TFCC current concept

The ulnocarpal conflict is not a rare condition and should be taken into account in the event of ulnocarpal pain. The conflict is created by too narrow a space of the ulnar head and the ulnar edge of the lunate and the triquetrum. During loading and ulnar deviation of the wrist, a direct contact between these bones is produced. This leads to degenerative changes on the cartilage and produces pain. The origin may be a congenital positive ulnar situation, or a trauma impairing the natural leveling of the forearm bones. We distinguish a fresh traumatic condition (ulnar impaction syndrome) from a chronic condition (ulnar impingement syndrome). The midcarpal bones may also suffer from a similar condition, which is the hamate tip syndrome.
Diagnosis is made by clinical examination including the ulnocarpal stress test, standard X-rays, MRI enhanced with endovenous contrast and subsequent wrist arthroscopy.

Therapeutic options include the ulnar shortening osteotomy and the resection of the distal head of the ulna. Decision can be made depending on the state of the TFCC, the age of the patient and the collateral changes in the wrist. If the lesion occurs in young patients without any concomitant lesion, a shortening osteotomy is more often chosen.

In all other conditions, the less invasive choice for the minimal resection of the distal ulnar head is made by arthroscopic and open surgery. The camera is introduced through the 3-4 portal and the burr through the 6R portal. At the beginning, a 3.5 burr —in more trained hands a 4.2 burr— is used to resect about 2-3 mm of the distal ulnar head during supination and pronation movements. Care is taken not to resect the foveal area or the DRUJ.

After the operation, a comfort splint can be adapted for 3-4 days, and immediate physiotherapy is initiated.

Scaphoid nonunion treatment is controversial and remains a challenge for surgeons. Arthroscopic bone grafting for scaphoid nonunion is a reliable, safe, and convenient technique for patients, which prevents any damage to the poor vascularization of the scaphoid. This video presents a step-by-step approach to the procedure.

Wrist arthroscopy is a technique which has revolutionized the treatment of wrist pathologies. To better understand it, it is necessary to use a suitable equipment and use mini approaches as demonstrated in this educational video.

The evolution of scapholunate dissociations takes place towards osteoarthritis. The SLAC 3 stage associates a radio-scaphoid with a luno-capitate arthritis. The principle of this intervention is to perform a tendon interposition plasty between the scaphoid and the radius and a partial arthodesis between the capitatum and the lunatum.

Wrist arthroscopy allows a thorough exploration of the radiocarpal and midcarpal joints simply by carrying out small portals. This video shows how to achieve them and what can be seen in the wrist.
The purpose of this video is to understand the principle of wrist arthroscopy and how to perform the portals in the least invasive way. We can draw tendon-bone elements on the skin in order to create anatomical landmarks. Before using the knife, using a single needle is essential to identify the exact position of portals. We always start the exploration of the wrist with the radiocarpal joint, and the 3-4 portal. To find it, there are several simple ways. Once the scope is entered in the radiocarpal joint, it is possible only by this portal to explore all the articulation from radial styloid to ulnar styloid. Instrumental 6R portal will be performed. The midcarpal joint is narrower than the radiocarpal joint. We start with the ulnar midcarpal portal, the easiest to find, then an instrumental radiocarpal portal will be used. Placing the scope in a radial midcarpal position allows to explore the scapho-trapezoid-trapezium joint distally as well as the dorsal surface of the capitate bone.

Arthroscopic removal of volar ganglia is a reasonable and safe approach, which requires understanding of specific technical gestures. The main indication being esthetic, the use of wrist arthroscopy is perfect. This video will show you how to perform this reliable procedure in a safe way. This young woman has a small volar ganglion, causing pain by creating pressure difference in the radiocarpal joint. Removing this kind of volar ganglion can be satisfied only by the radiocarpal joint. We will use a 3-4 portal for the scope and a 1-2 instrumental portal. Locating the origin of the ganglion can be assisted by external manipulation. It is usually located between the scapho radio-capitate ligaments and long radiolunate ligaments. Ganglion removal is carried out from the inside of the joint using a shaver. The operation may be considered completed when the anterior capsulectomy is performed and, possibly when we see the tendons. It is not necessary to close the portals, a simple dressing will be applied, and the patient may be able to totally use her hand and wrist the same day.

Dorsal wrist Ganglia (DWG) commonly miscalled “synovial cysts” treatment is controversial. Currently, arthroscopic resection should be considered the first choice treatment for Dorsal Wrist Ganglia due to its numerous advantages, including a significant low recurrence rate, rapid return to activities and low complication rate.

The arthroscopic resection of dorsal ganglia of the wrist is a safe technique which allows for a satisfactory resection of the cyst and the adjacent articular capsule. There are two different techniques for resection of the dorsal ganglia: either by passing through the radio carpal joint, or directly through the ganglion and through the midcarpal joint. This second technique will be demonstrated in this video. The patients' satisfaction rate is very high, particularly because there is neither cutaneous suture, nor immobilization of the wrist.

The origin and the physiopathology of wrist ganglia are still debated. We know for sure that most of them have a common origin on the dorsal aspect of the wrist capsule in correspondence to the scapholunate ligament. The most common explanation is that there is a valve mechanism at the base of the ganglion, which controls the variable volume of these ganglions.
Therefore, the ganglion can be healed by resecting this valve mechanism at the capsular level. Resecting greater parts of the dorsal wrist capsule can often lead to joint stiffness and secondary weakness of the dorsal capsule.
Therefore, the arthroscopic resection of the ganglion stalk will heal the ganglion using a minimally invasive technique and hence avoiding the disadvantages of open surgery.
Technically speaking, a diagnostic wrist arthroscopy is performed through the ulnocarpal portals. This allows to eliminate any co-existing pathology. It also allows to see whether the stalk of the ganglion is in an ulnocarpal or a radiocarpal position.
A shaver is then introduced through the ganglion itself into the stalk, and intensive shaving is performed at the dorsal capsule in correspondence to the origin of the ganglion. Complete resection can thereby be achieved. Special postoperative care or splinting is not necessary. Mobilization can be started immediately.