Was that a minute? All right, let's get started. My name is Charles Goldfarb, and I'm delighted to welcome you to our wrist arthroscopy webinar, where we're going to discuss the latest and greatest in wrist arthroscopy. We have three fantastic speakers, and I'll speak about them in a little bit. Your audio will be muted during the presentations. The webinar is being recorded and you'll get an e-mail with a link to this webinar. We welcome questions, so if you submit those in the Q&A section of the Zoom, that would be fantastic and we'll try to address those either in writing or we will verbally address them and contact webinarssupport at ASSH.org with any questions. Finally, if you need CME, claim your CME, which is available next Thursday at ASSH.org. We really have a good discussion plan for us today. I'm going to start off with a brief discussion of TFCC repair in 2022, and I'll share how we're thinking about this and techniques. Sanj Kakkar from the Mayo Clinic will follow that with a discussion of arthroscopic scaphelonate ligament repair for you to think about and potentially implement. Then Jeff Yao is going to share his top tricks for arthroscopic success. I look forward to learning from Jeff. Jeff is at Stanford. Then Lauren Shapiro from UCSF will be joining us to discuss the evidence supporting wrist arthroscopy. That'll be really helpful and hopefully she will not debunk everything we talk about prior to her lecture. With that having been said, and if we have time, we certainly will try to answer any questions and have a case or two time allowing. We would like to share tips and pearls for wrist arthroscopy success, discuss the scaphelonate ligament and the TFCC in particular, and review the literature. I'm going to start this off by discussing TFCC repair in 2023. As many things in hand surgery start with the anatomy. This is an old drawing, but I believe it is really helpful to emphasize the importance of understanding the complex anatomy and the ulnar side of the wrist. There's lots of different ways to think about this. This is obviously a cadaver picture. I like these two pictures as well. Here's the dorsal side of the wrist where you can see the dorsal radiocarpal and intercarpal ligaments. You get a little bit of a sense of the ulnar side of the wrist. Then over on the right, I think it's a really helpful drawing where you see the wrist open, so you're looking axially from distal to proximal, and you see the scaphoid and lunate facets, you see the TFCC, the ulnar tracheal, ulnar lunate ligaments, and the radiocarpal ligaments as well. When I'm scoping the wrist, I'm trying to keep in mind the larger anatomical structures. This is a brand new drawing from Sanja's recent article in the Bone and Joint Journal, which is a really interesting article, which talks about even when the TFCC is structurally intact, it may be functionally incompetent. What I like about this drawing is it emphasizes what I think is super important to understand in 2023, that is relationship between the distal TFCC and the proximal TFCC. That is the proximal TFCC representing the foveal insertion, the structural support, and the distal TFCC being what you see immediately when you're performing an arthroscopy. If we're looking to make a diagnosis of a TFCC injury, that is if we have a patient with ulnar-sided wrist pain, we're trying to differentiate what's going on. First of all, the clinical exam is critical, and I'll share a few points about localizing pain and assessing for instability. The MRI can be helpful, but for me is never the be-all and end-all, and then arthroscopic assessment is really helpful, especially if you understand the subtleties there. This drawing from 2010 is very helpful. If you see the finger overlaid on the ulna, and you can see the FCU, so the fovea is just volar to the ulna styloid and just dorsal to the pisiform. Localized pain in the fovea is a strong indicator of TFCC pathology. Dorsal and dorsal ulnar pain can be helpful as well, but localization of the pain is very helpful, ruling out LT pathology, ruling out ECU pathology, and testing DREJ stability is vital. Now, DREJ stability, I would argue, is very difficult to clinically assess. Use the contralateral side as one tool, but it is not easy to figure out. Sometimes you get lucky and you have a patient who can demonstrate a positive piano key sign, which is asymmetrical. You can see that when he presses his hand into his leg, you can see the ulna shucking up and down. That's really helpful, and especially when the contralateral side is different. But you're not always so fortunate. MRI can be really helpful for central tears. It can be helpful for some peripheral tears. Arthrogram is center-dependent on whether it makes sense to order an arthrogram and how it helps you with sensitivity. I would strongly suggest that a negative MRI does not rule out a TFCC tear no matter where you are. Steroid injections can be both diagnostic and therapeutic. I should say diagnostic for intraarticular pathology, not necessarily diagnostic for TFCC pathology. Ultrasounds increasingly been looked at, but I don't think it's quite ready for prime time and diagnosis of TFCC pathology. During arthroscopy, I think there's a few tests which I'm going to show quick videos on that are helpful. The trampoline test, the hook test, the suction test, mid-carpal, arthroscopy should be performed almost every time you do a scope. Then DREJ arthroscopy or sub-TFCC arthroscopy can be helpful as well. Here is what I would call as a relatively normal trampoline test, where you can see there's good rebound, good stability, you can't really get under the TFCC, that's a hook test attempt. This is a pretty normal appearing TFCC. Then here's the next one, which is you can see this trampoline test is a little bit different. There's a little bit more play, a little bit more laxity. So not quite the same and that is not a specific test. That's not a specific finding, but it's important to recognize. Then finally, this is a positive hook test. In this situation, the probe is coming in from the 6U portal, and you can see that you can put the probe completely underneath the TFCC, which indicates a complete foveal tear. One more time. Sometimes there's subtlety to this. This is a scream in your face, positive foveal tear hook test. We looked at this with cadavers and found that it's a very sensitive test for identifying foveal pathology. When you do identify foveal pathology, repair is recommended. Sometimes foveal pathology or absent insertion can be associated with gross instability, micro instability, or even difficult to assess instability. But any of those cases, if it's associated with pain, repair makes sense. There are many different techniques to repair a foveal tear. This is a drill a hole in the ulna technique. There's lots of simple ways to do it. A nice horizontal mattress suture can provide stability and allow the TFCC to heal. One thing that I have recognized in a large number of my patients recently, is that there can be multiple different types of combined tears. The one that has been previously under-recognized, and by me at least, unrecognized, is the combination of a central tear and a foveal tear. I think this is really important because for me, I've traditionally thought of central tears as impaction-related or just age-related, and I debride those central tears and don't think much more about it. The reality is, I believe I was missing something. When these two tears coexist, I perform a foveal repair on all of them. I debride the central tear and I repair the foveal tear. You can usually drive your scope into the central tear and visualize the subsurface of the TFCC quite well. Here's an example of just that. This is a young patient, a 16-year-old, and you can see that there's a large central tear, and you can see the foveal insertion footprint, which is with complete disruption of the deeper tissue. The Etsy classification, which is now more than 10 years old, is really helpful for thinking about foveal tears. I encourage you to look at this and consider it, whether it's a combined type tear or a simple foveal tear. Let me share one quick case and then we'll move on. This is a 14-year-old right-hand dominant female with a history of an outside-in TFCC repair by me two-and-a-half years ago. There was no central tear, no other pathology, and she was doing cartwheels six months prior to seeing me and she developed pain. We casted her for six weeks. She had moderate classic ulnar-sided discomfort. Her DREJ was stable. Her EC provocative signs were negative. LT was stable. Her grip strength was decreased and secondary to persistent discomfort. We took her to the operating room after the MRI was concerning. I personally have not found, and I'd be interested in our panelists' views, I haven't found much success in MRIs in a revision setting, meaning if I've previously operated on the patient, I think the TFC can be difficult to assess. I'm going to skip these and keep going. After a discussion of options, she was taken to the operating room. Again, this was a young patient with a large central tear, and what you can see, which is interesting, there were some fibers of the foveal insertion intact. I'm going now to show you that the hook test is equivocal. Hook test is not really positive, but you can completely get underneath the TFCC through the central tear. There's a little bit of laxity dorsally and ulnarly, and the wrist is just ratty. Then here you're seeing the real laxity of the foveal insertion fibers, which is obviously not typical. In this case, I've placed two horizontal mattress sutures and had a nice solid repair of her TFCC. My takeaway message, first of all, I think it's remarkable how frequently I'm performing foveal repairs. I rarely perform peripheral repairs anymore. Almost all of my repairs are foveal repairs. Identification of these patients and these injuries requires a careful clinical examination with supplementation of MRI, understand the normal anatomy, and identify the pathology. Thank you for listening. I'm going to stop share and ask Sanj to educate us on arthroscopic scapholinate ligament repairs. Hey Chuck, while he's loading his talk up, you mentioned that you recently shifted towards more foveal repairs. Is that because your capsule repairs are not doing well or what happened to those capsule repairs that you've been doing all these years that made you make the switch? I think it's a couple of things. One, I think I am wiser and I recognize foveal pathology far more frequently. When I've had to go back and perform a secondary arthroscopy in a patient with a peripheral tear, it always looks good. But in those patients where they have new or recurrent pain, when I go back, I almost always find a foveal tear. I think I personally missed foveal tears previously and I'm identifying them currently, and I just don't find many that are indicated for a true peripheral non-foveal repair. Am I overestimating things, Jeff? I don't know. I'm just wondering how many of those patients that you treated with a peripheral capsule repair ultimately required further intervention. I still do those and for those superficial tears, and they seem to do really well and are really happy. I'm wondering if I'm missing some of those foveal tears, but I'm getting away with it, and those patients are feeling better, or if they're going to come back later, or what do you think? Yeah, I certainly don't have the answer. Maybe Sanj does before he jumps into his talk. Yeah, no, it's a good point, Chuck. I actually wholeheartedly agree with you. I think, Jeff, this was probably a diagnosis that I didn't quite recognize many years ago. I think the number of peripheral repairs that I'm doing has fallen dramatically. A lot of these are either complete foveal injuries or partial foveal injuries with micro-instability. I completely agree with Chuck. I haven't completely abandoned peripheral repairs, but it's far the minority of my cases now. Okay, Chuck, thank you so much, and my esteemed panelists and the ASSH for the privilege of talking about arthroscopy and scapholunate instability. This is not going to be a full review of scapholunate instability. There's great talks on handy about this, and this is my disclosure slide. So in terms of the objectives, I just want to go over how to diagnose scapholunate instability with arthroscopy and appreciate the spectrum of injury, but more importantly, rather than sticking the scope in and then diagnosing it and then doing an open procedure, I want to show you how you can use arthroscopy to perform your repairs. So we'll start off with a patient that is not atypical, a patient who falls and is tender over the SL with positive provocative clinical exam, equivocal MRI scan, and we'll come back to this in a second. And so typically, we get numerous imaging modalities such as radiographs or stress radiographs and MRI, and I agree with Dr. Goldfarb's comment about TFCC. I'm seeing more and more scapholunate ligament pathology where the MRI is actually normal. And so I think really for my hands, arthroscopy is the gold standard. And I think most of us are well familiar with Dr. Geisler's classification many, many years ago. This has been modified by our colleagues in Europe. Essentially, it's similar to the Geisler classification, but what I like about this EWAS classification is that it breaks down the location of the injury. Remember, this is a mid-carpal diagnosis. Is the injury dorsal? Is it vulnar? Is it completely through and through? Because I think the treatments vary based on the location of the injury. So back to this patient. So how do we do this? Dr. Goldfarb showed you wet arthroscopy. This is dry arthroscopy. You can see we've popped into the 3-4 portal. No need to insufflate the joint. And here, what we're looking at, scaphoid above us, scaphoid facet below us. And as you come, you can see there's that subtle drop between the scaphoid and the lunate, and that should be a clue that there may be a scapholunate ligament pathology. Now, I would say always, always, always make the ulna mid-carpal portal first. The reason why is because if there's a scapholunate ligament problem, the scaphoid flexes and moves more distally. And you can see in this image, in the top left, you can see how there's a big step-off between the scaphoid and the lunate. And the triquetrum is the most dorsal ulnar structure on the ulnar side of the wrist. So even in a swollen wrist, you can find the triquetrum and just go distal and radial, and you'll pop in. And so here you can see I'm using the probe, and I'm using this to look for three things. I'm looking, where's the injury? So you can see there's a big dorsal injury there. I can easily reduce the carpus, telling me that probably a repair or reconstruction will work. But also there's a volar injury as well. And the cartilage looks relatively pristine. So in my hands, this was a through and through injury requiring a repair. So in terms of the surgical factors to consider, this was a great article by Mark Garcia-Elias, nearly what 16, 17 years ago, which goes through sort of the gradation of injury from relatively minor to major. But I found it difficult in the operating room to sort of put all this together when you're actually treating a patient. So we came up with this acronym of SCARCE, and it basically goes through checkpoints that you need to look at, be that the secondary stabilizers, the cartilage, is it aligned or not in the lunate facet? Is it easily reducible? Is it an acute or chronic injury or the extent of the injury? And so you'll see three of these, be that the cartilage quality, the reducibility, and the extent of the injury we deduce with arthroscopy. And so in terms of the treatments that you can do arthroscopically, we've got the diagnosis, how can you treat these? So if we go back to the Mark Garcia-Elias type of classification, if we sort of divide this into halves, I think the first sort of three, the more, I would say, more minor or repairable SLs, how can you use arthroscopy to help you? So if we look back in the literature, Dr. Whipple, who's obviously a forefounder of modern day arthroscopy, described this where you'll have the camera in the ulna mid-carpal portal, and essentially you reduce the scaphoid to the lunate. So you can put a K wire as a joystick or use a probe and then fire multiple scapholunate K wires to cause a fibrous ankylosis. And if you look at his outcomes, those that were acute, i.e. less than three months, had pretty good results, 85% good results. Those that are chronic, you can see how effective it is, drops off with time. In terms of capsulodesis, I think this has really gained popularity thanks to the innovative work by Christophe Mathelin in Paris. And just to sort of show you a schematic of what he's trying to do, essentially what he's trying to do in this diagram here is take a needle and put it through the capsule and put it through the scapholunate remnant on the scaphoid and another needle through the capsule and the scapholunate ligament on the lunate side. And you're passing a suture, and essentially what you're doing is you're reconstructing or repairing this so-called DCSS or this dorsal capsule scapholunate ligament septum. And simply by pulling on this, where I put that red arrow, you're performing a sort of capsulodesis back down to the carpus. I had the privilege of visiting him during my Bunnell because I was interested in this technique, but I wanted to sort of better understand the technicalities of how to do this. And so this was a patient of mine who had fallen, was tender over the SL, equivocal Watson shift test, and you can see on the right side had a dynamic scapholunate ligament instability. And so here's the mid-carpal arthroscopy, and you can see the cartilage pristine, easily reducible, and there you can see the scapholunate gap. So what do you do? You then bring the camera in the, this is in the 6R portal, and you look all the way across and debris the scar tissue between the dorsal capsule and the scapholunate ligament remnants on the scaphoid and the lunate. You then put the needle in through the capsule, and once you're there, you then drop your hand and push this through the scapholunate ligament on the scaphoid, and then take another needle, come through the capsule and go through the scapholunate ligament on the lunate side and push the needles in. It's about a 45 to 60 degree angle. And then you push the needles into the mid-carpal joint. And this is what you see. And through these, and especially if you're gonna do this wet, turn the fluid off now, you put the suture through the needles. So you've got two sutures coming through these needles and you grab them through the radial mid-carpal portal and you tie a knot there. You can see that I've shown this. This is exactly how Christophe described this. And you pull onto this. And you'll see, this is that same patient. And you can see, I'm basically cranking on that probe. Essentially, it wants to bend. I'm really torquing on it. And this is a powerful repair with that one simple stitch. And if you look at his outcomes, this was a study that he published with Abhijit Wahangurkar many years ago. Only 57 patients. He's got many more since then. And you can see the garcialized staging was gauged two to four. And his outcomes were actually very impressive. 98% satisfaction rate. And that's remarkable given it's a problem that escaped a suitable repair. So let's look at this patient. This is a patient of mine, as you can see, has got a scaphelonate gap, two-year history, pain also with wrist extension. So as Chuck mentioned, with the ulnar side of the wrist, you have to take all the factors into account. And when you look at the MRI, you can see that there's some edema over the dorsal of the lunate, indicating he has a degree of impaction with wrist extension. But there's the MRI. And look at the axial views. Next time you're looking at an MRI, that really gives you the game away. And you can see as a complete through and through dorsal and vulnar injury. So here I am, I have the camera in the 6R portal and I'm debriding all that scar tissue. The shaver's coming in actually in the 2R portal, debriding the scar tissue. And then I'm dropping, oh, sorry. And I'm dropping my hand such that I can remove all that scar tissue such that when the needles come through, I can see where those needles are going. So there's a mid-carpal arthroscopy. The cartilage actually looks pretty good. I can easily reduce this. Now there's a vulnar injury that we've reduced with the MRI. And you can see, I can easily drive this through. This is like a Geisler IV vulnar and dorsal injury. So now what do you do? So I've just passed those sutures and this is the dorsal capsulodesis. And you can see as I pull on those one stitch, you can see the blood getting squeezed between the scaphoid and the lunate. And here I am, I've let the suture go and now I'm gonna pull on it. And now you can see how it's much more stable. But remember this patient had a vulnar SL tear. So what's the plan here? So this is a little trick that you can do. It's very straightforward to do. You take an 18 gauge spinal needle and you load this from the back end through the front with a 2-0 suture, such that you have two tails coming out the tip of the needle. This is a schematic here on the palmar side. And so essentially you've made a vulnar incision, the vulnar radial portal, and then you pass the needle. So the camera's in the ulnar mid-carpal portal. The needle comes through the radial mid-carpal portal, hugs the scaphoid and grabs the capsule adjacent to the scaphoid. And then you grab one limb of the suture and then you pull that needle back, staying within the radial mid-carpal portal so you don't get a suture bridge. And then you hug the lunate and push it through the vulnar capsule and then tie the suture down. So here we are in this, with these pictures, you can see in the top right, the needle has gone through the capsule on the scaphoid side. I back out the needle, stay within the radial mid-carpal portal and push it through to the lunate side. And so here's the needle being passed through the radial side. I'll simply pull the needle back, okay? And then come and drop your hand and take the capsule through the lunate side and push it through. And here I am just pulling on that one stitch and you can see how it easily reduces that step off. And here you can see, I basically let go of the suture. So you've got the big diastasis. Now I pull on the suture and you can see how it's much more stable. Remember this patient was also impacting. And so now with arthroscopy, the beauty of it is that you can see exactly where the patient's impacting. No need to take a big osteotome and take it off. You can take a shaver and a bur and look exactly where the patient is impacting. Pakodil-Panel has a nice outside to inside technique to address the vulnar SL. And Steve Moran has a mini open technique to address the vulnar SL. So what about the bigger sort of degrees of instability, the stage four, stage five, what can you do for these? So this is a technique popularized by PCHO many, many years ago, basically taking two drill holes through the scaphoid and the lunate and doing a box reconstruction for the SL. And this sort of was the basis of the SL-360. And in his patients, he can see at 17 patients with static SL, chronic, you can see 9.5 months from injury. And again, pretty good outcomes. Our colleagues in Spain, Dr. Correa, has sort of pushed the envelope here with his arthroscopic skills. And he's doing this arthroscopically, doing a dorsal and a vulnar reconstruction, not a repair. And in this article, he had 27 patients with good outcomes. Finally, I know a lot of us like to do the RASL procedure. And I think Mike Hausman has published his excellent study of 18 patients with a mean follow-up over three years. But in the technicality of when you're doing a RASL, this was a nice biomechanical study showing that when you place that screw, as we know that screw trajectory is critical, it should be proximal to the lateral aspect or the oblique dorsal ridge of the scaphoid. So I think in summary, we do know that scapholunate ligament is a spectrum of injury. And following an algorithm using arthroscopy, I think can help you. I listed some factors, there's many factors to consider, but I think with the role of arthroscopy and without doing all this soft tissue stripping, I think certainly arthroscopy has a role to play in treating these problems. I think without further ado now, I'd like to hand the reins over to Dr. Yao. Who's gonna show us some tips and tricks for arthroscopic success. Jeff. Thanks, Sanj. Can you hear me okay? Yes. Great. Can you see my slides? Yes. Awesome. All right, great talks, Chuck and Sanj. Hard acts of follow, but I'd like to share with you over the next 12 or so minutes, my top 10 tricks and tips of hand and wrist arthroscopy, which I've learned over the last decade and a half that I've been doing this. Nothing to disclose, although just one disclosure I have to put up there. Sanj, just in case you're wondering, this is the football with the oblong ball, okay? That's called rugby, Jeff. All right. So as we're all sitting here, we know that there's an increased popularity in publication wrist arthroscopy over the last several decades. You can see the explosion of number of publications and this speaks to the increased interest in the techniques that we can do arthroscopically as the technology improves. I think there's a huge laundry list of things that we can do arthroscopically in terms of therapeutic indications. But to a certain point, when you're getting to salvage procedures, such as PRC, et cetera, arthroscopically, the question is, is this a triumph of technology over reason? And so in my opinion, I think there's set indications and when I teach my trainees, I like to talk to them about how, not only just learning the procedure themselves, but also learning how to stay out of trouble. And we did a kind of a review of all the complications of wrist arthroscopy and we kind of compiled them all. And you could see that the incidence of complications is only about 5%, which is not trivial. And so obviously as these indications expand, we wanna make sure that we remain safe. And so most of the complications that we found were related to portal placement, being nerve injuries, and then also incorrect indications. So I do recommend that, obviously choose your indications carefully and I'll talk about the portal placement in a moment. So in my mind, the best indications for wrist arthroscopy are listed below. And we're talking pretty much about all of these today, except probably scaphoid non-unions, which is a whole nother talk. So here are my top 10 tips and tricks, and these are all highlighted in red. My first is the poor man's arthrogram. I like to, when we established our portals, I like to insufflate the joint with wet arthroscopy with saline. What it does is help confirm your pathology. If you inject, and we found that the radial carpal joint takes about three and a half CCs of fluid. If you inject more than that, that means there's probably some communication from the radial carpal joint into the mid carpal joint and or into the DREJ. So this can help confirm or deny your perceived indication or your perceived pathology. My next tip is create your portals carefully. As I just indicated, the number one complication is the nerve injury. So it's not like knee arthroscopy or shoulder arthroscopy, where you just plunge your knife into the joint. You want to create your portals carefully, nick the skin with the blade, and then spread, spread, spread. My fellows hear this in their sleep, in their nightmares. They hear me say spread, spread, spread, as they're creating their portals. So you spread past all those important structures. The next tip is I like to say you're like a pilot. You do your pre-flight checklist before you even start. A lot of times the trainees will get in there and they're so excited they're in the joint, they just start, you know, shotgunning and looking at everything in a ramshackle kind of manner. So you want to make sure that you check everything before you get started. Make sure your scope's white balance, focused. And if you're using inflow, get the inflow going, although you may consider dry arthroscopy, as Sanj just alluded to. My next tip is always follow the same sequence. This way you will never miss a structure. I always follow the same exact sequence with every arthroscopy, regardless of what the pathology is. I take pictures of every structure so the patients can see it. And that way you don't miss anything at all. Dorsal wrist ganglions, I think are a very good indication for wrist arthroscopy. Who wants this open incision when you can have this type of incision? I think the key to arthroscopic ganglion incision is to find the stalk and make sure you size the stalk. I tell patients it's like taking care of roots in your, or weeds in your garden. You want to take it out by its root and otherwise it will recur. And so our next tip is to, is to inject a dye into the ganglion percutaneously. While you're watching it with the scope, you could use indigo carmine or methylene blue, and it'll turn, it'll light up bright blue and that will help you visualize it. So here we start with the 6R portal with our scope in the 6R portal. I've highlighted the ganglion with the circle there. And then normally you could see here, you could clearly see the stalk. You don't even need a dye to identify that on the left-hand side of the screen. But if you have trouble identifying the stalk, you just inject percutaneously the methylene blue and you can see it lights up bright blue. And then you know that that's where it's emanating off of the ligament and that's what you want to excise. And you just simply insert your shaver and just amputate the ganglion stalk off the scapulonate ligament without injuring the ligament itself. And that's what it looks like after it's been excised. We published on this and we found that with the dye, we were able to visualize all of the stalks. We did have one recurrence and that was with an occult ganglion. So for those, I tend to favor still open excision because I want to make sure I clearly visualize it. And we had no complications in this cohort of patients. Intercarpal ligament injuries is a very good indication for arthroscopy, as you just heard very nicely from Dr. Kakar, so I won't belabor this point. But one thing you might consider is what I like to call the bubble test. Lee Osterman taught me this test where basically inject air into the mid-carpal joint and have your scope in the radiocarpal joint. And if you find bubbles going from one joint to the next, you know there's some communication from the one joint to the other. It's kind of like the poor man's arthrogram but using air instead of fluid. So that's a nice little trick. I like to base my treatment arthroscopically based on the Geisler classification as Sanj alluded to. I like to use thermal shrinkage. Thermal shrinkage is somewhat vilified in the orthopedic literature, particularly in the shoulder literature, but I do think it's very effective in the wrist. The way it works, and this is again from our sports medicine colleagues, is that the heating of the collagen causes the heat label bonds of the collagen to break, whereas the heat stable bonds are still intact. And so there's a net shrinkage of the collagen fiber. It's sort of like when you put a piece of meat on the grill, it shrinks. And then over the course of six weeks, then that collagen matures, the heat label bonds reconstitute themselves, and that restores the stability to the collagen. The reason it works in the wrist is because we can cast a wrist for six weeks after this procedure to allow that collagen to mature. In the shoulder, you can't cast a shoulder for six weeks. It will never move again, and that's why it failed miserably in the shoulder. So this is my next step using thermal shrinkage. We also showed in our lab that we feel there's a denervation effect of using the heat probe on the tissue that also helps in terms of the pain relief that we see. And so this is what it looks like before and after treatment of the Volar Scapholunate ligament here with the thermal shrinkage probe. And here with a higher grade injury, you see pinning of the scaphoid to the lunate, and then the thermal shrinkage. We published on our results with mean seven-year follow-up with Geisler stage one and three with thermal shrinkage, and you see their outcome scores are quite good. And most importantly, zero of these patients required subsequent surgery at seven years. So it's a durable treatment. It's also been shown to be effective for mid-carpal instability, and Chuck has done some good work on this as well. David Hargraves has done a lot of work on this and has shown, at least in this study, from 2014 with good follow-up, all of these patients improved in terms of dash of frequency and severity of symptoms with no complications. There was some loss of motion, but it was relatively trivial. What about TFCC tears? We heard very nicely from Dr. Goldfarb, so I won't belabor this point, but I think arthroscopy is really the state-of-the-art treatment for TFCC injuries in 2023. One thing that was mentioned, but I would like to focus more on as well, is the DREJ evaluation of TFCC foveal attachments. As Chuck alluded to, I think we really are understanding these foveal attachments much more now and are diagnosing these tears much better. And I think that DREJ arthroscopy is key, critical to really evaluate the integrity of these fibers. That's my next step. I'll skip this video. What about ulnar impaction syndrome? I think historically we know that treatment options open include the ulnar shortened osteotomy, which is a very good treatment. Don't get me wrong. I love that procedure. But arthroscopically or open, you can do a wafer procedure as well. I would submit to you that microfracture can be a good option as well for an isolated, contained osteochondral defect. This is not a new concept. It's been published upon mostly from our knee colleagues with osteochondral defects within the knee. And so this is what it would look like for an ulnar impaction patient. You can see a significant osteochondral defect. If you have a patient that may not be, may be ulnar neutral or not ready to do an ulnar shortening, you're going in there to debride a TFCC and you find this big osteochondral defect, you can debride the loose cartilage, debride the calcified cartilage and use these microfracture awls to penetrate through the subchondral plate. And once you penetrate the plate, you can see egress of the blood and mesenchymal stem cells, which will hopefully form a nice clot on your defect and over time create fibrocartilage. It's not articular cartilage, but it is a resurfacing. And that's what it would look like when it's done. And I had a opportunity to see one of our patients five years after microfracture for a different reason. And we went in and scoped and you can see five years afterwards, you can see it's not normal by any means, but it certainly looks better than the osteochondral defect the patient had previously. And this patient did very well. In fact, we published on our experience of these patients with this problem and you can see the PRWE and their dash scores did not go back to normal. So just to be clear, this is not a curative procedure, but these patients did significantly better. And most importantly, at least at minimum, sorry, mean follow-up of 32 months, none of these patients ultimately required a secondary procedure such as an ulnar shortening osteotomy. Lastly, I think lastly, I'll talk about thumb CMT arthroscopy, which is I think another great indication for arthroscopy. Arthroscopic assisted reduction of bent fractures is one of my favorite procedures to do. We get in there with the scope, you could use the 1R and 1U portals to really visualize what you're looking at. When you first get in there, you see a lot of synovitis, you'll see a hemarthrosis, you go in there and clean that up with a shaver. And then you could see clearly the base of the thumb metacarpal, you could see the fracture, and then you can easily reduce it. And while you're holding it reduced, you could use needles as the kind of soft tissue protectors and percutaneously put your pins in so that you can visualize your reduction and make sure you have a nice anatomic reduction before you put your pins in. I think it's also a good indication for treating some early stages of thumb CMT arthritis for stage one, eating stage one, I do like thermal shrinkage. And for stage two, hemitrapeziectomy can be easily done. And you can see it's very easy to get your shaver and burr into this space and just remove the distal one third of the trapezium arthroscopically. It's very easy. You remove that bone-on-bone pain generator. My final tip is if you're resecting bone, I highly recommend using a smaller shaver or a smaller burr in a larger sheath. So in this case, a 2.9 millimeter burr and a 3.5 millimeter sheath. And what happens there is that because there's more space between the burr shaft and the sleeve, it allows for much more egress of bony debris. So you avoid that issue of clogging of your burr if you're using a standard burr. So use a smaller burr inside a wider sheath. And we published on our patients who were treated arthroscopically for CMT arthritis and these patients did quite well. And ultimately there are no bridges burned. If this fails, you could always go to your favorite open procedure. So to summarize my top 10 tricks for wrist arthroscopy is the poor man's arthrogram to help confirm or deny your pathology. Create your portals carefully. Spread, spread, spread. Stay away from those nervous structures. I always tell my trainees that an arthroscopy is like a pilot. You want your pre-flight checklist. Make sure everything's up and running before you get in there and just start scoping away. I always like to follow the same sequence. So make sure that you don't miss anything. So I follow this same sequence for every single scope. I think if you're doing arthroscopic ganglion excision, try using methylene blue or indigo carmine to inject percutaneously. That'll help you visualize the stock. If you want to assess the intercarpal ligament integrity, intraoperatively, the bubble test is a nice little test to look for bubbles that are injected from one joint to the next. I think thermal shrinkage has proven to be very effective in wrist arthroscopy, not so much in the shoulder, but definitely in the wrist. It is a very strong and effective tool. Fast style with DRJ arthroscopy, they assess the foveal insertion of the TFCC. For patients with ulnar impaction syndrome, microfracture I think is a nice option, which is minimally invasive, avoids long recovery periods that you would typically see with a normal shortening osteotomy. And again, for isolated osteochondral defects. And lastly, if you're doing any bony resection, whether it's a wafer, distal scaphoid excision, or trapeziacomy, whatever it may be, try using a smaller burr and a larger sleeve so you can help prevent clogging of your shaver. So with that, I'd like to thank you for your attention and I'll turn the mic over to Dr. Shapiro from UCSF who will talk to us about the evidence behind wrist arthroscopy. Lauren? Thank you. Let me go ahead and share my slides here. Is that sharing okay? Yes. All right. So with the last about 12 minutes, we'll go ahead and round things out here by reviewing the evidence supporting wrist arthroscopy. I have no relevant disclosures. As a brief history and evolution, early cadaveric descriptions of wrist arthroscopy were reported in the early 1900s, yet wrist arthroscopy really took off in the early 90s as we've talked about before. What's notable is that the TFCC was really only fully anatomically appreciated after wrist arthroscopy became more commonplace. TFCC debridement was one of the first therapeutic operations and has since evolved such that we now have many different repair techniques. More slowly but similarly, arthroscopic treatment of SL injuries is also evolving and increasing. We'll review the literature here to figure out if this is normal evolution or technologic hype. Here's a brief agenda of where we'll go today. I don't have a lot of anatomic slides in here, but I will try to hit the highlights as they relate to treatment and outcomes of wrist arthroscopy. We know the TFCC, particularly the deep fibers, are critical for DRUJ stability. The vascular supply and healing potential also plays an essential role in the treatment of injuries. The three main arterial branches supply the TFCC, notably most prominent in the periphery of the TFCC, leaving the central portion and radial attachment relatively avascular. As this has been covered in other talks today, I'll breeze through this, but I mostly wanted to focus on the acute traumatic portion of the Palmer classification. The ATSI described another classification system of Palmer type 1b tears that helps more readily distinguish between proximal and distal tears, as well as their effect on stability. Notably, as we've talked about here, some tears don't fit neatly into our classification systems. This two-institution study group demonstrated that about 10 percent of patients had combined central disc and foveal tears, bringing to light, as we've discussed, the point that identifying one type of tear doesn't preclude the presence of another. Preoperatively, only about 24 percent of these patients had an MRI that showed findings consistent with a central and foveal tear. But in general, what does MRI typically add? Multiple studies note that MRI is helpful. These numbers are higher than that of a systematic review evaluating many studies, but the literature does tell us that MRI is useful for detection and localization of a tear, better for the former than the latter, and better for central tears over peripheral tears. An MRR for ground has a high sensitivity rate, but also yields false positives. Transitioning to treatment, there are no well-conducted studies examining isolated TFCC injuries managed entirely non-operatively. There are, however, some studies evaluating the role of conservative management for TFCC injuries in association with a distal radius fracture. For isolated TFCC tears, one retrospective chart review study demonstrated that about 57 percent of patients noted symptom resolution with conservative management alone. A cohort study looking at the natural history of TFCC tears managed non-operatively demonstrated about a 30 percent rate of complete recovery at six months and 50 percent at one year. In looking at the surgical literature, authors treat patients conservatively, typically for anywhere from two to about six or more months, with a variety of different immobilization techniques, none of which has been proven to be superior to others. The debate of, and the literature on, open versus arthroscopic treatment of TFCC injuries particularly pertains to the 1B type tear, of which a majority is written. There are only a few primarily lower-level studies that evaluate open versus arthroscopic outcomes. Notably, fewer head-to-head, and a majority are in 1B type tears, but in general, both techniques demonstrate good outcomes. In a retrospective review of about 75 patients undergoing open versus arthroscopic TFCC repair, Anderson et al. noted a small clinical difference in postoperative flexion extension as well as nerve injuries, both favoring the arthroscopic group. However, none of these were statistically significant. Wrist arthroscopy has certainly evolved from diagnostic to therapeutic, with early therapeutic wrist arthroscopy being used primarily for TFCC debridement. The early literature, a majority of which reports on outcomes of debridement, demonstrates pretty good outcomes, as we can see here. More recent, larger retrospective studies of patients undergoing debridement note about a 14% complication rate. Ulnar shortening and repeat debridement were the most common secondary operations. In this study, patients with a positive ulnar variance had a higher risk of reoperation, particularly that of it being an ulnar shortening osteotomy. We'll go into more details and literature regarding ulnar variance and the consideration of a USO later in this talk, but this study presents good numbers for counseling patients and begins the discussion of when to utilize a leveling procedure alone or as an adjunct. Given the importance of location and tear characteristics on treatment, we'll go through the literature by tear type. Starting with 1A tears, these are typically confined to the disc. There are no articles that have separated out 1A lesions individually when looking at comparative outcomes of open versus arthroscopic treatment, nor debridement or repair. While these respond well to conservative management, when they don't, given the anatomic and vascular considerations, arthroscopic debridement is the most common method of treatment described. In general, these patients do quite well with a high rate of return to work. The Palmer 1B tears are those of the periphery. A majority of the TFCC treatment literature focuses on these tears, but there's great heterogeneity and occasional discrepancies in definitions and reporting of variables, including stability, patient activity level, et cetera. Again, most patients do well after open and arthroscopic treatment of type 1B tears. There's slightly lower rates of return to work for 1B tears as compared to 1A tears. Notably, and as we'll go into in a little bit later in this talk, it's important to identify injuries to both the superficial and deep fibers, as we've discussed before, and to consider patient age and ulnar variance as well. So diving into this issue of stability, these studies by Estrella and Anderson of about 35 and 75 patients, respectively, report the outcomes of patients triggered with open and arthroscopic techniques. Although published a little bit ago, I think they make important points that stability or lack thereof can be an important cause of failure after arthroscopic repair, particularly when utilizing just a capsular repair. These studies note about a 26% unsatisfactory rate and a reoperation rate of about 27%, with the majority of each resulting from instability. I think it's difficult to know if this is related to inadequate repair or failure to diagnose true instability. The important takeaway here is that in some circumstances, peripheral TFCC repair alone may not universally address instability, and that all patients should be carefully examined for both superficial and deep foveal tears. These are also slightly older studies with inherent limitations, and notably, our knowledge of the TFCC and its impact on stability has grown. That leads us to the question of how to test stability, and we've talked about this a little bit earlier in this talk. But again, important to note, prior to arthroscopic evaluation, the DREJ should be examined under anesthesia, and compared to that of the contralateral side, arthroscopic stability testing typically involves a combination of tests, and some authors advocate for DRUJ arthroscopy for further evaluation. The sensitivity and specificity from two well-done studies are listed here, but notably, the trampoline test may be best for distal tears, as isolated foveal tears may not be readily apparent during radiocarpal joint arthroscopy. The hook test may be best for evaluating foveal tears and confirming their repair. The suction test can be helpful when a TFCC tear is scarred in, making it difficult to demonstrate a positive hook. And what about the discussion of open versus arthroscopic treatment of foveal repairs in 1B type tears? Notably, while there's more literature on this topic than others, it consists primarily of lower-level studies, making it difficult to draw strong conclusions. In summary, however, the limited literature demonstrates that both techniques provide similar and good outcomes. And what does the literature tell us about age and ulnar variance in the treatment of repairs for 1B tears? Few studies, primarily retrospective in nature, with somewhat conflicting results detail predictors of failure being age and positive ulnar variance. Although controversial, increasing ulnar positive variance has been demonstrated to be a negative prognostic factor for success in TFCC surgery. A study by Dave Rusch's group evaluated patients treated for 1B type tears in a setting of positive ulnar variance with either scope repair or an ulnar shortening osteotomy. At final follow-up, patients had similar outcomes, suggesting that 1B tears in the ulnar positive patient can be managed equivalently well with repair or ulnar shortening. Equally important to consider, however, are the patient's age and activity level, the tear chronicity, presence of instability, evidence of ulnar carpal impaction, or other degenerative injuries. Other work out of Europe evaluated a small group of patients with persistent ulnar carpal symptoms after arthroscopic repair who were treated with a USO. Although a small study with inherent limitations, these patients did well after USO. And what about arthroscopic repair type? Most critically, I think it's important to know that many exist, all with good outcomes, similar rehabilitation protocols, and no technique demonstrating clear superiority. Isolated 1C type tears are relatively uncommon. They're traditionally managed with debridement, but open and arthroscopic repair techniques have been described, particularly for UT tears. There are only a couple studies that break out tear type and detail outcomes of 1C type tears and treatment, but in general, while traditionally managed with debridement, open and arthroscopic repair techniques have been described and demonstrate satisfactory outcomes, particularly for UT tears. Palmer class 1D tears comprise partial or complete tears of the TFCC from the radius with or without a bony fragment. Traditionally, these were thought to cause instability. However, this notion has somewhat waned. Despite this, it's always good to consider, especially when associated with a distal radius fracture. To summarize for class 1D lesions, open, arthroscopic-assisted, and all arthroscopic techniques exist. Some are treated with debridement and some with repair. Those who debride often cite the lack of vascularity, while those who repair often anchor the TFCC to the radius after or in a manner that aims to promote bony bleeding and healing. And again, most patients do well, yet the outcomes are a little bit more variable here. In summary, for TFCC tears, arthroscopy affords possibly a quicker return to sport and activity with the downside of more equipment, steeper learning curve, and added cost. There are not great head-to-head randomized studies, and as such, I think it's important to choose your approach thoughtfully, understand your anatomy, patient and tear characteristics, and arthroscopic capabilities. This webinar has already discussed many of the important anatomic considerations of the SL ligament, but I think these points are notable for the purpose of this webinar. So, let's get started. So, what are the advantages of orthoscopic SL treatment? Multiple classification systems exist, some of which are scope-dependent. In general, the advantages of arthroscopic SL repair is that as it avoids that large dorsal approach, it may lead to less stiffness, potential damage to the PIN, preserves the dorsal blood supply, as well as the secondary dynamic stabilizers. And reduction. It does, however, have a steep learning curve and requires special setup. There are a growing number of studies describing arthroscopic treatment of SL injuries, many of which have been discussed today, and we'll go through a couple of these in some detail here. So, walking through these studies, this is a technique paper describing arthroscopic reconstruction for one patient with a stage three Geisler injury. PC Ho and team reported their outcomes of an arthroscopic assisted reconstruction and noted that a majority of patients were able to return to their job with some limitation in grip strength and range of motion. This group out of Spain reported on 19 patients treated more acutely with a repair and capsulodesis, noting about 80% good to excellent outcomes. Methulin and team reported on 36 patients treated with arthroscopic repair with capsulodesis in the more chronic setting, noting good postoperative range of motion and grip strength. In summary, there's great heterogeneity and type of study, technique utilized, and teracronicity. Scope and scope assisted techniques may afford improved range of motion, however, this hasn't been firmly established and further study is warranted to understand the overall benefits, particularly with regard to range of motion, preservation of the dorsal structures, and long term outcomes to evaluate the prevention of arthritic change. Thank you, and I will hand it back to Megan. Perfect. Lauren, that was fantastic. That gave you the certainly the most challenging of topics, but that was incredibly helpful and it does actually suggest there is reasonable literature, and you know it's not sports is challenging to write about as we all know, but there's reasonable literature, although there certainly is opportunity for improvement over time. We only have a couple minutes left so I thought maybe we could clarify a few points made and if the audience has questions, please put them in the Q&A and we can we can potentially answer them, but I wanted to start by asking Sanj to clarify a couple things with his arthroscopic SL treatments. First of all, Sanj, from a technical perspective, what suture are you using and what is your postoperative protocol? For a general, maybe a type one to three type tear. Yeah, so if I'm doing those capsular DCs, it's a 20 fiber stick, because one of the ends of the suture is rigid and the other one is flaccid and so when you're pushing it through it, it actually goes through the needle. Much easier doing it dry than wet. And then in terms of rehab protocol, I just honestly I keep them casted for about four to six weeks, and then I basically then start dart throwers motion and FCR strengthening and ECRB strengthening for those. It is critical Chuck, especially when you're doing the bowler SL approach, you have to make that incision, that sort of bowler FCR portal, and when you first doing it, don't be shy, and you have to find the palming change branch of the median nerve and the median nerve because it's right there and if you don't find it, you have to find it and when I tie it down, I'm out of the scope tower, and I'm basically lying the hand flat on the table with two retractors looking at it and tying the suture down because if you're pulling up, you can pull through the suture through the capsule. That's very helpful. How long have you been doing these arthroscopic capsular DCs for SL? I think for the last now three, three, four years, I think really since my banal, I tried it beforehand and then saw Christophe do it and I was a little bit dubious and skeptical to be honest and then I saw it in my eyes, big step off, he put one suture, pulled on it and it just reduced perfectly. Jeff, similar for you? Yeah, I agree. When I first saw this, probably seven or so more years ago, I said there's no way that that one suture can really do as much as, you know, these huge anchors and tendon weaves and all these things that we're doing to correct this deformity, but it's amazing. As San showed, I have similar videos where it's just completely gapped open, you pull on that one suture and it just shuts right down and it just speaks to the importance of the secondary stabilizers of the dorsal capsule, the DRC that helps stabilize the scapulonate interval. In fact, some researchers around the world are now not even worrying about the scapulonate ligament at all and just doing capsulodesis procedures or stabilizing the DRC to stabilize the dorsal proximal scaphoid so it doesn't escape dorsally. So I think we all focus on the ligament itself, but I think we all have to understand that the secondary stabilizers are equal, if not more important than the ligament itself. Lauren, I don't know if you've had a chance to do this procedure in your practice, but you certainly had a chance to do it when you were working with Jeff. Confirm for us, are you a believer? Yeah, I agree with what's already been said and I think it also further supports the argument for arthroscopic treatment because it prevents further damage to those secondary stabilizers. Yeah, it makes a lot of sense to me. I wanted to ask Jeff a question about heat shrinkage. Do you just, and I use heat shrinkage also for mid-carpal instability and occasionally for mild SLLT, do you ever use it for other treatments? You know, there used to be talk about using a laser or heat shrinkage device for different debridement techniques in wrist arthroscopy. Do you use heat shrinkage probes for that type of work? I mostly use it for synovitis. I use it for the intercarpal ligaments, as we just talked about. Often when you're debriding a central TFCC tear, you know, with a shaver, you'll still have some frayed edges and I can't say for sure that it does anything, but I do like to use the shrinkage to sort of caramelize the edges a little bit so it looks a lot cleaner. I don't think that actually does anything, although the denervation effect that I alluded to, which I think definitely contributes to some pain relief, I think there's some benefit to that as well. So, and often for the ganglia, if I arthroscopically remove a ganglia, I'll use the heat probe at the area of the dorsal scapulonate ligament where the stalk is emanating from to try to kind of close or cauterize that area. Perfect. We are at eight o'clock. I don't know if there's any other pressing questions from any of the other panelists. If not, I would like to say thank each of you very much for your awesome talks. I think it's a great deal for us to think about and wrist arthroscopy is moving full speed ahead and I think there's a lot of new progress and I look forward to more of the same. Thank you, Chuck, for organizing this. This is great. Yeah, thank you. And thanks to Megan and the ASSH. Absolutely. Thanks to all the attendees. Hopefully this is helpful and you will be receiving a link with the video, which hopefully stands the test of time. Have a good night. Great talks, everyone. Great to see you. Take care. Bye.

wrist arthroscopy

advancements

TFCC repair

scapholunate ligament repair

arthroscopic success tricks

evidence supporting wrist arthroscopy

complex anatomy

diagnosis

arthroscopic procedures

recovery time