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A-1291 Chronic injuries of SL ligament: reconstruction
Greg Bain, Australia
Wednesday, June 13, 2018 · 2:37 p.m. · 16m 54s
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so what what we're going to do is look at some of the indications so
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the indications which uh uh well known to many people in this grid
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is uh it's usually the sub acute invoke a association and serve you the very cute
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environment we might just perform repair or stabilisation of the scuffle than i can double
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it's important that we have a correct abode for many and uh it's not
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uncommon in clinical practised that we get into the uh in the wrist
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and we're looking at bingham report the the structures back together but we're not i would reduce the this
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guy for that interval to the correct position for us to pay is useful with regard to this
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identifying how the the wrist moods and one thing that with an
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useful is to put the basically the what similar that
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reducing the distal sky fourteen taking it through a range of motion
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and saying if we are i wouldn't mind trying the motion
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and also reduce this guy for that enable after that uh and of the roast beef
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atrocities itself is also useful because it's uh it's interesting
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how often we would say patience to have some
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degenerative changes vertically or the right you started that's uh a little bit earlier than we might expect
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this patient on the top right is is a passion of mine who it three months
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uh i perform this out for us to be you know i had a plan to do this guy from the net like what reconstruction
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but there's actually more advanced degenerative chinese of the reading stalled in only the three
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month period so the interval at which definitely commit reconstructions is actually narrowing down
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so i would tending to do uh that the cute we pay is not actually
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doing them for court as long as we used to and the reconstructions
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uh whereas the other options which would be the savage options such as limber
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wrist visions would probably doing a little bit early than we had before
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we've been using for the c. t. scan to try and get a better understanding of some of these issues so
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on your top the top left you can see that clearly there's a static dice dice is at the interval
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but with regard to the forty city we can say that there is a little
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bit of opening up all this in double this guy for a lunatic level
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so when we look at this we weren't quite sure what that meant but with this is the sign patient
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and we can say here that this guy from the net interval opens up with a clenched fist
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few obviously could still clenched fist x-ray but getting a better understanding of this fall with forty modelling i
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think is helped just advance in how we going with regard to some of these complex issues
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this case is well demonstrates quite nicely uh the association
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with regard to the degenerative changes that occur
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and you can say that this passion has an hour trends location of the cop us
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and is impinging on the uh the lynette to say it with degenerative changes this
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actually this is not an example that we would be i mean this sort of treatment
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towards and then finally this is the case that kind was we we identified
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that there was a torso dislocation of the sky ford which
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we did not reduce on the uh standard model oscillation
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and this was not a condition that we were aware of and if you look at the classifications that have been
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described by would talk about the the dynamic and then the program i can and going out a static
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but this this system dislocation of the sky ford is not part of the spectrum i think
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it's something that we need to think about it and it's a form of lop dislocation
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i mentioned previously about the importance of this serial sectioning study
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so if in the zero sixteen study that divided the scuffle and i like mad which
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would later dice dice itself to the three millimetres at the sky fallen in double
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once they realise then the doors when the cop like mad and the doors already accomplishment then i can get a
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true dice dice is at the five or six millimetres so the importance of the second restrains is critical
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so with regard to the uh classifications and the top of the concepts that we would it would use
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we have this uh marcus the last i think is help us a lot
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with regard to the apostle tae or this is a complete to yeah
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going under those situations where we might look at repairing at all and also understanding the alignment
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whether we can reduce it and with this um a process which must be tied into account when assessing these passions
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in a scenario where uh in my practised for my have a perry learned or some other complex acute injury
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it would not be an comments in my practised to add to that as a as a black a repair
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and there's different ways of doing that news usual juror black technique was to repair and
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stylised hastily but i think till her that's modification over leasing it off the radius
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and translating and bring it back full would i the dorsal aspect the right is
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is technically simpler and maybe something that you can use in your practised
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a professor bernoulli describe the concept which is now well non of using the uh ready uh
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flex a copy right realised tendon which is true through the sky forward and out of
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the dorsal aspect of the this to sky for this title laws is the radius
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and although i'm many people critical this technique it was very
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effective at getting rid of the clanking and catching the
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passion had with dynamic activities and so although we're now trying
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to many more reconstructive techniques them all anatomically correct
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the idea of bracing and preventing the doors to sublet stations
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the bernoulli with with an important addition to our understanding
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i've already shown before this image on the left and you can see here how
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that the dorsal sky for becomes exposed particularly in in somehow the deviation
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and the bernoulli guys straight across the top of that province that also sublet station the concept
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of the the try tendon reconstruction is being popular and used by many surgeons and take
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the many citizens group quite expect and they're out the what interest may with this technique is
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i think it does provide some improvement with regard to symptomatic clicking and the catching
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in mine hands i was concerned that the patients had some stiffness and they're
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always disappointed in my own results with regard to the system die spices
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and it's interesting to note in the author's piper that actually stated then no longer do the x. rays because otherwise they might be
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disappointed so actually wondered whether in fact had there was this was
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probably not the right outside the managing some of these problems
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so uh what i want in my project this was whether rocket mike this better
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and have it surprised me that i didn't include the door soon accomplishment
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'cause it dawson in the cup like my is a is a primary straight but provides
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extra support across the back of the entire aspect of the proximal couple right
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and i also wondered whether to use some of the new generation and uh
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uh anchor devices uh that we might be out in a clinical practised get a
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better outcome and the other thing that we were doing was that east west
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um as casual basis which and i was to bring that
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entire capture from the this from the sky for
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run across to the uh around us all the cop us to help flaws that enable cross the back
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so this was a passion that presented to me a thirty six
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zero jen metaphor from a letter he presents it six months
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and we've done that uh uh my uh better get technique and we've opened that up as a catch
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a flat we've put it through hole through the sky ford like a many a surgeon's to
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and the thing that we did differently was would grab that uh if the attendant through the
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sky forward and we put a searcher anchor right on to the right you started
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yeah so right on to the uh the attachments side of the dorsal aspect this guy from at like mad
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and we put an anchor in their into that position as demonstrate in that to photograph the
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with this anchor it's a tangible anchor and we can advance the the wretched on there and i
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told that tendon through the hole through the doors its dorsal aspect of the sky ford
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had the you can see it's locked into position there so this reeks reeks recreates
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the tightening of the uh we have c. r. on the ball or aspect of the uh s. t. s. t. t.
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joint listen here that really hasn't got much a discussion but as we all know that this guy ford folding
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affliction that really what that's also saying is the s. t. tae joint is going to hyper extension so this manner
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that by tightening the f. c. atlanta map tends to bring the whole distal aspect of the campus down
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on to them all of our position of the sky full it and
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i think this is an important a contribution of this technique
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so we then place a second anchor and the second anchor goes into
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the other footprint of the the sky for the night interval
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so we can say here that we've identified that would put a drill hall in and with vance that
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position and then it's a tangible anchors so we're able to close that up so that lock scene
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and creates and and a gloss that decision so we can say on this little video
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so the first thing 'cause already in position in the first pile model
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and then as we rotate that it then pulls that together
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but also how lots that you shouldn't i that tight knit too much 'cause otherwise it only two dice dice
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is on the ball is sort of the the scuffle involve so with regard to fix a copy ready
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understand and within take it through the the dorsal casual similar the technique described by gas your loss and
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then we bring that we're all the way back to sky forward to reconstruct the dorsal into accomplishment
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so this is the final construct that we have at the time of the surgery and we put a plaque
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adding switches to be at a whole that whole construct into position so we then take that capture
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plus the other the entire aspect of the cop us again to help double braced across the dorsal aspect
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of the wrist so that would double breasted of the dorsal in the compound also ready accomplishments
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and that we would often plays a wire into the uh between the sky for like appetite low
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these days we don't tend to use it as often as we did in the past
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so this is a passionate to use we can say that would be never mind tine
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the into what the stifling that enable and this particular patient had a good clinical
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outcome uh to the point that times also concerned about with that come from a
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self stuff you say here is is actually pretty good is sort of a
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so he is is doing alright
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so but uh with regard to uh the technique that uh with the vault that it it it now with us to
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use to the ball respect to this to teach you want it also uses the flex a copy ready alice craft
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d. r. c. s. guy from the net ligaments in addition it and i
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was just to thing to reduce and stylus this guy from an interval
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with a double pass out of the sky forward seven interval and includes the dorsal in the coupling which
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hadn't been included with conventional techniques and a lot of cases now we're avoiding the need for pain
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i'd also like to share with your technique developed by a mark ross
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who's from a a breeze been a stride is a a
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colleague of as in australia and the technique that he's to that which i think is quite useful in has a someplace
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so you can see here we've got the the coppers in his model through hole through the
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sky for it and then through the uh lou night and the truck which from
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and i'd knowledge to these are his slides we can see here the drill holes going through the cop as as all shown i think it's the
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video that really highlights it best with this it's yeah tandem is gone through
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the sky ford and then through the hours are the cop us
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and the technique that mark uses is depends type laws the uh that
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interval but the interference bits screw that's placed with the uh that
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it's yeah ten income that for the truck return he also then spans
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across the sky forward to stride laws that the aussie alignment
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finally i just like to we're still going to find out just what to talk about some after scott peck options
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uh we've covered some of the the open options and as you say this this many different techniques that are being described
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in fact it's it's it's a challenge to actually work at infrared to switch to the
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base surgical options a lotta knowledge christoph mill around with regard to this technique
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over after stopping dorsal caption that pieces and so this technique involves price passing switches
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after stopping klee through the uh the remnants of the stifling that like mad
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and so in my view i think the role of this is really more for the dynamic instabilities
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but the advantage of this it's minimally invasive and so the patients can how to
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get back to activities a little bit earlier than they had in the past
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and finally there's a number of breast surgeons uh developing and working with
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a really pretty well after stopping reconstructions using ten graphs and i've had some experience with that as
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well and i might point out it's it's it is a difficult and challenging technique and
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wondered recommend you can see the indicator very model for this lot to go through some of
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the the concepts that we've been working with the first one is with regard to visualisation
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the wire cities you really need to create a a the the sky for lynette
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portals from paul and also so the three four pole works okay and
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of all uh a portal as well so the technique that we use for
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the ball portal is between the this radius guy fuck appetite ligament
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and along radio lynette like men and it creates a lot of the the into ligament is designed and so the
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technique that we use is to advance uh this card sort of got the start looking directly at that
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and then the start is advanced strike on to the interval is demonstrated on
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the slide on the top left once that's in position you can then
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say the trends elimination onto the floor aspect of the campus and then
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we rile wrote that through to the ball respect to the wrist
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with uh listen to rod another mike a small cot and take the scarf around to the other side
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it does look a bit scary but the important thing is to stay to the right you side of the f. c. out tendon
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to minimise the chance of injury to the palm like a tiny scratch so this got can then be introduced through to the dollar
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side and then looking at the ball respect the cop as an
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across the dorsal aspect of the um of the caption structures
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so once you've created that position it enables you to to do a number of different
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things you can now have the build up from the balls on the dorsal side
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and when you think about any out frost to be that we do we're always looking with the below
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this to to triangle light so this enables us to do that so with the buy in preparation
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we know if the the the by any anatomy we try to basically what i call the same troll it up with as ligaments are to be yeah
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we're recant constituent the anatomical footprint so we're looking through the replace it i
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think the best way to do this is to use a a um
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uh like a storm and pain and put on to the t. handle driver and then you can drive that through if you try to use any sort
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of chi a while power you find it very challenging whereas if you just
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have it as a a sharp sparked you can then just advancing through
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and i start in pain even a young fashion you can still advance
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that straight through the sky ford just part by hand control
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so where i would it to create a channel through which switches can be passed
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and the that the concepts all the using the f. c. at ten or
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a tendon graft and stable laws in these with interference fits screws
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the advantage of interference fits screws it tends to be a a stronger hall and avoids the the issues with the chi was
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so there are a number of ways of doing this i don't wanna be to take trading is to have it
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should be done for uh if if it's what you wish to look at that i think you should
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uh look at some of these all of this uh provisionally a specific cynically francisco occur all he's done some
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excellent working on now that he's presenting that here that if this is something it's interest to you finally
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um i don't know work the results of a sky from it like reconstructions are difficult problem
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and the reason why there's so many people in this room is because we're all actually challenged about this
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so i would endeavour to to to encourage you that those patients that have degenerative osteoarthritis
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or contractual you really should be looking at other options such is a limited rescission
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a recent systematic review demonstrate only seventy percent good results and that
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the technique that was used didn't really matter so much
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so the indications need to be a accurate and correct the procedure with
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putting at ten then into the rest to reconstruct the ligament
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a ligament tendon are not the same thing they don't actually work the same why entertained and if
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it goes through endorsed you to handle doesn't actually he'll to the end of to bind
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it only who's to the perry austen so he putting it into the sky foreign to learn
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i there's not much period estimate the articulates service so they might be some issues the
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and then the final thing is the executioner these techniques
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is technically challenging and to identify symmetry points
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in some of these other things as something i think that was still all struggling with
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so in summary i think that the uh the the complex procedures i think we need to hit the indications and
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