People can wander if they want. So thanks for coming. I'm Peter Weiss. I'm at Brown. And I'm going to talk about three things today. One for thumb CMC arthroplasty, one for capitate resurfacing, and one for total wrist replacement. And I do have conflicts with the CMC system and the total wrist arthroplasty, so I get royalties for those, just know that. So first thing we'll talk about is the thumb joint replacement. And this idea kind of started when I was a fellow at Indiana, and Jim Strickland, who was the fellowship director then, he thought of using vascular Gore-Tex graft, you know, what you do fem-pop bypasses with, and he would take a segment of that, about 25 centimeters, he'd flatten it out, and then he'd roll it up like a fire hose, put a couple stitches through it, and he'd stick it in the trapezial space. And the great thing about that is it worked amazingly well. Super easy surgery, did great, no pain, patients did awesome, until they all started hitting about three years into the surgery, and then they started getting a silicone synovitis reaction because of the delamination of the PTFE that was in the graft, and they all had to be taken out. But it always struck me as a fellow, I was always impressed at how the clinical results were really good until the, you know, the shit hit the fan, so to speak. So I always remembered that, and I tried some things using shoulder dermal graft, rolling it up, and that seemed to work quite well without the reaction, but the FDA would not allow bovine collagen to be used in any ectopic location, so it was used for shoulder, it was only approved for shoulder, you couldn't use it in the hand or wrist. But eventually, a year or two ago, human allograft, dermal allograft, was approved by the FDA, and that doesn't have any restrictions on its use in location. And that's where this product kind of came out. So we, all you guys know this, there's a lot of different techniques out there, they all seem to work relatively well with the thumb joint, but all of them have some pluses and minuses, and this technique does too, and I'll tell you my experience on it, I've done about 200 of these. So this is a rolled dermal allograft, it gets rolled up like a fire hose into a solid cylinder that comes in three different sizes, and like I say, I've done just about 150 of these with about a two and a half year follow-up for the long-term ones. It's a very quick procedure, it's like doing a trapeziectomy and then just putting this in there. I do combine this with another technique, I kind of like pants over vests, so I'll go through that with you. The great thing is it doesn't require any tendon grafting, K-wires, I don't cast my patients post-operatively, I let them start taking showers at 10 days, but they do wear a splint in between exercises, and the idea of this was that you put a structure in there that's not squishy, and so it'll hold the thumb out, and then eventually this will get replaced by the body's normal fibrous tissue. So these are kind of the indications, I'll show you a video of somebody, I've done quite a few of these for D-R-U-J hemiresection arthroplasties, for D-R-U-J arthritis, and I haven't done it for Keenbox yet, I've done it for distal scaphoid pole excisions, but I'll tell you if you do, just as an aside, you do distal pole, how many of you have done distal pole excisions for S-T-T arthritis, anybody? Yeah. They all go into D-C, right, and when you look at their x-ray, they actually do pretty well. If you look at their x-ray, I have a heart attack sometimes when I see the x-ray and the capitate looks like it's going to fall off the wrist, so I put this in there to try to, I thought maybe that would make it stick, you know, in place, and it wouldn't rotate, but it turns out they still go into D-C. So it's a good spacer, but it doesn't solve the D-C problem. It's really strong, when you put it in your fingers and you try to squish it together, it won't squish. So this is a little cadaver study we did, loading the thumb joint we did intact, then with the speed spiral implant, LRTI, and suture suspension at arthroplasty and trapeziectomy, and obviously the speed spiral had near normal mechanics because it's very hard. Now, I'll tell you that it doesn't stay hard, okay? I know it squishes, it starts getting squishy over time as it gets hydrolyzed. So while it's a good structural component short term, I think even after a week or two it's already going to be softer, and, you know, it's a race between having your body make nice scar tissue and replacing it, and the thing collapsing, right? It's always that race we got to fight. So I do a suture suspension along with the speed spiral. It adds about one extra minute to the procedure, and then I have a suture suspension, arthroplasty, plus a speed spiral underneath it, and I've been very happy with that. And the idea for this is that we're trying to get better pinch strength. We all can get pretty good pain relief, pretty good patient satisfaction, but a lot of the patients, if you actually examine them, they have kind of poor pinch strength. So we're trying to make that more robust. So here's what I do. So exposed trapezium, Wagner approach. I made this custom corkscrew that you can use over and over for 10 years. It's solid metal. You put that in the trapezium, and then I don't know if any of you used a McLamory retractor to get out the trapezium. Yeah, you have? Anybody else? Freaking, one of my fellows showed this to me. He saw it at a meeting. He came back. He said, Dr. Weiss, there's this foot retractor we got to, and I, you know, I was always chopping the trapezium, takes forever, longest part of the case, frustrating as hell, and he pulls out this foot thing, and he goes, let me show you how it's done, and the bone was out in like 10 seconds. They don't all come out in 10 seconds, but this one came out in 10 seconds, and I was sold. I've never tried a McLamory retractor to get underneath the trapezium. It never cuts the FCR, and it really does speed up taking the bone out in one piece. So that's another little trick. So then you take a big suture. I use number two ortho cord because it has a very small curvature needle, and you go to the very distal FCR, and you put a stitch in, pull it out so you get the two ends are equal length, and then you put another stitch in, as distal as you can go, and you lock that stitch, pull it out. So now you have a locked double throw stitch in the distal FCR, and two strands of ortho cord suture sticking out of the wound, all right? So you can see on the right, the ortho cord is, I haven't locked it yet. I'm going to pull that suture through my loop, and then tighten it up, and you can also actually put a knot down there. So you've done your double loop. Then you can take the suture, go through the APL, the insertion, go back through the APL, can go back down to the distal FCR, put one more suture in there, and then you can tie it. Put two or three stitches, and now you've got a suture suspension right there, and two strands sticking out of the joint. So then you have these spacers, and you can see this on the trays that are at the side here, and you put the spacer in there, and you just kind of move the thumb around, and see which size works. I'll tell you that 80% of the time it's a 15, which is the mid-size, and then only in like little women is it 13, and in massive guys it's 17. And then you say to the script, you know, open the implant size 15, and then you take a K-wire, and you just drill two holes through the graft, and then they have a really cool little K-wire in the set that has a loop on it. And so you put that through, and you pull the sutures through the implant. And so now you've got this suture suspension with the two stitches sticking out, slide it through the implant, push the implant in place. You kind of want to hold it in there, so I usually have an assistant hold with a pickup, push the implant down deep, and then you tie four or five knots on top of it. And then it'll be very, very stable. I think one key, because I had one patient, uh-oh, before I get there. You can actually unroll this implant a little bit so you can find the edge. It's kind of annealed, but you can cut that edge a little bit, and you can unroll a little bit of it to stick it, if you want, between the index metacarpal base and the thumb metacarpal base if you believe that there might have an impingement there. And you can also cut a piece off in the other direction and actually stick that in the STT joint. So if you're doing an STT arthroplasty at the same time, you can do that. And I think this is really important. I had one patient have a cyst that occurred, and I think I didn't close the wound correctly. You know, I left a little hernia there. I think you should use a 4-O-Vicryl or something. Close the whole Wagner incision up front to back so it's kind of like a waterproof seal. And I think that's really solved. That was pretty early on, probably a year and a half ago. I know of a couple cases where patients have the same thing, have a cyst, and there was some graft material in there. So the thing does degrade over time, you know. But out of the 150 I've done, I've had two where I had to, one where I just took a cyst out and there was no rent, and one where there was a rent there and I just took the whole implant out, but it had done its job. The patient was three months out, just took the implant out, closed it up, didn't do anything else. Patient was fine, very happy. But I do think you should close this carefully. I wanted to say the other thing about this. The code is 25445, okay. You can use 25447, which is your standard arthroplasty code, but the RUC committee has approved this for 25445, which is an implant code, okay. And an implant code, if you happen to have an ASC that you own or your partner in or whatever, pays a very high facility fee. So it will more than cover the cost of this particular implant. And secondly, if you happen to do an STT arthroplasty at the same time, the RUC has said you can actually code 25445 for the CMC with the implant, and you can code 25447 for the STT arthroplasty, okay. But only if you do the STT resection and put something in there, okay. So that's just good information to have. This is one of the early ones I did, five-month x-ray. They subside to, I have some patients where they subside maybe another three, four millimeters off of this. So you're gonna get, no matter what technique you do, you always get a little collapse. That's life with CMCs, unless you put a prosthetic implant in there, metal or plastic implant. Other locations, here's, I like this operation a lot. I didn't used to like it, but now I do. Hemiresection arthroplasty for DA or J arthritis. I just put some sutures through the distal end of that shaft, put it through the implant, put it, pop it in there. And this is the, this is a patient three and a half months after speed spiral distal radial and joint hemiarthroplasty. And that guy came back to get his other side done too. And I've had really good results with this indication. I mean, this is, I always worried about impinging and, you know, the dera kind of click and all that stuff. I've had zero problems with this operation. I really like this. It keeps the bones nicely apart. Just to the ulna, just put two drill holes, pop a suture through, back out, put the implant in between the distal ulna that you've resected and the sigmoid notch, sew it down, close up the capsule. You know, like takes no time, 20 minute procedure. I do immobilize them. I don't allow them to do pronation supination for four weeks. So I do put them in a long arm splint. So that's a little bit of a, but I just don't want to risk, I haven't taken one out earlier. So I don't know if it would work if you do it earlier. I just don't do it. All right. So now we're going to move on to the, any questions on that? Clear as mud? All right. So now we're going to move on to the arthroplasty and the total risk system. So as you know, with SNAC and SLAC risk, which we all see a lot of, you can do proximal or compactive with that. Everybody knows how to do that. That's been around forever. Four corner fusion, another surgery that's been around forever, does have high reported complication rates, although this particular paper was where they used excised scaphoid as their only bone graft. So it wasn't really a fair, other papers have shown better results, but they're stiffer than PRCs and you do have a non-union rate associated. Capsular imposition, I think that will wear out over time. That's my personal experience, but it is a short-term solution. Capital lunate fusion, that can work extremely well. And distal radius hemiarthroplasty, I've not personally done those. I don't like the idea of cartilage on a non-conforming metal implant, personally. So, what you can do is if you have capitate arthritis, you can resurface it with this hemiarthroplasty system. And the nice thing about this is it restores the height of the wrist joint. It's highly mobile, about the same as a PRC. It's very good fixation. And the curvature of this implant, it comes in a bunch of different sizes, so you can actually match it both in the sagittal and coronal plane with the lunate fossa curvature. So it has got this little feeler template. You put it into the lunate fossa and you can tell both in coronal and sagittal plane. And then you can pick the implant based on the measurements that you get. And we do know that the arc of curvatures from Jim Calandrucio's study of the capitate is always shorter than the lunate fossa. So if you do a PRC in younger patients, it's been shown in multiple studies, under the age of 50 or 55, whatever your cutoff is, those patients, they'll do fine for a while, but they're going to wear out. And the older patients, they probably, you know, it'll wear out too, but they're not high demand and they may be really low demand by the time it wears out, so it's not a huge problem. But this is the issue. It's not really a congruent joint. And some capitates have really pointy cartilage, pointy bone, and a really high loading wear patterns. So this implant comes in, like I said, and there's six different sizes available based on the lunate fossa. So you measure both the size of the chunk, the white thing that's there, not the screw part. You measure that, there's 12 and 15 millimeters, and then there's two different curvatures, arcs of curvature in both the coronal and sagittal plane. It's very simple to do with this little jig that you have in the set. So we were talking about wrist height, quite stable. You treat this just like a PRC. You close your capsule. I tend to cast them for four weeks. I still do that. I don't know. Anybody not cast PRCs? Yeah? And that hasn't been a problem? Okay. Just one? Maybe I'll change that. I've learned a lot by noncompliant patients. I stopped doing casting for thumb CMC when I had patients who took everything off, came in and said, oh, doc, I didn't really want this thing anymore and I feel great. I was like, what? I said, okay, I'm going to stop casting them because my retarded patient actually taught me something. So this has really good screw fixation that has kind of a little porous coating to it and kind of with bonium growth. And the clever thing about this also has a little flange on it that keeps it from rotating. And so you get this very stable construct with a good articular surface. Now long term, right, it's metal on cartilage. So probably at some point down the road, it's going to wear out the lunate fossa. But there have been plenty of these that have been in eight, 10 years and have not done that yet. But there are patients who have worn out the lunate fossa. And until now, we didn't have a solution for that. Okay? But now we do. So the solution is we've designed a new total wrist implant that can also be used with a current well-fixed hemi cap. So you don't have to take out the hemi cap. You can actually leave the hemi cap in and just put in a radial component. And you get a total wrist out of it, right? So you can have a reliable total wrist system. This is designed very differently than the current wrists that were out there. The problem with the current wrists, and I did a lot of them, the freedom, I like the implant, but the radius of curvature is down into the rate, the arc of curvature is down into the radius. And eventually that makes the poly wear. So what you really want is the arc of curvature to be in the middle of the capitate where it's supposed to be. And so our lab with Trey Crisco, Scott Wolf and myself, we did a lot of studies on this biomechanics. You can go read the ORS stuff if you're interested. And we've documented how total wrists work and don't work, why they have poor motion. That's because their arc of curvature isn't correct. So Scott has a separate designed implant by a different company that, but using the same data on how this, on how it should be designed. So we flipped, the poly now is on the radial component rather than the carpal component. And you have a much freer degree of motion in the articulation between the metal distal component and the poly. And the poly comes obviously in different sizes. So you can put this in as a de novo total wrist arthroplasty, you know, where there's nothing in there. And you can also do this with a patient who has a hemicap in and they've worn out their lunate fossa. So you just go in and you just put in a radial component. And Randy Culp who kind of worked on the hemicap has done a bunch of these in patients he saved up because they were worn out but he didn't want to fuse them. And so this implant, the beauty of this is it restores the center of rotation to the capitate where it should be, gives a much better degree of freedom, and you can actually do a dart thrower's motion. My first patient who's about three, four months out now, four months, you know, he can rotate his wrist like this. And with the freedom, it was always orthogonal. They could do this and this but they could never get out of plane. And if they got out of plane or they got too much motion, they would have poly wear and you'd have to do a revision on the poly on the carpal component. So yeah, it's just a blah, blah slide. So here it comes with jigs just like you would expect. It's a fairly straightforward implantation but like every time you do one of these, the first time you should have the, you should really memorize the surgical techniques so you know the order because I was, I always have to look at it again until I've done it a lot. So I know the order of the implants and after you do it five or ten times then, you know, you just know it. And it's good to have the rep there just to remind you of the order of the implants and which one is so they can point with their laser pointer so the scrub tech knows what to grab. And you basically, you put in the radial component, put in the carpal component and then you've got a tray where you can pick the size of the polyethylene that you want to put in the tray. And so this is a metal backed polyethylene disc essentially that snaps fits into the radial component. And the beauty of that is it's been shown in the knee literature that that's the kind of poly, metal backed poly constrained that lasts. It's not sticking out and wearing out at the edges. So this is what it looks like. This guy had all kinds of trauma previously, multiple procedures and he was my first patient. Always put that index finger screw really long, go across the CMC joint and usually I try to not go across the fourth CMC with the ulnar screw. This one, it went across it. The fourth doesn't really matter quite that much. The fifth, I wouldn't want it to stick into the joint. And then the central screw, you know, might also be a tad long here into the third CMC but there's very little motion there so certainly not bothering the patient. And with a well-formed radial component and you just pick the poly that allows the correct amount of tension. What's the correct amount of tension? People, my residents and fellows always ask me, you know, I don't know what the correct amount of tension is. I mean, I shuck it around a little bit and if it doesn't, you know, pop out, that's good. And I want to make sure that they have a decent range of motion in the OR because it's always going to be worse, right, when they're three months later. So you make sure at least they get to 60, 65 degrees both ways. And then I jiggle them around a little bit in a rotating fashion, get the dart throwers in there, make sure they feel pretty stable. But wrist implants nowadays, dislocation used to be a big problem with the Menin-1, the universal one because it was really shallow. Dislocation is not really a big issue these days. It's really rare. In fact, I haven't seen one in 15 years. Carpal screw breakout and carpal component migration, that still happens and especially in longer term patients, their radius component looks good, carpal component is getting loose and the screws can kind of erode out of this index finger metacarpal and you got to do a revision going forward. But I think this will allow less stress on the distal component because the degrees of freedom of the articulating surface is much greater than the current fourth generation design. So both this implant and the Scott Wolf's implant both have the same principles about getting that extra motion. That's it. So we have some kits if you want to try to play around with this stuff. Anybody have any questions? I'm happy to answer things. Yes. Yes. So there's two ways you can do that. What I like to do is before I put in the radial component, I take a K wire and I just drill a bunch of holes on the dorsal rim, put sutures through those already, leave them out, you know, out approximately, maybe two or three and then I leave them there, put a snap on them and then I put the radial component in there whether you cement or not, do the rest of the procedure, dorsal caps or flap flips down, put those sutures through the capsule, you're fine. Just tie it down. You can also, even after you've, if you forgot, let's say you forgot because I forget sometimes, you know, I'm moving along, forget to put the sutures in. You can skivvy a needle, you know, you need a pretty decent, you know, strong needle. You can't use one of the wussy needles but you need a good needle. You can skivvy a long Lister's tubercle and come out just dorsal to the implant, right? So you're not getting a big bite of bone but you're kind of just getting a, and then, you know, you don't want to yank on it too hard, just put the capsule on. You only need it to stick, it'll stick down in probably a week, you know, so you only need it there for a short period of time and if you're going to splint them anyways for 8 to 10 days till you take out the skin sutures, it'll be stuck by then anyways. You know, I've stopped closing like I do the Berger for a PRC or a four corner or for a hemicap or whatever. I do the Berger incision, the ligament sparing incision even though it doesn't spare the ligaments but it's a really good exposure. I don't even close those. I close it on the ulnar side. I don't close the distal or the proximal flaps anymore and I think the motion gets a little bit better when you don't do that. So it all sticks down. If you forgot to do it, you know, just tack it lightly or, you know, find some soft, just kind of just to hold it in place for one week. Yeah, Lorenzo, I haven't really seen that, to be honest with you. I don't think I've ever seen an index finger metacarpal issue that I could identify as that. But theoretically, there is, you know, three degrees of freedom there, so you could get something, especially with a longer screw. These do lock in as well, so these are locking. I think you really need to have a locking screw system to keep it a rigid three-body conforming thing, especially if you don't cement it, so that you really reduce the toggle factor. I'd be more worried about the ulnar side, so I don't know what to tell you. You've got, obviously, a good experience on this, so, I mean, I just haven't seen it. Yeah? No, I think if I was going to do a total wrist, if I knew I was going to do both sides, I had PRC, I would do the wrist implant carpal kimono. And the reason is, it's a broader surface area, so I think it's really, it was designed to match the radius, all right? The hemicap is a smaller surface area, so it's more force per unit area, you know, which is theoretically going to wear out faster than if you span it over a broader area. It's probably fine, but if you're going to pick, and it doesn't matter, you've got to put a carpal thing in anyways, hemicap, or the one that's designed for it, I would take the one that decreases the stresses, right, on the surface area. Yes? I don't. I should have gotten that from Randy. Randy was supposed to be here and share this talk with me, but he bailed, so I'm stuck with it. So, he didn't send me it, but he, Stephanie, do you have any? You do? I'm trying to think how I can get that. Well, maybe you could just show it afterwards if you want to see. I mean, he sent me one, I just don't, didn't save it. He sent me one, it looked, you know, from what you could tell, it looked great, you know. It was a motocross guy. Randy is, Randy's, he's a cowboy, you know, he tries some stuff that I wouldn't try, but he put a hemicap in a kid, he was like 28 or 29, who was a motocross champion, absolutely refused any kind of fusion, you know, and he said, you know, it's going to wear out, it's going to be bad, you're young, all this, he told him all, laid all the crepe, but the kid said, no, dude, I've got to have this, you know, I can't ride my motorcycle if I can't do this, and I can't, no, four corner for me, you know, blah, blah, blah. So he put it in there, the guy rode two or three seasons and then started having wrist pain, wore out his lunate fossil like you would expect, and he just put the radial component in, and the kid's doing great. Now, if he still does motocross, I'm not going to guarantee that that total wrist is going to stay in place very long, but, you know, it was a decent salvage at least for a little while, maybe when he's done motocrossing, he'll get a wrist fusion or something or something else. Great. So just once again, how many have done a total wrist arthroplasty before? I knew you, yeah, and of the people who have not done one, do you feel comfortable enough at this point that you might try this over a wrist fusion, total wrist fusion? Yeah. I haven't done a wrist, so I designed the synthese plate that was 2735. I worked on that with Jesse Jupiter and Hill Hastings and wrote that paper in Journal of Hand Surgery in 1991. So I worked on that plate, and which is basically still used today, right, in a lot of places. I haven't done a wrist fusion in five or six years, I think, and probably not five years before that. I just do arthroplasties, and, you know, occasionally I have to revise them, but our paper in core, which was a 13-year follow-up, had a 78% survival, 78% 17-year survivorship for the wrist implants, and those were the Integra IIs. Those were not Universal IIs. Those weren't the Freedoms, which were a little bit better than the Universal II, not a ton better, but better for the DRUJ, and I think this one, just the feel. You know, when I did the first case, I could just tell, by intraoperatively, I could tell that it was just, it just moved better. It fit better. It was, I wasn't fighting the poly. It just felt different, and I think if you do one, you'll get that same sense if you've had some experience with the previous implants. All right, well, I'll stop talking. And if you want to hang around or just ask questions, come up. I'm happy to help, and we can, you can look at the stuff if you want. Thanks for coming.

surgical techniques

thumb CMC arthroplasty

capitate resurfacing

total wrist replacement

vascular Gore-Tex graft

complications

PTFE delamination