Intrinsic ligament tears - PDF Free Download

Intrinsic ligament tears C. Mathoulin Paris

TFCC Ligament tears

TFCC s SURGICAL ANATOMY EWAS. Toshi Nakamura. Tommy Lindau Andrea Atzei Paco Pinal.

Anatomy correlates to Function DISTAL Component R D P Distal Component U Proximal Component

Anatomy correlates to Function DISTAL Component R D Distal Component U PROXIMAL Component P Proximal Component U

Anatomy correlates to Function Fovea Ulnaris as the CONVERGENT POINT D JHS 2008 Distal Component for the insertion of Distal Radio-Ulnar Ligaments and Ulno-Carpal Ligaments P Proximal Component Stabilizer of the ulnar Carpus

ARTHROSCOPY of 1-B TFCC Tears RADIO-CARPAL EXPLORATION LOSS OF TRAMPOLINE EFFECT TFCC PULLING TEST PATHOLOGICAL FINDING: Ulnar Tear

ARTHROSCOPY of 1-B TFCC Tears RADIO-CARPAL EXPLORATION LOSS OF TRAMPOLINE EFFECT TFCC PULLING TEST RADIO-CARPAL ARTHROSCOPY Evaluates DISTAL PORTION

ARTHROSCOPY of 1-B TFCC Tears RADIO-CARPAL EXPLORATION LOSS OF TRAMPOLINE EFFECT TFCC PULLING TEST Location of probe s tip?!?

ARTHROSCOPY of 1-B TFCC Tears DISTAL RADIO-ULNAR EXPLORATION PROBING DRU-J FROM RADIO-CARPAL DETACHED LIGAMENTS Exploration From R-C Exploration From DRU-J

Parameters for treatment of peripheral TFCC tear Anatomical Level of Injury D Distal Component Distal Tear P Proximal Component Complete Tear Proximal Tear

Ulnar Tears of TFCC Ewas-Atzei s classification TFCC: major stabilizer of DRUj RC-j DRU-j Instab. Distal Tear: + - -/+ Proximal T.: - + +++ Complete T.: + + +++ Massive T.: + + +++

Ulnar Tears of TFCC Ewas-Atzei s classification RC-j DRU-j Instab. Distal Tear: + - -/+ Proximal T.: - + +++ Complete T.: + + +++ R U HEALTHY DRU-j CARTILAGE Massive T.: + + +++

Peripheral Tears of TFCC Distal Tear: SUTURE (LIGAM. -TO- CAPSULE) RECONSTR REPAIR Proximal T. Complete T. FOVEAL REFIXATION (LIGAM. -TO- BONE) Non-Repairable e TENDON GRAFT Ulna

1B lesions

D après Pfirrman &al. Skeletal Radiol, 2001 Traditional

Prono-Supination Neutral Supination!!!

Technique Local-regional anaesthesia Tourniquet Outpatient surgery Elbow flexed 90 «Japanese» fingers traps 3-4 portal for vision 6R portal for instrumentation RUD portal for suture

Technique First Arthroscopic control of TFCC lesion

Technique Removal of scar tissue with a shaver

Technique Needle pinpointing of the right position for the RUD portal

Technique RUD portal

Technique Installation of loop of absorbable suture into the 34 gauge needle

Technique First 34 gauge needle inserted from the RUD portal into the meniscal part of TFCC with loop suture

Technique First 34 gauge needle inserted from the RUD portal into the meniscal part of TFCC with loop suture. The loop of absorbable suture is grasped with a grasping forceps from the 6R portal,

Technique Then second needle is inserted close the first one, and second suture is passed through the needle from RUD portal to 6R portal in the same way that the first suture.

Technique The simple second suture is passed outside into the loop Then the loop is pull down from the RUD portal in order to catch the simple suture into the joint

Technique Pull the knot tight at the level of RUD portal, avoiding a intra-articular knot.

Technique Below elbow splint in slight wrist extension and ulnar deviation for 6 weeks

D + 6 months 3-4 approach 6R approach

Clinical case

Arthrosc. Assisted TFCC foveal reattachment Foveal detachment could be isolated or associated to lateral lesion

Arthrosc. Assisted TFCC foveal reattachment Direct foveal portal (ATZEI 2008)

Arthrosc. Assisted TFCC foveal reattachment

Arthrosc. Assisted TFCC foveal reattachment Direct foveal portal (ATZEI 2008) MCR MCU 6-U 3-4 6R 6U DF D-DRUJ D F

Arthrosc. Assisted TFCC foveal reattachment Direct foveal portal (ATZEI 2008) 6-U DF

Arthrosc. Assisted TFCC foveal reattachment Ulnar fovea is visualized through D-DRUJ portal and roughened with shaver

Arthrosc. Assisted TFCC foveal reattachment

Material 157 patients (2007-2010) 52 females 105 males Average age : 36.4 y.o. (range 15-59) Average delay 21 weeks (1 to 60) Sport injury : 129 cases High level: 35 cases Fencing : 22 cases Tennis : 35 cases Golf : 21 cases

Material 157 patients (2007-2010) Ewas-Atzei s Classification Stage 1 (classical 1B): 91 cases Stage 2 (foveal isolated lesion) : 21 cases Stage 3 (Distal and proximal lesion) : 44 cases Stage 4 (complete and massive rupture) : 1 case

Results Follow-up 42 months : (between 24 and 65) Pain = 0 in 128 cases De Smet score : 70.25 (range 42 to 80) Mayo-Wrist Score :90.28 (range 65 to 100)

Total functionnal outcomes Flexion Extension Pre-op post-op controlateral 52,26 64,82 (p<0,01) 67,50 (p=0,26) 64,43 71,07 (p<0,01) 73,57 (p=0,35) Radial deviation Ulnar deviation Pronation supination Wrist strength 20 27,32 (p<0,01) 28,75 (p=0,48) 30 37,14 (p<0,01) 38,85 (p=0,27) 0-172 0-178 (p<0,02) 0-179 (p=0,16) 22,46 35,6 (p<0,01) 38,57 (p=0,18) No problem with sporty level +++

Conclusion 1 Arthroscopic Suture Indications: TFCC Distal Lesions Minor Instability Arthroscopic Assisted Osseous Refixation Indications: TFCC foveal avulsion Major Instability

Scapholunate ligament tears Acknowledgements to all EWAS members, Especially : Jane Messina (Italy) Abhijeet Wahegaonkar(India) Luc Van Overstraeten (France) Emmanuel Camus (France) David Slutsky (USA) Pak-Cheong Ho (Hong-kong, SAR China) Loris Pegoli (Italy) Adeline Cambon-Binder (France) Max Haerle (Germany) Andrea Tandara (Germany) Marc Garcia-Elias (Spain) Marina Carrara (Brazil) Gustavo Mantovani (Brazil) Martin Caloia (Argentina) Gabriel Clemboski (Argentina) Tanya Burgess (Australia) Antonio Pagliei (Italy)

Classical ANATOMY S L rsl TFCC Scapho lunate ligament : anterior, dorsal and intermediate

ANATOMY Tp IIM S R Distal stabilization: FCR + STT Ligt + RSC Ligt Importance of FCR (Salva-Coll, Garcia-Elias et al, 2011)

SCAPHOLUNATE LIGAMENT Main scapholunate joint stabilizer Meade et al 1990 Short et al. Looi et al. 2001 DORSAL PROXIMAL PALMAR 450 400 350 300 250 200 150 100 50 0 Yield Strength 118 +/- 21 63 +/- 32 Palmar Proximal Dorsal Berger et al. 99 260 +/- 18

SCAPHOLUNATE LIGAMENT Contributes to carpal proprioception Sensory innervation Mainly proximal part DORSAL PALMAR PROXIMAL Palmar Proximal Dorsal Mataliotakis et al. 09 Mataliotakis et al. 11 Importance of AIO nerve and PIO nerve too!!!!

ANATOMY «Only with sectionning insertion of the DIC a dorsal intercalated scapholunate instability deformity (DISI) ensued»

ANATOMY Normal aspect Isolated dorsal capsule tear with midcarpal SL spacing Midcarpal t

ANATOMY Normal aspect Radiocarpal Midcarpal t

ANATOMY Two days of laboratory work, 10 young fresh cadaver Arthroscopic testing and X-Rays measuring with and without load 1/ Normal wrist, 2/ section of Dorsal Capsulo-SL attachment (DCSS) 3/ section of SLIOL 4/ DIC section ( (J. Messina (I), L. Van Overstraeten (B), E. Camus (F), A. Wahegaonkar (In), A. Tandara (G), A. Cambon-Binder (F), C. Mathoulin (F))

SEVERITY SL LAXITY GRADE 6 4 2 ANATOMY CASES EVOLUTION AFTER SECTIONS Initial section adic/sl section SL 0 1 3 5 CASES 7 9 Two days of laboratory work, 10 young fresh cadaver section DIC section DRC Systematic worsening of SL diastasis after simple detachment of DCSS from dorsal SL t

ANATOMY 7 6 INDICE GRAVITE 5 4 3 2 1 0 Initial section adic/sl section SL section DIC SECTIONS This structure (Dorsal capsuloscapholunate Septum) is a bridge between the DST ligt and the dorsal SL ligt, and seems to be essential to the SL stability, and probably its tears could be considered as a first stage of SL instability!!! t

ANATOMY L C R S R DIC/DST DCSS DSL C Prominent role of dorsal radiocarpal ligaments: DIC/Dorsal ScaphoTriquetral Ligt Dorsal Scapholunate Ligt Dorsal Capsulo-Scapholunate Septum t

ANATOMY Four months of laboratory work, 17 fresh cadavers The DCSS structure was identified between the scapholunate ligament and the DIC DCSS always identified, consisting of three arches (two transverse arches in series along the distal line of the scapholunate interval, forming a confluence into the third which was larger than the previous mentioned) (M. Carrara (Bra), T. Burgess (Aus), C. Mathoulin (F)) t

ANATOMY Four months of laboratory work, 17 fresh cadavers It demonstrated a wide diffuse attachment along the scapholunate ligament and then arced dorsally fanning out to a longer insertion into the dorsal capsule. Four months of laboratory work, 17 fresh cadavers (M. Carrara (Bra), T. Burgess (Aus), C. Mathoulin (F)) t

Arthroscopic Dorsal Capsuloligamentous Repair ADCLR

Arthroscopic Dorsal Capsuloligamentous Repair ADCLR 1 thread through 3,4 P, then DWC and ULNAR remnant

Arthroscopic Dorsal Capsuloligamentous Repair ADCLR Retrieval through RMCP

Arthroscopic Dorsal Capsuloligamentous Repair ADCLR 2nd thread through DWC and RADIAL remnant

Arthroscopic Dorsal Capsuloligamentous Repair ADCLR Retrieval through the same RMCP

Arthroscopic Dorsal Capsuloligamentous Repair Radial remnant ADCLR 2 threads passing each in one of the 2 remnants of the dorsal distal part of the ruptured SLL Ulnar remnant

Arthroscopic Dorsal Capsuloligamentous Repair ADCLR Knot made outside patient (Nicky s knot) Pulled inside MCJ by proximal traction

Arthroscopic Dorsal Capsuloligamentous Repair ADCLR Second knot subcutaneous in 3,4 Portal

Arthroscopic Dorsal Capsuloligamentous Repair ADCLR (M. Caloia (Arg), G. Clembosky (Arg), E. Rodrigues(Arg))

Arthroscopic Dorsal Capsuloligamentous Repair ADCLR SL K-Wires +/- SC K-Wires only if unreductible Without pinning!!!

Material 35 patients 23 men 12 women Mean age : 38.4 yo (range 19 to 55) Sports injuries : 25 cases high level : 7 cases Average time between injury and surgery: 15.64 months (range 4 to 24)

Geissler Stages Stage 2 : 5 cases Stage 3 : 22 cases Stage 4 : 8 cases Material Garcia-Elias Suggestion Stage 2 : 3 cases Stage 3 : 16 cases Stage 4 : 16 cases EWAS Classification Stage 2 : 3 cases Stage 3A : 2 cases Stage 3B : 15 cases Stage 3C : 5 cases Stage 4 : 8 cases

RESULTS Follow-up : 29 months (range 24 to 40) Pain : No pain in 30 cases (85,7%) Moderate in 3 cases Failure 2 cases (Stage 5 according Garcia-Elias) ROM : normal flexion extension in 28 cases (81,8%) normal pronation-supination in all cases (100%) Strength : Normal strength in 29 cases (86,3%)

Total functional outcomes Flexion Extension Pre-op post-op controlateral 53.45 66.58 (p<0,01) 67.45 (p=0,26) 64.56 73.05 (p<0,01) 74.58 (p=0,35) Radial deviation Ulnar deviation Pronation supination Wrist strength 15 27.25 (p<0,01) 28.75 (p=0,48) 30 37,14 (p<0,01) 38,85 (p=0,27) 0-160 0-178 (p<0,02) 0-179 (p=0,16) 25.41 42.27 (p<0,01) 43.86(p=0,18) No problem with sporty level +++

Results Outcome was not related to : Stage (Geissler or Garcia-Elias) Outcome was related to : delay surgery (better outcome if short delay) Complications: - Slight flexion stiffness 4 cases (range 40 to 60 ) - One Sudeck (healed)

Results DASH: PreOp : Average 39.72 (range 17 to 64.30) PostOp : Average 9.53 (range 0 to 36,36) Mayo WS: Excellent : 27 cases Good: 4 cases Average : 2 cases Poor: 2 cases

Clinical case

Clinical case ADCLR Stage EWAS 4, Geissler 4, Garcia-Elias 4

Clinical case ADCLR SL pinning + Scapho-capitate pinning

Clnical case ADCLR SL pinning + Scapho-capitate pinning Pre ADCLR Post ADCLR

Clinical case ADCLR SL pinning + Scapho-capitate pinning

RESULTS D + 2 months Normal aspect SLIOL unrepaired, Stability of dorsal part

RESULTS D + 9 months

RESULTS D + 19 months

OUTSTANDING ISSUES Is the SLIOL really useless? YES What is the real importance of proprioception? Do we act on proprioception with arthroscopic repair? YES Does the distal volar ligamentous lesions (stt) exist??? Are isolated lesions of the DCSS pre-unstable lesions, or are they another entity? YES What is the real place of extrinsic ligaments? SLLComplex

Conclusion 2 DSL, DST, DCSS ligts seem essential in SL stability SLLComplex: a new concept!!!!!! Arthroscopic capsuloligamentous repair is a simple and reliable procedure convenient for the patient with chronic scapho-lunate tears These encouraging first results need a longest follow-up.