Chuck and Chris host Podcast Journal Club

Chuck and Chris discuss a three new Journal of Hand Surgery articles for our podcast journal club.  Join us and share any thoughts!

Isaacs, Nydick, Means, Merrell, Ilyas, Levine and RECON study group.  A multicenter prospective randomized comparison of conduits versus decellularized nerve allografts for digital nerve repairs.  JHS 2023

Guidi, et al Distraction arthroplasty for basal joint arthritis: 10 year follow- up JHS 2023; 48: 796-802

Carroll, et al Endoscopoic versus open carpal tunnel surgery: risk factors and rates of revision surgery.  JHS  2023; 48: 757-63

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Transcript

Charles Goldfarb: 0:03

Welcome to the upper hand podcast where Chuck and Chris talk Hand Surgery.

Chris Dy: 0:07

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: 0:15

Please subscribe wherever you get your podcasts.

Chris Dy: 0:18

And thank you in advance for leaving a review and leaving a rating wherever you get your podcasts.

Charles Goldfarb: 0:23

Oh, hey, Chris.

Chris Dy: 0:25

Hey Chuck, how are you?

Charles Goldfarb: 0:26

I'm fantastic. How are you?

Chris Dy: 0:28

I'm good. It's it is humid out there. This sweater is tough.

Charles Goldfarb: 0:33

Yeah, we're having a tough spell. I did bike into work we're doing this on a on an early morning and I did biking to work and I'm gonna it's gonna take me a while to cool down.

Chris Dy: 0:42

Yeah, it's well you know, take your time as you drink probably a hot beverage right now. Exactly. Yeah, I rode my bike to nowhere this morning and I'm very happy with it but it was very hot as I said he read as I went from my door to door to door on my car from my house to my car.

Charles Goldfarb: 0:59

We haven't talked to are you still a Peloton maniac or is that? Yeah, it's

Chris Dy: 1:03

actually surprisingly, one of our fellows Adam Mosa told me that he just signed up to get a peloton I think perhaps inspired by our talks about our dedication to routines. I made my normal spiel about how I know exactly when I can ride it whether you know no no weather issues don't have to wait for anybody to get off with the equipment I want. I just like predictability for that kind of thing. But yeah, so Adam is joining the peloton I claim but yes, I still am into it. I enjoy it a lot. And I like the predictability

Charles Goldfarb: 1:37

for sure when i i wouldn't say this is a criteria for choosing a hotel but once I've chosen hotel I do like to see check out what they have in the exercise room and it makes me It brings me great joy to have a peloton you know,

Chris Dy: 1:51

there's a certain member of our department leadership that apparently requires a 24 hour gym as part of the part of where they will stay and I made the mistake of booking a gym recently that did not have that and I really regretted it so I may have to update my like, you know, like a concert rider kind of thing. But you know else So speaking of if peloton wants to sponsor us, please let us know. Both Chuck and I like talk about it. But we do have a sponsor we are sponsored by PracticeLink.com The most widely use position job search and career advancement resource

Charles Goldfarb: 2:27

becoming a physician is hard finding the right job does not have to be joined practice link for free today at www. practicelink.com/theupperhand.

Chris Dy: 2:37

It is- it is job search these actually use some would argue it's always job search season. But you know, for those that are in training right now, it is a good time to at least avail yourself to the resources and do some homework at least about what what you should be looking for and what's out there. That kind of thing. So go check out that website.

Charles Goldfarb: 2:53

Yeah, for sure. The Yeah, it's interesting. We am recruiting in an area that's not exactly my own or our own, which is neuro rehabilitation, physical medicine and rehab training. And we looked at towards the end of the academic year, so May of last year. It's not that that's not the season, we have just begun the season. And it's it's exciting. It's an exciting time.

Chris Dy: 3:16

It absolutely is an exciting time, I still am, you know, how come bringing it back to Hanser dressed or remember the excitement of interviewing with us around this time of my chief resident here. And you looking at it across the table saying Who is this guy?

Charles Goldfarb: 3:30

That was a connection? You know, like it was it was Richard and Andy, right? That just that up?

Chris Dy: 3:38

That was before jobs that were posted were much better about that now.

Charles Goldfarb: 3:41

It's true. It's I think all three of our current fellows already have positions, which is somewhat remarkable and pretty exciting. Yeah, I

Chris Dy: 3:49

think I think two are locked in one is in the final stages. So we don't want to spoil anything. But yes, it's always nice. And certainly when our fellows come in without positions, it's nice to help them get where they need to go and be a sounding board for them. Yeah, so speaking of we just recently had our monthly journal club and we're going to dive into some articles. I think there. There are some interesting articles here with different perspectives and what we typically do you know, the first one I think we should talk about is an article. This one let's see here. Let's pull this one up. This one is about a different way of treating thumb CMC arthritis that at least I've been exposed to. So this is about distraction arthroplasty of the basal joint. The first Arthur author is Marco Guidi, and this is work has largely gone out of Rome. But the last author is Dario Perugia and this is published in the journal hand surgery in the August issue, and the concept here was that back in 2007, the author's described a technique in which they use the Palmeris longest graft and kind of wove it through a tunnel in the base of the radial base. To the thumb metacarpal and then wove it through a tunnel on the shaft of the second metacarpal, some more distal, almost forming like a triangle, and then doing some kind of fixation of the first limb back to the thumb metacarpal. So almost creating what looks a little bit like a slingshot to be honest with you. And using that, to provide some distraction at the thumb CMC joint with the idea that taking some pressure off of the joint would help a whole lot with would help a whole lot with with pain. So for early stage one stage two uneaten classification, thumb, CMC arthritis. Have you ever seen this before? Chuck?

Charles Goldfarb: 5:38

I have not- is my screenshare working for those on YouTube?

Chris Dy: 5:42

I see it working. And oddly enough, I just had the same screen up on my computers. I didn't realize I didn't need to do it to see it.

Charles Goldfarb: 5:48

Well, no, it I have not seen this technique. And it makes obviously a great deal of sense. It's it. Because one of the things we worry about, maybe we over worry about. But one of the things we worry about is proximal migration of the thumb. Right. And we measure that, and we've done some recent studies using the CMC and this theoretically, prevents that I would worry a little bit about if you over distract tightening the vector, the vector would change and doesn't seem to have been a problem. But that's one thing. I think you have to be careful of likely.

Chris Dy: 6:21

Yeah, I think it's interesting. I mean, so this, you know, for the early thumb, CMC patient, I guess once you've exhausted conservative measures, working with our colleagues and hand therapy, perhaps steroid injections. For the radiographically, early, I should say, patient. What's the role even before diving in the article? Do you have a role for you know, a metacarpal osteotomy? That's kind of the textbook answer. And then the new and cool thing is to do a little really small scope. I won't say the name of the manufacturer, but a really small scope. I put it in the CMC joint, something that I've never done, because it's just not something I'm interested in. I've talked about doing osteotomy has never actually done one. And you know, recently in our journal club, our chief of service Ryan Calfee said that in 15 years, he's only done two. So what's your experience with the radiographically? Early CMC or patient?

Charles Goldfarb: 7:10

Yeah, it is a really interesting topic, because this is one of those situations where there's a lot of talk about the very early arthritic patient, and what do you do about it? And everyone loves this concept of the osteotomy, including myself, but like Ryan, I've done very few, I would say my algorithm goes like this, if patients have temporary improvement from corticosteroid injection, and are looking for a longer term answer, I actually start with the scope, which is typically a 1.9 or a 2.0 scope, understand what's going on what the pattern of arthritis is. And then perhaps at that same surgery, you can simplistically do an osteotomy with panning and it makes it very easy. It's not a big and not a big deal at all. So that's my algorithm. But I've only done a handful of those because I just don't see that patient.

Chris Dy: 7:54

Right. So I mean, you know, for completeness sake, and discussion, you know, what's the what's the exact point of the osteotomy? Are you trying to offload specific areas of the basal joint? And have you had success with, you know, seeing that pressure being taken off, like perhaps the kissing lesion? Or is that better addressed with the scope?

Charles Goldfarb: 8:13

Well, the scope doesn't, all the scope allows you to do is to breed synovitis, smooth arthritis. And unless you really are aggressive, and you want to actually do a Hemi resection, it doesn't allow you to do that much. So if there is a pattern of arthritis that's localized dorsally, then if you change the angle of the base of the thumb, metacarpal, you change the loading patterns. And so that's it very simplistic, and therefore, you know, simple is good. And so simple approach to what ends up being a complicated problem. But if you have the dorsal subluxation and metacarpal, the arthritis can be can be relatively predictable.

Chris Dy: 8:53

Early, you know, it's, you know, it's also simple

Charles Goldfarb: 8:56

trapeziectomy

Chris Dy: 8:57

Denervation, which, you know, was brought up was a very interesting discussion yesterday, one of the things I love about our journal club and our faculty is that we're not afraid to disagree. And I think that one of our partners and I had a healthy discussion, as much as one could have at six in the morning about, you know, denervation as an option. Unfortunately, Ryan Calfee came to came to support me on this one, because I think there is an emerging body of evidence that in the rate, bright patient population with appropriate expectations and counseling, that is a surgery that can provide some temporary perhaps symptomatic relief when a patient isn't ready to go through the rehab for a standard at least what we would consider standard trapezius ectomy and suspension of some kind of sort, because that certainly takes a while to get over. Yeah,

Charles Goldfarb: 9:43

you know, we you and I've been criticized for not disagreeing on this podcast, but I don't I don't necessarily disagree with you. It's not something I am going to do. But if if you or someone feels comfortable with the identification of the appropriate nerves, there's literature to support you which we feel strongly about in this division to make sure that, you know, we're not going to go do things that don't have the right support. There is literature to support it in the right patient. I do agree with you that it makes sense. But it's not going to be for all of us. I'm not a derivation fan, anywhere. So I'm not going to add that necessarily to my to my treatment algorithm. But I'll tell you what, in the right patient, I will send them to you for that surgery.

Chris Dy: 10:25

Well, thank you. I appreciate that. Well, I mean, I think that you know, in the OG listeners will understand that our thoughts on deactivation, at least mine have evolved over time, I remember on this podcast talking about how I wasn't a fan of it for the wrist. And I'm not trying to be an early adopter, I don't want to be the first one to do this. I want to see the literature and understand it a bit more. And, you know, talk to people who have had experience with it. And I think it's an option. Just like yesterday, in our another great thing about our service is that we do a research meeting every month, and you've reflected on your experience in your crafting original literature around thumb CMC techniques, and how perhaps, after looking critically at your own results and our group's results, perhaps you're going to change your practice. And I think that that is the best part about kind of, you know, people ask, like, why do you do academics? And I think that that's one of the reasons why is when you have a group of this nature that really pushes, you know, research questions and tries to look at things critically. You know, and and honestly, I think that you can, you know, really influence practice for the better.

Charles Goldfarb: 11:25

Yeah, without going off on too much of a tangent, you are exactly right. We can't, it's impossible for us as surgeons, and I would say our therapy listeners would probably agree, your last patient has an undue impact on your recollection of success. And so the only way to understand results is to look at them carefully. And, and we should talk about that another episode in depth maybe and we can use the CMC example, and talk about what will or won't change with our protocol. But to bring this article to a close, I think it's interesting. There is no perfect solution for the CMC, this is yet another option that we have. And this is this is pretty, there's good follow up and good results. So it's absolutely got me thinking,

Chris Dy: 12:06

well, it's standard academic, blowhard fashion, we didn't actually talk about the article. But you know, so just to summarize, I think, you know, they had 15 patients with, you know, impressively tenure follow up, you know, and they had a couple of patients who had radiographic progression of disease, they didn't report any, you know, reoperations, the, the paper itself is impressive, because of 10 year follow up, it obviously has some shortcomings with regards to assessing patients further on and some biases and how they were assessed. But I think in terms of not only proof of concept and short term, but seeing some long term results, it's interesting, I can't say this, there was some modification to the surgical technique, which I'd love to, you know, you know, talk to the authors about at some point about, you know, why they evolve towards that and really get a sense of, you know, you know, their experience, their rehab protocols are a bit different than ours in terms of they are a little more liberal, and they move patients little bit earlier than what we do for at least a, you know, an fcr suspension. So I think there are some differences that might be contributing here. And clearly, there's gonna be some bias in the patients who decided to follow up, probably towards, you know, more supportive results. So I think I agree with you entirely. This is a nice article to read to kind of makes you examine your own practice, preferences for thumb CMC arthritis from the surgical perspective.

Charles Goldfarb: 13:21

Yeah, great summary, and to give you joy, let's talk about two other articles that are both nerve based. And they're both super interesting and you want to do the carpal tunnel one first.

Chris Dy: 13:35

Sure, sure. But before we do that, we do have to shout out our newest sponsor. The upper hand is sponsored by Checkpoint Surgical, a provider of innovative solutions for peripheral nerve surgery through its nerve master educational programs. checkpoint is committed to engaging thought leaders to develop lead and support peripheral nerve surgery education,

Charles Goldfarb: 13:56

and on October 13, and 14th. Checkpoint Surgical is co hosting the Ohio State University First Annual combined fellows and practicing surgeons nerve tendon and functional reconstruction course- I'm exhausted. The course faculty are outstanding and include Dr. Amy Moore, Sanu Jain, Kyle Eberlin, and Jason Sousa. To learn more about this program and to register please visit nervemaster.com You can also find the link in our podcast episode description. Checkpoint surgical is driving innovation in nerve surgery. Wow!

Chris Dy: 14:29

You read that copy really well. You sound like you could be like, you know Guy Roz like, you know, just you he gets you on some more podcast. I feel like people are gonna steal you away and start having you pitch things like you know, soda pop

Charles Goldfarb: 14:42

and whatnot. Well, for sure I'm holding people off right now as we speak.

Chris Dy: 14:45

That soothing, that soothing radio voice of Chuck Goldfarb. Now that'll be a great course, and outstanding faculty. And I think that it's a nice segue into our nerve article. So you know, I think the next we're going to talk about is from the University or Rochester. You know, the, the group did a really nice job examining their examining their experience with endoscopic versus open carpal tunnel at a single institution. The first author is Thomas Carroll, senior author is Bilal Mahmood and friend of the podcast, Warren Hammert is the second last author. This was in the August edition of JHS as well, the American version, just for those listening overseas. But they did a retrospective cohort study of patients who had either an endoscopic or open carpal tunnel release at their institution among a number of surgeons almost all of whom were fellowship trained in hand surgery. Overall, it was 4338 patients over the period of time that they examined. And, excuse me, it was 3280, who ended up in the study and the split was about 76% open and a quarter endoscopic, they looked at their one year revision rates, and it ended up that the revision rate was three times higher in the group that had an endoscopic endoscopic primary release and the rates, you know, they were 2.1% and endoscopic and 0.71. In the open group, so Chuck, what's your initial thought about, you know, these rates of revision and perhaps how this fits into your, how you think about the surgical technique options?

Charles Goldfarb: 16:17

Yeah, well, I'll start by saying that's a lot of carpal tunnels. That's six years of carpal tunnels. So you know, we can do the math, what is that a, you know, a little less than 800? Maybe it's 700 a year from their group? I don't think we do anywhere near that many carpal tunnels. Thank God for that. I don't want that practice,

Chris Dy: 16:35

easy.

Charles Goldfarb: 16:39

But there is something to learn. I mean, I think one of the principles of research is, you know, do what you, you know, look into what you do and better understand what you do. And so this is a great look, I think I will echo the basic sentiments of our group, which is wow, I think we were surprised with a rate of revision for the open of point seven, one and 2.08, for the endoscopic, we all kind of had the same reaction. You know, I don't remember the last time that I did a revision of a carpal tunnel that we had done ourselves at an average of 143 days. And so it's just interesting, again, not questioning the authors, in fact, I think is good information to have out there. But it's one of those things, where am I remembering correctly? Or is this number really high?

Chris Dy: 17:23

Well, I mean, I think that there are some, you know, analogous things about this group with ours in terms of, you know, a group of surgeons, probably around six to eight surgeons, you know, at a single academic center that is probably doing their own revisions if it were to come up. So the numbers I think, are, although, you know, our chest thumping thing as surgeons is to say, well, you know, my rates lower than that, you know, if we honestly, if we took a critical look at ours, it probably would be somewhat similar. Although I agree with you, I don't know the last time knock on wood, gonna go knock on wood real quick. I've had to revise my own, I literally don't want to jinx a good thing. But it does help me get a rate to give patients which, you know, I honestly, I probably would have quoted, you know, just easier to say less than 1%. So I think that's helpful. And this is surgeons that are revising. They're doing revisions that were originally primary was done in their group. So if somebody left, you know, and had a revision somewhere else outside of the university system, I don't think they were counted. I think the group generally thought our group, you know, thought rate was high. But you know, one of our faculty said, Well, you know, it probably is about right. And you know, it for context, there was an admin data study that was done by one of our former fellows, Lauren Wessel, when she was at HSS, and had a much higher revision rate, you know, closer to 5%. Using admin data now, you know, anybody that's done a those big data studies knows that there's a lot of flaws and that kind of data. So I think that this study provides probably a more realistic number, which is helpful.

Charles Goldfarb: 18:47

Yeah, my takeaways are, you know, this is something to talk to our patients about, there is a risk of needing a revision carpal tunnel within the first year. That's number one. Number two is, for me, at least is yet another reason to be hesitant in considering endoscopic, I think this is one reason to be hesitant and considering endoscopic and the other is I'm convinced there's a higher rate of complications. Now, the literature suggests that, but it doesn't really strongly confirm that. And I guess I would say in the medical legal world, it's clear that it is scopic as a higher complication rate. So I think both of those things, but I applaud the authors for sharing this information. I think it's interesting information is something that I will think a lot about,

Chris Dy: 19:31

right? I think it's honest reporting, which I think is really helpful. You talk about rates of issues after surgeries. I think that there's a lot of bias and what what folks will publish and what they won't. So I think that it's it's helpful to see something that appears to be a very honest reporting structure. And I think that in terms of endoscopic, I think there are many, many, many surgeons who perform endoscopic very well and very safely and I think that, you know, that's one thing to consider When you're counseling patients about this, I think that it's not one size fits all for practices. It's just not something that I'm personally comfortable doing. I've had some experience with other techniques. You know, and I still kind of my go to is, is an open carpal tunnel release or I guess, mini open for that reason?

Charles Goldfarb: 20:19

Yeah, I think that's well said. And it's good. Thank you for saying what you said, which is that there are plenty of surgeons out there who do 100% under scopic. They're really talented at it, they do it quickly. They do it safely. And I'm certainly not arguing against that. But for me, personally, I've done the endoscopic route. I didn't love it, because I just didn't have the same level of confidence that I have with a mini open. So with a 1.5 to two centimeter incision, I feel really good about it. I can see everything I feel very safe knock on wood, I've never had a significant complication. And I hope it continues that way. So anyways, let's pivot to our last Yeah,

Chris Dy: 20:56

yeah, well, before we pivot, there wasn't one interesting point that was brought up, I think in by one of our partners during Journal Club about how, you know, perhaps there's a bit of a bias towards revising an endoscopic that because of the reputation that it has, in the literature about potentially having a higher incomplete release rate, if there are some lingering symptoms, or even probably something like pillar pain or whatever that's hanging out for a longer time, there might be a lower threshold to revise to an open, and I don't think it would be reversed, you really wouldn't do it in endoscopic after doing an open. So I think that probably is contributing to some of the higher rates. And I think it's fair to acknowledge that, you know, not being somebody who does endoscopic, but I think it's important given that it is so frequently used throughout the US and probably elsewhere.

Charles Goldfarb: 21:40

Right? And that's, that's totally fair. And that's absolutely accurate. Because I think, yeah, the person who does, you know, 300 endoscopy a year probably feels pretty darn confident about their ability to obtain a complete release. If you're doing fewer than that, you can't have the same level of confidence as you have with open now, to be clear, you could be an open carpal tunnel surgeon and not do a complete release. But I you know, and then certainly that is a risk. But I think those who are comfortable with that approach, really appreciate the visualization that you get with an open.

Chris Dy: 22:13

So bring us home with the with the last article. Chuck, your favorite topic.

Charles Goldfarb: 22:17

Oh, my God, I love this topic. So first of all, Jonathan Isaacs led this study by the RECON study group, which I had not heard that I'm sure you had. This is a multicenter prospective randomized comparison of conduits versus decellularized, nerve allograft, for digital nerve repairs. This study was multicenter, and it is looking at basically the outcome of 183 patients who, which was ultimately their final number. And they had two groups, a short gap repair group, and a long gap repair group. And we can talk more about the details. And basically, the allografts provided somewhat clinically superior results to conduits. But it wasn't as dramatic an outcome or finding I think, as many of us would have expected. So I probably butchered that in your mind. So let's, let's talk a few details.

Chris Dy: 23:18

I don't think you butcher it. I think you you got it. You know, it's interesting, because if you look at the long gap versus the short gap, so you know, short gap, again, five to 14 millimeters long gap 15 to 25. That is an interesting decision making group because, you know, some of the classic testable questions, you know, support use of a conduit up to up to 25 millimetres, but I think that the, if you really dove deep into those articles, you know, it is not clear that a conduit actually works quite well. So I think that was the impetus for this. And I applaud the authors, and particularly Jonathan for the leadership on this because doing a study this size is really, really hard. You know, multicenter, you know, it's nice. I mean, I think the only way to do a prospective randomized study of this nature is with the industry support that they had from the manufacturer of the polygraph. But it is a lot of work, and really hard. So I applaud the group for getting that done. And, you know, for the short gap, there really was no substantial or statistically significant difference between use of a conduit, which was a bovine conduit in this in this study. And the acellular nerve allograft where you did see the difference was the longer ones. And you know, going into reading this my practice was for any gap and a digital nerve was to use an acellular nerve allograft just because I've been trained a ton with conduits, and when I've handled them, I have not had, you know, a great experience. You know, so this is actually making me question how I would approach a short gap. What about you?

Charles Goldfarb: 24:50

It, you know, I use conduits when they first came out when they were our only option. I never was really thrilled. But those were the early conduits. They were rigid. They were not you easy to work with. So I didn't love them. But the newer conduits are certainly easier to work with. They are less expensive, and they're simply easier to have available. You and I've talked in our group talked about the fact that holographs need and you know, need insurance approval that's not always provided. And so I think it actually makes me think more about using conduits in the right patient.

Chris Dy: 25:27

Yeah, and I think this is interesting from a just, you know, the, there's the science of it. Right. And the clinical research, but then there's also the, you know, the practicalities of a lot of our, you know, listeners probably work in surgery centers, where you have you have, everybody in America has a prior authorization issue, acellular nerve allograft is not widely available throughout the globe. So that's an issue of conduits are probably more frequently available, at least my understanding, don't need prior authorization in America for insurance. And I would imagine, and I'm not sure this have a longer shelf life than something because it sits on the shelf as opposed to something that needs to be in a freezer. So I think this is interesting for a short gap. But I do want to reflect on it and think about it more before changing practice. But I think the cost difference might be a big deal, too. So you know, aside from the shelf life thing, depending on where you are at your institution with costs, the conduit might be a cheaper option for the short gap. So that is something to think about. With regards to the long gap, I think the results are pretty interesting, you know, so aside from assessing things, but two point discrimination, they looked at kind of ASSH, more qualitative grading for normal sensation. And it was better in the long gap group at 40%, as opposed to 18% in the log gap conduit group. So with long graph with an hour long gap with an ally graph was 40%. And conduit was 18%. It's a long gap. But you know, 40%, is also not great in terms of normal sensation. But I think that many of us don't strive or counsel about normal sensation after digital nerve injury.

Charles Goldfarb: 26:57

Yeah, I would say number one, I guess I was somewhat disappointed in the overall outcomes not being critical, but surgeons at all. I think it mirrors my experience, I don't think everyone does wonderfully, no matter how you treat their their significant digital nerve injuries. Number two, you and I had a conversation, I asked for your advice. And I followed it when I had I needed to do a digital nerve that along a long gap ended up being about three centimeters, and the polygraph was not approved. So I used an MABC branch, which worked out really well. So I appreciate your advice. What What are your thoughts as we close about the use of about these results? Were these better than you might expect worse than you might expect? Or this is what you expected?

Chris Dy: 27:39

I think they're slightly not as impressive. I would have expected. But I appreciate I think they're real. And I think they're valid. And I think they're honest. You know, so honestly, I don't know and you're older than I am and you've done this longer. How much does you know their mean follow up? Or their minimum follow up was six months and not more than 15 months? Prepare? Was there a window? So you're looking at a group that probably is between six months to a year and a half? Or a year and a quarter? I should say? And do the results evolve beyond that? For digital nerves? Because honestly, I haven't done enough even having, I think, a relatively busy nerve practice and seen them back over time because I don't necessarily see them back. But Are things going to change? Is this 40%? You know, quote, normal as sh sensation grading in a long gap aalegra For Paragon a shift over time to something like a 60 or an 80? If you follow people over time.

Charles Goldfarb: 28:32

Yeah, I wish I could answer that. My sense is things do improve a bit more. And patients also adjust to the you know, what becomes the status quo for them. You know, people get used to that lack of sensation, and it bothers them less. But objective testing. My sense is it does improve over a longer period of time, but I can't quantify that.

Chris Dy: 28:54

Well, I think that a lot of our hand therapy, listeners will probably have some experience with this as well as our surgeons that are listening. So please feel free to chime in and send us an email Handpodcast@gmail.com or leave it in a five star review telling us what you think. Either about the use this article about acellular nerve allograft or conduit for digital nerves are about endoscopic versus open carpal tunnel release or about some interesting techniques for thumb CMC.

Charles Goldfarb: 29:21

Perfect, love it. This was fun. Have a great day. All right, bye bye.

Chris Dy: 29:24

Go read some articles. Take care.

Charles Goldfarb: 29:26

Hey, Chris. That was fun. Let's do it again real soon.

Chris Dy: 29:29

Sounds good. Well, be sure to check us out on Twitter@handpodcast. Hey, Chuck, what's your Twitter handle?

Charles Goldfarb: 29:34

Mine is@congenitalhand. What about you?

Chris Dy: 29:37

Mine is @ChrisDyMD spelled d-y. And if you'd like to email us, you can reach us at handpodcast@gmail.com.

Charles Goldfarb: 29:45

And remember, please subscribe wherever you get your podcast

Chris Dy: 29:48

and be sure to leave a review that helps us get the word out.

Charles Goldfarb: 29:51

Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time