Chuck and Chris catch up on with listener submitted questions and then discuss the volar approach to the scaphoid for scaphoid nonunions.
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As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
Complete podcast catalog at theupperhandpodcast.wustl.edu.
Chuck and Chris catch up on with listener submitted questions and then discuss the volar approach to the scaphoid for scaphoid nonunions.
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:in thank you in advance for leaving a review and rating that helps us get the word out. You can email us at Han podcast@gmail.com. So let's get to the episode. Oh, hey, Chris. Hey, Chuck, how are you?
Charles Goldfarb:I'm really good. We're, we're here together early on Friday morning getting ready to go to the or
Chris Dy:nothing. Nothing like a little podcast before a big OR day?
Charles Goldfarb:Absolutely. Do you have a big one? Hey, you
Chris Dy:know, I can't say but it's, you know, it's not a small case. Put it that way.
Charles Goldfarb:Excellent. Well, hope you make our fellowship recruitment dinner tonight.
Chris Dy:Oh, no, I will. We didn't put a we intentionally did not put a free function in gracilis today. For that reason?
Charles Goldfarb:Excellent. I have little finger fractures to stamp out. So I think I'll be fine.
Chris Dy:Good, good. Well, you can hold down the fort, but I'm sure that we have tried our best to make sure that we are set up for success. Yes, it's fellowship recruitment weekend, so we're really excited about it.
Charles Goldfarb:Absolutely. We have a great day of interviews scheduled a great dinner tonight as mentioned. Yeah. Should be fantastic.
Chris Dy:Yeah, by the time this episode drops, everybody will have already come and gone from St. Louis. I'm hoping that in the traditional washy fashion, it goes off in the way that we expect it to.
Charles Goldfarb:Absolutely the the weather is cooperating. It is unbelievably unseasonably warm, which will take every day.
Chris Dy:This is this is pretty standard February in St. Louis, for anybody, you know, listening. I hope when you're listening, this is a pre Super Bowl or right after the Super Bowl. I guess this is going to drop on Sunday. So it's gonna be a beautiful fun weekend. Absolutely.
Charles Goldfarb:So any, any reader or I should say listeners submitted questions.
Chris Dy:Yeah, we have a great question to kick off, kick off the episode. This is from Chris Gayton. Dr. Gayton is from Myrtle Beach, South Carolina. He says that he's actually listened to every episode. So thank you, Chris. We're listening to every episode. And hopefully you're not tired of us yet. But question is, how do you position for Middleton oasis? This is sometimes a not a favorite surgery for some because you're uncomfortable against a stretcher and trying to see under the elbow, especially when the shoulder doesn't rotate. So Chuck, what are your thoughts on this?
Charles Goldfarb:Yeah, unfortunately, as I mentioned, I've had a fair number of these procedures lately. And I think of you always, as I embark upon them, I you know, you there are certainly those patients who lack external rotation. And that makes it really tricky. Thankfully, many of my patients are younger, and that is less commonly a problem. To be very kind of straightforward, my patients are supine, I make a massive towel bump that I put under the elbow in maximum external rotation of the shoulder. And that seems to work well for me, I will occasionally do transpositions and allow the Cubitus position over an arm holder when I'm performing arthroscopy in the same patient. Or if I'm doing something with electron fracture, for example, but typically supine external rotation. Big Bob, what about you,
Chris Dy:and that's the same positioning for a straight inside to decompression and for transposition.
Charles Goldfarb:Yes, every time I do an insight to I am prepared to do a transposition and as we have discussed, I do fewer and fewer insight to decompression. And again, partly because of my age, the age of my patients, as I say your age.
Chris Dy:We need any special counsel talking about your age. So for for me, I think it it tends to be very similar. Totally understand, I do have a broader age range. And in my practice, then chuck, you know, the shoulder external rotation thing is an issue and you know, you could still go so far as to you know, even check it before surgery. I think I have, you know, seen some folks who are doing, you know, these in the office, do them with patients prone, you know, doing wide awake inside to decompressions not my favorite thing to do. You know, occasionally we'll have to do like you said a insight to decompression or ulnar nerve transposition session when some physician for another procedure like an elbow arthroplasty where they're lateral or even prone, and it can be a challenge. Just because you're doing what I think is a relatively routine and honestly one of my favorite surgeries upside down. And it just, it can become a little more challenging, but I think if if one were to routinely run into this, I think positioning prone and just having the arm kind of hanging off would be a very reasonable thing to do. You know, I think in terms of if you're going to stay supine, I don't mind being against a stretcher. I think just shifting them all the way over to the side of the bed ahead of time, which is probably not anything novel or new. And then I prep the same way for a transposition that I do for a inside tube just because you never know. You know, I like to do a sterile tourniquet just to not lose any, any potential room around the elbow, which does give you a little more maneuverability to put your bump in. I remember one time in residency working with Bob Hotchkiss and he was big on the sterile tourniquet because you never want to get boxed out on your draping for an elbow, any elbow surgery. So even for an insight to and just for ease of our setup and the team that I'm working with, same way every time sterile tourniquet and get get the sterile drapes as high as you can before putting on that sterile tourniquet. And then it is very similar a stack an entire stack of blue towels COVID wrapped around it that sits under the brake Ium. And it's, you have to position it so much so that you can have it at the very edge of the medial Appa condyle. So that you can work underneath it. If you're watching on YouTube, I'm trying to illustrate that but be able to work underneath because if the bumps shifts out here, and then you lose the ability to work down in that plane. So even if they're not fully externally rotated, you still have that ledge. So if anything building up that but more and then we're if we're doing a transposition, I typically have them have a separate bump that can hold the elbow in a semi flex position just to free up somebody's hands. And for us, that used to be what we would call the Johnson bump bag from Jeff Johnson and pod four, which was a rolled sheet that they would then cover and sterilize, which apparently is now illegal. So now it ends up being either some kind of big, bulky Jones cotton fluff that they would use as a dressing for somebody else. But that's probably way too much detail. But I guess if you're asking this question, you want details?
Charles Goldfarb:Yeah, just for a difference of opinion. I absolutely. Never use a sterile tourniquet ever. I don't find the need. I've never been burned. I do a lot of elbow surgery. So different ways to approach this for certain. But I think the general principles are the same extra rotation, big bump, good exposure. And there you go.
Chris Dy:So coding question also from from Chris, is there a CPT that you add to the cubital tunnel code for when you're doing your subcutaneous adipose fascial fat flap. And then for a submuscular transposition, I will preface this answer by saying we are not here to give coding advice. We can only tell you what we potentially would do here. Coding is up to the physician and their team. And all of the live code that comes with it is up to you.
Charles Goldfarb:That does sound like a legally advised response, which
Chris Dy:seems smart. I don't give coding advice. But we're gonna say what we do maybe.
Charles Goldfarb:Yeah, well, I would say that, you know, we use the standard 64718 For transposition or decompression and and I cynically believe that's why the compressions took off, because you're talking about a 10 minute surgery versus at least a 45 minute surgery for most. I do not add a code for the fascia cutaneous flap, I do add lengthening to 4305 for the flexor pronator mass when I do a sub muscular. So for me, it's either a singular code or for sub muscular two codes. What about you?
Chris Dy:Same thing for a sub muscular. For the because it is truly a flexor progenitors, the lengthening for subcutaneous with the adequate fascial flap I have been listing it. And then actually, before Chris said this question, I actually had asked our billing seem to look because I do add requests that they add a code and I had 1574 Because it's technically a pedicle flap from a known vessel that Dr. Yamaguchi described for us. So and the looking at the for us in our experience, again, only us it is a code that is reimbursed at the similar rate, both in terms of how often is actually paid just binary yes or no. And then the actual collection rate is similar to when I asked the same billing team to look up the easy lengthening code that's put in addition to 6471. A
Charles Goldfarb:nice to hear great question and maybe I just learned something today.
Chris Dy:I don't think you did. But I'm very proud of myself for doing some coding work. I never do this stuff. But I did start to think about it in a question from a former fellow Andrew Sobel, you know, proceeded when I did that. And then this perfect time, and Chris had the same question. So thank you, Chris, for the question. Really appreciate it. Hopefully it was helpful. You know, certainly email us back if you have any other follow up questions, or anybody listening, we love listener mailbag stuff, so Han podcast@gmail.com. So with that, we should thank our first sponsor, absolutely.
Charles Goldfarb:The upper hand is sponsored by practice link.com The most widely used position job search and career advancement resource.
Chris Dy:Becoming a physician is hard finding the right job doesn't have to be joined practice link for free today at www dot practise length.com/the upper hand. So
Charles Goldfarb:I've done a lot of cubital tunnel surgery lately, and I've done a lot of revision skateboards lately. What have you been busy doing?
Chris Dy:A lot of distla radius fractures as we talked about last episode. My --- I've had a pretty you know pretty good mix I've actually the last few weeks have been very happy I fit the the hand surgery triathlon. I don't know if you're familiar with this concept of our fellow Emily's all those had not heard that term, but using the fluoroscope the microscope and the arthroscope in the same day
Charles Goldfarb:that is a new one for me. And it does not sound like a good day. What do you throw in the microscope? I'll
Chris Dy:Oh man, I love those days. For me, that's the best you know. And again, the arthroscopy does not come up that often for me, I'm, you know, kind of general hand surgery level arthroscopy certainly not a master like Chuck. But it's a nice thing to do and nice thing to offer and I love having that. I know that you don't technically have a microscope at the main facility that you work at. So perhaps that is limiting your participation in the Hand surgery triathlon.
Charles Goldfarb:It makes me laugh at myself because my children often give me grief and the old man's triathlon sometimes I participate in at home, which is rowing, biking and lifting. And so they laugh at me when I do the Old Man Triathlon.
Chris Dy:That's a pretty good triathlon. I mean, come on, you know, you're about to have a partial knee replacement. You know, I, what else can you ask for?
Charles Goldfarb:And you got to be able to laugh at yourself. I liked I liked the concept of the de triathlon. I like
Chris Dy:Yeah, so it's been it's been relatively busy, steady. It's been good. It's a success. I think we talked a couple of weeks ago was getting a little bit too much. But now things have quieted down. Have a nice, you know, our day to day, nerve surgery, more relaxed, less running around, and a distal radius fracture to fix in the afternoon, but
Charles Goldfarb:yeah, I wish I could agree with the call down it has not at all, but maybe it's because I'm about to go out for a little bit of time next week with a small surgery. My
Chris Dy:my iPhone, here you go. Good luck to you on your surgery, can't wait to hear you hopped up during your recovery. My wife has advised me that and you know, we talked about this on prior clinic or prior episodes, but I need to stop scheduling the makeup clinics. Because I think that is what so that's what's been hurting me and I it's a very hard thing to just let go of that. But I think I'll follow that advice
Charles Goldfarb:is good advice. But it's just hard. I mean, do you hate to make patients waiting or are not seeing them in a timely fashion and I had I had a very was going to be a very short afternoon clinic yesterday and it was a large number of patients and they were quite complicated and it was very frustrating. I haven't been frustrated like that in clinic in a while. But I think the key is knowing what you're gonna see and planning ahead, but it's not always easy to do. Absolutely.
Chris Dy:So before we get into this volar scaphoid technique at a deep dive. Why don't we thank our other sponsor, checkpoint surgical? Absolutely.
Charles Goldfarb:The upper hand is sponsored by checkpoint surgical eye provider of innovative solutions for peripheral nerve surgery.
Chris Dy:Checkpoints next professional education program. Upper extremity acute nerve injury management will include an overview of intraoperative ultrasound imaging to augment nerves zone of injury assessment. Now that sounds really cool. The person will be led by luminary faculty, luminary nice, including doctors Deanna Mercer Amber Leis and Brooke Baker and takes place on March 15 and 16th in Scottsdale, Arizona. That sounds really cool. To learn more about this and other educational programs sponsored by checkpoint surgical, please visit nerve mastery.com Checkpoint surgical driving innovation in nerve surgery,
Charles Goldfarb:they really are hosting some, some really good courses, I have to applaud the efforts. Yeah,
Chris Dy:and I think interoperative assessment with ultrasound is really cool. I mean, I've tried, I've done that a handful of times. And it's been helpful, and certainly not to a skilled photographer just yet. But even in novice hands, it can provide useful information. And you know, it's not as limited by you know, things like the tourniquet, which can be an issue as you get later on into a case. And checkpoints, also helping sponsor our WashU peripheral nerve course for those of you watching on YouTube. Here's the flyer, April 5 to sixth. Here in St. Louis, keynote speaker, Susan MacKinnon. We really want everybody to come and check it out ortho plastics, neurosurgery coming together, I think for the first time in WashU history to host this meeting, and hopefully the first of many, but some great sponsors including checkpoint, I'm trying to wrangle practicing into exhibiting. So anyway, please come check us out. I think it'd be really fun meeting. Registrations open. I think there are still some spots left. But you know, if we tell you the spots are limited, maybe you'll be more interested. So check it out. Move
Charles Goldfarb:quickly. I will not one that'd be very new for a spot in this course, even though I think it'll be a fantastic course. That's too much nerve for me too much.
Chris Dy:That's okay. All right. So tell me a bit a bit about some of these revisions. scaphoid cases that you've been doing that sounds honestly quite awful from my perspective, but it is it is a such a technically demanding surgery, both in indications selecting your surgery, and then the carpentry and the plumbing, for lack of a better term can be really quite tough.
Charles Goldfarb:Yeah, it's interesting, you know, I always try to understand and so I two cases. And I'll just briefly give the highlights and then we can talk about the technical and the revision setting. You know, one of the cases was does a 16. Now, I'm sorry, an 18 year old, who was treated out of state, and had initially apparently been treated for a scaphoid non union from a bowler approach with two micro acutracks.
Chris Dy:So do you feel like what's the right size screw? You know, whether it's an accurate track screw or not, I mean, those micro type screws to is okay, if you've got two of them, right? It's usually one is unless they're quite a small patient, one probably is not enough unless it's backed up with kwire or something, or,
Charles Goldfarb:yeah, I don't, I haven't seen any anatomical studies but one micro acutrack for a waste non union and a standard human being is in my mind is probably not enough. For me, it's almost always a mini sized. And occasionally, in a revision, I'll do a standard but a micro is tiny. It looked tiny, it was tiny, and the bone didn't heal.
Chris Dy:So, you know, I guess the basic hand surgery and orthopedic principles when you're thinking about a bona healing, you know, is it a blood supply issue for this bone? Is it lack of inadequate immobilization of the bone either in some settings casting versus fixation? Is it infection? Like what What's your thinking just for the very basic people maybe that earlier on how do you approach this in terms of how to figure out what's going on and what you can do to make it better?
Charles Goldfarb:Yeah, let me let me briefly have the second case, because it gets to one of your points. The second case was also a waste non union. And this patient had not previously been treated, and was treated with a vascularized bone flap, which in retrospect, and for me, it just wasn't necessary. And I think it compromise the carpentry so to speak, and the fixation, which which led to another non union, non union of the non union. So I think from a basic principles standpoint, waist scaphoid fractures should typically heal. They are rarely compromised by blood supply issues. And so we as surgeons, when we approach these need to restore the anatomy, ideally, apply a compressive screw and add bone graft, if necessary, which in a non union, it would be necessary, but those are the simplistic, basic concepts. Right.
Chris Dy:And you know, you say here that just to clarify, you say that the blood supply is rarely an issue, but that is the textbook concern for at least any skateboard factory more relevant for proximal pole fractures, as opposed to skateboard waste fracturing, just want to make sure that that distinction is made for those that are listening. Is that Is that an accurate summation of what you're saying?
Charles Goldfarb:Yeah, so you know, this skateboard blood supply comes in distally and travels proximately. Therefore, the further proximal the fracture line is, theoretically, the greater risk of a blood supply compromised, and an avascular necrosis type situation, or simply a non union. I'm just my point earlier was simply that I don't recall, real blood supply issues for any waist fracture, it can happen, but really, we think about blood supply issues with proximal pole.
Chris Dy:Right, right. And then I guess your other point that I wanted to expand on a bit was saying that these nonunions in the setting of no prior surgery, typically, they don't typically require anything more than good fixation, and some cancellous bone graft. And I think with all the excitement that there has been with various pedicle bone flaps, and then subsequently free, you know, cartilage type transfers, you know, vascularized, free flaps, essentially, of bone. There has been a bit of a pullback, and I think there's been another suggestion that you really don't need much more than what you described in terms of getting good compression for the first you know, surgery for a non union adding some cancellous graft is that do Would you agree with that?
Charles Goldfarb:Yeah, and the technical part and this is this has been demonstrated by mechanically out of Seattle is you want your screws center center in the axis of the scaphoid. So it's centered on the PA center on the lateral. And in both of these cases, these revision cases just did the screw was far from the center center axis. And sometimes it's difficult to place that screw exactly where you want it but it needs to be pretty close or exactly center center to maximize the patient's chances of healing and so not overdoing concepts like vascularized bone graft and focusing on the basics that is you know, make sure if it's a non union you to breed the non union site you add can sell his bone graft and you put a good screw in. So
Chris Dy:for for you, um, When you talk about the approach to something like this, when do you need something more is one question. And then the second question is you talk about being center center, but there are some, you know, fractures that are in nonunions, that might be the exception to that rule where you want to be more perpendicular to the fracture itself, as opposed to being center center to maximize fit. So can you talk me through when you need something more than maybe answer the second question first, because that might be more direct.
Charles Goldfarb:So there is a higher rate of non union for oblique fractures. And that's pretty well established. And, you know, it is a little tricky to decide when do you want center center? Or when do you want your screw perpendicular, I think if you can have a good entry point, that is an appropriately starting an appropriately placed starting point. And you can create a screw trajectory, which is perpendicular to fracture line, which allows compression, I'm not against that buddy stretch. And that would be for the oblique fracture pattern for most other fracture patterns center center. That's my approach.
Chris Dy:Yeah. And I think that's where those micro screws, or at least a smaller diameter screws can be really kind of useful to, to accomplish that. You know, so then, let's get into the second question. I just want to say, you know, there's the scaphoid nonunion that presents after inadequate immobilization, either, you know, they it's a missed fracture, or they've had casting, and it's just not enough, and then you're looking at screw fixation with some graph perhaps can't sell his craft. That's a separate entity than what we're about to dive into now, which is the patient who has had surgery, and now has a non union after an attempt at surgical treatment. So is that a fair way to set the stage for the rest of the conversation? Yeah,
Charles Goldfarb:it's a fair way to set the stage. And I would say your previous also question, you know, when do you need more than a screw. And, you know, the screws we have to choose from no matter what the manufacturer is, are really good and really strong screws. I think the beauty of cancellous bone graft is it simply brings, you know, healing factors into the area of the non union without providing structural support. I'm not against structural support. And actually, in both of these cases, I went to the crest, I can sometimes use a roussy technique in some of the bowler cortical bone from the distal radius along with bowler and cellos bone from the distal radius. But when I really am worried, I do go to the iliac crest and one of our partners, Marty Boyer always goes to the crest. And I don't know about you, I do think the crest is slightly better. I think the bone graft is slightly better. But it's also a bigger deal. So I don't do it often. I just happen to do it twice in these most two recent cases.
Chris Dy:Yeah, and I think the iliac crest is probably the gold standard in terms of structural, yeah, either by cortical try cortical support, depending on when and where you're using it. It hurts so much, in terms of, you know, the thing that patients will describe afterwards and there's definitely some technical skill in terms of how to do it appropriately. And you can obviously get a lot of counsel as to while you're working in that in those between those tables. You know, I I guess one thing is that actually one of these cases was discussed in conference on Monday and I was the only one that brought up the the modified per se as an option. So you know, I think that because mainly because you weren't there to bring that option up, you know, but I think the conversation was good about you know, when you potentially go to the crest is when you think about when you need more than just a screw and can sell us is it largely based on pre op deformity and or the prior surgical approach? And how do you assess the deformity? What's your best way to do that?
Charles Goldfarb:The simple answer to your question is yes, preoperative deformity sets the stage for what do I need? Do I need more bone graft? Do I need iliac crest and So absolutely, I am not someone who always wants a CT scan. Although the intra scaphoid angle on a CT scan is most helpful. Plain radiographs will give you plenty of information, especially if you use the secondary indicator of the loonie position. So if the illuminate is tilted dorsally which which happens when the scaphoid flexes through the through the non union, then that's an indication you're meant to open the scaphoid to correct the humpback to for me, but it's the humpback deformity. And if there is a humpback, and for me, I've not found a way to deal with that successfully from the dorsal approach. So humback deformities for me are always volar. I think most people would agree with that. I think there's some that might try to do this dorsal I think that's tricky.
Chris Dy:I think that is tricky. I think you can get a little bit of correction, maybe from dorsal, but obviously as you're working dorsally and you're getting more towards the waist and you're doing more manipulating, you're getting to that blood supply that Dr. gelderman very beautifully illustrated, you know, 40 years ago, you know, with you know the concern about doing too much storage slowly, so you need a little bit. But if you need any real correction, you really got to go. volar. And, you know, I think that the interest rate wedding was a good point for the, for the residents and fellows, you know, that was described by Amadeo and you know, originally on the lateral film, but a CT scan gets you a much better perspective on that just making sure you reformat your CT scan appropriately request that from your radiologist so you can get a really good scaphoid assessment. So we're gonna have to wrap up pretty soon. But can you talk me through kind of your, your volere approach? I think we I don't think we've gone through that volar approach in detail on the pod.
Charles Goldfarb:Yeah, I think it would be it would be good and hopefully lead to some some listener questions. So I essentially, you know, if you're on YouTube, especially if you're a younger listener, my finger is on the skateboard tuberosity, which is just distal to your wrist crease. And so what I do is I have a longitudinal incision of the fcr, and then an oblique extension over the thinner musculature. And that gives you great exposure of the tuberosity of escape void of escape void, and trapezoidal joints, as well as more approximately, so make your decision. I released the volar ligaments, that is the radius scaphocapitate, long radiolunate for later repair, to repair those on your way out. And it's a sharp approach for me, essentially, all the way down to the joint. And then you expose the skateboard. Do you think about the same way? Do you do anything differently?
Chris Dy:No, I do I think about it the same way. And I was just thinking this is approach. This is an approach where, you know, we just, you don't get to see it enough. I think, you know, what I make sure to tell our fellows, you know, if somebody's doing a bowler approach escape, we definitely see that case, because scaffold nonunions are something that a general practicing hand surgeon should be able to tackle, you know, especially considering the growing evidence that some of the MFC, MFT, things are less or more narrowly indicated, I should say. So this is something that you should be able to tackle and approach and you know, I agree entirely with the with the incision, and and what you described.
Charles Goldfarb:Yeah, and the fiddle factor can be high once you're addressing the scaphoid itself. And so a rapid approach is super helpful, because you don't want to waste time with a prolonged approach. It shouldn't take long. But to your point, if you're not doing this approach all the time, then you you move a little more slowly. So once things are exposed, old hardware has been removed, whether from dorsal or Bohler. And I will say that I don't mind going both sides of the skateboard. I don't think that's a big deal. Ideally, you'd just pick one side and you go volar in this case, and then it's preparation of the nonunion. So that has to be done really well. And I typically put joysticks in the proximal and distal skateboards, so 0.062k wire, all right, was that a 1.1 millimeter or one? Maybe it's I don't know, but Well, I think it's a 1.2 - 1.2 mm . Anyways,
Chris Dy:we have a chart we have a chart in my or convert these things. Because even the reps don't talk American. Talk to me and millimeters oh my god, K wires are actually in standard units. So anyway,
Charles Goldfarb:so joysticks open up the scaphoid curette runs your get to good Kitselas bone if you don't do that, it doesn't matter what to do after.
Chris Dy:Right. So you're talking briefly about getting out the hardware, sometimes you if they that hardware was inserted in, you know, retrograde manner, you know, are you having to, you know, trim back some trapezium, or just in general, if you're putting in in retrograde screw, you do have to take a little trapezium at the st joint, right?
Charles Goldfarb:Yeah, it makes these two cases made me think about how to put in hardware in a way that if you have to take it out, it's not a disaster. And so, it, these were both quite challenging, because number one, the screws were countersunk, quite a bit. And number two, they weren't inserted in what I would say the typical location is, so you have to work a lot harder to identify the entry point, you don't want to destroy the cartilage of whether it's the proximal scaphoid or the distal scaphoid. And it becomes very, very tricky. But ultimately, you have to take out the hardware one way or the other.
Chris Dy:Right, so hardware is out, you've opened up you've got your, your joysticks, and you've depleted the non union site. So then we don't have to get into the technical aspects of you know, we should maybe in a follow up episode talk about you know, your approach to harvesting a modified per se, or try cortical or by cortical iliac crest. How do you approach the fixation part of it?
Charles Goldfarb:What I think is critical is is once you have opened up the escape void and placed your bone grab, I like to create the skateboard as a single mobile unit. And so I do place a derotation K wire off axis. Typically its a 0.045 and that allows me then to move the scaphoid is a unit and the reason that's so helpful is you can put a retractor underneath the distal skate void giving you better exposure to the articular surface at the trapezium, which allows you to put a better homerun screw in a retrograde fashion. So for me that's critically important and allows just a much more satisfying progression of steps. Do you do that same thing?
Chris Dy:Um, yeah, I think I think that's super helpful. I think the rotational wire is helpful, and I agree it does help with the exposure. I'm what I'm pondering right now is whether I would actually then after I've gotten that skateboard in better position, then choose to do a percutaneous dorsal or mini open approach if I haven't already done that to put the screw from in an integrated manner. But I guess at that point, if I already removed hardware and kind of gone to the trapezium, it might make more sense to get your home run screw, as you call it from, you know, from distal to proximal or retrograde.
Charles Goldfarb:Yeah, especially if your distal fragment is the smaller fragment. In that case, obviously, you would put your screw in from volere and from distal, to give you the best possible stability. But to your point, it's never wrong to go back dorsal it's easier to put the homerun screw in from dorsal for sure. I typically have been on one screw person, and you sort of have to balance placement of the screw without dislodging your bone graft, especially when it's a by cortical or tri cortical graph. But that graft is a source of stability as well. And so if you've, if you tailored your graph, well, if you've done good carpentry on your graph, and you put it on the volar aspect of the skateboard, hopefully your screw starts and proceed slightly dorsally. But still, hopefully this inner center location, right
Chris Dy:as we draw to a close, I mean, you're really hoping for an interference fit of that of that cortical graft on a bowler aspect. Question for you. Would you ever consider a plate in this situation?
Charles Goldfarb:I would consider a plate I have not placed a plate I have done K wire only fixation. I don't love K wire only fixation. But again, if you've done your carpenter correct, and you have good press fit. In our case, it was by cortical iliac crest. I don't think it's crazy to stick to K wires if you can't get a good starting point because of a previously placed placed screw, which makes everything more challenging. So it's it can be really tricky in these revisions with hardware removal I played is not a bad idea. And I would I would probably stick to you know a two Oh plate or something like that. But I don't have any personal experience with plates. Have you done plates?
Chris Dy:Haven't I know that there is one manufacturer that does have a scaphoid specific plate that's been talked about quite a bit and published about quite a bit. I have not yet. But if I were to, you know, that might be the one situation in which I would consider this. You know if it does help obviously secure the location of your of your carpentry. So that was fun. If you IF listeners if you want to hear more about Chuck's adventures with revision skateboard and get into some of the weeds and details about you know the trade off, let us know or if there are any other questions, feel free to send in suggestions for topics and look forward to catching up soon.
Charles Goldfarb:Fantastic. Great to see you. Have a good day. Enjoy those nerve cases.
Chris Dy:get to enjoy your case. All right, take
Charles Goldfarb:care. Hey, Chris, that was fun. Let's do it again real soon.
Chris Dy:Sounds good. Well, be sure to email us with topic suggestions and feedback, 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
Chris Dy:remember, keep the upper hand come back next time