Season 3, Episode 7. Chuck and Chris review the excellent JBJS Hand Surgery Update which reviews key manuscripts in 2021. Written by Deb Bohn and Kelsey Wise, this is a great summary of new, key information in the hand surgery world.
Bohn DC and Wise KL, Whats New in Hand and Wrist Surgery. JBJS, 2022;0: 1-8
Chris also references this review article on the ulnar nerve
Goldfarb, C. A., & Stern, P. J. (2003). Low ulnar nerve palsy. Journal of the American Society for Surgery of the Hand, 3(1), 14-26. https://doi.org/10.1053/jssh.2003.50006
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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.
Season 3, Episode 7. Chuck and Chris review the excellent JBJS Hand Surgery Update which reviews key manuscripts in 2021. Written by Deb Bohn and Kelsey Wise, this is a great summary of new, key information in the hand surgery world.
Bohn DC and Wise KL, Whats New in Hand and Wrist Surgery. JBJS, 2022;0: 1-8
Chris also references this review article on the ulnar nerve
Goldfarb, C. A., & Stern, P. J. (2003). Low ulnar nerve palsy. Journal of the American Society for Surgery of the Hand, 3(1), 14-26. https://doi.org/10.1053/jssh.2003.50006
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:Oh, hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:I'm happy to be back at it. How are you?
Chris Dy:I am happy I'm excited. We did congenital we did sports. What's gonna be next? I you know, it's a it's a broad world we live in with hand surgery.
Charles Goldfarb:Is it though? Are you just hoping as nerve again, you're hoping we're going back to the well?
Chris Dy:Always always. And we're gonna get into the What's New in Hand Surgery 2022, which I'm happy and sad to say I did not author this year.
Charles Goldfarb:You're happy? You're happy to say it, you did three years did a great job and you handed it off.
Chris Dy:Oh, you know, what I'm sad about is I did not have the foresight like are like the subsequent section editor Deb Bohn did to have a resident help.
Charles Goldfarb:Yes, and not just any resident we might add?
Chris Dy:That's right. Kelsey Wise is going to be joining us as our hand and upper extremity fellow here at Wash U in August of 2022. So just probably six short months, she'll be here with us. So shout out to Kelsey, great article. Deb, great, great job on summarizing a ton of literature. I don't think I ever hit this many citations. 109 Very impressive.
Charles Goldfarb:It's impressive. You know, I think I mentioned but in case I didn't I do this every year for congenital only. And we do it to award the Paul Manske congenital hand, best congenital best manuscripts. And it's a labor of love, it's really helpful to remind me of what's out there because I don't read every journal every month. And so I know you felt that way when you did this work. But it's not easy to stay up to date and literature without some comprehensive looks occasionally.
Chris Dy:yeah. And honestly, I felt a bit out of touch, you know, not doing it this year. So it's great to read it. I'm also happy I didn't have to spend the I can't count the number of hours doing it, but I'm a little sad about it. So yeah, we'll spend the next two weeks talking about about this article. But Chuck, I had I think probably recently one of the greatest days of hand surgery I have ever had.
Charles Goldfarb:And that means it wasn't all nerves.
Chris Dy:No, it was literally so I'm actually going to bring it up in giving the fellowship kind of nuts and bolts talking I'm going to talk about how we do a lot of bread and butter hand surgery here on top of our individual niches like mine is you know, the peripheral nerve stuff, yours being the congenital, the sports but each of us has a really busy gentle hand surgery practice. And it was a great day it was it was CMC arthroplasty it was you know, carpals, triggers it was repairing a lacerated, dorsal cutaneous ulnar nerve. It was anti-claw tendon transfers, it was distal radius fracture, tendon reconstruction. It was like one of the best lists that I think I have ever had. And that was followed by a day of doing a tendon transfer nerve reconstruction the following day, and then a plexus. So it was it was a fun, fun week, for sure.
Charles Goldfarb:That is good stuff. And there's no you know, having a hugely busy, diverse week of cases is something special. I want to know more about this tendon transfer the anti claw.
Chris Dy:Well, you know, one of the things that we started doing based on fellow feedback was to do a surgical technique lab. So mixing up our standard anatomy cycle with, you know, fellow selected cases and attending would take them through how they would do a specific type of surgery. So, Dr. Lindley Wall was kind enough to be our first faculty to step in and we talked about different tendon transfers. She did some median to radial or excuse me, the standard suite of radial nerve tendon transfers used to treat a radial nerve palsy. And then she also showed some static and dynamic anti claw tendon transfers. So in the lab, we actually did a Stiles-Bunnell, and lo and behold, the following day we were doing Stiles Bunnell tendon transfers. And this was interesting because it was a patient with advanced ulnar neuropathy compressive neuropathy, who I had tried to supercharge on and had some improvement both on clinical exam and objectively on nerve studies at the one year mark, but it wasn't enough and he very clearly and plainly said to me if I could get my finger straighter here, and if my finger didn't drift out, so the Wartenberg deformity where the small finger goes away from the ring finger, it would help me at work and he's a manual labor kind of guy. And I think it's just high level philosophically as a generation of surgeons that's trained with nerve transfers being one of the first things you think about, I think we're a little more hesitant to offer tendon transfers from the get go. And even offer tenant transfer transfers in a time where we're not seeing our nerve transfer give the result that we want. So it was It was humbling to see that I had not gotten the results that I was hoping to get. But it was also affirming to know that there was there were some other options. And it was time to just kind of, say, call a spade a spade and make the next decision.
Charles Goldfarb:So good stuff. I mean, really lots to unpack and not to belabor it. But two things I want to ask of you, of course, it's going to be, of course, there's always two things. The first is I think the audience needs to understand what you mean by Stiles-Bunnell transfer, and was their clawing as the primary complaint or abduction of a little finger, or both, and maybe describe what you mean by cloning, just to be very specific.
Chris Dy:Yeah, so it was both. So the deformity you see is MP hyperextension, and then inability to fully extend the PIP and DIP joint of the ring and small finger. And that is because of the lack of the the ulnar innervated lumbricals, which flex the MP joint again. So now the MP joint's in extension. And then the lack of the ulnar innervated interossei. Which will help to extend the IP joints and the IP joints. And the reason this deformity is accentuated is because the the radial nerve and its EDC is intact, and it's going to draw those MP joints in hyperextension. So there are a couple of different ways you could treat those. That deformity and there is a great review article written in the old journal of the American Society for Surgery. The hand before it was the JHS was the Journal of the hand society. And it was written by a young Chuck Goldfarb and Peter Stern. And I love that review article. Because it goes through all of the different that's a great article. And it's an out of the rotation reading that I assign. And it's great because it really spells out all the, you know, components that go into a cloud deformity and as great physical exam, pearls. So if you're looking for a great article, Chuck, we'll put that into the show notes.
Charles Goldfarb:If I can find it.
Chris Dy:Citing himself or me citing him, and he'll include it but it's a great article. But anyway. So there are different ways you can treat the clawing deformity. And maybe this is an episode in and of itself. But you know, there are a couple of ways to treat it, you can either statically treat it by using some kind of tether to keep the MP joints in flexion that's been described either through intentional bow stringing of the a one and a two pulleys, or advancing the volar plate and doing a capsulodesis of the MP joint capsule so that it stays stuck in flexion. Or you can take a loop of the FDS and cut it distally and sew it back to itself, often attributed to Zancolli so a lasso kind of procedure. And that's great in terms of keeping the MP joints down. Now, if you are flexing them down, and they aren't able to fully extend there, you can consider also istyles Bunnell transfer some kind of dynamic transfer. And then you can either use the FDS to the ring, or you can use the FDS in the middle. And in this patient, we chose to use the FDS to the middle, cut the FDS distally, brought it back proximately, split it in half, and then pass it through the lumbrical canals.
Charles Goldfarb:Wow, you know, what's interesting is, this used to be, you know, taking care of rheumatoid patients and dealing with patients that needed tendon transfers, whether it be from polio or whatever, was a big part of a hand surgeon practice. And those two things just don't happen very much. And so there are no experts who have done a ton of these anymore. And so it makes it more important, that preparation, getting in the lab doing the right reading, and really trying to get this right. But it's a fascinating evolution of our field.
Chris Dy:Well, I kind of honestly I kind of worry that our our trainees aren't seeing enough tenant transfers to just the point that you stated. And you're less likely to offer something if you're less familiar with how to do it. Now we can all clearly read about it, watch videos, practice it in the lab, but if you haven't done it in training, you haven't seen the results in training. It's just like, it's like learning a whole new procedure. And it's weird because it's a procedure that's been around for over 100 years. So it's just it's interesting how things have been flow. And I think that we as educators and I, as a nerve surgeon have a responsibility to know how to do these alternative techniques. Because the nerve isn't always going to work out or the patients are going to come to you too late. If they've had treatment elsewhere or it's been unrecognized. Then we have to show our fellow To do these 10 transfers, I honestly I didn't see much in my training, you know, along the way. And it was something that I had to go seek and kind of learn on my own. You know, some of us, I think, have done them more I know, Marty's done a fair bit of tenant transfers. And so of you, they just didn't follow my rotation, which is kind of the nature of the beast.
Charles Goldfarb:Yeah. And we tried to in these situations, when this, this procedure is you did might happen a couple of times over the course of the year, again, depending on luck of the draw. And so that becomes a case where we want as many of the fellows to see as possible.
Chris Dy:Right? Absolutely. Well, it was great, because, you know, the continuity of going from the lab, being with our resident who was with me, and then doing it and seeing it, you know, in the obviously doing the surgery was great. Continuity is wonderful. It was probably the best possible educational setup.
Charles Goldfarb:Love it. Love it. Alright, we got some some hand updates to go through.
Chris Dy:Yeah, you know, one thing I want to point out, okay, so this is written by Deb Bohn, who does a lot of pediatric and congenital hand surgery. And last year, you're giving me hell about not having a congenital section. There's no congenital section. So Deb, what, what what gives?
Charles Goldfarb:But there is a pediatric section at least there's something.
Chris Dy:Yeah, yeah. And and I will say the peripheral nerve section seems to be substantially shorter than the last three years. It is two paragraphs.
Charles Goldfarb:Yeah. And it's it is right at the end, y'all. It's just trying to compensate for the over emphasis the last few years.
Chris Dy:Right, right. Right, right. So the first they lead off with carpal tunnel syndrome. So it's super interesting. I think the article that that I was attracted to the most, you know, they talked a lot a little bit about, you know, diagnostic ultrasound versus CTS six versus nervous studies. But the thing that caught my eye was actually the randomized study that they cited. Looking at injections versus night splinting, we oftentimes see injections versus surgery. And I think you and I have talked about that article in the past. But injection versus night splinting, is that ever something that you've considered?
Charles Goldfarb:Meaning do I consider one versus the other for my patients?
Chris Dy:Because I usually guys usually start with bracing and injection comes in after they failed bracing.
Charles Goldfarb:That's exactly right. For me, it's a ladder approach. And we have some patients, many patients actually to be fair, which is a compliment to the primary care physicians in our community. Many patients come in having having already done the brace, which takes them one step up the ladder. But for me, I agree with you completely. It's brace first, especially in the mild carpal tunnel and see what happens. And then consider an injection with all the pros and cons.
Chris Dy:So do you does this does this finding that they saw in they randomized 100 patients, and they saw 95 To follow up and they either went to a night splint or to a corticosteroid injection, and those who had an injection had a superior relief of their nocturnal paresthesias, and pain as well as improvements on their Boston carpal tunnel questionnaire at one three and six months. Does this make you think of maybe offering an injection earlier?
Charles Goldfarb:No. I mean, I think it's really good information. And it may help a patient who is on the fence about whether or not to accept an injection to get one. But what's missing is what happens if to me is the year because we have data on sponsored a year we have some mediocre data to be honest about the success of injections of the year. But if most my patients aren't looking for a temporary fix, and I do think for some patients to splint, it really mild, early carpal tunnel can be I feel like treated with a splint. While Granted, most are not successfully treated long term with this one. But injection is is rarely the answer for me long term.
Chris Dy:You know, it's you encouraged us to read an article from JAMA open, like Open Network JAMA for our journal club a couple of months ago, and it was looking at randomized trial of injection versus at two different doses versus surgery. And looking at the longer results, and I'm thankful that you made us read that because it gave really useful information. You know, the fact that, you know, it's interesting the way that the author's cited that that there was significantly less surgery or significant improvement in the symptoms and the patients who had an injection compared to those who had had surgery. But what I thought was interesting was that 85% of those who had an injection ended up having surgery at one year. So it really is just kicking the can down the road. Now clearly as a hand surgeon maybe I'm biased towards the the fact that I can offer a surgery and if they had seen primary care physician physiatrist a neurologist who may feel more comfortable with an injection versus surgery. You know, the the treatment algorithm may be different because it's treatment options are different.
Charles Goldfarb:Yeah, you know, I think probably some of the listeners are thinking to themselves, I don't see this patient who hasn't tried to slant who hasn't tried an injection, because some of us have practices where there's a nurse practitioner, or a primary care physician associated and those steps are taken before they walk into the hands surgeon's office, you and I, for better or worse, and maybe eventually, it'll evolve as all of medicine probably should. I don't want to become a technician, I like this interchange and making a patient centered decision. But for you and I, we see patients at all points along along the treatment path. And so like you, I like splints, injections are fine. But my patients and I believe I try to give an open ended offer of an injection, I don't mind doing an injection, you know, there's no no skin off my back, so to speak, but most don't choose that.
Chris Dy:And we must remember that not all injections into the carpal tunnel end up in the carpal tunnel. You know, and that's that's what David Green showed that was an article that I pulled into one of the recent, one of the prior editions of what's new in hand surgery.
Charles Goldfarb:That's right. That's exactly right. It's an important point. Now your ultrasound would help with that. But not all of us will be using ultrasound.
Chris Dy:That's right. And and maybe you don't have to, but I think it's just being aware of just being super cognizant of the fact that you need to know exactly where you are and where you need to be. So what an interesting study they did here, which I would not have thought of to do is, you know, there was an article out of the European journal in which they numbed the digital nurse to the thumb, and found that that decreased dexterity as they measured it, and also numbed the digital nerves to the index and middle finger. And she found that that affected grip and Chuck pins strength, suggesting that the numbness in these distributions would be the reasons why patients with carpal tunnel syndrome, perhaps even without feet are compromised, have decreased dexterity and strength. Do you is that match your practice for patients who maybe have mild or moderate stage carpal tunnel to have decreased grip and strength?
Charles Goldfarb:Yeah, I think it makes sense, because most patients that we see do not have thenar atrophy, or at least visible thenar atrophy. And and I really do question patients about the buttoning of buttons and the dexterity. And they often complain of strength issues. But if you get them to use the dynamometer, they test okay, but I think this feels accurate. It's super interesting, I wouldn't have thought to do this either. And I think it's interesting, I think it's accurate.
Chris Dy:One thing that has come up a lot in the kind of the lay popular culture is the connection between carpal tunnel and work. And you remember in the 90s, they're all the ergonomic keyboards and the the big deal about repetitive typing, you know, also vibration exposure. And there's an article in here that they looking at vibration exposure and potential impact on outcomes as somebody who trained in that era. And I'm not saying this in a joking way, but obviously, as somebody who trained through that, what are your thoughts about work related carpal tunnel and occupational exposure, and perhaps how this article might have, you know, changed that.
Charles Goldfarb:You know for a while, there was a very strong sense that work, especially sedentary work on the keyboard doesn't contribute. And then some studies have suggested otherwise. And you know, and the, the AAOS guidelines have tried to tackle this with mixed results, to be honest with you based simply based on the quality of the literature. You know, this obviously didn't get to the etiology of, as they call it hand arm vibration exposure, but it does get to the point that they might do more poorly in an outcome. And so maybe it's not simply their that their work comp patients, maybe it's the nature of their exposure, and the quote unquote, trauma to the nerve that leads to, you know, decreased, you know, outcomes. And this was a this is a well done study using pretty reasonable outcome measures.
Chris Dy:Is it the vibration exposure, or is it the position of the hand and the wrist during the vibration exposures, meaning you're typically if you're holding something like a jackhammer, you're probably gripping it pretty heavy, your wrist is cocked back and you're you're flexing through your extrinsic finger flexors. Is that contributing too?
Charles Goldfarb:I think if you are ergonomically, I think you can get this first of all, this is a hard one to define right? But I think you can be exposed to vibration in an ergonomically okay position without that wrist extension and forceful grip, or you can be exposed in a pretty good position with the wrist locked in neutral. So I have a hard time honestly answering that question. But I would expect in most patients You're right. It's a combination.
Chris Dy:And I know this isn't in this week's this year's article, but what are your thoughts about the keyboarding and the typing and then again, to me it mechanically or mechanistically kind of makes sense. If you're poor ergonomically, and your wrist is cocked back in front of your keyboard, you're already in wrist extension, we noticed increase in depression, your carpal tunnel, and then you have repetitive long finger flexion, a long flexion activity of your fingers. Again, that makes sense to me to put pressure on that median nerve.
Charles Goldfarb:The interest, this is obviously a huge topic. Susan MacKinnon at our institution was involved with I believe it was one of the original reports from NIOSH, looking at the role of kind of repetitive typing and development of carpal tunnel. And as I mentioned before, it's gone around and round. And what's been really fun, I guess I put that in quotes to to watch is in the worker population, the work comp administrators will send patients these very detailed tests, that assess keystroke, their keystroke analysis test. And they will say, this person does X number of strokes per minute, over an eight or 10 hour day and they give you these numbers. And there's like these bars, and if you're over 60,000 keystrokes, and oh my god, you're at high risk for carpal tunnel. And if you know, it's just they're trying to be very rigid with the science and I just think that's silly. So I think you're right, I think it you know, positionally, getting the wrist in the right position. matters. I think it's really hard to know this for sure. But I think in some patients with high level exposure, yes, they can develop carpal tunnel related to work. But what it really gets back to not to get on the tangent is the laws of each state. Right? I mean, we've talked about this Missouri, and Illinois Tuesday's where we treat patients frequently have completely different rules, whether the work injury must simply contribute, or whether the work injury has to be the predominant cause. And those are light years different.
Chris Dy:This is why so many people don't like to take work comp. But you're also listening to two guys who take work comps.
Charles Goldfarb:Yeah, it's super interesting. And that's where there's three day courses on it.
Chris Dy:Yeah, exactly, exactly. So we talked a little bit about different carpal tunnel release techniques, and our last last week's episode, and you talked about wanting to use this carpal clip. And I talked about potentially wanting to use ultrasound guidance. But the standard for both of us is to do a mini open carpal tunnel release. And the challenge with I think newer technologies is that it would add a lot of costs. And there's an article here that was a multi state administrative database study that looked at over 500,000 patients patients and showed that about one out of five had an endoscopic carpal tunnel release versus an open release. Supposedly based on I mean, complications is tough to measure and administrative datasets. But as no difference in the rate of complications, growing use of endoscopic three fold over the study period of 15 years. The cost was $2,000 more per patient. How do you feel about that?
Charles Goldfarb:So it is an interesting study. And I guess I'll start with the complications issue, which again, like you said, it's hard to document with this type of database. What's interesting, though, is that I think a very experienced person using endoscopic when compared to a very experienced person using a mini open technique likely have very similar outcomes. It's the people who do far fewer carpal tunnel releases, I think in those hands into scopic is not as safe. I really just don't think it is. There's no question that a mini open release gives you a great reliable result. The surgeon doesn't really have to stress in the O R, it's a reliable, you know, 10 minute procedure and patients who do well, but piller pain is real. And it does delay back to work. And so is that is the slightly higher expense at the time of surgery while doing an endoscopic procedure worth it. I think the financial assessments of this would say yes, if you look at cost to society, it's absolutely worth it in those patients who need a rapid return to work to consider endoscopic.
Chris Dy:So $2,000 versus getting somebody back to work maybe seven to 10 days, even 14 days faster. from a societal perspective, that does make sense that it would it would be worth it. But unfortunately, we don't always have a societal perspective.
Charles Goldfarb:No, we don't and sometimes we have a very personal perspective that the surgeon is going to look the surgeon let's let's just be very honest here. The surgeon fee means surgeon reimbursement necessarily, but the surgeon fee is higher for endoscopic This center collects a higher reimbursement as well, from charging for it endoscopic procedure. So there's all kind of misaligned interest here, which ultimately our health system needs to figure out.
Chris Dy:You can you can be in charge of figuring that out. You're very you're very good leader and administrator, I look forward to seeing what's next on your docket.
Charles Goldfarb:I'll get right on that.
Chris Dy:Now they moved on that in this carpal tunnel section to close with a landmark article by Velicki at our second author, none other none other than the man, the hammer, the workman with his hammer, just looking for nails, Chuck Goldfarb. Talking about carpal tunnel release and pediatric and adolescent patients. So what what was your experience with this article? Now we've got the insider scoop here.
Charles Goldfarb:Well, Katherine Velicki, did a great job. She is in orthopedic residency. And now she was a fourth year medical student previously, and you know, Lindley Wall, and I certainly treat our fair share of pediatric and adolescent patients with a variety of issues. And and their the literature is really limited, we're trying to make a small contribution to the literature. And I think that the findings feel good in the sense that they feel accurate, you know, you can all you can do these analyses, and you walk away thinking, does this help anyone, I think it does, you know, clearly, post trauma acute etiology peptone release should be utilized and should be expected to provide a good result. And if you have a tumors etiology, and often for us, maybe that means macro, actually, or something, putting direct pressure on the nerve, then those patients do well. Other etiologies, where you're seeing a patient, much later months and months after a trauma, if you have some unusual genetic condition, the expectations need to be tempered. And that's the message not that it's not appropriate to do the surgery. In those cases, just the expectations should not be the same.
Chris Dy:It's interesting how different our practices are because I typically think of myself as an ER first and I remember one time you're at a town and I saw one of your patients who was having just was wanted to come in. And it was a patient, it was an adolescent patient with a lysosomal storage disease. You had done a carpal tunnel. And I was like, I had never even thought about this. It's just because of the way that our practice tightens or that stuff, obviously, and rightfully so goes to you and Lindley and it's something that I had never thought about.
Charles Goldfarb:You know and that's, it's interesting that, you know, that's what I like, right? I mean, as you and I've talked about, and we've said on this program, we all have good bread and butter practices, but our niches are strong, and that's why you know, we sell, you know, referred internally and I think it helps us provide the best care for the patient.
Chris Dy:So that that was a fantastic contribution to literature and cat is now. No, no, seriously, Cat is now a resident at OHSU. And she is actually just got an article accepted for her wide awake, not her wide awake, for the the local only hand pack, the environmentally friendly hand pack so shout out to Cat
Charles Goldfarb:Yeah, she did. She did a great job and she's gonna do great things. And as you know, I adopted your and her environmentally friendly, very limited hand pack and I like it. So I appreciate that contribution as well.
Chris Dy:It's called the cat pack. Cat pack is going strong in Chesterfield and in South County. So they moved on to thumb CMC arthritis. And there was there's a really interesting article here that I thought was matched my practice. So I came out in practice, and my first I think year like a board collection, I was curious because I didn't have any thumb CMC surgeries. And that continued into my second year. I didn't do any thumb CMC surgeries, but I was seeing the patients, I was injecting them. And I don't think I'm gunshot offer surgery when I think it's the right time. But this, the these three studies that they talked about here matched it. So they looked at patients who had had a thumb CMC injection, and the three rates that they said the patients who had surgery after injection was 12% 13% and 9%. Do you think that does that feel right to you?
Charles Goldfarb:You know, it does not feel accurate, but I can't argue with this. And then you get into the question of to the injection, are we just treating arthritic flares and we get the patient over the flare and it burns out? Are some of these patients going to therapy? I get you know, I guess part of what you said though rings true. You develop a large enough base of patients that are being treated with injections and they do come back. There clearly is a group that comes back regularly and is fine with injections. There's a group of patients that you inject the go away and may never see him again, or it may take more than five years. And there's a group of patients that just aren't interested in repair. injections in one injection makes them better. But that's it. So it's super interesting. And it's pretty compelling.
Chris Dy:These numbers feel right to me, I'll be very honest with you. You know, they Yeah, I now I do a fair bit, not a fair bit, I do some thumb CMC surgery, certainly more than I did early on just because the patients, I've developed a relationship they come in, they've got to run their course with the injection, then they decide they want to move forward. We'll never know the patients who don't come back, you know, whether they see somebody else and having surgery, or they just decide it is what it is with their thumb. But I think one of their conclusions here was talking about the influence of surgeon attitudes towards treatment. And the interchange we're having right now reflects the, you know, the lack of agreement on perhaps when to pull the trigger for surgery. And it is all about how, and I don't want to say this the wrong way, because we're not selling surgery, but it is kind of how you frame the discussion. You know, when you talk to patients about what the recovery is going to be like and what to expect from it.
Charles Goldfarb:Yeah, I'm, you're certainly right. And we can talk about scripting this more, I really feel like I'm neutral. For all patients, I probably have not like a third party might listen to my spiel and say, Oh, my God, you're the surgeon, you just you only know it and you're pushing these patients towards surgery? I don't think so. But who knows.
Chris Dy:Well, one thing that has informed and perhaps skewed how I talk to patients, is a study that we did with former fellow Jeff Stepan. And Jeff's been on the program a couple of times. And, and Jeff did a qualitative study at, you know, looking at, you know, patients experiences after this kind of surgery after a thumb CMC surgery. And oftentimes we tell them that it's, we don't tell them how long it's really going to take to get over this surgery. And I've certainly shifted my timeframe to be longer, based on the results of that. And also that's informed by literature. One of the other studies in this section, talks about the time to return to work after a thumb CMC surgery being three and a half months. And that feels about right. And you know, in terms of returning to activities, where you're no longer cursing your surgeons name or thinking about your surgeon, that probably is beyond six months. And once I tell people that you can kind of see the air go out of the room, and I don't want to wait that long. But you do have to balance that with saying you get great pain relief from the surgery even early on, when you're not using your thumb right away.
Charles Goldfarb:Right, and you're 100% Correct. And it's a little bit of a danger with this procedure that we at WashU have taken to be a step up, which is using using artificial internal brace so to speak, or what's it called suture?
Chris Dy:The generic term is a suture tape.
Charles Goldfarb:Suture tape? Yes. Generic term.
Chris Dy:I could see those wheels turn.
Charles Goldfarb:I couldn't, couldn't pull it in. And that's what happens when you pass 50 Chris and I mean because the return to work is faster and return to life as faster. So but I think you're still right. I think even those patients are not, you know, quickly, quickly. Great. What's interesting, though, in the same article, they discuss timing of surgery, relative to onset of symptoms, which then makes this even more of a quandary, if you believe the results they looked at as Baca at all looked at 121 CMC joints treated with LRTI. And they found that post operative quick DASH now quick DASH is not the best metric in my mind, but it is a metric. Those patients who had surgery at less than two years after symptom onset, versus more than two years after symptom onset had a significant, significantly higher improvement in their quick DASH score. So earlier surgery is better outcome, but yet, we're not pushing surgery.
Chris Dy:But I would I would insert some input from the David from the David Ringian inside of things. And what about their coping mechanisms? Is there something about those patients that are better equipped to deal with, you know, surgery? Or is there something about their personality that leads them more towards surgery? And what we want? We'll never know, but how did their surgeon talk to them about the surgery?
Charles Goldfarb:That's exactly right. And we know we have our own surgeon, Dr. Ryan Calfee, who's going down that garden path towards understanding these variables and the role of anxiety and depression and outcomes. And, you know, David Ring was certainly, to my knowledge, the first and certainly the loudest proponent of the psychological components of health and impact on hand surgery, and he's certainly not the only voice anymore.
Chris Dy:You know, it's it's interesting for thumb CMC patients, they spend so much time with our therapy colleagues that I really trust that there are therapists to talk to them about kind of what comes and What surgery entails what that recovery is like, and that oftentimes I think will kind of make the patients feel at ease with the decision that they come to, if not also informing the decision that they come to.
Charles Goldfarb:I totally agree. So listen, I would vote we'll we'll stop here and come back and hit the rest of the articles mainly focused on wrist trauma. And there's a couple other topics, if that sounds okay to you.
Chris Dy:Sounds okay. I'm really excited about the pediatric fracture section coming up.
Charles Goldfarb:Well hold your horses, as my mom used to say, we will get there and we will dive deep.
Chris Dy:Sounds good. Hey, you got to give me a win.
Charles Goldfarb:I've got one. So Saturday, the 12th of February marks my third child's ACT exam. So she just got home and took the ACT. And we're in a really happy places that joy is time between taking and receiving one score. And it's all optimism. It's like the beginning of baseball season.
Chris Dy:In 2022 how long does it take to get your ACT score back?
Charles Goldfarb:Well, first, you got to recover from filling in all the bubbles.
Chris Dy:Right, right. They've never they haven't exerted that effort before.
Charles Goldfarb:I think it's a month. I think it's a month.
Chris Dy:Wow, that's crazy, still huh.
Charles Goldfarb:Isn't it crazy. And some of it's the psychometric evaluation of the exam, I'm sure and all that kind of stuff. But it's just a happy time in the household. And that's the win.
Chris Dy:Well, that is wonderful. I still remember, you know, taking different exams at Prometric, where you know, you have various like, all walks of life taking all sorts of exams. And there were some people who had instantaneously find out if they pass their nursing boards. And then there's all the doctors who are leaving, you're like, Oh, my God, I have no idea how that went. I'm just glad it's done. And I won't find out for six weeks.
Charles Goldfarb:Yeah, well, that's what my son just went through taking the MCAT. So he won't know for I think a few more weeks.
Chris Dy:Right? Well, my when was one of the things that I've been wanting to do is to be more present and try to play more with my kids like actually play. And there's a lot of times where they'll ask, like, Can I can I play? Can I play and I'm often like, No, I gotta go do this, I got to do that. So this morning, I stopped. And even for five minutes, I built the Lego tower. It felt really good just to sit down and play for five minutes. And I think my son really appreciated that even though I was literally in and out of there in five minutes, that I spent good time in there and build this tower. It was kind of like, you know, one of those clinic visits that you know, is only going to be like three or four minutes, but you made it feel like 30 and everybody's happy at the end. Total win.
Charles Goldfarb:Yeah. Is that is that it often? I love that it's often not the amount of time is the investment during that amount of time. You know, like how are you fully there? And it's never enough of course never. But that's good. I love that.
Chris Dy:It was it was an awesome tower. So total win.
Charles Goldfarb:I didn't doubt that. Alright.
Chris Dy:See you next week.
Charles Goldfarb:All right. Take care. 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 hand podcast@gmail.com.
Charles Goldfarb:And remember, please subscribe wherever you get your podcasts
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