So, in my allotted time, I'm going to discuss a few applications of arthroscopy for de-energy instability. So, let's start with deep radioulnar ligaments. So, Dick Berger's described the hook test, Dave Roosh originally described it as a drag test, and Didi Mundt has also described it as a ghost sign, but this is where you can basically take the TFC and pull it all the way towards you. Now, we really can't see the deep radioulnar ligament from the radiocarpal joint, but Andriace thinks this is so diagnostic, he doesn't do DREJ or arthroscopy anymore, so this is that same case. You see, there's no deep radioulnar ligament at all, but this is the way it's supposed to look. When you're looking at the... When you're looking from the vulvar aspect of the DREJ, you can see sometimes this amazing anatomy where you have the radiocollateral ligament, excuse me, the deep radioulnar, the vulvar radioulnar, and the ulnar collateral attaching together, so that's the difference between the two. But Andriace has come up with classification with Ricardo where you can have either a deep radioulnar ligament tear or a peripheral tear, and sometimes you can have both, and you can make that diagnosis using the hook test and using radiocarpal arthroscopy and the trampoline sign. Now, there's a number of different ways to do this. This is an all-inside repair by Will Geisler, and there's a commercial kit available to help you do that. But essentially, what you're doing is using a lasso to thread a suture through the peripheral edge of the TFC, and then you're using a press-fit screw to tighten it down. And truthfully, this is one way of doing it, but you can also use a mini-open technique, which is my preferred one by Minimi and others. And either way, you want to do this early on. Dick Berger at one conference said that in his experience, if you did this beyond six months, there was a high failure rate. So there's a limited time potential for healing after this operation. Now, Toshi Nakamura, I think, has advanced our understanding for radial-sided tears because there's always confusion in the literature as to what to do about them, whether you repair them or debride them, and what the indications would be. But he separated these out and made us realize that you can have a stable radial tear, but you can also have an unstable radial tear. So the stable tears are amenable to arthroscopic debridement, but if you have instability, you need to re-establish stability rather than casting them for eight weeks and hoping that they'll get better. And it can involve either the dorsal or the palmar aspect of the radial ulnar ligament. So when you're examining people, of course, check the other wrist, because usually they're the same. The difference is even if they're unstable on the other side, they're not painful. In a true lateral x-ray, you can get a good feel for whether they're subluxed. So in this case now, here we're looking through a 4R and a 6R portal interchangeable, and you can see that there's a radial tear that exposes the sigmoid notch. So one of the key things here is to create a bleeding area of bone so it could reattach. And I use Tom Trumbull's technique mostly, where you're bringing something in through the 6U portal and then a meniscus repair needle. But sometimes I find it so hard to find those two drill holes. Now I'm just making one big drill hole with a cannulated drill guide, and then passing both limbs of the suture through that, and then using a press fit screw or something else on the radial side of the wrist to anchor this down. And it's much faster and much quicker. But occasionally you can get really good tissue and a good repair that cinches down right into that sigmoid notch and makes you feel like you've actually done the right thing. And other times I give up in frustration and wind up debreeding it, so it's not an exact sign sometimes. But once you've reestablished the tension, then that presumably will also improve the radial ulnar instability. Now this is a case where arthroscopy helped. I didn't really believe this patient had this problem. He seemed to have dorsal subluxation of the ulna. This was following a collies fracture. He had limited active supination, and if you really examine him, you can see there's limited forearm rotation. Don't let the carpus move instead of the forearm. And he did have some subluxation on MRI compared to the other side with a radial ulnar styloid fracture. But again, he also had the increased instability, and of course, we're testing them both in pronation and supination to see the direction of instability. The TFC was lax, but otherwise was normal. I could not find a tear. And this is DREG arthroscopy, and you don't always see the radial ulnar ligaments as perfectly as that first example, but you can still get a good feel of whether they're still strongly attached by putting your probe in through the dorsal portal. So in this case, the radial ulnar ligaments were fine. So I went ahead and did an open capsulotomy in this case, looked at the deep foveal radial ulnar ligaments and saw they were intact, and then I did a reefing. And a reefing was nothing more than just a vest over a pants tightening of the capsule. And it surprisingly worked remarkably well right on the table. And in fact, there's a few series of studies by some investigators, Mance and another one out of Finland by Bill, that shows that dorsal capsular reefing is also effective. But I think patient selective or patient selection is the key. So you can find this article in the Journal of Hand Surgery. This is a press test, which is really demonstrating the same thing, that when they put their hand on a table and push forward, you get volar subluxation of the ulna. What's really happening, though, is the ulna is staying the same, and it's the carpus that's moving the opposite direction. So in his case, he had 11 patients, dorsal instability of the DREG, positive press test with symptoms for three weeks to six months, and a good follow-up. And reasonable outcomes, but wasn't batting 100%, which is true of pretty well any procedure. Now ulnar repaction probably is the most common indication that we all use. You can see here under dry arthroscopy using Paco's technique, the area of chondromalacia on the dorsal LT tear. And then when you look on the volar side through an ulnar portal, you can see the palmar tear of the LT ligament as well. And we can't really do much for it other than to debride it. Geissler 2 lacks any of the LT joint, which may be amenable to an open shortening. And here's a TFC tear under dry arthroscopy as well. So in this case, the treatment is probably to do a shortening procedure if it's an ulna neutral or ulna positive, but it's also to debride the tear. And so in this case, you can see here's a massive TFC tear. You can put the scopin right through it and assess those deep radial ulnar ligaments. So it's an easy way to look at the DRUJ as well. But when you're doing the wafer resection, sometimes it's hard to get a concentric excision of the ulnar head. You tend to make a big gouge in one side of the head and then leave the other parts intact, which is frustrating. When you look at the x-ray, it looks like you haven't done anything at the end of the case. So part of this is you want to pronate and supinate the forearm while you're doing the debridement here. But then you can also use this TFC tear to get access to the DRUJ. And then you can put the scope in the DRUJ and the burr in through the hole in the TFC and get a more adequate resection. Now I've done this also with an ATAK TFC. And what it does is it allows you to spare the deep radial ulnar ligament because you're actually looking at it while you do the debridement. And so this is another technique that's not necessarily hard to do in certain instances. So this is now showing a DRUJ wafer. And I've used it for both using a dorsal DRUJ portal and a volar DRUJ portal. So here we are demonstrating the edge. Now I'm in the DRUJ and I'm looking up through the hole in the TFC. So you certainly don't need to do that for the debridement part, but it certainly helps to do that for the bony resection part. And this is really showing another one here under dry arthroscopy with a tear that's a little bit more radial. And putting the scope in from the volar side rather than the dorsal side and doing a concentric resection. Let's see if I can advance this a little bit more. So here you see what it looks like from the radiocarpal joint, relatively reasonable resection. But once you get in the DRUJ, you see that there's a lot more that you can still do going up to the insertion of the radial ulnar ligaments. Now I've only seen two of these. Dick Berg described the ulnar tracritural split tear. And what I learned by doing this is I went back and read his anatomy and there's actually a medial and lateral part to the ulnar tracritural ligament. It has two perforations in it. One is the pisotracritural orifice. The other is a prestyloid recess. So here you can see there's a tear that the first time I wasn't sure this was a real finding, but it was a definite split. And essentially, you're just putting an 18-gauge needle on either side of the split and then using a suture lasso to bring them through and close that gap. And of my two cases, one was free of pain, 50-year-old chiropractor, and the other, a 35-year-old workers' comp lady had the same pain. And some of that might have been chronicity. In the workers' comp lady, the pain was present for more than two years. So this was not effective in her case. In Dick's series that he reported recently in the hand clinics, he had 36 patients with a reasonable follow-up and good DASH scores, but two of them had instability that require open surgery. Thank you, Chairman.

arthroscopy

de-energy instability

radial-sided tears

ulnar repaction

suturing technique