The Upper Hand: Chuck & Chris Talk Hand Surgery

Deep Dives on Surgical Technique: TFCC Repair

December 05, 2021 Chuck and Chris Season 2 Episode 46
The Upper Hand: Chuck & Chris Talk Hand Surgery
Deep Dives on Surgical Technique: TFCC Repair
Show Notes Transcript

Season 2 Episode 46.  Chuck and Chris discuss TFCC injuries and repair.  We briefly review examination diagnosis but the deep dive focuses on repair technique.  The importance of foveal TFCC injury and repair is highlighted.

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As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
theupperhandpodcast.wustl.edu.  And thanks to Eric Zhu, aspiring physician and podcast intern.

Charles Goldfarb:

Welcome to the upper hand, where Chuck and Chris talk hand surgery.

Chris Dy:

We are two hand surgeons at Washington University in St. Louis here to talk about all aspects of hand surgery from technical to personal.

Charles Goldfarb:

Thank you for subscribing, wherever you get your podcasts.

Chris Dy:

And be sure to leave a review that helps us get the word out.

Charles Goldfarb:

Oh hey, Chris.

Chris Dy:

Hey, Chuck, how are ya?

Charles Goldfarb:

I'm doing pretty well. It's a It's a Thursday night. We both had busy days. But what better way to cap off the day?

Chris Dy:

Yeah, you know, it's been it's been a fun one. I just spent a little bit of time on Firsthand, my side gig Other than this, and you know, the day job, but I'm excited to spend some time chatting with you. I think we're going to get it into one of these technically heavy detail episodes that everybody seems to dig so much.

Charles Goldfarb:

Oh, I am looking forward to it. And that is that's a lot to have to host two podcasts on the same night. Can you share who your guest was?

Chris Dy:

Yes, we had a great conversation with David Ring. I will say that having co hosts for each of these things makes it incredibly much more enjoyable. So Megan Conte Mika and Peter Stern, obviously for Firsthand and some guy named Chuck for the for the old podcast.

Charles Goldfarb:

That is awesome. I have to say I had a side gig podcast last night, which is pretty interesting. Honestly. I have I have a co host, Alexander Aleem. And this is for the AOA as you I think, you know, and we interviewed Jim Herndon, who is a giant in hand surgery, and I'm sorry, a giant an orthopedic surgery. He has a ginormous five volume book coming out called a birth of a specialty I think that's what's called about orthopedics in Boston, at Harvard Medical School and the various hospital. It sounds fascinating. It sounds dense. But he was just sharing some stories and anecdotes is pretty cool. Pretty fun.

Chris Dy:

Talk about a labor of love both your other podcasts as well as Jim Herndon's book. Interesting. We were just reading a David Ring's New England journal article about a wrong site surgery and it was in the format of the m&m from the the Massachusetts General Hospital in which Jim Herndon contributed his thoughts. So you know, perfect timing on that.

Charles Goldfarb:

Yeah, really interesting. It was a 14 year project for Dr. Herndon.

Chris Dy:

Wow, wow.

Charles Goldfarb:

Yes, that is more years than your children have combined, I believe.

Chris Dy:

Yeah, yeah. I mean, my math, if I've met my arithmetic serves me correctly. They've, Dr. Herndon has been working on it for five more years, and the kids have been in existence combined. So yeah, well, I look forward to checking that out. You know, how often are you guys doing the AOA podcast?

Charles Goldfarb:

It's about once a month, on average was probably not 12 months a year, maybe 10 months a year? What about you?

Chris Dy:

We do once a month for Firsthand. We slowed down recently, we're taking January off. And we had a little hiatus just to make everybody miss us a little bit. And we'll talk about that for our podcast in a little bit.

Charles Goldfarb:

Yeah, well, you and I have discussed we might need a little hiatus ourselves.

Chris Dy:

All good. So let's jump into this episode. Everybody loves the technical aspects here. So I want to present a case to you. So I've got a 25 year old gentleman who comes in six weeks out from an injury in which he was using a drill and drill bit broke, and it kind of torqued his wrist a little bit. And he is like I said six weeks out, he's got pain on the ulnar side of his wrist. And you have evaluated him and you've determined they're not frank instability, but there's enough instability where it causes them pain. In addition to having localized tenderness over the owner fovea, you have sent him for imaging and you obtained an MRI with or without an arthrogram that shows a TFCC tear. And I will let you fill me in on the details of what you would like that MRI to show specifically and how it would change your management.

Charles Goldfarb:

Yeah, and we could you know, we haven't done a lot of imaging discussions we can and should. The problem of course imaging is that like politics is all local and it depends on quality or magnet quality of your radiology partners etc. I will occasionally use an arthrogram I have to say many times I do not use an arthrogram It depends a little bit on where the patient may be getting the test done. I have many patients come back and say the arthrogram was one of the most uncomfortable interventions ever because of the placement of the needle in the wrist joint so I actually try to avoid it if I can but I'm really you know with with the description that you provided. You know, you can get a peripheral tear and have pain only when you start to have even a suggestion of some laxity, and by laxity, we're talking piano key testing or shock of the DREJ, then I worry, there's really a bigger type tear, a structural tear that may affect the fovea. Those can be hard to pick up on MRI. So I think it's a combination of exam and discussion with the patient and the MRI contributes.

Chris Dy:

So before we get into the specifics of how you tease out the differences in those tears and the implications, so if I'm starting out in practice, and like you said, All imaging is local, should I just call a radiologist and ask, you know, what's going to give me a better picture at the place that I'm having most of my imaging done? I mean, because I think we talked about this before on this podcast, or one of our other venues, maybe it was conference or hand conference, but remember starting out in practice, and you saying, I always get an arthrogram? Why would you do anything else, duh?

Charles Goldfarb:

It's funny-

Chris Dy:

Maybe not with a duh at the end, but you know.

Charles Goldfarb:

Maybe with the duh. I was actually thinking, as I was talking about you and I have discussed this, but I don't remember where either.

Chris Dy:

Multiple venues.

Charles Goldfarb:

Yeah. So I do think that's probably good advice. Many radiologists will recommend the arthrogram. It probably does give a little additional information. It's a cost benefit analysis. And I even I'm not even talking physical cost. I'm talking kind of the implications of the needle placement of getting the arthrogram, injection, etc. I would say most of us would agree that it would increase the sensitivity, and likely the specificity for identification of a TFCC tear. How much again, very local so I would I would talk to your radiologists get a sense of what's going on. And then once you do a handful, and you'll get a sense of whether it's helpful or not.

Chris Dy:

In 2021 with your skills of being a hand surgeon for at least 50 years. Do you feel like the arthrogram extravasation down the sigmoid notch, the so called J sign, does that help you establish any prognosticators about tear? Are you getting all that info on your examination? Since you've been examining patients for about 60-70 years now?

Charles Goldfarb:

Yeah, 80-90 years.

Chris Dy:

It just keeps going up.

Charles Goldfarb:

I don't think there arthrogram really helps me I think I can get a sense of what's going on by clinical exam. MRI definitely adds information. Like I said, Let fewer and fewer reasons for me to get the arthrogram moving forward.

Chris Dy:

I mean it's interesting over here to talk about like surgical details, but I noticed that the stuff that I'm super comfortable with, at this point in my career, I guess six year six and a half years of practice now, I order less studies for that stuff. But the stuff where I'm still populating my algorithm on clinical exam and how patients look and how patients are going to do, I still get studies and I would say probably get more studies now. Because I'm still trying to own what I see on my exam, what I see in the OR versus what I see on their imaging, because I've become more interested to see how good I am at predicting that now.

Charles Goldfarb:

It's such an interesting point and is so true. And certainly when you get old, like one of us, you don't want to stop being inquisitive and stop trying to improve that correlation assessment of imaging. And but I do wonder less tests than I used to. And I think I do that from a place of knowledge. I'm not critical of those who ordered tests, and sort of there's value in test. But I do think my indications have narrowed for sure.

Chris Dy:

So say you've got this patient and say they've got quote, just a peripheral tear, but they still got that subtle instability on your exam. How are you getting what what are your options here for treatment? Are you going to, you know, try some therapy. So maybe you're just widget, you're going to do an injection? Are we going to the OR?

Charles Goldfarb:

So essentially the six week timeframe which you described, so twisting, you know, drill injuries six weeks, because that's that's quick, honestly, most people don't come in that soon. If they did, I would really strongly consider a cast. The problem, of course, with recommending a cast is a it needs to be a long arm or a monster, and b I can't give good data and I can't promise it'll work and then you put someone in a cast for six weeks, and you may not have anything to show for it. But I do think that's reasonable in the acute or subacute setting. Once this is it three months or six months, I really do like a single injection with a wrist splint, anti inflammatories, activity modifications, I do not believe in repetitive wrist injections, but a single injection gives me a lot number one, it hopefully helps the patient maybe not forever but helps the patient number two, it is a diagnostic test, let's be honest. And it also helps me and the patient. Understand that if the injection works and wears off, then surgery really feels much more comfortable rather than just jumping Surgery? I don't know, do you? Does that resonate? Or do you see it differently?

Chris Dy:

Yeah, no, I have resonates with me. I mean, I try not to jump into surgery quickly. And you know, I think that, you know, the injection is totally reasonable. I like a wrist widget, as many of our therapy colleagues have pointed out in the past. I guess for me, say we fast forward to three months, some relief from the injection, still has that instability absolutely wants something done. They come to the master the professor, the Executive Vice Chair, Chuck Goldfarb, and they need to know what are you going to do to me? What What can you do to help me?

Charles Goldfarb:

Well, let me first say that of all the therapy tricks and tools, the risks widget is one of my favorite, it is a fantastic option for all things onerous added risk pain, it can be TFCC it can be ECU it can be vague wrist pain, there's a chance the wrist widget cures it so I love that suggestion. We you know sometimes that therapist custom Macomb you can order it on Amazon, there's there's a variety of different types. It's a great tool.

Chris Dy:

I love the risk, which it mainly because it I see a lot of vague on their side of risk paint my practice, and maybe it's because I, I'm seeing certain diagnoses and there are they're seeing me and I'm not seeing them, but it works. It works. It's a great first step, and patients seem to like it. And obviously our therapy colleagues provide a great resource with that.

Charles Goldfarb:

So so let me let me envision the Chris Dy ulnar sided wrist pain exam. Starts with cubital tunnel, careful examination, make sure that nerve is stable, and then a distal ulnar tunnel, a tinel's and a compression test. And then we don't want to forget the sensory branch of the ulnar nerve.

Chris Dy:

Yeah, exactly exactly the nerve of Calfee, as our partner Ryan Calfee described in his award winning article. Yeah, so I mean, you always got to start with the thing that's most important. And there're apparently bones and tendons and stuff underneath.

Charles Goldfarb:

Irrelevant. Alright, so in all seriousness, if this patient comes to surgery, and for me that, you know, there are a lot of variables, but a younger patient who had a great response to an injection, that wore off, whether that'd be three months or six weeks, I really feel is a good indication for surgery. The reason I think it's a good indication is number one, an arthroscopic intervention done well is safe, minimal morbidity, can be done, you know, in a relatively short fashion, and I just have good results. So I like it. And I don't think everyone would agree with everything I just said. But I like the procedure. So for me, it's a wrist arthroscopy, as I think I've said on this show before. I don't love diagnostic wrist arthroscopy as I like to have an idea of what I'm going to do. I don't almost ever do a wrist arthroscopy to just see what's going on. That doesn't feel right to me, although again, I recognize that for some it can be a true diagnostic tool, but in the scenario we've provided, and yes, you're going to confirm what's going on with the TFCC and with the ulnar side wrist pain, but kind of have a have a sense of what might be going on before the case.

Chris Dy:

It's interesting what we did last Firsthand in November with Jeff Greenberg from the Indiana Hand center to maybe feel like ordered way too many MRIs because I like to know really have a good sense of what's going on before I hit the O R. But his feeling was that I presume he's ordering less MRIs and he's using the the scope to confirm his clinical diagnosis, which again, after many years, has been honed to the point where maybe he doesn't need an MRI. So I think you know, there are a lot of ways to do it. I fall more into your camp than then his but maybe one day I'll get there.

Charles Goldfarb:

Yeah, I think I'm heading in that direction. But but I'm not there yet. And there's so many is so many variables, whether it's work comp or not, and getting approval and, and the like so maybe I'll just talk through the the scope process, how I how I, how I do.

Chris Dy:

Why don't I give you, why don't I give you a lightning round. And you can answer some of these questions. How about that?

Charles Goldfarb:

Making it easy for the old guy.

Chris Dy:

Alright, perfect. So in the OR, normal hand table?

Charles Goldfarb:

Normal hand table with a leg.

Chris Dy:

Okay, hand table with the leg, why the leg?

Charles Goldfarb:

You don't want the hand table kind of wobbling up and down without the stability. So just like you would insist on a leg to that hand table for a scope case I insist-

Chris Dy:

The right the right kind of the cool kind of scope, the microscope.

Charles Goldfarb:

Yeah, the other kind of scope.

Chris Dy:

As a as a rule for our residents and fellows if there's word scope involved, but a leg on the table.

Charles Goldfarb:

There we go. We just simplified it.

Chris Dy:

There you go. So I feel like this is the consensus agreement of 2021. So okay, tourniquet, yes. Okay. And then the we've talked about the Linde med traction tower in the past and shout out to the to the reps who have contacted us to trial their new tower I've tried it once or twice, and it's fantastic. But you can sponsor the podcast, email us. And if you're using the old tower that everybody had from the 1990s, that had the VHS tape on it. Do, what do you do in terms of setting that up, because the VHS tape video says that you're supposed to strap that down to the table.

Charles Goldfarb:

Yeah, so I still do use the limit tech tracking tower, I do not strap it to the table, there's two straps, I use one to hold the forearm to the vertical portion of the traction tower, the other to hold the arm to the base of the traction towers that allows you to apply traction to the fingers safely. I use towers that I'm sorry, use towels to protect the skin. And I use 10 to 12 pounds of traction, almost always to the middle and ring finger alone.

Chris Dy:

What is preventing the traction that you're applying through the finger traps from pulling the patient off the table?

Charles Goldfarb:

It's only 10 to 12 pounds of traction. And I think as long as you hold the arm down to the tower that caught the setup is more than 10 or 12 pounds. So I've never pulled the patient off the table.

Chris Dy:

So as a non expert in wrist arthroscopy, I set it up a little differently. I follow the old video and the old video which is amazing. You know has the picture of somebody with a tourniquet on and then a strap over the tourniquet which I will do because I don't like stuff moving around when I'm trying to do my wrist scope.

Charles Goldfarb:

No, I'm only, only got love for you that is the only way of doing it.

Chris Dy:

Okay, so we've got the wrist in traction you said 10 to 12 pounds, finger traps on which fingers?

Charles Goldfarb:

Just middle and ring. That's it.

Chris Dy:

Okay. Does it ever vary based on where you're trying to get to?

Charles Goldfarb:

Yeah, I guess if it's more radial sided pathology I might go index and middle. I've never used all four, I don't think it's necessary. So it's two fingers, not more than 12 pounds. been happy with the two central digits.

Chris Dy:

I've been told never to commit the sin of drawing your mark landmarks on a patient until your in traction is that correct?

Charles Goldfarb:

Absolutely.

Chris Dy:

What do you draw?

Charles Goldfarb:

I depends on who's with me. I draw a transverse almost always three, four portal. And I draw where I expect the six R portal to be although I always confirm that with needle localization prior to making that decision.

Chris Dy:

Why transverse for three, four.

Charles Goldfarb:

It looks much better postop I don't think it matters, it doesn't matter a darn bit for access. It heals better. It's in Langer's lines, it looks better.

Chris Dy:

And then in terms of getting to your mid carpal joint down the line, we'll talk about that in a second. Do you go through the same incision that you've made for three four?

Charles Goldfarb:

Same incision, I take a curved hemostat, small, curved hemostat. And I go a little more ulnar and a little more distally such that I'm in line with the third metacarpal about a centimeter distal to my three, four, joint entry spot.

Chris Dy:

Insufflate the joint?

Charles Goldfarb:

No doesn't help. I was taught to do it that way. It doesn't change a darn thing. It doesn't make it easier. It doesn't you don't, you can't put fluid in there that will separate the bones. There, you're not there. You're not increasing the joint to nerve or joint artery distance. Totally unnecessary.

Chris Dy:

I like it because it helps me or the trainee who's establishing the portals understand exactly where we need to go. I recognize that putting in a wrist or arthroscope into three four is kind of like tying your shoes for you. But for the rest of us. We like to have a little guidance.

Charles Goldfarb:

Oh my god, it's totally unnecessary. Yeah, no, no, no problem. I mean, unless you're a dry scoper like some of our friends are but no, no problem at all. I just don't think it helps me.

Chris Dy:

Okay, so take me through exactly how that how you're establishing the portal like every nitty gritty detail.

Charles Goldfarb:

Skin incision, transverse to the dermis and epidermis only. Blunt dissection down to the dorsal distal rim, or the distal dorsal rim of the radius. And then using the curvature of the hemostat I pop over and into the joint, I spread reasonably aggressive. You don't want your portal being huge, because then the scope will just slide in and out. And that's not stable. But you also don't want to struggle every time you you choose to pull your scope out.

Chris Dy:

For the for the former Gelberman trainees Is this the Gelberman, like a person spread or is this. Where is it on that spectrum?

Charles Goldfarb:

Yeah, if a 10 is like your biggest spread ever, this is a seven.

Chris Dy:

Okay, got it.

Charles Goldfarb:

Yeah, so good, but not great one. And then I proceed with a assuming I can see and there's not too many air bubbles or just things that are irritants. I start with my diagnostic arthroscopy, which I do the same way every time, which I can talk through if it's helpful.

Chris Dy:

Yeah, let's do it, so same way every time.

Charles Goldfarb:

Yep. So you're looking right at the membranous portion of the SL ligament and the ligament of Testut volarly, when you look radially you're looking at the scaphoid facet of the distal radius, and the proximal and a little bit of the proximal waist of the scaphoid. You can see a little bit of the styloid. And then most importantly, I like to confirm the radioscaphocapitate and long radial lunate ligaments. So from volar radial heading centrally, short radial lunate ligament also visible essentially straight ahead. I always pull the scope back, drop my hand, so I'm looking up. So I'm seeing the dorsal SL, which is perhaps the most important ligament on the radial side. If all that looks good, I move ulnarly. And then I'm looking at the proximal aspect of the lunate. I'm looking at the lunate facet of the distal radius and I'm heading over towards the gold which is the ulnar wrist and the TFCC.

Chris Dy:

Is there anything you're doing on the radial side before you establish portal on the other side?

Charles Goldfarb:

Other than just making you know, assuming we're dealing with owner said risky No, I'm just just taking a look to make sure I'm not missing anything. If I do see significant synovitis or something like that. I want to know why because that's pretty uncommon. But otherwise I just move move to establish my six our portal with Anita localization, incision blunt dissection, placement of my shaver in the joint.

Chris Dy:

Okay, so you've got your shaver in the joint now. Do you? Let's say you are wet arthroscopy, so no dry arthroscopy, because you don't want to burn in Blaze, anything that doesn't need to be handled as such. You know, when you're looking at this, are you using your shaver to assess things like the TFCC are using a probe?

Charles Goldfarb:

I think you could do either, I'm actually been using a probe more, it really does give you a better sense of stability. So when I look at the TFCC, I start with a trampoline sign. And this is one of those tests where you need to establish your own personal parameters of what's normal, what's not normal. Really the TFCC should be like a military made bed, really taught intense without laxity. If there is laxity doesn't

Chris Dy:

like a trainee on their first day of the Goldfarb rotation,

Charles Goldfarb:

the laid back Goldfarb road

Chris Dy:

Oh, yeah, sure. A stranger at the golf our rotation of seven years ago.

Charles Goldfarb:

The Yeah, so you're if you have laxity when you do the trampoline test. So you're bouncing your your instrument on the on the TFCC. You don't necessarily know what's going on, but you know something's not right. And that can be a central tear. That could be a peripheral tear, that could be a subsurface or phobias there. But you know, something's not right. So I do that.

Chris Dy:

They're all trampoline tests. Do. Is there anything? Is there any sort of internal control? Is there any other tissue in there that you can push on to give you a good sense?

Charles Goldfarb:

No, I really don't think there is. So it is it is, you know, and there's age related degradation, I would say and there's different changes over time, but now.

Chris Dy:

Okay. All right. Then what else? What else do you use to assess? Well, there's

Charles Goldfarb:

always synovitis on the owner side of the wrist, and especially in the freestyle, it resets the freestyle recess is essentially do owner. There's always synovitis there because I think that's what's contributing to your pain. You know, the synovitis develops because of pathology and incentivizes what I believe is causing the pain and incentivizes what I believe the corticosteroid injection takes away and then by the time you're back in the or it's back. So you bring it and then you're really looking for what's going on and so you can look vulgarly and what you're looking for Volvo is a good understanding of the owner to control and own the loonie ligaments. And if you're one who believes the male experience, there can be a split tear between those two ligaments i i don't see that often. But I trust the people who report it sounds good car believes strongly. That's a commonly missed diagnosis. So always look for it. And you're getting you're using your probe you're using your kind of historical context to see if there's pathology, inflammation, volere and owner. We're looking door so an owner right under the ECU tendon, so it's pretty uncommon to have a straight owner tear, most of the tears are really dorsal and owner and you're looking for a separation between the TFCC and the dorsal capsule, and sometimes that can scar in and so the tissue may not look completely normal. You may put your shaver in that area, it's really hard to injure the TFCC with a shaver and so I'm okay trying to clean that area up and see if there's a tear. Central tears or radio sided tears are usually obvious, but you need to make sure you don't miss one. And if there is a tear in either of those locations, presumably the dorsal part of the TFCC and the volar. Part of the TFC are okay so you do breed those with a shaver with a biter and you want to just try to stabilize them so that there's less kind of wiggliness or rubbing, because I do think that can contribute to pain. You don't stitch a central tear because there's no blood supply, it won't heal radial sided tears, almost no one repairs them because there's no need to and it's actually pretty tricky to do. So.

Chris Dy:

That's the longest and most passionately you've ever talked on the podcast in almost two years, we've been doing this.

Charles Goldfarb:

I'm just getting started. So so

Chris Dy:

how do you how do you assess you published on this the hook the hook test? Like tell me what that how that plays into your algorithm here? And I'll describe it first.

Charles Goldfarb:

Yeah, so I'll describe it, then I'll give you my my two cents. So trying to understand whether whether or not there's a subsurface tear of the TFC is tricky. Some would advocate a D or uj. arthroscopy, I think that's really hard to do and visualize well, some would advocate a straight owner like a six you portal, which has its own risk of nerve methodology or nerve injury. But I think a hook test is really great. So the hook test is basically your probe goes in the six, our portal, and you're trying to get a hook underneath the owner side of the TFCC. And if there is not a phobia attachment, you can lift the TFCC up. And again, it's a test based on your experience. But you can, you know, make that diagnosis. The suction test is also an interesting one, it's not always positive, even if there is likely a phobia tear. But if you put the shaver in and turn on the suction and the whole TFCC rises, then there's nothing, keeping it down to the all night. And that's a clear positive sign of a filial tear.

Chris Dy:

Before I get to my next question, we asked you how when you're doing your normal scope, how much suction do you have on do you ever have suction on I mean, is it just a small bit, the full suction the whole time.

Charles Goldfarb:

So I turn suction on whenever I shave, and I use the suction install, I turn on maximum. And I use it to bring the tissue that needs to be to Brita to the shaver. And then I use it for this and otherwise I don't use it.

Chris Dy:

So what's the importance of a subsurface foveal? Tear?

Charles Goldfarb:

I'll start by saying the first 10 years of my practice, I wasn't aware. And I would say most or all of us weren't aware that that was a real entity. Except for in massive traumas and things like that. And if you can't see it, you know, we didn't fix it. So I was never taught to fix it. I don't know how many fovea tears I may have missed. I gradually became aware and learn to recognize these tears over the last 10 years or eight years or something like that. What's remarkable, and here's the most controversial thing I'm going to say is that I do a lot of scopes, at least I think my volume is high. I probably on average, do two risk scopes a week for owner side of risk. And I've actually looked at the numbers recently. So that's about rights and there's more but but I would say two is a safe number. When I do a TFCC repair 75% of them are now Ferrovial repairs may be higher versus peripheral repairs. That's remarkable. And certainly I may have a little bit of a lower threshold for performing that kind of repair. If I get a weird trampoline sign if I get a positive hook test if I have a positive suction test, if I have preoperative suggestion of instability, but it's real. I do not think I'm over calling it and I'll keep going on my passionate diatribe. You know Marty Boyer and I used to have these discussions in our anatomy session, because Martin because used it used to be that we only did an outside in repair and that will be a small incision near the ECU. You use the ECU sub sheath as the stabilizing post and you put a switch through the TFCC classic still very appropriate when it when it calls when it's called for GFDL started talking about using suture anchors, or even meniscus repair kits that like deploy a little, a little device to repair the TFCC. But unless you're using an anchor, or an animal down to bone, or unless you are bringing the TFCC down the bone, the other TFC repairs do not provide stability. They might help pain, but they don't help stability. And so this fovea repair is a stabilizer it does make a fundamental difference to the stability of the deer year.

Chris Dy:

So what what types of tears either characteristics of the tear itself or disability Why is it one of the tears or injuries that aren't addressable with the fovea repair before we get into your technique on the fovea repair

Charles Goldfarb:

straightforward Central or essential TFCC or perhaps related to own a carpal impaction peripheral tear. I mean, I don't think it'd be wrong to treat a peripheral tear with a fovea repair but I don't Do you need to do it? And then you can just read it or do it Do or do a outside and repair?

Chris Dy:

Do you see peripheral? Do you see peripheral tears with instability? Are they typically Fulvio tears that have instability?

Charles Goldfarb:

It's folio tears that have instability. And it's rare. I don't want to misrepresent this. It's rare that you do a Dr. EJ shocking. And it is moving all over the place. And even if you do a good piano key where the patient puts both hands down on the table, and you tell him to push into the table, it's rare that you see a big difference between the owner mobilizing on one side versus the other. But it's just a sense and the patient will tell you, if you if you ask them and listen, the patient will tell you.

Chris Dy:

So tell me about how you do your folio repair in 2021.

Charles Goldfarb:

Yeah, so there are different techniques and I I have really mainly use one technique, sometimes you can freehand it, being very careful to protect that sensory branch, the older nerve, and when I freehand it, I make an incision, an extended six U incision protect the sensory nerve. And then you can place a needle dorsal and vulner to the styloid. And bring those up and under the TFCC and put a horizontal mattress suture and tie it over the owner side of the OMA but what I almost always do is is what we most people call an owner tunnel approach. So you make an incision, just proximal to the styloid. Work volar to the ECU down to bone, you place a K wire through the bone and not a horizontal angle and not a very vertical angle. And you drill to the fovea is where the fovea is essentially where the styloid meets the flat part of the distal Oma. And so your your goal is to exit the K wire right at that point, the shorter the tunnel, the more ability you have to place a wide horizontal matters suture. The longer and steeper the tunnel, it's very hard to separate your sutures and so you can more vertical the tunnel the more vertical the tunnel, so I shoot for a short oblique tunnel rather than a very vertical tunnel.

Chris Dy:

Do you ever use the the the aiming arms that are supplied for that?

Charles Goldfarb:

I don't find those helpful anymore? I think they can be there's nothing wrong with them at all. But I don't I don't use them now.

Chris Dy:

Okay, so then you've inserted so you've drilled this tunnel with K wire? How are you?

Charles Goldfarb:

I'm sorry. So I placed the keyword confirmed by CRM radiograph over drill it with about a three millimeter drill bit. And then essentially, the technique that said I use is the Arthrex that I don't work with our techs and essentially put the suture through the TFCC. You pulled out your six our portal, and then you put a essentially a loop through the TFCC in a horizontal mattress type fashion, pull the loop out of the six our portal, then you put your suture through the loop and pull it all down through your tunnel, and you've got a great horizontal mattress.

Chris Dy:

So you talked about having a wide mattress, how wide is the right width?

Charles Goldfarb:

Well, a you don't want it to pull through. And sometimes the TFCC can get, you know less substantial over time, but it's usually a pretty sturdy structure. I hope that is at least two to three millimeters wide. That mattress and usually it's just one mattress I have done to mattresses on occasion for strength purposes or for kind of size of tear or size of patient. But usually it's one strong suture. It's firewire because it's Arthrex. And then you basically you can do whatever you want to, to anchor the suture. I usually just use a little anchor into the

Chris Dy:

bone. What's the caliber of that suture? Is it a two? Oh,

Charles Goldfarb:

it's a it's a two? Oh,

Chris Dy:

yeah. Yeah. And then when you're anchoring it down. Do you have any pearls for tensioning? Or how you position the form the wrist as you're doing it to keep it on traction all the time? What are your pearls for that?

Charles Goldfarb:

Yeah, great question. If you put this stitch suture ease centrically I always worry that I'll lose rotation and my sutures never, it's not always perfectly in the middle of the distal ulna, but I haven't lost rotations that's point 1.2 is always tension it with no finger traction. So I'm sitting there attended 12 pounds of traction I released that I apply maximum traction on the suture as I put the anchor into the bone, and as I put the anchor into the bone, I release my hold on the suture and just push it into the bone. And it's been pretty good. Again, I haven't overtightened haven't lost rotation and it seems to do the job and the idea is that you're you're you're kind of irritated just to own it with that drill hole. Sometimes I'll put a shaver down on the on the distal aspect of the owner before I put my suture to quote unquote roughing it up, but you're hoping that that TFCC adheres back down the bone which provides stability and heals.

Chris Dy:

So for that technique, you describe using that on their tunnel, when would you use that outside? And I think you described it as being a peripheral, not foveal tear that that you're obviously doing more than to breeding. Is that an accurate assumption or a summary?

Charles Goldfarb:

That's exactly right.

Chris Dy:

That's exactly and then in terms of exactly how you would do that. You gave a little bit of a description earlier for somebody who's learning how to do it. How would you do it?

Charles Goldfarb:

Yeah, so I use my six our portal. So I always make that portal longitudinally in case I need to extend extend my six our portal, I look out for that transverse branch of the sensory owner nerve as uncommonly present but I look out for it. I dissect down to the ECU sub sheath at the joint level, I open the ECU sheath and sub sheath and put up a rag Nell retract of the small end of a rag now to pull the ECU more owner Li. And then I use a meniscus mender is called the meniscus mender to it's a right medical first generation meniscus repair set, but it has perfectly small size needles. They're curved, is inexpensive. And essentially I put those through the ECU sub sheet and into the TFCC. And again, I create a horizontal mattress suture. I pull it down to the ECU sub sheet and type

Chris Dy:

is that device that I'm saying this in all seriousness? Is that device still widely available?

Charles Goldfarb:

It is? It absolutely is. I think it's only used to my knowledge for the wrist but who knows.

Chris Dy:

Okay, good. And then are there any other repair techniques that we should talk about open? I mean, is there still a role for an open TSCC repair? I know that's how some people only do

Charles Goldfarb:

it. Yeah, I would say two things. First, there is you know, you can do a straight owner repair with two needles, you know, two needles are cool, they're in the anesthesia set if you ever need one, they all anesthesia always has them. And I think there may be in their lumbar puncture center. But if you ask the right person from the anesthesia supply team, they'll find you two needles. And they are essentially not sharp and so they won't cut your suture. So if you visualize from the six are, you can put your suture in from the three four portal and you can basically create a horizontal mattress and tie it over the ulnar capsule. So you basically take it, you put it through the TFCC, from dorsal to volar and radial to owner and you and then you have a little incision, so you protect that sensory nerve. And then you can hold the suture outside the capsule, pull the needle back, and then push the needle through again, because the needle won't cut the suture. And then all of a sudden you have a nice horizontal mattress which you can tie over the capsule. I don't do that repair very often. Because one, true owner sided tears are not that common in my experience. And two, you don't want to close down that pre styloid recess, because if you do that you will lose rotation. And then your last question is Yeah, owner sided, open TFCC repairs are absolutely appropriate. And they're really good arthroscopy and good surgeons who choose that technique, I will sometimes do it, I find it difficult to put the sutures exactly where I want them. You can put an anchor in or you can put drill holes through the older styloid but is absolutely appropriate is dealer's choice. And I like it.

Chris Dy:

When was the last time you did one,

Charles Goldfarb:

I have done one recently, it was a situation where it was a bad distal radius fracture without an owner styloid fracture, I fixed the radius there was still gross instability. So I made a I made an incision. And there was a massive faux veal tear of the TFCC. So I put I put one anchor and I wondered after the fact that I've done too. And I did it open repair and it was it was fine. It was fine. Where did you put the anchor. In this case, I put the anchor doors to kind of dorsally near the styloid. So my incision was the you know, there's different ways to do it, you can make a straight older incision, or you can make essentially a transverse incision under the ECU tendon. And in this case, I was more dorsal. So I put my anchor there and then I did a grasping suture of the TFCC.

Chris Dy:

So for you, what would you advise people who are learning how to do this technique and you know, shot because I noticed that in my training, I mainly saw you use the ulnar tunnel technique. I never saw you use a meniscus mender I never saw use it to a needle and I certainly didn't see an open repair. But one of the limitations of growing up in this era of newer techniques is that you don't learn the old school way of doing it.

Charles Goldfarb:

There used to be a great course By the by Anna and the hand society for wrist and elbow arthroscopy, and it was a shame that that course is not offered, because a lot of this is just being at a course. And I really think it's true a course that focuses on repair techniques and arthroscopic techniques. And, you know, having a good senior partner helps doing the right fellowship helps. But I don't know the answer to your question. I mean, you have to get exposure somehow. And I really think the problem with arthroscopic education is you have to see enough to be comfortable with pathology, because I still think our definitions of what is pathological are not completely clear,

Chris Dy:

at least well, on top of that there is the variability in who's reading them, which I know is the topic of one of our fellows research projects.

Charles Goldfarb:

So absolutely. We're working hard on that one.

Chris Dy:

So is it is the postdoc protocol, the same for all of the different techniques you describe,

Charles Goldfarb:

actually, for me, and there is no science here. For me, it is not, I use a shorter arm splint and cast for a peripheral repair. I just don't think there's much of a risk of that tearing out. So I keep life simple for the patient. For a fovea repair, I use a sugar Tong splint for two weeks and a monster cast for four weeks before I start therapy.

Chris Dy:

Wait, hold on. So you're for the terror that what you do, you do not have a bone tunnel, you are less restrictive. But for the repair in which you have a bone tunnel backed up by a suture anchor, you are more restrictive.

Charles Goldfarb:

I just don't think the torque is with rotation is much on that peripheral repair. And I worry more a because it's more significant for the fovea repair and I would hate for it to fail. I just worry more about it and again, may be nonsensical. I hope a listener will call me out and educate me if they disagree.

Chris Dy:

Well, it's clearly worked. So it has worked. Yeah, exactly. And when do you start, you know, for our therapy, colleagues listening, so say your peripheral repair. What's your protocol in terms of initiating motion? When do you get them out of that short arm? splint? Cast? orthosis?

Charles Goldfarb:

Yeah, so it's six weeks, there's actually do you want to be really precise, five weeks and five days later, start therapy in both groups. volar resting splint, active and progressive passive motion. Once passive motions restored, strengthening can begin that's usually eight weeks strengthening between eight and 12 weeks and depending on how the patient's doing ramp up thereafter.

Chris Dy:

So the rehab protocols don't change just the initial mobilization between the two groups. Yes. Okay. And at what point do you sprinkle the holy water on the patient?

Charles Goldfarb:

Every every visit every visit? I have a big bat. Meeting. I need it.

Chris Dy:

Fantastic. Well, if at listeners have any other questions about protocols and details for arthroscopy and TFCC repair, send it to us. I'm not going to pretend to try to answer any of them. But we'll ask Chuck. We'll call we'll just change the name of the podcast asked Chuck. So hand podcast@gmail.com as Chuck your arthroscopy questions,

Charles Goldfarb:

yeah. And I hope all you sports lovers out there, which we know is the majority of the listeners. I hope you guys are all happy and satiated. And look, I'm still learning so educate me if you see things differently, please.

Chris Dy:

Fantastic. Well, we'll see you next week.

Charles Goldfarb:

Thank you. Hey, Chris, that was fun. Let's do it again real soon.

Chris Dy:

Sounds good. Well, be sure to check us out on Twitter at hand podcast. Hey, Chuck, what's your Twitter handle?

Charles Goldfarb:

Mine is at congenital hand. What about you?

Chris Dy:

Mine is at Chris de MD spelled dy. If you'd like to email us, you can reach us at hand podcast@gmail.com.

Charles Goldfarb:

And remember, please subscribe wherever you get your podcast and be

Chris Dy:

sure to leave a review that helps us get the word out.

Charles Goldfarb:

Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand come back next