Chuck and Chris start with a brief discussion on coding before taking a deeper dive on acute median nerve repair based on a listener question regarding tension during repair (tension on the nerve, not tension of the surgeon). We then pivot to volar scaphoid approach and pearls.
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See www.practicelink.com/theupperhand for more information from our partner on job search and career opportunities.
See https://checkpointsurgical.com or www.nervemaster.com for information about the company and its products as well as good general information about nerve pathology.
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.
Chuck and Chris start with a brief discussion on coding before taking a deeper dive on acute median nerve repair based on a listener question regarding tension during repair (tension on the nerve, not tension of the surgeon). We then pivot to volar scaphoid approach and pearls.
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.
See https://checkpointsurgical.com or www.nervemaster.com for information about the company and its products as well as good general information about nerve pathology.
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 podcast.
Charles Goldfarb:Hey, Chris.
Chris Dy:Hey Chuck. How are you?
Charles Goldfarb:I'm really good. I'm having fun. I'm looking forward to our episode today.
Chris Dy:Yes, absolutely. It's some exciting stuff coming on with the podcast, we got a new sponsor coming our way in addition to our existing sponsor, but it's the time of the year where everybody's kind of, you know, looking around and saying, you know, things are new. And you know, we've got new residents have been in for a while fellows are kind of in their second month now. Have you had any good discussions with them about your favorite topic coding?
Charles Goldfarb:You know, I haven't talked about coding. Yet with fellows. What's been interesting is no one wants to talk about coding until they have to talk about coding. And so even in the early part of the year, I don't think fellows really care. Even if we ask them to do some coding, and they do some coding this year. They don't do a ton of it. I talked about it throughout the year. They they get nervous in June, and then they want coding last year. Yeah.
Chris Dy:Yeah, I remember feeling nervous about it. But it also kind of knowing this, I don't know. I mean, I guess knowing I was going in academics, and just kind of it didn't really matter as much to me. But I think that it really matters to those that are going into, you know, private practice type job or any kind of job where you know, some academic places you're in the coding you do yourself is pretty, or at least the guidance you give the coders is super important. You know, I honestly have probably left a lot of our views slash dollars on the table because of my ineptness with coding.
Charles Goldfarb:It is it is interesting, I think in 2023, we all should be highly aware of the codes. I mean, it's a it's a law. But But aside from that, you know, we are responsible for what goes in. But to your point. If you have really good coders on your team, you're probably okay, maybe there's some missed opportunity. If you dictate well, and know what to the lingo to put in your dictation, and you have Professional Coders working for you that can help. But if you don't have that you really need to learn how to code because it is absolutely money on the table.
Chris Dy:Yeah, and I guess this is a very American centric discussion, because I think in, you know, other parts of the world, the healthcare systems work differently, perhaps better. I listened to a different podcast all time called pivot. And Scott Galloway talks a lot about how healthcare in the US is just such an opportunity for disruptive innovation. Because you know, it's such a behemoth in terms of cost, and most people are not satisfied with their health care.
Charles Goldfarb:Oh, it's Yeah, we could talk for many episodes about the debacle that is about American health care. And the coding part it you know, I actually do enjoy some aspects of coding. It's interesting, we in the department have talked about are we doing it the right way, I recently had the opportunity to use Codex, which is the workbook Academy's coding platform, I was honestly disappointed, I hope I don't make anybody mad by saying that it was basically the same as a spreadsheet, I have an Excel. And so I don't know, I It does seem a little weird that in 2023, we're using, you know, very simplistic trying to apply simplistic codes to complicated procedures, and there's got to be a better way, and we aren't there yet.
Chris Dy:I'm telling you, ai ai is gonna take whatever we document and should be able to code and but I guess he said, you know, we're, you know, legally we're responsible, but I think that's a huge opportunity, you know, for, for generative AI to really pick up on how to code properly and how to not leave, you know, opportunities on the table. We actually had a listener as a listeners, coder, emailed my admin asking how I code, certain procedures that we've talked about on the podcast. And so I thought that was that was an interesting part of it. You know, are there any particular parts of coding that you wanted to discuss today, other than just giving me a general rant?
Charles Goldfarb:No, it was interesting, because there's some thought that each of our surgeons should code their his or her own cases. And I do that anyways, personally, I may be nearly alone in the department in that philosophy. And our coders are really good. And they're not 100% But they're really good. And to me, like, I think there's some people who are listening to us right now thinking that you and I are both crazy for not coding every single case ourselves and making sure we get it correct. And I can't disagree with them. I think that is really important. If you don't and to the trainees or to the students, if you don't decide to go into a situation where you're coding yourself, you still have to understand it because the lingo matters, what you say affects what you get paid.
Chris Dy:Right? Right, right. Yeah, I probably am crazy for not paying more attention. I think an interesting experiment for anybody wants to do it would be to you know, have a surgeon a code their own list in surgeon be not code their own list and see what, what, what you come up with and what actually gets billed, etc.
Charles Goldfarb:Always thinking like a research study designer, I love it.
Chris Dy:Have to have to. So hopefully somebody does that. And tell us about it. Because that's not anything I'm gonna be doing anytime soon.
Charles Goldfarb:So if you are out there, and we are filling you with outrage about missed opportunity on coding, email us, please interact with us.
Chris Dy:Yeah, tell us tell us hand podcast@gmail.com. And if your argument is compelling enough, we'll have you come on the podcast and teach us how to teach us how wherever leaving opportunities on the table, because I guarantee you like you're saying there are some listeners saying these academic guys they have no idea what they're what they're missing out on. But I think there's probably some bias and how I ended up in academics. Not a professor kind of thing.
Charles Goldfarb:I want to make sure you're feeling okay. You don't don't look your usual energetic. So should we talk a little about nerve with that? Would that boost your spirits?
Chris Dy:We should. But before we should thank our first sponsor, the upper hand is sponsored by practicelink.com, the most widely used physician job search and career advancement resource.
Charles Goldfarb:Becoming a physician is hard finding the right job doesn't have to be joined practice link for free today@www.practice.com/theupperhand.
Chris Dy:Yes, yes. Check it out. Now, you know, a few episodes back. Megan Conti Mica talked about, you know, her job search and everything. And I'm sure, you know, like she said, having all those resources in one spot is going to be helpful. So and you can find the job where you have to do your own coding, I'm sure.
Charles Goldfarb:Most jobs from require it.
Chris Dy:So we have a great case that was sent in by a friend of the podcast, Dr. Andy Nelson. And, you know, he brings a case of a woman who is in her 50s It is a hairdresser. And it has immediate nerve injury from on the dominant hand. And, you know, I think there's a lot of different ways in which you can handle the meeting or for those of you that don't know what a spaghetti wrist is a spaghetti risks is when you've got multiple tendons and likely nerve and artery lacerated in the distal forearm, you know, so, something that comes up, I learned when I was in India, that they call this a full house, not a spaghetti wrist. But, you know, inevitably you've got, you know, probably a median nerve that is completely lacerated or partially lacerated, which is also an interesting discussion. But in this particular case, Andy talks about a median nerve that is completely lacerated in sends a nice picture of the wrist and neutral in before freshening up the ends, he's probably got already, you know, a centimeter gap. And once you freshen that back, that's going to end up being probably a two and a half centimeter, three centimeter gap with the wrist and neutral. So, Chuck, how would you think about this case, just in general,
Charles Goldfarb:you know, the, the mechanism of injury really matters because that will have as does the acuity because that'll affect how much nerve you need to resect to have bulging basketballs to maximize your potential for recovery. And so the first step is you know, thorough debridement I typically in general repair tendons first and save the nerve that also takes a little tension off the field which can be helpful. And then I try to mobilize the nerve without the vascular arising there. And once I've done my resections I just you know, stop and take a look and decide what the next step is.
Chris Dy:Absolutely agree with that. So I like tendons, tendons first repair tendons as you go save the micro for last. So if you're doing if you're going to do the artery or usually the hand is perfused, but if you're doing the radial or ulnar artery as bonus micro tip it's like great for beginning of the year fellow micro training because it's nice big juicy vessel and they get some reps on the scope and practicing their anastomese season that kind of thing. But yeah, tenants first and I you know, as much as I'd like to hold tidy like you know, tag everything as you go and like you know, identify just repair them as you go because otherwise you're just going to get caught and this is not the beautiful you know, modified winter's government eight strand flexor tendon repair you're in the forearm you can go nuts with some bigger sutures and just get it done. You know, so I think that that to help you know for case expedition, and then before we talk about the actual kind of nerve decision making we should thank our new sponsor.
Charles Goldfarb:Yes, we should. The upper hand is sponsored by Checkpoint Surgical welcome Checkpoint, a provider of innovative solutions for peripheral nerve surgery. Through its nerve master educational programs. The company is committed to engaging thought leaders to develop lead and support peripheral nerve surgery education.
Chris Dy:So on October 13, and 14th Checkpoint is co- hosting the Ohio State University, The Ohio State University's first annual combined fellows and practicing surgeons, nerve tendon and functional reconstruction course. Guys, that is a mouthful. The course faculty includes our friend Amy Moore, who's been on the pod, Dr. Sanjay Jain, Dr. Kyle Eberlin and Dr. Jason Souza. To learn more about the program and register, visit nervemaster.com. And the link will also be in our podcast episode description here for the upper hand. And checkpoints article driving innovation in nerves surgery. There we go.
Charles Goldfarb:Yeah, I mean, I'm not a nerve guy. I do use checkpoint. I have a case this coming week I'm excited about so I appreciate them signing on. And hopefully it can be a win win.
Chris Dy:Yeah, absolutely. So that being said, in this particular case, probably not one which I would use a checkpoint. didn't plan it that way. But you know, I think sometimes, like, if you get there really early, that may have a role before valerian degeneration kicks in. But that's usually not the case. In terms of identifying targets, now I was having this discussion about you know, how to identify, you know, if you're doing a group particular nerve for an older nerve, you know, some of the old school techniques were to keep the patient awake, and use a stimulator on the proximal end of the nerve to help differentiate sensory versus motor. That is a technique, I don't think that it's used very often anymore, but perhaps will have a role. But you know, backtracking back to our median nerve laceration in the distal forearm, just proximal to the wrist crease, it's about a two and a half to three centimeter gap with the wrist to neutral, actually had a case like this recently, Andy, and I think that, you know, I really wanted to primarily repair the nerve, I really, really wanted to, the patient really did not want a nerve harvest. And I tried, and you know, we the most, I will flex the wrist for something like this would be about 30 degrees, because I think that's the most you can ask, you know, of a torso blocking splint without creating any issues. So if you are going to go the path of doing that it is high risk, high reward and work from many others. But also, most recently, our partner David Brogan has shown that if you prepare the nerve primarily, and it's under a little bit of tension it, it'll be great. If it works. If it ruptures, you're completely out of luck. So, you know, I think that is the challenge here. Are you willing to take that risk? Do you trust the patient? Do you? Are you willing to roll the dice, and for me, that situation rarely comes up where I'm actually able to primarily repair the nerve. And then if you do primarily repair the nerve, I think, you know, kind of moving slowly over, you know, six to eight weeks to get the wrist out of that kind of slightly flexed position. And I've used ultrasound in some cases to monitor the nerve coaptation. I think ultrasound is not great at telling you if the nerve is if nerve regeneration is occurring, it's, it's okay, it's telling you whether there's Frank dis continuity, because whatever your repair, you know, whatever repair you have, you're gonna have some sort of pseudo neuroma formation because you never get it perfectly repair. So there'll be some enlargement, and you can only tell whether that thing is split apart or not. And at that point, it's too late. So that was a mouthful, had been thinking about.
Charles Goldfarb:You know, simplistically, every one of us is tempted to go for the primary repair, because it's better, right? It's only one junction to heal. And if you can get away with it, of course, we should do that. It's faster, potentially better. But the reality is, and this is hard, this is hard in the middle of the night, it's hard at the end of a long day. If there's a two and a half to three centimeter gap, I don't think a primary repair is typically the right thing to do. And, you know, you have to bear in mind the ramifications of this repairs to frickin median. They're in the form, you got to do the best you can do for the patient. And I'm certainly not being critical of anyone. But you have to I think, I think and I've been guilty of really trying to cut corners, you shouldn't do it.
Chris Dy:Right. Absolutely. And then, you know, I think if you're looking at a nerve repair, and you're trying to figure out whether the co aptation is going to is under too much tension or not. I think using a single nano Nylon is probably the cleanest way to do it. I think that the Adel nylon tests been described, there's some work out of Indiana showing that and I know nylon suture one suture is probably better in terms of matching the appropriate resting tension of the nerve. So I tend to use nine oh, nylon, although, you know, again, when you're trying to rationalize or justify a decision, you've gotten, you know, you're holding the nerve together and the fellows putting in or your assistant is holding the nerve and you're putting in an eight oh, nylon and maybe two and trying to see. But you know, I think it's it's again, while it's really tempting, don't fool yourself. And that's what we did in that case recently is that we, you know, I had a very skilled fellow working with me at the end of the year, and we were like, Let's try to get this repaired. And we both we looked at ourselves, we're like, Well, who are we getting here? So we went in harvested from the leg.
Charles Goldfarb:Alright, I'm gonna give you a challenge. in two sentences, max, tell me why tension is bad.
Chris Dy:So tension is bad, because if you have excessive tension is going to cause ischemia and ischemia will stop nerve regeneration. And then the second sentence is that if you if it is under too much tension, it may also just rupture. Bravo. Yeah,
Charles Goldfarb:I didn't think you had it in Yeah.
Chris Dy:Yeah. I've been blabbering since it's my favorite topic. But the other questions that Andy asks are, you know, so aside from what size suture what the tests, you know, so if you do get it together, I think you have to be honest with yourself and passively extend the risks to about 30 degrees, you can't just put it in neutral. And if it if it shows signs of gapping, just take it down. But honestly, but by the time you're fresh in the hands on these, usually the retracts a little bit and you're just not able to get it put together properly. Now, if you're there sooner after the the injury itself, you're there pretty quickly, I think you've got a really good chance, but the longer you wait, the more likely it's going to retract on you. And you know, like you said, this is a nice little pearl you mentioned, you know, sometimes getting the depending on where the nerve is injured, sometimes getting the tendons repaired helps because as many of you know, the median nerve tends to hug that kind of epimedium of the muscle of the FDS. And sometimes that kind of brings us closer together, but I never constantly rely on that.
Charles Goldfarb:Right? Right. Okay, so you're in the or you made the decision, you need a graft? Is this an age based decision? Or is this a convenience decision? What are your choices?
Chris Dy:I think that you know, your choices are that you could harvest autograph from somewhere you know, I think the classic the classically described as sural nerve but you're in it that's different now obviously has to be a discussion about donor site morbidity, and you're in a different different extremity. And you know, it's kind of honestly a pain in the butt to harvest the sural nerve sometimes, especially if you're on your own or if you have limited help. Another option would be harvesting something from the ipsilateral extremity so something like medial and a brachial medial brachial LABC. Some people even say Sue, for sure radial nerve, I tend to stay away from the more causalgic nerves like an SRN. But you know, if you do it well and take care of your proximal stuff, I think those are good options that you have. The testicular density is higher in the cervical nerve, which is nice, which I think for like you said, this is a high stakes operation, I think that that's where I would go typically, outside of autograft, your options would be at least in the US and a Sellier neuro valid graft, typically available off the shelf. And I think that, you know, if there are some case series and some emerging data from prospective studies, which are funded by the group that makes the positive that processes and cells the neuro valid graph, that suggests that doing an ally graft is just as good as doing an autographed. I remain unconvinced that if this was my nerve, that that's what I would want. But I think that is a reasonable thing to consider. But it's not my personal preference. So the if you read if you're listening, the Ranger studies demonstrate that there are some cases in which this would work with a seller Derval graph. But again, that's just not my personal preference. I think that you know, the standard is is tricky, because historically, cable autographs have not performed very well. But I think as we become more discerning, I think if you were to look at the more recent literature cable autograph to perform, okay.
Charles Goldfarb:Yeah, I think well said it is interesting how our field is advancing. And my analogy would be autograph versus Allah graft plugs for oats procedures for OCDs. And there is a push by industry to use allograft. And my god, the difference for both patient morbidity and surgery convenience, really favor the Allah graft. I just have a hard time I do consider it for every case, and I will use it but I typically like you, in situations like this would favor autograph and would personally favor this or older.
Chris Dy:Yeah, so I mean, I'd love to hear from listeners. You know, I think that I've kind of given my stance on this and multiple venues, including on the podcast and reached an episode prior episodes as well as on the podiums. But I know that there are a lot of people that use a cellar and are valid craft and have had fantastic results. I would love if you would share your experiences with us. Tell us on it. Tell us about how it's gone for you. And tell me if there are papers that I need to read, because you know, I'm certainly open to that. And the next question is whether I would wrap anything around the nerve. Chuck, do you have any reps there?
Charles Goldfarb:I do not. And I'm pretty confident you are going to say you do not wrap the nerve ever if I've learned anything from you. I hope I've learned correctly over the years. You do not wrap anything do you use to seal?
Chris Dy:Yeah, so it's I guess if we're going to be truly technical, it's an off label use from the FDA for nerve coaptation but I use it to seal not for anything structural, I think it hangs around for a couple of weeks and it's gone. But I think it, it does help with minimizing some gapping. Potentially, you shouldn't bank on your to seal. I know there are some places where all they do is the fibrin glue. For those who are not familiar with the seal. It's you there are some places that use only fibrin glue for nerve computations. I think that works in your favor, perhaps in children. But I don't bank on the fibrin glue as being the structural part of my co optation. I still like lining it appropriately tension free, you know, with with suture, and I used the fibrin glue to help sometimes with you know, creating the holograph the cabled autograph to see me with that. But I don't rap. Sometimes if there is a kind of question about whether it's a hostile environment for the nerve graft, I'll mobilize some of the adequate fascial tissue in that area usually can find a nice portion of the radial forearm fascia pedicle off of the radial artery that's really useful to flip and turn down. And I've used that a lot in revision cases.
Charles Goldfarb:And then maybe my last question that we're going to pivot to a far more interesting topic. Bones. How long do you what do you tell patients? Okay, so the patient comes in sharp laceration, the forearm, you ended up you know, as you're getting to a 10 days later, and you end up doing a sterile nerve autograph? What is the period of time? Do you tell them one year to know what kind of recovery they're going to have? What do you tell them,
Chris Dy:I usually tell them nine months to a year to really know, you know, and explain to them kind of how long it takes for nerve to recover and regenerate. One interesting wrinkle I'll add here is that probably for this case, like I did recently, I would probably use the doing nerve transfer for the recurrent motor branch of the median nerve. So borrowing, transferring the nerve from the hypothalamus that Bertelli is described, certainly leaving the rest of the ulnar nerve in zone two alone, but finding a branch that goes to the ADM and doing a nerve version of the of one of your favorite 10 transfers, the Huber and transferring that over to the recurrent motor branch, I think you can get a lot of length out of your recurrent motor branch as your neural license. And often I'm doing a carpal tunnel release for this case anyway. So that helps move things along. I've seen recovery from that pretty quickly, because you are pretty close to target. And that will outpace the sensory recovery that you're going to get. You know, I think you could also make a justification for not doing that, because you're close enough to target to see some reasonable outcome. But I think there's minimal downside to doing it. And it's a synergistic type transfer.
Charles Goldfarb:And this is end to side.
Chris Dy:No, this is end to end
Charles Goldfarb:oh,
Chris Dy:I go in and on this one. You know, I guess if, if I'm gonna do it, I'm going to do it on this one.
Charles Goldfarb:Love it. Love it. Great conversation, even though it was nerve. I enjoyed that.
Chris Dy:Yeah, sure. You did. Sure you did. Why don't we talk about bones? You we had recently had a well, first off. Thank you, Andy, for sending that in. Super helpful. Hopefully, this was a good discussion. I know that the listserv may have provided you have some better responses than that. But hopefully, we helped you out a bit there. And then we had a discussion recently about skateboards and how to deal with them. And we talked about using dorsal approaches, but we didn't really talk about when you would go volar on a skateboard.
Charles Goldfarb:Yeah, so let's let's do that. First, I would say that I've not personally been super successful with percutaneous, or limited bowler approaches. So for me, if we're going volar let's start with indications. Why would you choose to go volar over dorsal and I would say you would always try to avoid going volar because it's so simple to go dorsal. But when the indications are right, volar is an important technique that you gotta have. And you can expect really good outcomes. So what should we just pop back and forth? What are the indications to go volar for you?
Chris Dy:Yeah, so I mean, usually, honestly, most skateboards aren't coming in acute fractures aren't coming in with, you know, quote, The humpback deformity. Usually, that's more of an a, you know, non union setting or delayed diagnosis kind of setting. So, you know, to me, that's usually the reason why I'm considering going volar is if I have a lot of flexion, through the waist of the skateboard, and I need to correct that, I don't think you can get a lot of effective correction from the dorsal approach and get a little bit, but not a whole lot. So, you know, for me, dorsal is more of when you're playing it where it lies, or you got to do a little bit of correction. But if you have to do any meaningful correction, I go volar. How about you?
Charles Goldfarb:Yeah, I think that's well said it's typically a non union with a humpback deformity. And the other trick is where the fracture line is located surface approximate pole nonunion first of all, you're not gonna have a humpback in most cases, and you just definitely go dorsal waist and distal waist, you're much more likely to go bull or both for access and correction of the humpback deformity. As well as placing the screw in the right position because the more distal your fracture, the more important it is to have your screw running in a retrograde fashion from distal to proximal. And I think that's basically it. That's why you go volar
Chris Dy:Right, right. I think one of our partners had a case And that was quite challenging that it was a proximal pole and a setting of a prior malunion through the waist, which all of that sounds incredibly challenging. But yeah, I think you described it very well. Usually with a proximal pole, you're not going to have that kind of humpback deformity that you would classically see with something a little bit more distal. And then, you know, I think going, going volar does make much more sense if you've got a more distal oriented fracture pattern.
Charles Goldfarb:Yeah. And it's, it's not a complicated approach. It is an approach where you have to gain confidence, because it's simply not an area where we work all that much. Maybe we can just briefly talk through the approach and then
Chris Dy:you're, yeah, definitely, you're in a hole. You know, in the, I think getting the exposure is key. So how do you design your incision and kind of talk me through how you do it,
Charles Goldfarb:I would say the first and those of you on YouTube can see the first non intuitive piece is your escape for to scaphoid tuberosity is at your distal risk crease, and then you've push on it, it hurts whether or not your skateboard is broken. But that's, that's your skateboard tuberosity that's where your screw is going to enter. So I make an incision, which is V shaped, so it's oblique across the peen or eminence, and then it comes over the fcr tendon. And I do use the fcr tendon sheath as part of the approach. And I sharply dissect down to the tuberosity. And I open the sheath.
Chris Dy:So how do you manage your, your fcr?
Charles Goldfarb:I typically, well, first of all, before he gets the fcr, sometimes you'll encounter that transverse, that transverse branch of the radial artery contributing to your superficial arch. And in that case, I just if it's in the way, I don't mind cauterizing. Yeah, tying it if you want to be fancy, but I caught her eyes. And then you do have your fcr tenant. So your STR tenant is running right owner to your tuberosity. And I just mobilize it typically taking it more owner. And then your deep approach is through the radio scape, oh capitate ligament. And so you cut that as you're cutting capsule as well, that's a real ligament and it must be repaired. And then you have your you have your exposure, I will say that it's not quite that simple. And it's sort of a sharp dissection around the scaphoid. Taking care of the cartilage. Obviously, you don't want to go too far radial and dorsal because you don't want to get into your blood supply. But it's straight volar using that tuberosity as your as your lighthouse.
Chris Dy:Do you use the do you keep the RSC together with the capsule of a layer for your closure later? And do you have any tricks or pearls about how to be able to identify that later? Is it stout enough so that you know that to repair it on the way out? Or do you tag it with any suture anything like that?
Charles Goldfarb:I haven't felt the need to tag it. It's stout enough to repair and I usually try to put two horizontal matches two or three sutures at the bottom type sutures. there and I think that's more than sufficient. I think it heals fine. You just got to remember to repair it.
Chris Dy:Right. Right. And what are your pearls in terms of the carpentry in terms of getting, you know, dealing with your deformity? You know, and getting that back out to length and getting rid of the flexion deformity.
Charles Goldfarb:I think there's a couple different ways to approach it. I do think 0.062 Kirschner wires are helpful as joysticks just to place and pull apart. And then your expose your non union site aggressive curatives because you want to have good bone again and the waste usually can get back to good bone with good bleeding and healing potential and just have to prepare the bone ends thoroughly rather than quickly.
Chris Dy:Right, right. Right. And are you? Are you have the mindset of taking down a tourniquet and looking at bleeding at the proximal end? Or is it just you know, you know what you're seeing? You have faith?
Charles Goldfarb:Yeah, let's just like I wouldn't do that for approximal. I wouldn't do that for a waste. There are certain people who believe in it, I don't know, my decision about whether to use a vascular as graft or a nonvascular as graft is made before the surgery. And it's always not almost always non vascularized. So I do not believe in letting down the tourniquet. I think your next decision making process is are you going to use a structural interposition? Or are you going to count on your screw to you know help with the correction of the skateboard hop back to formally and if you're going to use I'll just keep babbling for a second. If you're gonna use bone, you have two choices in my mind, you're either going to use an iliac crest, which is beautiful carpentry has to be done well. I think it's the best bone in the body. I think it's just more conducive to healing. Or you're going to use a route a type technique where using some cortical distal radius with some cancellous underneath it. Either those are appropriate or neither of those is appropriate. My personal preference is just the screw. How do you think about it?
Chris Dy:Um, I like the route say I hate going to the hip unless I absolutely have to. I mean it hurts. You know, it just you know, I actually had to have the conversation with somebody the other day about you know, them, you know whether we had to go to their hip or not. So I told him, I tried to avoid that. But it already had just the radius autograph from somewhere else. So we had that conversation. Is there any role for Allah graft?
Charles Goldfarb:Not for me. No. I mean, look, the disarray is so easy. It's right there. No, I don't think there's any role at all. Yeah, so
Chris Dy:I saw some of the modified receipt techniques when I was in residency, because I think that Scott Wolfe was published on that a few years back, and he so some of those cases ended up in that series. And I think it's a nice technique, it is very just technically, finicky. And carpentry wise, you just got to get it right. But like you're saying, you just, that's your one shot at it. But I think that's a nice way to kind of maintain the maintain the fuller, fuller correction, and get it out to length and then the screw, I don't typically rely on the screw itself. How have you kind of evolved towards that?
Charles Goldfarb:Well, the screws are obviously sufficiently strong to count on that I think it's a little more technical, to depend on the screw. Don't get me wrong, the carpentry has to be excellent if you're depending on the bone for your correction. But in some ways, once you do that the case is done, you know, you insert your graft, and then you just put the screw down the center are the best of your ability center center. If you're depending on the screw placement, then you have to do a couple of things. One, after your thorough preparation, I generally pack some cancellous bone in the deficit. I then place a derotational kind of stabilizing k where that needs to be pretty volar to prevent the skateboard from collapsing. Then I place my longitudinal k where over which I'll place my screw, also somewhat bowler, and then I place my screw. And so it's just more important that you get all of those steps exactly right. If you're not going to depend on the bone grafts to help with your position.
Chris Dy:Right? Do you ever leave your leave a K wire or your de rotation wire or some other supplemental wire in addition to your to your retrograde screw?
Charles Goldfarb:I have but generally I find that one, you know mini size screw is sufficient meaning I think if you're using small screws, you might need two screws, which I think a lot of people these days favor, I understand why some people do that. Skateboard plates are still being utilized. I have no experience with that. In general, one good screw to me accomplishes our goals.
Chris Dy:Right. I guess if I were to think of one indication for a skateboard plate, this would be it in terms of you know, correcting some crazy deformity. But that has not been our experience. And if you have experience with a skateboard plate and love it would love to tell us please, please do.
Charles Goldfarb:Yeah, absolutely. I am you know, people talk a lot about whether you need to take down part of the trapezium to get access to the distal pole the skateboard to have your screw in the perfect trajectory. And absolutely, I think that's that is a part of it. If the question becomes can you lift up your skateboard so if you have a link the proximal distal poles with K wires, can you put a home in retractor some kind of retractor just lift up the whole distal skateboard and that can allow you good access? I think it can but you have to be careful not to close down the hub back in the act.
Chris Dy:You've done so much work to get the carpentry I just just nibble a part of the trapezium and get your ankle. You know you've done all that work, why put it at risk?
Charles Goldfarb:Yeah, never heard of a single complaint regarding removal some of that trapezium so I totally agree. And some people they are trying percutaneous go right through the entire trapezium and I again, I've never heard of an issue with that. So I'm not against it. I just personally haven't done that.
Chris Dy:So your postdoc protocols the same pretty standard prolonged immobilization, anything different than after a dorsal?
Charles Goldfarb:No, it's been six weeks of immobilization, and then removable brace, depending on various factors, I always quote eight to 10 weeks for sort of a waste non union. They're certainly ones that take longer, the more distal you go, I absolutely believe the faster and heals the younger the patient, the faster it has the potential to heal. So these should heal if you if you do your surgical job, right. The one factor, I will say with a waste non union chronicity does matter. I think once you get to that four to five year timeframe, there's a little bit of science that says those are less likely to
Chris Dy:heal. More expectant management. So
Charles Goldfarb:to say, expected management. That's exactly right.
Chris Dy:And you mentioned on the earlier about, you know, repairing your RSC on the way out I think that's something that probably should be restated that's important, but they're your volar scaphoid . Not as exciting as the median nerve. But it's exciting
Charles Goldfarb:Exciting to some of us different strokes. I love it. That was fun. We hit both sportsy and Nervi topics and I had fun with it.
Chris Dy:All right, great. I guess we need a congenital topic soon. I can't believe I just said that.
Charles Goldfarb:Yeah, it said no one ever. Alright today. Hey, Chris. That was fun. Let's do it again real soon.
Chris Dy:Sounds good. We'll 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