you can do a closing versus opening wedge osteotomy. You can use bone graft, and then you need to address the ulnar column as well. So if you're gonna plan a corrective osteotomy, you need to first decide your approach, decide whether you're gonna do a closing versus opening osteotomy, opening wedge osteotomy, whether or not you're gonna use bone graft, and then what to do with the ulnar column, particularly if you cannot restore a congruent dysradiated ulnar joint that gives you back forearm rotation. So I'm gonna go through some of the literature here to kind of give you an idea of what the literature recommends, and then I'll tell you what I do personally. So when should we proceed with surgery? So early versus late reconstruction has comparable results, and this has been published in numerous articles over the years, but early reconstruction is technically easier, there's a shorter period of disability, and there's better grip strength. So the toughest decision, you have a malunion in clinic, it's three, four, five months out, they're doing okay, it's easier to do it at three, four, five months out rather than two years out, right? But that's a difficult decision, and I know many of us have been in clinic where like, well, should I just wait a little longer? They're probably gonna get better because most of these patients, the X-ray doesn't look great, but they're going in the right direction, do I really wanna do a big osteotomy on them? So I think that's the hardest decision here for these patients, but there is evidence that early reconstruction is technically easier and gives you overall better grip strength, but in the long term, if you look at several articles, there's comparable results between early versus late reconstruction. So you won't be faulted for waiting to see how someone does before making that decision. It may make your operation a little bit harder. So Vohler versus Dorsal approach, there's a lot of literature actually from here in Boston regarding which approach is better. Both approaches result in excellent quick dash scores, but patients treated with Vohler plating reported better range of motion, earlier better range of motion and fewer complications. And that shouldn't be surprising given some of the complications associated with dorsal plating, you're gonna do a dorsal approach. So again, you can choose how you wanna do this. I remember when I was a fellow, I was taught to do this dorsally, but now with the advent of the anatomic Vohler locking plates most more people are going Vohler and it seems to be the best option in terms of avoiding complications. So do you do a closing wedge or what is the pros and cons related to this? So bone to bone contact is important. So closing wedge osteotomy allows you to do that and it's technically easier, but the cons are it can worsen ulnar carpal impaction if you do shorten the radius and it requires you to do an ulnar sided procedure as well. So any, because you could exacerbate disarray ulnar joint incongruity and you will not improve their forearm rotation. Opening wedge osteotomy has pros in the fact that it restores Vohler tilt, radial inclination and radial height and an ulnar sided procedure is not necessarily required if you can restore the narrow anatomic configuration of the distal radius. The cons are that it potentially increases instability of the construct because you have a gap and you don't have that cortical contact and there's a higher rate for non-union. So that's a little intuitive, but you can get a better correction, a three planar correction with an opening wedge osteotomy. But if you look at the clinical outcomes of corrective osteotomy opening versus closing wedge, a closing wedge osteotomy actually has a better overall outcome looking at grip strength and the male risk score and the dash score. So doing a closing wedge allows you to get a better overall functional and clinical outcome, but to get a better radiographic outcome, doing an opening wedge osteotomy gives you that better opportunity for a better radiographic outcome. However, I'd said earlier that your radiograph doesn't necessarily correlate with your functional outcome. So it's easier to do a closing wedge osteotomy and what the literature shows is that it's a better overall clinical outcome by doing that. So what about hinge versus distraction osteotomies? You know, what's better? Because sometimes you can do an osteotomy by hinging it or you can do a complete distraction to get a true three plane reconstruction or a restoration of your distal radius articulation or distal radius. There's much higher incidence of complications when radial contact is not maintained between the distal and proximal fragments in the distraction type osteotomy group. So if you have a full gap, you're gonna have more complications and you have a higher rate of non-union. If you can hinge it and in some way, you're gonna have less non-unions and a better overall outcome. What about bone grafting? Because this is something that everyone debates about. So it really depends on the size of the gap, but if you have cortical contact with a hinge or some sort of cortical contact, you do not need bone graft. The literature showed that no bone graft versus allograft bone chips, the osteotomies healed. There was no difference in outcome and time to union. So as long as you have some cortical contact, you're okay and your fixation is stable, you're okay without using, you don't need to use bone graft. If you have a significant gap, that's a different story. And volar cortical contact can often be maintained using a volar locking plate. And I think that's one of the reasons that that's a more effective way for these osteotomies. So in 2014, there was a study, 20 patients with symptomatic dorsally malunited extra-articular fractures underwent corrective osteotomy using a volar locking plate without additional bone graft. All patients healed without loss of correction. So again, there's enough literature to support that you don't need bone graft unless you have a sizable defect and sizable gap and no cortical contact. So what about arthroscopic management of intra-articular malunions? So this is technically very challenging. The picture on your left shows the intra-articular step-off and then there's a correction there on the picture on the right. There's an algorithm here published by these authors. If you have carpal cartilage loss, then it doesn't make sense to do a osteotomy. You're gonna do a salvage-type procedure. The question is, is if your radius cartilage is intact, they recommend at less than three weeks, so it's an early malunion, do an open osteotomy. If it's a much longer time, do an arthroscopic osteotomy, which doesn't make sense to me intuitively because I think it would be much harder. So they actually use a saying that at three months, you should really consider whether arthroscopic osteotomy is even possible because you have enough early healing. But they do show some reasonable results with intra-articular malunion reconstruction arthroscopically but they need to be done fairly early. So we talked about the distal radius. Now what do we do on the ulnar side of the wrist? The literature supports that if you lengthen the distal radius, so if you do a distal raised lengthening osteotomy, we already talked about a closing wedge having a better outcome, right? But the distal raised lengthening osteotomy was found to have better reduction of pain and improvement in overall function because you can restore the distal ray ulnar joint better and make it more congruent rather than shortening the radius. So that's a decision that needs to be made. If you wanna avoid an ulnar sided procedure, then you should do a distal radius lengthening osteotomy. And this is Jerry Wang's kind of algorithm that I'll just give you a second to look at but it seems to make sense in the fact that if you don't have DREJ arthrosis and you don't have significant shortening then doing an opening wedge makes sense. If you have significant shortening or DREJ arthrosis some sort of ulnar shortening osteotomy or distal ray ulnar joint salvage procedure is necessary and Sanj mentioned that. What about computer guided osteotomies? These started back in 1988 and they're becoming, there's more and more companies that are doing this, particularly 3D printing of your templates for this and we'll see what this shows. It's a three dimensional corrective osteotomies. There's been several studies and they've looked at outcomes and they've shown significant improvement in motion and you can restore the distal radius normal configuration very well. There is some complications but there's quite a few articles out there treated with 3D guided distal radius osteotomy systems and you can see that they're available and the reality is they looked at the dash scores and so forth and there was no significant difference at three, six or 12 months compared to ones that they did not use these 3D reconstructions and while radiographic findings were better their overall function was not necessarily better. So computer guided osteotomies, there's not enough literature to support it and they're more expensive. It's just more expensive so you'll have to look at the cost benefit and I do mine through a VOLAR approach. I use a technique where I can release the distal radius, release the carpal tunnel through the same incision as a disarray fracture as well as for a corrective osteotomy. I tend to do VOLAR plating. I try to do a closing wedge osteotomy if possible. If I have to do an opening wedge I will do so but I will plate all VOLARly. Make sure anytime you're doing an osteotomy, particularly if you're distracting, you should do a carpal tunnel release in some way because you can have some post-op complications but even if you do it right, you may still have some situations. This was an older but very active individual who was having a lot of pain and limited motion. I did a distraction, tried to maintain cortical content, ended up using some bone graft. I still couldn't restore appropriate forearm rotation and ended up doing a distal ulnar resection because there was arthrosis in the DREJ and it was limiting motion. So that's the end of my talk and I'll take some questions later on. I'd like to introduce our next speaker, Chuck Goldfarb, who's gonna talk about pearls on basilar thumb management. Thank you. I am seriously impressed it's 530 you guys are still here listening hopefully I can entertain and educate you a little bit I think we all you know CMC arthritis is something we all treat and treat regularly I'm not here today to tell you which procedure to do because in my honest opinion you can do a multitude of different procedures and get similar results so I am going to share some of my thoughts on avoiding complications and then what to do if you if you have an unhappy patient. All right so I'm gonna go through what I think are a few critical points that hopefully are intuitive but laid out in a way to make them memorable and then we'll go through what to do like I said when things go wrong so you know CMC arthritis should not be the most difficult diagnosis to make but it's not always seen in isolation and so we one of the top five papers was about the role of STT arthrosis and the role the MP joint in patients with CMC arthritis so we have to think about those concomitant potential pain generators. Carpal tunnel syndrome exists in about 30% of patients the numbers vary from study to study but about 30% of patients so should be ruled out in every patient generalized wrist arthritis and even the querve veins can coexist and so don't be so tunnel vision to only recognize the CMC arthritis in a patient where that may be the obvious diagnosis. And then the second question is when when do we consider surgery and you know in our society often patients push for early surgery which might be right for some patients I personally prefer to not make the patient earn a surgery as I've heard others describe but I don't want to rush to a surgery in this situation because I can't this is not a surgery in my hands this 95% successful I think you can make the vast majority of patients better but I don't rush to surgery and so for me the patient has to fail non-operative care and I'll talk a little bit about what that means I do like topical treatments therapy has a role for some patients in my hands that's a choice for the patient whether they want to go to therapy or not and I describe it for them including splinting and activity modification I really think we have to guide the patient for their expectations of what surgery can do for them and then they have to understand preoperatively what the post-operative course looks like and that gets into your surgical choices because I think the post-operative course can vary significantly based on what you do intraoperatively I don't generally refer to the American College of Rheumatology and Arthritis but I thought this was somewhat helpful and to make this very complicated chart more simple generalized approaches includes hand orthoses anti-inflammatories and steroid injections and that's really all this recommended I'm sure you like me hear a lot about PRP and other injection options and again I'm not here to tell you whether those work or don't work I don't use them in my practice I do use steroid injections as we'll see therapy for me has a real role in the treatment of CMC arthritis again it's a little patient dependent but there are good studies and if you haven't read them this is only one of them this is a systematic review which basically showed that therapy can be helpful and it's about stabilization and re-education and no one wants to wear a splint full-time and so it is about talking through that with the patient and the pros and cons of continued therapy versus surgery and then the win and I'm sorry we talked about the win and then the which surgery to consider so here's a somewhat lengthy list of your options arthrodesis was in favor then fell out of favor and I think people consider it one option today I do use it in my work comp population in younger heavy laborers and I find it to be very effective arthroscopy is potentially has a role denervation I'll speak on briefly hematobin distraction arthroplasty implant arthroplasty isolated osteotomy and then the classic tendon based procedures so I think about the following or you should think about the following the stage of arthritis so very early stage arthritis might lead me to consider an arthroscopy plus minus an osteotomy I think that absolutely has a role but we have to think about that option again typically the younger patient maybe with some mild dorsal subluxation additional diagnoses affect my treatment choices including the MP joint one of the things I've learned over the last few years which hopefully you guys all already know is that if we can control the base of the metacarpal then we can control the MP joint and say I almost never do concomitant MP procedures and so if you're if you're base of your metacarpal is up then you're much more likely to see MP joint hyperextension but whatever you do at the CMC joint if you can keep it down then you can generally control the position of the MP joint you can do that with arthrodesis you can do that with your technique for however you treat the CMC joint so that's been really helpful for me and it's affected my choices for procedures I have not done denervation procedures but they are appealing because the published literature is pretty good I think it is a technical procedure and it requires a good understanding of the nerve anatomy of the CMC joint but I think it potentially has a role and I look forward to learning more from those who are doing this procedure and then technical considerations and this is avoidance of you know post-operative complications as well when I was in training everyone did a Wagner approach I think most of us now do a straight dorsal incision I think you can see everything you need to see it's much easier to protect cutaneous nerves it's worked well in my practice protection of the radial artery is an obvious one and complications around the radial artery are real I don't let my tourniquet down for many procedures including say cubital tunnel procedures but I do always deflate the tourniquet prior to closing with a CMC procedure and then being technically accurate with your chosen procedure and that's why we all have our favorite procedure there's nothing wrong with having a favorite procedure and if you do it well it makes sense to continue to do it and then in my hands therapy matters I'm very fortunate to have wonderful therapists to work with and they help me achieve success this study is interesting looked at over 3,000 patients from the NISQIP database and reported a 1.3% complication rate overall and half of those were wound complications but insulin-dependent diabetes and a higher ASA level had a strong trend as well as renal dialysis so failure so up to 5% of patients will undergo a second surgery for CMC continued pain we think that subsidence is typically the indication or the the finding that leads to that second surgery but why some patients subside and have no pain and other patients subside and have pain is very confusing we heard a little bit again this top five papers that anxiety and subjective considerations play a role in kind of outcome in general and that may be the case here what we hope to avoid is the other stuff right painful neuromas are in our control extrusion of an interposition graph if you use one is in our control and the MP joint and decision-making at the time of surgery is in our control so hopefully those we can avoid subsidence I'm not convinced we can control completely so this is a study out of our institution which you which assessed 10 patients undergoing revision surgery and 20 primary surgeries as might be expected outcomes were worse including pain and perceived function despite similar objective outcome so that's really important to consider before and to educate the patients on prior to surgery so symptom relief in any revision surgery is unpredictable this study looked at 50 patients so a large cohort 5% overall revision rate and scapho metacarpal impingement was the most common indication for surgery risk factors were age not surgical technique and they reported that most of their patients were improved this study again a large group at least two-year follow-up for revision CMC arthroplasty and they reported 20% complication rate primarily related to pins the scores were okay not great and so revision surgery can be helpful if you especially if you address other co-existent pathology so what happens if you have to take a patient back to the OR it's tricky especially early in your practice I think it requires several longer conversations I will always consider a steroid injection post operatively usually not before three months if a patient's just not making progress before I would consider taking a patient back to the operating room so that helps in two ways one it can just help get the patient over the hump so to speak allow more therapy to be effective for them but it also if it temporarily provides relief confirms the pain generator and can make you more confident of a second surgery I like to limit my approach and so I like to stay out of the CMC joint so to speak with a revision procedure so a mini tightrope is my personal procedure of choice I don't work with arthrx and then I go very slowly after surgery I like early mobilization after primaries but I do not rush things if it's a secondary surgery so one example complicated example 47 year old male had two years of pain and chronic health conditions and had multiple previous treatments around the hand and wrist including CMC injections had an arthrodesis with dysteridious bone graft which failed to heal was revised with an LRTI and comes in now with CMC pain and clicking decreased strength and overall and so original surgery revised to an LRTI which I don't have images of so what's the next step for me it's the mini tightrope which led to improvement but not resolution for this patient and again the reason I like this is I'd simply stay away from that CMC joint so my take homes are and I feel strongly about maximizing non-operative care and that requires conversation and patience when I decide to take a patient to surgery I spent a little more time with this procedure than I might with others talking about both the intraoperative expectations and the post-operative course I generally use one technique but I think it's just it's a discussion with the patient and I you know I try to avoid revision surgery I try to avoid revision surgery when I do my first surgery but it's just much less predictable so I think be careful and again spent a long time talking about a revision surgery with the patient thank you very much thanks Chuck so our next speaker before our case discussions is Julie Adams she'll be talking about lumps and bumps in the hand and wrist and hopefully her talk will come up quickly to Bobby that was a that was a great series of talks and shifting gears a little bit sort of from operations to reoperations is how the sort of keep yourself out of trouble and not inadvertently find things or find surprises or be surprised by things that happen so I think that when you think about approaching unknown masses in the hand or wrist being aware that common things are common but uncommon things are also possible so the great majority fortunately of lumps and bumps in the hand are going to be benign but there are some bad actors that are quite possible if you treat each lesion like it could be a malignancy someday you'll be right and you'll be glad that you took those appropriate precautions and I think the other principle is that you're only as good as your pathologist and ancillary services so being aware of what your facility can and cannot do is important being aware if you have the capability to do frozen sections but also being aware of what your pathologist expertise may or may not be. And so you may make a decision to take a patient to a different facility, you may make a decision to take a patient elsewhere if you don't sort of have what you need or what you might need based on your preoperative imaging and workup. Also I think that being aware, particularly with the Cures Act, that the open notes era, your patient may be seeing the pathology report before you do. And so sometimes preparing the patient for that and being aware of that to forestall any anxious phone calls. And also putting in your note what you think it might be. So if they see, oh my gosh, this is a giant cell tumor of tendon sheath, oh my gosh, what am I gonna do? Do I need a PET scan? You've already talked to the patient about, there's this thing and here's what it is and it's sort of an annoying, locally aggressive thing, but not particularly dangerous. So I think that having those conversations ahead of time and conversely making sure that you follow up on pathology reports. I was involved in a situation that the hospital system EMR that shall not be named, but is very common and has four letters, went through an upgrade and there was a little snafu. And the little snafu was that they didn't release the pathology results to either the open notes. They also didn't release it to the four letter EMR that's very common, Care Link, that gives the treating physician the pathology. And so the patient drove down to the medical records and got their results after like three weeks and then called the physician's office to say, oh, by the way, I have cancer. When's my revision surgery gonna be? So I think being really aware of systemic issues can really help you and also the capabilities of your facility. Well, like always, we take a history, we do an exam, we may or may not do imaging studies and we may or may not biopsy. So being aware of how long this mass has been there, being also aware that we as humans sort of measure time based on things that may not necessarily be related to the mass. So that's why a history of trauma may be a red herring. I never had this till I fell at work and you're looking at it and you're like, oh no, you've had that for a while. But the patient may relate it to a history of trauma knowing again that that may be a marker in our own minds and may not be a real association. So certainly associated medical conditions, the presence or absence of pain and fluctuation in the mass, fluctuation in pain. Does it get bigger or smaller in size? Does it go away altogether? What's the nature of the lesion on exam? Is it soft and mobile, ball-audible? Those are all good things. If it's firm or fixed, that sort of makes you scratch your head a little bit. Subcutaneous versus deep, tender or non-tender. Are there skin or vascular or nerve symptoms or other changes? And then certainly transillumination. Now the key with transillumination, of course, is that if you have the very helpful office staff that buy you the really expensive little flashlights, they're gonna transilluminate everything. I mean, my whole hand transilluminates with those. So you want your staff to buy you the cheap stuff, the really, really inexpensive stuff. So go to someone who doesn't like you to order the equipment or just say, I'm really parsimonious, get me the cheap stuff so that you can get the little wimpy flashlight so that you don't transilluminate everything. Imaging, always plain films, because the last line, if you think you need an MRI, inevitably, pre-authorization, they're gonna ask, do you have plain films, what did they show? And so being aware that if you have a patient that you're thinking, I need an MRI, go ahead and get plain films, even though you and I know that that's not productive to our diagnosis, but ultimately, the pre-authorization is going to demand that did you get plain films. Additionally, in the soft tissues, you can see some associated findings that may be helpful. You may see some arthritis in the joint. You may see calcifications in the mass. You may see bony erosions or even sort of compression or scalloping out of the bone as the mass has grown. Ultrasound, in my practice, I found incredibly helpful. You can determine is this a solid or cystic lesion. You can use for biopsy or aspiration as guidance, and you look for color flow changes and vascularity. I think it's also very helpful if you have a mass and you don't have an ultrasound, but you wanna convince yourself and the patient that this is a benign lesion, aspirate the mass. If it decompresses and or you get fluid out, you know that you can be rest assured that it's not cancer. Imaging, I think that really talking with your radiologist when you order the scan and also being very specific as you order the scan when what you write in that little box in the four-letter EMR that is very common, you give a bit of history and you also are very specific. So for example, if you have a patient who has a hand lesion and it's quite small, depending on the cuts of the MRI or a CT for that matter, it may be so thick that they miss the lesion. And so specify, I want really thin cuts or I want half a millimeter cuts or I want overlapping cuts. So I think that it's also important to be empowered to send the patient back if the patient is not adequately positioned in the scanner. As you all know, there's a sweet spot in the scanner and if they're in the middle, you're gonna get good images. If they're sort of to one side, probably not. The talk is about soft tissue lesions, but certainly CT scan is helpful for certain bony lesions. Biopsy, you can do this by ultrasound guidance, being aware that there may be sampling error. Incisional versus excisional and being aware to let your pathologist know, providing history and enough tissue. I've sort of learned that most pathologists don't read your note. So they are not going to go into the chart and look at your beautiful note that says, here are the things I'm worried about. Here are the possible differential diagnosis and by the way, this is a recurrent lesion and previous biopsy showed blah, blah, blah, blah, blah. They aren't gonna do that. They've told me that. So I think that if you print out your beautiful note and staple it to the pathology requisition thing, they will and maybe circle that part, they'll probably read that. And I'm not trying to disparage anyone. I did a year of pathology, but realistically, they are really busy and so you wanna like empower them and help them out so that they can help you out. Also knowing when frozens are and are not helpful. In many cases, in other subspecialties, dysplasia is incredibly difficult for a pathologist to tell based on a frozen and so they're not gonna call it. Certainly, lipomatous tumors and cartilage tumors, they're generally speaking not so helpful. And there's a commonly stated axiom that the person who will do the definitive surgery if this is something bad should do the biopsy. I kind of think in hand surgery, it's not necessarily practical or reasonable. And certainly, the way I approach these patients, if definitive surgery would be changed by me doing an excisional biopsy or would be unchanged, it may be reasonable to go ahead and take it out. So for example, you have a patient and there's a lesion over the middle phalanx. You know if it turns out to be something bad that to get margins, the patient's gonna end up with a ray resection. So it may be reasonable to go ahead and do an excisional biopsy. Go ahead and send it to the pathologist. Certainly, tumor type matters. Again, about frozen not being helpful. Be aware of contamination of the field. And again, making that incision that you would want somebody to make. The longitudinal incision, the incision that can be excised if it turns out that your musculoskeletal pathologist needs to be involved. Common things are common. Uncommon things are possible, but not all. And we'll talk about some specific examples that you can kind of visualize and know and also some bad actors. Again, my task with ganglion cysts, I really like transilluminating it with that cheap pin light, not the expensive one. If it doesn't transilluminate and it's sort of over the dorsum of the wrist, be aware of mimickers, so dorsal anomalous muscles. And those don't transilluminate. They also don't decompress if you stick a needle in them. They just hurt and bleed a little bit. But an MRI will tell you that. And certainly, lipomas do transilluminate. Lipominous tumors, you wanna look on the MRI for fat signal in T1 and T2. Again, frozen's not particularly helpful, but they have a very typical appearance. And then you send it off for final pathology and the pathologist tells you. Worrisome lipominous lesions are the ones that are very big or deep. Not so worrisome if it's superficial. Certainly worry if there's some signal differences on MRI. Beware some special cases. So there's intraneural lipomas. And probably, no, not probably, definitively the world expert on intraneural lipomas is Rob Spinner. And so I stole this cartoon from his article. And so if you talk about these lipohamartomas of the median nerve, so patients may have very, very subtle enlargement of the tissues distally. And they may present later on with carpal tunnel type symptoms. And so look very carefully, especially in a young atypical patient for a slight enlargement of the digits and sort of hypertrophy of the tissues. And I think the shock that people may get is if they do open carpal tunnel release, they see, oh, there's this big fatty thing and the nerve fibers go in and then they sort of disappear. And the treatment in general is for that is a carpal tunnel release rather than trying to dissect everything out. And Rob has a beautiful cartoon that kind of explains some of the differences. A lot of the intraneural lipomas are found incidentally on MRI scans for other reasons. Vascular reasons, certainly glomus tumors, classically subungual, bluish, and cold sensitive and can be readily excised. Hemangiomas, the ones in childhood often envelope and sometimes that can be helped along its way with metoprolol versus vascular malformations which sort of grow as the child may grow. Pyogenic granulomas, I think all of us see these in office, more common in pregnant women. And I think the mimickers that you have to sort of be aware of that might look sort of like this, you could see A melanin, that should be A, no space, melanocytic melanoma, and some other bad actors. But most of these we either excise or we do silver nitrate cauterization. Epidermal inclusion cysts, typically you'll have a patient that tells you that I had trauma, penetrating trauma to my finger and they'll often tell you every few months I have drainage from this thing and it decompresses and then it kind of builds up again. So kind of a easy history in many cases and MRI is generally definitive. Dermatofibroma, this is sort of, I try and stay away from skin lesions. I'm like there's really good dermatologists you can go see but I think that this is something to bear in mind. This is the benign variant and there's this test, this pinch test where it sort of has this little wrinkle or dimple for a dermatofibroma as opposed to this guy. I'm sorry my slides got out of order, which is the bad actor, the sarcoma, which is sort of similar in appearance but if you see this in our office, because we are seeing patients with a lot of skin issues, be aware that this is a problematic actor with a high rate of recurrence. Again, giant cell tumor of the tendon sheath is a very common, typical gross appearance. I tell these patients that they may recur and the literature suggests up to 30 to 50%. It's sort of an annoyance because they often come back and I think if you tell them that and make them aware of that, that's an important thing. They will also sometimes have these radiographic sort of almost scallops where it's grown. It may not be the right term to say erosions but the bone is almost scalloped out from pressure. This is one of the bad actors, an epithelioid sarcoma presents as an ulcerating nodule in many kinds and sometimes can be mistaken for infection. High rate of local recurrence, high rate of lymph node metastases. They can be painless. They are often on the vulvar surface and spread sort of without respect to fascial borders. Synovial sarcoma, again, sort of a lump and bump. This one happens to be on the shoulder and can be slow growing. Calcifications are fairly common, also a bad actor. Again, liposarcoma, like we talked about, is one of the fatty tumors and I think that the bottom line is you wanna be very cautious. You wanna treat them all like they could be something bad because someday you may be right, it may be something bad and be aware of the basics of evaluation and treatment. Know your limitations, know your medical centers and idiosyncrasies as well as your availability of the ancillary help you need and know some bad actors and lesions that masquerade. And finally, I think that it's really important when we have patients who come in our office and they may have a lump or bump and we order an MRI because we know it's not a ganglion, we know it's not arthritis, we don't know what it is but we want to find out and there's many patients that may or may not be aware from that conversation. So being aware of the fact that we need to educate them that you have a mass, I'm not sure what it is, I'm ordering an MRI, it's unlikely to be a malignancy but it could be and so providing clear documentation about I'm ordering this test to help us find out and this could be something that you need to follow up on. So I think that that's a very important thing to keep us all out of trouble. Thank you. Questions on the app, I'm glad I figured out how to use the app, but choice for CMC arthrodesis, we can go down the line, so Chuck, you wanna start first? Sure, you know, the literature supports K wires, but I personally, in 2022, I'm not a big fan of K wires if I can avoid them. Some manufacturers have very specific plates that allow compression, which is ideal. To me, to avoid the reported 20% non-union rate, it's really about preparation of your bone surfaces and that distal aspect of the trapezium. So I don't think that the plate necessarily matters, but I use a plate and screws, and I'm not too picky about which one. I agree, I've used staples as well and tried to use compression staples because of lower profile hardware, but I was not happy with that, so I've reverted back to using plates and screws. Yeah, I would agree with that. I've used K wires, I've used staples, I've used screws. I typically use plate and screws, although I like K wires for this, and I think they work pretty well, but I actually like CMC fusions. I think they work really well in the right portion of the population, which is kind of a younger active patient. Well, I'm sending you online then, because I don't wanna- Thanks. I know I like tension band. I've just found tension band works well, so I tend to prefer tension band. I would say one thing, I have seen a number of complications in my community from using the headless compression screws. I don't think you have enough there in the trapezium to get the bite and the compression that you need, and some of you in the audience may do it better than has been done in my community, but I've revised a fair number of those, so I would stay away from that personally. So second question, CMC arthritis, how many tight ropes do you use? I know in the literature there's some examples of using more than one, but I use one. I've only used one and not revetted it. I will use a tight rope in a revision situation. I only use one, and I'm smiling because I think Sanj has a different opinion. Yeah, I use two, and I think the reason, biomechanically stronger, but I think the reason why initially I used to put two is when you put one in, and if you pull on the K wire as hard as you can when you're putting the tight rope in it, you can get impingement of the index finger and the thumb metacarpal, and in the packet there were always two, so I'd put the second K wire in, and then I would pass the second tight rope in and not pull as hard, but now they've changed, so now to put two in, you have to open up two packets, so now I just put one in unless I've done the other side and he or she's got two in, and they're expecting two on the other side. So one of the tips about using a tight rope is, one, make sure it's not prominent on the index finger. If you pass your K wire multiple times, you could have a delayed fracture, but the goal is to have distal pull of your thumb metacarpal to prevent subsidence or that's pistoning against the scaphoid, so if you're too flat with your tight rope, you won't get that distal pull, so you have to have a vector, oblique vector that's distal so that when you tie it, the thumb metacarpal is distal and you wanna try to match it to the base of the second metacarpal, but not too tightly, so. No, go on, Chuck, please. No, it's not my first choice, as I mentioned, but I do really like it in revisions and Jeff Yao has taught us that it's a really good option, but there are technical tricks to avoid trouble. Yeah, in Jeff's paper, he says that you should be aiming for the proximal third of the index finger metacarpal and another little technical pearl is when you cut the knot, so what I usually do is I aim, I put my index finger and I aim for my index finger on the dorsal on the corner, I find that easier to do than putting a guide, but the other thing is that when you cut your knot, don't cut on the knot, cut maybe about a centimeter or 15 millimeter tail, and then you take two pickups and bury the knot and the suture underneath the interossei muscle and close the fascia over the top and knock on wood for me, that's been pretty lucky in preventing having symptomatic buttons or symptomatic knots. So Dr. Adams, there's two questions here for you on your talk, so the role of ultrasound rather than MRI for evaluating in mass and do you recommend imaging every mass while in board collection period? Oh, good questions, very good questions. I think that ultrasound is good, like if you have it in your office and you can just pull it out and take a look, that's super helpful, but if you're like a little confused on an ultrasound or you're not clear, I will go ahead and get an MRI every time. Board collection, great, great question. So I think that it really depends. I think your indications need to still be pure, right? That's the whole point is you wanna practice medicine in a reasonable fashion, so I don't think it's reasonable to get an MRI on a ganglion, something that you know about. I think that it's reasonable if you have a mass and you don't know what it is, it's reasonable to get an MRI. I think that if you have a mass that's in a location that may be difficult to figure out how to get it out, you think you know what it is, you think it's benign, and the MRI would help you for preoperative planning. What about ultrasound for some of these superficial lesions? During board collection, you can get that confirmation with a simple test. Yeah, I mean, if you have the confidence in your ability to interpret that ultrasound, I think that's totally reasonable. What about concerns for spread or seeding if you aspirate lesions? Yeah, so you want to, I mean, we all aspirate ganglion cysts, right? And I think that the idea is if you're doing an ultrasound-guided biopsy and it turns out to be something else or some sort of needle biopsy, then they're gonna excise, so going right over the mass is kind of a good principle. And last question, what's your operation of choice for CMC arthroplasty, primary CMC arthroplasty? That's a little bit of a loaded question for me. Hopefully next year, we will report a prospective randomized trial of a classic LRTI versus trapezium excision with a tightrope. And that's, I don't work with Arthrex, but that is a proprietary name. I've been really happy with the tightrope procedure. It's interesting, I'm not sure the data's gonna bear that out, but time will tell. But I have been happy with the rapidity of recovery and getting patients back to activity really fast. And that's your primary? That's my first choice. I still do LRTI, I've been doing it for years and it's been reliable. I do a trapeziectomy and a suspensionplasty with a slip of the APL and wrap it around the FCR then through a hole in the metacarpal. It kind of pulls the thumb into the adult beverage holding position. And I've been happy with it and it works well. I think that's super important, controlling the base of the metacarpal, it doesn't get talked about enough. Yeah, I think for me, it's two operations. I do actually quite a lot of partial thumb denovations, thumb CMC denovations. I've been actually pretty happy with that. We're looking at our outcomes on that. You repeat what you said, Dr. Chhabra. We were talking about that earlier. Okay, and then the other one is tightrope. But with the tightrope, I do at the end after passing it, I do, as Julie mentioned, I imbricate the FCR and the APL together with a couple of 2-0 sutures. Just in case I ever have to take the tightrope out, you built a natural suspension in there such that I'm not worried about subsidence if I take the tightrope out. Five minutes? Okay, we'll do one quick case. So this is a 61-year-old right-hand dominant police lady who comes in. In 2012, she had a thumb trapeziectomy and FCR suspension at prostate done elsewhere. And she comes in with pain. So she has pain when you load her thumb metacarpal. She's tender over the ST joint. She has Z deformity on appositional pinch. And she has no signs of any neuroma or any infection. And so this is the x-rays that she comes in with. And you can see there's an anchor placed in the thumb metacarpal base. Remember, the FCR is being used. And she has this impingement on the scaphoid. Thoughts? Chuck? I guess I would start in the clinic. And I'd want to understand the mobility of the thumb ray. So sometimes that's obvious clinically. Sometimes you want to use CRM to assess how mobile it is. I want to make sure we're not missing the diagnosis. As I mentioned in my previous talk, you want to make sure there's no dequere veins. You want to really understand the MP joint. Sounds like there is some MP joint issue. But theoretically, hopefully in this patient, if you can replicate in the OR, distracting and flexing the metacarpal, that may stabilize your MP joint. I would want to know that. Okay, and then let's say the MP joint is still unstable. And you can get her out to length with fluoro. Then what would you do? Still me? Yeah. I would use a mini tightrope. And then I would address the MP joint. How old is the patient? 64. Yeah, I have not had- 61. I have not had great success with soft tissue procedures at the MP joint. Now, as I said, I don't usually address the MP joint, but when I do, I will fuse it. Okay, Julie? Yeah, so very similar approach. But the MP is very, very stiff. It's sort of in hyperextension, and it's quite stiff. We'll back out to length, so clearly I need to figure out what I'm doing wrong. So I will do a tightrope, but I also back it up with something biologic. So she's headed to FCR, it's all gone. I usually do. I tend to be much more aggressive with the MP joint than Chuck mentioned. I think it's very hard to control the base of the thumb metacarpal as it subsides. Even after revision procedures you could tend to have MP joint pain and then you're going back to operate on someone who's already struggled with their thumb. So I tend to, you've got to make sure they don't have carpal tunnel symptoms because there's a high incidence of carpal tunnel. People don't, they don't diagnose it at the time of their CMC procedure. I also agree I use fluoro to see if they piston and impact with grip and then if you inject them with lidocaine if their pain gets better that's a good way to show that it's the base of the thumb that's causing problems. But I like to stay out of the CMC joint in a revision too if I can get them out to length. But I would treat, I do a lot of cases where I do a tight rope, MP fusion, and carpal tunnel release if it hadn't been done before as a way to address in a revision type situation. Okay. So Chuck sort of touched upon the nuances of, especially in a revision patient, it's a big discussion to have and a lot of things to go through so we're not going to label the points. So for me you can see her incisions, her old incision, I dotted out the other ones that I was planning. I think the key thing for me is number one, find the radial artery and I really do mobilize that all the way pretty distally and then I take out all the scars I can and as it was mentioned it was hard for me to get her out to length so I really had to come volar to the thumb metacarpal, release everything, and as long as you don't slide with your freer volarly because you can cut the FPL, just hug bone, I could get her out to length. So what the freer elevator is pointing to, so this is the scaphoid that the thumb metacarpal on the left was wearing onto the scaphoid. And so here what I did is I put two tight ropes in. You can see how I'm putting those K-wires in the bottom right. I'm really sort of getting that as ulnar as I can in the index finger metacarpal. And then I routinely for revisions I put an anchor either in the capitate or the trapezoid. I did address the ST joint as well. And then you can put whatever sort of allograft material that you want in there. Julie made a good point about using, doing a reverse Thompson. I just, I didn't do that at the time and I routinely just put this in just to scar and get as much sort of scar tissue in that base. For the MP joint, I'm actually, I do address the MP joint but I'm not, I don't jump straight to fusion. Sometimes it's a hard sell and they look at you like, wow, there's nothing wrong with my MP joint. I agree it needs to be corrected. And this is a nice little technique by Eduardo Zancoli, the Zancoli transfer. And what you're doing in the top left is you're taking the vola slip of the APB tendon and you're tinnitizing it distal to the A1 pulley. And so you put a suture also in the apex here such that now when they fire the APB actually as a dynamic flexor and stabilizer, the MP joint, and I've actually been pretty happy with this procedure. And this is that patient several years out. And you can see I put that capitate after debriding the ST joint, I put the anchor in the capitate and then I put the interposition. Okay, I think we're bang on time at 6.15. So thank you all for your attendance. I'd love to thank the faculty as well.

ICL on Common Complications

hand and wrist surgery

ulnar wrist pain

distal radius malunions

basilar thumb arthritis

lumps and bumps

surgical approaches

preoperative education

patient selection

pathology reports

revision surgeries