Perfect, so as kind of the session finishes up across the way, and I'd say we get started so that way we can get through this sort of really nice panel. So my name is Eric Wagner, I'm at Emory, I'm going to sort of lead us off and then introduce my colleague Dan to say he's also going to be kind of co-moderating. We have a whole bunch of great speakers from kind of all corners of the United States and all corners of the world to talk about how to treat these challenging patients. So without question, young wrist arthritis is one of the more challenging and controversial topics. As you know, there's many ideologies with regards to wrist arthritis from Watson talking to us about the different stages of slack arthritis, you know, very similar type of progression of snack arthritis, Keenbox with Professor Keenbox and some of the others that have sort of improved upon the understanding of this disease process with the different stages that you all are very familiar with, and obviously we're talking about the more advanced stages with regards to wrist arthritis, Pricers, and then fortunately we don't see as much of this, but the rheumatoid arthritis or inflammatory arthritis with those kind of classic deformity of the ulnar translocation, the rhetocarpal arthritis and this kind of zigzag deformity that you see. And so, you know, regardless of what we're talking about, when you have a young patient with advanced arthritis, it's a bit challenging. I'm going to introduce some of the treatments, I'm going to talk about a couple of considerations, and then I'm going to introduce my colleagues to sort of teach you about what they would do for these young patients. So as you know, there's many different options out there, and there's lots of controversy about each of these options. Partial wrist innervation, Dick Berger was one of the ones to really popularize this and talk about it a lot. PRCs, actually back in 1944, T.T. Stam talked to us about it or taught the world about this, has made a comeback in recent years. Four-corner fusions is something that's been around for a while, and it's sort of seen its ebbs and flows as well. Capital interface actually was around before four-corner fusion, and in some realms is a reasonable option. And then you have total wrist arthroplasties, that's sort of down the down phase of the hype curve, I'd argue, and for the most part. And then total wrist fusions, obviously, is the ultimate salvage. I'm going to introduce you to some considerations for you to think about as you listen to some of these talks, and then hopefully give you some insights into how to think about these patients. So if you have proximal lunate arthritis, relatively easy decision to make, I think. Proximal capitate arthritis, once again, I think it's a relatively easy decision to make, at least if you're good with partial fusions or PRCs. But if you don't have either of these, that's when it becomes very controversial, and that's sort of, I think, one of my favorite topics, and that's hopefully what you'll kind of get some more insight into how to approach these patients. You can look at other factors, like age, and if they are laborers. So Peter Stern sort of talked to us that PRCs in these young laborers had high failure rates, and then when you looked further out, the younger patients, once again, had higher re-operations and failure rates. So for a while, under 35, under 40, was thought of as something that you really can't do a PRC, and I think a lot of people still have that as a cutoff. We looked at this as well, and in general, across a large portion of PRCs over a relatively long-term follow-up, you can see age did have an impact. So under 40, you did have a higher risk of revision. Laborers also had a higher risk of revision. So kind of confirming what Peter Stern taught us. Interesting enough, selective neurectomies actually independently improved patients' clinical outcome measures. Naturally, not necessarily their revisions, but I would argue, no matter what you consider, at least consider doing a selective neurectomy at the same time. But that led to this study, where we looked at under 45, four-corner fusion versus PRC. So PRCs, we know, are at high risk in this patient population. Are four-corners also at high risk in this population, was basically the question. Relatively long-term follow-up for both, and in general, the decision was which, in this high-risk patient population, was the best outcome. I'm going to just briefly talk about some of these outcomes. So slightly different follow-up, but for the most part, pretty good follow-up. Arc of motion was very similar, pain was very similar, maybe a little better arc of motion in proximal carbectomy, not, I would argue, not clinically significant, even though it's statistically significant, and grip strength was a little better in four-corner fusion. This is interesting. This is, I think, one of the things I think I took the most out of this, was radiocarbon arthritis actually was not that different, especially when you account for the follow-up. Those Kappa markers are very, very similar, regardless how you grade the arthritis. And so, although people talk about the proximal carbectomies as a joint that's not matched to the lunate fossa, the capitate not being matched to the lunate fossa, I would argue something maybe slightly different is the reason why you see similar rates of arthritis. So if you look at the whole radius, and you look at how much you've removed by taking out the scaphoid, and how much is left, regardless whether you do proximal carbectomy or four-corner fusion, you can get a sense for how much surface area you're taking away. And so it's like taking an Allen Edmond shoe, or taking one of my, actually, I don't know if my wife has a Christian Louboutin, but let's say she did have a Christian Louboutin shoe, and having her step on it, it's going to hurt a lot more with a Christian Louboutin shoe than this Allen Edmond shoe, because you're taking away a lot of this force. So I'm not sure if it's just the radius curvature, I think that there's maybe more to the story. In general, there's no differences between a lot of these complications or revision surgeries. Interesting enough, smokers did do worse with four-corner fusions, they had non-unions, as you'd imagine. This is the other kind of interesting thing. So those of you, I think, are very familiar with the different types of lunate. So type 1 and type 2 lunates, with regards to the presence or absence of a hamate facet. And its potential impact, our Australian colleagues showing, helping to prevent scaphoid translation, and our Mayo colleagues showing that maybe it helps with DC or carpal collapse. Maybe what you're not as familiar with, though, is the capitate morphology, so you have flat, spherical, and V-shaped. And you can imagine, the more V-shaped it is, likely the more it's going to wear, potentially the higher rates of arthritis. And that is what we found. So when you looked at the type 1 lunates versus type 1 capitates versus type 2 lunates versus type 3 capitates, there was a significant difference in arthritis. And you kind of imagine that, but it was sort of first time, I guess, quantifying that. So briefly, I'm going to talk about a couple examples. This is a patient with wrist arthritis, 40-year-old, very young, very active, works as a laborer, likes to golf, supposedly quit smoking, question whether they actually did or not. You can see they have pretty classic slack arthritis, sparing of both the lunate, and it looks like, at least at this point, the mid-carpal joint, but I do find it hard to tell totally on that. So lots of different options, and this gentleman, we did do a lidocaine challenge for him, and did do this selective anorectomy. This is just a brief video to show the technique. So Dr. Gottschalk also has one, but you can see that you can do a selective anorectomy through a very small incision. You can expose the PIN that's just sitting on the dorsal side of the interosseous membrane, and then the AIN is on the ventral side, or the folar side. So it's pretty easy to find both of these. You cut out about a centimeter segment of the nerve on each side, and you have a relatively minimally invasive approach to doing this. Now, I don't think this is perfect for everybody. I do think about 30% of them do not get complete pain relief. I have started adding in isoscopic styloidectomies, and ones that have really bad styloid disease, because I don't think they get complete pain relief with this. But nonetheless, I think it's an interesting option. This patient did quite well with it, and got back to most of their activities. This is an older patient, but super active, and I wanted to show this as another option. So progressively worsening pain, works as a farmer, and smokes. So this is the x-rays. Without question, with the exception of the smoking, I think a radioscapulonate fusion would be a very reasonable option in this patient. I don't think a total wrist was reasonable, because of the activity level. I don't think a wrist fusion, he didn't want a wrist fusion, and naturally can't do a four-corner fusion with this. So what do we do? This is definitely controversial, but didn't get relief from the AI and PI injections, so we did an arthroscopic proximalcovectomy with this interposition. This is, sorry about the choppiness, I don't know why it's so choppy, sorry about the choppiness of the video, but you basically use a 4-0 or 4-5 burr to take out the scaphoid. You start with a 3-0 burr, and then you go up to a 4-5. You take out the inside of the bones, then you take a little pituitary ronger to take out the cartilage caps. And initially, it sounds harder than it actually is. Once you've tried it, it's not as hard as it sounds. And then, this is kind of the cool part of it. You can make the midvolar portal, use these shuttle sutures. Lorenzo is going to talk a little bit more about this technique. This is something that his institution has sort of pioneered in using as a way to do these minimum invasive arthroscope approaches. This is just the marking pins ruler, measuring out the graft size. I fold the graft over three different times, so it's a pretty thick graft, it's about a semi-and-a-half thick graft. You extend the incision a little bit to shuttle the graft through the 3-4 portal. And then, you can see the graft gets in there, and you can see a pretty significant graft size. It does wear down over time, as you can see, but you still maintain some space with it. And the beautiful thing is, you got back to pretty active, I mean, you don't have to restrict them post-operatively, and you get them back pretty quickly. So, lots of different options. I'll tell you my algorithm. I like AI and PNs for pain relief, but it doesn't really necessarily improve their function, and you have to make sure they understand that. PRCs for pain relief, they preserve motion but don't improve motion, and I do prefer it if it's a type 1 capitate or type 1 lunate. I also think older patients do do better than younger patients. And then, far-corner fusion, I do think are better for the younger patients, the higher-demand people, but they have to understand there is a risk of complications, and I do think they should quit smoking. Thank you for your time, and the next talk is my pleasure and honor to introduce somebody who doesn't need a whole lot of introduction, but somebody who is very insightful on a variety of things, but especially with regards to wrist arthritis, and I've had the pleasure of working with him on this for a period of time, so Dan Osei. Thank you. All right. Well, that was a lot of really insightful tips there, and I think you'll see there's a lot of synergy between many of the talks. I will acknowledge that I actually quote some of Dr. Wagner's data in my talk as a way to justify the reason for partial wrist arthrodesis as a technique, a very useful technique in the young patient, if I can actually get this file open, and then talking a little bit about some of the technical details. It's getting late in the day, even the IT is ready to be done. All right, so, you know, again, actually Dr. Wagner did a nice job talking about the issue. This is, I think, probably everybody in the room, you know, struggles with this problem, just like a young patient with a CMC arthritis. You'd like to not have to intervene in the way that we would for an older patient, but sometimes you're forced. And this is a patient who initially came to me with milder radioscaphoid arthritis, had a number of injections, but by, I think this was four years later, clearly had had more advance of the arthritis. You see widening of the gap. I didn't put the laterals in here. He did have a DZ deformity and clearly has not just worn down the joint, but really almost scalloped that scaphoid fossa of the radius. The injections, radiocarpal injections, are no longer working. I did attempt to do a diagnostic ANPN injection. It didn't work, and so we had a real conversation about, you know, what the next steps were. And so, you know, how do you treat this patient? Not the most fun situation, loves to play golf, has a two-year-old and one on the way, really needs a lot of help, has a classic dorsoradial swelling. You know, this is a very unhappy patient. And so we have a lot to say on this topic. This is one of those things that if you do a PubMed search, you're going to see a ton of research. And any time I see that, it tells me that we don't have a perfect one-size-fits-all solution. And so, you know, the issue is what can we learn from what has been done before? And so I try to delve a little bit deeper. And a lot of these papers, and again, Dr. Wagner talked a little bit about this, there are a lot of nuances when you look at these things. And when you look at this graph and you look at sort of different ages, what you see here is that the probability of fusion in a patient who is, you know, say 35 or so, after your intervention for a proximal oral carpectomy, which there is a ton of literature supporting this is probably the intervention of choice. As much as a lot of us have liked partial risk fusions, we've seen the complication rates be 20 times higher, the rate of repeat operation much higher. So that's becoming harder to justify. But I would argue that in a 35-year-old, having a 32% probability of a fusion following that initial surgery is pretty substantial. And that is something that I talk to my patients about as perhaps justification to think otherwise. If you look at a number of other studies, what do we see here in a younger population? This is actually a mixed population, but we see that this is the problem. When you looked at partial wrist arthrodesis compared to PRC, the conversion rate in general was quite a bit higher in the proximal wrist arthrodesis group. So this is the problem. We have to tease out these patients who don't fit the typical, say, slack wrist from a pseudo-gout kind of thing or a rheumatoid wrist or somebody like the second patient that Dr. Wagner showed in their 70s and has far more substantial arthritis. And so this paper started to give me a little bit more pause. There was a period of time that I actually almost stopped doing partial wrist arthrodesis because of the growing consensus against that procedure. And when you looked at patients who were a little bit younger, and this was a large population-based study done out of Utah, what you see is that the conversion to total wrist arthrodesis was really not different between the two groups, again, looking at a younger patient population. So maybe, as Dr. Wagner said, it's not the procedure but in whom you're doing it in. And so we all know that dogma is everywhere in hand surgery, certainly in orthopedics. I'm not a plastic surgeon, but I'm sure it's riddled through the plastic surgery literature. And these are the things that I think have made people continue to do partial wrist arthrodesis despite that growing evidence against it. It does seem that preserving on the styloid is a problem as you shorten that carpus. We do think that patients who do well seem to have better grip strength even though the literature has not necessarily supported that over the last five to ten years. And so are we fooling ourselves? It's hard to know, but these are the things that I think really require self-reflection as well as a conversation with patients. And so for me, the patient. So it is complicated, but I think this is probably closer to the truth in this specific patient population than some of those general population studies. And so for me, I think that there are a lot of things that are really important. You saw that slide by Dr. Wagner looking at the myriad approaches. Some people will excise the triquetrum. Some people will try to do a capital lunate fusion. There's no doubt that this is an easier procedure technically for the surgeon than a four-corner or a three-corner or an intercarpal arthrodesis. But this is very telling. And the work out of the Mayo Clinic, you know, it showed us that there's a 50% nonunion rate with capital lunate fusion. So that is not part of my practice anymore, despite the fact that it's easier for you. It may not be easier for the patient. When you look at some of the biomechanical studies that have looked at that problem with capital lunate fusions, the real issue here is that the contact forces when you do a capital lunate fusion are far higher than when you do a four-corner or a three-corner fusion. And that's probably the reason, along with some of the capitate morphology issues, along with the type 2 lunate issues that Dr. Wagner talked about. I think that increasing the contact pressures between the lunate and the lunate fossa are going to be a recipe for disaster and will ultimately lead to failure of your partial wrist arthrodesis, at least in a large population of patients. And so what are some of the tips that could be helpful? I think that more compression is better. I do, you know, and there's no conflict here. I don't have any consultancy with anybody that does screws. But there are biomechanical studies that show that more compression is better. And you do get more compression from a cannulated screw than you do with staples. And for me, the principle here is pretty simple. It's not that staples don't work. It's not that a number of different techniques don't work. But when you have a technique or a procedure that has a relatively high failure rate, doing everything that's in your control, at least this is my editorialization here, to try to improve the likelihood And in general, I do think if you're going to use two staples, at least by these data, two staples between the capital Lunate interface is better than one. And again, the mechanics studies tend to show that you get better compression, which probably is going to facilitate a more solid, more reliable fusion. This is probably the biggest thing. And I think about all these studies that have. You've really got to get healthy bone there. You have to restore that capital lunate angle to zero degrees. That lunate's tilted into extension and you have flexion through the capital lunate interface. You have to correct it. I'll oftentimes use a finger or use a freer or a Penfield elevator to push the capitate bolerly. And when you do that, you'll see that that lunate which is extended is going to go back into its normal position. And when I'm with trainees, that's something that I think they sort of underappreciate a lot of the time. And so I'm really sort of helping them do the simple part, which is just placing K-wires and screws and whatnot, but it's really that angle, that articulation that has to be restored in order to get a good result. Richard Gelberman was one of my mentors in fellowship and in early practice, and he always said you want on the lateral for the screws to be parallel in both the capital lunate articulation as well as the triquetramine hammate. And so I really spend a lot of time trying to make sure that that is the case on my intraoperative x-rays, and I think that's really important. Another little tip is that trying to get the screw trajectory from the triquetramine into the hammate can be quite challenging. Everybody that has probably done an extensile dorsal approach, I find it very hard to get all the way around, and what ends up happening is that your trajectory ends up going from dorsal to volar as you go down from the triquetramine to the hammate. So I'll make another counter-incision just along the ulnar styloid, protect the dorsal cutaneous branch of the ulnar nerve, and then place my screw over there after I've done all the carpentry and the preparation of the joint surfaces from my extensile dorsal incision. I always use bone graft. I think that it can be a pain in the butt. Certainly there's a lot of stuff on the shelf that can make your life a little bit easier, but again, the same principle applies here. This is a surgery that we know has a higher complication rate than some of the other options. Make sure that you have as healthy, as good bone to maintain everything that you can do both carpentry-wise as well as biology-wise to facilitate fusion. The styloidectomy issue is a good one. I do sometimes do it, and I think what I end up doing is bringing the wrist from ulnar to radial deviation and seeing whether there's any sign that perhaps you're going to impinge the trapezium on the radial styloide. I find that preservation of that proximal row oftentimes obviates the need to do it, but if it's going to be a problem, that's not an issue. This paper by Richard Gelberman always talked about the fact that the relationship of the radius scapho-capitate And so again, I think with those principles, I've been pretty happy. I think we all are victims to not knowing whether somebody had a problem. So, I think it's important just to remember the requirements for wrist motion that are going to make your patients happy. A lot of studies that show that more extension is better than flexion. But Cooney and Ahn found that 40 degrees of extension and flexion with 10 degrees of radial deviation and 30 degrees of ulnar deviation allowed patients to do all the activities of daily living. Remember that radiocarpal motion accounts for 50% of extension and 36% of wrist flexion. So, I think you have to remember that when even the best four-corner fusion is going to have limitations. I think recently Kirk Watson, who I spent some time with, who did these all with K-wires and did the operation in about 30 minutes, published a very small series and certainly selection bias in his best patients, I'm sure, with a long-term outcome. These patients had an average follow-up of 18 years. Note the age, though, 49. I think really Kirk Watson pioneered this operation, so I'm going to show you some studies comparing proximal rotocarpectomy to four-corner fusion. Four-corner fusion was really not performed in the United States to any large extent before the early 1980s. But 68 degrees of total motion, but if you follow these patients, almost like with proximal rotocarpectomy, 73% show joint destruction when you look at the radiographs, and 27% have severe joint destruction. Despite this, he showed a quick dash in his paper of eight, which is remarkable. This more recent paper coming out of Chicago showed that a similar total range of motion and suggested that patients with very poor motion to start with probably would benefit more than patients that had reasonable motion, but again, the post-op arc in this study by some very excellent surgeons, 36 and 36, and essentially they said that the motion the patient comes in with for most patients is going to be the motion they end up with after four-corner fusion. So Dan talked about all these things. The other thing I'd just like to point out is now that I know more about the blood supply of the carpus, I think it terrifies me more than probably it should. But this is a patient who had a peri-lunate dislocation done elsewhere, and this lunate certainly is compromised then with its blood supply. They have a plate put on, and look, they created a keen box disease. That lunate is gone. That decapitate is now resting on a non-union. I think that these more invasive plates where you're drilling, you know, half of the dorsal portion of the bone away and putting on these screws that go everywhere run the risk of just compromising the blood supply. I would agree with Dan that screws are my preferred means of compressing the bone, and I usually just put one in, and I try to get it centrally. Because if you get it centrally, you know, you're going to still have a fair bit of the blood supply that's preserved in the dorsal half and the volar half of the bone. But I think the future is learning how to do it arthroscopically. Because if you can do it arthroscopically, you don't have to create a dorsal capsulotomy, which is going to devascularize some of the lunate. And we do have the potential of patients getting better motion. This is the lynch-eyed maneuver that Dan was talking about, and if you do this arthroscopically, I think you have to plan for a long day, which many of us don't have time for. But I think taking out the scaphoid through a small volar incision or by using an extended 3-4 portal and just removing as much as you can of the ronger, and then, as Eric said, using a 3-5 barrel burr to get that bone out as quickly as possible. I put the screw in from the triquetrum into the capitate. Sometimes it catches a portion of the handmate. But for that other screw, I tend not to, based on some anecdotal research that we have at Mayo, showing that screws that go through the articular surface of the lunate into the capitate, those patients tend to show signs of degeneration at that articulation at the radiocarpal joint quicker than those that have them placed the other way. The easiest way to put that screw in axially is to just put a large, usually a Steinmann pin, a 4-5, whatever cannulated drill you're using will fit over one of the Steinmann pins. Go in the inner metacarpal space. If you look at the patient, most patients will either line up axially between the index and long finger or the ring and the long finger, and you can get that right in there. And then you do have to pass the drill through a fair bit of subcutaneous tissue. But I think, for me, it's the best way to get that fixed and gets it done. Again, I do try to avoid the placement of the screws in that direction. This gentleman on the right-hand side has got probably one of the best results I can get. I don't know if I can do better than that in terms of postoperative motion, and he went on to be a carpenter and be very happy with that. But I think that's the type of, that's my best result. I can't get better than that, so you have to appreciate that and tell your patients that, and probably half of them are not going to achieve that. Screws also are the most efficacious in terms of cost. So why not PRC? And we went over the fact that many of these radiographs go on to show arthritis at the capitate interface. So I'm just going to try to, Dan's already been over the biomechanics of these, and we know that four-corner fusion has better load sharing when compared to PRC. There's a lot of shear force with PRC. When you do a four-corner fusion, your patient is never going to have dart thrower motion. And actually, all of the, many of the biomechanical studies tend to suggest that a PRC should deliver more normal arc of motion for many patients. But unfortunately, we run the risk of developing arthritis. A lot of great studies showing that it works great in patients with Keenbox disease, 20-year outcomes in this study, this study from Johansson in 1969, presenting patients with 20-year outcomes. Again, great, great outcomes in these patients. We, however, did a 20-year outcome study, and we found that really only about 10% could go back to heavy manual labor. It's an easy operation, as Dan said. If you can get the bones out in one piece, and the McGladrey is a great tool to use, or any of the corkscrew-type devices to pull out the bones, I think you can then look at the capitate head, and if there is evidence of osteochondral injury, you can use Joe and Wrigley's technique of an oats, a mini-oats procedure. I use a pediatric trefine for this procedure, and I over-trefinate the capitate to remove the damaged area, and then I would use one size smaller trefine to embed my cartilaginous graft, as you see there on the lower right. I can't say that that makes any difference, but I do feel better about doing it in some patients that have a big area of wear. In this study with Marco, we looked at patients that were, at a minimum, over 15 years, so paralleling, I think, most of the study that you showed, Dan, by Dr. Stern. The mean age of these patients, interestingly, was 41 when they had their proximal oral carpectomy. The average follow-up was almost 20 years. Patients had the same motion as when they started, so there was no improvement in motion, but I think the biggest concern from this study was that most patients were on pain medication at final follow-up, and very few felt that they could return to having manual labor. They can certainly go back to work, but being a farmer in Minnesota was tough. We found that some things were very beneficial to improve your outcome, and that was doing a formal norectomy. I know you always do a PIN norectomy when you lift up the capsule, but when you started dictating, they did a formal AIN-PIN norectomy, and they started doing better. Interposition flaps didn't do any better, and there was no improvement with radial styloidectomy. I think we just need to tell our patients this, and maybe individualize it for those patients that are heavy manual laborers, less than 40. We looked at 144 patients. Eric did this when he was working with us, and again, we tended to find that formal norectomy, patients did better if they're older than 40, if they weren't manual laborers, if they had the diagnosis of Keenbox disease, and then we found that some particular bony shapes tended to have a higher risk of arthritis, certain capitate shapes, and the type 2 and type 3 capitates that are seen there on the right tended to do a little bit worse. So you can try to look at the bone shape and pick the patients that are best for PRC versus a four-corner fusion. So Dan's really gone over all of this. I don't think you can show any benefit of one procedure over the other, and because of that cost is the major driver, I think the PRC, from an academic standpoint, is better. Dan did mention that the one finding in this study with patients less than 45 years of age, they did have a better dash score with four-corner fusion, but interestingly, the patient-rated wrist exam, which is more specific for wrist function, was equivalent. And you certainly can go to the Journal of Hand Surgery. It was very interesting to see that the motion was really the same. The amount of patients that degenerated and needed a total wrist fusion was the same, and the biggest problem was the higher complication rate with four-corner fusion, and this has been brought out in several systematic reviews. This very large cohort series looking at four-corner fusion and the incidence of conversion to fusion and cost found that when they compared this to PRC, there was a higher incidence of fusion, very interesting, just as Dan was saying, higher cost, but no difference in readmission rate. For me, proximal oral carpectomy is great for an older person with SLAC, with SNAC. This is a patient that had bilateral PRCs, an eight-year follow-up, but you definitely aren't going to have the manual labor that you can't do a four-corner fusion in. This is that pseudogout case where you have a massive VC, you go in, the lunate has been on a sharp angle, and all the cartilage is worn away. And when you do the proximal oral carpectomy, even though you've counseled the patient at least five years here, they end up with painful radiocapitate arthritis, and then what do you do to salvage these patients? Do you go into a total risk fusion? I think you can consider interpositional, as Eric showed, with some type of decellularized dermal matrix. So unfortunately, neither of these operations are perfect. They roughly have a similar failure rate. I do think that proximal oral carpectomy works best for lower-demand type 1 capitates in the diagnosis of Keenbox disease. Do a formal neurectomy. It adds, you know, 10 minutes to the case. And I think if you compare it to four-corner fusion academically, PRC is probably superior and costs less. Thank you. All right. Thanks, Dr. Moran. As usual, I always learn something incredible. I believe next we have Dr. Rizzo, who's going to talk to us a little bit about total risk to arthroplasty versus total risk to arthrodesis. Thanks, Mike. Hard to follow Steve, but I'll do my best. My charge is to speak about arthroplasty and arthrodesis, and I thought I'd share a case. This is a 55-year-old, a manual laborer with bilateral risk to arthritis, and just take you through his journeys here as we go. You know, certain questions come to mind. How should we treat him predominantly? What are his demands? What kind of arthritis is it? Bone quality, activity level, compliance, smoking, things of that nature. Arthrodesis can come to mind as a treatment option. I wish my patients loved arthrodesis as much as I do. It's a great procedure. It's fairly predictable. Occasionally, you have to remove the hardware. CMC joints sometimes are a little finicky, but once they heal, they're really durable, and it's really quite satisfying. There are the indications, pain, pancarpal disease, poor bone stock, poor soft tissue support, severe deformity. Patients who fail total wrist arthroplasty are in my indication list, and certainly if you've had a previous infection, you want to consider more arthrodesis. In terms of pearls and pitfalls, you know, the position of fusion can be catered to the patients. Most of the precontoured plates put you in about 10 to 30 degrees of extension, which helps with gripping, but I think it's important to optimize the position and discuss it with the patient. This is a case of the same patient who had one wrist fused in slight extension, the other one in slight flexion. More or less, I would just probably put them in neutral, but this worked out pretty well for her. Preservation of the vulvar lip of the distal radius will help to maintain the wrist length and protect the carpal tunnel. Sometimes you can be overly aggressive with your carpentry, and you worry that you're going to compress the carpus into the ulna. You can always shave off a little bit of the carpus so that the ulna is not impinging, or do a minor wafer procedure at the same time. The precontoured plates are nice, but I do use them with caution. Sometimes the contour, as you start to compress the plates to the bone, actually creates separation of the carpus, depending on how they contour. So keep that in mind, particularly in patients who've had a prior PRC or severe collapse of their carpus. And sometimes I've aborted the precontoured plates and just gone to a straight plate and put a little touch of bend in it to not compromise the compression. I like locking screws, especially in patients with poor bone. I don't use locking screws at the most proximal or distal holes. I tend to sort of space them in throughout the construct, including the, this is a board question, radial scaphoid, radial lunate, capital lunate, scaphocapitate, and third CMC joints should be denuded and included in your fusion mass. You can also choose not to denude the CMC joint and plan to take the hardware out. I tend to fall in more of the camp of denuding the CMC joint, and if they don't heal or have hardware loosening, then take the plate out, because most of those non-unions are asymptomatic in my experience. Splinting a patient will help them wrap their mind around what a fusion feels like. Fusion's a tough sell, and at initial conversation, patients get this sense that they won't be able to use their hand, I mean, their wrist. But if you give them a wrist splint and help them wear it religiously for a couple weeks for everything, I mean, everything, in the shower, getting dressed, preparing their meals, hygiene, it really gives them a sense of what the fusion would be like, and a lot of them might come back and say, yeah, that wasn't so bad. Some will come back the other way, though. There's a race that goes on between the bone healing and hardware failing, regardless of what fixation you use. This is a case of someone who had locking screws in the metacarpal, a rheumatoid patient, and you can see it didn't heal, and those locking screws acted like a drill, sort of effectively almost leading to a fracture of the metacarpal. So be cognizant of that. The fixation's good with the locking technology, but it also, something's going to give if the bone doesn't heal. Again, the third CMC is the most common complication. I'm in non-union site. Occasionally, someone will have painful hardware and tendon irritation, but by and large, and most studies would agree that this is a procedure that can be replicated and be pretty predictable in terms of taking away the pain. So this is what the patient had. He had this done elsewhere. He had this procedure, and this was his fusion. It came to me with, later, and I'll talk to you a little bit about it, but let's look at fusions. Let's look at bilateral fusions, and this was a study done with Sanjka Kaur and Basam and Eric Wagner when Eric was with us, looking at 13 patients who had bilateral wrist fusions. This is my patient, the lady I showed earlier, and at a 14-year average follow-up, 12 of the patients were satisfied, and the patients tended to adapt pretty well, which really helps us feel better about the possibility of fusions. However, the story's not always so great, and some patients who've had fusions on the other side do come to me saying, gee, I cannot do that again with another fusion on the other side. This patient did pretty good, though. I mean, this is her functionality, and she ended up adapting quite well to her bilateral wrist fusions, and this is a case of a patient who came to me from South Dakota with a wrist fusion and was effectively terrified of having his other side fused, even though I tried to talk him into a partial wrist fusion, and the reason he didn't want to have that was because he was told he was going to have a partial wrist fusion on his right side and woke up with a wrist fusion complete, and that sort of bummed him out. Let's look at this guy's left side, and in this case, I think a partial wrist fusion would be an attractive option when I looked at it initially. Steve touched on this quite nicely, how much motion do we need, and he also touched upon this in terms of how we think of slack wrist, and there are some studies that suggest that what we think we're going to see when we get in there isn't exactly what we end up seeing in having to resort to a plan B at the time of surgery, and this is a case of 18 patients who had more severe changes on the lunate, which led these surgeons to go and go to plan B, which in their case was a proximal row carpectomy. Sometimes, as Steve showed in his case, you know, you see the lunate, and the lunate looks pretty ratty, so it's important to have a plan B in these cases, and this patient had cystic changes in the vulvar aspect of the lunate facet with some spurring, and when he got in there, it actually looked quite worse than we expected, so he ended up getting a total wrist, and why would anyone consider a total wrist? It takes a beating. Eric gave it a beating here in the introduction, and it's taken a beating throughout the meeting pretty much, but it does have some value. Patients like it. It's motion-preserving. It's pain-relieving, and it has an option of allowing us a motion-preserving wrist. This is a nice case that I think is illustrative of how patients like it. John Stanley's group looked at a cohort of patients who had a refusion on one side and a replacement on the other, and despite clear evidence that the replacement needed more re-operations and was more frustrating and more footsie, most would have the arthroplasty again, despite that evidence. Of course, survivorship's an issue. Osteolysis, loosening, it's technically challenging, and what do you do when it fails, and basically you end up going to effusion, which earlier studies suggested is not as predictable, but I think nowadays we're getting better at fusing after failed wrist replacements, but circa 2014, if you look at a systematic review of total wrists, basically the conclusion is the evidence does not support its use over arthrodesis. So historically, we've tried multiple generations. The newer generation implants do seem to help, and basically, I'll talk you through the technique. I like to make a Z-plasty of the capsule. You can also elevate it sort of from the first compartment only. I think the Z-plasty allows you the opportunity to tension it appropriately to cover the tendons after unclosing. I think a wide U-shaped flap, if you're just starting on total wrists, make your incision big, make sure you can visualize everything. A U-shaped flap is nice in some ways because it allows you a cuff of tissue, and you've got complete visualization, a cuff of tissue to re-approximate, and complete visualization. Some systems, like the Freedom Wrist, require that you take that capsule off of the distal radius, so you're going to need drill holes to suture the capsule back down, but the re-motion still allows you to cuff because you don't have to remove any of the radius with a saw in the re-motion. This is important, having your capitate aligned appropriately and centered appropriately. Make sure that that guide is aligned in with the capitate. Use the lunate fossa as the key. Confirm with fluoroscopy. Secure it, and take the time to get this right, because if you get this wrong in the beginning, you're going to be frustrated the whole case. You can then cut the distal, make your carpal cut. Confirm that it's also parallel to the CMC joint. Make sure your exposure is adequate. In this system, you start your cut, and then you freehand it the rest of the way. In terms of the radius, Lister's tubercle is a good marker for the center. You want to go in the dorsal, Volusar junction. Again, confirm with fluoroscopy, and then you can over-drill when you're satisfied with the position of the guide pin. Then you begin your carpentry of the radius. The radius carpentry is tricky. It does require the use of these pineapple burrs, which I would encourage you to have handy, because you're not making a formal cut. of the radius, you're gonna have a lot of sclerotic bone that you have to sort of work around, and as you broach, contouring the bone to get the broach to seat is gonna take some effort, and this is a laborious process. Ideally, when you put the distal component in, you want it to be center-center. Some wrists have a tendency for extension of the capitate, so keep that in mind when you're trying to center it, because it can be a little tricky, and again, I like to confirm a fluoroscopy. And ideally, you want to avoid crossing the CMC joint with the broach on the capitate. Sometimes, it's impossible, and you may have to broach, but ideally, I try my best to avoid it. You may need a burr also if it's sclerotic. And in terms of screw placements for the distal component, it's okay to cross the index CMC. You want to drill towards the index and the ring finger, but when you go in the ring finger trajectory, try your best. When trialing, ideally, the wrist should be stable to 40 to 50 degrees extension and 40 to 50 degrees of flexion, in my opinion, 30 or 40. Forty degrees of radial and ulnar deviation, you can shuck, and you should be able to shuck about two to four millimeters. You can augment if it's excessively loose, augment with a poly that's... If there's a somewhat loose fit, you can do impaction grafting, which is my preference, and I like to avoid spinting whenever possible. I'm not in a rush to get these patients moving. There's no rush. The patients will have a functional arc of motion. The key is to make sure that the implant's stable and that they heal. And after about two to six weeks of immobilization, you can get them into a removable split and start motion. There's a whole litany of studies that look at total risk. This is the most recent meta-analysis. Just to contrast the one from 2014, this meta-analysis was much more encouraging with respect to total risks in the newer generation implants. And also noted that despite the fact that there are still higher complications, as we would expect with total risk, that the newer science is more promising. And there's been some fairly large studies that have shown pretty good results both in Europe and in the United States that were included in this literature review. But no doubt about it, loosening remains a problem. The actual mechanism of loosening, we debated a lot yesterday at one of the ICLs. And it's probably a combination of stress shielding and osteolysis from particle debris. And unfortunately, the only option with a failed wrist is often fusion. Berber also did a meta-analysis looking at failed total risks. And the literature review on treatment of failed total risks is that it's fraught with challenges. And fusion, to me, is the most predictable treatment. But this is that patient one year after his total risk. And he had the fusion on the right and the wrist on the left. And it's pretty satisfied. So both of these are options that I think are important and are mainstays in the treatment of wrist arthritis fusion. It's more reliable, but also robs the patient of any hope of pain, of motion in the future. And preoperative splinting, I think, is helpful to temper expectations. Arthroplasty, as you would expect, is higher risk but higher reward, preserves motion, but invites further surgeries and complications. And the optimal treatment, of course, needs to be individualized. And should be based on the patient's needs, lifestyle, desires, and understandings of the risks and benefits of each intervention. Thanks. Thank you. I'm actually going to talk next and then after me I'm going to have Dr. Bernego from Lyon, France, but how many of you in the audience do partial wrist innervations? So a fair number. So this may be geared for those of you that either are not aware of it or maybe have not seen it. I'm Mike Gottschalk. I'm at Emory with Eric Wagner. These are my disclosures, probably none of which are relevant to this talk. But just a brief case example, 42-year-old female, history of seropositive RA, progressive wrist pain, trial of DMARDs, corticosteroid injections. These are her x-rays, more symptomatic on the right wrist than the left. And you can see there's some concentric arthritis. And then on the laterals, same idea, kind of some pain carpal arthritis. So surgical options, right? We've talked about almost all of these in some way, shape, or fashion, whether it be a proximal rocapectomy, a partial arthrodesis, total wrist arthrodesis, or even a total wrist arthroplasty. I think for me, this is probably my favorite procedure that I do. And the wrist denervation can be quite successful in the correct population. And these are my indications. And certainly as you stray away from these indications, you'll find that the results may not be as good as what you like. Some of the advanced arthritis, specifically radial-sided arthritis, is somewhat controversial. But I will tell you that the lidocaine challenge for me works well in the office. If you are over-aggressive with the amount of lidocaine you use, you'll find that your results for the selective wrist denervation is not as good. And that's probably because you're getting outside of the AIN, PIN range, and you may get some of the median nerve proper and some of the other nerves around the wrist. I should also credit Eric and some of the Mayo folks for some of these slides from Dick Berger's original article. And this is the technique adapted from them using pictures. I'm going to show you a video as well. But essentially, it's about a finger breadth proximal to the DRUJ. It's a 3 to 4 centimeter incision centered over the fourth compartment. You open the fourth compartment. You shift everything from radial to ulnar. And you'll see that the PIN is right there. This is obviously also a great nerve if you're ever doing digital nerve injuries and you want to take autograft. There's very little downside in taking it. Essentially, once you find this, you open up the IOM and you go slightly ulnar. And I'm going to show you this in a cross-sectional area. And it's fantastic because you can really find it here shortly. And you'll see this in another thing. So here I'm just marking out our incision. The best part about this for me is that it's done in the ASC. I can do it under regional anesthesia. And I don't always use a ruler, but I think it's a nice effect when you're making a video just to see, okay, look, I can make a straight line. And I'm clearly marking out. So here, I like to use, the reason I use centimeter increments is just so I know exactly how much I'm lining it up and how far distal from the DRUJ I'm going to go. And this is the same patient. So here, similar, I did this under loop magnification, come through the skin, through the dermis. I'll use some tenotomy scissors to essentially go through any adiposity that may be present. And then I'll use, here shortly, you'll see a sweeping motion with just some sort of, whether it be Ray-Tech or any sort of stuff. And this will, if you ever use this, this kind of helps dry out the wound and will really get you down to the fascia, makes it look nice and neat. Here, you'll see we open the fascia either with a knife or scissors. And here, what I'm doing is I'm going on the far radial side. And you'll see here shortly, once I dissect down here, that there, right, I just moved out of the way, is that PIN that's essentially up on the screen. And I use electrocautery just to help dry out the wound. I try and keep the artery intact. But then when I take the nerve, finally, I'll take the nerve in a little bit of a segment. Then I cut through the IOM. And then essentially, as I mentioned, I go from slightly radial to ulnar. And as I pull it back, you essentially find the nerve just there. And you'll almost see a twitch of the pronator quadratus. And that, to me, is like a signal that, yes, I've got the nerve. And I've got the nerve just distal to where it is. And that's normal. And then I close up the fascia. And then here, you'll see that this is in the stage of telemedicine still where we weren't seeing everyone back. But she had almost no motion before surgery, very hard to move it. And she's got almost full motion. I was trying to tell her what I wanted and mimic on my screen. So it took a little while to understand. But full motion, no pain. They get a soft tissue dressing for two weeks. And I let them go do whatever they want. So as I tell everybody, there's almost no downside in doing this. So what exactly is the area that's covered? You'll see, I think this gets a very central, broad area, both on the anterior and posterior side. You're not going to get everything covered on the ulnar side if there's ulnar pathology. And you're not going to get everything covered on the radial side if there's radial pathology. And that's as you'd expect, right? And so you can use this. And Dr. Bernier is going to talk about her technique for arthroscopic styloidectomies. And you can use this as an adjunct. So here, this just shows cross-sectional areas. And yet again, these are from the Mayo folks. I should credit them for these slides and with Eric. And you'll see that here, when you look closely where the nerve is located, here's the PIN right here. And then as you go, it's a few millimeters away. And there's your AIN. And it's just from a radial to ulnar direction. And it's about two to three millimeters. So there is obviously a complete denervation of the risk that you can do. And this has actually worked well in certain people's hands. There's a technique guide in JHS from 2011 that tells about the various areas that you do. I do not do this. That's not to say that you can't. I think it works well in the right hands yet again. I think the biggest issues that you find sometimes are cutaneous neuromas if you accidentally are overaggressive with certain nerves. But yet again, it can be a good operation. So outcomes, yet again, Dr. Dick Berger, who wrote the original article, and you look here, and this was over a two-and-a-half-year follow-up, 80% pain relief, 15% reoperation, pretty good. Yet again, when you look at the folks further down the road, and this was that seven-year follow-up, about one-third of patients had reoperation. And their scores ultimately did pretty well. So yet again, I'd like to acknowledge everyone that's helped, and thank you guys for your time. talk to us not necessarily So, good afternoon. Yes, my talk is not about immunotropicity, first of all, because we don't use it in young patients. It's mainly for older patients, and because it's much more fun to talk about arthroscopic radial steroidectomy. So, I'm really happy to be here. Thank you for the invitation. So, this is my talk. This is the outline. And which kind of patient could we treat with arthroscopic radial steroidectomy? There's three different scenario. Either patient with overuse with isolated curative steroidectomy, patient with either slack snag with either isolated palliative, or combined with the slack snag treatment. Of course, in some cases, there is no way to perform the surgery because it's really too late, like in this patient with the second row radial translation. The technique. I will speak today about the three-portal technique that we published recently with Guillaume Herzberg, and I would like to acknowledge my co-author for this presentation. We know for a long time from Dr. Roche and his team the two-portal arthroscopic technique for radial steroidectomy. But you can imagine that with this two-portal, when you have the scope into the three-fold, you really don't see very well the dorsal part of the radial steroidectomy, especially because you have synovitis, and so this is the main concern with these two-portal techniques. You can see here the dorsal synovitis may be eyed with the dorsal arthritic rim with the proper view, like in this right wrist. The solution is to have another view from a volar view. So when we speak about volar portal into arthroscopy, you can be afraid, but actually, this volar view, the volar radial portal is just behind the FCR. So you retract the FCR, you are between the medial nerve and the radial artery, but you perform a small incision, and you just retrieve the FCR, and you are between the radioscaphocapitate ligament, just like you can see in this slide, and the long radiolunate ligament. The portal can be performed either in-out, so you can see the space between those two ligaments, but we prefer the out-in. You can see it's really a small incision. As I told you, you remove the FCR and go through. So we will speak more about the technique now. Most important, as usual, the setup and the installation. Especially for this technique, you need a very critical screen placement to avoid neck pain, but not hollow, because you need that the two surgeons, one from the volar, the other from the dorsal, or your assistant, to be able to see the screen. This is very important. And you need space for the volar portal preparation. First of all, you will have your scope through the 3-4 portal, and your burr through the 1-2 portal. The burr, the shiver and then the burr, will remain into the 1-2 portal during all the procedure, and when you have the scope into the 3-4 portal, you can burr the volar part of the radial staloid, and then you put your scope into the volar radial portal, and you can see very well the dorsal part of the radial staloid, and you can remove it. How much restriction? The usual question. Of course, at the beginning, it is recommended to use the scope just to be sure you remove enough, and go really step-by-step, because it can go fast. This is an example. A right-handed 57-year-old patient. You can see the setup. So the screen placement is really critical. Anterior portal, a small longitudinal incision, and you remove on the ulnar side the FCR, and then you are really between the radius scaphocapitate and long radionuclide angle. Then the dorsal portal. So you first perform the volar portal, so then you are done. Then you do your usual 3-4 portal for your scope, and the 1-2 portal. You put first the shaver, of course, and you will explore, as for all arthroscopy, you will explore the joint. So this is the trocar through the volar. This is the shaver through the 1-2 portal. So first, you need to perform a great soft tissue debridement. Then you start with the burr and the volar rim. And before that, you plan how much, I mean, size of the burr you have to remove. Then you switch. Your burr is still in the 1-2, and you switch. This is the view from the volar portal. And this is the automatic washout because we use dry arthroscopy, as you can see. We just put some syringe and then remove the bone. And this is the removal of the bone from the dorsal rim of the wrist. Which potential complications? Of course, too much resiction. This is the usual complication from the radial styloidectomy. And that's why the arthroscopy is very useful in this kind of surgery because you see very well the insertion of the radioscapulocapitate ligament. So you can't remove too much styloid. And of course, you have to pay attention to the nerve and the artery. This is our experience. 28 patients treated with this technique. You can see there are different indication from isolated, curative, or palliative, or combined with other procedure, like the APSI, the pyrocarbon implant to replace the proximal pole of the scaphoid. This is a typical patient, elective radial styloid pain. This is an overuse syndrome, and an isolated curative which treat the pain. Another patient, 65, SNEC2. An elective, again, elective radial styloid pain. It was an isolated palliative in this case. So of course here, you don't treat the SNEC, but especially in those patients, it's almost the same patient that for the denervation. It's used to be patient with really elective pain, but still some motion. So you don't want to perform a non-salvageable procedure, a big procedure. So just by removing this radial styloid, you can help them. In summary, the arthroscopic radial styloidectomy with the three-portal technique is recommended in this patient, and the three technique is really helpful not to avoid the dorsal rim of the radial styloid. Thank you very much. question I think it I haven't seen a lot So, I will end this session with the arthroscopic options. a few options that are really relevant with arthroscopy and either, and in the case of the SNAC one, but that's the same principle, you can. doing an astroscopic bone graft of your scaphoid. or when, if it's not possible, when you have a non-solvable proximal pole, you can replace it. Moving on to STLAC2 and STLAC2 stages, as you know, there are only palliative options. And as it has been said before, you can use one of the most favorite techniques, the proximal rocapectomy. Well, this can be also performed with arthroscopy, but you should know it's a very demanding procedure, and you have to take some time to do it. And as Steve Warren said before, I do my proximal rocapectomy arthroscopically, but I've stopped resecting the scaphoid. Under arthroscopy, I now use a small volar approach of a few millimeters right here on the distal pole, five to 10 millimeters to remove the distal pole of the scaphoid, and the rest is done with arthroscopy. And this can save you 45 to 60 minutes of procedure. And the rest is pretty straightforward. And as Eric Wagner said, the main trick is to start with wrist instrumentation, but as soon as possible, switch to shoulder-sized instrumentation to remove the rest of the bones. Otherwise, you're gonna be here all day, and it can be very painful. Partial fusions, four or three bone fusion, and can also be performed with arthroscopy. It's even more demanding than the proximal rocapectomy. But it can be done in the same principle. You can do a small volar approach to remove your scaphoid and remove the rest arthroscopically, and then burr all your articular surfaces of your bones. And doing or not a graft depends. Some people in France believe that since you do it arthroscopically, you don't need to put a graft in it because you preserve the vascularization of the bone. I still use bone graft, and I took a bone marrow biopsy, which I harvest the graft from the distal bridges and put it inside the bones arthroscopically, and then release the traction and do the fixation with screws. I think, as Daniel said, it's the best way to go when you try to do a fusion. But this is what I really wanted to talk about, is the complete treatment of complete option, arthroscopic option for SLAG2. This is a technique that we developed in Paris. Radial carpal tenderness interposition, because, as you know, in France, we're very fond of organic food. We're also fond of organic surgery. And we try, when possible, not to use any implants or to resect any bone or to avoid any fusion. So it starts with a radial stalectomy, and then in your radial staloid, you would put an anchor, and this anchor will be the point of attachment of a palmaris longus graft that you previously harvested. And your palmaris longus will be passed outside and inside through the volar and the dorsal capsule, as you can see on the drawing on the right. And if it's a SLAG2, you can also try to do something on the scaphoid in its base, even if it's not a complete, perfect reconstruction, you can at least stabilize the scaphoid in its base with a dorsal capsule or ligamentous repair, and then pass your tendon, such as this, in a pericatenous fashion, through the 3-4 and the 6-R portals, and then also, in the same spirit, with the volar portal, and then tie a knot on itself on the 1-2 portal on the anchor. And you will have, at the end, this type of, so you can see the two strands of the palmaris longus between your scaphoid and the radius. This is something that we are using in young patients, which is the topic today, and we have been good results for like eight to 10 years now. Two-thirds of the patients never been reoperated so far, and the rest are considered as failures and have been converted to a proximal rocarpectomy, but most of the patients are fine, and we avoided any implants fusion or bone resection. And as you can see on the X-ray, most of the time, you can recreate a small space between the radius and the scaphoid. Of course, it's not a normal X-ray, but it's always something. Moving on to stage three. Well, not many options there because, of course, PRC with capitate resurfacing is not possible. And the partial fusion of the wrist is always possible, as you know. What we lack data on is proximal rocarpectomy with some interpositions, just like tendons interposition or metrics or something, but we don't have any data yet. Substantial data. Finally, stage four. Of course, I won't pass any time on this slide because not many options. These are slides on the thumb, but we're not talking about the thumb today, so I will pass. And I will finish with this suggestion of technique that you can use also in mid-carpal. You know capitates isolated or combine arthritis. This is something that we developed recently also in Paris. As you can see, we love to put tendons everywhere. And this is technique of putting a palmaris longus between the lunate and the capitate for isolated lunocapitates arthritis, but also in case of SLAC or SNAC3 when we want to preserve any aggressive surgery. And we have only four patients with this technique so far because it was developed last year. So far, so good, but we don't have any clinical reasons to show. And I'm sorry for that, but all the people, all the patients operated were between 20 and 30 years old, and they preserved a good range of motion with no pain so far, so we'll have to see in time. So to sum up, arthroscopy can be really helpful, but as you know, the more early you are, the most efficient you will be. Fusions are possible, but really demanding, but they have the advantage of preserving the vascularization of the bone and so avoid risk of non-fusion. And there's a huge place of, in our belief, a huge place for tendon interposition, which is very relevant with the use of arthroscopy. Thank you very much. All right, well, we're a few minutes over time, but certainly wanted to thank everybody for sticking it out to the end. Certainly happy to answer any questions or have our wonderful panel answer any questions that anybody has, but hopefully everybody learned a little bit that can help with some of our patients.

treatment options

wrist arthritis

types of arthritis

PRC

four-corner fusions

total wrist arthroplasties

motion preservation

selective neurectomy

bone health

arthroscopic treatment options

minimally invasive treatment