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Pathomechanics, Spectrum and Treatment of Carpal Instability Scott W. Wolfe, MD March 12, 2017
Scott W. Wolfe, M.D.
Rehabilitation of the Hand: Seize the Evidence! Philadelphia, March 12, 2017
THE SPECTRUM, PATHOMECHANICS AND
TREATMENT OF SCAPHOLUNATE DISSOCIATION
PATHO-MECHANICS OF THE SLAC WRIST:
The Importance of the Midcarpal Joint
Scott W. Wolfe, M.D.
Dr. Wolfe has consulting and/or royalty agreements with:
TriMed, Inc.Conventus, Inc.
Elsevier, Inc. Extremity Medical, Inc.
Rehabilitation of the Hand: Seize the Evidence! Philadelphia, March 12, 2017
PATHO-MECHANICS OF THE SLAC WRIST:
The Importance of the Midcarpal Joint
Scott W. Wolfe, M.D.
Wrist hemiarthroplasty is not FDA approved for use in the United States
Rehabilitation of the Hand: Seize the Evidence! Philadelphia, March 12, 2017
Scott W. Wolfe, M.D.
PATHO-MECHANICS OF THE SLAC WRIST:
The Importance of the Midcarpal Joint
Wrist hemiarthroplasty is not FDA approved for use in the United States
Rehabilitation of the Hand: Seize the Evidence! Philadelphia, March 12, 2017
PRIMER ON CARPAL KINEMATICS
scaphoid
lunate
triquetrum
SLIL LT
THE “INTERCALATED SEGMENT”
Landsmeer, JMF The equilbrium of the intercalated bone. 1961
Pathomechanics, Spectrum and Treatment of Carpal Instability Scott W. Wolfe, MD March 12, 2017
THE “INTERCALATED SEGMENT”
• No tendon insertions• Motion initiated by mechanical
articulations in midcarpal joint• Limited by ligamentous
constraints
THE “INTERCALATED SEGMENT” LIGAMENT ANATOMY
THE “INTERCALATED SEGMENT” LIGAMENT ANATOMY
S L
RSCLRL
RSL
SLIL
dSLIL
KINEMATICS:Flexion - Extension
scaphoid
lunate
triquetrum
SLIL LT
Proximal row motion in synchrony, guided by scaphoid
Weber, E.R.; Ortho. Clin. N. America, 1984
KINEMATICSScaphoid pulls proximal row into
flexion
Weber, E.R.; Ortho. Clin. N. America, 1984
KINEMATICSTriquetrum pushes proximal row into
extension
Triquetrum “engaged”
Hamate
Triquetrum
“Helicoidal”
surface
Pathomechanics, Spectrum and Treatment of Carpal Instability Scott W. Wolfe, MD March 12, 2017
Scaphoid is a connecting rod
Gilford, 1943; Fisk, 1970
When the scaphoid’s not happy, the midcarpal joint is not happy.
MIDCARPAL JOINT IS INHERENTLY UNSTABLE
R CL
scaphoid
lunate
triquetrum
SLIL LT
Proximal row motion is in synchrony throughout F/E and RUD,
and is guided by scaphoid
KINEMATICS:SL Dissociation
scaphoid
lunate
triquetrum
SLIL LT
KINEMATICS:SL Dissociation
scaphoid
lunate
triquetrum
SLIL LT
KINEMATICS:SL Dissociation
scaphoid
lunate
triquetrum
SLIL LT
DISI
Dissociation Diastasis
Disaster
Kitay, A., Wolfe, S.W. Scapholunate instability. JHS 2012
What causes degenerative change, and how can we
prevent it?
Answer: Disruption of the midcarpal joint
Pathomechanics, Spectrum and Treatment of Carpal Instability Scott W. Wolfe, MD March 12, 2017
What causes degenerative change, and how can we
prevent it?
23 y.o. RHD male 7 months post basketball injury
What causes degenerative change, and how can we
prevent it?
23 y.o. RHD male 7 months post basketball injury
Rotatory subluxation?
gap?
or DISI?
56 yo ♀ physical therapist;no known injury, 10m of mild wrist pain, FROM
GAP DISI
Rotary subluxation
56 yo ♀ physical therapist;no known injury, 10m of mild wrist pain, FROM
WHY?
COMPLETE SLIL FAILURE…but she is
highly functional and has minimal
discomfort.
• 6 cases• Xrays judged by 2 surgeons to be nl
• MRI interpreted as SLAC II
WHY?
Scaphoid mal-rotation and gap may not be sufficient for DJD
Pathomechanics, Spectrum and Treatment of Carpal Instability Scott W. Wolfe, MD March 12, 2017
Scaphoid dorsal translation• SLIL incompetence
allows dorsal translation of scaphoid (p< 0.05)
• Perching of scaphoid on dorsal rim paradoxically increases RS joint space
Dorsal rim loading causes scaphoid DJD
Scaphoid dorsal translation• We question Watson’s analogy of “nested spoons”• Symptomatic patients have more than rotatory
instability• “Unhinged” scaphoid allows capitate to drift dorsal• Disrupts integrity of midcarpal joint DJD
21 confirmed SLIL ruptures compared to 21 normal wrists
p < 0.001
Scaphoid dorsal translation• We question Watson’s analogy of “nested spoons”• Symptomatic patients have more than rotatory
instability• “Unhinged” scaphoid allows capitate to drift dorsal• Disrupts integrity of midcarpal joint DJD
Dorsal Tangential Line Method
Dorsal translation may be a predictive parameter for repair outcomes
63 yo male 4 mos after HE injury
Dorsal translation may be a predictive parameter for repair outcomes
63 yo male 8 wks postop modified Brunelli
Dorsal translation may be a predictive parameter for repair outcomes
63 yo male 9 mos postop modified Brunelli
Pathomechanics, Spectrum and Treatment of Carpal Instability Scott W. Wolfe, MD March 12, 2017
Dorsal translation may be a predictive parameter for repair outcomes
63 yo male 4 yrs postop modified Brunelli
PRWE 46, complains of pain with light to medium activities
HYPOTHESIS
Abnormal scaphoid sagittal alignment disrupts midcarpal
kinematics and leads to degenerative arthritis
The midcarpal joint is critical to complex (coupled) wrist motion
JHS 2005
JHS 2015
Limitations in midcarpal motion decrease function
Can the scaphoid be dynamically stabilized?
Scaphoid friendlycarpal supination muscles:FCUAPLECRL(FCR)
56 yo ♀ physical therapist;no known injury, 10m of mild wrist pain, FROM
Can she dynamically stabilize her
scaphoid?
Her midcarpal joint is only minimally maligned
What is the role of therapy to strengthen the “friendly” muscles of anti-pronation?
Pathomechanics, Spectrum and Treatment of Carpal Instability Scott W. Wolfe, MD March 12, 2017
SURGICAL OPTIONSThe primary goal of SLIL repair or
reconstruction is to preserve midcarpal architecture and function
6 mos postop
MUST CORRECT DORSAL TRANSLATION!
Modified Brunelli “TLT” reconstruction
The primary goal of SLIL repair or reconstruction is to preserve midcarpal
architecture and function
MUST CORRECT DORSAL TRANSLATION!
Yet we continue to struggle with outcomes of SLIL repair and reconstruction
JHS 2014
…CAN WE IMPROVE OUR
REPAIRS?
82 wrists:
TLT reconstruction more predictable than repair!
NEW CONCEPTS:“DOUBLE ROW” REPAIR
Mini Mitek suture anchor – 2-0 Orthocord and 3-0
Ethibond suture
• 51 cadavers, 3 repairs– Double loaded, single loaded, transosseous
• MTS machine, load to failure, cyclic load• Double loaded >> Transosseous > single• Higher number of cycles to failure
JHS 2015
Pathomechanics, Spectrum and Treatment of Carpal Instability Scott W. Wolfe, MD March 12, 2017
2 anchors – double loaded 2 anchors – double loaded
2 anchors – double loadedCompression clamp is key
Blatt capsulodesiscorrects rotational instability
SLIL repair corrects coronal plane instability
NEW CONCEPTS:GRAFT AUGMENTATION
Tendon graft augmented with Labral Tape©
Novel idea, no data.No distal scaphoid support; loosening may lead to rotation/translation
Pathomechanics, Spectrum and Treatment of Carpal Instability Scott W. Wolfe, MD March 12, 2017
What’s new in chronic SLIL reconstruction?
11m post TLT repair
??
Same patient, 18 months postop
• 20 patients prospective study; good outcome scores 3y• Increased coronal gap in most• Progressive DJD in 20%
2013
Long term studies show slow decline in radiographic outcomes
• 20 patients prospective study; good outcome scores 2y• VAS 3, DASH 20; ROM reduced by average 33 degrees• OA progression 15%: converted to 4CF
2015
Long term studies show slow decline in radiographic outcomes
JHS(E) 2016
Back to the future?
RASL SLAM/SLT
BLB
RASL1997
8 wrists, 5 dynamic, 2DISIOriginal technique followed38 month followupDASH 15, PRWE 265/8 radiographic failures
2011
2014
“Technique abandoned”
SLAM/SLT2014
• Early results, 11m– 13 patients
• 1 failure– 2.1mm SL gap– 59º SL angle– 102 deg F/E– 55lb grip (62%)– Longer term results
necessary– Large implant
JWS 2016
Biomechanical feasibility study vs.Blatt Capsulodesis, TLT.
Comparable to TLT, improved over Blatt.
Pathomechanics, Spectrum and Treatment of Carpal Instability Scott W. Wolfe, MD March 12, 2017
Necessary components of an ideal SLIL reconstruction• Address entire SLIL• Correct rotation and translation• Restore midcarpal kinematics to
prevent DJD• Sufficient strength to allow
earlier wrist motion• Durable
• Innovative technique• Transosseous tunnels• No screw• 11 wrists• 12 months follow-up• Improved grip, PRWE• Maintained SL closure
SLAM/SLT
J. Wrist Surg.2013 SLT procedure
23 y.o. RHD male 7 months post basketball injury
Scaphoid articular surface with planned exit point for graft
SLT 2016
• More than 100 SLT repairs• Indication > 6wks • Reducible, no arthritis• Minimal use of K-wires• DTM and limited arc F/E
begun at 2-3 weeks
Mark Ross and Greg Couzens, Brisbane
Pathomechanics, Spectrum and Treatment of Carpal Instability Scott W. Wolfe, MD March 12, 2017
Spiral Tenodesis
• Marc Garcia-Elias• 1 case reported• Cautious but
optimistic approach• May be indicated for
acute SLIL
What’s new in early SLAC disease?
• Maintain the midcarpal joint!• Few outcome studies of RSL fusion• Technically difficult to align MC joint• Progressive DJD in 20%
Normal RSL fusion
2005
What’s new in arthroplasty?
• Midcarpal hemiarthroplasty– Replaces proximal carpal row– Preserves carpal height– Anatomic midcarpal geometry– Ligament sparing
NOT FDA - APPROVED IN THE USA
MIDCARPAL HEMIARTHROPLASTY FOR WRIST ARTHRITIS:
4y UPDATE
Scott Wolfe, MD,Greg Packer, FRCS(Orth); Joseph J. Crisco, MD
Hospital for Special Surgery, New YorkWeill Medical College of Cornell University
Southend University Hospital, Southend-on-Sea, EnglandRhode Island Hospital, Brown University Medical Center
METHODS
• 22 patients followed prospectively• SLAC (13), OA (3) PT OA (2)• Inflammatory arthritis (3),• Kienböck’s (1)
• Avg age 50.6 yrs (range, 23-74)• Mayo, DASH, ROM, grip, xrays• Mean follow-up 4y (range 3.4 – 5.5)
Pathomechanics, Spectrum and Treatment of Carpal Instability Scott W. Wolfe, MD March 12, 2017
No other SLAC wrist procedure or arthroplastydemonstrates increased ROM post-operatively
PRE-OP POST-OP SIGNIFICANCE
MAYO SCORE 34.2 59.7 0.001
DASH 50.3 25.9 0.01
F-E ARC (DEGREES)
63 99.2 0.005
R-U ARC (DEGREES)
22.4 34.5 0.0005
GRIP (KG) 14.1 20.7 0.008
GRIP(% OPPOSITE
SIDE)
66.3% 96.3% 0.05
Patient #1 5.5y
DASH 0.0
Grip 85%
FE 82%
KinematX Total Midcarpal Wrist Replacement
• Replicates midcarpal joint
• Modular components
• Long stem fixation of distal component
• FDA submission 2017
Exciting times for wrist reconstruction and
rehabilitation• Preservation of midcarpal joint
function– Reduce dorsal translation– Stronger repairs
• Prevention of degenerative arthritis
• Maintenance of carpal kinematics
Special Thank You to Aviva Wolff, Ph.D., Trey Crisco, Ph.D, and the entire HSS Dart-thrower Team!
LRMALabLRMALab
Howard Hillstrom, PhD
Aviva Wolff, PhD, CHT
Andrew Kraszewski, MS Engineer
Andreas Kontaxis, PhD
Sherry Backus, PT
Rehabilitation of the Hand: Seize the Evidence! Philadelphia, March 12, 2017