Season 3, Episode 8. Chuck and Chris complete their review of the excellent JBJS Hand Surgery Update which details 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. Part 2.
Bohn DC and Wise KL, Whats New in Hand and Wrist Surgery. JBJS, 2022;0: 1-8
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theupperhandpodcast.wustl.edu. And thanks to Eric Zhu, aspiring physician and podcast intern.
Season 3, Episode 8. Chuck and Chris complete their review of the excellent JBJS Hand Surgery Update which details 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. Part 2.
Bohn DC and Wise KL, Whats New in Hand and Wrist Surgery. JBJS, 2022;0: 1-8
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:Fantastic. Looking forward to recording another episode.
Chris Dy:Yes, what's new in hand surgery part two for 2022.
Charles Goldfarb:There's a lot to discuss, including the highlight of your day that pediatric fracture section.
Chris Dy:You mean the peripheral nerve section, right, a very short peripheral nerve section. Kelsey, I'm going to give you hell about this when you arrive for your fellowship,
Charles Goldfarb:Plenty of ink has been devoted to nerves. So I think we're prioritizing correctly,
Chris Dy:And rightfully so. But any interesting cases recently,
Charles Goldfarb:I did have an interesting case it so as part of my responsibilities, I work in the peds division, as well as in the head division. And we have conference every Friday morning. It's actually pretty cool conference. It is. It is the all of the trauma cases for the week, and then selected pre and post operatives that are, you know, somewhat interesting or exciting or whatever. And the trauma cases are always fun. And we on Friday, we got into a discussion about, you know, should you really care if you put a smooth pin across the distal radius growth plate for one of those displaced metaphyseal fractures in a 12 year old? Does it really matter? Are you really going to shut down the growth plate? And we always have the same discussion? And my general answer is, I think if you put a couple of 6-2, or 4-5 k wires, across the growth plate coming from the styloid, heading proximally, you don't do multiple passes, but you just get it right, I think the risk is infinitesimally small. And that was the discussion. And that's my perspective. And I think most people agree with that. I had a case a while back, that patient was treated elsewhere. And there were three or four large K wires placed across the growth plate, large relative-
Chris Dy:Like site like Steinmann pin size wires?
Charles Goldfarb:Relative to the size of the radius, yes. And there was a growth plate or growth plate arrest. Now, you never know if that was the fracture or the treatment. But in this case, it might have been the treatment. And in fact, I would think it is. And so I this was still a young patient who had plenty of growth remaining. And so we had a significantly shortened radius with a normally growing ulna. And while you know, some, we certainly can accept some difference in forming our choices were to number one, take out the physeal bar. And that the success of that is more challenging and the radius, more successful and larger physis like the distal femur. And in this case, the bar made up about 70% of the physis. And so that's too much also sent more centrally located. And so we gave the patient the choice of shortening the ulna and bleeding the growth plate of the distal ulna or lengthening the radius with an external fixture, and they did what I would have done and again, perhaps I bias them. But we had started the process of lengthening the radius with an external fixer. It's a procedure I do relatively regularly that I really enjoy and really like, and it should provide some good outcome. So I'm excited for the patient.
Chris Dy:Now, is that a uniplanar frame?
Charles Goldfarb:Yeah, so I use uniplanar frames on the forearm, I use them on that, you know, metacarpals, when a multi when a basically a circumferential frame or circular frame is required. We're fortunate to have a couple of outstanding partners who do this all the time, typically use the Taylor spatial frame. We use that in the upper extremity as well, but I they apply it and they manage it.
Chris Dy:So what's the rate of growth that you expect in terms of the osteogenesis?
Charles Goldfarb:Yeah, for the distal radius, you know, classically, you hear about a quarter turn a day. With each turn each, each quarter turn being a quarter of a millimeter. So one millimeter a day lengthening, about an inch a month when you do the math, I think it's a little slower in the distal radius in the hand, I do about three, three turns a day is my typical. And then consolidation. People say is twice as long as the lengthening phase. So if you lengthen for six weeks, you expect three months for consolidation. I don't think it's quite that much. But those are the numbers I've talked about with patients because it is not easy to have a frame on for that long.
Chris Dy:Now, what is the reason that you go at that pace? Obviously the nerve surgeon in me is saying you know, how are you going to evenly distribute this extra tension across the nerve if you're if you're lengthening the radius, and is just that related because a millimeter day sounds awfully familiar to me.
Charles Goldfarb:Of course it does everything does it goes back to nerve now, you know thankfully there's there's almost never I don't recall a nerve issue at all with lengthening is purely about the body's ability to make bone. That's it. It's not, Chris, about the nerve.
Chris Dy:Well, it was interesting at the I attended the ASPN meeting virtually this year and during the the kind of poster session they do at cocktail cocktail hour kind of thing. There was a case that was presented at the very end that was a sciatic nerve injury that was treated, which which I had never seen before. With instead of doing a graph for the largest nerve in the body, which clearly is going to have some issues, direct repair of the sciatic nerve accomplish through shortening of the femur over a rod and then eventually re lengthening distraction of the femur. And it was a case that I was kind of wow, I would never have thought that would have worked. And clearly this ended up working Otherwise, they wouldn't have shown it, I would think. But the rate of distraction osteogenesis was dictated by the potential growth, the growth rate of the nerve.
Charles Goldfarb:I have not considered that type of treatment in any of my patients. And while it's interesting, I'm not sure my patients would line up for that choice, but.
Chris Dy:Well, you know, old school treatment of, you know, acute radial nerve palsy, you would shorten the humerus as part of the treatment again to direct repair. So.
Charles Goldfarb:No, I totally hear you. I totally hear you that that is something and let's- took it back to nerve.
Chris Dy:I was going to say, sorry I took it back to nerve.
Charles Goldfarb:Of course you did. But hey, I mean, the sciatic nerve is vitally important. And whatever is necessary to get a good outcome, you know, is I guess in play?
Chris Dy:So what's the teaching lesson? You know, when you're presenting this case in conference, you know, you mentioned that this was a you were talking about case conference for peds and you know, the sign in 10, or the K wire passes, and that, in the case he presented was different was treated elsewhere. What's the teaching point for the residents and fellows in terms of, you know, the use of pins for displaced distal radius fractures that you produced.
Charles Goldfarb:So pins are appropriate. And there is certainly a way to place your pins avoiding the growth plate. Usually, when you see that Metastasio fracture, you typically see one pin entering just proximal to the growth plate, and the other, and that's a retrograde pin. And then the other pin is an antegrade pin from the radial side of the radius heading up and across. The problem with that approach is neither pin has a perfect bite. And so the cast becomes more important. And you can be very successful with that mechanism, I would argue that you can be just as successful excuse me, perhaps even lower risk with two retrograde, smaller K wires, not not small but smaller, through this dilute across the growth plate into the proximal fracture fragment. And you don't want to use pins that are too big you don't want to repetitively drill, but I think you can be very successful with incredibly low risk. Just get it right the first time. Get it right. I mean, honestly, though, you just need to get it right into the epiphysis. Right. And then when you have that, then you you're done. And you can feel safe driving across the growth plate. And across the fracture.
Chris Dy:We are going to talk about growth plate trauma as part of the pediatric fracture section. So as a nice segue, but to continue going in order on the What's New in hand surgery article, they talked about wrist trauma next.
Charles Goldfarb:Yeah. And I think this this first paper is interesting. Okoli et al looked at 134 patients treated with a volar locking plate and non operative treatment of ulnar styloid fractures and outcomes were the same. Does that match your experience?
Chris Dy:Yes. And that's why I did not find this article to be very interesting. Yeah, I mean, I think that it's not so much the styloid fracture, it's either styloid or the neck fracture and with frank instability, and I think it's the stability of the DREJ that matters. And then for the fractures that are slightly more proximal kind of distal shaft getting towards the neck. It's whether there's residual displacement of that fracture, you know, after you fix the radius.
Charles Goldfarb:So I think this is yet another example of a paper, which does is useful, it does confirm what I guess 10 years ago would have been very controversial. And so I think the lesson here is don't look at the size of the ulnar styloid fractures, not a matter if it's the tip, or the base. I mean, look at those things, factor them in. But what really matters is what I know you do and what I do is you fix your radius fracture as you normally would, and you examine the DREJ and if your ulna styloid, or distal ulna fracture looks okay. And you and you have instability, my first choice is to try to find a position such as supination that provides stability and then mobilize them in that position. But I try not to treat it at all, and it doesn't affect my post operative care if the DREJ is stable.
Chris Dy:So it's interesting. We talked in a conference, our hand conference about you know, how much it matters to lose certain motions. So we live more in a pronated world than we used to here splinting them in supination, why not just fix the styloid fracture and see if you can keep them in neutral instead, or if not immobilize them? Across the forearm?
Charles Goldfarb:I think fixing the styloid fracture and getting it to heal is another big step in the surgery. I honestly don't think it's the simplest thing. There's all kinds of different techniques. And when there's all kinds of different techniques, it doesn't always mean one of them's best. And so if I can get away with avoiding surgery there, and doing three or four weeks in supination, I think then you can expect for return of rotation, and I think you're better off honestly.
Chris Dy:Okay, so maybe it wasn't as plain vanilla, and boring an article as I thought it. You know, one thing that I have to remind myself of when I'm talking to patients is always to remind myself to talk about the ulnar styloid fracture, because of all the literature like we take a totally for granted, but a patient has no idea and they're, they see their x ray. And if they're astute, they'll look at the fracture. Or they'll look at their report more commonly, and say, Well, why wasn't this other fracture fixed?
Charles Goldfarb:It is highly relevant. Because in my practice, the fractures healed or healing at six weeks, motions getting better, and the ulnar sided pain persists. And so the sooner we mentioned that and explained that everything's going to get better, except for that ulnar sided pain, and that can be six to 12 months. Patients don't ask about it anymore. You just have to get it out there.
Chris Dy:Do you have a role for steroid injection to help with that pain?
Charles Goldfarb:I have not routinely done that. I haven't found it necessary. Because patients accept that it'll get better with more time. What about you?
Chris Dy:You just tell them to suck it up?
Charles Goldfarb:Suck it up, be strong.
Chris Dy:I actually had not one of our partners, I think, does it. And I had not heard of it until it was mentioned in conference one time. And I said, Oh, well, that might be a reasonable option.
Charles Goldfarb:What do you think of the next paper, which I thought was was a little more interesting, in which Klifto looked at 192 patients with a disc radius fracture, and evidence on X ray of scapholunate interosseous ligament injury, the fracture was treated the volar locking plate, the scapholunate ligament was ignored. And there were good outcomes at 12 months and 24 months and no difference. Whether or not there was a scapholunate injury?
Chris Dy:Well, I mean, I think I'd have to read the original paper in detail. Because, you know, I don't know whether they looked at signs other signs of, you know, the scapholunate instability, you know, just widening doesn't mean that there's instability could be wide on the other side. So maybe they took that step, maybe they didn't, what's the SL angle? What's the, you know, is alluding and extension, all these kinds of things. Because those are the things that I look at when I see a patient with this radius fracture, and SL widening like the gap there. And then also the fracture pattern, you know, is a chauffer type fracture with real stylet, where you clearly see the fracture line heading right in towards the SL interval, or is it your standard metaphyseal, distal radius, fracture, bending type fracture with a little bit of intra articular extension? Those are very different things. So I'm not surprised to be honest with you, if it unless they took tremendous care to go into all those different nuances, that there was no difference, you know, and honestly, you're immobilizing paint most patients for a fair bit of time after this anyway, so probably that helps if there is even some kind of ligamentous injury at the carpus.
Charles Goldfarb:Yeah, and let's be honest, it's probably not the 24 month follow up that matters is probably the five year the seven year the 10 year that matters to know if it really is impactful for future carpal health, so to speak.
Chris Dy:So one article that caught my eye here was talking about we talked about this in the past with a prior case that I had to I had encountered about flexor pollicis longus rupture after volar plating. And this article by Moriya talks about the average time to see flexor tendon rupture as nine years after volar planing in an elderly cohort. Does that match what you've seen?
Charles Goldfarb:Well, I have been doing this for a while and I have been using volar plates for a while and honestly, it's uncommon to see them right. But yeah, they happen a long time after plate placement part of that self selected, right we take out the plates, we believe our way too distal. And I think that feels right. What about you?
Chris Dy:I think that sounds right. And it's terrifying to me as a surgeon because honestly like a patient doing well with the volar plate, even if I position did exactly where I want it, I discharged them pretty early, I usually I'll be honest with you don't see a lot of these patients after two or three months from surgery, if I'm confident in how they've recovered, and if I'm confident in the position of my fixation, and I don't routinely take out plates that I'm that I like the position of. So while I counsel them about this possibility, they're not gonna remember that in 10 years, like, very honest. And that worries me, because that's an average of nine years, so could be 20. On the other end of it.
Charles Goldfarb:It's super interesting. It's an important point, though, that all of us should, should bear in mind. And there's a lot of, there's a couple other interesting papers, and there's some that probably will need to dive into, I do think very briefly, we or I should say, I could do better with bone mineral density testing, in my patients with just radius fractures, I try to be good and try to tell every patient with a fracture to see their primary care doctor, and or I send them over for testing. But I have to say, I'm not positive, every patient is taken care of the same way. And that's on me.
Chris Dy:You know, I agree. And I've gone through phases where I'm very good about it. And I've gone through other phases where I'm not great about it. And it is often reading a paper like this, that reminds you to do it. So this paper looked at, you know, the fracture free interval after a wrist fracture. And you know, whether they got a bone mineral density test, the average time until their next fracture was 819 days. And if they did not get a bone mineral density test, the average time was 579 days. So you're looking, you know, roughly a year, maybe, you know, and that's something where we as hand surgeons, and orthopedic surgeons in particular can be much better at in terms of so called owning the bone. And, you know, I admit that sometimes it's very difficult to get your patients into bone mineral density testing. And in an academic center, it's also tough, you don't want to kind of get into referral patterns too much in terms of who should be doing this endocrinology versus us in orthopedics. And, you know, it just becomes a little complicated. It'd be nice to set up a very easy pathway, it's probably something we should look at.
Charles Goldfarb:I think we probably should, and it should become part of just our standard algorithm. And the problem, of course, is you don't want to add one more thing to a patient's mind when they're being treated for a new distal radius fracture. And so really, it's probably at that. Maybe we do it at the six week visit or the 12 week visit if there is one, or the six month visit if there is one, but you don't have to do it, you know, right away and but it, we should probably do it.
Chris Dy:I'll be honest, I often am better about asking if I have a trainee with me.
Charles Goldfarb:There's many advantages to trainees, and that is exactly one of them for sure.
Chris Dy:So how often are your distal radius fracture patients returning to yoga?
Charles Goldfarb:Well, hopefully often, but but that gets back to the last point when they you know, obviously, the yogi's is that the right way of saying it, they need that wrist extension, which is the benefit of early motion. And hopefully, I can say that most patients get satisfactory wrist extension. But when they do go back to early yoga, it is the ulnar sided wrist pain, which gets them if they do it too soon.
Chris Dy:Mm hmm. For sure. I, I found this paper to be useful, because I never know how long to tell them how long it's going to take to get back. So you know, they mentioned 90% Return to yoga at a mean in seven months. So to me that's a useful factoid that I will indeed incorporate into practice.
Charles Goldfarb:I think it's a nice little number that's easy enough to remember. Should we jump there's one article mentioning on scaphoid fractures. And you and I think we've discussed it maybe a journal club, which I thought was a good discussion is the discussion of a really nice randomized trial of skateboarding nonunion is treated with corticocancellous versus cancellous only bone grafting there was no significant difference in healing, but cancellous only may have had to not may did have a higher malunion rate. And the corticocancellous also demonstrated better quick dash scores. So interesting. I'm a cancellous only, but I recognize there are some benefits to the corticocancellous.
Chris Dy:Yeah, I think that the corticocancellous obviously gives you more support for deformity correction. But you know, I think that if you get your deformity corrected, and that's part of it, you're not just putting the screw in when the scaphoid is flexed. That's gonna be a huge consideration. You know, I think that most of us start to get a little more concerned and alarms go up when we see the scaphoid flex and that higher interscaphoid angle and that's when I honestly would think more about using something that's structural as opposed to purely cancellous bone.
Charles Goldfarb:Yeah, and they're trying to remember I'm not gonna remember it there is an article which discusses the quality and the kind of guess the induction properties of distal radius bone graft versus iliac crest bone graft. It's really interesting because I have to admit as much as I hate going to the crest and I don't do it often, it's better bone.
Chris Dy:It is. But you know, and also I would love to see I was doing a combined case of lumbar trauma colleagues and I think one of their now sources to go to is a distal femur, which and I've also seen people take from the tibial plateau, proximal tibia. So that has a lot of the advantage I think you would get from the crest without the god awful pain from the crest. That being said, I did have one patient who fractured through that distal femur site, because I was taking care of her for something else. So that clearly has an issue. So I may just stick with my distal radius for now.
Charles Goldfarb:Yes, hey, listen, it works. And most these patients heal, but it's an interesting thing to to think about for sure.
Chris Dy:So we should jump to an article that you actually talked about in our congenital episode, our first and first of many congenital episodes. But you talked about Doug Hutchinson's article, about trigger thumb, you want to summarize anything that that you didn't touch on last last time?
Charles Goldfarb:Yeah, so Hutch is a hand surgeon in Salt Lake City. He's been a friend for a long time. And he this was a kind of a passion, effort, he essentially stopped operating on trigger thumbs to see what happens. And he said he enjoys his practice more. Not operating on every trigger thumb. But I honestly don't know that the results were as expected the impetus behind his papers interesting. Because essentially, Dr. Baek, who is from South Korea, a senior surgeon there had written an article saying that you don't need to operate on these at all. And I was running some course and Hutch and Baek were kind of on a debate, one side versus the other. And I think this, it was the impetus for his study, he looked at 93 thumbs 78 children followed over five years. And so essentially, what he found was that about a third had spontaneous resolution, and nearly half proceeded with surgery, but at a median of four years after presentation, which is super interesting. I think the takeaways are that risk factors, and this is what I will take away if it's more than 30 degree IP flexion contracture. And if it's bilateral, then I think we all feel very comfortable moving ahead with surgery, unilateral, less than 30 degrees, maybe give it a chance to resolve.
Chris Dy:Now, have you incorporated that into your practice?
Charles Goldfarb:I have I mentioned that to families, vast majority of minor bilateral, so which again, puts you a little tour surgery, I don't again, it's not a knee jerk surgery, I generally send patients away and say, you know, if in six months is still a problem, call or come back, and we can set the surgery if you like. But this is just one more bit of information. I think this was a very patiently done. Study that, you know, in our era of trying to get quick results, it's hard, so I really applaud him for this.
Chris Dy:Speaking of surgeries that don't bring many people joy. What about this article on Mallett fingers. For many of us, we've been shying away from surgery because study after study showing it doesn't matter the size of the Mallett fragment, what matters is joint subluxation. But now this study is showing that even with the DIP subluxation, the outcomes are no different for a mallet finger. So what did you do you believe that or is there any? Is there any reason in 2022 to operate on the mallet finger.
Charles Goldfarb:So this is interesting, and I'm aware of this paper and I've carefully reviewed this paper it was extraordinarily well done. And as you said, the size of the fragment, and the alignment of the joint did not affect outcome. The drug was subluxated and 50 patients it was congruent in 168 patients and motion and general evaluation did not differ as the authors recommended non operative treatment for all I have to say one of our partners would say the same Linley wall believes that these patients can generally be treated without surgery. It's a hard one for the surgeon to look at a large fragment, it's a hard one for the surgeon to look at a subluxated joint and ignore it. And it's hard for families.
Chris Dy:So it's not just a surgeon, it's the family and the patient patient sees the X ray. I mean, you see that there's a big factor that you're not fixing. And they see they might pick up on the fact that the joint is subluxated. But they're gonna focus on that fracture.
Charles Goldfarb:Yeah, anesthetics matter, you know, having a big bump there matters. So it's a little hard to believe but it's not. It's not I believe it. You know, it's just a little hard to reconcile, I think with what I see. So I don't think it's quite that cut and dry. But I'll tell you, it does make me reconsider my surgical practice. earier and go a little slower.
Chris Dy:Right? Right. My criteria, I very, very rarely will operate on a patient with a mallet. So I like this paper. It's a tough discussion to have it honestly, just getting to the root of what we do as surgeons, it actually is more time to talk to patients about not having surgery than it is to talk to them about surgery.
Charles Goldfarb:Yeah, oh, that's, that's for darn sure, always has been. And as much as we've joked about the pediatric section, what I'd like to do is jump ahead to nerve and round out this well, nerve, and then we should talk about equity. I think that's an interesting section briefly. But tell me your thoughts on on, I guess, as it was labeled spontaneous peripheral neuropathies, such as Parsonage-Turner, and the timing of surgical intervention.
Chris Dy:I think this this one comes down to, you know, the patient's personality, their willingness to do something, and then the circumstances surrounding their nerve palsy. Patients don't love jumping back into another surgery after they've just gotten over their first surgery. And there's definite that plays into the decision making calculus for patients as well as my willingness to offer them another surgery, it is often not a slam dunk, you know, let's do surgery, you're going to get better. It's more of a, let's do surgery, because there's nothing else to do about it. And I saw patient I saw a patient like this recently, where we're just continuing to watch their postoperative nerve palsy that is unrelated to their surgery, it's not because the nerve was injured in surgery, it just is out. And it often is the aim. And it's very tough to sit there and watch it. But I'm not sure that surgery is going to alter the natural history. Although these studies would suggest that there may be some role for that early on. The problem is, it's not necessarily whether you're going to do a decompression, to me, it's whether you're going to do something more. Because if you're going to jump in and say let's do and some would consider doing something like a neuro transfer, at least reverse and decide, theoretically, don't lose anything, you have a window of time in which you can do that, you know, in terms of, theoretically, if the electrical has been cut off to that, that muscle, you have a window of time before denervation related atrophy sets in and you lose that opportunity. So to me the decision is more, are we going to do something more? You know, because I'm oftentimes, you know, if I'm going to do a decompression, I'm probably going to consider doing something more now, as I talked to this patient about it last week, it was more of okay. If we go in and we decompress them and to stimulate the nerve. And if that's if they get a good response, that's it. But if I don't get a good response, or they're, you know, if it's a feeble response, or it's no response, then maybe we're going to consider doing a nerve transfer because I'm there. And that opportunity to do it is right then and there. And I think that is one consideration. And I think one of the other articles that wasn't in this years, but it wasn't a past year was the concept of micro neuro lysis. So basically doing a neuro lysis, using the microscope to find smaller, constrictive bands, that circumferentially run around the nerve that Scott Wolfe and Steve Lee have found with their high image high, the high resolution ultrasound and their advanced MRI. And that's super interesting to me as well. But I think this is an area that's still evolving it honestly, it doesn't come up enough, where there's a big impetus to study it. But clearly, you know, we're still trying to figure this one out.
Charles Goldfarb:Well, and you were nice enough to give me advice on a patient not in the not too distant past that had the PIN palsy, spontaneously. And then I think we waited out. I think he ultimately he may have followed up with you. But yeah, it comes up occasionally. And when it does, it's a big deal for the family. And, and this is this is helpful, I think, at least to some degree, but I like your algorithm.
Chris Dy:Yeah, it's it's really super interesting. This condition. And I think that, you know, I know Scott Wolfe is spending a lot of time studying this now. It's kind of one of his passion projects. And I hope that more comes out from that work. And I'll be honest with you, I think the rest of the articles in the nerve section are not as interesting to me. Be very honest. But there were a couple of good ones. I mean, I think that there was it was surprising that in evaluation, clinical evaluation of patients with nerve injury, complete nerve transactions were missed in a third of the patients, which is shocking, but not that surprising. That makes sense?
Charles Goldfarb:Yep. Totally. And then the other was processed nerve allograft performed better than conduit in both small and large gaps in terms of functional recovery. I don't think that's surprised you.
Chris Dy:No and I don't think that's the the question anymore. Like, I think there have been enough studies showing utility of processed nerve allograft in gaps of this size, they call it large, but 15 to 25 millimeters is not large. I think the question now in 2022, and it's been for a couple of years is what's the role of processed nerve allograft relative to a to an autograft. And I think that continues to be a question of interest. I think there are passionate people on both sides of the argument. And I think that it's important to consider conflicts of interest of those who are discussing on both sides.
Charles Goldfarb:Yeah, I love that. I love it. And maybe just in closing, I'll say, there's a nice section on equity policy and education, which emphasizes what we all know is that there is more work to be done. And I don't want this to be an afterthought, because this is really important. But there's more work to be done on gender and racial inequity in our in our profession. And there has been progress. The hand society is better than most parts of orthopedics. Let's be honest, but certainly needs to be further improved. And so I look forward to watching and doing what I can to help with that progress.
Chris Dy:Absolutely. I mean, in addition to the articles that are included here, Lauren Wessel, our fellow from last year, and I looked at the representation on hand society panels submissions, and this was in a year where Amy Moore was the co chair. So Amy was a co author on this paper too, and just came out and JHS global open, global online. So NJHS go, we just published the fact that the subtle not so subtle encouragement to me, ie requirement that you include people from underrepresented backgrounds, on your panel submission, surprise, led to significantly greater representation of women on ICLs, and symposia. So I think that's, you know, it's it's small, a small but important example of a simple policy type thing that groups can do to address a larger problem.
Charles Goldfarb:Yes, well said and well done. Lauren et al on that paper. Congratulations, Dr. Bone. Congratulations, Dr. Wise, I think this is a great addition of the annual update on hand surgery. And as usual, I learned a bit.
Chris Dy:I learned a lot, it was great to read. I can only imagine the amount of, well actually, I know the amount of work that goes into that. So congratulations to both of you for that. And I look forward to next year.
Charles Goldfarb:Absolutely. I got a win for you for the week.
Chris Dy:Yes, let's see, it.
Charles Goldfarb:Might be a little corny. My win is that I appreciate my team. You know, we are not islands. And we cannot function alone. And I am fortunate to work with a great team, a nurse who's extraordinary therapists who are fantastic. And Karen, who kind of keeps my life together. So I'm grateful for my team.
Chris Dy:That's fantastic. Well said, and obviously super important. And even you know, in the era of COVID, and everybody wanting to change jobs, you have managed to keep your team together. So congrats on that.
Charles Goldfarb:And I try to keep it going about you.
Chris Dy:My win is the fact that, you know, we finished conference early one Monday and I was on my way down to our south county location. And I felt like having a donut. So I stopped and got a doughnut. And I decided to get donuts for the team support a local business. And that's now turned into a donut competition in South County. All the various clinic teams are bringing in doughnuts from different places throughout the south county region to compete and see who has the best doughnut. So we got a whole Rating Board we got you know, there's a scoring system. And, you know, shout out to Jean Szerzinski who has put that together? You know, and I know that you you worked with Dean for many years. So it does bring honestly, it's it's fun. And it brings uh, you know, a little morale lift during you know, it can be a kind of a tough time.
Charles Goldfarb:You know what, I think South County has a lot of donut options more so than in our area of the world. And I'm jealous. And maybe it's something to try to do at Dunkin Donuts is the closest to me.
Chris Dy:And I will say I will close with one thing. We I had a patient come in, and shout out to you if you're listening, who I was going through my whole spiel about carpal tunnel syndrome and the release. And she's like, I know, I listened to your podcast. And she was she was quoting back things that I said I'm like, Oh, my goodness, I hope I remember what I said on the podcast. But if you're listening, I hope that you've enjoyed the podcast and thanks for listening to the end.
Charles Goldfarb:That's awesome. All right. It's been fun. And I'll see you soon.
Chris Dy:Alright, see you next week.
Charles Goldfarb:All right. 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 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 Using and remember, keep the upper hand. Come back next time.