Chuck and Chris discuss use a listener submitted case as the basis of a discussion of the PIP joint. We break down treatment considerations for a dorsally subluxated PIP joint that is stiff in extension. Dive in with us- complicated discussion! We also briefly touch on FPL ruptures, the rheumatoid hand (and the disappearing art of treating it).
The stiff finger was a part of our discussion- here is the reference which might be helpful.
Jupiter, Goldfarb, Nagy, Boyer Posttraumatic reconstruction of the hand.
J Bone Joint Surg Am; 2007 Feb;89(2):428-35.
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As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
Complete podcast catalog at theupperhandpodcast.wustl.edu.
Chuck and Chris discuss use a listener submitted case as the basis of a discussion of the PIP joint. We break down treatment considerations for a dorsally subluxated PIP joint that is stiff in extension. Dive in with us- complicated discussion! We also briefly touch on FPL ruptures, the rheumatoid hand (and the disappearing art of treating it).
The stiff finger was a part of our discussion- here is the reference which might be helpful.
Jupiter, Goldfarb, Nagy, Boyer Posttraumatic reconstruction of the hand.
J Bone Joint Surg Am; 2007 Feb;89(2):428-35.
Subscribe to our newsletter: https://bit.ly/3iHGFpD
See www.practicelink.com/theupperhand for more information from our partner on job search and career opportunities.
Please complete NEW Survey: bit.ly/3X0Gq89
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
Complete podcast catalog at theupperhandpodcast.wustl.edu.
Welcome to the upper hand podcast where Chuck and Chris talk Hand Surgery.
Chris Dy:We are two hand surgeons at Washington University in St. Louis here to talk about all things hand surgery related from technical to personal.
Charles Goldfarb:Please subscribe, wherever you get your podcasts.
Chris Dy:And thank you in advance for leaving a review and leaving a rating wherever you get your podcasts.
Charles Goldfarb:Oh hey. Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:It's good. We're recording in the evening. It's kind of nice. I found some energy. I hope you did too.
Chris Dy:I did. It's it's it's been a day. You know, in my young ish attending yours, I think I've kind of gotten the two room thing down down better than before. You know, block utilization ended exactly at 4:58pm. So you'd be proud. But I had this whole day planned out as in my mind, I was like, I gotta get home, I was gonna make dinner I wanted to hang with the kids a little bit. And I get home and I'm locked out. It's just the worst feeling I switched cars and I forgot to pull my house key and my wife is on console. So she got called to the hospital dual console. My father in law who's almost always home left to bring one of our kids to an activity so I'm sitting there doing emails outside in not pleasant weather. It's really frustrating because I had this whole everything planned out to a cadence of like when I was gonna get the oven preheated to dinner and prepped everything in and it was gonna be all good by the time my kid got home from hockey practice and then blown away. Did you order pizza now got it done. How long we got we got done we just push the timeline back a little bit. My wife was kind enough to come home before seeing the console she's already on her way to the hospital letting me in the house gave me a look. Welcome lovingly left me the key and then went and saw the console. I got dinner ready and it's all okay. Just push back or recording time a little bit.
Charles Goldfarb:Yeah, I my my story is my family used to spend a fair amount of time up in New Hampshire with Talia's family at our lake house. And those used to be many, many weeks. And now it's not and they left yesterday. Yeah, Monday morning early. And I'm joining them late tomorrow night after a crazy day in the or so. I don't usually stack cases before I catch a flight but I think I'll be okay.
Chris Dy:The the old Rick Wright adage. He's given me so many pearls of advice over the years. He hasn't given them directly to me, but he's kind of given when he was here at Wash U giving like junior faculty advice and one of them was there is nothing more stressful than operating before a flight. It's true. But yeah, yeah. So here we are, and excited. We've had some great engagement from folks recently. There's a really great review that I was hoping you'd let me read. I would love to hear it. Thank
Charles Goldfarb:you. Alright, so
Chris Dy:This is recently from Britt Mitch. OTRL. Five stars, of course, always five stars. Oh, thank you for all that you do. Chris and Chuck, not Chuck and Chris. Thank you. Oh, and I want to thank you so much for creating this podcast, which has provided me the opportunity to listen and learn about the hand and upper extremity over the past year and year and a half. While I study for my ch T. That's it. For those outside of the US that is a certified hand therapy examination has many many hours of patient care contact related to hand and upper extremity in a really rough test. So birth continues, I'm happy to announce that I have successfully passed my CHT exam on the first attempt. Listening to the upper hand helped me to understand the surgeons perspective. I really enjoyed it. Appreciate the collaboration episodes and discuss options with AC. You helped me make my studying experience more interactive, and I have learned a great deal from you both. Thank you for answering my questions I had along the way while I study for my exam, I plan to continue to listen and learn to the upper hand as I continue into my professional career as a CHT. Well, Brett, thank you for that. And congrats on passing your exam. It's wonderful.
Charles Goldfarb:Absolutely. It's not an easy test. And I've known very impressive therapists to take it more than once. And so congrats, and I'm glad to hear you're gonna keep listening, because maybe you'll share some insights with us moving forward.
Chris Dy:Yes, yes. And we're gonna get do a little bit of a listener grab bag email episode today. So remember to send questions, comments, thoughts, suggestions for episodes to hand podcast@gmail.com. And maybe we'll get on this new thing, threads that everybody's doing. By the time this drops, it'll probably reach you know, half of the world. But But yes, for now, send us an email because we're old.
Charles Goldfarb:You know, I am on Threads. And it the way it links into Instagram is really nice, I would say and I kind of had been boycotting Twitter as I think you know, still not eager to go back on Twitter, but just comparing them. content on Twitter still is significantly better than threads. But I'm hopeful. I'm hopeful. It's just
Chris Dy:a different vibe different I think different generations. It's a lot of podcasts I listened to I've had way too much coverage about the threads thing So I've been forced to learn a lot about threads and about Twitter's recent issues. I'll say, I have also been off Twitter for a while out of kind of pseudo protests as well. But, you know, I guess there's there's a reason to re engage. But first, before we go further, let's thank our sponsor.
Charles Goldfarb:Absolutely. The upper hand is sponsored by practice link.com, the most widely used position job search and career advancement resource.
Chris Dy:Becoming a physician is hard finding the right job doesn't have to be joined, practicing for free today at www practice. link.com/the upper head, and a special shout out to Ken Allman at Practice Link, he was kind enough to host 12 of our WashU orthopedic residents at a recent soccer game in his amazing luxury box. So thank you for that. I know the residents really, really, really enjoyed it.
Charles Goldfarb:They loved it, they shared a great picture, which can appreciate it. And yeah, it was it was very, very generous. And, and, and, and we as a department had an event. We haven't had a whatever you want to call it an annual event, a holiday event, anything in quite some time because of COVID and just trying to find the right venue. And you are traveling but Saturday night was really something special. Actually at the soccer park. There's a huge venue, that Michelob Ultra club. It was awesome. And it really Amanda did a great job and the vibes are really good.
Chris Dy:Yeah, I heard I heard great things from from everybody who had a chance to make it unfortunately, it fell on my son's birthday. So as you mentioned, couldn't make it myself. But I look forward to doing it again. Going at some point in the future. I heard the other hand service to come some hardware
Charles Goldfarb:to hand service took on some hardware. Yes, we are. Our division was the Press Ganey highest average score, which I think should come to no surprise to us, at least. I think we do. Well.
Chris Dy:I'm glad I'm glad we have people like you to bring up the score because again, if an average so when my clinic we keep to your Kelly's. So that is the number of patients that have cried during office encounters with me. So sometimes my scores probably aren't that good.
Charles Goldfarb:Your scores are good part a population matters to these things. There are a no workup probably doesn't help my scores. Dr. Calfee, it leads the way for us. He was edged out for the highest in the department, but still pretty impressive.
Chris Dy:Yes, I believe was that Dr. keener on the shoulder service on that trophy?
Charles Goldfarb:absolutely impressive work by Dr. Keener? Yes. Well,
Chris Dy:speaking of impressive work, I wanted to get your thoughts on a case that has been emailed to us by a friend of the podcast. We have tremendous reach Chuck, this is our second discussion we're going to have based on a case from Yonas in Athens, so Yonas Laconis , thank you for emailing this question and obviously for your questions in the past. So here's the here's the case. And he said maybe suggests a subject for an episode. So the case is a 45 year old right hand dominant man who sustained a left small finger tip dislocation six months ago in a basketball game was reduced to close reduction and an outside institution immobilized for a few weeks and then sent to physiotherapy in the comments, and unfortunately, they didn't have any dedicated hand therapists in Greece. At least aren't that many. And he came to Mr. Yonas' clinic with a subluxated very stiff PJ pap joint which is stuck in extension with no active or passive flexion. And there was no difference in the position of the MP when when the MP Jo was flexor extended, and his di t motion has zero to 20 degrees actively and passively. No pain, and he's managed to cope with his activities of daily living again, this is affecting his small finger on the left side. But the lack of flexion bothers him. For example, He cannot fit his hand in a boxing glove seems like quite the active guy. I hope to be like that when I myself and 45 Given a severe stiffness. So what do you think the most appropriate course of action is? So Chuck, what do you think maybe you can hit the honest did send us some X rays. I don't want to be at risk for vertical pimping. But do you want to tell us what the X ray show?
Charles Goldfarb:Yeah, let's do this. Maybe if you're honest, gives us permission and we can blind it. Perhaps we could share it on social media at the time of the podcast drop if we get permission and is blind and maybe that'd be okay. Yeah,
Chris Dy:yada, yada. So we'll have received an email and likely given permission by the time
Charles Goldfarb:Yeah, so let let before we talk about the X rays if it's okay, let's let's break down the physical exam the key points. So one point that caught my ear was the fact that the PRP joint was stiff and extension. The DI P joint really didn't have much flexion and when you move MP joint it did not affect the PRP joint motion. So there's kind of three separate points. And so number one moving the NP join and reassessing the PAP joint is, you know, a test for intrinsic tightness as soon as what yawns was getting at and though the note no evidence of intrinsic tightness That's number one. Number two, the PRP joints step. Now classically, I would say that could be for maybe three reasons. Maybe you have others. Number one, there can be a capsular, contracture, dorsally. Number two, there could be significant scarring of the extensor mechanism. And number three, there could be something intrinsically going on inside the joint. Any other reasons you can think of? Yeah,
Chris Dy:well, I think this is good. So first off, for any of you listening, who are in training, this was a perfectly presented case, in terms of all the pertinent positives and negatives. I mean, honestly, you can tell this, this, this doc knows what he's doing. So, you know, I think the points about the reasons for for the stiffness are really important. So you mentioned that there could be a dorsal capsular contracture and a dorsal contracture would limit you from, you know, passive flexion, presumably, right, exactly. And then you mentioned that there could be some adhesions on the extensor mechanism, which would limit you could potentially limit you in both potential for passive flexion as well as the ability to, to actively extend so that you know, and then I think you have made, you know, you had a great presentation and paper with with Marty Boyer that we often referenced here in our, in our teachings, about the stiff finger, there was a great ICL paper. And you know, you can't even assess active motion until you have passive motion. And I think that's a super important point. And then the last thing you commented, you actually had three things this time not to, I'm impressed. You've, you've grown. Your third thing was about potential intrinsic issues in the joints. So what do you think that could potentially be in a case like this, where you have a PAP fracture dislocation, and just to give away a little bit of the X ray, there is a very small volar plate ish type fragment, not a huge piece that we get super excited about putting a screw in or anything like that, but one that would, you know, give us pause?
Charles Goldfarb:Yeah, not a piece that one would think needs to be fixed. But in addition to that the joint alignment was was not ideal. And we can talk about more, I would say that an intra articular MalUnion could limit flexion. And obviously, joint subluxation can limit flexion.
Chris Dy:Are you focusing on the limitations that deflection because that is just the first way to talk about it? And then we'll talk about the limitations and extension later or because that's just what Jana said, is bothering this patient?
Charles Goldfarb:Well, both I think we're you know, we're starting by, you know, thinking about the reasoning behind the limited flexion. Is it only the joint are there secondary considerations as well, I think in this patient who again, the X rays do show some joint subluxation in the coronal plane, and also some slight dorsal subluxation in the sagittal plane, with some mild or throws is so all of those things can be hurting us, but doesn't mean they're, they're the only reasons for the joint being stuck and extension.
Chris Dy:Sure, I think that's a great point. So I'll break down the X ray. So we have just based on the image, the file names on the images, it looks like we have one injury image, which is a lateral of the small finger with it in what appears to be a very long Illuma foam splint that wraps around all the way from the tip of the finger to presumably the MPs based on the appearance on this kind of snapshot of the X ray. And we've got a we've got a PIP joint with a small volar fragment, I'd say probably less than 10% of the surface kind of more in the volar plate fragment category as opposed to an actual volar lip piece. That's probably fair to say, and you've got some subtle dorsal subluxation with I think, what looks like a V sign on the dorsal aspect of the joint, they're suggesting that as you said, this is not just a boilerplate fragment without any instability, there is an element of dorsal subluxation and pap instability.
Charles Goldfarb:Now the DIP joint is interesting, because classically, one loses flexion of the DIP joint when the PIP joint is stuck in flexion. So a boon airtight posture. And the reasoning behind that is, so if you have your Pap joint stuck in flexion, whether it's a Volar plate contracture, or whatever, what happens there is your dorsal what should be your dorsal lateral band slide mole early, and then you lose the ability to flex the tip joint. But this is not that situation. That's the common situation. Here, it seems to me like there's probably just some scarring of the extensor mechanism. And if you believe in the oblique redneck about a ligament, and maybe it's limiting us as well.
Chris Dy:Right, right. Right. So I mean, I think that you've covered a lot of ground there, you kind of switched up and talked about volere. I'm gonna try to digest this for everybody. He switched up and talked about reasons for limited extension after he said we weren't going to talk about that with your boilerplate contracture, but you know, then to go through the final X rays that Yanis was kind enough to send us you've got now got a joint that looks like it's chrome Nikoli subluxated that starts that looks like it's got some cartilage were on the base of the middle phalanx and Marty Boyer would kill me for saying looks like a few times in the last couple of minutes when I described X rays, but there's cartilage were at the base of the middle phalanx. So a chronically subluxated joint with some early arthritis. And then, as we described above, kind of the limitations in motion both for the PIP and the DIP.
Charles Goldfarb:Right, so we did throw a lot at the listeners who don't have the hopefully will have the ability to see the X rays. But I think fundamentally, what we're talking about this case is a chronically subluxated join. And the real question becomes, can this joint be salvaged? And you know, I don't for me, and I'd love to hear your thoughts. advanced imaging doesn't help me. So I don't think a CT scan or an MRI gives me useful information. For me, it's about the X rays, and likely about intraoperative decision making, although I always like to go into a case with a plan. How do you think about
Chris Dy:I think about the same way, I mean, I think that if this patient had better passive motion, but had limited active flexion, or limited active extension, I think an ultrasound might be pretty useful to look and see if you can spot some adhesions, I think that's challenging in some clinical settings, just because you may not have the small enough probe to be able to get it on the finger, that's actually a limitation I have in the clinic that I work in mainly. So we just don't have the small footprint probe to look at flexor and extensor tendons, apt to look for adhesions. But I think if you've got that available, that might be interesting. But truly advanced imaging, such as a CT or an MRI does not add anything for me.
Charles Goldfarb:So in this case, where there looks like that, thank you, where there appears to be, there appears to be some arthritis, and a joint is not particularly well aligned. In a young ish, I don't mean to offend you, because this patient's not super young. But it's not old, either. 45, do you think it, you know, is reasonable to consider an option to explore and potentially reduce the joints? Or is it your sense that in this case, the horse has left the barn?
Chris Dy:You know, I'm not, I don't think the horse has left the barn, I think this is this doesn't get down to, you know, and I hate to use this term, because it's kind of a catch all term of patient preferences and expectations. And if you get the sense that this patient, you know, even if you don't have specialized therapy is going to be able to do whatever you ask him to do. And understands that at the end of the day, they may still have either the same finger or a worst finger that's been operated upon one two or three times and is okay with that, and is willing to invest the time, energy effort resources to do it, then I think it's reasonable, I would not throw this, I would not throw the towel in on this one meeting give up on this one.
Charles Goldfarb:So I think that's very fair. In a little finger, we do have some younger listeners, the little finger is designed for flexion. And it is necessary for power grip. And we get we get our grip strength from the ring and little fingers. And if that little finger doesn't flex, then functionally it's a problem. And so if we would hope to restore motion to maximize this gentleman's function, and so in this age group, I probably would explore as well, trying to get a sense of whether the joint arthritis is diffuse. Or perhaps if we're lucky, it's just the volar aspect of the middle phalanx. And if we can reduce the joint and if we have to consider something like a Hemi Hemi, we could do that.
Chris Dy:Does the does quantifying the amount of post traumatic arthrosis on the middle phalanx affect your your willingness to engage in some kind of joint preserving procedure, either quantifying that during intraoperative inspection or during preoperative imaging, even though both of us said that we probably wouldn't, you know, does that influence? Is it 30% of the join? Is it 50% of the joint? Does that tell you like is this worth saving or not?
Charles Goldfarb:I think it does. And let's just use the Hemi hemiarthroplasty as an example, and I have done a fair number of those procedures. And they're not all universally successful. And I think the ones that are successful are the ones that have a limited amount of arthritis on the volar aspect of the middle phalanx and the head of the proximal phalanx is good. And so in those patients, you can really recreate that volar buttress of the middle phalanx. But if the head of the proximal phalanx is arthritic, then my expectations for a good outcome or decreased and so either preoperatively or interoperability I really do think you have to be honest with yourself. And I think you should have variable options available. So you should potentially be prepared to do a heavy homemade arthroplasty depending on the patient preference, this gentleman's young, but you should be prepared to consider an arthroplasty that is either a silicone or some type of arthroplasty. And then finally, in a 45 year old, especially if they you know, power grip and durability is your option, you have to be prepared to perform a fusion, because that's probably his best option.
Chris Dy:There's a lot to unpack there. I think that's uh, you said a lot of really important things you mentioned, you know, a limited, say proximal phalanx head is clean. And you've got some post traumatic arthritic changes at the base of the middle phalanx, you said a limited amount. And what is that kind of threshold in which you're like, oh, yeah, this is going to do well, versus you get a little more censored?
Charles Goldfarb:I think it meaning. So if we're talking how much arthritis we're not, the depth of their arthritis doesn't matter. It's simply how much from volar to dorsal, that base of the middle phalanx. And what you're trying to do with that piece of bone is, you know, recreate a volar buttress. And so, you know, you can replace 70, or 80%, of the base of the middle phalanx. But that probably is not ideal. I think if it's 60% or less, I think you're set up to have an outstanding outcome.
Chris Dy:And my threshold for that, even though I don't have the same depth of experience you do would probably have been around 30, or 40%. I just don't I mean, that's a lot of carpentry that you gotta get perfect if you're going for 60 or 70%. But I agree with what you said about wanting all the options and just to backpedal a little bit. For those of listeners that may be a little bit earlier on and experience. You know, the reason that this base of the middle phalanx is so important is that, as Chuck mentioned, it's a buttress that stops the keeps the joint reduced. And if you lose that buttress, say you have, you know, big fuller lip fragment, that joint is just going to ride out dorsally. And that's what's happened in this case. So you mentioned potentially being ready to do all the things, is this a single stage reconstruction for you if you're exploring I mean, I think some would argue maybe do do your inspection, do your releases, get all your passive motion, ensure that you can keep your passive motion and then come back. But I can also see somebody saying, Why would you go back to a joint twice?
Charles Goldfarb:I look, I mean, a single stage operation is always preferable, but if the patient is insistent and you believe that there is a reasonable chance of success, then absolutely you can always come back and do a fusion or do a different type of arthroplasty. And in a young patient, this you know, this joint has some coronal instability, which is not the kiss of death, but you would prefer only sagittal instability. That is the middle failings rotting dorsally that would be the preference for a Hemi heading arthroplasty when there's criminal instability can still work. It's just a little trickier. But I think in this patient, I would approach it virtually with the idea that I'm going to work to save the joint.
Chris Dy:So just to summarize your plan here, so if this is somebody who you know, we believe could do well with a single stage procedure volar approach shotgun, open the joint, take a look at the base of the middle phalanx and then plan for a heavy handed arthroplasty
Charles Goldfarb:if we're going for and I think there's some element of examining in the clinic. Also, live cm fluoroscopy can be helpful. This is not a slam dunk by any stretch. If this patient said, Look, I need to have one surgery, I need to know what's going to work. And I don't want to take any chances than the absolute right answer would be a fusion 100%. And if I fuse this joint, and fuse it in about 15 degrees of flexion. And I think the patient would do really well. But if I could restore motion in a painless fashion, then we'd all be happier.
Chris Dy:So to summarize, for fusion is that tension band is that little plate.
Charles Goldfarb:I'm a tension band fan. I do that from dorsally which is a little complicated here and we're gonna go boldly first, but what about you what's your first choice?
Chris Dy:If we're going to do a fusion I tend to like plates. Compression plating, I think that we talked about this on a prior episode. She mentioned it recently with one of the fellows we were doing an MP fusion for a thumb and you know, their experience recently with one of our partners Marty Boyer was you know, they did a bunch of tension bands on somebody's PMP joints and I just like the dorsal plating I think it is somewhat lower profile and if you actually put the screws in and so that they're not sitting out I think it probably is a little less prominent than some tension bands when they're not done perfectly well by somebody like with the experience like you cost more obviously, you don't always have to use the locking screws and the fancy technology but I think some of those some of these plates that that are in the existing hand modular sets are pretty nice.
Charles Goldfarb:Yeah, especially the new plates that are designed for there's no doubt they are they make it a little bit easier, and they decrease the fiddling but Yeah, I think this is an interesting case, it's the the PRP joint, as we all know, is super tricky. It has to be anatomically reduced. And so the missed opportunity not necessarily by the, the surgeon who wrote in, but the missed opportunity was identifying a non anatomical reduction early and correcting that. Because if you don't get the joint perfect, even if it requires a k, where you don't get the joint perfect, it's going to go in the wrong direction. So you have to have an anatomical reduction, you can always deal with stiffness, but you have to have the anatomical reduction first.
Chris Dy:Right? Yeah, there are a lot of ways to get to that anatomical reduction, you know, from the earlier identification of the subluxated joints, you know, even something as simple as a dorsal blocking splint, you know, checked under fluoroscopy. And, you know, kind of looking at seeing the position of stability of the joint and acknowledging that you're going to have to flex the PIJ to get it to be concentrically stable, and that you're gonna have to fight through some of that lack of extension later on, but you are going to get the flexion that you are wanting. And if you don't do a dorsal blocking, split, there's a dorsal blocking pin, then you kind of progress up the ladder to something like a dynamic x axis azuki timeframe. And then you kind of get into these really big reconstructive options. So if you have something that remains unstable, do you ever just pin the joints and flexion? Not a dorsal block knee pin, but just a pin?
Charles Goldfarb:I have I mean, I that's not my first choice. But again, you got to figure out a way to get the joints stable, let the soft tissues heal. Take out your pen and worry about motion later. Yeah, so in the right situation, which would be a really complex situation. I don't think there's wrong dependent joint. I really don't.
Chris Dy:Right. And then I do want to touch on one thing that you mentioned, you mentioned, this would be a volere approach. And you know, shock getting the joint. How do you deal with the dorsal tissues, the dorsal capsule potentially being tight, which could limit your flexion? You know, both the capsule and potentially the extensor tendons?
Charles Goldfarb:Yeah. So we and that is Marty and I and I think I think all of us now have this sort of the same belief that we don't like operating on both sides have a finger at the same time. And the theory there is that if you operate dorsally and vole early, then it's probably too much, especially for a little finger and you'll get resultant swelling. And the swelling will limit your therapy success after surgery. And so we typically operate on one side only. In this situation, if you're going volar, I think there's a you can deal with the dorsal capsule without too much trouble with a fear elevator, or something like that, I think it's a little trickier to scooch around, so to speak the side of the joint to get the extensor mechanism. So I think that's a fair concern. But that may be that may mean you're looking at two servers.
Chris Dy:Right now, I think the sensor to license if you do have to do it is a nice one done a week. So kind of lower, less morbidity for the patient. And honestly, you get some useful information. And you're lucky if you get to that point where you're working on on the extensor mechanism after such a big surgery. So just to summarize for Mr. Yonis, who was kind enough to send us this case, the consensus among between Chuck and I would be for probably a single stage surgery really going for your for your release, and moving towards a heavy handmade, if at all possible. So single stage, go big or go home.
Charles Goldfarb:Yeah, looking for the home run with a baseball analogy, given the the all star games tonight looking for the home run. But it may not be possible. And if it's not possible, then we should do the best thing for the patient, which is probably providing stability with the VIP joint fusion.
Chris Dy:All right. So I wanted to zoom through a couple of other quick emails that we have an email from a longtime listener, who, who recently enjoyed our episode about FPL rupture. And I'm not sure if I have permission to share his name. So I won't maybe we'll reveal it in a future episode but hand surgeon in the US who asked us about potentially what's the role of AIP joint fusion for somebody with a really chronically delayed FPL rupture after the case that this listener is mentioning is 13 years after volar planing had an FPL rupture. So what do you think about IP, some IP joint fusion as a treatment option the patient needs describing is actually I think both of us are agrees elderly, five years old.
Charles Goldfarb:Yes, a little older than I, either. There's absolutely nothing wrong with an IP joint fusion. And I think it's a conversation with the patient and hopefully the family because you're you're not giving them back what they had before. And that's problematic for some patients, I think you would provide a really good thumb for that patient. And they can use the thinner musculature for flexion of the MP joint. And I think the patient would do really well, but they would not be happy unless they truly understand what you're accomplishing with that IP joint fusion. For that reason, I tend to prefer to reconstruct The FPL, but it's not wrong to fuse the IP joints.
Chris Dy:Yeah, and I think this, this listener had a really good point that he tried non operative treatment to see if just trialing it to see if the patient could live with it. But the patient didn't like the instability. And when somebody like doesn't like instability, I love the option of giving the maximum stability with the fusion.
Charles Goldfarb:Yeah, that's a great point. It's really a great point,
Chris Dy:would you go ahead and remove the volar plate? If the FPL is already gone? Do you just remove the plate at the same time? Because how often do you see FDP issues for the index through small.
Charles Goldfarb:it really depends on how prominent the plate is, you know, sometimes you're surprised with an FPL issue. And sometimes you're not surprised and that the whole issue develops. If the plate is not prominent at all, I probably would, I wouldn't feel the need to remove it. If there's any question though, and you're going to the operating room? Take the plate out. That's my opinion, do you see any differently?
Chris Dy:I don't, you know, I think I have a lower threshold to remove the plate. But this listener actually did something pretty slick and did the the IP fusion awake. So if your point is if you're going to the bar, but if you don't have the Monterey CGI, you could clearly do a volar plate removal awake, it's obviously a little more tedious and trying and you know, a little more effort on surgeons, surgeons part. But, you know, if the patient is undergoing any sort of anesthesia with a block, at least, you know, regional block and some sedation, I think it's fair to just take the plate on both. You don't have to worry about it anymore.
Charles Goldfarb:Yeah, you know, we had a really interesting discussion on Monday morning conference about a classic rheumatoid patient, which got me thinking and morning, I have been talking since there are things that we are losing, that trainees just don't get to experience in the care they're warming to a hand is one of those and you're not, you know, I've had a couple of this year and we saw that one and but they just don't happen much. Thanks for the disease modifying anti rheumatic drugs tend to transfers are not exactly. Well, they're just not as common as they used to be for a lot of reasons, including what you have, personally single handedly destroyed in our patient population by using nerve transfers. Without you, we'd be doing way more intended transfers.
Chris Dy:Oh, hardly hardly, we did write an interesting paper and one of our current partners Marie Morris, when she was a resident, we got a nice grant from the and society to pull data from the aapos, looking at how frequently nerve transfers were being used, and new graduates who are doing their case logging, and went up six times, just over the course of a decade. Now probably a lot of that is to be honest with you kind of AIN- ulnar nerve supercharging kind of thing. I don't think there are tons of new board eligible orthopedic surgeons that are you know, doing over Linz and all sorts of transfers. But you know, the, the very accessible transfer of like an AIN pronator quadratus supercharge is probably being done a lot. I I'd say two things in your in your fashion, one of us brought up in conference, how it's a shame that our trainees are not learning more about these tenant tracers, and then another one on this podcast, then shut them down immediately with some clip of that intergenerational differences yet, you then went and talked about this with Marty Marty about what to do about it. So you're welcome for the idea. I look forward to seeing whatever content you and you and Marty to create. I agree, it's, it's a shame that our trainees don't get the access to care, the rheumatoid hand and wrist. And then with regards to tenant transfers, I completely agree I actually tried to get the residents and fellows to to the tenant transfer cases that we do for nerve patients as much as we can, because you need to know how to do some of these basic things. If you're gonna call yourself a comprehensive nerve surgeon, you need to know how to deal with issues when they come to you late or when your own reconstructions for somebody else's don't work.
Charles Goldfarb:Yeah, all well said Marty, and I are not producing any content, but I think you are got enough content to produce what what we talked about is in a practice like ours, there clearly is already some specialization. And, you know, do we all need to know how to reconstruct the rheumatoid hand? And the answer that clearly is we do not. But the concepts and the kind of approach is absolutely something we have to still teach. But it's interesting, because, you know, I've thought about this a lot. As we get into practice, you do not want to narrow your practice too early. And you and I talked about that. You want to keep your practice as broad as possible for as long as possible. And then you want to narrow to stuff that you are passionate about, because once you narrow your practice, you can't go back out. But things like this super specialized things like the rheumatoid hand or, you know, Marty, I trade back and forth. I do wrist arthroscopy. He does joint arthroplasties. But we're older. So I understand where our younger partners don't want to give up something like the rheumatoid and they want to be a part of the reconstruction. So I think we have the best of both worlds. He's not sending the patient to Marty. He's doing the case of morning.
Chris Dy:Yeah, agree entirely. And you know, honestly, I've been, I've been on both sides of that in terms of sending the case versus doing it because sometimes it is really hard to just coordinate schedule. And, you know, not delayed the patient's care for many months just to, so you can have that experience. So I'm torn on that. And, you know, I feel like that's something where I wish I had more experience with rheumatoid hand and wrist with with arthroplasties. I'm fortunate enough to have partners, a partner who is excels at it. So yeah, I think that's it, it's certainly a different ballgame. Once you step outside of the academic arena, and you're at a smaller group, and or potentially solo practice, I wanted to squeeze in one more listener email as it relates to FPL. So Bob vandermark, who has listened for many for a long time, and as always given us permission to share his thoughts. You know, he's he shared that about the FTL rupture, his junior partner couldn't find any literature about FTL reconstruction techniques. So, you know, when we get our article out there, you know, he mentioned, Bob mentioned that we might want to mention wide awake as an option. He's done one FTS, one reconstruction using FDS. And he said, The Rupture was old in the FPL muscle was not good. And he's kind enough to send us an article about just general principles about using wide awake to help judge your tendon transfers. So it's a great way to to set your 10 intention. And then the other advantage that Bob states about wide awake is that the patient can see what the reconstruction looks like said my patient was a farmer and remarked that the repair looked pretty weak. And he would have to be careful not to screw it up a great example of patient education. So what do you think about that?
Charles Goldfarb:Well, I think it actually feeds into what we just said. So if you can do this procedure wide awake, it does negate to some degree and experience issue, because you can judge your tension with the patient helping you with active motion. Without that you have to depend on experience and reading to know exactly how to tension each of these tendon transfers. And so the wide awake surgery may be part of the answer to the lack of experience with these cases. I don't know that I'm up for a lot of wide awake, big tendon transfers, but I applaud those who are,
Chris Dy:I've done, I've done some and, you know, I think that it is way more work on your end that way more is more work. Just because you've got to, for lack of a better term, entertain the patient, and engage them and calm them when, you know, sometimes the local needs to be kind of added back and that kind of thing. So it's more effort and what is can already be a challenging case, especially if you've got trainees with you who you want to engage in have participated in the case. So but I do think, you know, the, the tensioning that I've established with doing some right away tenant tracers I've been really happy with. So yeah, I kind of go back and forth. And he always kind of wait for the right patient because you know, the the patient's condition and you're playing surgical treatment may be right, but the patient themselves may not be right for Well, I
Charles Goldfarb:don't exactly well said, Well, we kind of went all over the place, even though we only had two cases. I think we approached it from a lot of different angles. I hope it was comprehensible. And hopefully we can share those x rays.
Chris Dy:Yeah, absolutely. So thank everybody for listening. If you'd like to grab bag stuff, or you have a suggestion for a topic, feel free to email us at handpodcast@gmail.com. And we look forward to talking with you again soon.
Charles Goldfarb:Yeah, I think we do have a couple of we've talked about some topics which I am really excited about one we may have a guest on to talk about distal radius Malunions and approaches in 2023. And two, we want to we need to hit that therapy episode. We have some real real opportunity there because we It's been too long.
Chris Dy:Macy's back from there from from her parental leave this week. Oh, good timing. Good. Time to be chomping at the bit for sure. Have a good one. All right. See ya.
Charles Goldfarb:Hey, Chris. That was fun. Let's do it again real soon.
Chris Dy:Sounds good. Well, be sure to check us out on Twitter@handpodcast. Hey, Chuck, what's your Twitter handle?
Charles Goldfarb:Mine is@congenitalhand. What about you?
Chris Dy:Mine is @ChrisDYMD spelled d-y. And if you'd like to email us, you can reach us at handpodcast@gmail.com.
Charles Goldfarb:And remember, please subscribe wherever you get your podcast
Chris Dy:and be sure to leave a review that helps us get the word out.
Charles Goldfarb:Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time