Hand & Handgelenk

Arthroskopische Rekonstruktion des TFCC mit Micro SutureLasso™ (Inside-Out / Outside-In)

Über Standard-Portale wird das Micro SutureLasso™ durch das TFCC-Gewebe neben der Ruptur geführt. Das Micro SutureLasso kann unter Anwendung der Outside-In- oder Inside-Out-Technik eingeführt werden. Ein spezieller 2-0 FiberStick ermöglicht den direkten Durchzug eines 2.0 FiberWire-Fadens durch das Micro SutureLasso und das TFCC-Gewebe. Die Ruptur wird bei beiden Techniken mit einer Matratzennaht vernäht. Zum Abschluss der Rekonstruktion werden die Fäden anschließend auf der Kapsel verknotet.

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Hand, Wrist, and Elbow - Next Generation in Repair and Reconstruction

Imaging and Resection

Sanj Kakar, MD (Rochester, MN), describes the targeted over-the-top TFCC foveal repair technique using the NanoNeedle Scope System.

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Targeted Over-the-Top TFCC Repair Using the NanoNeedle Scope System

Hi, I'm Sanjay Kakkar from Rochester, Minnesota. It's a privilege today to introduce you to the over the top Tfcc Foveal repair. So the kit that we need for this is the nano needle. We also have the 2.4mm nano needle low flow sheath. But if you do wet arthroscopy, you can use a high flow sheath system if you need that. Next is the second generation nano cannula. And this is really important. This is your working cannula. Traditionally when we do arthroscopy we have the camera coming in three four portal and the shaver or the working instruments coming in six. This is going to be different because you'll see that the second generation nano cannula will be coming in through the three four portal, allowing us then to pass the straight micro SutureLasso, which will then go through the Tfcc and then through that we'll pass the nitinol passing wire. In terms of the repair stitch, there's two stitches you can use. You can either use the 200 FiberStick or you can use the 0.9mm SutureTape. So we've completed our diagnostic radiocarpal and di arthroscopy. And we've determined we need to do a foveal repair of the tfcc doing an outside to inside technique. So a couple of things that we need to do. First of all, we have the drug portal and we need to breed the footprint of the fovea. So here you can see I'm underneath the tfcc. And I've created this working space. And so there's two ways to breed the fovea. We can come in through this portal which we'll do today. And you can see I'm pushing right here. That's the foveal insertion. It's volar to the ulnar styloid. And we can bring the nano curette to debris. This area the second way is through our ulnar incision to come underneath the tech and debris. That either way works, but it is important to get a bleeding bed for the tfcc to adhere to. I just also want to show you the foveal side. You can see here where I'm pushing right in this area here. Now, when I see a patient in clinic and they're tender in this area to me is either an ulna split tear. This patient doesn't have this. You can see this is the styloid recess or it's a tfcc tear. Be that peripheral or a deep, but that is made. Arthroscopically. So now what we're going to do before we debride the footprint of the fovea is oftentimes this thick capsule here. And remember our camera is going to come through the XR portal. So I think it's really important to debride this capsule. So you get an unimpeded view. When we bring the camera through the XR portal here you can see we're doing this dry. You can see the shaver right here. No need for any fluid. And I think with the two millimeter shaver works great. Or sometimes if the capsule is thick from scarring you can use the Torpedo. And so I'm simply just bringing my hand and I'm looking, turning my eyes around so I can see that capsule and debris this away. And you will find that this pays dividends for you later on. So I do urge you to do this step just so when you put the camera through the XR portal, you get a good view of the Tfcc. Now the question comes up is how much do I debride? Well, we're going to be working down in this area here, so debriefing back here doesn't really help us. But where we need to be is more in line. You can see Tfcc Tftc with my shaver. So this area here needs to be debrided. Here you can see we have the nano Curette, and we've made the working space underneath the Tfcc. So this pops in and you can see before me shredding. I'm right there. So now what I'm doing is I'm turning and I'm making sure I'm as ulnar as I can. Because what you do not want to do is debris the ulnar head. And you can see how ulnar I am right here. And I'm basically coming down onto bone, curating that footprint to get a healthy bleeding bed for us to do our foveal tfcc repair. So we've debrided the fovea, as I mentioned, you can either do that through the portal or through the ulnar incision. Now, invariably for me when I'm doing this procedure, oftentimes remember the ulnar side of the wrist is like the low back pain of the wrist. And they have different pathologies oftentimes with an ECU problem. And so for me this is a utilitarian approach. I'm basically from the hamate body cheating volar. And then I've come around to the distal ulna and it is curvilinear incision, which will allow me to address multiple pathologies at the same time. So the key thing is, once I've come through the skin, you have to find the dorsal sensory branch of the ulnar nerve. And so a little trick here is to find the basilic vein. And once you've found the basilic vein you can then find the nerve. Remember the nerve is going from volar to dorsal and invariably bifurcate or trifurcate. And so I think once you've found one branch, look for the second and third branch of the nerve. So now we're through the skin. So the next thing is just spreading. And in my mind's eye I'm trying to find the dorsal sensory branch of the ulnar nerve. Remember it's coming from volar to dorsal. So the nerve should be going in this trajectory. And here I can see the basilic vein. So right here is the vein. And typically I would buzz this. So now I found that now I'm thinking to myself okay where is the nerve. The nerve should be coming from volar to dorsal. And I'm seeing a structure right in the base of the wound right here. Again, this actually looks more vein as opposed to to nervy, but right there here. So now you can see this structure just here. So if I spread longitudinally to it now you can see there's the nerve. And this is absolutely critical because there you can see the nerve right here. And as we're passing our sutures, if we're not careful we can inadvertently cut that. And so here you can see there's one branch of the nerve. And here there's another branch. So this is least bifurcated if not trifurcated. So now I'll take a 90 degree. And typically I'll put a vessel loop here. So once I'm around the nerve here we are. We've made this. And here we're just going to put a tape around this. But typically it's a vessel loop. The key thing when you put this on is that you do not put a snap on the actual vessel loop or stitch, because that can get tethered and that can pull on the nerve. So once I'm around this, basically what we'll simply do is tie a knot in this and then let this hang. So again do not put a put a snap around this. Just loop this on itself. And there you are. And then you can use this to retract the nerve. And sometimes we'll just put this around the small finger and keep this out of harm's way. But you need to find the nerve to retract this out of harm's way. Okay. So now what we've done here is we've put a retractor around the nerve. I typically don't put a self retainer in because that can give you neurapraxia of the nerve. But what I want to show you here is the extensor retinaculum. You can see this goes all the way to the volar side of the wrist. So what I'm going to do now is incise the extensor retinaculum. Cheating. The reason for this is oftentimes these patients have concomitant ECU pathology. And so if the sub sheath is poor I can use this tissue to do an ECU sub sheath reconstruction. So here's the distal ulnar and the ECU is dorsal to you. So the extensor retinaculum that we incised we've taken it dorsal. And we'll use that if we need to do an exact reconstruction. And so we talked about earlier addressing the foveal insertion of the tfcc and debridement. So you can either do that through the drug portal or with the camera coming in the three four portal, you bring a needle underneath the tfcc, confirm where you are, and then bring a nano curette and debris the periphery of the foveal insertion. Now remember you basically go from volar to dorsal. You'll hit the ulnar styloid and to sometimes bring the fovea into view you can supinate the wrist so you're directly on the direct foveal portal and debris. This. But we've already debrided the fovea through the drug. What you'll see now is that we have the camera coming in the XR portal. And we have the working cannula coming in the three four portal. So now in the wrist the tfcc is right below me. And remember we did the debridement of the synovial tissue earlier. The reason for this is if you didn't this is what you would see. You wouldn't be able to see the tfcc. So we debrided this. Now I'm coming in. If I go and look towards the three four portal, there's inter sulcus ridge through the working cannula. We'll bring in the straight micro SutureLasso. So this comes out and then when I'm passing this, it's really important that you stay in the middle. So I'm actually looking at this to ensure that I go through and do not pierce the water, the plastic dam inside. So everything is under direct vision. So I come and try and find my needle. And here's the straight micro SutureLasso. So under direct vision I'm coming over the lunate facet and I'm working my way over. And I want to take a bite now as radial as I can on the tfcc. Because if I go to ulna, I can. Sometimes in patients with poor quality, the suture can rip out. So here you can see I'm on the tfcc. So just to backtrack I'm not going to push down. So I don't want to injure the cartilage. But here's cartilage. So I come down I come down I can see tfcc right here. You can see the spongy nature of the tfcc. And I push straight down. And in this way, now I'm down onto ulna. Through this comes the nitinol passing wire through the handle of the straight micro SutureLasso, and I'm going to keep my eye out on the ulnar side to ensure that it comes out the distal ulna. So typically we oscillate this through. And there you can see we've come straight out. Okay. And then I'll take out the straight micro SutureLasso. And then you can see the nitinol passing wire at the tip. And so through this I'm going to pass a limb of the 200 FiberStick. And if we look back at the footage here, you can see the needle piercing the tfcc. So through this, now comes one end of the 200 FiberStick. And once we've got that, we'll now pull and we'll pull the needle out. So, so now you can see the suture passing through this. Now what's nice about this cannula is you can see there's some serrations on the side. So I can stick the suture through there so I don't grab it. And then again I'm going to now take the straight SutureLasso. And then I come on this side to see where my needle is. So once I see the needle, there it is. Okay, now there's two things that you can do. So that suture that we just passed went through bone. You can now take this and actually push this through the capsule and do a suture repair through the capsule. But what we're going to do now and that'll still be a foveal repair. So now what I'm doing is I can see and if you can't see a little bit, wipe the camera on the soft tissues, bring it back. That gives you a better view. And now I can see the tfcc right there. I'm going to put the needle straight through. Lift my hand. Now we're going to pass the nitinol passing wire through this coming out the ulnar side of the wrist. And there you can see it comes there okay. And then we'll take out the SutureLasso that will come out. What we'll then do is feed the other limb of the end of the 200 FiberStick through that, and I'm going to be watching directly in the camera to ensure we shouldn't get a soft tissue bridge because we've come through the cannula. And that's the beauty of this technique. So as we pull this, we can now see the suture coming through and we'll pull both limbs. And there you are. And there's your stitch. And you can see there's no soft tissue bridge because we work through the cannula. That will give you your foveal repair. So that stitch. Now as I pull on both limbs, you can see it's pulling this down. And if we want to double check that, what we can simply do is come through. And there's your stitch right there. And that gives you an excellent purchase. And typically I'll pass 2 or 3 sutures. So I go as volar as I can in the middle or dorsal. Now what we'll do is tie this down straight on a bone bridge. Or you can put a PushLock. But the key thing when you're tying this down and putting a PushLock is that you take the traction off the wrist. Otherwise you'll tie this in a loose position. So we've passed a two FiberStick suture through here. Next we're going to take another bite, but we're going to use a 0.9mm SutureTape exactly the same process that we're going to demonstrate. So here again is the tfcc. I've come slightly dorsal to it. I'm looking at it. And now through there we're going to put the nitinol wire and come out the ulnar side. Okay. And now we'll feed the 0.9mm SutureTape through the nitinol loop and then pull it out through the ulnar side, and then we'll dunk this again in the cannula so it's out of our way, and then we'll come in with the orange handle and we'll see exactly where this comes through. And as we pass this we can see the tape. And we're going to come ulnar to it just like before. Get a WideBiter tissue. I'm happy right there. And then through there comes the nitinol wire. So you can see we do this under oscillate mode so we don't wrap up any soft tissue. And then through this again we're going to put the end of the 0.9mm SutureTape and then pull this through. And as it comes we want to guide that suture into the cannula. There it is. So it's over the finger. And there we are. And so we'll pull this flush. And so now you can see the comparison of the two FiberStick. And then here you've got the 0.9mm SutureTape. So here you can see we've put the camera in the three four portal. And we're looking at the repairs so you can see the volar suture is a 200 FiberStick and the dorsal suture is the 0.9mm SutureTape. You can see they both lie flush and flat. And as I pull on that, you can actually see how it's restored tension to the footprint of the tfcc. So as you'll see, you saw this in real time. We've placed two sutures through the fovea. No need for fluoroscopy. You can see how efficient the process is. We didn't make a large ulnar tunnel which can cause fracture. And also remember with the ulnar tunnel, sometimes if you're a little bit radial, you'll injure the cartilage of the ulnar head, which potentially could lead to degenerative changes moving forward. And you can see it's relatively atraumatic suture passage through the tfcc. So we've loosened the traction. So here and we've got the wrist in neutral. And as I said you can tie this with over the bone bridge or PushLock anchor with the nerve is out of the way. This is just fat. We've dissected this earlier and so simply now we'll come down and then just put a sliding knot down. We'll do this with the stitch. Typically I just do this with a 200 FiberWire and then we just cut it right on the knots. So here you can see we've tied these down. It's very low profile even with the 0.9mm SutureTape. You can see the knot stack is very low profile. You remember earlier I identified the extensor retinaculum. So if there's an ECU problem we would use this. But typically what I would then do in this patient is take this extensor retinaculum and repair it on the on the volar side to cover the knot stack. If we want to look at the quality of our repair, you can see now with this tied out of traction, the stability of the tfcc is rock solid. The foveal footprint has been restored. Negative hook test. Here's the trampoline. There's a normal buoyancy of the tfcc, and there's our repair completed.

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Arthroscopic Repair of the Triangular Fibrocartilage Complex (TFCC) with the Micro SutureLasso™

Micro SutureLasso, TFCC, Short 70° bend, sterile, qty. 1

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Arthroskopische Rekonstruktion des TFCC mit Micro SutureLasso™ (Inside-Out / Outside-In)

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Hand, Wrist, and Elbow - Next Generation in Repair and Reconstruction

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Arthroskopische Rekonstruktion des triangulären fibrokartilaginären Komplexes (TFCC) mit dem Micro SutureLasso™

Arthroscopic Repair of the Triangular Fibrocartilage Complex (TFCC) with the Micro SutureLasso™

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Targeted Over-the-Top TFCC Repair Using the NanoNeedle Scope System

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