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A-1299 Reconstruction of TFCC
Andreas Schweizer, Switzerland
Wednesday, June 13, 2018 · 4:18 p.m. · 18m 38s
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colour we will have a uh you you have said already but maybe some
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reputation is not is not too bad so first uh so mention
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to at and that to me after forum i uh uh to to
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allow a a goat pro soapy nation the the bony structure the
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morphology is is very important to allow a one hundred fifty we're
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up to one hundred eighty degrees of of uh of range
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of motion as you see here from the front that the radius is
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is wrapping around all are at the this is that that's
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why the shape is so important uh that this this movement is
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is possible and stability uh as well is is supported um
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you have also a a a slight lateral over onto posterior movement of the wall against uh
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outrageous as you already set of a couple of meters uh which is very important
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you feel later this is allowed to uh to to uh in conference soft uh
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off the wall that overhead as a as a rate is is it uh
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about fifty percent smaller than the than the radius of the of the sigmoid knowledge and this is
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allows a allows a colliding off dollar head against or in the in the sigmoid notch
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as you say before um when you don't even know turn you to position the rate isn't or no
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or uh or compressed against to to want we get there and uh the ligaments in this post
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in this uh in in in this load or or not so
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important as compared with your helper nation or in soapy nation
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the rate isn't all or shifted the port and then the ligaments become
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uh become very important now whether to stay belies there's sort of a lateral
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a forum forces this isn't the first line the t. f. c.
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uh the the solar regular joint capsule the interests as membrane and a little bit
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less the pro nature and uh did you see you tend in she
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shortly the anatomy again uh you have the
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of the t. f. c. you have the the the dorsal and the palmer regular ligament
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you have the uh the disk we have the the will know latent electric control equipment and
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the the mayonnaise 'cause some woke as well as the sushi to as a
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as a whole composition uh to make disability around is a disjoint
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but we have also the intro service membrane which is very important
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for the stability of of uh of these two bones
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you notice from investigations of load when you have a normal
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forum about eighty percent of the logo through the radius
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and uh is shifted through the interest as main brain to the
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to the whole now we know this where i'm in a examples ran the radio
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head is a is a way of because of a fracture off to
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uh it's decision that the input interests as member and becomes very important the low chance
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fair from the membrane to the from the radius total low is very high and
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uh if the if the membrane is is a part as in a six low
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prestige and then the complete sensibility of these two bones uh or a parent
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but the interest as membrane has also stability in the a. p.
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a direction as we know from from these measurements as you see in a yeah
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i around section that the altar postures as a a range is much more
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a a a prominent as in a intact membrane so back to the t. f. c. um
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the t. f. c. has a also two sections in a in a it is still
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a proximal way we you see here uh the the for the all
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of the people in which is the mechanical the most important
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one and you have also uh superficially and concerning it uh the
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range of motion you have what appears position do you have
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the this to ligaments or or or tension differently in a in
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a new to position the about about both uh limbs or
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or the same then your uh and uh and also the superficial ones that when you are in the pro nation it's
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it's mostly the palm are a part of the ligament british tension
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and d. f. in a in a soapy nation it's wiser
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so the dorsal but a a part it's completely the the
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other way around for the for the superficial a ligament
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when we test it in a a p. direction than we see that uh the palmer ligament this
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most important want against two protection dual head coming out to the dorsal side and uh sorry
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and in the in a in a in a in the the shifting to all the hat properly
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it's mostly the dorsal part which is ligament bases
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at testing clinically testing is very important and
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i have to say it's it's not so easy to do in this test uh it's it looks nice and it's
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but it's very difficult to to judge whether there is an instability or not easily it is is the
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is the the way the giving way you sit here or not or how much is is the weights it's rather uh
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a a qualitative uh not a quantitative a test
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you can also do a x. rays and as you said before very important look that uh the
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p. c. for men to stay free to or in line or at least to believe it
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just another part that you really can say that a dual low is is this located but
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you you have you have to pay for it you can do a it and arise
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uh yeah this is an intact you use you very nicely the insertion of the of the for
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the ligaments and the superficial well you can do without joe graffiti and you can show
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that uh the parts of the of the ligaments or disrupt that it's here but it's really
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difficult to to say whether there is any stability or not even if you have a
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a positive test in a more i and you see a disruption does not say that
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there is clinically uh and instability appendage needs a treat and it's a bit
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better as you said also in l. just copy you can pass the you can
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test the trampoline you come paul on the on the t. f. c. here
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uh we sure got about a good to not just company can go even been all the t. f. c. and
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c. but the insertion to of the to the uh
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part of the ligament is uh is torn and
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you can also uh uh um uh do with this uh uh um does lesions good
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or or uh applied different a stage as a as a as a described by
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a pipe bomb about even though we don't we don't know all these investigations to not say
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is there instability or not just the patient have reconstruction or not also this kind of
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uh of measurement would you what has been mentioned before is not really
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conclusive concerning it's a really instability not it's on this one
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um when you do with testing pressing on uh uh let the the patient pressing
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on the table but be make make sure that the patients pressing with this
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p. c. for tried by yourself any press with the p. c. for dole had
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is going up and down if you press on the scale of late
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that nothing nothing um nothing moves and this is the test uh to to really
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uh be able to say there is it's ability reuse this but to quantify
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um the the the shift of the old lovers the radius
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the the this ultrasound is here ultrasound probe that looks
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like a the this this is the the cross section this is uh the go outside you see here
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the the the floor of the fourth compartment here the overhead lifted top you press down with this
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uh this is in a in a normal range and this in a pop allergic situation
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lifting up till ahead is okay here but here you see that all the head
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goes far below this uh this tangential line of the fourth of the uh of
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the flow of the force compartment and this is out of uh out of
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for a out of the normal no normal space uh this is uh how it looks
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when we when we make a video you see the overhead uh going op
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and coming down the does in the code range does not go on that uh on that uh on the to stage
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of the of the of the radius and he here we can see that the older had goals for below
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the the level of the of the ratings and you can also
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measured base you can quantify it you can do we ratio
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uh which allows us to quantify this uh this instability and allows us to say
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to to the patient um uh whether we have to do something or not
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okay we come back to the uh it a stabilisation or procedures
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we know that many different procedure half we describe the uh
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most of them or or not on a comical i will our don't want to discuss on on them i will
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concentrate on a on a bryan adams reconstruction technique uh which is
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some atomic call it tries to reconstruct the the door
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so on the palm or not deal or ligament want to show see uh due with some uh and and uh
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a modification of this of this procedure we see you to drill holes this is the
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same through the radius at the insertion point of the of the tolerant the dorsal
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a a ligament and here at the for the all the dollar side and
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t. v. due to a drill holes for putting out the tent
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and here is the situation where the tennis ball to you see here
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to reconstruct the triangular uh was uh a t. f. c.
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a a configuration and you're here putting out the tendons and this way
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we can uh anatomical the reconstruction to the the deli given
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the operation technique is uh is shown here we do with a door so well
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nor approach curved then you go through to a fifth comma extension compartment
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then we open the joint in a in a in a curved fashion you see your overhead here's the t.
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f. c. is allows us to see below all the the the the t. f. c. here and
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and also between the t. f. c. n. to carpal ligament d.
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v. do a cult so we can really a charge the
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and uh and uh a t. f. c. itself the thickness of the t. f. t. t. f. t. itself which uh
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which has some inferences uh oh for the operation as well as as you
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afterwards yeah the t. f. c. is left the top you can also
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a charge to uh to injury or connie can see batted the the deep ligament is really
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completely torn or but there's just some some fibres are still still as they left
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then we need another incision on the palmer side uh
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first to to take the the the palmer's longest
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tendon and uh secondly to come to the palmer side of the radius surgery whole uh comes up
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tend to do a whole is made from door slowly to paul morley is you hit the trail you
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really the review do this on to imitate image intensify
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control uh we use a candle lighted trill
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put in first that uh the k. wire guiding light here we check uh aunt on both uh
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both projections that we are to write space to be as near as possible
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uh to the to the blue note for site and the sigmoid knowledge
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usually the we can also use some some guide uh devices uh
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for instance used for the a. c. l. reconstruction
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sometimes it's difficult to get a try it's both a right spot that the
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first time then you have to put in another second came i
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don't in your happy and then you end up with a whole which is that uh that that uh really does still lower corner
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um for the second drill hole into the whole lot it's very important that this is also at the right spot if your
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not in the fall we are here somewhere here or yet and the
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tension of the ligaments will not be gotten you have either
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a a a restricted probation or so p. nation and the laxity
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in in one of the older till the position so make
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sure that uh the the drill hole is in front of
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the of the style it particularly when you're operating on
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the patient and try to to be nation dollar stay no it isn't no really on the palm or side cannot or
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will not on the lower side make sure a bit a
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bit the distillery does you can also put some units
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in front and back of the store they to to uh to localise it and to weasel has it for use uh
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for yourself that after the trail hold that the trial is made in dollar shafted with the l. the drill holes
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a tool for the the pullout sutures use the first to the second one
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so this is arrangement of the drill holes on the over here on the radius than a a friend is pull through
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like this then the tendon just poured through from the palmer to the to the dorsal side and uh
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and did from the dorsal side to that overhead it's quite easy from
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the palmer side to the to the to the dorsal site
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it's a little bit more difficult because you have to make sure
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that no we have like certain is between the uh to
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senator croft that the second uh uh the second ten just pull through to overhead as well
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here second this is the first already in then the tendons or or
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tangent and here it's uh it's very important that you tension there
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the uh the the crafty neutral position because if you're in pro or soapy nation then you have a shift
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in the in the in the in the bones and you tend to either the pole model that also
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a part of the of the of to reconstruct too much or not to not enough
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there are some uh some possibilities to to to increase strength you can
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if you have a uh go to a a good t.
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f. c. you can also a a suture the t. f. c.
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together if the if the croft to increase the strength
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there is also a possibility to not pull out the the the real holes through to a
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shaft parts to do some tools smalls directly
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a proximal to the the joint surface
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and to fix it with indifference cruise i think uh that makes the the primary stability
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a better and you you can bet attention the the ligaments as compared as
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you when you attention to do some martin put uh threats through it
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it everything loses a little bit out but with uh is that uh i'm
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into france cruise i think you can you can get a better stability
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if if the t. f. c. is a very thick it has a very good quality you
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can't even uh put it through the t. f. c. itself and pull them out too
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with uh these to drill holes to uh to prevent the the
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drill hole in uh in in the uh through the radius
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after treatment this um up around cause for four weeks put all uh put the cost
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in involved a little bit stupid nation because this is a this is a
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where you have to rate isn't all in a more accurately break that a a situation and
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after four weeks you you start with the with the with the the range of motion
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simple soapy nation off to sea monster can stored strikes training and off to six months you
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you can give a uh you can left that activity is free for for everything
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pete false or or the pitfalls you can also have an instability
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secondarily due to um our union so make sure that the that there is no money in in their
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um because if you're correct them audio new new tension the ligaments as well as this so oblique
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band the port of the of the the support of the internal says membrane and you don't have to
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uh a goal for a t. f. c. reconstruction as show by this example you see uh
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dismal union here if it just passes of the of the this already law
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joint and uh if you correct it you see that the joint
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does val and afterwards and jointly stable without doing anything on uh on
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the on the d. wrote on the on the t. f. c.
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oh and also be aware about about this
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is uh you see a snapping in the this already allowed joint
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this is again another pathology which usually goes to uh
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two mile union of the shaft if you have a million human in the shaft middle third done um the
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proximal third is cheap in in in place by the by the central band of the intro says membrane
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and uh and the radius flips out when the patient goes in in soapy nation and uh
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if you if you see snapping race like this you should always do an x. ray of the form
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uh we usually do a three d. analysis has done by
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this patient you see here there's a about an english
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of about ten degrees and you have to you have to correct this we do this three dimensional it
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uh with this this guide so you can be pretty sure that it's very accurate uh
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and you see it without the construction of doing anything you want on the t. f.
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c. to patient has a has a good range of motion without any snapping
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uh this is to control of two months so in conclusion um testing stability pro nation to be
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nation clinical investigation is is very is very important uh we we can do a um
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x. rays and rise but no one gives us
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really a quantification of the instability uh
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try to use that alter sound test it it's very helpful uh pete false check
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from our unions of this uh radius or to shaft um for the construction we do
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not anatomical on with the palmer as long as as i showed before he
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sure that the two holes are at that at the right spot
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particularly the one at uh that's that will no fixed uh
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fix the a ligament with indifference grows if possible and
Conference Program
A-1298 Practical anatomy and imaging
Jan-Ragnar Haugstvedt, Norway
June 13, 2018 · 4:03 p.m.
132 views
A-1299 Reconstruction of TFCC
Andreas Schweizer, Switzerland
June 13, 2018 · 4:18 p.m.
292 views
