Name: Case Presentation: Over-the-Top TFCC Repair Using the NanoNeedle™ Scope 2.0
Uploaded: 2026-07-09T00:00:00Z
Channel: Arthrex
Description: Sanj Kakar, MD (Rochester, MN), presents a case example in which he uses the NanoNeedle™ scope 2.0 to treat ulnar-sided wrist pain using the over-the-top foveal triangular fibrocartilage complex (TFCC) technique.

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Sanj Kakar, MD (Rochester, MN), presents a case example in which he uses the NanoNeedle™ scope 2.0 to treat ulnar-sided wrist pain using the over-the-top foveal triangular fibrocartilage complex (TFCC) technique.

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VID1-009385-en-US | A | Case Presentation: Over-the-Top TFCC Repair Using the NanoNeedle™ Scope 2.0

Sanj Kakar

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Case Presentation: Over-the-Top TFCC Repair Using the NanoNeedle™ Scope 2.0

Speaker  Hi, my name is Sanjay Kakkar. I'm a professor of orthopedic surgery with a specialist in hand and wrist surgery. Today, I'm going to share with you a case about ulnar sided wrist pain and specifically how nanoneedle technology has helped us in the management of patients with this condition. So I want to start off with a case. So this is a young patient who comes in with a two year history of ulnar sided wrist pain and instability. Every time she prono supinated her wrist. We treated her non-operatively initially with splints and injections and certified hand therapy. But despite this continued to have symptoms. She was tender in the fovea, she was non-tender over the ECU and had negative signs of ulnar impaction. You can see in the X-rays here. There is a little degree of ulnar positivity here. When you look at the clinical examination in neutral rotation, you can see gross instability of the druj. And this is why the history and the physical exam are so important in managing these patients. Because when you look at the MRI here and then actually when you look at the read by a musculoskeletal radiologist, they actually thought that the tfcc itself was okay. Now, how do you get that sort of differentiation between the history and physical exam and the imaging? This is where that is absolutely critical in the assessment of these patients. And so how do we fix the phobia. There are a myriad of different techniques to try and do this. Speaker  You can do an outside to inside ulnar tunnel technique which works well. But there are some technical nuances with this. If the tunnel isn't in the right position, you can get a fracture of the distal ulna. And also you're limited about how much of the tissue can you grab when you're coming from outside to in the other way, is using an anchor and anchors work great, but sometimes you're limited number one by the quality of the bone in the distal ulna, and secondly, by the number of sutures within the anchor. So given this I'd like to introduce you to the over the top tech foveal repair technique. Some of the advantages that I've seen in my practice is that it's relatively efficient. You don't need fluoro in the operating room for this. And more importantly, it allows me to place the sutures exactly where I want to. When you see different types of injury patterns. And so what's critical for this is the use of nanoneedle technology. Now this is the third generation of Nanoscope technology. And what's really helpful for me is not only the assessment using the Nanoneedle in the Radiocarpal joint, but critically in the druj. And what's really helped is the high resolution. It's now 720 by 720 resolution with 120 degrees field of view. In addition, it's relatively flexible. So when it's in a tight space like the Druj, it allows me ergonomically to navigate the anatomy of the DJ to exactly see where the Tfcc is injured. Speaker  So here we are, the cameras in the three four portal. You can see the scaphoid above us, the scaphoid facet below. We're sweeping to the ulnar side. There's the inter sulcus ridge lunate above us and lunate facet below. And as now we're coming in, we're doing this in a dry manner. You can see we're right over the tfcc. And you can see that rocking back and forth. That was me doing the Foveal sign. And so here, now we're doing an assessment of the Tfcc. This is the trampoline test. We'll also do the hook test. And then we'll also do a suction test to assess the tfcc from the Radiocarpal joint. Here I'm taking the two millimetres shaver, which is what I use frequently, and again, just debriding to make sure that there isn't a peripheral tear that's under degree of the Synovitis. But the critical aspect of this case using Nanoneedle technology is assessment of the fovea doing dry arthroscopy. So here we are. We're in the druj, the tfcc above us, the distal ulna below us, and we're pulling back the camera. And you can see that the fovea is injured and scarred in. So it may be structurally intact but functionally incompetent. And so having done that assessment, now what you'll see in this picture is that we've actually switched the camera now is coming in the six hour portal, and you'll see a grey working cannula in the three four portal. Speaker  You can see I've made an ulnar incision. And there's that blue vessel loop protecting the dorsal sensory branch of the ulnar nerve. And we have to debris the foveal insertion. And so you can do this either through this incision underneath the tfcc or through the D IJ portal. And so now through that working gray cannula, I've taken this orange handle needle coming in through the center of that gray cannula. And I walk it along to basically judge where that's going to go through the tfcc. Now I'm taking a flexible wire, and I'm drilling this through the orange handle needle coming out through the ulnar side of the wrist. So that needle now has gone through tfcc, through the fovea, and out the ulnar side of the wrist. Through this, you can shuttle sutures. I either use a 200 fiber wire or more recently, the 0.9mm suture tape. So here we're shuttling it through the wire, going from radial to ulnar. So that's one limb of the suture. Now, what's nice with that cannula is that I can dunk the suture within one of the cleats, thereby ensuring that I don't impale this when I'm coming through with the orange handle. So there's the orange handle now coming through again. I'll take my next bite in the tfcc and then I'll advance the flexible wire through, and then I'll shuttle the suture through this. So thereby we've created a sort of horizontal mattress suture. Speaker  Now in this patient, you can see I've passed three sutures. And now what's really critical is that you have to release traction and tie these down in neutral. Or you can fix this with a push lock. But you have to be out of traction. And so here you can see three of these sutures have been passed restoring the natural tension of the tfcc. So now we'll pull on them. And now when I'm using the probe you can see how we've restored the footprint of that tfcc back down to bone. And so now you can see Pre-operatively on the left and Post-operatively on the right. You can see we're out of traction and we've restored stability of the druj. So this is a biomechanical study because you may ask, okay, how many sutures do you need to pass? And so what we did in this biomechanical study is that we had cadaveric specimens. We assessed the native stability of the Druj. We created instability and then wanted to delineate the number of sutures to restore stability. And so here we basically had the intact specimen. We cut the tfcc and we passed three sutures. Suture A was in the middle, B was volar and C was dorsal. And so here you can see that suture configuration. Again a is the central suture B is passed volar and c is passed dorsally. And you can see now after a suture passage the stability that I showed you in that clinical case that we've restored the tension. Speaker  The key take home point in this is that passing three sutures, as I showed you in that patient restores stability about 98% compared to the native intact state. So if patients just have pain only are typically passed two sutures. If they have instability I'll pass three sutures. So how common is ulnar sided wrist pain in the pediatric and adolescent population. Well it's actually relatively common. This is an article that I published with our partners at Mayo Clinic, and what you'll see is relatively how common it is. And it's not just a tfcc problem. There's a myriad of different conditions. And while imaging is helpful, it's not 100% accurate. So I think in summary, when you're managing patients with ulnar sided wrist pain, the key takeaways are that it's a clinical diagnosis and the history and physical examination are super important. Imaging can be helpful. But as I showed in this case, it's not always 100%. So you need to maintain a high index of suspicion. For me, Nanoneedle technology has been critical in the assessment of many issues of wrist pain, but specifically the Tfcc. And with the over the top technique that we've shared today, for me, it's a predictable method of repair. It's efficient, it's safe, and more importantly, it allows me to dial in my repair and reconstruction and place the sutures exactly where I want to place in the tfcc.

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Case Presentation: Over-the-Top TFCC Repair Using the NanoNeedle™ Scope 2.0

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