The Upper Hand: Chuck & Chris Talk Hand Surgery

Chuck and Chris Talk Wrist Salvage Procedures with Steve Moran

March 20, 2022 Chuck and Chris with Steve Moran Season 3 Episode 10
The Upper Hand: Chuck & Chris Talk Hand Surgery
Chuck and Chris Talk Wrist Salvage Procedures with Steve Moran
Show Notes Transcript

Season 3, Episode 10.  Chuck and Chris welcome back Steve Moran to talk hand surgery.  Specifically, we discuss wrist salvage procedures the proximal row carpectomy (PRC) vs. the scaphoid excision and 4-bone fusion.  We talk technical aspects of the both procedures including neurectomies, handling of the capsule, order of operations, etc.

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Charles Goldfarb:

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 ya?

Charles Goldfarb:

I'm great. How are you?

Chris Dy:

I am fantastic. I feel energized. I'm drinking coffee out of this wonderful mug.

Charles Goldfarb:

Yeah, you know, I am drinking tea out of a wonderful mug here. And can you read what that says? Dr. Dy?

Chris Dy:

Yeah, yeah, it says expensive degree that nobody will ever use. A liberal arts education.

Charles Goldfarb:

For those who are not on YouTube, it says Williams College, which is really important because it is a link to our guest. today. Would you like to introduce our guests? Would you like me to introduce our guest?

Chris Dy:

I would love to our guests. Our guest is a man who has a yearning for a bigger coffee cup. And Chuck, maybe as we go back to the swag bag, we would look at bigger cups. But you know, Steve Moran is coming back to the pod. So Steve, welcome back. As you all know, he is a world famous hand and wrist surgeon and plastic surgeon at Mayo Clinic. And he is second in line to the ASSH presidency. And so we're honored to have Steve back. We had a riveting discussion before on Kienbock's disease. So now we're here to talk about the next level of treatment of Kienbock's. So to say.

Steve Moran:

guys, thanks for having me back. I'll tell you, thank you for what you're doing. Your podcast has taken off. My residents and fellows are all talking about it. And then I see a lot of positive vibes coming off the listserv. So I think you guys are doing something great. And I know it's a lot of work. So thank you for doing it.

Charles Goldfarb:

Thank you. I you know, Chris, I don't know that I shared with you. But I was recently with Steve, one of his other accolades. And there's many we can get it a few more, is that he is on the American Board of Plastic Surgery. And there recently was a question writing session, which might to the listener sound like the most boring use of one's time ever, but it's actually super fun. And it was good to see people interact with people. But that's yet another accomplishment. But at this meeting, Steve was very clear to say that he believes what put us over the edge, so to speak, was the previous podcast on Kienbock's. We were middling around not doing much exciting. And when that podcast dropped, all the sudden there we went. Do you think that's true, Chris?

Chris Dy:

I actually was about to quit until that episode came out. And you know, the fan mail was ridiculous. And I got asked to sign a bunch of podcast mugs. Just people started coming out of the woodwork. So it's funny you speak about question writing. I'm very proud. We had a plastic surgery resident rotating on our service recently. And she spent some time with me. And we were talking about anatomy during the case. And I kept asking our resident, this plastic surgery resident and our fellow because they were all rotating out of a long case, the origin of the lumbricals. And nobody was getting it right. I was like, Guys, this shows up every time on the in service, blah, blah. Well, the plastic surgery in service was a couple of weekends ago. And she nailed it because it was on the in service. We talked about how it came off at the FDP and she was so happy. It's like if at the very least, if you learned something, you got one question right on, your in service because of me.

Charles Goldfarb:

I love it.

Steve Moran:

It is a labor of love writing those questions. It's a I wouldn't say it's the most scintillating thing that we do. But but it is an important job.

Chris Dy:

But I'm sure that you now that we're hopefully emerging from the worst parts of the pandemic, you at least get to connect. Right. And I think that's probably one of the best things about doing stuff like that and doing oral boards and all that kind of stuff. Right?

Steve Moran:

It was great to be able to see everybody again, and it's been forever. I think that was the best part of the meeting for sure.

Charles Goldfarb:

Oh, yeah, no doubt i i wasn't, you know, I can be social at times. And other times I'm quite content and, and there's lots of there's lots of, there's lots

Chris Dy:

I don't know what kind of psychopath stuff that just was, Chuck.

Steve Moran:

He's just an introvert, there's nothing wrong with that.

Charles Goldfarb:

There's been a lot of research out there about introverts. Which I don't know I'm really an introvert, but introverts during the pandemic kind of were like, okay, things are fine. But I will say for those of you listeners who have not yet been back to a meeting of any kind and zoom does not count at all. If you have not physically been to a meeting. It is it's really hard to put into words how good it was just to see and interact with people and it was awesome. I was super excited and it was even better than I thought I was going to be and I was sitting in a room talking about Orthopedic questions or sorry, hand surgery questions all day.

Steve Moran:

It was good. Hopefully the annual meeting will be 100 times better.

Charles Goldfarb:

I'm sure it will.

Chris Dy:

Steve, before we before we jump in on the topic of choice, can you tell us what it's like to now be in line for the presidency for the hand society? It's an incredible accomplishment. Congratulations.

Steve Moran:

Thank you, Chris. You know, it's an incredible honor. And, you know, quite sincerely, I belong to a lot of different societies. And there is really, I really don't think there's any other society like the ASSH. I think, you know, Chuck, probably you probably say the same thing, the things that the hands society is given to me, I don't think I can pay back the time that they've given me like, for example, the Bunnell and visiting professors all over the world, and really learning so much to take better care of my patients is really special. The leadership line and the administrative staff are exemplary. And so I think just being exposed to a lot of other societies and groups, I really think it's just something it's where I want to spend my time. It's where I want to give my money. So I think that that's the best part about it.

Charles Goldfarb:

Yeah, that's well, that's well said, time and money. And that that's right. I did it does. As an organization, it does give me far more than other organizations. It's funny, I believe I directly followed you in the Bunnell award and we both maybe it was maybe it wasn't directly but anyways, I followed you because you're a lot older than me. And

Steve Moran:

I have more hair Chuck. That's all that matters.

Charles Goldfarb:

Look at this I got-

Chris Dy:

Y'all need to log into YouTube and check out the hair on these guys.

Charles Goldfarb:

So, but we both visited Steven Hovius, who's a remarkable plastic surgeon who focuses on kids in Rotterdam. And Steve had shared this remarkable video where Steven, you know, drove, you know, biked you to work on the back of his bicycle, kind of put the saddle on the back, and it look harrowing. And then I did the same thing, but I knew about it before I got there. So it wasn't as as harrowing as your experience was.

Steve Moran:

It's, I don't I don't like to share this story. But you know, I was a little heavier back then Chuck. And when we in that video, when we go over the bump, I bent his tire, and we made it to the restaurant, but he could not make it home. And he had to like, carry his bike home. It was a thing like he had a bike repairman come to the hospital next day to fix it. That's how important bike transportation is in Rotterdam. But that was a good that was a good wake up signal to me that I had to drop some pounds. So that was a, the Bunnell was important for so many reasons.

Chris Dy:

Way to break the stereotype of the American Overseas guy.

Steve Moran:

I know. I know.

Chris Dy:

One thing one thing that I think it's interesting, some patients and probably more for both of you than for me will go online and look me up on the WashU website. And something that patients comment on all the time is where I've traveled and what I've seen. So you know, for people that are fortunate enough to do the Bunnell or any of the other traveling fellowships, but even if you don't, there's value in going somewhere learning something obviously for the educational content but trainees and patients will look up where you've gone and what that that makes them feel better for some reasons like I'm fixing your distal radius fracture, why do you care that I traveled internationally for nerve stuff, but they care.

Charles Goldfarb:

Yeah, it does bring and I'd love Steve's opinion, it does bring validation, when you say that it actually immediately makes me think of kind of flipping it around. It makes you think of Louisville and their hand Fellowship, which attracts Internationally and has forever. What you know, it's been the mecca of advanced hand training for many years, I think, a little less so today than in years past. But as I understand it, and Steve, you are more well traveled than I am, and you probably understand this better. But as I understand the importance of Louisville, it was simply that if you were overseas, and you were a young academic hand surgeon, sometimes to take the next step, a year spent in Louisville would kind of get you over the hump and advance your career. But like I said, you're more well traveled is what's your what's your sense of what Chris shared.

Steve Moran:

Well, I mean, I the Louisville fellowship has trained so many remarkable leaders in hand surgery, you know, from Raja Sabapathy, Paco Del PInal, I mean, really people who have changed hand surgery internationally. I think it's incredible to travel. I tell all the fellows in residence that you got to get out of this country and just get a fresh perspective. I think. Also, you know, volunteer missions is another place where you see that people can do so much. With so little. I think that all those things make you feel a lot smaller, a lot more humble. And I think it's something that everyone should do. And I mean, I think that, you know, the ASSH provides you that opportunity. You can go on outreach missions, but even better, you know, at the meeting, go to the international joint international committee can meet these people and, you know, invite yourself over there, they'll love to have you there's, there's friendly as you guys are. And I think it's just a great way to get out of your little circle of comfort.

Charles Goldfarb:

Yeah, before we jump in, yes, I think that's very well said. Of all the work you do, you know, with hand surgery and hand society and, and the board. Nothing we do is more important than our family. So I want to comment on your sweatshirt. And I want you to tell me a little bit more. So for those of you, you know, we all appreciate

Chris Dy:

I think he was wearing that sweater the last time we recorded too but I don't think we were on YouTube.

Steve Moran:

Plugging the school, plugging the school, you know. So chuck, Chuck and I were a year apart in in college, and we often talk about our kids, they're roughly the same age. My my two oldest are now full time musicians. My middle son is at Berklee, and, and he actually will be joining us for the meeting this year. I don't know if you guys noticed the big thing Jeff has rented out the House of Blues. For you know, Mark Barrett's hand band extravaganza, Battle of the Bands, and your partner. I should I'm throwing this out there. Now this is gonna be everywhere. Marty Boyer and I will be playing with some musicians from the Berklee School of Music. Last we will be the last band on so hopefully, there will be most of the people that will still be there will either be too tired to remember or something else so they won't really remember mistakes will be forgotten and we will be playing live.

Chris Dy:

Hold on.

Steve Moran:

Dr. Boyer leather pants and a cut off is what I heard he may be wearing.

Chris Dy:

I had Marty over last night and it's funny enough one of the kids his nickname for Uncle Marty is Uncle Party. So ready to go here?

Charles Goldfarb:

Steve, I think you're trying to promote this event. Honestly, Marty and leather pants and a cut off I think might keep people away. So let's-

Chris Dy:

Are people able to compete in this battle should hand surgeons and hand therapists coming to the hand society kind of get their get their bands ready. Or are we is this a closed competition professional circuit only?

Steve Moran:

That is a good question. And I think Mark Hertz is going to be looking into that. I think that you know, there are several there are several super talented people in the ASSH and I am a hack, though Chuck knew that we were quite a quite a famous band in college this this close to not ever being a hand surgeon and being a professional Rockstar. But seriously, I think Mark is going to be working on this I think it's you know it'll just be a good time. Just a fun time and to get everyone when is when can you have the House of Blues all to yourself. I mean, this is gonna be fantastic.

Charles Goldfarb:

It is gonna be great. And don't sell yourself short. I know you're a talented musician and and I don't know your wife, but I don't know if she has musical talent or it's all coming from from you. But your kids have really done remarkable things already.

Steve Moran:

They're working on it, or I'm going to be working for a long time.

Charles Goldfarb:

Alright, let's jump into the content before we lose our listeners. Hopefully, they've enjoyed this banter. So that you know, I did a couple of things. We are here today to discuss proximal row carpectomy and scaphoid excision with four bone fusion as a salvage procedure for whatever ails your wrist and that could be I don't know if it would be Kienbock's necessarily but could be Kienbock's obviously, radial sided pathology so the first thing I did was just search our guests on PubMed and I have to say Dr. Moran, it exceeded my expectations. And so I don't know if there's more than one Steve Moran but 332 cited publications. I feel confident saying that's more than Chris and I combined we feel not worthy.

Steve Moran:

Chuck, first of all I'm a little upset that you haven't read them all I read all of your articles right before I fall asleep at night. And I so but yeah, we you know you're talking about a subject that I have struggled with. For a long time. I have done everything in my power. I don't want to get to the punch line before we get to the end of the podcast but I've done everything in my power to try to show that proximal row carpectomy is not an ideal operation. And I, you know, I don't, these two operations are very people are very passionate about them. They're like your favorite soccer team or football team, you know, where you train tends to be the way that you do things. And I think that there's still such a lot of debate about them.

Chris Dy:

Well, let me let me talk to you a case to you know, get things started. So on top of Kienbock's, what about a patient who comes in, say, their mid 40s? Female, and she comes in with wrist pain, you know, all of a sudden, it started, I can't remember, you know, with if there was an accident or anything like that may have fallen on it or something like that. But she comes in, and you see that there's pretty advanced Kienbock's disease. And you're, you're saying, Okay, there's a little bit of collapse here. You know, we're starting to see some increase in the radial scaphoid angle, the wrist don't look, right. She's having pain you've tried and you go fast forward, you've tried injections. You've tried to immobilization with a brace, and you've perhaps sent her to see some therapy. She's not better. What's your decision making algorithm now?

Steve Moran:

Chris, that's a good case to start with. You know, I think that, you know, it always boils down I where I always start is, you know, what's the minimum requirements for functional wrist motion? And there's a lot of studies that look at that. But I basically boil it down, people need about 40 degrees of flexion extension, 10 degrees of radial deviation and 30 degrees of ulnar deviation, and then what do they do? So if they are a farmer, pounding in fence posts every day, that's a lot different than someone that's sitting at a computer programming all day. So I think that always starts with the patient, I still a little individualized for me. Kienbock's is one of the conditions for proximal row carpectomy they you that they do very well. So I think that is a really good solution. I mean, I think you want to make sure that there's no arthritis at the lunate facet, the capitate still looks okay. But that's a great option. It's a quick recovery. You know, if that patient however, say she, you know, works on a farm, and she does have to put in fence posts every day, then I might offer her a scaphocapitate fusion. I, you know, I know that that's not the one of the procedures we're talking about today. But I do feel that for my manual labor patients, that that tends to take pounding a little bit better than a PRC. However, the literature states that for Kienbock's, proximal row carpectomy is a great solution.

Chris Dy:

I love that I'm gonna go full Chuck mode, two things. So I can't remember Chuck and I talk at so many different venues whether this was hand conference or on the podcast. But, Chuck, you mentioned that not everybody after a PRC for Kienbock's does well. Why do you think that is? And then the second comment I'll make is, Steve, you drove a distinction between the manual labor versus the the keyboard professional, but the literature may not suggest that that matters as much for a PRC. So anecdotally, do you still believe that maybe we'll go to Chuck first. And I want your thoughts on that second comment.

Charles Goldfarb:

So to be clear, I do like proximal row carpectomy is for Kienbock's. My experience has been in using that as a bailout option. Occasionally, the patient comes in and they're Kienbock's is so severe. And you know, they have arthritis. And as long as you then involve the head of the capitate as, Steve said, then I think a PRC is reasonable. But usually, for me, I have done something else first. And maybe that's a vascularized graft, as Dr. Moran taught us, maybe it is, maybe it is simply a shortening of the radius. And if that doesn't lead to improvement, then a proximal row carpectomy is often my next step. What's interesting is I have my population definitely skews younger. And there are adolescents certainly with Kienbock's that we treat. And we certainly try really hard not to do a salvage type procedure in an adolescent. But there's a group of them that fail. And I, you know, my algorithm for the adolescent not to go down the wrong path here, but I do try to unload them, whether that's a cast or a scaphocapitate pin to unload the the Lunate and give it a chance to heal. I do use vascularized graphs, I do use radial shortening, but occasionally all of those fail in a PRC might be appropriate. And I think the results are good. They're just not great in that situation. Steve, I'm certain before you answer questions Chris's question, but I'm certain that you've had experience with this same adolescent population. How do you think about them in Kienbock's?

Steve Moran:

Yeah, Chuck, I think the same way, you know, I do think we give them all a trial of immobilization. But I do think that, as you were saying, I'm so hesitant to change the anatomy. I want to do everything I can to get Keep all the bones in there. And obviously you don't want to use a young adult we've, we've had really good results with vascularized grafting in young patients. I think the cases where we don't do vascularized graft is usually where the lunate cartilage is fractured. Greg Baines great work to look at both sides of the lunate cartilage. So, but if you if you fail with a vascularized graph, you have every option open to you, you haven't really damaged anything. But but to Chris, to kind of get back to your point. You know, we we did a study a long time ago, where we looked at, there was over 80 patients that were over 15 years out from proximal row carpectomy. So they had their proximal row carpectomy a long time ago, like Jim Dobyns, Ron Linscheid time. And the majority of them were, you know, Midwest farmers in and 15 years of follow up, the motion they started with was the motion they ended with the grip strength was a little less, but roughly the same. But when we sent them a questionnaire, and we said, you know, do you have pain in the wrist? Yes, every day. You know, I can't, I couldn't go back to heavy manual labor. But they, but they didn't ever got anything else done for it, which I was so interested about that they just afraid of going back to doctors. And then we did another study looking at patients under 45 younger age group that had PRC in four corner fusion. And essentially, we found that the results were the same between the two, I was so sure that, you know, four corner fusion would be far superior, but it wasn't. And we had just as many deteriorations to total risk fusion. And actually, there were more reoperations as you would imagine, four corner fusion for hardware. So despite my best efforts, I have not been able to show that there's really any benefit over four corner fusion, I was really trained that that was the only way to go. You had to do a four corner fusion, proximal row carpectomy was gonna fail. But that's doesn't look like that's the case.

Chris Dy:

Now, I want to get back to your scaphocapitate thing in a second, because I think listeners will want to know about that. But, you know, should we be afraid of a PRC in the younger patient, one of our partners, Lindley Wall, that paper when she was working with Peter Stern in her fellowship, does a PRC work in this young ish patient? Or should we shy away from it and try some other procedures? We know you're biased, but.

Steve Moran:

Well, I mean, I'm I, Dr. Stern has got excellent results, we definitely know that there are things you can do to make a proximal row carpectomy. work better. And I think that is, you know, looking, looking for the right patient. First off, you know, I think if you have the patient that's got the right job and got the right mindset that they know, they're going to still have some pain, but they're going to keep the wrist motion, it's going to be a quicker recovery. And I think setting expectations is critical. But I think there's a lot of little things, doing an AIN PIN neurectomy, I think we've shown that that's really adds no time at all in we could all say we cut the PIN when we go in there, but I mean, really cutting it out. Cutting the AIN out. I think that helps. We've shown that. I think also looking at the shape of the capitate. You know, there's different shapes to that capitate some can be very pointed, and Steve Viegas talked about that. But I think if you have one that's more rectangular, the most common type, they tend to do better. And you know, I think if you go in there and there's a lot of osteochondral damage on the head of the capitate already, you can consider doing like a mini Oats procedure like Dr. Imbriglia has talked about, just really try to set the patient up as best you can. And, and then I think, you know, hopefully, if the patient does fail down the road, we'll have some salvage procedures I've certainly salvaged proximal row carpectomy with a variety of different things whether it be meniscal allograft, in the lunate fossa or even cartilage vascularized cartilage transfers, but these are, tend to be heroic attempts. And for many patients at that point in their life, they may just want a fusion.

Charles Goldfarb:

So I don't want to rewind too much, but I think our listeners would appreciate the technical here. Both the surgeons and the non surgeons who listen. Just talk us very briefly through your approach. And kind of the steps you take to maximize your outcomes. that would that would be helpful for me to hear, I think for all of us to hear.

Steve Moran:

Sure. So for a proximal row carpectomy patient you know, once you've you've come to the decision, you're at that fork in the road with the patient. For the proximal row I still use the ligament sparing capsulotomy is this talked to us by Dr. Berger and you know, I I get in there and I'm take the lunate out first by just cutting whatever's left of the ligaments, and then I, I'll save all the bones and I tried to take them out in one piece because they are a good source of cartilage graft. If you end up looking or you, you scuff the capitate or something goes wrong. And then I take out the triquetrum sharply, and then I will take out the scaphoid. And there's a variety of ways, you know, I think that's the hardest part, you can either put a threaded K wire into it or, you know, there, there's almost like a corkscrew for a wine bottle that you can put into the scaphoid to kind of pull on it. But I find that the Cobb or the McGlabrey osteotome helps to kind of get around that and scan almost scoop the scaphoid out and then I make sure that the radioscaphocapitate, ligament is still intact, I haven't damaged anything. And then I just plicate the capsule. The one other tip I would say is that as you are taking out the triquetrum, I really try to stay on the periosteum I certainly have seen patients that have ended up with ulnar sided instability, I think because we're maybe too aggressive around the TFCC in the remaining ulnar, carpal ligaments. And then I look at the radiograph to make sure that I'm not going to end up with styloid impingement onto the hamate later on, which I think can certainly happen. And then I plicate the capsule and close. And then for them. It's usually, you know, three weeks of immobilization. And I started some general range of motion. If you want, if you want to get into it, we certainly can talk about my technique for four corner fusion that's changed a lot over time. But that's how I do proximal row carpectomy.

Charles Goldfarb:

Yeah, I was gonna say maybe let's, let's finish with this. And then yeah, we should talk about four corners, then we can talk about the literature. I'm sorry, Chris, go ahead.

Chris Dy:

I was just gonna ask if you're insisting that the carpal bones be removed on block or in one piece, how heavy of a sigh. Do you release when your trainee or perhaps yourself ends up you know, not taking it out in one piece?

Steve Moran:

Oh, no, that's, I do suffer from a little ADHD. So I mean, you know that you have to be reasonable. Not the amount of time. I don't think you have to take them out carefully. But if it's simpler, and you're going to be safer taking them out in pieces, taking them out in pieces. I don't think that's a problem. I just think it's nice to have one of them intact, because I use if I do have a scuff, or if there's a bad problem with the capitate, I use the little pediatric trephines to like punch, I'm sure you guys do is to use punch out a piece and then you can put it into the capitate like the regular article and you don't do it all the time. But I think it just you have a little bailout in case there's a problem.

Chris Dy:

Well, you had Chuck when you said Oat's and you had me when you talked about nerve so I clearly know your audience, Dr. Moran.

Charles Goldfarb:

It it's funny because I thought in response to Chris's question, the answer was gonna be well, we're the Mayo Clinic, it always comes out in one piece. We don't have those errors. They may have at WashU.

Chris Dy:

Listen, listen, our partner David Brogan who trained at Mayo corrected me saying you always have to say the world famous Mayo Clinic before you say Mayo clinic.

Steve Moran:

World infamous, I guess.

Charles Goldfarb:

So, is there a role for capsular interposition in a proximal row carpectomy, where the cartilage is not perfect? Do you ever use that simple technique?

Steve Moran:

Yeah. So that's a great question, Chuck. And, you know, people have done everything with this operation. It's been around since the 1940s. But you know, Eaton used to take off the head of the cavity so that you had like a smooth surface between the hamate the capitate and he left the distal articular surface of the scaphoid would to have a big broad surface to low chair. And, you know, I think it's very tempting to put something in there. And certainly I've had inner positional material work over time. But when we, again, the retrospective studies, but when we looked at the results, there's no difference between doing radial styloid ectomy and interposition graft or a capsular flap. Those didn't really affect the long term outcome. The only thing that did was the the formal neurectomy PIN AIN.

Chris Dy:

So quick question before we jump to four corner, and scaphoid excision, when you talk about you talked about capsular plication. Exactly how do you do that? And then we should talk about your post op protocol after a PRC.

Steve Moran:

I think if Well, I mean Chuck you certainly, if you're gonna if you think you're going to definitely do a capsular flap, then I might consider doing a different exposure to the wrist. You could either have a distally based flap that you pulled underneath, or you could make a proximally base flap that you could just lay in there. But if you if you really think you're going to do a capsular flap, I don't think the Mayo capsulodesis is ideal for that. It's good for exposure but not for that. So I would probably choose one or the other before I went in. You could even make a very broad regular base flap and then cut it in half and lay half underneath. But if I'm going to put something in there, I usually Unfortunately, we'll take something off the shelf, whether it's meniscal allograft, or some decellularized dermal matrix, because I like the ability to plicate that capsule down to kind of take up the redundancy from losing the proximal carpal row.

Charles Goldfarb:

You're just talking about over tightening the capsule just to get get some tension back.

Steve Moran:

That's right, Chuck, just to get a little attention back, particularly on the ulnar aspect of the carpus.

Charles Goldfarb:

Okay, that's super helpful. And so you always perform a PIN and AIN neurectomy in this situation.

Steve Moran:

I do now. Yep. I do now.

Charles Goldfarb:

That's interesting, because I have not, and while my results, you know, I trained it with Peter Stern as you as you mentioned, and Peter felt and feels very strongly that the PRC is a great operation. Not everyone agrees, as we all know, and, and my partner Marty Boyer has never been a big fan. It has been interesting to kind of watch the evolution and thought, and I think more and more people are appreciative of the PRC, and recognize some of the challenges with the four corner. But there clearly is a role for the four corner as well. So Steve, when do you think about performing a four corner instead of a PRC?

Steve Moran:

So again, I'll admit my bias here, I was kind of trained that the capitate is bigger than the lunate fossa. So I mean, you know, the capitate sits, you know, shares half of its articulation with the scaphoid and the lunate and then you drop this larger sphere into this usually rectangular fossa. And what's going to happen, you're going to get load Edgeware, essentially, in then you have shearing over these bumps. So, you know, and we know doesn't always correlate with outcome, but if you follow these patients, after 10 years, they all have degenerative changes at the capitolunate interface. So that that just like it makes it makes me uncomfortable. Um, but despite that, again, I haven't ever been able to show that it's bad operation. So for four corner fusion, I would go with the patient that is okay with having longer mobilization. It's okay with losing more flexion I think you know, in is willing to accept the fact that we may have to go out go into either fix a non union or take out hardware. So we know, the literature says that it's, you know, it's more expensive to do four corner fusion. It's not as cost effective for OR time either, and there's a higher risk of secondary surgery. So I tend to do the surgery. Now with just two compression screws. I think there's a strong argument that can be made maybe for doing it is minimally invasive. As you can see, don't destroy any blood supply the carpal bones, but I usually take the scaphoid out and morselize it and prepare the cartilage and or remove the cartilage in and use that as bone graft. And then I place a compression screw from the triquetrum into the capitate. So sometimes it goes through the hamate and then I place one for put a K wire down either between the CMC joint of the index and long finger or the long end ring and one of those if you look at the x ray ahead of time, that space is one of those will be axial with the capitate and the lunate. And then we put a compression screw in there. And if you can do that can always sometimes go use a additional staples or something else, the patient's usually do very well because you haven't done a tremendous amount of violation of the soft tissues.

Charles Goldfarb:

So interesting. A couple of things that you do differently. I'd like to follow up on those so you place your own. I also use two screws, you place your ulnar screw first. Now is that screw through a separate mid ulnar incision, or is that through your dorsal incision?

Steve Moran:

No, thanks, Chuck. I make a little stab incision here in just pass cannulated the K wire with the cannulated screw.

Charles Goldfarb:

And that's what I do. Chris has taught me that we're both being silly. And there's a better way.

Chris Dy:

Well, no, I mean, I think I think that it's interesting. Why do you do the Why do you do that screw first because I actually think of maybe I'm thinking about this incorrectly. I'd love to learn I should think about that fusion as the the afterthought as opposed to the capitolunate.

Steve Moran:

That's a great question. I'm going to take a little sidebar I just want I don't know if you guys have noticed that I do have two cups here today because this cup is just too small. So I want to be a sponsor. I have to pour from this cup into this cup. This is your cup I love your cup.

Chris Dy:

Chuck I'm almost empty. I actually had to refill earlier.

Charles Goldfarb:

I can't believe a guest is disparaging our coffee cups.

Steve Moran:

I love the cup. I love it. I love it. I told you my wife loves it. It's right size for tea. But like on a long discussion like this, you need to have coffee anyways. Sorry. Back to your point, Chris. You know, you got I got all these K wires in there right to stabilize everything. And you're right that fusion is probably not necessary. But I, I think the screw that goes from the capitate the lunate you get one shot. If that screw if you're putting compression screw in there. And you know, I think there's so many things can go wrong, I like to have something fixed a bigger target. Everything else is squared squared away. So I just have to tighten that one screw and then I can be done. I do think that if you're using these compression screws, they they take up a lot of space in the inside of the Lunate which is a bone that I certainly have created Kienbock's disease in by putting in these screws. I don't know check if you want to talk about that at all. But but you know, so I just I want to be careful. So that's why I do it that way.

Chris Dy:

How much do you endeavor to prepare the joint surfaces aside from I mean, so are you doing the side to side joint surfaces? Are you also doing the triquetrum and the hamate? Are you just kind of putting the screw in to stabilize things?

Steve Moran:

Well, you know, I think that probably all the problems we've seen with the circular plate are because we're not paying attention to the carpentry. I really do take a lot of time to denude the bone between the force of the capitate lunate and the triquetrum and the hamate in between the bones I will do a little bit between the triquetrum and the lunate, but not sometimes between the hamate and the capitate. But that's a very stout ligament. So I don't spend a tremendous amount of time there. But I will you know, if it's sclerotic, I'll put drill holes in and then you know, I really will pack it full of bone before I compress down the screws. I do think that joint preparation is critical.

Charles Goldfarb:

Yeah, I certainly agree. You know, we, we haven't gotten into some of the details, nor do we need to, but I always go antegrade with my screw from the Lunate to the capitate. The reason I do that is you know, the lunate is a very, you know, from a proximal distal standpoint, it's not a long bone. And so getting the wider part of the screw there, just like we treat a proximal scaphoid from dorsal I try to that's how I think about it. I've also had a more difficult time with attempted retrograde screws, but I like your pearl longitudinally, not trying to come from the dorsum of the capitate. Trying to come from distal to proximal truly does make sense. I think that's really interesting. I will think about that more, thanks for sharing that.

Steve Moran:

And but you know, just we looked at all types of fixation, Chris, no difference in outcomes, it doesn't matter what I say you should just do it. However it's easiest and safest for you. And that's probably the most important thing.

Chris Dy:

So I am part of a travel club. And we've talked about, you know, in some have have trained at Mayo, and some have trained elsewhere. And we talk about choice of fixation here convinced me to use headless compression screws as opposed to the sexy plate.

Steve Moran:

Oh, I can't, I can't I just think you know that. Some people, gosh, you know, one of my partners, Alex Shin, that guy can put that plate on him in like five minutes. And he always gets great results. And I think it's just whatever you're comfortable with. I have having seen patients come in from elsewhere, you know, you certainly see plenty of that come in with prominent hardware with nonunions with screws that go into the pisotriquetral joint you know, all kinds of things with those plates. And I you know, I I just think after, you know, Dr. Gelberman is a big influence on my research, as you guys know, and looking at the blood supply to the lunate, there's not that much blood supply in that bone. And I really feel if I'm like firing screws in there and reaming off that 50% of the dorsal surface. I can't I can't sleep very well. So I have to. I think I just rather put one compression screw in.

Charles Goldfarb:

Yeah, like anything. I mean, you know, if you are technically proficient and get the results you and your patients hoped for, keep doing it that way. But I'm with you. I think screws make a lot of sense. Before we shift, I think we should briefly highlight the literature. Are there any other technical pearls? either Steve or Chris that we should touch on prior to shifting gears and talking briefly about the literature?

Chris Dy:

I think the post op protocols are super important here too. So I mean, if you want to share your post op protocols, both you for each PRC and four corner that probably would be of interest to our surgeons and our therapists that are listening.

Charles Goldfarb:

Yeah. Steve, take us from you said you cast the PRC for three weeks which is shorter than some our partner Lindley Wall agrees with you. She does more PRC than I think Chris and I do and she loves the three week mobilization. What are the expectations after that? Do you splint? how aggressive do you get with your motion? And when do you tell them they can be hammering fenceposts? If that's what they need to do?

Steve Moran:

Yeah, so for So You heard what we do with a proximal row carpectomy. You know, and we still give them after those three weeks, they certainly are in charge of wearing their wrist splint whenever they need to for discomfort. But for the four corner fusion. The one quick thing I want to say before we leave the technical pearls, you know, we do always recommend flexing down the wrist in correcting the DISI before you get too far in your procedure. So that one pin, which we call the Linscheid pin here because you're correcting the DISI keeps the lunate in the proper position. Because we all know that if you end up fusing with that lunate, in extension, the post operative risk motion is really ruined in for a manual labor. Getting the wrist back in extension is key for maximizing grip strength. So okay, but having said that, they aren't now in a cast it least for six weeks, in like maybe eight because I'm I'm still, even though I have compression screws in there, I still really want them to show some signs of healing. So it's just a longer rehab for me. And then I let them you know, two months, they start doing range of motion. And I'll let them go back to heavy manual labor when they feel that they are relatively pain free for like, if they want to do a fence post, that's pretty significant throttling of the wrist, but if they feel up to it, they could go back at three to four months.

Charles Goldfarb:

That's super helpful. So you're, obviously you're leaving some of this to the patient, but from a proximal row carpectomy standpoint, it sounds like by six or eight weeks, you're letting them go. But for four corners, it's looking more like four months for the heavier tasks. Does that sound right?

Steve Moran:

Yes. And you know, obviously, my PA should be here. Because when I leave the room, she obviously tells them the real story. I mean, she she's like pushing at the door, so that she can say yeah, yeah, let me let me tell what's really going on here. But I think that if I'm being conservative, it's probably you know, you're moving your hands and your wrist and you go back to things but if you really try and do like, you know, fix the tractor, change the power, takeoff and all these things, and I think it's gonna be about four months.

Charles Goldfarb:

So let's just briefly I think we should wind down and we're grateful you joined us here for another pod. What I think's interesting about the literature on PRC versus scaphoid excision and four bone fusion, is for me, at least you guys may both correct me. You know, I was finishing my training in 2001. Well, after Dr. Moran, and the article from Scott Kozin and Mark Cohen, Cohen came out, which which really was the one for me at least that set that really kind of informed my thought process for a while, which is now changed. But basically, it said younger, manual labor four corner, older, lower demand PRC by comparing their two practices. And I'm curious as to your thoughts on that kind of precedent setting paper, which is in the journal hand surgery. And then your thoughts on the evolution of our understanding because you've contributed a lot to that evolution.

Steve Moran:

Yes, Chuck, we were in the same fellowship class. So I mean, yes, I we read the same paper. And, of course, you've got two great surgeons there. You know, Mark Cohen can like fix a scaphoid that's like in 50 pieces. I mean, you know, the guy's a, he's a, he's a great surgeon and Scott Kozin goes without saying, I mean, those guys are phenomenal surgeons, what you're not seeing there is what they told the patients ahead of time. You know, I think that that setting up the expectations in who you're going to choose to do these operations on is critical. One of the things we looked at, like 150, proximal row carpectomy, is to figure out what was the predictor of a good outcome? Was the surgeries done after 1990? And you know, could it be different techniques, but I think we knew at that time, we had two good options, and we're choosing the patients more appropriately. So you know, there are patients you're going to go in on, you're planning to do a four corner fusion, you're going to go in there then the lunate's going to be toast or I mean, it's very unusual, but like in a bad DISI, you know, they can get all the cartilage can be worn off the bottom and you got to do a proximal row carpectomy. So, you know, I think you have to be prepared for both. I really tried to individualize it to the patient, but I think in broad strokes, what they found in that paper when that was published holds true for me today. I mean, that's that's my two major categories. You're right.

Charles Goldfarb:

Maybe I'll just close this thing. What it's been remarkable how much literature has come out on this topic. Whether it's Nick Kazimierz, who's at Utah, talking about Cost Assessment, your work on younger patients, but it really to me has become more clear that it is absolutely crystal clear that the cost, we all know cost matters, but four corners more expensive, more likely to require revision surgery. Compared to PRC, we know that younger patients do just fine with PRCs. And so I think it is is still a choice that we as surgeons make. But the choice kind of how to categorize that choice is what's changed. And I think I have a better understanding of who will do well and what other factors to consider. So that's that's my take, Chris, I don't know what your take on the literature is.

Chris Dy:

It's interesting to hear to grandpa's talk about the literature when it came out. But it's also interesting to know that both of you have contributed a lot to to this particular topic. And you still believe the findings of the Kozin and Cohen paper. That's super interesting. I'm not saying that either, you know, whether in a good way or bad way, I think it's interesting, because, you know, there is a lot of power in kind of that level five experience and, you know, seeing how the literature may apply to your practice. I want to ask one question of each of you before we close, what's the shelf life of a PRC?

Steve Moran:

Chuck, are you gotta go first?

Charles Goldfarb:

Yeah, well, you're our guest, I'd like you to have that opportunity.

Steve Moran:

Okay. Well, okay. I, you know, in that paper, we wrote back in 2011, some of those patients were were 19 years out, they had the same, you know, the same motion before and after, I mean, the shelf life, I guess is when the patient has pain tells you they want you to take to fix it. But I mean, it can last a long time. It I remember I presented that paper at the the ASSH to it. The IWIW wrist associated workshop and Kirk Watson said, well, nothing lasts forever. You know? And is is is that is that? Should we say that? I mean, shouldn't we try to get the patient one operation last semester? Like we can't, I don't think we can do that yet. I think what I would like to say in summary, before we go to Chuck, because he should always have the last word, I think that we we don't have a perfect solution. That's what we should say about all this is that you know, you young people out there you resins and fellows who listen to this podcast all the time. should think of a better way to fix this problem. Whether that's with cartilage grafts or stem cells or exosomes or better arthroplasty, there needs to be another solution that is outside the box. Got to travel the world to maybe see the solution. But I think that's, that's what we're really looking at here. We have an imperfect we have an okay, but an imperfect solution to this problem.

Charles Goldfarb:

Yeah, I think that's really well said I don't have much to add. The only thing that I don't think we've mentioned, which is important is that clinical outcome and radiographic outcome are different. And then we know it 20 years, most patients at the PRC are likely to be doing well. Just don't X ray them, because you're going to see arthritis. And we don't need to know that is the reality. I will close by saying, you know, it was great to see, I saw Steve, God I think it was last weekend for this for this conference we mentioned and I was really hoping to catch up at dinner. That didn't work out Steve's very popular and people were flocking just set it to his table. And but I do feel like-

Steve Moran:

They still put me at the kiddie table. I want you to know that there's like a big table for all the professors and there's a small table and that's where I usually am.

Charles Goldfarb:

Yeah, well, I feel like we caught up today. So I'm so glad you came on both to educate me and just to catch up. Thank you.

Steve Moran:

Yeah, thank you guys. And thank you again for what you're doing. I think so many people love this. I you know, I was very skeptical. But it's, it's, it's really doing well. So congratulations and gosh, keep it I know it's a lot of work for you guys. And keep it up. Tell me when you want the check so we can get some bigger mugs.

Chris Dy:

Might have to take you up on that one.

Steve Moran:

If you send me another one, then I can have two and then they'll never know that I'm refilling the coffee cup, because I'll just pick the other one up. Be a little colder, but it's okay.

Chris Dy:

Thanks. Thanks for joining us, Steve I'm gonna go get a refill on my coffee.

Steve Moran:

Yeah, have a great day, guys. Thanks so much for having me.

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. And if you'd like to email us, you can reach us at handpodcast@gmail.com.

Charles Goldfarb:

And remember, please subscribe wherever you get your 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