Thumb UCL Repair/Reconstruction

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1 2.5 mm PushLock /3 mm x 8 mm Bio-Tenodesis TM Thumb Collateral Ligament Repair/Reconstruction Surgical Technique Thumb UCL Repair/Reconstruction

2 Introduction and Diagnosis While collateral ligament rupture of the thumb metacarpophalangeal (MCP) joint is a common problem, experts have disagreed on the amount of laxity that defines a complete ligament rupture. The variable degree of stability in this joint from person to person and within the same patient accounts for much of this. Most authors will agree, however, that the results of nonoperative treatment for a complete ligament rupture are unpredictable. In 1962 Bertile Stener, MD, identified the lesion that bears his name and identified its significance. This lesion results when the force of injury is significant enough that the torn edge of the ulnar collateral ligament becomes trapped behind the leading edge of the adductor aponeurosis. This causes poor ligament-to-bone apposition, impaired healing and persistent ulnar laxity. Patients presenting a history of tenderness over the collateral ligament and laxity that is significant (>30 ) warrant exploration and possibly repair or reconstruction. The comfort level for exploration is increased when there is a soft endpoint on the stress exam or a palpable Stener lesion. Radiographs also provide important clues to the cause of instability because of the restraining effect the collateral ligaments have on volar subluxation. If one collateral ligament is torn, the proximal phalanx will rotate volarly on the side of the tear with the intact ligament, serving as the axis. Thumb Metacarpophalangeal (MCP) Joint and Ulnar Collateral Ligament (UCL) Repair A The approach is a lazy S-shaped incision from the ulnar midaxial proximal phalanx curving dorsally along the MCP joint and then proximally along the ulnar border of the metacarpal. B The subcutaneous tissue is divided by blunt scissor dissection. Care is taken to identify and mobilize branches of the superficial radial nerve. The adductor aponeurosis is divided from its insertion on the extensor pollicis longus and reflected volarly to expose the ulnar collateral ligament. When a Stener lesion is present, it will appear as an edematous rounded mass just proximal to the proximal border of the adductor aponeurosis. Deviate the thumb radially to expose the joint and inspect and define the edge of the torn ligament. C Usually the ligament is avulsed distally from the base of the proximal phalanx. Secure healing to the surrounding periosteum and to the bone within the drill hole can be expected, therefore making it unnecessary to use a burr to expose cancellous bone with this technique.

3 2.5 mm PushLock Knotless Suture Anchor Repair of the Thumb Ulnar Collateral Ligament (UCL) 1 2 A 2-0 FiberWire suture is placed in the ligament. The suture technique is the surgeon s choice, however, a cruciate or simple horizontal mattress stitch is sufficient. The suture is used to temporarily approximate the intended insertion site and the drill hole location is marked. This hole is usually created at the ulnar volar base of the proximal phalanx where the ligament edge naturally lies under slight tension. A hole is drilled at a slight oblique angle away from the ligament with either a 1.8 mm or 2 mm drill, based on the density of the bone. In most cases of acute UCL rupture in young patients, the 2 mm drill should be used. In cases of very soft bone, a punch may be used. If the surgeon is uncertain of bone quality, the punch or 1.8 mm drill should be used, and if insertion of the anchor is too difficult, the hole can be overdrilled with the 2 mm drill. 3 4 Pass the suture ends through the eyelet. Adjust the tension of the ligament by removing the slack from the sutures until optimal tension is achieved. Completely advance the driver into the bone socket until the anchor body contacts bone. Evaluate ligament tension. If it is determined that the tension is not adequate, the driver can be backed out and tension readjusted. 5 6 Impact the metal striking head on the back of the PushLock driver to insert the anchor into the hole and lock the sutures at the tension achieved in step four. Rotate the handle counterclockwise to disengage the driver from the eyelet. Cut the sutures flush to the bone. The remaining suture can be used to close.

4 3 mm x 8 mm Tenodesis Screw Reconstruction of the Thumb Ulnar Collateral Ligament (UCL) 1 2 Two.041 inch Guidewires are driven bicortically from ulnar to radial through the insertion sites of the UCL, or at the metacarpal head and phalangeal base. A cannulated 2.5 mm or 3 mm drill is used to ream over the Guidewires and prepare the bones for the tendon and Bio-Tenodesis Screw. The drill reams through the ulnar cortex and up to, but not through, the radial cortex. This is done for both metacarpal and phalanx. 3 A 2.5 mm to 3 mm Palmaris or other tendon graft is harvested. The length of the graft should be in the mm range. Eight millimeters of the phalangeal end of the graft is whipstitched with 2-0 or 4-0 FiberLoop to improve pull-out. The SpeedWhip technique is the suggested method to create an even texture and decrease prep time. 4 5 The needles on the whipstiched graft are passed radially through the phalanx and the graft is pulled into the drill hole. Tension is applied to the graft using the sutures exiting the skin radially and the graft exiting the drill hole distally/ulnarly. A 3 mm x 8 mm BioComposite or PEEK Tenodesis Screw is advanced into the drill hole, locking the tendon is place. The screw should be distal to the tendon in this hole. Remove the driver by pulling straight out. If the driver is difficult to remove from the screw, use a hemostat or other blunt instrument to provide a radial counter-pressure on the screw.

5 Surgical Technique 6 7 Tension the graft to the metacarpal drill hole and mark the tendon once where it will enter the hole and a second time 8 mm beyond. This defines the area of the graft to be whipstitched using the SpeedWhip technique. Whipstitch and cut excess tendon away from the graft. Bring the whipstitched FiberLoop needle, sutures and graft through the phalanx and out the radial side of the thumb. Reduce the metacarpal phalangeal joint and tension the graft into the metacarpal drill hole by pulling the FiberWire radially. An accurate repair of the dorsal capsular tear with the 2-0 FiberWire suture should be done prior to anatomic repair of the aponeurosis. 8 Insert a 3 mm x 8 mm Tenodesis System Screw proximal to the graft. Recheck the tension on the graft and remove the handle as before. Trim sutures on the radial side of the thumb. Aftercare for UCL Repair or Reconstruction Following surgical repair or reconstruction of the UCL, a forearm-based thumb spica splint is fitted for continual wear. In most cases the IP joint is not incorporated into the splint, allowing free motion at this joint. During splinting, care is taken to position the thumb halfway between radial and palmar abduction to avoid stress on the new repair and to allow for index-to-thumb opposition. Additionally, care is taken to position the MCP joint in slight flexion. Patient education regarding splinting, thumb/hand use and precautions is reinforced at the first post-op therapy visit. Time is also spent discussing edema and scar management techniques during this visit. During the first four weeks, gentle AROM exercises maintain IP joint, uninvolved finger and wrist motion. At four weeks post-op, the forearm-based thumb spica splint may be replaced with a hand-based thumb spica splint. At this time, active and active-assistive exercises are initiated several times a day to the wrist and thumb. Exercises should strive to restore normal sweeping circumductory motion to the CMC joint to avoid excessive extensor forces at the MCP joint. Light prehension activities are introduced. At seven weeks, PROM may be initiated if patient lacks motion. At this point, dynamic splinting can also be considered if necessary. At eight weeks the patient may be introduced to progressive strengthening using putty, etc.

6 3 mm x 8 mm Tenodesis Screw System The Tenodesis Screw System provides solid interference fixation and exact tensioning in ligament reconstructions. Both the Bio (PLLA) and PEEK screw system may be used in conjunction with 2-0 FiberLoop to facilitate intraoperative tissue-tensioning and fixation. Tenodesis Screw insertion provides superior and immediate fixation for hand and wrist indications, such as collateral ligament reconstruction. 3 mm x 8 mm Tenodesis Screws w/inserter Actual Size Implants: BioComposite Tenodesis Screw w/handled inserter, 3 mm x 8 mm AR-1530BC PEEK Tenodesis Screw w/handled inserter, 3 mm x 8 mm AR-1530PS 2-0 FiberLoop AR Disposables: Bio-Tenodesis Disposables Kit for 3 mm x 8 mm screw w/handled inserter AR-1530DS UCL Reconstruction UCL Repair 2.5 mm PushLock Knotless Suture Anchor The 2.5 mm PushLock Suture Anchor provides a secure means of knotless fixation in the hand and wrist. Accommodating two strands of either size 0 or 2-0 FiberWire, this two-piece anchor enables a no profile repair that is quick and straightforward. The 2.5 mm PushLock uses a PEEK eyelet to place the sutures at the bottom of a drill hole, allowing the surgeon to tension precisely by hand and lock the sutures in place by impacting the tak portion of the anchor. Both the high strength radiolucent PEEK and the absorbable PLLA 2.5 mm PushLock optimize tissue tension and fixation without knot tying. Mini Bio-SutureTak Disposables Kit AR-1322DSC (Disposable punch for soft bone, 1.8 mm & 2 mm drills for harder bone, drill guide) Implants: Mini Bio-PushLock, 2.5 mm x 8 mm Mini PEEK PushLock, 2.5 mm x 8 mm AR-8825B AR-8825P 2-0 FiberWire, 18 inches w/tapered Needle, 17.9 mm 3/8 circle AR FiberWire, 38 inches w/tapered Needle, 22.2 mm 1/2 circle AR-7250 Actual Size 2.5 mm x 8 mm Bio-PushLock and PEEK PushLock Anchor w/ Suture Inserter This description of technique is provided as an educational tool and clinical aid to assist properly licensed medical professionals in the usage of specific Arthrex products. As part of this professional usage, the medical professional must use their professional judgment in making any final determinations in product usage and technique. In doing so, the medical professional should rely on their own training and experience and should conduct a thorough review of pertinent medical literature and the product s directions for use. Developed in conjunction with Steve Topper, MD, Colorado Springs, CO View U.S. Patent information at , Arthrex Inc. All rights reserved. LT EN_D

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