Chuck and Chris welcome Macy Stonner back for an in depth discussion of CMC arthritis and post surgical management. As usual, Macy brings great insights which are pertinent for anyone caring for patients with thumb pain. We also discuss a listener submitted question on the differences between TMR and RPNI.
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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 our 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 welcome Macy Stonner back for an in depth discussion of CMC arthritis and post surgical management. As usual, Macy brings great insights which are pertinent for anyone caring for patients with thumb pain. We also discuss a listener submitted question on the differences between TMR and RPNI.
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 our 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:Great. We have a special guest. That's why I'm great.
Chris Dy:That it? Well, you know, I'm sure there are many reasons to be great. But we do have a special guest. We're happy to welcome back Macy Stonner. Hello, everybody. Is our therapist extraordinaire that everybody keeps asking for. And she's here to provide some interesting perspectives. So excited to have you back. Grace. Thanks. It's
Macy Stonner:always fun to be here.
Charles Goldfarb:She's also an award winning therapist. We shouldn't let that slide.
Chris Dy:Yeah, I think they asked for both you and I one of our colleagues, Mitch pet to provide some some insight as to why Macy was voted the researcher of the year for WashU occupational therapy.
Macy Stonner:Well, thank you very much. Yeah, I was very honored. It was actually called director's choice award or something, just to kind of honor. Those who do research, program development, clinical stuff, kind of a jack of all trades, master of none type thing where you kind of excelled small areas, and nothing huge. And one. So yeah, I was very honored.
Chris Dy:You're being way too humble. I think it's it's very, very challenging to do research as a clinician in general, but especially I think in in the therapy, specialties, just because there is even less protected time, if any protected time typically for for research and less resources. So your ability to not only to serve as an investigator, but also to be a collaborator has been remarkable. And I've always really appreciated that, you know, you do incredible work.
Macy Stonner:Oh, you're very sweet. And I have great mentors. So thank you for that. Yeah,
Charles Goldfarb:definitely. And I appreciate it participating in one of your studies looking at tendon outcomes, which is just a super challenging area to research. And I think your contribution there was an important one, and I look forward to your building on that
Macy Stonner:very much. We're not talking about tendon outcomes today, are we
Charles Goldfarb:we are definitely not
Chris Dy:a few weeks back, he's sent out a really cool email to our to those that are on our our listserv. So if you're not on the listserv, and you want to be on the listserv, you can find information in the show notes. But then also email us at handpodcasts@gmail.com. And we'll make sure to get down there. But you did ask for some feedback. And some questions. Would you hear back on the survey Chuck?
Charles Goldfarb:Responses are still coming in. And to be honest, I feel like we are multi dimensional in our approach, every time I log on to this question with this tool, I always forget how to do it. Because let's be honest, we do not want to overwhelm the listeners with another piece of email. So these are quite infrequent two or three times a year. And so maybe we'll save the responses for the next episode or two. So I'm excited. Read the email, please send us your thoughts so that we can make the upperhand podcast even better.
Chris Dy:What a tease. What a tease Chuck, hey, if there's anybody out there that wants to be a social media intern for our podcast, I can't say that we can, we can commit any, any resource to you aside from fantastic mentorship is a great experience. But we are in sore need of finding folks who would love to help with that. So yeah, let us know.
Charles Goldfarb:I did get a great email from a friend and former fellow Kevin Lutsky, Kevin was in Philadelphia for many years. And he, I was gonna say recently, it's been a couple years relocated to the University of Vermont. And it's just so interesting to me, not that I have overly grandiose expectations for the impact of our podcast, but we were emailing about a case and he said, By the way, one of our residents just told me about the podcast, I had no idea. I love it, I'm hooked. And first of all, thank you Kevin. And Kevin does great work with the and study as well. But it's awesome when someone discovers it, and they like it so very cool. Very cool.
Chris Dy:And we want to hear about it if you discover it you don't like it's just keep that to yourself. But Kevin heads up the effort tougher the head society to do the perspectives newsletter, which is really cool, because it's, it's, you know, kind of like this podcast that talks people talk about their experience with being a hand surgeon not necessarily just about hand surgery itself, but about life. So if you haven't checked that out, make sure you check that out.
Charles Goldfarb:Yeah, and maybe I'll share one more comment. And then if we have time, let's do a quick listener submitted question which will be for you, Chris. And then we'll jump into Macy and our expertise is so Okay, that sounds great. So we have a, we had a comment again on one of our mini streams from Laurie, who was commenting about making content make as guest appearance for just a radius malunion pod. And she said, excellent discussion, practical, informative, and I will be incorporating this knowledge into my practice. That's a win.
Chris Dy:Absolutely, whenever anybody can find something that they can use, honestly, in that conversation I learned from you and I learned from it and so I thought it was fun, too. So thank you, Lord, for that, that feedback. And for listening.
Charles Goldfarb:Yeah, basically no pressure today, you just gotta, you gotta up the game. And then make sure people write in stuff like that about your therapy, pearls of wisdom. All right, challenge accepting. All right, before we get there, Chris, I have a question for you. Which actually, I think is a very fair question that I must admit, I could use some clarification on as well. What is the difference? This is from anonymous, what is the difference between TMR and RPNI, I have heard of TMR, and worked with a patient that has had this but I'm not familiar with RPNI, Dr. Dy- enlighten us.
Chris Dy:Okay, so I'm trying to figure out how to keep this really brief without losing Chuck and then eventually losing bassy. So TMR is targeted muscle reinnervation. rpmi is a regenerative peripheral nerve interface. Now, those are two techniques that are typically used for neuroma treatment. But TMR has the additional advantage of being able to be used in a setting potentially, of helping somebody who's going to get a myoelectric prosthesis, particularly one that picks up signals from surface electrodes. And the idea here is that for TMR, you're doing you're taking a major, usually a major peripheral nerve or an important sensory nerve, but usually made your peripheral nerve. And sometimes it's an ascending of an amputation or other other times you're doing it intentionally to treat pain, but you're trying to give that nerve something that grow into so with TMR, you are de innervating a muscle by dividing the branch that goes to that muscle. And that's intentional because you already have a major nerve that you're trying to get to reintegrate into something you're trying to give it a targeted and targeted muscle reinnervation. The impetus of this initially was to treat the amputee. But in the studies that that were performed, and largely led by folks at Walter Reed and then University of Washington as well. They found that that actually helped a lot with neuroma related pain after amputations. The reason being the thought being is that you've actually given that major peripheral nerve, something to do, rather than allowing it to be a potential pain generator. So that's been a really useful neuroma treatment. or p&i is a different way to treat an neuroma. And that's again, a regenerative peripheral nerve interface, where you're essentially taking a piece or a cuff of muscle, and it's almost you're completely, really dividing it out, and you're making it a free piece of muscle. And by deactivating that muscle, now that muscle is receptive to receiving re innervation. And then you're taking a cut nerve and and you're putting it into that cuff of denervated free muscle and allowing it to grow back into that, again, giving that nerve something to do with the thought being that if you're planting a nerve into denervated muscle, it will then try to reintegrate said muscle. That's what it is.
Charles Goldfarb:So yeah, a couple questions. Number one, can anyone do these procedures? Is this a hand surgeon nerve surgery? Surgeon only procedure do our orthopedic trauma colleagues do this to tumor surgeons do this who does this operation?
Chris Dy:Honestly, anybody could do it if you really want it to, I think like anything, it does tend to come down to indications there can be some technical things that are tricky with like size mismatch for for TMR, but can be overcome. Like one of for example, one of our fantastic orthopedic oncology partners Ian English, I think has actually done TMR and RPNI on his own when he's doing some of these big oncology resections, or at the very least has learned enough from usually is collaborating with David Brogan. And you know, he's learned enough from David and from his past experience, and he's come up to me saying what do you think about doing TMR RP and I and this particular patient so I think if you want to do it, you can and the idea behind doing especially something like rpmi is that you can take the surgeon, the surgeries and take them out of the hands of the nerve surgeon because you can't have a nerve surgeon there for all of these cases. And perhaps you could avoid having to go back for a second surgery. So I think anybody could do it doesn't have to be a peripheral nerves surgeon doesn't necessarily have to be a hand surgeon just happens that those are the two populations that tend to hear about these things more.
Charles Goldfarb:One more question for you that are born from Macy. Do you have a preference over those two techniques? score. Do you use both techniques in different situations?
Chris Dy:I think you got to know how to do all the neuroma surgeries. One of the comments that I think that was made at this past year's ASPN meeting is that we're not going to have an algorithm that says, you know, always do the RPNI or always do TMR, it's going to potentially be you know, this nerve and this situation responds better to to RPNI or this was responds better to TMR. Sometimes you're at a level anatomically where you actually don't have any good targets for TMR. Sometimes you're in a level anatomically where you have some great targets for TMR. It's a complete freebie. So I think it's important to know how to do RPNI, TMR, potentially Intraosseous or intramuscular, transposition of a neuroma and all the different things just so that when you're in the gym, you can figure out how to best serve that patient that particular moment.
Charles Goldfarb:may see, I don't know I know you're not really involved with lower extremity amputations, or at least not very commonly. But what's your experience pain and seeing these patients after either of these neuroma type surgeries?
Macy Stonner:Sure. So I feel like the ones that have been performed for neuroma pain, we don't see a whole bunch of I have found it, working with them for many weeks or months on desensitization, and graded motor imagery and things like that, and then they ended up going to get the surgery and they're like, oh my god, I'm so much better. So it kind of de emphasizes a role for us, which is great, because they do so well. But in terms of prosthetic training, we see them quite a bit. Again, we don't battle to the lower extremities I refer out for those but the upper extremity ones, I've seen quite a few. And there's a big role for just like the cognitive component of understanding the new roles of the muscles in their arm and their residual limb. So like learning how to fire each one and learning not to code contract, a lot of mirror type exercises. But it's particularly important for the process, prostitutes to join those sessions as well to be collaborative approach. And it's really enjoyable to kind of see everything fall into place, especially when they get their EMG machines and kind of visually have biofeedback to look and understand how to activate their new motor pathway, in a sense.
Charles Goldfarb:Sounds like an episode to me.
Chris Dy:Yeah, and absolutely, it's, I mean, there's some fascinating work being on the videos of watching somebody, you know, figure out how to use a prosthesis after having TMR is pretty incredible. You know, and the idea for for at least in the setting of prosthesis is to get those signals closer to the skin where they can be picked up, you know, by by the prosthesis. So, yes, we fantastic episode, completely nerdy, and we might lose you within the first few minutes, Chuck, but what's your perspective on these things is, you know, a relative outsider to, you know, have you ever thought of using these in any of your patients? Or is this something where you're just kind of still learning about it?
Charles Goldfarb:I would say I'm still learning about it. It doesn't have direct relevance to my practice frequently. Certainly, the concept of implanting a nerve into muscle and I will just say it like that has is part of what I do if I'm treating an aroma or trying to prevent a neuroma. But I have to say the explanation was actually helpful for me, and I think I need to continue to process this as I look for indications in my patients, because let's face it, I, you know, I take trauma call and so I see the injured worker, particularly and this is relevant, highly relevant.
Chris Dy:Yeah, I mean, I think that, you know, the classic papers that describe neuro treatment from back in the 70s and 80s. You know, the Lee Delon and Susan MacKinnon were initially describing this, you know, transposing nerve into bone, for example, and transposing nerve and muscle. What's different here about TMR? Obviously, we about rpmi, compared to you know, dunking the end of the SRN into the brachioradialis muscle belly is that you know, that muscle belly that you're dunking it into in that, you know, in that setting without our p&i is actually still integrated. So the thought is, maybe it's not actually growing into that muscle, because muscle is not theoretically receptive because it's already got integration. So you really are just potentially giving that nerve a road to nowhere. Whereas in rpmi, you're trying to give that nerve something to do. And think it's a philosophical difference. And, you know, maybe it's academic, but I think it is important to know how to kind of do all these things, you know, before we because we're still trying to figure out what works
Charles Goldfarb:right. At the risk of this becoming a nerve episode. I'm taking co host prerogative, and I'd like to thank our sponsors before we shift amazing
Chris Dy:yeah, so let's well stay with under theme let's talk about our one of our sponsors. The upper hand is sponsored by checkpoint surgical, a provider of peripheral innovative solutions for peripheral nerve surgery. The company invites you to visit them at booth number 605 at the ASSH annual meeting in Toronto to learn about their new products as well as attend their Industry Forum on Thursday, October 5 at 11:30am.
Charles Goldfarb:The program nerve injury reconstruction challenges will be moderated by Dr. Scott Kozin, Chief of Staff at Shriners Hospital for Children in Philadelphia. and past president of the ASSH to learn more about this program and to register to attend. Please visit nerve master.com. Checkpoint surgical driving innovation in their surgery. Let's go. I'm already excited.
Chris Dy:You know that guy's got codes and you you've been around him before.
Charles Goldfarb:He's masquerading as a nerve surgeon. He's a congenital hand surgeon don't let him fool
Chris Dy:Yeah. Well, you know, the ceiling for being a congenital neurosurgeon is much lower. A congenital search is much lower than being a nerve surgeon. Right?
Charles Goldfarb:We're sure it is. All right may see. 57 year old, delightful female patient of mine has had three injections for thumb CMC arthritis, she's right hand dominant. She does not have any structural abnormalities does not have any contractures. She's tired of the injections despite initial good results. And so she has requested surgery, we discuss the options with our surgically we discussed classic lrti we discuss new suspension plasti techniques. And I would love to know how you think about her care for a typical lrti. So just so the listener understands what I mean by lrti. This is a procedure that was described 50 years ago, and essentially it It includes a complete trapezius ectomy, I harvest the entire fcr tendon, pass it from its insertion on the base bowler base to the second metacarpal through the thumb metacarpal. And then I create sort of an anchovy or ball and pack it in the deficit where the trapezium was excised. So, I have seen this patient, I'm operating this patient, I've immobilized her for four weeks and we can talk about that and she shows up in your office. Make me look good, Macy, tell me what you're gonna do.
Macy Stonner:Okay, so before I even ask this person to move her thumb, I'm just going to look at her thumb and I want to document how she's resting. So has she resumed a quote, what I call collapsed posture is her CMC joint kind of flexed in her MCP joint, extended to hyper extended, does she look like she's a deducted and kind of tight into the poem? Or does she look rock solid? Does she have her CMC joint kind of resting and a little bit of extension with her CMC, excuse me with her MP joint flexed, so I just want to look at her resting position, because that's going to tell me a whole lot of I guess how I want to fabricate her orthosis, how long she's going to be immobilized and the frequency and type of exercises that I will provide her. So let's say she looks a little bit loose, like she's a little bit not recurring again, Z deformity, but just not quite tight enough. I'm probably going to be really nitpicky about her splint and really kind of support that CMC joint into a little bit of extension and Palmer abduction, keep her MP joint flexed. And I probably want her to stay immobilized for another two weeks. Don't hate me, just because sometimes I don't. I'm not wanting to get them moving too quickly. Like, what's the point I, it's a pain procedure. I want to make sure that they stay pain free. Especially in this particular case, if she looks a little bit, a little bit loose with the CMC joint. She just might have had a lot of laxity. preoperatively. And who knows might have just been a tougher case. So I would probably Dr. Goldfarb looks like he wants to say something. Sorry.
Charles Goldfarb:I don't want to interrupt here. Okay. He wanted to.
Macy Stonner:Okay, can I keep going? Okay, so I would bring her back depending on how swollen she is, within a week or two, just to kind of monitor position because the worst is if they're really small, and they lose swelling, and then the splint doesn't fit is great. And they look like they're kind of self flexing a little bit or just not quite a supportive. So I'll monitor that. And then at six weeks, start some exercises. What exercises gosh, there's so many you could do but I just want to make sure that she can Well, I'm gonna stop you first. Yeah, sorry. I can. I can go on and on. So
Chris Dy:you are blinking. You're blacking out like an old school, just like going so does your Chuck mentioned doing an LRTI his patient does that initial assessment, which I think was incredibly thoughtfully stated. Does that change whether based on the type of suspension plasti type procedure they had, whether that was with a with a thick suture tape or whether that's with other tendons or is is that just for LRTI with an fcr suspension?
Macy Stonner:No, that assessment is for anybody that has a CMC arthritis reconstruction. But I'm going to be a little bit more conservative with the lrti folks in like an internal brace for example. But even if somebody comes up with an internal brace, it says it five to seven days get moving. I'm very fortunate to have quite a bit of autonomy in our clinic, and I'm going to look at that thumb. And if I don't really feel like they're stable or pain free enough, I'll still email the surgeon and make sure it's okay. But have them probably continue to be a little bit more immobilized for a while,
Charles Goldfarb:do questions. So the first course, of course, of course, two questions. The first is, we as surgeons, like simplistic protocols, and so one of the critiques of the lrti is the length of immobilization. And classically, it was six weeks and then some people, Doug Hutchinson has talked about four weeks, and could it go down to two weeks, and what I'm hearing you say is, maybe the initial immobilization needs to be a, you know, particularly addressed for each patient. And so maybe we as the surgeon need to do what you as the therapists are doing in the clinic and say, Okay, I've just done my reconstruction. I've gotten nice extension of the CMC joint, I feel comfortable with the posture, maybe this one's a two weaker, whereas someone else is a six weaker. So that's my first question. Don't answer that. And the second question is, regarding LRT eyes, have you seen bad results when you mobilize and LRTA too fast? I mean, they're in related questions. But we talk about prolonged immobilization for lrti and quick mobilization for suspension plasti. Do you have you seen problems in either direction?
Macy Stonner:I'm trying to understand your question. And so I think you're asking, do you see problems with too much immobilization? Is that correct?
Charles Goldfarb:I guess I'm really asking to make it really simple because you and I are both from Alabama and you got to make things simple from people. Do Do we need to immobilize LR T eyes longer? Have you seen problems when we've mobilized LRT eyes too fast?
Macy Stonner:I think no more than six weeks, I think six weeks is great. Because coming from the outcome that I don't want to see is recurrent pain. That's the outcome that I would see normally, as opposed to the outcome based stiffness. Like, I rarely see somebody long term who's having a lot of chronic stiffness from prolonged immobilization. So I'd rather see six weaker, you know, splint versus cast, I think that's great. That's a lot of time to be immobilized for the patient safe. But regardless, from an outcomes perspective, I think that's fine. There have been some cases where I see for weekers do just fine, pending, their postures good, they're pain free, they look stable, and they don't resume, you know, repetitive pinching and activity too early. So between four and six, in my world is excellent. The problems that I see is when the orders are for hand base, thumb Spica, because I feel like they often get some risk discomfort. So I feel pretty strongly about including the risks there for lrti. Too, you mentioned something about two weeks? And that seems mean, I don't think people would be particularly painful for lrti.
Chris Dy:That's two weeks after the initial, you know, seven to 10 days after surgery, or is that that's two weeks post op two weeks post op. You mentioned the risk discomfort after an lrti. If you leave the risk free, do you think that's from the you know, crossing the wrist with the fcr that you've harvested? Or do you think that's just because you know, the nature of having a surgery at the thumb base and having some swelling? Like if you did anything other than an fcr suspension? You know, something that doesn't cross the wrist? Could you leave the wrist free?
Macy Stonner:I think so because that's my assessment as well, it's got to be that because for the internal brace, folks, we always do a hand based and wrist pain is rarely a problem. And so my only hypothesis of that would be because of the fcr tendon involvement.
Chris Dy:So I have two questions to ask when I'm like Chuck, I'm going to ask them one at a time so as to not confuse the one who was answering the questions with like, Wait, which one? Like cities and I'm gonna ask Chuck's question. I'm gonna, I'm gonna ask Chuck's question a different way. Because I actually really want to know the answer. So you know, to go outside of thumbs up for a second with my straightforward distal radius is we have kind of a faster protocol. Yes, with Jamie and I will call a brick tops protocol, but then for like the, for somebody with a more complex fracture, we will go slower. Now, I call that the normal protocol, slow protocol. So I think that I think that
Charles Goldfarb:the,
Chris Dy:you're saying that you can tell based on somebody's initial posture of the phone after surgery, that they're either going to pretty solid or they're collapsing back. Now, can we just have a fast and slow protocol for these based on that initial assessment, regardless of the type of surgery that we do?
Macy Stonner:Sure, if you're looking to make it more black and white, and I think that's fair, but just to go Back, it's not 100% about just the way they look, I'll ask them, How are you feeling? I feel great. It's like, oh, my pains a 10. Okay, and then I might have them touch each finger and kind of see what their zones doing. But most of it is observation and kind of looking at how they're posturing.
Chris Dy:So I think that ultimately, you know, my second question is that, you know, there's we talking about this. Yeah, the outcome of this, you're describing it as more of a let's make sure they remain pain free surgery.
Macy Stonner:That's what I care about. Yeah,
Chris Dy:yeah. And I think that's absolutely fair. I mean, that's what this is for. The thing that tends to hang up patients, at least when I counseled them about surgery is, you know, how long will it be until you're using your thumb without thinking about it? You know, because I remember listening to one of our current partners, Ryan Calfee counseling patients about he's like, yeah, it's gonna be about six months until you use your thumb without thinking about me. Is that an accurate assessment because we did some qualitative work with one of our former fellows, Jeff Steppan, who actually interviewed a lot of my lrti patients. And I was definitely under appreciating how long it took for patients to get back to functional recovery. So is there anything we can do that would move up that functional room, you know, pain free function, you know, earlier,
Macy Stonner:encouraging them to go slow. And the quote I use is, let's do this right the first time, let's just be conservative in the beginning, and it's going to have better outcomes for you long term, I'd normally say four to six months to use your hand normally. But again, they might have full range of motion with a zero out of 10 pain, with just gentle activities by eight weeks, that doesn't mean that they can go riding and using a hammer and be pain free. But my I've gotten babbling now, but I think the biggest thing is just do it right the first time, the first six to eight weeks, just adhere to your precautions, be gentle. Don't go too hard, too fast, and make sure to be compliant with your splints.
Charles Goldfarb:So really, it's really interesting, because we are maybe internally rather than externally motivated to try to get patients moving ASAP, right, that seems to be the goal, shorten the period of immobilization, because that's better. And I've always sort of hesitated on whether or not that's true. And it seems like four to six weeks of immobilization after a surgery like this, while inconvenient. It shouldn't be sold to a patient as a negative. And I'm guilty. You know, as I talk about the benefits of suture tape suspension plasti, I say well, you can get out the you know, you could have a cast at five days, and that's wonderful. It maybe it is, in certain people, maybe it's a priority. But it does seem like this, this shouldn't be about rushing you through recovery necessarily. Because hopefully this patient has a lot of, you know, functional pain for years when treated in the right hands postoperatively.
Macy Stonner:And I'm particularly biased because at our center on Tuesdays, I'm on walkins, which to listeners just means that I come into work with a blank schedule. And as physician clinics that are running will send patients who need same day services, and Dr. Martin Boyer works on Tuesdays. And so I see so many of his patients, and he has a lot that have had from outside institutions or just second opinions, and he sees that have had two or three different CMC procedures. And so a lot of times we're a little bit more conservative with those because of their history. So again, I'm recognizing my biases in some cases.
Chris Dy:Wow, that sounds like a clinic I wouldn't want to. Before we move on to our next question, I did want to shout out one of our sponsors. The upper hand is sponsored by practice link.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 joint practice link for free today at www.practicelink.com/theupperhand. All right, I like this conversation. We should keep going a little bit more.
Chris Dy:I have one question. I'm gonna jump in. I'm gonna jump jump jump I know about this wrist pain thing because that's not something I typically have thought about. And now you said it's because you know perhaps harvesting the fcr there are a lot of other procedures that use tendons that crossed the wrist. Like a while we type suspension. Genny Del Signore your suspension uses tendons that crossed the wrist and doesn't, you know harvest them, but does change their their course a bit. Have you noticed because I think you see, you see patients perhaps or your colleagues do from our from the other surgeons at our institution that use some of these different techniques. Have you noticed wrist pain is an issue for that for those patients too.
Macy Stonner:I don't get too bogged down with the incredible details of the surgery like surgeons do. But what I do notice is whenever they get out of their postdoc dressing that includes the forearm all the time and they go straight to a hand based whatever procedure that is what With a tendon reconstruction like lrti That's when I noticed the issue. So internal brace like I had mentioned before, typically not at my Did that answer your question like it's all about the length of time. So if somebody goes from a cast, you know, at six weeks and then to a hand base, they're probably fine. But it's from that early stage of two weeks post op during their dressings and they go to the doctor, get their stitches out, and then a hand base, typically, that's when you see the problem.
Charles Goldfarb:So let Thank you that was helpful. Chris just needs to be told things two or three times to really let it sink in. So that's great. For the benefit of the listeners, of course. We go back to the initial nerve conversation now just kidding, let's definitely not do that. So Alright, so let's say we're now at six weeks, and this patient didn't look perfect. So you immobilize her to get her to six weeks, she's now six weeks, she's pretty happy you liked the posture? What do you focus on with your therapy between six and 10, or six and 12 weeks, just what are the basics that you have this patient doing.
Macy Stonner:So have them touch their thumb to each finger, I want to see if they're stiff, can they oppose the base of the small finger. If they can't, and they're stiff, like particularly with their MP joint or whatever it might be, I'll probably give that to them as a very informal exercise to work on composite flexion of the thumb. That's one thing, if they have full motion in that plane, and they can touch their thumb to each finger. However, they collapse, they kind of Gosh, can even see my thumb kind of like like that. I'm not going to give that to them. Because I know that that exercise is going to encourage that posture. Going back to our non op CMC management podcast, I'm going to resume those exercises where you really tried to bring your thumb out into extension and flexion and make an O and then work on making a C and work on more like extensor strengthening of the CMC joint so that they have a stable base of support when they go open a Ziploc bag with their earrings and their socks on for example. So it kind of depends on what their example is like at that initial meeting. And this is for any surgery, it doesn't matter what kind of CMC procedure they had. And go ahead, sir,
Charles Goldfarb:no, no, you go ahead.
Macy Stonner:Let's say that they are pain free, swollen and stiff. I'm going to treat it a little bit more like a fracture, like just range of motion exercises, swelling management, is
Charles Goldfarb:this Dr. Dee's patient?
Macy Stonner:No, no. Anybody. So I'll treat that one a little bit more to like your general fracture management just working on range of motion, edema, management, you know, functional activities and that kind of thing. But in terms of anybody with a CMC procedure, I want to look for a few main things. One, Palmer abduction, did they have a tight webspace? Do they have at least you know, 45-50 degrees of abduction is their MCP joint hyperextending. And is they're seeing EMC joint kind of sitting in a flexed position in the palm. And so those are the three things that I I care about, and and their pain, when they say I feel so weak, or I drop things, those are all things you definitely want to listen to and respect. But I always encourage them, we can always work on strength, we can always work on things to help you function a little bit more in life. But right now, we got to make sure that your thumb maintains a really healthy solid position, whether that's with more immobilization or Dynamic Stability Exercises, as we mentioned in the other podcast,
Charles Goldfarb:this is really great. And we unfortunately don't have too much more time. I love your emphasis on the control of the base of the metacarpal. Because it seems like that is vital to everything. And we talked about surgical techniques to do that. And, and I think we Chris, I certainly agree with you. If the patient is doing well posture, Lee and I have to throw in this little tidbit. I'm a history guy. So the test you described going towards a test going to each fingertip, and then based on the small is the Kapandji, you can score the capacity score, which we use in general a lot. I think Kapandji was a French surgeon, and that just looked it up 1986 This was described, which I think is just really cool. Of course the articles in French, so I can't really say any more about but if this patient is doing well, when do you start strengthening,
Macy Stonner:when they're pain free, whether that be at 10 weeks, 12 weeks, 14 weeks. So they gotta be pain free for the most part, and their thumb has to be solid. So to be 8-10 or 12. So like on a referral that I write for you. I would often write like initiate strengthening, strengthening no sooner than 10 weeks of doing well, for example, pending pain and as long as they have not resumed a collapsed position. Okay, I would write that on a referral I, particularly to my internal Millikan colleagues, because they know what I mean. And we all kind of agree with that management. Have to be honest, a lot of people with these procedures don't need strengthening. Because if you give them plenty, for example, or clips or something to strengthen their thumb, yeah, it'll make them stronger. But as they do it, it hurts. So I'm a proponent of saying, I'm not going to repetitively just strengthen you arbitrarily. Because yeah, you're going to get stronger, but it's going to continue to hurt. So let functional daily activity activities beat or strengthening every time you open a paperclip or Ziploc bag or cook. You're still applying resistance through your CMC joint, you're going to naturally become stronger in time. But I don't want to necessarily just arbitrarily Have you pinch something repetitively.
Chris Dy:I think that's fantastic summary. And I think that probably as surgeons, we have an under appreciation for how long it takes to move somebody through the rehab process after the surgery. Because we pretty much do the surgery and largely put it in your hands or having to understand that you have a protocol that you work with that maybe we talked about when we started working together. I want to ask you as we come to a close one question, kind of wildcard question, because Chuck and I have been talking about this, and I think there's some interest in this. What are your thoughts about denervation? For thumbs teen? MC, is that something that you think has some potential or No, seriously, like, we're all trying to figure out what the sweet spot of helping patients through a, you know, you said, this is a painful condition, and one of our primary goals is to alleviate pain. So what are your What are your thoughts about that?
Macy Stonner:I think, conceptually, it sounds really cool. Given that their deficit might just be some numbness at the base of the thumb, if that's what you would expect, I have to be honest, I've only treated two or three from their first post about visit coming from the surgeon, and they live far away, and I lose a lot of patients to distance. So you do that first initial visit where they're painful, and then I don't get to see their outcomes because they go to a therapist in their town. So I'm so sorry. I don't have a lot to say on it. They don't I can't. I can't comment on the outcomes I've personally seen. But I think in theory, it sounds novel, and potentially excellent. I just, I don't know. Sorry.
Charles Goldfarb:Yeah, I mean, creating a Charcot joint makes a lot of sense. And we should we should all we should all go
Chris Dy:Touche. Good point. Good point. I think there's some room for room for exploration here.
Charles Goldfarb:may see, I think our listeners every time we have you on I know they walk away just like Chris and I are grateful. Because your perspective is really super helpful and makes at least me think about what we can be doing better as a surgeon. So thank you for your time.
Macy Stonner:You're very welcome. Thanks for hanging out on a Saturday at 7am.
Chris Dy:Thank you. Well, thank you for doing that. Oh, no, this
Macy Stonner:is this was my request, so that I could get it out of the way and go handle my young kids throughout the day. So
Chris Dy:well. It's exactly how I feel. Yeah. Cool. I have a wonderful, wonderful day.
Charles Goldfarb:Bye. Thank you. 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.
Chris Dy:What about you? 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