Season 3, Episode 4. Chuck and Chris take a deep dive on scaphoid excision and 4-bone fusion. After a brief case introduction, we discuss our decisions, preferences and techniques. We also briefly discuss other options including proximal row carpectomy and capitate resurfacing.
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theupperhandpodcast.wustl.edu. And thanks to Eric Zhu, aspiring physician and podcast intern.
Season 3, Episode 4. Chuck and Chris take a deep dive on scaphoid excision and 4-bone fusion. After a brief case introduction, we discuss our decisions, preferences and techniques. We also briefly discuss other options including proximal row carpectomy and capitate resurfacing.
We plan a newsletter launch soon. Subscribe here: https://wustl.us6.list-manage.com/subscribe?u=c6fe13919f69cbe248767c4e8&id=10e0c1dd85
Survey Link:
Help Chuck and Chris understand better what you like and what we can improve. And be entered for drawing to win a mug! https://bit.ly/349aUvz
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
theupperhandpodcast.wustl.edu. And thanks to Eric Zhu, aspiring physician and podcast intern.
Welcome to the upper hand, 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 aspects of hand surgery from technical to personal.
Charles Goldfarb:Thank you for subscribing wherever you get your podcasts.
Chris Dy:And be sure to leave a review that helps us get the word out.
Charles Goldfarb:Hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:Doing well, you know where I am?
Chris Dy:Your background looks a little different today.
Charles Goldfarb:Because I'm at home because of the Snowmageddon 2022.
Chris Dy:I think it got a name. I think it's winter storm Landon. At least that's what my Bank of America email told me. They said that they care about me during this winter storm. I don't know if they really do.
Charles Goldfarb:And I've gotten so many emails telling me the 16 places that are not open today that everyone needs to send an email. It's like, oh my gosh, but winter storm Landon does not sound quite as terrible as Snowmageddon.
Chris Dy:So well, you know, so you're working from home today. I had to come in today. For better or worse I was. I had a case I had to do this morning, a fracture case, didn't want to wait on that one. So I braved the snow, I dug my car out from snow. That's the one thing that I think that we really messed up on with the new house is not measuring the garage, and realizing that a two car garage for a 1936 house is not the same as what the expectations you would have for a two car garage in 2022.
Charles Goldfarb:Well, I think St. Louis, I don't want to say is unique in this regard. But there are a lot of small garages in St. Louis. You know, part of the appeal of St. Louis is the remarkably I guess, varied, but consistently great architecture. And so many neighborhoods with so many cool houses, and so many small garages, we actually borrowed a friend's car to try in my old house Garage before Talia got her newest car. And this was five or 10 years ago whatever, just to make sure it would fit it's just a common problem.
Chris Dy:But a total afterthought on my part because even in our old house when we got a new car we were I was totally upgrading my dad life and I was getting a Honda Pilot. And I actually didn't think about that before we pulled the car in and got home from the dealership and it narrowly made it we're talking like half an inch on each side. I don't like that probably is something I should have thought about before purchasing this car.
Charles Goldfarb:So you had to get up early turn the car on shovel shovel it out and scrape it off and.
Chris Dy:Well you were kind enough because we were supposed to record very early this morning and you were kind enough to give me an out because I was just you know I'm a Florida boy I was very nervous about the weather this morning and you know everything like you My schedule is usually pretty efficiently packed and I know exactly what time I need to leave my house to get to know the location I'm going to get into you know to the holding area for for case and it was completely blown to hell this morning just because I had to get up and you know get up earlier to do my normal morning routine so worked out and then I had to shovel snow around push snow off my car. I mean I look ridiculous out there because I was like you know what would work really well here to get the snow off the top my car a broom. So I had like one of those aside sidewalk, you know, sweeping things and just like sweeping the snow off, starting the car, going back in and then and then of course there were unfortunately some distressed motorists along the way on Forest Park Parkway. So yeah, everything just slowed to a halt.
Charles Goldfarb:Did you wave at them when you drove by them? Or did you
Chris Dy:No, I'm a Florida driver, like my hands are like ten and two the whole time. You know, white knuckling the whole thing.
Charles Goldfarb:Amen. That's what happened when I drove to work yesterday. I have my wife laughs at me because I told her to make sure her car has a full tank of gas and I ended up driving my car, which was good, but Oh, it's so funny. We are lame.
Chris Dy:Yeah, Talia grew up in the Northeast. So this is like nothing to her. Right?
Charles Goldfarb:That's right. That's exactly right. I will say working from home is interesting. You know, I work most weekends, you know, good chunk of the day or mornings at least, or whatever. And I'm home today because I had a big case cancel and I just had meetings the rest of the day. And it's fine. And I started off today great. But now it's like usually on a Saturday or Sunday at about noon or 1230 I'm thinking about a nap and that's not built into my schedule today so stay focused.
Chris Dy:You can tell Karen for your work from home days to build in a little bit of a you know genius time you know, to sleep and catch up. I find that when I work from home there's just a lot more snack breaks which is a problem for me so.
Charles Goldfarb:That too. That too.
Chris Dy:Yesterday I had a bunch of zooms that I had to do just because I was supposed to be doing academic stuff and I did but I had to tell my my kids these are times when I can absolutely not be disturbed versus you can make an appearance on screen if it helps keep the peace. So and I'm very proud of myself, my father in law got through the day with only one hour of television yesterday for the kids. And that was when I had a deposition when I just definitely could not be involved. One of my, you know, patient is involved in a work comp thing so I was trying to help out, but I was like, Yeah, TV's totally fine during that one hour.
Charles Goldfarb:Yeah, you're, I think your only mistake. So what I've heard about your day so far, is getting your normal workout in. So I did not work out. I don't usually get up early to workout. But I'm planning to shovel snow this afternoon. Once it stops snowing.
Chris Dy:That's the two day situation. My wife actually last night was like, So what's our snow shoveling plan? I was like what it normally is I do it when I get home.
Charles Goldfarb:Well played. Well played. Yes.
Chris Dy:So I speaking of white substances, I had an interesting case in which I wanted to ask your opinion, because I had a patient who, you know, came into the clinic. She's in her 50s 60s ish. And she had the classic, you know, dorsal central wrist pain, and the classic dorsal wrist swelling, I was I came in the room was like you got a SLAC wrist just not even looking at the X rays. And we talked about treatment options. And we got her X rays, and she has a SLAC wrist. But of course, she doesn't remember any injury. And you know, I thought her capitolunate joint didn't look great. So I was really hoping just to do a PRC. But, you know, we had talked about you know, in the setting of her capitate base not looking good that we probably would have to do a four corner fusion. So how do you talk through that decision making process? With a patient? You know, I know some people are more willing to accept a little bit of wear on the capitate. And some people are putting in little pillows of tissue in there to help smooth that new articulation.
Charles Goldfarb:Remind me how old she is.
Chris Dy:50-60s
Charles Goldfarb:Okay, yeah, it's so super interesting. And I think some of the audience hopefully will shout at us on Twitter or write us an email on their opinions, because to me, there's three options, there's got to be a number Chris, there's always one, two or three options. So three options.
Chris Dy:But you usually stick with two. I'm proud of you for expanding.
Charles Goldfarb:My emails are largely reading the same way, by the way lately, I guess we get all we get comfortable with ourselves. So three options. Number one is a four corner fusion. And just to hit on that I like the operation. I think results are reliably good. I think literature in the last few years has shown that PRC honestly is better. It's more reliable, less frequent revision surgery. So I do like PRC better in the right population. But I like the four corner fusion. So we can talk more about that if you like. The other two options are the capsular interposition, which I am not convinced there's any literature on that's substantial. But basically taking a dorsal capsular flap, and you can base it approximately you can base it distally and then you carefully sutured into the volar wrist capsule without taking too big a bite with that median nerve proximity, flexor tendon proximity. And I'm going to happy with that as well. I don't do that often. But I've done that. And I think the third potentially really intriguing operation, which I know at some sites is gotten more and more utilization is the capitate resurfacing which I have not done. But I remain intrigued by it and hopefully hope to do it at some point.
Chris Dy:What would be the right patient for you in terms of the capitate resurfacing,
Charles Goldfarb:The patient you just described 60 some odd year old where maybe a smoker that you really don't want to do a four bone fusion on and resurfacing the cavitate might feel better than a capsular interposition.
Chris Dy:So we talked about options. We told her you know, this is possible, you know PRC possible four corner fusion, and even if her lunate didn't look great, possible total wrist arthrodesis. So I don't have any experience with the capsular position. I have not done any capitate resurfacing. So that was the list I was offering her and we go to the operating room and you know I elevated my capsular flaps and I see a speaking of Snow White chalky substance. So and then there's complete dissociation between the scaphoid and the lunate. What do you make of that?
Charles Goldfarb:Well, I guess I have two follow up questions. One is have you given her steroid injections and would you consider that on her first visit to the office? ie is that the chalky substance? Are we talking to something else?
Chris Dy:Nobody's given her a steroid shot. I actually offered her and walked out of the room with the impression I was giving her a steroid shot when I came in to give her a shot. She said you know I don't want that. Let's just Let's just cut to the chase. So I said okay, here are the options. And so I was fully prepared to do that, but nobody else had given her steroid shot.
Charles Goldfarb:Yeah, so um, you know, most likely this is gout, I guess potentially pseudo gout, but probably gout. And we, you know, we did share our experience. It's been a long time, maybe 15 years ago on this subject. And I think it's the culprit. I mean, I don't think this is, you know, a trauma and gout, I think it's gout that is eating away at the scapholunate ligament and led to arthrosis doesn't change my treatment or my approach. But I think it's gout. My second question, and we can talk about that too gout and assessment and what it means. But my second question for you is, and I guess this is a theoretical question. So you say you've never done a capsular interposition? What's the role of, you know, I know that for you, you know nerve is, is really everything. Not everything, but really important to your practice, like me sports and congenital and kids really super important. It's interesting, you know, do we do enough as a partner, as a group of partners, that we operate together on things like this?
Chris Dy:No, I think I think that's interesting. You know, if it was a problem, where I didn't think that we each had reliable solutions, while it may not be the solution that everybody else comes to, I think there's enough equipoise in the literature, meaning that there's a lot of uncertainty as to what the right thing to do is, but you've got a number of things that have reliable and predictable options. I don't know. I mean, I guess if there was somebody who felt very strongly that a capsular interpositions are the way to go, maybe I should have called that person. And maybe that's an area where we could be better at it now. But I think that these are reasonable solutions that many hand surgeons and practice would have offered this patient.
Charles Goldfarb:Totally agree. And I'm not suggesting you didn't do absolutely the right thing.
Chris Dy:Yeah, yeah, you were Yeah, you were you totally. That's what you're doing.
Charles Goldfarb:No not this time. No, I agree there's not clearly a better answer. And you certainly had the right tools in your toolbox to take care of it. So. So I mean, I'm in agreement, I think this is a very reasonable option, I might have chosen capsular interposition, but not with the idea that there was anything wrong with the scaphoid excision, and four bone fusion.
Chris Dy:Can you give anybody any pearls about a capsular interposition. Before we dive into other technical things.
Charles Goldfarb:I you know, I used to do a Blatt Capsulodesis a lot for scapholunate. And so with that operation, you are creating a one and a half centimeter wide, capsular flap, so dorsal wrust capsule based on the radius, and then you attach it to the scaphoid distally, I don't do that operation anymore. I'm not sure if you do capsulodeses, but I don't remember the last time I did that. In this case, I actually like distally based flap better and I make it at least two centimeters wide. So essentially, a longitudinal incision, kind of in the radial 1/3 of the of the wrist joint, another longitudinal incision in the ulnar 1/3 of the wrist joint, and then I take the capsule off of the radius, leave it attached distally. So now I have a wide, a nice, wide substantial capsular flap, that then I can suture, as I mentioned carefully to the volar ligamentous structure. I do like the operation. I have no idea if it stands the test of time. But I have not revised any of these in my practice, not that I've done more than half dozen to a dozen.
Chris Dy:Same indications as the capitate, resurfacing this kind of patient?
Charles Goldfarb:I think so. I think so certainly far cheaper. I don't know what the capitate resurfacing costs. It might be more fun in operating room. But I don't know about cost analysis for that.
Chris Dy:Surgeon enjoyment is not included in our case logs with cost. It's interesting you mentioned, it's interesting you mentioned the capsulodesis because I actually raised a Blatt Capsulodesis flap as part of an SL reconstruction case because I knew I wasn't going to be able to reconstruct the SL ligament actually wanted the trainee to see, here's how he would do this in case you don't have access to various, you know, implants like a suture tape or something like that. But the suture tape, I think, for me has supplanted the use of the Blatt. But it's important to know how to do a Blatt in case you need to bail yourself out.
Charles Goldfarb:Yeah, and you know, as you mentioned, I mean there's many ways to accomplish the same goal. What was probably not super healthy is sometimes we have a little bit of groupthink, I think for the right reasons. But like you say we're we've been pretty happy the internal brace for SL and we've been very, very happy for the internal brace for CMC. And I did an LRTI yesterday and Harrison, one of our fellows was super excited, because he had seen a lot of LRTI which is fascinating. And we you know, it was great and we did together. There's nothing tricky about it, but it was fun for him to see.
Chris Dy:Right because if you go into a practice where you're at a Surgery Center and they say Why are you spending this much money on a surgery? That's going to make a difference because you could do an LRTI on the cheap using an FCR and or various the Wilde or the, you know, the technique that Jeanne Delsignore described there are a lot of ways you can treat thumb CMC arthritis in a very cost effective manner.
Charles Goldfarb:Absolutely. And I'm not here to promote anything. But we have two papers coming out on this, which I'm excited about one's a retrospective study on a large number of LRTI versus the internal brace and another is a prospective study. So those data will be interesting. I'll give teasers as we go along.
Chris Dy:Oh, people are on the edge of their seats during their commutes. So let's get to it. Let's get to the meat of this episode. So I wanted to talk detail surgical technique about four corner fusions. Just because I know there are a lot of ways to do this. You know, in essence, so say for example, you've gotten your surgical approach done. You're staring at a bare spot on the capitate. The lunate proximal surface where it articulates with the radius is okay. You've decided you're going to do a four corner fusion. How do you prepare your joint surfaces just to get started?
Charles Goldfarb:I would like with your permission to go back and emphasize two things. One, the approach for me is simply through the third compartment. I transpose and leave the EPL transpose I do not routinely take out the post interosseous nerve but don't have any issue if you know others might. I'm really about
Chris Dy:Just don't bill for it separately.
Charles Goldfarb:I agree with that. I'm all about the nerves. I'm gonna save them. Yeah, I don't believe in billing for them. But some some out there will
Chris Dy:Some do, some do that's cool.
Charles Goldfarb:And to be very clear. You know, one of our favorite studies is Kirk Watson's study of defining SLAC wrist and apparently reviewing 4000 radiographs of various wrist arthritis patterns, though proximal lunate is always okay.
Chris Dy:Until it's not.
Charles Goldfarb:But it's always okay. But you do have to confirm that so, so wide exposure. And then the first step is obviously removing the scaphoid in these situations with a little bit older patients and patients who've been in pain for a while, it's usually not the hardest part of the procedure. You know, there may be some scarring of the scaphoid tuberosity to the volar capsule. But getting some Hohmanns around the scaphoid to me is the simplest way to get this scaphoid out. I don't use threaded K wires, I don't think they're necessary. I am super careful about the volar capsule, especially the radioscaphocapitate and long radiolunate ligaments because if those are cut, you will see translocation of the carpus. But getting the scaphoid out is the first step. Usually not so hard.
Chris Dy:I agree with that. And I think the last point you made about the RSC and making sure that you don't get that ulnar translation of your carpet is huge. And for that reason, you know it is largely a blunt dissection to release the scaphoid on the ulnar side. I like to use them a mcglamry elevator from the foot world and I've seen that that seems to work well for me. I just don't like taking a knife and going along the volar surface there because I think you can get into trouble there for for a number of reasons. So yeah, I agree it usually not the hardest part. Are you the kind of guy that likes to take the scaphoid out in one piece? Is that a pride point for you?
Charles Goldfarb:I'm the kind of guy who wants to get the scaphoid out fast and if it's in one piece awesome but no, there is no requirement there.
Chris Dy:Do you ever split it from the beginning?
Charles Goldfarb:No, I actually don't split it. I think the question is I like the you know dissection near circumferentially grab it with the biggest rongeur I have and then the slow alligator roll and either comes out or you hear that snap and then you got two pieces. What do you do?
Chris Dy:With the biggest Rongeur it might be more than two pieces. I actually just heckle the trainees until it's no longer possible for them to take it out in one piece and then I make it into multiple pieces so they don't feel bad. It's kind of how it goes usually.
Charles Goldfarb:Do you care if there's a little shell of scaphoid volarly that's scarred to the capsule or do you meticulously work to get that those fragments-
Chris Dy:No, I mean It hurts my ego a little bit. I think in at least in orthopedics, we're all guilty of trying to make X rays look a little bit better sometimes unnecessarily but no, I mean, at that point, you know, it's more about moving on to the next part of the case because I don't like to think that little volar shell's gonna make a big difference. I will try to get it if it's in the field, but I don't endeavor.
Charles Goldfarb:Totally agree. Totally agree. So are you a keep the triquetrum and truly do a for bone fusion? Have you transitioned to take out the triquetrum, do you fuse the triquetrum? What's your strategy?
Chris Dy:I will keep the triquetrum I will try to do a fusion of the capitolunate for sure. And then if I can get the triquetrum and the hamate together if it presents itself very easily to me. I will denude those surfaces, the triquetrum and the hamate, but if it is not presenting itself very easily, they will just be held by a compression screw. I think technically, yes, you should really try to get those surfaces but I don't think it's worth extra a ton of extra effort during the case. How do you what are you? How do you think about it?
Charles Goldfarb:Yeah, I agree. A while back, the St. Louis group and the Memphis group led by Jim Calandruccio and Dr. Gelberman looked at this this capitolunate only fusion with removal of the scaphoid and removal of the triquetrum. At the time, the results were not better, and probably were a little worse than just a four bone fusion. So we didn't really go in that direction as a group. My general philosophy is, you know, it's all about the capitolunate. And a patient with gout though I do worry about the ligaments, you know, the LT and others. And so, I will my general procedure is fused the capitolunate. And then I tried to place a screw triquetrum, hamate, capitate, that's through a separate separate ulnar sided incision where I protect the sensory branch of the ulnar nerve. And I've been really happy with this. And you know, there are occasional rare nonunions but I've been really happy with it.
Chris Dy:Do you think that a non union of that joint really matters?
Charles Goldfarb:Of the-
Chris Dy:Triquetro-hamate
Charles Goldfarb:No. And I certainly have never seen a broken screw or never seen pain when I want to have pain afterwards. It is more at the foveal area kind of ulnar wrist not related to triquetro-hamate. So here's here's a, here's a I guess I read my mind question. What's the hardest part of the procedure for you? And maybe I'll go first, the hardest part of the the easiest part of the procedure for me is denuding the proximal capitate. The hardest part of the procedure is denuding the distal lunate.
Chris Dy:Yeah, yeah, it's interesting because when I came up the other day, I told the trainee that you're going to do the capitate. I'll do the lunate because I'm never satisfied with anybody else doing the lunate. And I'd rather and I said I told the trainee I said the Lunate disappears relatively quickly. If you're too aggressive and I'd rather than be me than you.
Charles Goldfarb:It's hard to get good cancellous bone on that distal lunate and you can do a crappy cartilage resection and have that sub cortical bone. But if it doesn't heal, that's why and so you really that is does need to be done precisely. It's also why our partner Lindley Wall believes strongly that for even for total wrist arthrodeses, we should take out the proximal row. I don't think she's wrong.
Chris Dy:Yeah, it's a it's a hard surface to get to fuse and clearly the capitate is easier surface to work with. And and that's setting the obviously the radius is relatively easy to work with. You know, I think that it is frustrating how long it takes to do the lunate I try not to get out the power tools. But I think inevitably for the lunate I have to get out the burr.
Charles Goldfarb:Yeah, I don't like it. I don't do it very often, probably less frequently than you because I like it less than you. But occasionally I'll get it out. Otherwise, it's just rongeur curette, rongeur curette, a few F bombs, rongeur curette.
Chris Dy:I was gonna say just a few, huh. So I think the hardest part of the case actually for me is once you've taken down that mid carpal joint, I think we talked about this on a prior episode. Once you take down to mid carpal joint, and then you're trying to fuse the lunate to the capitate. And I like to use a headless compression screw. So you're trying to get the headless compression screw kind of right mid axial on the lunate kind of right at the most approximal part of that concave surface, or excuse me convex surface so that then when you try to flex the wrist in order to do that, you want to flexing through the capitolunate joint that you just prepared. So how do you guard against that?
Charles Goldfarb:I think you're right, that is technically the hardest part and the more severe the arthritis ie the more dorsal intercalated you know lunate dorsiflexion so sorry, I said that very awkwardly, the more the lunate is tilted dorsally the harder that is, and so my my sequence of steps, which is certainly not foolproof, but I've been pretty happy with it is get the cartilage denuded from the proximal capitate the distal lunate. I then flex the wrist to try to get the lunate back in a neutral posture and then get the capitolunate joint aligned in flexion. And then I place a derotation or a static K wire away from where a planned screw is and then you know usually you can extend the wrist or so you're manipulating the capitolunate joint to place a temporary K wire and then you can flex the capitolunate, and then you can flex the wrist with the capitate secured to the lunate and place your longitudinal K wire. To me it;s that derotation wire which is everything.
Chris Dy:I think to get to that step though can also sometimes be challenging. I agree 100% that putting that extra wire it is critical. Do you ever use a pointed reduction clamp or anything like that to hold the capitolunate joint compressed, while you put it in that derotational wire and while you put in your headless compression screw?
Charles Goldfarb:No, the only time and I'd love to hear your technique. If you do the only time I've used a pointed reduction clamp is when the capitate is shifted in radial direction. And you need to reduce the capital in a joint in that plane as well. So the capitate needs to shift ulnarly and the lunate needs to flex a little bit. And so for when I have both of those situations, I have used the pointed reduction clamp, tell me how you use it?
Chris Dy:Pretty similarly. I mean, I think that it's something that is useful at times, but again, you know, you don't want your you don't wanna bugger up that lunate surface too much I like it, once you've put in your derotational wire to use the proximal tie in and not so much park it on the cartilage surface of the lunate. But then the pull it up against that K wire, and then clamp it distally at the CMC joint, and use that to just hold a little extra compression, I think for the maneuver that we were talking about to try and get the capitolunate joint reduced. What I found is if you have an extra set of hands, if somebody else's, is assisting you, instead of having them pull traction and flex through the you know, essentially by grabbing the hand, I have them just pull some gentle traction and then I when I'm looking down the radiolunate joint, I will take a hohmann or something and just kind of put the lunate where I want it. And then I'll put my derotational wire, and then things seem just to kind of fall into place. But I find that doing correcting the lunate rather than trying to, correcting the lunate by manipulating it proximally rather than trying to work from distal to proximal is the way that I've gotten around that.
Charles Goldfarb:Yeah, the only other pearl I have I like that. The only other pro I would say is it sometimes taking off the dorsal lip of the lunate, or the volar lip of the lunate, and releasing volar scar between the lunate and the volar capsule can help mobilize the lunate and help with this process. But the key is that you do need to get the capitolunate alignment. And that's tricky at times, especially when the bones osteopenic because then you have to be careful not to place that temporary k-wire too dorsal or your screw too dorsal because then you'll you'll break the lunate and then you got real trouble.
Chris Dy:Oh yeah, that's the that's the thing that we're obviously we're worried about in this patient with not great bone. You know, and I think that, you know, the point of making sure that the lunate is out of extension out of its dorsiflex position and getting that to correct and and making sure the capitolunate joint is appropriately reduced and not flex to the capito- You know, the capitate isn't flexing down. Also super important. Do you typically put any cancellous autograft in there? And when do you put that in? I found that I need to remind myself to put that in before I do my derotational pin because I don't want to open that thing up again.
Charles Goldfarb:I usually do I simply just take some cancellous bone from the distal radius. I think the morbidity is near zero. And I believe it makes me feel better whether it's statistically increases the chance of healing or not. I don't know. But I almost always do.
Chris Dy:Yeah, I almost always do. And especially in patients probably gonna have a harder time with bone healing. I was telling the trainee that I honestly I'm gonna feel better about it because if it doesn't fuse and I didn't put in the autograft I'll wish that I had and like you said minimal morbidity, I make an incision kind of like you just proximal and radial to listers to keep myself away from the EPL essentially ends up being underneath the second compartment. And making a small window and shelling out as much cancellous as we need.
Charles Goldfarb:Love it. So you and I both put two screws and mainly, you know lunate to capitate. And triquetrum to hamate or triquetrum to hamate to capitate.
Chris Dy:Yeah, no, I like if I can, if I can make it work. I like that kind of where they converge at the tip at distally at the capitate. But if it's not going to work out, it's not going to work out. I prepped the triquetro-hamate surface if it's within my field if it's not, I don't go nuts. Um, I used to routinely make a separate incision like you described, I think if you can get it from within your dorsal approach, great. Sometimes you need to make a separate capsular incision kind of over by the fifth compartment just to sneak in and sometimes that's nice because then you're working underneath the dorsal cutaneous branch of the ulnar nerve as opposed to making a new skin incision and going on top of it.
Charles Goldfarb:Nice I haven't done that. But that is a nice tip. That's a nice tip.
Chris Dy:Well, I remember when I was a trainee, Ryan Calfee does it exactly the way that you described. And then I was doing one and I made my small counter incision and I was with the fellow and so yeah, this is how Dr. Calfee does it and then we're like no, Dr. Calfee doesn't do it that way. I was like, What are you talking about? Like Dr. Calfee just does it all through the dorsal incision. So then I said Ryan is like hey, what would changed because that's how he taught me he's like, oh, yeah, you know Just one day just like thought that, you know, you could just I heard it at a meeting you just go through that dorsal incision. I was like, oh, okay, so now we're changing. Cool.
Charles Goldfarb:All right, maybe I'll learn something here today, thank you.
Chris Dy:But if you are going to go through that through a separate incision, one thing that is nice if you can find the right sized angiocath that can be a nice little protector for your guide wire, just so you feel like unless you make a bigger incision and really dissect out that nerve, using a small angiocath can be a nice protector as you're drilling.
Charles Goldfarb:For sure the benefit of going from the ulnar, a separate small ulnar incision is that that gives you the best chance to really get all three bones with that screw. If you think that's important, I don't think anyone would would say that is the most important feature of your screws.
Chris Dy:Right. And also, because of the the angle at which you're inserting the screw, you're going to get more central in terms of the sagittal plane in terms of not being too volar or not being too dorsal, it will put the screw exactly you have the opportunity put the screw exactly where you want to biomechanically.
Charles Goldfarb:Yeah exactly, I do close dorsal capsule. And I tend to immobilize for six weeks, what about you?
Chris Dy:I close the dorsal capsule, I immobilize it, treat it like a fusion. You know, I think maybe I immobilized too long, I think based on talking to others, but I have seen these fail, you know, fortunately, not mine, but I have seen them fail. So that is one thing that I'm concerned about. And I think that's one important preoperative consideration in terms of talking to patients about the surgery, the surgical options, the fact they're gonna have to heal a fusion you mentioned earlier, you know, talking about difficulties with bone healing. I want to ask you, do you have any experience using plates for this because I know that's a newer technique that has gotten some airplay.
Charles Goldfarb:It's a newer technique, that's an older technique. And so these circular plates were
Chris Dy:Old technique with new plates?
Charles Goldfarb:Yep, you know, industry and surgeons are always looking for ways to make things easier, which I'd be grateful for. And certainly, the approach is very simple. And we used to use circular plate and those kind of fell out of favor, I have not used the newer plates, pretty happy with the headless compression screw. Of course, the issue with the original plates, the circular plates was they would impinge with dorsiflexion and further limit your ability to extend the wrist, which is a big issue. So you have to recess them appropriately. If that's your technique of choice.
Chris Dy:When was the last time you use one of those?
Charles Goldfarb:I've taken out a couple in the last few years, I probably hadn't put one in and 15 years.
Chris Dy:Yeah, I think that impingement risk is real. Obviously, the goal is to preserve whatever motion you can you're already taking one joint surface away or a couple you know, the basically the carpus away. So preserving what you can is super important.
Charles Goldfarb:And what do you quote patients as far as motion? So if they come in and she's got a wrist that sore, and I don't know, maybe her motion is 50-50. You know 50 extension and 50 flexion pre op. What do you tell her she's gonna have postoperatively?
Chris Dy:Half. Half of what she's got pre op post op, and I think that doesn't set the bar too high doesn't set the bar too low. That'd be people been pleasantly surprised how well people will do. I mean, there's a numbers is a classic decision making between PRC and four corner fusion, which I think has been debunked recently was that four corner fusion is going to be better for strength and not as great promotion and vice versa, meaning a PRC is going to be better for motion not as good for strength. That being said, there are a number of very reasonable studies that have demonstrated that grip strength is still pretty good after a PRC. And that motion is still fairly good after four corner fusion. I think if one thing is that, you know, really if patients rely on certain range of motion for different exercises or different vocational things that they need to do, that may make a difference in terms of how you decide which surgery to offer them.
Charles Goldfarb:Yeah, totally agree. All right. I love it. I'll send also four corners to you.
Chris Dy:Maybe I'll find a new plate to use No, I like I like the technique that we described. If anybody else has any, you know, additional pearls, please feel free to share them. Email handpodcast@gmail.com And Chuck, we have to end on a win. Can you give us a win?
Charles Goldfarb:You want to know my win, Chris? I'll tell
Chris Dy:What's your win? you.
Charles Goldfarb:I played meteorologist for our department this week and was trying to figure out when we were going to be open and when we were going to be closed and we didn't get it exactly right but I was pretty happy we had a good conversation and got it kind of right.
Chris Dy:Well, thanks for getting it kind of right. Whatever you my wind was honestly just getting to work today. No, not gonna do anything else. It was a source of stress this morning. I was like I think I could do this. I did. Did you know when I saw I logged in to epic this morning on my phone because I was on call last night and I saw that my patient and made it in. I was like, Alright, good. As long as the patient's there I'm going in. So. Alright, so we'll catch up next time.
Charles Goldfarb:Awesome. 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. What about you?
Chris Dy:Mine is @ChrisDyMD spelled dy. 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