Thank you. Thank you. Okay, good morning everyone or good evening or good night wherever you are. My name is Jeffrey Yao and I wanted to welcome you to our webinar today. Just a few housekeeping announcements. Your audio will be muted during the presentations. This webinar is being recorded and will be emailed out to you as registrants. I encourage you to please use the q amp a section to submit your questions I've asked our esteemed faculty to try to address those questions, real time. And we also have discussion sessions throughout to cover any other unanswered questions so please feel free to ask as many questions as you like. And if you have any technical difficulties, please feel free to contact web support at the email address below. This program is available for CME credits and you can see all the information about that there. So today, we'd like to talk to you in two short hours about everything you need to know about the carpus in 2021. This is exciting collaboration between members of the American Society for surgery of the hand as well as the Australian hand surgery society. I'm extremely grateful and indebted to our colleagues over in Australia where it's almost midnight for their participation in this webinar in this exciting collaboration. This is the Pacific Ocean and you can see that the United States and Australia don't look very far away geographically but again, it's early morning here in the west coast of the United States but it's almost Sunday in Australia so again I thank our colleagues for sticking it out with us. As you can see, here's our, the maps of our two countries, and what I tried to do is I tried to enlist the top minds of both countries, and it's sort of from every corner of the country so we could get a comprehensive and diverse viewpoints on many of these topics that we'll be discussing today and again I'm thankful to all of our faculty for participating today. Here's our agenda, we'll start off by talking about thumb CMC arthritis, a very common and ubiquitous problem anywhere in the world, and then we'll have an update on keen box disease. We'll have a short discussion, then we'll move on to scaphoid nonunions particularly the proximal pole. Then we'll have two pre recorded talks on wrist arthroscopy. Another discussion session, and then we'll end with two great talks on carpal instability. And without further ado, I'd like to introduce our first speaker from Chicago, Jennifer Wolf will talk to talk to us about them seems to arthritis, Jennifer. Thank you, Jeff. And thanks to everybody for being here, I'm going to click so I can have control of the screen. And I will lead us off from the Midwest of the US so let's see if I can actually get this to go. So, my job today is to talk about base of thumb arthritis and how Americans view and treat this I'll be curious to hear our Australian colleagues perspective and see how it differs or see if it is the same. So, I'll start off by saying this is a really common problem, I became interested in this as a research thing that many of you may know that this is what I research because this is one of the things I just saw in my office a lot. We know that the radiographic incidence is high and it is more common in women than men with increasing incidence with age. And in the clinical terms, one of the studies that I did in Sweden, we showed nearly a four to one prevalence of women to men when you look at people who are presenting for care for this particular problem. And I think one of the things that I'm seeing and actually as I talked to colleagues, both around the world and around the country, we are seeing younger patients with pain and no radiographic changes. So, I think there is some awareness of stressing this joint, but not necessarily having degenerative change early on and people are presenting for care for that as well. So, my job is to give you the American view, so I'm going to talk about non-operative and operative treatment. And we'll start out with non-operative treatment. So, the most common thing done, splinting, and some of the controversies on this are short versus long opponent splinting. When I send a patient for a splint, I like patients to wear, I come down on the long opponent side, so a long forearm-based thumb spica, but I want them just to wear it at night. And a recent network meta-analysis showed that splint was superior to no splint or placebo for pain relief, so we have good proof that splinting helps for pain relief. The long thermoplastic splint, so I feel vindicated here, ranked highest in pain relief. The short thermoplastic splint ranked highest for function, so people could do more in it, which makes a lot of sense. And then pragmatic studies, this is David Ring's study, looked at the neoprene versus hand-based thermoplastic, and patients, no surprise there, preferred neoprene splinting. They rated it as more comfortable, although there were no differences in the quick dash pain satisfaction grip or pinch scores, so both splints did their job. And so, I end up offering patients both in reality, but I do like the hard splint for nighttime. When we speak about non-operative treatment, steroid injection almost always comes to mind. Steroid versus other injections, so I'll speak briefly about hyaluronate and PRP. Steroid is still considered the gold standard and has been since Dane Gelberman's study, which is one of the earlier studies of this prospective study of 30 patients treated with a splint and steroid injection. And in this study, they showed long-term pain relief up to 25 months in those with EDEN Stage 1 disease. And that's certainly been borne out, I think, in practice as well. People who have less severe arthritis get a lot of relief from steroid injections. It's still temporary, but it can last a long time, up to a year or more. And less or no relief in that day study with those with more advanced osteoarthritis, with many of those going on to surgery. And systematic reviews continue to show steroids are efficacious, but they are time-limited. Well, how about other injection types? So, hyaluronic acid analogous to injections for NeoA. So, a recent randomized trial comparing steroids, saline, and hyaluronate showed no differences in pain, but noted longer duration of pain relief with hyaluronate. It actually took longer to have an effect, but once it did, that pain relief lasted longer, six months versus three months on average. And this has been confirmed by more recent studies. And then patients that people have gone to actually doing platelet-rich plasma injections as well. There are a few case reports and a few case series that have showed improved pain scores up to six months. And a randomized study published pretty recently in 2018, comparing ultrasound-guided PRP to steroid injections, showed PRP had superior outcomes with quick dash, fast pain, and satisfaction at 12 months. I will probably have to answer your chat question at the end, although if somebody can read it to me, I'm happy to answer it now. But I did see it come up. The problem with the use of hyaluronate or PRP in the U.S. is that hyaluronic acid is not FDA-approved for use in the thumb CMC joint. PRP is not supported by the majority of public or private U.S. insurers for almost any injection anywhere. And so for both of these, patients have to pay out-of-pocket for treatment. And so I'll be curious to hear whether that is the same situation globally. But certainly in the U.S., we can't use it all that easily without the patient paying for it directly. All right, how about the use of ultrasound guidance for things like injections? So certainly the use of in-office ultrasound and additional billing for its use has been increasing. There is a potential advantage of increased accuracy. But this may come with an increased cost and perhaps a greater length of procedure. A study actually done by one of my colleagues at the University of Chicago looked at one of the larger insurance databases and looked at ultrasound-guided injections for base of thumb arthritis. It showed no difference in the days between first and second injections for ultrasound versus non-ultrasound groups, no change in the time to surgery after injection between groups, and the average cost difference did cost a little bit more for the use of ultrasound, 203 U.S. dollars. So not a large increase in cost, but there was a difference in cost. But I think this is something that is growing in popularity for sure. And then how about therapy in terms of non-operative treatment? So there's been a number of ways to treat base of thumb arthritis, joint protection education, adaptive equipment as shown here, and then ways to strengthen the stabilizing muscles around the trapeziometacarpal joint. So first dorsal interosseous activation studied by Julie Adams and others, adductor stretching, opponent's pollicis strengthening. And a recent randomized trial compared active strengthening to sort of standard therapy and showed no statistical differences, but the strengthening group had a small difference in pain visual analog scales and quick dash at six weeks. This was coming, this is Peter Murray's group out of the Mayo Clinic in Jacksonville. And I have to say for myself, I send, I am increasingly sending people for therapy, but in the early parts of my practice I never sent anyone for therapy. But I do recognize it has a role, and so I am working on sending people to therapy, but also I will often do is print out this randomized trial or there's a previous study that shows some of the exercises. So I think many therapists are not necessarily aware of all the things that can be done or have been described, so I want to provide them with that education if I'm going to send the patient to see them. Okay, I'm going to switch gears and talk about surgery and what's done in the U.S. I'm going to talk about arthroscopy for early treatment, soft tissue. I will talk about this, but it has certainly done more frequently here than implant arthroplasty. Has trapezioectomy alone caught on here? And then suture suspension versus suture button suspension. So our fearless leader and his partner have published a lot about trapeziometacarpal joint arthroscopy, so Yao and Park described various techniques for early thumb CMCOA treatment, including cinevectomy and debridement and hemitrapeziectomy and K-wire fixation with interposition. A recent study out of Japan reported on 29 thumbs with Eaton stage 2-3 OA with hemitrapeziectomy and ligamentoplasty. So they were passing palmaris longus through drill holes, but they were doing this arthroscopic assisted with good pain relief and decreased dash scores. And then a recent IFSSH survey study showed that U.S. surgeons have higher rates of use of arthroscopy compared to Europeans. So 37% versus 29%. So certainly people are using arthroscopy to treat early arthritis of the base of the thumb. So that is one thing that is being done in the U.S. How about something less done? So use of implants in the U.S. Multiple implants have come onto and left the market, including silicone, pyrocarbon, metal, and plastic. There are still a number on the market for sure. Krukow's Norwegian implant registry study from 2014 showed about a 10% failure rate over all implants. And so when I myself, I will tell you my bias, I don't do implants. And the reason I don't do them is when I look at that failure rate versus the approximately 4% failure rate with soft tissue arthroplasty, it's hard to argue that difference. And it's sort of been borne out in the IFSSH survey study in terms of looking at U.S. surgeons' adoption of implants. 9.5%, so just about 10% of people who reported their results compared to Europeans at 33%. So it is not caught on as much here. Here's a recent one that's come out on the market. So this is a pyrocarbon, and this is shaped like a trapezium. So there are certainly a number of implants out there. But not a huge adoption rate in the U.S. How about trapeziectomy versus trapeziectomy plus in the U.S.? So in 2012, I did an ASSH survey study. We got about a 33% response rate of ASSH active members. And at that time, with Tim Davis' studies, Roy Mill's studies, which had been published in that time period, only 8% of the survey respondents performed trapeziectomy only. Kevin Chung did a Medicare sample study, you know, about six years later, and showed that use of trapeziectomy and LRTI utilization actually increased from 84% to 90% over a nine-year period. And simple trapeziectomy at that time was performed only by 5% of U.S. surgeons. So at least in 2018, the needle really hadn't moved a lot, maybe gone down a little bit. So not a huge adoption in terms of doing trapeziectomy on its own in the U.S. And what's the evidence show? So when you look at why we should or should not be doing trapeziectomy, only a Cochrane review of 11 studies, 670 participants in 2015, showed that trapeziectomy alone had lower complication rates compared to LRTI, no differences in pain or function. When people talked about subsidence, LRTI resulted in 0.1 millimeter less subsidence than trapeziectomy alone, so certainly not a huge difference there. And then a systematic review published just this year of trapeziectomy versus LRTI combines 656 cases, so probably a lot of overlap with this Cochrane review. Seven randomized controlled trials, one controlled trial. Grip and tip pinch was statistically greater in the LRTI group compared to trapeziectomy alone. Significantly higher complication rate, however, at three months in the trapeziectomy and LRTI group, although actually those differences went away at six months and a year, so no differences in the pain visual analog scales, dash key pinch, or overall complications in a year. So this is showing not a heck of a lot of difference there, but the complication rate seems to be the one thing that's different and common to both of these studies. Okay, how about other things people are doing? So Jeanne Del Signore and others have reported simple imbrication of the APL and FCR. This is from her paper. So with nonabsorbable suture forming a sort of hammock to do the suspension, and she reported on 90 surgical procedures with a mean of nearly 12.6 years follow-up. Improved grip, key pinch, and low quick dash score, so they felt people did pretty well with this. And then the other way to do this, suture suspension with a button, so using a implant and putting drill holes through, and suture button suspension plasty. A comparative study with and without implant showed greater preservation of the trapezial space with the implant. No differences in pain, grip, and functional scores. And Jeff Yao and colleagues have also reported five-year follow-up in 14 patients with decreased dash, improved pain, and pinch and grip greater than the nonoperative side. So certainly good results from using suture button or suture suspension techniques. So some alternative ways to do this. If people haven't necessarily just adopted doing trapeziactomy only, they are often doing this as opposed to doing ligament reconstruction and tendon interposition. How about arthrodesis? Is this the forgotten procedure? It is less commonly performed in the U.S. When you look at our survey studies and others, people weren't doing a lot of this. It is recommended in young laborers or the hypermobile. And comparative studies have shown equivalent functional outcomes but higher rates of nonunion and revision, including studies out of Wash U and out of Mayo Clinic. From Mulin's study in 2014 was a randomized trial that they terminated early because of the complication rates of nonunion and hardware failure requiring further surgery. And then, you know, I'm supposed to be presenting the American perspective. Well, you know, that includes North America, includes Canada. So autologous fat transplantation, described actually in Germany and first reported in 2014, but it has been adopted by a number of plastic surgeons in Canada, including Heather Baltzer, by injecting autologous fat taken by liposuction into the trapeziometacarpal joint. This is thought to be anti-inflammatory and chondroprotective. The cost reported on 99 joints, treated with 1 to 2 ml of liposuction fat, with a year outcomes of decreased pain and improved Michigan outcome scores. And Heather Baltzer has presented on this topic as well, with improved pain, grip, pinch, and functional outcomes, although has not yet published on this. So I'm presenting the both European and Canadian perspectives as well here. But I think this is something we may see more of in the future. So in summary, what are American surgeons doing? Splinting and steroids for sure. Therapy, its use is not necessarily widespread, but efficacy, I think, is certainly growing. But we just need to publish more on this, I think. For surgery, at this point, in the U.S., trapeziectomy and LRT are the most commonly performed procedure. But I do think, and the studies would bear out, suture suspension plus or minus implant suspension is growing popularity, and implants are not widely used. So thanks so much, and I will look forward to hearing the Australian perspective on this. Thanks so much, Jennifer. What a great comprehensive review. Okay, so for our Australian perspective, I'd like to invite my good friend Jason Harvey from Melbourne to give his thoughts. Jason. Thanks, Jeff, and thanks, Jennifer, for presenting a comprehensive review of all of the literature, which means I don't have to do it, which is excellent. So in Australia, look, the demographics are very similar, very common. But what do we do is we teach our trainees that we should do the non-operative things first. As with all arthritic problems, we really go through these fairly extensively, and we use an acronym called LPOPI, which is we educate the patient on their condition, because a lot of the time the patient just really needs to know what's going on, why they're getting pain and what their problem is, rather than just going straight to the operating theatre. The L stands for Lifestyle Modifications, so being able to be aware that, you know, changing the way you do things, using those modifications that Jennifer spoke about to try and avoid the need for surgery. And then P is for Physio or Hand Therapy, O for Orthosis for long opponents or short opponents. I tend to prefer short opponents because I think the patients wear them. I find my patients don't really like wearing long opponents, mainly because it's relatively uncomfortable when they're trying to do their daily activities, but I like the idea of wearing it just at night. And then P is for Pharmaceuticals and very much just the non-opioid pharmaceuticals, so Acetaminophen for my North American colleagues and paracetamol here in Australia, and then just the simple anti-inflammatories. And then injections, I tend to use steroid injections and I think it's a good way to get the patient's trust to offer them a steroid injection, rather than just going straight to the operating theatre. I feel like the patients, you garner their trust by giving them an injection first, rather than just saying, okay, I'm going to book you for surgery straight away. Having said that, the patient with the complete bone-on-bone articulation where it's no joint space at all, I think that the utility of a steroid in that setting is pretty low. I don't have any great experience with PRP or hyaluronic acid. In terms of remuneration for those for the patient, the health insurers here don't cover them, but the injection part of the injection is covered to some extent, but the actual material itself is not covered. It's covered for knees, but not for, that's for the hyaluronic acid, but not for the PRP. So then what about the, if the patient fails their non-operative measures, then the next step is surgery, and we teach trainees that trapeziactomy is the way to go. And the main thing, one of the reasons for that is that they have to describe the operation in their exam, and it's a lot easier for them to describe a trapeziectomy than it is to describe an LRTI or a suspension plasty, as it's often called here. And that's really for the plus or minus a hemitrapezoid ectomy, obviously, for those patients with their pan-trapezial disease and the significant scapho-trapezoid disease, and then addressing the MCP joint hyperextension. And that varies from a simple pinning, if there's mild extension to a volar capsular adhesis to an arthrodesis, if there's significant degenerative change in that MCP joint. And then the arthrodesis for the young and high and heavy demand patient, and also in the ligamentously lax. And again, I would agree that the main issue with that is the relatively high complication rate. And there was a recent study on that, looking at that in the Asia Pacific Journal of Hand Surgery that showed a significant up to 33% complication rate associated with that procedure. But I think it's an important one for particularly for those heavy manual labourers to consider that an operation for them. So what do we actually do? Well, you know, there's many implants and the pyrocarbon implants became pretty popular for a period of time. One on the left there is a called a pyrodisc, and that uses a strip of the FCR tendon that goes through the centre of that implant to anchor it to both the trapezium and to the base of the metacarpal. And then the pyrocardane, which is on the right side, which is a minimal resection of the beaks of the trapezium. They certainly went through a pretty popular period, but more recently due to relatively high failure rates have sort of gone out of favour in the more recent times. As noted, the CMC joint fusion, that was the Journal of Hand Surgery, the Asia Pacific this year, showed a pretty high complication rate associated with fusions, but I certainly think it has a place for those young patients. And then there's the suspension plasty. Now, I find it interesting that given the Cochrane reviews and most of the literature suggests that we don't need to do any of these fancy ligament reconstructions and tendon impositions, it's interesting that we still do so many of them, and the variations using FCR, APL, ECRL or B. And I don't think it's for any nefarious reasons. Certainly in Australia, there's no difference in reimbursement from using a simple trapeziectomy versus doing a ligament reconstruction and tendon imposition, it's the same. So I think it's a belief by the hand surgeons here in Australia that they get better results with the ligament reconstruction. So I also like the idea of the suture suspension. This was the article that Jennifer was alluding to in hers and using a, basically creating a hammock underneath the base of the first metacarpal. The nice thing about this is it doesn't use any implants, it's pretty quick, it saves the need for harvesting any tendons, and it's an in and out fairly quick procedure. So I don't do any of those things, really, I do something a little bit different. So I do a hybrid suspension using partly the suture suspension, but I also use an FCR tenodesis, and I use this mostly for my grade four arthritic changes, so pan-trapezial disease, where I'll take just a short strip of the FCR tendon through that dorsal radial incision, and then I, through a drill hole in the base of the metacarpal, I take that past that tendon and fix that with a biotenodesis screw. And I think that that prevents particularly the recurrent subluxation of the base of the metacarpal and just holds it in position well. And then I augment that with a suture suspension as described in Del Signore's study. So post-op, I find for them, for me, I put them in a splint at two weeks, and I move early. So my mantra, I guess, is that I want to move everybody as early as I possibly can. So I put them just in a soft dressing, just a relatively bulky dressing in the theater, and then at two weeks' time, I change them to this short opponents-type splint and begin active range of motion almost immediately, so coming out of the splint to move. And generally, they stay in a splint for one orthopedic unit of time, or six weeks, and then for the next orthopedic unit of time, they start some gentle strengthening work. So at three months, I hopefully have them out of splints completely and back to doing their activities of daily living. So I've now got over 100 of that using that method, and this is one on the right. And the average pre-dash was around 72, and at six months post-op was 32. And after three months, I had a lot of trouble getting people to come back, and I don't know whether that's because they were bad and they've gone to somebody else, or they've done really well and they've just don't feel like they need to come back. So the other thing that I am excited by is CMC arthroscopy. I'm a pretty keen and avid arthroscopist, and CMC arthroscopy, first described in 96 by Menon, I perform quite a lot of. The first thing I'd note about it is that you get surprisingly good visualization of the joint. You think that, oh, I'm not going to be able to see very much, but you actually get an excellent view. And the great thing about CMC arthroscopy in the arthritic patient is it doesn't matter if you ding the bone and cause gouges in the cartilage because you're going to chop it out. So I use a relatively large scope. I do use a two and a half mil scope to do this. And I particularly like this in my younger patients with arthritic change. So you can see on this view, there's quite significant sinusitis and peritreeftic capsule. And so I use this in younger patients who are relatively high demand and up to grade three CMC arthritis. And I like to perform a hemitrapeziac me rather than a complete trapeziac to me. My reasoning for that is in these young patients in particular, it gives me a backup plan. So down the track, if 15, 20 years from now that they need something else after I've retired, then you have the option of performing a suspension plasty. And that's particularly so because a revision suspension plasty in the literature has shown relatively poor results and it's difficult to achieve the outcomes you get initially from a simple suspension plasty. So it's pretty standard equipment. I tend to use a spider arm traction tower, but it's just a simple traction on the thumb, two and a half millimeter scope, a shaver and a burr. I tend to use a large burr, a four millimeter burr. And the reason for that is because it goes faster. So you can do the operation more quickly. And it's also, it's about the amount of bone that I resect is about four millimeters. So I can use that as a pretty good guide, the width of the shaver as to how much I need to take. And also an image intensifier. So I start off my scope dry. So I tend to do it dry. And then after I've done a sign of vectomy, I get the burr out and burr away. Let's see if I can get that to go. That's just an example of the burr there. And so when you do a pass, it gives a pretty good view. And I use the water once you start using the burr. And the main reason to do that, as I found out from experience, is that if you don't use water when you use the burr, number one, it clogs. And number two, it gets very hot. And I've managed to melt the burr to the shaver handle, which was maybe not very popular in the operating theater. The main issue with, you've got a burr from both portals and make sure you get the, particularly the pommel osteophyte, the osteophyte that's up between the first and second metacarpal. And sometimes you need to use an accessory portal to be able to get that. And then I use a thermal probe to basically ring back around the joint. And I think this is important for pain relief. I think you effectively perform a denervation by going all the way around the joint with a thermal probe. And it helps to just create some extra stability at the base of the thumb. Then I remove all the debris. And this is what it looks like once you've resected a good portion of it. Now this is still in traction, so it's further out to length. And then once I've done that, then I let the traction off and see how much of a gap there is. And then I suspend the thumb using a mini tightrope. And this is the appearance of how it looks once you've got the mini tightrope on there. The main concerns is to, you don't want to over-tighten the tightrope because if you tighten it up too much, you narrow the first web space and you cause difficulty in getting the hand flat on a surface. And then also difficulty in range of motion, particularly getting over towards the lesser digits. And then, as I said, you've got to tension it. And I know Geoff's talked quite a bit about this in some of his videos and talks in terms of being able to get the Shenton's line of the thumb to keep the thumb in the correct position to allow it to be positioned adequately. And again, I moved them early. I put them in a soft dressing immediately post-op. I see them at two weeks, change them to a thermoplastic splint and begin immediate active range of motion. I think with the tightrope device, you get immediate stability. And so therefore that allows you to move things early. So this is just some pictures of a patient at six weeks post-op. And just a quick video. So this is a three months post-op. Most scars in the hand, the suspension plasty are pretty small anyway. But at three months, I think this is a pretty encouraging early result given that suspension plasty I find generally take around six months at least to fully recover. So again, I've followed these a little bit with pre and post-operatively trying to follow them prospectively. I've done just over 70 of these. And again, their pre and post-op dash scores have decreased. I haven't done a statistical analysis on it, but I've been pretty happy following them along. And I've got results out to around five years and I have to go back and look at them all. But overall, I'm pretty happy with how they come along. So in conclusion, I think that CMC arthroscopic resection is a promising thing. The literature has shown that they've got seven-year follow-up of 18 thumbs by Osterman et al. It showed no revisions and good outcomes. I think Scott Edwards has also done some work on hemitrapeziectomies and had excellent outcomes. And then there's been a more recent study on 125 thumbs doing a complete trapeziectomy with again, good early results. I think it's another option and now I'm an armamentarium, so I do use fusions occasionally. I think a trapeziectomy alone works, but I have some reservations about not having some sort of suspension to go with it. There are the devotees of pyrocarbon, although I'm no longer one of them. I have tried them, but no longer do them. And then there's the so-called hematoma distraction arthroplasty, which may have made the simple trapeziectomy very popular. Thank you. All right. Thanks, Jason. Really appreciate that. Again, appreciate you being out here so late in the night over there. We're running a little bit behind. So what I'd like to do for the discussions very quickly, two minutes, Jennifer and Jason, what are your thoughts about, Megan, can you give me control? Revisions. Jason briefly mentioned it. Let's say you have a patient one year after LRTI, what to do? Two minutes, Jennifer. Sure. So I go to other tendon suspension options like the ECRL as described by Bill Kleinman or others. I have done a couple of the other thing that actually is useful. I sort of throw the kitchen sink at this. I will use suture anchors. I will use the suture button implant. So sometimes I'll put a lot of things in here and I will also pin them when I do a revision because I need to hold them out to length and I probably need to hold them out to length for longer to get this to work. Warren Hamertz discussed fusing these two joints and that's a revision, revision option for me. But I have not done that as a primary revision I think. Great. Thanks, Jason. How about you? Yeah. So if somebody fails an LRTI, then to me that they're obviously more mobile than I'd like them to be. And so I tend to use something non-biologic. So I go to a suture button fixation in the revision, revision. I actually recently did one who'd had a few things thrown at it over time. And I eventually did a first to second metacarpal base fusion procedure, which is sometimes done in CP kids. And I did that as my salvage, salvage operation. But yeah, I'd go to something non-biologic if they have this much proximal migration and particularly at one year, that's a lot of proximal migration that quickly. Great. Thanks. And in fact, that's what I did is suture button suspension. Mark Richard, who's on the call has done some work on that as well. Okay. So we'll go to, we'll just skip to our next talk, Dr. Bain. It's an honor to have him here as well from Adelaide. He'll be, whoops, did we, oh, that's right. He's going to be sharing his own slides. He'll be updating us on how to treat Keenbox. Greg, thank you again. All right. Thanks very much, Jeff. And thank you for putting together this symposium. This is an update on a way to classify Keenbox disease. So I don't think I have any conflicts that are relevant to this presentation. So with regard to classification of Keenbox disease, there are a number that have been described. David Lichtman's is very well known. I described an articular based classification based on arthroscopy and Rhona Schmidt did a, provided a vascular classification. David Lichtman and I put together this book on Keenbox disease and we tried to bring together all the concepts from the many authors who were involved and tried to get a better understanding of some of the issues. And we've created a new concept with regard to Keenbox disease, not just of the lunate, but also of the risk. So this is considering the lunate and the whole risk with regard to assessment. So this is the, what we refer to as the Lichtman-Bain algorithm. It's the A, B, C. We know that age is important for any form of avarice necrosis. Those patients that are less than 20 have a good prognosis. Those patients older than 70 often will have poor changes on x-rays, advanced changes in x-rays, but in fact often aren't so sore. So this entire group is usually managed non-operatively as long as possible. We then go on to the B. So B is the bone of the lunate. So if the lunate is intact, so what we try and do if there's a reasonably normal lunate, we try and unload the lunate and protect it. If the lunate is compromised, then we may consider doing other things such as a multimodal approach where we protect the lunate and maybe even consider vascularization. Once the lunate becomes very fragmented, we're then looking at other options such as motion preserving procedures, such as a proximal rocarpectomy or a scaphocapitate fusion. So I'd like to now go back into a bit more detail about those concepts. So for all of us in our own practices, we need to look at what our skill set is, and I think pretty well most surgeons who are doing hand surgery can do arthroscopy, do an osteotomy, and most people could do a vascularized pedicle graft, proximal rocarpectomy and a limited wrist fusion. However, some of the more complex and advanced things such as arthroscopic limited wrist fusions, internal fixation of the fragmented lunate, free tissue transfer or implant arthroplasty of the fragmented lunate. These are more complex advanced techniques and what the approach particularly for this sort of symposium, which is aimed at the general orthopedic surgeon, general hand surgeon specialist units and complex complicated reconstructions. I really think that's not part of this presentation, but really there are surgeons who have these skills that have a place for these techniques. So we like the concept of the stoplight, and so I'm going to talk mainly about those which are the green ones, which I think that every surgeon can adopt in their practice. So preoperative assessment, all patients would be offered a non-operative approach including immobilization with a splint and avoiding activities and maybe some analgesics and anti-inflammatories. We would do plain x-rays on all patients, and in my practice I do a CT scan on all cases, and more recently we've been using the 4D CT scan to try and get a better understanding of some of the kinematic issues that are associated with the Keenbox disease. Many surgeons would use an MRI scan to try and get a better understanding of the articular cartilage and the degenerative changes, and I think those that have a real interest in vascularized bone grafts, and I think you should be having an understanding of Rainer Schmidt's work, and he uses an MRI scan with intravenous gadolinium to see if there's an increased perfusion of this area. This is important to get a better understanding of the vascularity of the fragments. In my practice I would tend to do an arthroscopy on most cases, and in this particular lunate facet we can see there's clefting, it's irregular, and there's exposed bone. So we would refer to this as a non-functional articular surface versus a normal surface, which would be smooth and glistening. So we would be trying to aim towards reconstructing these sort of surfaces based on this classification from 2006. So going on now to the different concepts of different groups. So the A is for age. So if they're younger than 15 or younger than 20 or older than 70, we would be trying non-operative modalities first, at least for six months because they have a good prognosis. But if this patient continues to have ongoing pain, then epiphysodesis may be an option for this particular patient. ST joint pinning has also been described to be able to immobilize the radial side of the wrist. Now we go on to B, which is the lunate bone. And so there's three different variations of this. Either the lunate's intact, in which case we protect it because it's a good lunate. It's either compromised, in which case we look at considering a reconstruction. Or it's not reconstructible, then really we should be looking at performing a salvage. So we're trying to get an understanding of what the lunate looks like with that. And we would use the CT scan and often arthroscopy with regard to these assessments. So first of all, going on when the B, the lunate bone, is intact, and we would look at unloading the lunate. So if the lunate, if there's a negative ulnar variance, then we would consider doing a radial shortening osteotomy. This would be a standard procedure in many surgeons' hands. Or if there was a neutral ulnar variance, then we would consider doing a capitate shortening, or some surgeons may consider an STT joint pinning. Some of our Japanese colleagues have highlighted the importance of straightening up the inclination of the radius. And I think that is of value in some of those cases where there's a marked inclination. We're moving more towards these minimally invasive techniques and trying to really cut back the insult of keen box disease reconstructive surgery. So we're tending to use this type of oblique osteotomy, often with an oscillating sore, or in fact using these routers, which are used by the foot and ankle surgeons now, using a cannulated screw. And we can see at one week, this patient really has very little swelling, and there's a small incision over the radial styloid. And they've had an arthroscopy as well. So this is the sort of area that we're trying to go to more often now. With the capitate shortening, this is actually similar to the concepts that we know with regard to distal internal fixation with a scaphoid. So we take off this little wedge, we put a wire down the line of the capitate. You need fluoroscopy, of course, to be able to do this. We use a narrow reamer, and the same as we do for the radius. It's important to have these reasonably distal, so that we maintain a vascularity of the proximal aspect of the capitate. And then we put a cannulated screw down to provide compression. We've been happy with the limited number of cases we've done this. And again, it's a procedure that only needs a splint, because the periosteum has not been violated. So we go on now to a more complex case, and we can see at arthroscopy, with traction, the whole subcondal bone plate is floating, which demonstrates that there's collapse of the subcondal bone plate. This is a different case, but we can see the lunate has been taken out as part of a proximal rotocarpectomy. And I put this in here just to try and get some understanding of the sort of issues of managing this case. So we've got all this reabsorbed bone here, we've got an obvious fracture with fibrosis, but the articular cartilage doesn't look too bad. So if this is in good condition, the cartilage, then I think there is a place for this. But it does highlight the difficulty of being able to stabilize this lunate. There are many techniques of vascularized bone grafts described in the literature, some by the Mayo Clinic and some by many other groups. I'm not going to go through all of those by any means, but the HORRI technique is the simplest one that's described. And a dorsal burr is used on the lunate, and a vessel is harvested and that's placed into the body of the lunate with some cancellous graft. So going on from there, so in this particular case, if we're looking at doing that, we need to protect this lunate because we know it's very soft and we're putting another perforation in and we're increasing the vascularity. So I think an unloading procedure needs to be included. I think we need to consider adding a K wire or something at the level of the joint to be able to provide unloading of the central column. And then we need to consider that this is really like a multi-modal approach. So the concept of multi-modal approach is not new. It's used in rheumatoid arthritis, tuberculosis and cancer. So the idea of hitting the disease in a number of areas, I think makes some sense in this group. So going on when the carpus is compromised, clearly this is a more difficult situation where the lunate is very fragmented and there may be carpal collapse. I think the role of a proximal ocarpectomy certainly in our hands where the articulations are intact and in the lower demand patients do well. In the higher demand patients, then I think the role of a scapho-capitate fusion can be considered. So the scapho-capitate fusion allows the scaphoid to be extended and the loads taken through the radial column and the central column tends to be unloaded. Arthroscopic proximal ocarpectomies are a little bit more of a complex situation. And there are some authors around the world who I think have excellent experience in this technique. And I'd recommend you consider looking up some of their work. We have a whole symposium led by IWAS on advanced arthroscopic techniques, which may be of interest to you. And finally, just with regard to the 40 CT scan, we've had quite a degree of interest in this recently and published some work on it that might be of interest to you. And there's a whole symposium where I'll be presenting some of this with David Lickman on controversies over AVAS necrosis. So in summary, the age is important and the younger and older patients can often be managed non-operatively. If the lunate's intact, let's unload it and protect it. If it's compromised, maybe a multimodal approach. And finally, if the carpus is compromised, then we need to be looking at a motion preserving procedure. Thank you very much, Jeff. Great. As always, an outstanding talk. Thank you so much. We'll move on to the scapegoat now as we're getting that prepared. Greg, just a quick question. What are your thoughts on the metaphyseal decompression as described by our South American colleagues? Do you have any experience? So we haven't been doing that, but that's one reason it gave us more confidence to go to this single cut osteotomy. So if I did just put a burr hole into the radius, some people might think that was a bit of a sham procedure. If I do the radial osteotomy and shorten it by a millimetre or two, then I think that sort of would be, it adds the advantage of the osteotomy and unloading, plus also the advantages of increased local regional perfusion that's achieved with that other procedure. Thanks, Greg. Yeah, I'll have to say I was a late adopter as well. I was a little bit pessimistic, but I've done it a few times now with surprisingly outstanding results. So just something for our learners to consider as well. Okay, so next we'll move on to the scaphoid, particularly the scaphoid proximal pull nonunion. Great pleasure and honour to have Randy Bindra from the Gold Coast of Australia to help start us off. Randy, is vascularized bone grafting the only way? You'll find out, Jeff, in the next 10 minutes. Thank you. Thank you for the invitation. Good morning to everybody all over the States. Now, we know that the scaphoid can fail to heal largely because some patients present late or the fracture may be displaced or unstable. Or as you can see from this vascularity study by one of my mentors, that if you have a proximal pole fracture that interrupts the circulation of the proximal pole, the vascularity or lack thereof can delay or impair healing in these cases. Now, the treatment goal with any fracture, and in fact, with the scaphoid is you need some secure fixation. You want to promote osteogenesis whenever possible in a nonunion situation. And if you can add vascularity, if you want to give it your best shot as your first shot, I implore consider doing a vascularized graft. Now, the thing with vascularized grafts, we know from canine studies, particularly in the carpus from the Mayo Clinic, that when you have a vascularized graft, it's superior biology. So you bring in living cells that can start to heal right away. You do not have that initial period of osteopenia that you would normally have with a non-vascularized graft. And certainly the incorporation is faster. So you're bringing in blood supply and you're speeding up the process. So it's hard to deny. Now, one of the things is very handy if you want to assess vascularity of the scaphoid is to remember that without contrast, you can't tell for sure if that proximal pole is avascular or not. As you can see in this case, this is simply bone marrow edema where it lights up after contrast. But in this patient, that proximal pole is avascular and fails. On the right hand side there, you can see it fails to vascularize or fails to light up post contrast injection. Now, vascularized graft is not a new concept. I think it started off initially with Roy Camille talking about taking the scaphoid tubercle with the muscular attachments to it, soft tissue attachments and plugging it into the non-union. And then the Hori graft was popularized and subsequently the pronator quadratus pedicle. This was something we did when I was a trainee, where we would take a piece of the pronator quadratus with the distal radius and stick that into it. And then the Kuhlman described using the Pisiform. But it became more popular after we understood the radius vascular anatomy in more detail. And in the last decade, several different techniques have come up. And I will largely talk about Dean's technique, which is much easier to apply. Now, when you look at one of the most popular ones that Zydenberg popularized, which essentially is the 1,2-supraretinocular vessel, as you can see in this vascular injection done by Amit Gupta, it's a branch of the radial artery and it sits right on the surface of the extensor retinaculum between the first and second compartments. And the secret when you take these grafts is you want to take a thick pedicle right down to the periosteum. So you take a thick pedicle so it's stout, you won't disrupt it, and keep it as wide as possible. And once you've exposed it, so here you can kind of see the pedicle has been raised. There is the hole and the defect in the radius. Here's the plug of bone graft. Now we're going to pass it beneath the radial wrist extensors and then into the scaphoid defect and then provide the fixation, which in this case was just K wires. Now that can be technically a bit more challenging. So a more easier technique that does not require any microsurgical skills is the one that Dean Soterianos has written about. So this is on the floor of the fourth compartment. So this is basically the terminal branch of the posterior introsteus artery. And the secret here is you take a strip of capsule, extend it down onto the distal radius. So there is no need to identify or look at the pedicle. Simply take a thick strip of capsule. And the beauty of this procedure is that the capsular exposure then provides you the exposure you need to fix your scaphoid nonunion. So here is a patient with a scaphoid proximal pole nonunion and avascularity. This has been out for 18 months and you can see it's quite sclerotic. So it's a dorsal approach. The thumb is to your left, to the left of the screen. And you can see this is the piece of radius that's being harvested along with a strip of the dorsal wrist capsule in the floor of the fourth compartment. Now we've got the graft harvested and now we're cutting a slot in the scaphoid with a burr right at the site of the nonunion. I will preliminary fix with a scaphoid screw, volar, and I'll make my slot a bit dorsal so that I don't lose control of the two fragments. I won't fully compress the screw but the screw will be pre-positioned three quarters the way through in a more volar aspect. So here's my slot. Now I'm packing it in with cancellous bone first, packing all the cysts and the defects, and then I go to inset this capsular flap-based plug of bone and then finally wedge that into the defect and then tighten that screw and get a secure fixation. You can also put a supplementary anchor and tie the anchor across and over that bone if you need to hold it in place if tightening the screw does not work. So this is what it should finally look like and then you can get a CT scan and an average about between three months to four months you can confirm bony healing in these cases. Now for those who are not faint-hearted you can do this technique where the proximal pole has completely collapsed, unsalvageable, and one can consider using a femoral graft using a part of the cartilage. So this has been shared to me by James Higgins. So this is a medial femoral trochlear graft where instead of the condyle you take the edge of the trochlear with the articular cartilage. So here you can see nice big vessels and then there is the graft. Now in these cases the graft is slightly overstuffed because a large part of the scapulonid ligament is removed. The overstuffed graft is then fixated with a screw. The anastomosis is done and because of enlarging the graft, so you kind of enlarge the defect so you can put a large bone chunk and certainly these microvascular grafts heal quite quickly and they seem to keep the carpal instability largely by virtue of overstuffing that part of the joint. And we look at this paper from Berger and Higgins combined, they had 15 of 16 unite. Now when you look at meta-analysis of literature with these vascularized grafts, the first study looked at all scaphoid non-unions. The second study from 2015 looked at only proximal pole non-unions and you can see vascularized bone graft clearly have an advantage 92% over 88% and in the largest study 91% over 80%. So much better unions than non-vascularized graft. And when you look at patient outcomes, so in this study they look purely at the patient outcomes, vascularized versus non-vascularized graft and once again you can see that the vascularized grafts do really well with 90% returning to activity by four months and patient satisfaction as high as 90% from what would normally be a very complex problem of a proximal pole non-union. And the infection rate with these vascular pedicle grafts is quite low. I mean if you look at infection rate 1.5, neuropathic pain 1.5 and complex regional pain. So the complications are low, Jeff, and diffusion rates are high, satisfaction rates are high. So clearly it's the way to go. You do get a poor outcome obviously if your pole is avascular. Females seem to have done less well in these meta-analysis. Smokers are a problem. If the scaphoid is collapsed certainly a vascularized bone may be small and you may consider using a larger medial femoral condyle graft and screw fixation seems to do better than K-wire. So wherever possible supplement the fixation with the screw might give you better results. So when would I do a vascularized graft? I would do it for all proximal pole non-unions because the first shot is your best shot. So that's the best time to do it. Or if I have a waste non-unit that has failed for whatever reason I would consider vascularizing it. The type of graft you use is surgeon's choice but I find the dorsal graft using the capsule is probably the best for a proximal pole. But if I have to revise a waste I would take the Vohler graft like the Kuhlman graft using a branch of the Vohler carpal arch. Thank you. Thanks Randy. I feel the same way. I call it the kitchen sink approach. You got one shot at getting this thing to heal, throw the kitchen sink at it. In fact I did one of Dean's flaps yesterday actually. But Mark, thank you again Randy, but Mark Richard from Durham, North Carolina will tell us that actually vascularized bone graft is overrated. Mark? Thanks Jeff. And that's exactly what I'm going to say. Randy, wonderful talk and I share a lot of your views but I'll share over the next 10 minutes the parts that may be a little bit different in my practice. So there are my disclosures but none relate to this talk. And just to again define the issue at hand because I think a lot of this comes down to semantics and words. And we're talking about proximal pole fractures of the scaphoid with AVN. We know the blood supply and I don't need to review it for this group but it's retrograde and the tank tends to be empty by the time we get to the proximal pole. So that's what we're concerned about as far as blood supply for healing. So it's not black and white and that's really what I think this boils down to for me. We've learned over the last year and a half there's a lot of gray in the world and that certainly applies to the clinical scenario that we're talking about today. So I'm going to try and separate those two things and I think one of the things that's different for me is that we're talking a little bit about apples and oranges when we talk about vascularized bone graft. I think there's a big difference between a free vascularized cortical structural bone graft that has structural integrity and heals the way we think of vascularized bone grafts healing and these pedicle cancellous things or the vascular pedicles alone with supplemental cancellous bone graft and I think when we talk and review the literature we put these together and I'm going to try and separate them for us and I think in the end I hope that you'll agree with me that there is a difference in a place for each of these. So Randy pointed this out well that there's literature out there that vascularized bone grafting in the carpus and the scaphoid does show superior union rates for proximal poly at the end when compared to traditional bone grafting. There's multiple options as he very well went over but the data is limited and prone to incredible selection bias and it's an incredibly heterogeneous group and that's what we have to sort out. Advantages of a true vascularized bone graft versus a non-vascularized bone graft is that as Randy said the cells remain alive and dynamic. You have improved cell survival incorporates differently. There's no creeping substitution which is what happens when we pack a cancellous graft that's non-vascularized in there. That gives you improved strength, less osteopenia, low incidence of stress fractures probably more relevant to long bones and a higher and faster union even in difficult environments and that's the structural MFC or MFT as Randy was showing and I think there's a role for that. This is one that I did with a couple of my partners and a baseball player who's a three or four time loser and attempted attempts at healing it before but I do think that this heals very differently when you have a large chunk of missing bone and we ask it to heal along those roots of vascularized bone that does not go through creeping substitution. That's not what we do with many of these other procedures that we're talking about. Vascular pedicles like the HORI procedure, all of these little pedicle things off the back of the distal radius or the perinatal quadratus, or you can even go from the—Dr. Urbanik, when I was a fellow, would do a lot from the index dorsal metacarpal artery, so you didn't cross the wrist joint and risk giving a little bulk back there. But I think we're going to go over a little bit of science, which is a welcome injection at this time in our lives, and I just don't think that these heal the same way. Trickling blood on a cancellous autograft or allograft that's going to go through creeping substitution cannot be called a vascularized bone graft. It's not the same thing. I'm not going to go through this in great detail, but the whole thesis of my talk is that we just have to get back to understanding how to fix scaphoids and be respectful of all the characteristics that go into treating bones and fractures and treating non-unions with biology and stability, and imaging comes into play, and all these modalities matter because the scaphoid could not be a more three-dimensional bone. I could make my scaphoid look fractured on any C-arm view I want to put my hand under, and I have no trouble with my scaphoid, but you're always looking at a 2D projection of a 3D problem, and when we get a scaphoid fracture, it's incredibly difficult to see at first before those osteoclasts show up, but even once you see it with the osteoclasts, I think you have a hard time characterizing the plane of the fracture, and I think that is part and parcel one of the difficulties with getting these to heal and then treating them appropriately in the second time around. So the MRI, there is MRI evidence in the musculoskeletal literature that you can get some understanding of the vascularity of the proximal bulb, but I think that's also a little bit debatable, and we have to be careful with what we're defining, we're measuring. It does not seem to correlate with what we see intraoperatively. So here's again just one of the cases that we're talking about. This is my own patient, so something that I did, 22-year-old male, three-year history of scaphoid nonunion. I got an MRI that was suggestive of some decreased vascularity to the proximal pole that may be different than AVN or true infarction, but I did exactly what Randy showed us. The Dean Citerion has described capsular flop. It's very user-friendly to elevate, and this could be a whole different discussion for the Keenbox disease talk that Dr. Bain was talking about, but when you lift this up and you have that little cancellous chunk, you cannot tell me that that's the same thing as a vascularized bone graft we do in any other setting in the body. There's no fixation into the graft. It's really cancellous, not structural. I don't know it's going to stay where I put it, and the addition of the micro-anchor I think lets us know, if we're being honest with ourselves, we're concerned with where it goes. You do conventional autograft that's non-vascularized and it's going to go through creeping substitution. Just trickling some blood out the end of that cancellous bone shouldn't be any different than putting hematoma on it, and I don't think any of us would call hematoma in this situation a vascularized bone graft. So as we turn the corner into some of the science in my favor here, I think the papers that you know that I'm going to bring up are Scott Wolf's group in the Scaphoid Nonunion Consortium that just let us think about this a little bit different. This is a prospective longitudinal registry of 35 patients with scaphoid nonunion, and they did non-vascularized autogenous grafting with headless screw fixation. I think 34 of the 35 were from the dorsal distal radius and one was from the iliac crest, but all non-vascularized, and I think there's three things to point out. One is the definitions here. Ischemia is when the blood supply is insufficient to support physiologic function. Necrosis or osteonecrosis or avascular necrosis is bone death resulting from the absence of blood supply, but it can be focal. It doesn't have to be the entire involved pole, and I think that's what we're mismeasuring on some of these evaluative tools. And then infarction, which we don't often call it, but that's what we're really worried about. Infarction is diffuse osteonecrosis with empty lacuna and granular degeneration of marrow fat. And when they did this study and they evaluated, they got MRI, they evaluated punctate bleeding intraoperatively, and then they did histopathology. There is no correlation between the three of those with each other, and there is no correlation with time to union or union rates. So this is the paper that kind of turned the corner for a lot of us on whether or not you truly need to bring in a blood supply in these scenarios, and 33 of the 35 healed by 12 weeks, which I think any of us would take that in our practice for these challenging problems. Another paper, a kind of similar summary statement of the group, but does anyone need a vascularized graft? Many hand surgeons still do it, but I'm not sure that we're not treating ourselves when we do it. There's no good evidence that shows differences in union rate or time to union between these. I think a lot of our definitions are blurred, and I think we have to be careful about that moving forward, and I agree with the summary of the group that future studies should look to control for these factors that we know we may not be describing the same way amongst ourselves with larger cohorts to be able to understand where they're actually necessary. So final couple of slides about what do we do if we're not going to do vascularized bone graft. We get back to the principles we were all taught as residents in orthopedics or plastic surgery, biology and stability. Every non-union should be evaluated for biology and stability. And it's interesting to me, and I catch myself doing it, and I think some of you would agree, if I'm taking care of a long bone that has a non-union, a radius and ulna, a humerus, I look at Mark Brinker's paper from 2007 JOT, metabolic endocrine abnormalities, and I work those patients up for that, and very, very commonly I find these abnormalities and I treat them. And I have to be honest, I don't find myself thinking of that when I do it in the carpus, and that's something I've tried to turn the corner on recently, but I think we need to think about those things. The carpus shouldn't be any different in its ability to heal a bone than long bone, so something that I'm kind of interested in with my own patients. If you do want to bring in some blood supply and vascularity, I know this is going to be debated, but the metaphyseal core decompression that Greg was talking about does increase the vascular response to the capsule, and this is a series out of a very good group out of Buenos Aires that had proximal pole non-unions treated with a cancellous graft, and the headless compression screw and the metaphyseal core had 21 of 23 healed in this group, so something to consider. Lastly, stability. We're very dogmatic about central placement of the screw in our scaphoid fractures. This is looking at waste, but when you look at this paper that I think a lot of us teach our residents and fellows, and they look at central third placement or eccentric placement, and you look at the stiffness of those constructs, it's increased stiffness with central placement and increased load to failure, so we think of those as stronger constructs. That's only true if you're perpendicular to the fracture line, so as you kind of think about the Rousset classification, the Herbert classification, the AO classification, you notice the obliquity of a lot of these fractures, and this gets back to the imaging and understanding what we're treating and how we should be treating it according to the principles that were taught. I think we have to be focusing on perpendicular fracture fixation, both acutely and in the non-union setting, and I'll show you just a slide or two that I think may help support that, so this is a finite element analysis looking at optimal fixation and acute scaphoid fractures, and this is looking at either perpendicular fixation or long axis fixation with a little bit of obliquity to the fracture line. If you look on the left, that red little seismic measure there, much less movement in the fracture fragments if you're perpendicular than if you're down that long axis. If you go and look at B2 fracture, same thing, B3 fracture, same thing, so we really do want to be perpendicular to the fracture line. Higher fixation stability is achieved when the screw is perpendicular rather than centrally. I think perpendicular takes priority. Very last paper, another one looking at central versus eccentric and looking at the amount of bone we leave ourselves to have interface with the opposite side to heal. When you're eccentric, so if you're going on the central axis, you're going obliquely across the fracture site, and you're stealing some of that potential interface for bone to heal across with metal because of the obliquity of the screw, and that's simply what this was showing. If you look at the box plots, as far as the available surface area, you get less surface area available for healing if you're eccentric to the fracture line, not perpendicular, and that's what they showed, especially in B1 fracture. So final thoughts on this, B1 fracture should be treated with a screw perpendicular to the fracture line to improve stability, maximize area of bone. B2s, you tend to be able to do both. Central axis is typically perpendicular, but we have to be thoughtful, and B3 should also be perpendicular to the fracture plane to maximize the potential healing area. Proximal pole infarction is rare. I think that's probably different than AVN. It is by the definitions, the histopathologist. Vascularized bone grafting is a heterogeneous term, and all vascularized bone grafts are not created equally. We have to be reminded of that from time to time. We just need to get back to basics. Principles of fracture care, evaluation of biology and stability, and we probably should be thinking more about metabolic and endocrine causes for our non-unions, even in the carpal patients. Thank you. Mark, thank you so much for that really great talk and for really outing many of us who, who, you know, I think you're right. We're a lot, we're mostly treating ourselves and telling the patient that we tried everything possible, but whether or not that vascularized pedicle really does anything remains to be seen. So I'd like to ask you, do, in your practice, do you ever use those pedicle grafts, those local pedicle grafts anymore? And then number two, for both you and Randy, you know, for Dean's, you both presented Dean's capsular pedicle, and I like that. I said I just used it yesterday, but as I'm doing that, I'm cutting through the capsule. I'm cutting through all the secondary stabilizers. I'm wondering to myself, do you think that may cause other issues down the road? Yeah, I find myself asking those same questions more and more commonly over the last 6-12 months, Jeff. I totally agree. I, I also worry about using the vascular, the dorsal capsular graft in a previously operated, especially if it's dorsal, you don't know if that you're not looking for that pedicle. You don't know if it's been blown through. I think if they had a scope before, it's probably okay. If your portal's in the right place, you're probably okay. But I, I actually am doing more and more, I like the hybrid Rousset for a lot of these, and I've had good luck with that. I find myself doing these capsular flaps less and less for scaphoid nonunion. I haven't quite gotten myself away from doing it for the Keenbox for trying to bring in a blood supply, and I can argue to myself that might be a little bit different because it's not fracture, but whether or not it's doing something or the other things I'm doing in conjunction with that are what's making a difference, I, I don't know. I think, Jeff, when I'm taking that pedicle, you're stopping short of the dorsal intercarpal ligament because that's where the vessels are getting vascularized from anyways, right? So I think as long as you don't go too distal, you're okay. You won't compromise stability of the wrist. I think the length of the pedicle is based on approximately where it's off the radius and distally stopped short of the mid-carpal joint, and that gives you enough access to, to get access to the nonunion. So I still think it's a nice window to get into the wrist in either case, so seems to work. Thanks, Randy. Okay, so now we'll move on to wrist arthroscopy, and Jeff Becker initially wasn't going to be able to participate, but I'm grateful that he's actually left a very important dinner party to join us, but he pre-recorded his talk, so we'll start with that talk. Megan, if you can move to the next slide, and then he'll be around for the Q&A later, but let's start off with his pre-recorded talk. Thank you. Scaphoid nonunion, the role of arthroscopy. The arthroscope is a tool to increase our understanding and to help us improve our results. It's not the arthroscope, but it's the mind and the hands and the experience at the end of the scope that make the difference. It's not keyhole surgery. You can see more. You can understand and see the anatomy of the injury. You have to make an incision to cut it open to get there. You destroy it. There's minimal damage. You preserve the capsule and the innervation, which assists with rehabilitation after the surgery. There's less pain, less swelling, and minimal scarring. So the proximal pole nonunions and the waist nonunions, they are different problems, and I'll share that with you. Here is a proximal pole nonunion. It's small. There's cystic resorption, distal to the nonunion, and this is a surgical technique. The arthroscope has been placed in the ulna mid-carpa joint. We're looking at the small proximal pole fracture. A needle is inserted so it's directly in line with the fracture to make instrumentation simple. A shave is inserted, and the palmar surface of the proximal pole nonunion is excised, so you get a good clear view of the nonunion, so you can start instrumenting to excise the nonunion. A burr is inserted once we know exactly where the nonunion is, and it's really important to be confident that you know where the nonunion is before you start using the burr. The proximal part of the nonunion and the distal nonunion is to bride it with the burr to trabecular bone. Once the nonunion is excised, we can stabilise the lunate and the mid-carpal joint by inserting a radio lunate wire. The wrist is dorsiflexed, ulnally deviated, and supinated, and wires can be inserted to internally fix the nonunion. You can see the 3k wires transfixing the nonunion. It's not only adequate to see this happening, but it's essential to probe the wires in the proximal pole to ensure that the fixation is mechanically stable and adequate. The graft is then morcellised in a bone mill, packed into a 2.7mm cannula, and then inserted under direct vision into the nonunion. It is then packed firmly around the k wires and into the nonunion site. The exposed cancellous bone on the mid-carpal joint surface of the proximal pole of the scaphoid and the nonunion are then covered with fibre and glue. Over 12 years, we've treated 30 proximal pole nonunions arthroscopically, and they all united except one, and that was due to a technical error. I relied on fluoroscopy to check the internal fixation, but I learnt you have to see and feel the fixation. You have to see the k wires going into the small proximal pole, because the moment we failed, we had minimal fixation on the proximal pole, and it looked adequate on fluoroscopy. So, is a nonunion through the waste of the scaphoid? Now, I don't know what that does to you, but when I look at that, I feel pretty uneasy, and there's a reason for that. From 2009 to 2021, we treated 54 nonunions of the waste of the scaphoid. 51 united, 3 did not, and they look like this fracture, and what we've learnt is that this is not an isolated fracture of the scaphoid, but it involves the entire wrist, and if you don't deal with the entire wrist, you'll have problems. Here you can see that we've demonstrated a deep dorsal peripheral tear of the triangular fibric cartilage with a 100% hook test. We've debrided it, and going to repair the dorsal peripheral tear with a double strand of 2-slash-0 Bicryl. I'm placing the sutures inside you. I'm not going to tie them, because we've got a lot more work to do. Now, we're doing another suture. This is an all-in-side parkopanal technique, where we're going to repair the more ulnar portion of the tear, and here we have a scapholinate dissociation, the scaphoid on the left, the linate on the right. There you can see the fracture. I'm performing a dorsal scapholinate capsulodesis. You can see the scapholinate ligament. I'm moving the needle up over the scaphoid, and then retrieving it on the dorsum of the scaphoid. You can see the fracture there, and then another suture to railroad our repair, and then another suture to railroad our repair over the top of the linate into the mid-carpal joint, and then retrieving this suture, and when it's pulled through, you can see the scaphoid non-union. You can see the suture all the way along from dorsal to the scaphoid to the triquetral linate joint. Once that's done, we're going to reduce the Dizzy and hold it with 2K wires from the radius into the linate, then reduce the scaphoid and internally fix the scaphoid with 4 1.2 mm K wires. We can now see the scaphoid is internally fixed with the wires. We're checking that the wires are going through into the proximal bowl. The non-union's been debrided, and we're going to pack it full of bone graft, and this is harvested from the iliac crest and processed with a fine mill, packed in tight, and then covered with fiber and glue. Our sutures are then completed in the triangular fibrocartilage, and you can see it when you look back on it. That degree of displacement in the scaphoid can't happen without a peri-linate injury, so we've dealt not only with the flexion deformity and the loss of the bone in the scaphoid, we've dealt with the unexpected scapholinate dissociation, which we didn't appreciate on pre-operative imaging, and we've dealt with a deep distal peripheral tear of the triangular fibrocartilage, all in the same procedure. So the next thing you can do with arthroscopy is, you know, occasionally you don't know whether the scaphoid is united. The traditional view is that there's more than 50% trabecular bone reaching the scaphoid non-union is technically united, but sometimes it's difficult metal interference from your wires and your screws, and sometimes it looks like it's healed with the trabecular bone grinding on trabecular bone. It looks, for all intents and purposes, too united, but that can be a false positive. So how do you deal with this if you're uncertain about union? Well the first thing is you can remove the splints and move, which involves a risk. The second one is you can splint longer and repeat your CT scans. The third one is to put a scope in, and here you can see a patient three months after arthroscopic reduction internal fixation of a trans-scaphoid pre-lunate fracture, and we're uncertain whether or not it had united. Putting a scope in, probing the non-union, it's solid. So we know we can remove the splint and get the patient moving, and here you can see it went on to really solid union. So this was a way of getting the patient out of the splint and rehabilitating earlier, and not waiting longer and delaying the rehabilitation. Here's a difficult case, six-month-old trans-scaphoid dorsal pre-lunate fracture dislocation, which I reduced, bone grafted, fixed, and that was done using an open technique. But I wasn't certain whether or not it had united at five months. He had some pain. The screw was slightly prominent. So we put an arthroscope in, and we could see that there was a non-union. There was fibrous tissue across the non-union, and the bone was very osteoporotic and soft, and you can see this defect at the non-union site after it was debrided. So what we did is we did a combined open arthroscopic procedure to remove the metal, and then arthroscopically excise the non-union, internally fix it arthroscopically, and then pack the defect with bone graft, all done arthroscopically. So combined open and arthroscopic techniques, they work well together in some circumstances. And three years later, you can see that his scaphoid's united. He doesn't have a normal wrist, but we haven't had to do partial fusion and that's about as good as we can get with this type of an injury. So arthroscopic assessment of scaphoid non-unions is extremely rare. We estimate we use it in approximately 1 to 2% of cases but it's a useful tool to have when you don't know whether the scaphoid has united and when you need more information to confirm union. So in conclusion there are many different ways to fix a scaphoid non-union. My preference is arthroscopic bone graft. Very rarely a vascularized medial femoral bone graft and I'd like to conclude by gratefully acknowledging PC Ho who developed this technique and for teaching me how to do arthroscopic bone graft. Thank you. We'll move on to the next video hopefully this one will play a little bit smoother if not we have it uploaded hopefully and to play off outside of the zoom platform but go ahead and play that if you would Megan. This is Dr. Kakar who will be talking to us about his role of arthroscopy with ulnar-sided wrist issues, TFCC and ulnar-triclical ligament injuries. Thanks. Hi my name is Sanj Kakar. It's an honor to be here today and I want to share with you some tips and tricks in arthroscopic foveal repairs of TFCC injuries. My disclosures are on the SSH website. So before we dive into the treatment of TFCC foveal injuries I think it's important to have an understanding of the soft tissue anatomy. There's many ways to understand this. My mnemonic here is is RUPUT. R stands for the sigmoid notch of the distal radius which gives you 20% stability of the ulnar carpal joint at the DRUJ. U are the ulnar carpal ligaments. P is the deep head of the pronator quadratus. E is the ECU tendon in its sub sheath. R are the radial ulnar ligaments and T is TFCC. So if we look at the radial ulnar ligaments this is a study done by Toshi Nakamura many years ago. The TFCC is a confluence of fibers which has a superficial fiber inserting into the styloid and the deep foveal fibers which are the primary stability of the DRUJ. And here you can see the foveal insertion of the TFCC. When you think of the ulnar carpal ligaments this is a prosection by Mark Garcia-Lias and we're looking at the palmar side of the wrist and you can see that there's a natural confluence between the ulnar lunate and the ulnar tricuitral ligaments. The radial ulnar membrane more and more discussion is being held about the importance of the distal oblique bundle of the introsteous membrane giving you stability at the wrist. And also the ECU tendon in its sub sheath so this is a dynamic stabilizer. So if you look at the ECU it's the only tendon that runs with the ulnar and when it compresses it drives the distal ulnar into the sigmoid notch giving you a dynamic stabilizer of the DRUJ. And finally is the deep head of the pronator quadratus muscle in full supination when this activates this drives the distal ulnar into the sigmoid notch. So how do you treat this patient when you see this patient who has gross instability of the DRUJ? Is this a bony problem? Is this a soft tissue problem? Is this both? There's many classifications out there. This is a classification taught to us by Mark Garcia-Lias the four leaf clover algorithm where you essentially ask four key questions. Is there a bony problem? Yes or no? For example is there a distal radius malunion that needs to be corrective? What's the quality like of the cartilage? Is it arthritic or not? What is the quality like of the static stabilizers of the DRUJ namely the TFCC? And what about the dynamic stabilizers such as the ECU? So you go through this as a checklist and you have to identify what's causing the problem and address all of these. These are not mutually exclusive. One of the things that I want to try and talk about today is also about the acuity of the injury. We're taught that if something is acute you can repair it and if it's chronic then you need to do a reconstruction. I think actually the key determinant is what is the quality like of the soft tissue and this is able to be repaired or not. This is a nice classification by Andrea Atzi which basically looks at the quality of the tissue at the TFCC and also where the location is and through this you can work out those that can be primarily repaired and those that need to be reconstructed. Now how do you test the TFCC especially regarding its foveal attachment? There's many different arthroscopic classification systems out there but sometimes the TFCC is also scarred in. So how do you assess where the TFCC is competent or not? Well what's the hook test? So here you can see in this video the probe is going from ulnar to radial. You can see that it freely lifts the TFCC off the fovea. So here this is a positive hook test. What about the trampoline sign? Now this is more subjective and you can see that there's a natural buoyancy of the TFCC. So this is a normal trampoline sign. What about the suction test? So here's an example here where you turn the suction on and you can see how the TFCC completely lifts off the fovea. So this is either a determinant of foveal detachment or if there's laxity of the peripheral side of the TFCC and this is healed by scar tissue. So here you can see in this patient now we've repaired it. Now when we put the suction test in you can see that we've restored the natural buoyancy of the TFCC. What about DIG arthroscopy? I think this is a critical tool to help you assess the foveal attachment. So look at this case. So this is a patient who had a bad accident. You can see has a distal radius and ulnar fracture that underwent a close reduction in percutaneous pinning by our pediatric orthopedic colleagues and you can see has a nice reduction. Four months later you can see has a pretty anatomic reduction of the distal radius and the ulnar but he comes back 10 months later and he has pain and clunking and look at the gross instability of the DIUJ. Now when you look at the MRI, if you look at the image on the left and also the axial view, the DIUJ looks to be well located and the TFCC looks to be intact and this is the MRI read stating that the patient essentially had an intact TFCC. So if we go back to that four-leaf clover algorithm, the bone looked good, the sigmoid notch looked aligned, there's no post-traumatic arthritis, the ECU was clinically stable but this patient had a TFCC injury. So how do we treat this? So this is a modification of the technique described by Wei-Chen Chen many years ago. So here we're doing a radiocarpal joint arthroscopy and this patient had a negative trampoline sign and the hook test was negative. Now the mistake here is to stop. Here we need to look at the foveal attachment and how do we do this? Well we do this through DIUJ arthroscopy. So the camera is still in the 3-4 portal and the needle comes in underneath the TFCC and you can see that there's gross laxity and then the DIUJ arthroscopy starts and look here we're underneath the TFCC, we're getting all the way to the ulnar side and you can see that this foveal detachment of the TFCC. So now we make a working portal just volar to the ulnar styloid. We're coming in underneath the TFCC with scissors and now you can see we're using a curette to debride the scar tissue of the foveal insertion of the TFCC. We want to get that fovea insertion back down to the distal ulnar. So now the shaver comes in, we're debriding this area. So now we're going to do the arthroscopic foveal repair. So we've made an ulnar-sided incision. We can see the dorsal sensory branch of the ulnar nerve and a vessel loop goes around this and now we're incising extensor retinaculum cheating as volar as we can. So once we've done this we'll then take the extensor retinaculum and take this dorsally and then through DIUJ arthroscopy or through the radiocarpal portals we're basically debriding the foveal insertion of the TFCC and you can interchange between your portals. Now we're taking a 0.062 K wire and the beauty of doing this arthroscopically is we can see exactly where the foveal insertion should be. We're critically actually a little bit dorsal there so we'll just raise our hand and go slightly volar and now you can see through the radiocarpal joint arthroscopy the anatomic position of the ulnar tunnel. So once we've made the ulnar tunnel now we're going to put sutures through this 0.062 K wire hole. So there you can see I'm mobilizing the TFCC and now we're taking an 18 gauge needle with a loop 2-0 PDS it's gone through the ulnar foveal tunnel and then we're pulling this out through the 6R portal. So once we've done this once we'll take another 18 gauge needle and just push this slightly volar and you can see it comes out right at the footprint of where the fovea should be. So as we push the needle through this 2-0 PDS out of the 6R portal. So now we have four limbs of suture going through the ulnar foveal tunnel. So we now will cut this and now you can see we know which suture runs with which and here we're taking a 20 gauge needle and we're just pushing this through the TFCC and there you can see we have a suture a loop suture which will act as our shuttle to shuttle this stitch back through on itself. So here you can see the grasper comes through the 6R portal or pull this through the 6R portal pull the needle back so we don't cut the suture you can use a wire loop for this and now we'll take one end and shuttle this back. So this suture now has gone through the bone through the fovea back out the TFCC and so you can see we we've done this and now we'll repeat this several times. So here you can see the needle comes back in and we're pulling it back on itself using this suture shuttle with this PDS suture. You can see as we'll pull this back this suture has gone through the distal ulna through the TFCC and back on itself and you can repeat this several times so this is our other looped 2o PDS and we'll repeat this again. So we know which suture goes with which and then we'll tag these and once we're happy with which suture then goes with which we'll then come through with the 20 gauge needle shuttling this suture back out across itself. So here comes the needle and then we're going to push this through and then shuttle the suture back across itself. So here you can see the foveal repair that we've done and now this is all of us taking the wrist out of traction and we've tied this down and you can see the immediate stability of the DIEJ by tightening that foveal repair and this is just showing the wrist out of traction having a nice stable repair. So this is the patient three months post-op. This is the contralateral wrist. This is his uninjured wrist and you can see as natural laxity of the DIEJ. Now this is the one that we operated on and you can see as good full passive prono supination and when he does this actively you can see as excellent range of motion and now we'll check his stability of the DIEJ. So he has a little bit of laxity but much stable, much more stable compared to the uninjured side. And so we're just checking stability in different forms of rotation and you can see from his viewpoint how his prono supination is and this is his wrist flexion and extension. So I could have picked many articles to share with you. If you look at the literature this is a study out of Japan showing good results at 20 months of follow-up. Another study showing up to four years of follow-up showing good stabilization of the DIEJ. So in summary I think when you're treating DIEJ pathology you need to have a classification system. The four leaf clover algorithm allows you to sequentially check what's causing the problem and the key thing is to treating these instabilities and pathologies at the same time and these are not mutually exclusive. Thank you very much. Thank you to Dr. Kakar for putting together that wonderful video. Unfortunately Dr. Kakar was not able to join us today but I do want to acknowledge him and appreciate him for his work. Very quickly again we're a little bit behind schedule here so I just wanted to ask Jeff since you were so kind to join us. You showed some really amazing videos. I was also a little bit of a late adopter to arthroscopic management of scaphoid fractures but I've started using it more recently and I've had surprisingly or not surprisingly but very good results and I think it's because of the vascularity is not disrupted as you alluded to and as PC has described. I'm a little bit less courageous than you though. I will do it for a kind of waste non-unions where the reduction is maintained. You have some osteolysis at the fracture site. It's a relatively stable fracture. That's my sort of ideal indication. Jeff you showed some pretty dramatic proximal pull non-unions. I guess my question to you is did you feel there's any limitation or is there any non-union that you won't address arthroscopically? You know, thank you. This has been a bit of a perception changer for me. Nearly 20 years ago we presented a series at the Australian Hand Surgery Society showing that you can internally fix proximal pulls, small ones with too many screws and that would heal. We didn't publish it but fortunately Scott Wolf's gone on and done that and shown you can fix small proximal pulls and the vascularity has got nothing to do with it providing the small proximal pull is intact. If it's intact, it's not fractured, you can do it. Now the paradox here is the smaller it is, the easier it is to get to unite. It's a much easier fracture once you learn how to make sure that you fix the proximal pull with three 1.2 millimeter K wires. You've got to make sure you're in the proximal pull and it's essential that you neutralize that with a wire from the radius into the lunate. That's the best way to do it. Now small proximal pulls will unite, nearly always. The one that we missed was a technical error because we didn't know we had to turn the scope around, feel and see the wires in the proximal pull. But the middle thirds, that case that I showed you, the ones that fail in the middle third are the ones that have got the severe flexion deformities with major loss of bone and this type of fracture is a perilunate, it's like a chronic transcapular perilunate injury and you you have to make sure that you get it all. I don't know if you saw that case I showed you, had a scapular instability with a wide drive-in sign in addition to the fracture and a deep peripheral tear of the triangular fibrocartilage. And if you're unfortunate and you have a floating, rocking lunate, then your wire from the radius into the lunate is not going to hold it. So we believe that the last four to six percent that we're having trouble with in the waist, not the proximal pull, can be fixed by addressing everything and getting the whole wrist stabilized. And with the small proximal pull I think that this is the technique of choice because you can fix very small, I'm really sorry that that video didn't play but I'm sure Jeff will make it available to the participants that are watching, but you can fix incredibly small proximal pulls this way and you can't, I don't believe you can do it with a screw from the back, even with a mini screw. So it's been a real perception changer for me. So thank you for asking that question. Thanks again and I'll be honest to the participants, it is not a technically easy procedure. It does take a lot of patience and technical skill. That being said, I think it definitely is a very powerful tool in our armamentarium, at least for my hands, for the simple waist non-unions it's been a game changer. Okay, without further ado, let's keep moving so that we stay on time. I'd like to introduce Mark Ross from Brisbane in Australia who has done a lot of work on carpal instability and he'll share with us his thoughts. Mark, thank you for joining us. Thanks very much for the invitation to speak tonight, Jeff. These are my declarations, but none of them are relevant to this talk. This is really the culmination of a group thought process that began with the discussion amongst a group of us, including my partner Greg Cousins and Scott Wolfe and Mike Sandow when we observed traumatic cases of non-dissociative carpal instability and we started thinking about what ligamentous disruptions might have allowed the entire proximal row to either flex or extend and this evolved into thinking about what causes these other problems. Ultimately, this has just been accepted as an article in press in the Journal of Hand Surgery and a lot of these concepts are discussed in this article which you will be able to read shortly. It's 50 years since Winshed and Dobbins described the traumatic instability of the wrist and more than 40 years of reconstruction seem to have hit a glass ceiling with most reconstructions demonstrating 80 to 85 per cent border excellent results. The question is asked, why do we even sometimes see radiographic appearances of gapping recurring or even worsening after open procedures? So there's a number of myths that I think we'd like to try to get people thinking about and perhaps dispel. The extrinsic and secondary ligaments, particularly the DIC, the DRC and the LRL are more important than the classic intrinsic ligaments. Secondary ligament attachments to the lunate are critical. The traditional dorsal approaches risk further iatrogenic destabilisation of the carpus and treatment should be tailored to the underlying kinematic problem and we would make an appeal for people to consider replacing the term mid-carpal instability with proximal row instability. The real problem that we see is that both cadaveric and clinical studies show that complete division of the scaphelinate ligament in isolation does not cause DZ and people have postulated about carpal morphology and row wrists versus column wrists and lunate morphology. But more recently there's interest in the secondary stabilisers and we think there's an excessive focus on these intrinsic ligaments and that the term secondary stabilisers should probably be replaced with primary or critical stabilisers. These are ligaments, the long radial lunate, the volar STT, the dorsal endocarpal and the dorsal radiocarpal ligaments. This study that Scott published two years ago is certainly worth referring to and it's basically a cadaveric serial sectioning study and they basically divided various ligaments after the SL in series. So you can see here all the specimens with the SL divided and radial lunate angle does not go above 15 degrees. Then if you divide the volar ST these ones had the biggest effect and dividing the dorsal endocarpal attachment to the lunate had the second biggest effect. So this led us to look at revisiting the dorsal capsular attachments to the proximal row. This is one of the original drawings from Dick Berger's work and you can see that the attachment of the DIC to the lunate isn't represented. Steve Villegas probably was the closest to this but this is a largely forgotten paper and he noted 90% DIC attachment to the lunate and 99% DRC attachment to the lunate. So Scott with his access to cadaveric specimens at HSS performed this, which is in press with Journal of Hand Surgery at the moment, and basically they took cannabis specimens and demonstrated the clear attachment. So this is an osteotomy of the triquetrum to reflect the DIC proximally and show that there's still significant and substantial attachment of the DIC to the lunate. And then after you divide that, you see there's also the DIC attachment, and that's a very robust attachment. And basically there was significant coverings of the whole of the back of the lunate with both the DIC and the DRC. And probably the most important portion is this deep portion, which we would suggest should be called the dorsal scapulae lunotriquetral ligament. And this forms an acetabular-like covering, which embraces the proximal pole of the capitate. And this ligament prevents dorsal shift of the capitate on the lunate. It prevents lunate extension, and it prevents dorsal scaphoid shift. And if you lose the connection of this ligament to the lunate and or the scaphoid, it can lead to these changes and therefore to DEEZY. And we proposed the concept of mooring lines, which we've published in this paper, which has just gone into press. And the concept is it's like when you try and anchor a boat, using these four mooring lines gives the best stability. And if you want to get a DEEZY, you have disruption of a dorsal ligament on the mid-carpal side, and a volar ligament on the radiocarpal side, which allows the lunate to rotate. For a VEEZY, you get a dorsal disruption of the radiocarpal joint and a volar disruption of the mid-carpal joint and the lunate flexors. My personal view is that, and this is probably shared by Greg and Scott, that most important stabilizers are the DIC attachment to the lunate and the volar STT. Probably the LRL stretches over time as a secondary phenomenon, which is why you see progressive development in DEEZY in most of these injuries. So this lunate attachment is very important. And I think we've got an increased understanding of identifying this and also treating it. We're not really sure whether MRI or MRA is best. We used to do a lot of MRAs up until about 10 years ago, but then found they were unnecessary. But we're now revisiting them, but certainly arthroscopy is the most predictable way to assess these. So this is a 3TMR showing very clearly these dorsal mooring lines intact. This is a partial scapular lunate injury. And you can see here with non-contrast, it's a bit difficult to say for sure. You think maybe there's something going on, but when you put contrast into the joint, it's very clear that there's this disruption. Again, on the axial view, not really sure. SLs are certainly intact, but there's a clear disruption of the dorsal capsule from the back of the lunate. You can also see these lesions in high-grade injuries. This is clearly a static injury with the typical dorsal translation of the scapula, but more importantly, you can see very clearly this disruption of the dorsal capsular attachments. And here's the LRL with increased signal, but intact. And you can assess these arthroscopically. This is a normal one. You can see that there's a direct synovial reflection off the edge of the articular cartilage on the back of the lunate. And here's one where you can see there's that bare bone distal to the articular cartilage. You can treat this arthroscopically. When we treat these arthroscopically, which we're doing now instead of a dorsal capsule odysseus described by Matalan, you can debride this bare area, place an anchor into the bare area of the lunate through the distal edge of the DRC, retrieve one suture limb through the DIC, and then tie it over after the traction's released. And you can see here, placing the anchor into that bare bone on the back of the lunate, and you can see when you approximate the capsule, how it pulls the lunate back up out of extension. And you can then just retrieve a suture through the DIC and tie it. There are implications for open treatment. Scott performed this cadaveric study, which is again, just going into print, where they basically compared the fibre-splitting capsulotomy with the window approach. And they also looked at repairing the fibre-splitting capsulotomy with a baseball suture around the edge versus anchor reattachment. And you can see that the approach alone creates significant carpal malalignment compared to the window approach. And when you look at the repair, if you repair with the baseball stitch, the gap remains, that's the one in red. If you use anchors, it's partially corrected. And if you do the window approach, it's never disrupted. It's the same with the radio lunate angle, and it's the same with the dorsal scaphoid translation. And this is the capsular approach that we use almost exclusively now. And you can see you get good exposure of the carpus. We've used this for our SL reconstructions. And again, you can see here, we've just opened this window and you can actually see that bare area on the lunate. We didn't dissect the capsule off the back of the lunate. You can preserve the pin when using these capsular approaches. And we now use this with a suture into our tendon graft in our reconstructions performed through a window approach. So to summarise, it's important to look for these extrinsic and DIC ligament lesions in carpal instability. And these ligaments are probably the primary stabilisers. You should look for these in all grades of carpal instability. And when you're treating these surgically, don't make the instability worse with your surgical approach. It's very easy to perform almost any of the surgery you need to through these capsular windows. If you see the lunate bare area, reattach the capsule whether you're doing arthroscopic or open surgery. The distribution of extrinsic ligamentous lesions varies according to the kinematic problem. So we need to start thinking about these carpal instability as a group of different kinematic problems related to different primary stabiliser ligaments. So all SL injuries are not the same and it depends on what the extrinsic ligament lesion is. So we know that in our traumatic non-dissociative instabilities that the DIC attachment to the lunate and the volar STT were the most important. In partial SL injuries, the DIC attachment to the lunate is significant. In early complete SLs, again, it's the volar STT and the DIC to the lunate. And then later on when DZ progresses, you see LRL attenuation. So it's important to tailor the treatment to the kinematic problem, which is determined by the extrinsic ligament pathology. So if you've got dorsal proximal pole translation, it probably relates to the DIC and certainly access methods, such as the SLAM or the SLT are very effective at correcting that rotary subluxation. If there's severe lunate extension, probably the LRL should be addressed with something like the anathema or the spiral thanadesis. If the scapula just pronates, flexes without dorsal translation, then pretty much any of the procedures will work. And if there's ulnar translocation, then you do need to address both the LRL and the DRC and their described procedures to perform that. Thank you. Mark, fantastic. I really, that was great. Very nicely codified within 10 short minutes. And I know it's almost one o'clock there, so really do appreciate your insights. Okay, so taking us home, Ryan Calfee from Washington University in St. Louis will tell us what to do with our slack and snack wrists. All right, Jeff, hopefully you guys can hear me okay. Thank you so much for inviting me. These talks have been great. I think I'm closing this with the most simple talk and least elegant talk after I've watched all these amazing things that people have done. So we're going to do the slack and snack wrists now. I don't have any disclosures. So here's my kind of overview and summary. I mean, at the point that we have a slack or snack wrist, arthritis is present, cartilage is damaged. There is no going back. So the joints that's involved, if they have failed non-operative treatment, which are the things that we usually do first, and I was just going to talk more about surgery here. At this point, then we're talking, the joint has to go away or get stiff. Now, the one exception would be maybe an early stage one slack where there's a very mild wear at the styloid and some could argue to do a styloidectomy and reconstruction of some sort, but that doesn't happen that often for me. Salvage procedures, when I talk to patients, it's important to realize that there's a give and take. We're going to give up motion and we're going to get pain relief. It's not making the wrist normal, but it's usually a good trade. And then also just to keep in mind, if you have that patient show up with a slack or snack wrist that is very stiff, and I might just say roughly a 40 degree arc or less, then it's probably not worth trying to preserve a tiny amount of motion. And I probably go to a total wrist arthrodesis. Others may do an arthroplasty in lower demand patients. So here's the ultimate outcomes because I think what most of us do here in the U.S. are going to be proximal row carpectomy and four corner fusions. And in the end, we could show slides with 40 different papers, but the outcomes are essentially the same. What I tell patients are basically, you're going to look like my patient here on the right. You typically get about 50% of your wrist motion. And again, the papers may show slightly different numbers, but it's easy for me to say, you're going to take two rows of wrist bones. You're going to leave one joint remaining, whether it's a fusion or a proximal row, two hinges to one hinge, you keep half the motion. Grip strength's usually about 80%. Pain is down. It's not all the way away, but usually kind of a one or two out of 10 instead of a seven or eight out of 10 when we start preoperatively. Good function. And again, you look at my patient, his motion is not perfect on the left side, but he's smiling. And that's what we usually have. Maybe that's just the Midwest of the US, I don't know. And I think you do get some long-term arthritis in both procedures, because whether it's the lunate on the radius or the capitate on the radius, all the force is now going through that single joint. It's not going to be preserved forever. Okay, proximal carpectomy. What are the advantages? Well, it's technically straightforward. There's no hardware, no bony union needed, which I think is great, especially in my patients that are heavier smokers. Potentially you can move them early. So I've definitely gone to patients just going into a removable wrist brace at a week or two after this procedure if they're not too uncomfortable. And it's tried and true. I believe one of the early publications was back in 1944 by Dr. Stam. And so going from that normal carpus to this, everybody can do it. Now, what are the disadvantages? As people will talk about with long-term outcomes, people worry about that radiocapitate arthritis. And at least with PRC, what we worry about is that you get the picture on the left to start with, and then with hopefully 10 or 20 years of motion, that motion though does involve some sliding of the capitate dorsal and volar, as you can see in the middle. And eventually, many years later, you may end up with more arthritis like you do on the right. But again, this usually is going to be preserved for quite a while, although this may be worse and quicker in people that are young or laborers. And so I may be worried about those folks. So technically, what do I do for this? Again, way simpler than everything else that's been shown in this webinar. I like K-stick joysticks, K-wires to put them in, to take the bones out in their entirety. You just have to be careful on that joystick and the triquetrum. Don't put it too far through or you catch the pisiform and realize it's pretty hard to get out otherwise. Lunate triquetrum always come out as a single bone each for me. The scaphoid is different. Sometimes it's quicker just to use a runger and take it out in pieces, especially in snack wrists, because I find that they're way more scarred on that volar aspect. I do like to get rid of the posterior osseous nerve. I know there's some concern about changing proprioception, but I'm happy getting rid of it. Sometimes the AIN as well. And then for acute trauma, I would suggest that when you get the open transscaphoid perilunates or lunate dislocations like we had here where this person's lunate was really sitting in the breeze on the volar aspects, proximal carpectomies are a great option instead of doing hours and hours trying to get the scaphoid back and get everything pinned and reconstructed. The only thing I do different with PRCs for acute trauma is pass one K-wire. This was one with two K-wires. Usually I just use one from the radial styloid into the capitate neck. I want to avoid the cartilage at the capitate head that we're going to rely on. So the second K-wire shown in this particular X-ray, which was my X-ray, isn't perfect, but you can see on the lateral, it's actually pretty dorsal. So I think we avoided the cartilage. And I like taking a final X-ray in the splint before we walk out of the OR, just using the mini FLIR scan. And it's because even if you do a good job preserving the radioscaphocapitate ligament, the lunate's not, or the capitate's not going to go ulnar, but with positioning, you can push it volar, dorsal, and sometimes even radial. So I just like my final little FLIR scan in the splint leaving the room. Now, what about this? When you get some arthritis, and now you've got maybe a slack wrist, but have that mid-carpal arthritis, do you go ahead and do a PRC? And I would say for me, no. For others, there are definitely all sorts of modifications and things that have been done that have been shown to work, maybe not perfectly. You can interpose dorsal capsule. You can do a capitate head arthroplasty, osteochondral resurfacing of the capitate, or even dermal allograft interposition. All things, if you really want to proceed with a PRC, but you have some mid-carpal arthritis. My preference though would be just to have a really nice capitate head that has preserved cartilage if I'm going to go ahead with the PRC. Here's one case, and again, I don't have a lot of experience with this, but this was somebody who was middle-aged female, had had a distal radius fracture, had persistent pain, pretty big smoker. I did not want to do a four-corner arthrodesis. She didn't have great motion. So we went in to do a PRC because she had all the arthritis between the scaphoid and radius, and the capitate looked really good. The scaphoid that we took out, we had a big barrier area on the proximal portion looking at us there, the yellow bone. The problem was is the distal radius had a lot of fracture lines, and I wasn't so sure that that surface was going to be perfect for the PRC. Here are the multiple kind of lines through the lunate facet. So in this case, just a nice dorsal capsule interposition. When I do the PRCs, I make a little inverted T where you take the capsule off the radius and then split it longitudinally. Even if you do that, just suture the longitudinal limb back together, and then you take that dorsal capsule and basically dunk it down between the capitate and the radius. So when you look in from dorsal, all you're seeing is the capsule sewn in, and now the two bones have that tissue in between, and that may help in this situation. How about four-corner arthrodesis? Now, the advantages here are that you have this more congruent radial lunate joint, and you maintain the carpal height, although I'm not really sure that changes ultimate grip strength or motion in the digits at all. Disadvantages all really come down to hardware. No matter what construct you use, they can all have hardware problems. You can have issues with nonunion with any of them, and it's a little bit more technically involved. And then it requires some immobilization, at least for everything that I've ever done, to get this to heal afterwards. So the couple tips I have for four-corners for me, I think the really full exposure is helpful. Again, I'm not doing anything like this fancy through a scope but I want to elevate second all the way through the fifth compartment off the capsule. I don't want to worry about EDM. I want it off the tracheotome so I can see everything. Really good debridement of the mid-carpal space. I think the easiest bone graft for this for me is just taking a curette, basically going into the second compartment just on the radial side of the listers, and you just pop right in, take all the graft you want. One technical thing is really getting that capitate to sit over the lunate. So here's a good example of one of our patients where the capitate's kind of falling in between the scaphoid and lunate, and this is really common. And yet to get this all to heal and fuse correctly, I think you really want to, once you get your debridement, get that up over the lunate so everything's in line. And then you also have to work to correct the lunate extension. So hopefully at the end of the case, we've got a lunate that looks like this where it's really looking right into the capitate, although I have to admit that sometimes that can be more difficult than I would like it to be. And then I like to put the two screws. This is my preferred construct here, actually, with the two screws just to get the mid-carpal area to fuse. A lot of times you can actually put a mini-homen underneath the tracheotome, which is my second bone to fix, lift it up just a little bit, and get that second screw through your incision dorsally without having to make the stab incision on the ulnar side, worrying about the ulnar sensory branches coming up dorsally. Okay, just a couple of things in the literature I think that are worth remembering. So the paper by Stern and others in 2005 is the one that really gets quoted a lot. They had 21 patients with proximal row carpectomy, four failures, everybody that failed was 35 years or younger. So that's kind of become the standard, I feel like, in the U.S. for, hey, this is what's young, is too young, is 35. Although, again, this is a small case series. Dr. Wall published with Dr. Stern also many years later, 20-year follow-up. Remember, the outcomes are pretty good with PRC. 65% did not need any further surgery at that time. A good number of people did, but that's 20 years out. And then finally, if you look at comparing studies now that really are meta-analyses, systematic reviews, cost-effectiveness studies, really all the recent papers are mixed. One will say proximal row carpectomy's better, one will say four-corner fusion's better. There's not a consensus. And just remember, even though these are kind of good analytic studies putting together a lot of data, they're all based on basically a whole lot of small case series. So the data aren't great, but there doesn't seem to be a consensus. And so in summary, I would just say that I believe that PRC and four-corners really do provide comparable outcomes for slack and snack wrist, and these are good outcomes. I also believe that PRC outcomes will rival, if not exceed, a lot of our expectations for the more complex trans-scaphoid perilunates, and sometimes even the major scaphoid non-unions. So for the basic ones, I'm just going to fix the scaphoid, but in the bad ones, PRCs are really a good option. And then I generally favor PRC over four-corner personally, but not so much for the younger, higher-demand patients. So with that, thank you very much, guys, and I know it's late over in Australia. Thanks, Ryan. You're too humble and you don't give yourself enough credit. I thought that was an outstanding talk. Thank you very much. And I have a ton of questions for everyone on this panel. We have such an elite panel of experts in the field from both countries, and I could go on forever, but I do want to be mindful of everyone's time. I know it's very early in the morning in Australia, and I don't want to take much more time away from those of you to enjoy your weekend. I do have one favor of the faculty. If you wouldn't mind all turning on your cameras, I wouldn't mind getting a group photo of everyone. I don't actually even know how to get onto the, I think, Megan, can you stop and, there you go. And I, again, would really like to thank everyone who's participated, both as a faculty member and as a participant. It's been a real treat for me to spend the last two hours with you all. Learned a lot from you all. And again, I appreciate you spending time with us away from your families. Thanks again. I got a photo, so thank you very much, and have a great weekend, everyone. Thanks, Jeff. Well done. Thanks, Jeff. Thanks, Jeff. Thank you, Jeff, and all good to be able to get together. Yes, sir. Bye-bye. Even virtually. Hope to see you in San Francisco. Yeah, try it. Thank you.

scaphoid proximal pole nonunion

vascularized bone grafting

non-vascularized techniques

patient's condition

severity of nonunion

surgeon's expertise

union rates

non-vascularized bone grafting

fracture fixation

positive outcomes

optimal approach

specific case

further research

treatment options

scaphoid