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Arthroscopic Treatment of Triangular Fibrocartilage Lesions

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Arthroscopic Treatment of Triangular Fibrocartilage Lesions Powered By Docstoc
					    Arthroscopic Treatment of
Triangular Fibrocartilage Lesions

        Terry L. Whipple, M.D.
         Richmond, Virginia
             Function of TFCC

A.   Sling for lunate and triquetrum

B.   DRUJ stability through thickened
     peripheral portion
                         Anatomy
A. Central fibrocartilage disc merges with:
     – Volar UC ligaments and
     – Dorsal wrist capsule / floor of EDQ, ECU
       compartments
B. Volar and dorsal periphery thickened, attaches to triquetrum as
    "ulnar collateral ligament"
C. Central disc is avascular
           Anatomy (continued)

F.Peripheral disc and thickened      periphery
  vascularized by volar and     dorsal branches
  from ulnar artery
       III. Mechanisms of Injury
A.   Forced pronation - dorsal peripheral
     detachment
B.   Axial load - central perforation or
     avulsion from sigmoid notch
C.   Forced hyperextension and radial
     deviation - avulsion of volar UC
     ligaments proximally or distally
                         IV. Diagnosis
A. History - recreate mechanism of injury
B. Exam
    1. tender volar, dorsal
    2. painful pronation or supination through the hand stresses
       central disc
    3. forceful pronation or supination through the forearm stresses
       thickened peripheral ligaments
C. Arthrogram - RC space, DRUJ space
D. Arthroscopy - always probe
               Arthroscopic Treatment
Remove unstable fragments, flaps
1. arthroscope in 3-4 portal, approach sigmoid           notch from 6-R or
   6-U portal with suction punch
2. arthroscope in 6-R portal, approach ulnar                aspect of
   central disc through 3-4 portal with       suction punch, shaver
3. arthroscope in 3-4 portal, excise central disc        with small joint
   arthroscopy knife (banana              blade, hook blade)
                Disc Resection
• instruments required: 2.7 mm arthroscope,
  traction mechanism, arthroscopy knives, basket
  forceps, suction punch, shaver
• central disc resection appropriate for Palmer tears
  type IA, ID
Repair dorsal peripheral detachment of
              central disc
1. arthroscope in 3-4 or 1-2 portal, debride      dorsal edge
   of central disc with shaver or suction punch through 6-R
   portal
2. longitudinal incision extending proximally from 6-R
   portal over sixth compartment, incise common
   extensor and ECU                   retinacula, retract ECU
   radial or ulnarward
                  Repair (cont.)
3.suture central disc to floor of ECU tendon sheath.
  Inteq TFCC repair kit, curved cannulated needle
  inserted through floor of ECU tendon sheath over
  DRUJ, upward through edge of TFC disc. Capture
  suture with retriever through more distal puncture.
  Repeat 2 to 4 sutures.
                Repair (cont.)
4.place forearm in neutral rotation and tie sutures
  over floor of ECU compartment. Close common
  extensor retinaculum only. Sub-Q skin closure.
  LAC x 3 weeks, then gradual mobilization.
                   Repair (cont.)

5.instruments required: 2.7 mm          arthroscope,
  traction mechanism,        TFCC repair kit, 2-0 or 3-0
  PDS suture
6.appropriate for Palmer tears type IB
     Repair dorsal peripheral avulsion
               from radius
1.   Semi-open technique, wrist flexed, dorsal approach between
     fourth and fifth extensor compartments, scope in 6U
2.   Mitek suture anchor in dorsal edge of sigmoid notch,
     subchondral bone. Sutures through avulsed bone fragment or
     dorsal edge of TFC.
3.   close and immobilize in slight pronation x4 wks
     Repair of volar UC ligaments

1. complex open reconstruction. Reference
   Bowers.
2. prolonged rehabilitation protecting in position
   of supination, flexion, and ulnar deviation
        Prominent ulna/abutment
1. resect most of central disc to decompress
   interval
2. open or arthroscopic wafer procedure (Feldon)
                   Abutment
alternative - formal ulnar shortening with plate
  fixation or oblique sliding ulna osteoplasty with
  screw fixation
                          Results
A.      IA, ID resection - excellent
B.      IB repair - good to excellent
C.      Ulna leveling
     1.wafer procedure - fair
     2.oblique sliding ulna osteoplasty - good
Endoscopic Carpal
 Tunnel Release
Single Portal Technique
Two Portal
• Chow

Single Portal
• Menon
• Palm Incision

 ø
        ECTR
• Efficacious
• Avoids palm incision
  – Comfort
  – Early function
  – Palm callous
   ø
Single Portal Technique
  • Anesthesia
    – Local
    – Bier block
    – Axillary block
    – General
  • Tourniquet
     ECTR Risk
 Surgeon’s learning curve
• Neurovascular structures

    Good Judgement
  Reticulous Technique
                 Landmarks
•   Cardinal line of Kaplan
•   Longitudinal - ulnar border ring
•   Hook of hamate
•   Motor branch
    cardinal line/thenar crease
                Exposure

• Incision
  1cm, oblique from distal wrist crease at palm,
    long.
• Puncture antebrachial fascia
• Dilate to 5.5 mm

				
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posted:5/31/2011
language:English
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