Yeah, I agree with Mel that you can get the volar ligament pretty well from the mid-carpal joint in that sort of that cleft in between the two bones. I haven't had much success in terms of seeing any definitive stability after that immediately. I do see the tissue shrink, but I never really feel like I've definitively changed the stability. But I do think with the immobilization, that's what scars it in. We're also doing a study now where we're looking at the innervation of those ligaments to see if whether or not adding that probe to the ligament actually causes a de-innervation effect, which makes sense. And we're trying to define that on a histological level. Okay, I'm going to finish up with arthroscopic management of TFC tears. And with time permitting, we'll do some cases after that. Or we can continue to take questions, whatever works out best for everybody. This is my disclosure slide. During this talk, I am a consultant for a company whose implant I will be discussing today. So tears of the TFCC are a common cause of ulnar-sided wrist pain. Traumatic tears usually occur with an extension and pronation force to an actually loaded wrist. These patients typically have pain with ulnar deviation and rotation of the wrist. My patients typically complain of playing golf or twisting open a jar or wringing dry a towel. Danny Palmer helped us classify these tears based on whether or not they were traumatic or degenerative. For the purpose of this discussion, I'll focus on the traumatic injuries. And then he subclassified these based on the location, whether they're central, peripheral, volar, or radial. And we'll go through each of these individually. Regarding initial treatment, obviously a good history, clinical findings, and studies are always used to formulate a plan. Nonoperative management is always the initial treatment. I usually immobilize for at least four weeks to allow for potential healing of the tear. We did a small study a few years ago that showed that about 57% of our patients treated with a cast healed with just immobilization alone. And that's because the acute peripheral tears would be expected to heal given their vascularity. And I'll go over that more in a few minutes. Corticosteroid injections can be used if you think there's some synovitic component to it as well. Otherwise, surgical intervention, either debridement versus repair, may be employed. And this is based on the location of the tear. So going through the individual tears, the Palmer 1A tear or the central tear, these are typically unlikely to heal because they're avascular. Again, the vascularity to the central disc is very poor. This usually involves a flap which interposes and is likely to result in continued pain despite nonoperative treatment. I tell people it's sort of like having a little piece of your nail hanging off the side of your finger every time you catch that on something. It's painful. And these may be debrided, as Glenn talked about, up to two-thirds of the disc may be removed without affecting load transfer. And that tends to be an effective treatment for those. Palmer 1C tears or the Vohler tears, I'm going to skip the 1Bs and come back to those later. But the 1C tears are usually treated nonoperatively or with debridement. But as a couple of our faculty alluded to already, these only extrinsic split tears may be treated with repair. If repair is necessary, obviously you want to be mindful of the nerve ester structures that are running right in that area of Vohlerly. And those only extrinsic split tears have been described by Berger and colleagues. But they haven't published any results on their series as of yet. The Palmer 1D tears or the radial tears are controversial. Again, there's little to no vascularity to that area. So repair is arguably not likely to work. However, the argument there is that if you repair these by decorticating the sigmoid notch and repairing the ligament down to the sigmoid notch, theoretically you're revascularizing it there. The repair options are, in my hands, quite difficult. You can do this arthroscopically with meniscal suture needles or open via dorsal approach between the fifth and sixth compartments. There was a study done in Philadelphia which, to my knowledge, hasn't been published yet but showed that comparing debridement versus repair, the debridement had satisfactory results when compared to the repair. If you were to employ a repair, the open technique is seen on the left and the arthroscopic technique is seen on the right. You can see what these meniscal needles are used to penetrate the articular disc. They're drilled through the sigmoid notch and out on the radial side of the radius. You can imagine this is somewhat of a blind shot. Not only is it difficult, but there are some nerve vascular structures, the dorsal radial sensory nerve, for example, that are at risk with this technique. And lastly, I'll talk about the 1B tears. These are the most controversial. The most work that's been done on TFCC injuries are on the so-called peripheral or 1B tears. The first question is whether or not repair is necessary or if these may be debrided. Most authors and surgeons would agree that repairing these peripheral TFCC tears is the treatment of choice. However, I'd just like to point out one paper that came out last year in the Archives of Orthopedic Trauma Surgery looked at 36 patients with Palmer 1B tears all treated with debridement alone and they had quote-unquote promising subjective and objective outcomes. If you look at their results, about 48% were excellent, 39% were good, 13% fair on the Mayo Modified Risk Score. The only confounding thing is that they did include a corticosteroid injection post-op in all their patients. This brings into question whether or not a repair is truly necessary, but until further literature supports this, I still do believe that repair is necessary. And I think that's due to its healing capacity. Glenn showed this slide, I think, and it shows again the blood supply to the periphery of the TFCC is very rich and therefore this ligament has the ability to heal. In terms of treatment, there's a number of different options, as I alluded to earlier, to fix this. Open repair was the gold standard for many years, and then arthroscopic-assisted treatment options came around, either inside-out or outside-in, the so-called Whipple and Geisler repair is the mainstay for many surgeons worldwide still. And then some all arthroscopic techniques have been described. I've just listed a couple here because if you look in PubMed, you'll see probably at least 50 different techniques that have been described, all of which report good outcomes. And I think as long as you bring that articular disc back to the ulnar capsule where the blood supply is, this has a good chance of healing. Just the, what I consider the gold standard probably in the U.S. right now, the so-called Whipple-Geisler outside-in repair, using some meniscal needles, basically used to penetrate through the ulnar capsule, through the articular disc, you pass a suture through that, capture it with a suture lasso with another needle, like that, bring the first needle out so it doesn't cut the suture. There's a blown-up view of that. And then bring that suture limb through the capsule to create a horizontal mattress repair and then tie that down the capsule. And I use this for many years with good success, although for, I do think it has its foibles as well. Rehabilitation with this, typically six weeks in the Munster cast and then starting active range-of-motion exercises, concentrating on rotation, supination is usually the last to come back. And then after 12 weeks, we start strengthening exercise, or earlier if they're progressing quickly. There's been a lot of talk and controversy and literature recently about the whole so-called foible versus capsule repairs, either repairing the TFC back down a bone versus just a capsule repair. What's the, is there a difference in, does it, you know, does it make a difference I should say. Andre Aztay and Riccardo Lucchetti published a nice new classification scale, taking the Palmer 1B peripheral tears and then subclassifying these based on essentially the stability of the DREJ. And that really makes a difference in terms of the treatment. The only literature that looks at head-to-head foible or bony versus capsule repairs was this paper by the Mayo Group, 2008, looked at 75 patients looking at half arthroscopic, half open, with a mean follow-up of almost four years, and found no differences between the two groups in terms of outcomes. But I do think there are some problems with current repairs. Obviously with an open repair, you have a larger dorsal incision, potentially a longer recovery time. And as we just heard, the results are no better than the arthroscopic repairs. And then if you have an outside in-type repair with a knot tied over a button on the outside of the skin, you have issues with buttons. I've anecdotally seen two cases of patients who have had septic arthritis from having a button with sutures going into the radial carpal joint. And that button can become malolorous and cause skin changes as well. But most commonly, people tie these knots underneath the skin, and the concern there is that you have a large subcutaneous knot, and as you know, there's not a lot of subcutaneous padding on the ulnar aspect of the wrist. And so these knot stacks can be somewhat problematic and irritating for patients. I think anybody who does this technique has run into a patient who's been somewhat irritated with this issue. And so I think that's one of the major problems with that outside-in technique that I used to use all the time. There's also the possibility of a nerve injury. The dorsal branch of the ulnar nerve runs right in that area, and you're tying these knots in that area. So obviously if you do this technique, you want to make sure you identify the nerve and protect it. There's also a presumed weaker repair with this. You're using a monofilament suture, or even if you're using a braided suture, you really I've never found that I can get a really tight knot with this technique. So we described a technique using an all-inside repair technique using a pre-tied suture device. Basically this was initially described for meniscal injuries, and it has two PLLA blocks with a pre-tied suture between them. So this introducing needle places the suture, actually places the first block on one side of the tear, and you advance the block through the capsule for a vertical mattress-type repair. It's a new technique for the use of TFCC repairs with the potential for decreased operative time incisions, and we eliminate that issue with prominent suture knots. We wanted to study this first to make sure that it was not only strong but safe. We did some cadaveric studies with iatrogenically produced peripheral TFCC tears, and we compared this repair to what we considered the gold standard at the time, which was outside in two OPDS suture repairs. And then we dissected these out and measured the distance of these implants to the closest nerve vascular structures, the dorsal branch of the ulnar nerve and the ulnar nerve vascular bundle. And then we loaded these to failure on an Instron, and the first thing we noticed that with the ulnar dissection, again, you saw this slide earlier, these prominent knot stacks can be irritating the ulnar skin, but these blocks for the suture devices are much lower profile. Also, you'll see that because the needle is coming from the 3-4 portal in a dorsal-to-vulnar trajectory, the risk to the dorsal branch of the ulnar nerve is much less with this technique than with the outside-in-type technique. Both techniques were safely away from the vulnar nerve vascular bundle, the ulnar nerve vascular bundle. We then dissected these discs out and then loaded them on an MTS across the repair, and we saw a significantly increased load-to-failure with our suture device when compared to the two OPDS repair. Subsequent to this, we started doing this in patients, and we published a few years ago a retrospective review of our first few patients having this done with patients with an MRI consistent with the TFCC tear with no concomitant GRJ instability, but they had persistent ulnar side risk pain despite immobilization and injections. We looked at range of motion, grip strength, return to activity, and any complications and looked at QuickDash and PRWE. This is how it's typically done. This is that Acumed tower. Again, I don't have any relationship with Acumed, but that is a useful tower to use for all types of risk of arthroscopy. The standard portals I use are a 3-4 and a 6-R portal. The 3-4 portal is my viewing portal, and the 6-R portal is my initial instrumentation portal. Let me go back and play this. Let's see if I can play this video. This is what we typically see. This is a right wrist, and you can see the loss of the trampoline effect, and I can get my probe underneath the peripheral TFCC here consistent with the peripheral tear. Now I switch my portals, and my scope is coming in through the 6-R portal, and the instrument is coming through the 3-4 portal, although now I've also moved the scope from the 6-R portal to the 4-5 portal. I think the visualization is a little bit better from there rather than the 6-R portal because you're looking right down on the tear if you're using the 6-R portal. This is what the instrument looks like. What I'm demonstrating there is that there's a trigger that triggers the implants. My scope's, again, in the 4-5 portal, and the instrument's going in through the 3-4 portal. You can see it's being advanced to the ulnar aspect of the wrist, and I'm following it with my scope. The blue cannula is what I call a banana cannula. Basically it allows you to get your introducer needle in, and then you peel it off like a banana peel and take that off. Then you can see the introducer needle right there, the first block with the pre-tied suture right there. I usually use a vertical mattress configuration. You could do a horizontal mattress if you prefer. The first needle's punch is through the articular disc, which I'll demonstrate right about now. This is essentially unedited video, so you can see that this repair does not take a large amount of time. What I'm demonstrating now is on the outside, you can see it's tenting the ulnar skin, and that's as far as you want to go, obviously. Once you tent the skin, you're through the ulnar capsule, then you deploy that trigger, and it deploys the block. Then the first block is deployed, and you bring the introducer needle on the other side of the articular disc and just push it through the ulnar capsule. This will give you a vertical mattress stitch. Again, if you look on the upper left-hand image, you'll see soon the skin will be tenting, and that's when you know when you've gone far enough. You can see that it's safely away from the area of the dorsal branch of the ulnar nerve. Once the blocks are deposited, then you just remove the introducer needle. It's a pre-tied suture, and you simply just pull it, and it'll reduce itself. It'll pull the TFC, the articular disc, back to the ulnar capsule. And then there's a knot pusher and cutter, which basically will tighten the knot even further. This takes a couple of seconds because my fellow is fumbling with putting the suture through the device, but once you put it through, you follow this through into the joint, and you just tighten the knot a little bit tighter, and then the same device has a cutter, so you just push the trigger, and that cuts the knot. So this is what a repair would look like after the repair. You can see the trampoline effect is restored. You can see the amount of tension on that suture. I really feel like I can't get that same amount of tension on my arthroscopic repairs when I tie it over the capsule. Just by way of comparison, this was a pre-op image and you saw that the trampoline effect was lost there. So the results of our study, we had 12 patients with a mean follow-up of 17 months. Supination was about 78 degrees. Grip strength was 64% of the contralateral side. See the quick dash and PRWE were quite good. Meantime, the full activity was about five months and we had zero surgical complications. So this technique showed excellent short-term results. One year follow-up, 93% achieved excellent subjective outcomes. And I think the benefits of this technique are its ease of use. There's a lack of those prominent suture knots that tended to bother my patients on the ulnar side. There are no extra incisions that are necessary. We've shown it to be safe as well as strong. And I think the strength of the repair is really the game changer for me because I've reduced my mobilization from six weeks in a monster cast for my outside in-type repairs to short-arm cast for four weeks. Now I've shortened it even further to two weeks. And from my understanding, I think Dr. Gasson, who also does this technique, now doesn't immobilize his patients at all. It's just a soft dressing. So that's a really game changer. Imagine being in a monster cast for six weeks versus no immobilization at all. I think I would choose the latter for sure. So to conclude, I think central volar and radial TFCC tear should be debrided. Although if you have an ulnar extrinsic split tear, then you can repair that as described by Berger et al. Peripheral tear should be repaired, but not all peripheral tears are the same. Again, for Palmer 1B tears, if you look further into the Aztec Luchetti classification and you have DRJ instability, I think if it's unstable, you really want to consider a foveal or open repair or an arthroscopic foveal repair if you choose. But if the DRJ is stable, any repair technique is fine, capsular or foveal. With that, I'm happy to take any questions. And we'll go to some cases. Oh, we don't? Okay. Well, we thank you all for coming. And if you were inclined, we would really value your feedback. Thank you all.

triangular fibrocartilage complex

TFCC tears

ulnar-sided wrist pain

nonoperative management

surgical intervention