The Upper Hand: Chuck & Chris Talk Hand Surgery

Chuck, Chris, and Macy Discuss the Thumb CMC Joint, Part 2

June 12, 2022 Chuck, Chris, and Macy Stoner Season 3 Episode 22
The Upper Hand: Chuck & Chris Talk Hand Surgery
Chuck, Chris, and Macy Discuss the Thumb CMC Joint, Part 2
Show Notes Transcript

Season 3, Episode 22.  Chuck and Chris welcome hand therapist Macy Stoner back to the show to continue the CMC joint discussion.  Macy shares her thoughts on the role and specific modalities for nonsurgical care as well as thoughts on recovery post CMC arthroplasty.

Article referenced: Outcome of a Hand Orthosis and Hand Therapy for Carpometacarpal Osteoarthritis in Daily Practice: A Prospective Cohort Study.
Tsehaie J, Spekreijse KR, Wouters RM, Slijper HP, Feitz R, Hovius SER, Selles RW.
J Hand Surg Am. 2018 Nov;43(11):1000-1009.e1. doi: 10.1016/j.jhsa.2018.04.014.
PMID: 29776723

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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 you?

Charles Goldfarb:

Fantastic. How are you?

Chris Dy:

I'm fantastic. You know, I really enjoyed our conversation with Macy last week, and I look forward to hearing the second part of it. You know, I will say that I've learned quite a bit already. And I've incorporated some of the teaching and strategies that she has described to patients, both for the non operative treatment, and also what to expect after surgery already into some of my clinic conversations. So I hope those of you that are listening who aren't as familiar with therapy have done the same.

Charles Goldfarb:

Yeah, we don't usually have an opportunity to learn from our non surgical peers and Macy really has a lot to share. So it's been it's been very helpful. If you're okay with it, why don't we take a listener submitted question. Before we dive in? This one's from Jason Ghodasra who writes-

Chris Dy:

Hold on timeout, timeout. So Jason, I will say we love your email. Chuck and I both struggled with your name. And for somebody who has a often mispronounced last name. I feel so bad doing that to you. So I think let's say it's Jason Ghodasra that maybe that is that. You can tell us if we have butchered your name, and we're sorry, but we love your question.

Charles Goldfarb:

Yes, that's, that's well said. So Jason is an orthopedic hand surgeon in a large private practice in the Chicago suburbs. Very nicely, he wanted to thank us for our, quote, awesome podcast. And I like this next sentence. While I love my job, and partners, private practice can be academically isolating. And the podcast has added a weekly conference lecture that I've missed since graduating from fellowship. That's, that's really fantastic. And we're glad we're filling that void.

Chris Dy:

That was kind of the goal, I think, for us, aside from just being able to hang out an hour a week. But yeah, that's fantastic for us is to hear that it's been able to fill that void for you. And, you know, thank you for this email. I think both Chuck and I learned quite a bit. And I think it's a good fodder for discussion.

Charles Goldfarb:

And so we have to be, you know, when we have these discussions about cost and pricing and you carefully, enter murky waters, and we don't want to disclose sensitive information. So we'll be very vague about things. But I think Jason said it well, in his email. I was recently listening to your episode on JBJS hand and wrist update. And you mentioned that the surgery center collects a higher facility fee for endoscopic carpal tunnel versus open carpal tunnel. And let's be clear, Chris, and I work in a hospital based outpatient center. And as we all know, it's very different reimbursement model than a true ASC. So Jason continues in the area where I practice, the opposite is true. The facility fee reimbursement for the ASC is 80 to 100 dollars lower for endoscopic carpal tunnel than open carpal tunnel, which is stunning to me. And he recognizes and he goes on to say he recognizes that reimbursement rates vary. And you know, we're in St. Louis, and he's in Chicago. But interestingly, you know, many of his partners and Jason himself do primary endoscopy carpal tunnels. So Chris and I went back and just to double check this, I pulled some actual data. And sure enough, the numbers are really something in St. Louis, and again, I got to be a little bit vague, but in the scopic pays, sometimes double facility fee compared to open carpal tunnel release. Now it's not universally true. But that's really remarkable.

Chris Dy:

Yeah, I think that you know, that's something to keep in mind if you're a new surgeon, and you are fortunate enough to feel facile, doing both techniques and comfortable offering both techniques. That's something that may play into your decision making. But I think that most surgeons aren't always considering facility fee in their calculus, what they might consider for better or worse is their own professional fee. And I'm not judging one way or the other. But Chuck, do you feel like the professional fees for the surgeon which are separate from the facility fees For those of you that are less initiated with the wonderful American healthcare system, do they often go in parallel? So for example, like, say in Jason's market in the suburbs of Chicago, where the facility fee for the endoscopic is lower with the surgeon fee also be lower typically, or are those pretty unrelated?

Charles Goldfarb:

Well, typically, I think of them as going hand in hand, Jason relates that the surgeon fee is or the procedural fee is $50 to $100 more for endoscopic versus endo for endoscopic versus open. And in our world, it's that the reimbursement difference is even greater. So it's more notably, positive for endoscopic. But, so for someone who has thought about these things for a long time, when we opened our outpatient surgery center 15 years ago, we spent a lot of time, I think you were still in high school, then. But we spent a lot of time thinking about cost and emphasizing cost. But the reality is, it's so challenging, as you said in our American healthcare system. To put all this together, it just doesn't make sense. And it varies from city to city from ensure to ensure. And as as physicians, it's really tough for us to try to use cost or reimbursement data to influence our practice. And honestly, it's probably for the best, right, we should do the right thing for the patient based on our training, our experience and our expected outcomes, and the chips fall where they may now some of the listeners might not agree with that approach. But that hasn't been our approach, and I think will continue to be our approach.

Chris Dy:

Yeah, and I agree with you entirely. It's frustrating when we have to deal with this side of, of medicine, at least American healthcare. You know, for example, yesterday, I was doing a prior authorization slash peer to peer for the use of a nerve allograft for a digital nerve. And this particular insurance company had placed the use of that nerve allograft on their exclusionary lists. So automatically, unbeknownst to me, my peer to peer was going to be in vain anyway, because the quote peer who was not a hand surgeon, you know, would not have been able to overturn that decision anyway. So now I have to go through an emergency appeals process, which takes at least three business days on the holiday weekend in the States. So this patient surgery, which has already been postponed one time and pushed back a week is now going to be postponed again for another week, or we're going to have to harvest a nerve autograft, which you know, that works. It's great. It's, it's going to work well. But he'll have another incision, more operative time. It's just really frustrating. But what we can do, you know, so first off, Jason, thank you for your question. Really, really appreciate it. I think it brings up a lot of good things to discuss. But when we have our meeting, at the IFSSH, our live podcast taping we can debate these intricacies of healthcare delivery with our audience. So if you want to come check us out at the IFSSH here is the info. So we are going to be doing a live taping. The live taping is going to be let's see here on Wednesday, the eighth of

June at 5:

45. Local London time in the south gallery room 13 will be there for 45 minutes, we're going to record an episode we hope to see lots of people there. If there are enough people there, we'll just do a free for all q&a. The room holds 70 people so please don't embarrass Chuck and I for asking for a room.

Charles Goldfarb:

Are you bringing some swag to London with you?

Chris Dy:

There will be swag. We have actually have a little bit of the old swag and a ton of the new swag. So please come into the slide that we're bringing is actually perfect for those who are attending a meeting and need to demonstrate some kind of meeting registration if you get my drift could also be used for other things like keys, maybe hospital IDs. I mean, it's just it's gonna fly off the shelves. It helps that we're giving it away. But yes, it will fly off the shelves.

Charles Goldfarb:

I love it. I love it. All right, Jason. Thank you again. And without further ado, we're going to jump back into part two of Macy educating Chris and I about the thumb CMC joint. What is I love this we just get to pimp you with questions. What is the definition because all of our listeners may not know and I certainly can always use a refresher. What is the definition of in the importance of if any, iontophoresis in the care of the CMC arthritic patient?

Macy Stonner:

So that is not a modality that I practice typically and I don't know if it's because it became a little bit more we'll say antiquated but a little bit more in the past when I started practicing, but there are some physicians that request it with their patients. I'm going to be completely honest and say I don't have experience with this. Um But it's basically dexamethasone infused into thumb joint, I believe to help decrease pain. But the instructions are to do it three to four times a week. I worked at the Milliken Hand Center, which is in the middle of the city, and there's so many patients that I have where our biggest deterrent for therapy is transportation, parking, getting there from work, so many people like, it's such a difficult thing to get people to come sometimes to have them come three, four times a week for that it's difficult would be difficult, I believe. And so more frequently now in 2022. I feel like they have more portable units where they would take them home, and just do that as an independent therapy at home. But, again, I want to be really honest and say I don't have a ton of experience with that modality.

Charles Goldfarb:

And this is ultrasound.

Macy Stonner:

Yes, ultrasound guided steroid. Yeah.

Chris Dy:

Do you know one way to infuse dexamethasone into a joint? One time?

Charles Goldfarb:

Big old meal.

Macy Stonner:

You also asked previously, Dr. Dy, about joint protection?

Chris Dy:

Yeah.

Macy Stonner:

We talked about joint stabilization exercises. Joint protection isn't as fancy as that it's not rocket science. But it's it's a thought process that a lot of people may not have. So some people correlate therapy with exercise based treatment, you know, a lot of no pain, no gain type mentality. And so when they come to therapy, for CMC arthritis, they think that's what it's gonna look like. And you kind of have to re educate them that, you know, it's not that kind of thing. Joint protection, there's some strategies that we just want to help you understand. And the first we have like a little bullet point, handout we give our patient with like the basics of it with some photos. So the first one is to respect pain, or always let pain be your guide. If you're doing an activity that causes a lot of basic thumb pain, probably not the best idea, that's not the kind of thing that's going to make you stronger. And that seems like a very simple thing to understand. But you'd be surprised at how many patients don't know that. Other things that we instruct them is in the use of modifications and adaptive equipment in the kitchen. So like, different types of ways to open jars, whether that's with a gadget or like a device or just a technique where you grip it. Different types of knives. We talked about the importance of using larger joints, as opposed to smaller joints. So if you think about your thumb, CMC joint versus your elbow or your shoulder, it can withstand so much more force as the shoulder. So like we talked about taking groceries in from the car. So many people will put seven bags in one hand seven bags in the other because they don't want to take two trips. It seems simple, but telling them about the importance of like having a big shoulder bag and stuff while your groceries in there. And again, it's, I guess, a little bit more of a simplistic type thing to educate them on. But we've had good receptivity to that type of education in this population.

Charles Goldfarb:

Next question, I feel like I'm the attorney. What is the role of paraffin wax treatments for CMC joint arthritis like dipping your hand in the in the thingy and leaving it there for 20 minutes,

Chris Dy:

Dipping your hand in the thingy and leaving it there. That's the very technical description from our full professor.

Macy Stonner:

So definitely, I definitely think it has a role but not because of the wax medium, but because of the heat. So that can be warm towels, a heating pad that you plug into the wall, warm rice that you put in the microwave and slightly grip, paraffin, whatever makes the patient feel better. I'm all for. I do instruct patients and keep therapy for this particular thing. But I'm always very honest and say this isn't going to make your arthritis go away. You can do it once you can do it five times a day does not matter. But uh, it's not something that I would have somebody come to therapy for once or twice a week just to do paraffin. I would instruct them how to do it using a home unit or if they were already coming for other things, and they wanted to do it then great. But I mean, I think we all know that it's not going to change the course of their arthritis progression. But if it helps the patient manage their day a little bit better. I'm all for it.

Chris Dy:

Macy without naming names. What are some of the misconceptions that you have to correct when patients come in? Perhaps they've seen a hand surgeon either at our medical school or somewhere else? What do you have to unteach?

Macy Stonner:

That they need to come once or twice a week for five weeks? Because I feel like that would be I don't I don't have enough to teach that patient that often. I would say so I would feel fraudulent billing somebody's insurance that frequently for this diagnosis. I didn't truly believe that I was making an impact. So the frequency at which the referrals written And then if it says something like strengthening work conditioning, work hardening or something like that, where you think strengthening of the thumb. So a lot of people have like therapy putty where they're just pinching it to strengthen their thumb. And sure that's going to strengthen you. But it's going to make you much more painful. So what's the point of a really strong thumb? If it hurts so bad, you're not going to use it? So those would be my things.

Charles Goldfarb:

What, I do want to share one paper, which I literally think is the only while there's a couple of papers, but what other modalities do you believe are helpful? Or have we hit them all?

Macy Stonner:

I would say or go to heat, warm rice, or paraffin or heating pad, not cold. I mean, they, if they particularly find that helpful for them, great, but most people don't like it. Electrical Stimulation? No, I don't have a lot of experience with patients using a tens unit on their thumb. But if it makes them feel better temporarily, then sure. At least ultrasound, no evidence to suggest that's going to do anything. I think we've had them all.

Chris Dy:

Good. Chuck, before we jump into that paper, what do you tell people to do at home, Macy? You mentioned the exercises, you know, making an O and then see what else do you teach them? And how frequently do you ask them to do it.

Macy Stonner:

So the exercise, I wouldn't say, I write on the top of their paper, this is a lifelong exercise. If you do it once today, zero times tomorrow and seven times next day. Great. This is something to have in your back pocket to pull out throughout the years. That's the only thing I have them do like on a regular basis well with those parameters, but the other things, being cognizant about the thumb posture, and a lot of the drop protection techniques are the heat all day every day, they can incorporate those things into ADLs. And that type of thing. So it's, it's not the kind of therapy that you think of okay, at my Exercise folder, and I have to do these four times a day, and then I do 10 minutes, and then I hold for five seconds. Like, it's not like that. It's more come to the session for an hour. Let me educate you a lot about what this looks like and how to incorporate basic strategies into everyday life, whether that's cooking, driving, brushing your teeth, etc. So it's not the sexiest treatment, I would say. And I might treat this diagnosis very differently than some of your listeners here. But I'm just here for my insight, I guess.

Charles Goldfarb:

That is why you are here. Because we value your insight and you feel passionately about CMC.

Macy Stonner:

I do.

Charles Goldfarb:

Alright, so my favorite paper in the literature on this topic. And again, I said there were a couple there are, but most of them are like meta analyses looking at outcomes, and they really aren't that helpful. Just like honestly, the surgical papers aren't that helpful. Because every you know, in my opinion about every surgery does pretty much the same, which is good. But not that you know, doesn't help distinguish. So this is a paper out of Rotterdam. The first author's last name is Tsehaie, I'm not going to try to pronounce it. But the title of the paper is outcome of hand orthosis and hand therapy for CMC osteoarthritis in a daily practice a prospective cohort study. So well designed study Rotterdam, I visited they're part of part of one of my traveling fellowships, we've been back a couple of times, it's a really good group of plastic surgeons primarily, that really kind of get hand surgery, adult and pediatric. And bottom line just to cut to the chase is this had this. This study had a 2.2 year follow up. And the magic number is only 15% of patients that were sent to therapy ended up having surgery in that timeframe. Just pretty remarkable. They paint and proved primarily early on the MHQ Score, Michigan hand questionnaire was basically flat over the period of the study. And I think it has to do a lot of what we just heard from Macy it's about teaching patients what they can do, how they can manage their pain. And, you know, I think the lesson for me is just don't be so quick to run to the operating room. You know, I'm a surgeon, I love surgery, I think it can be very helpful. But you know, many patients will like the concept of trying to avoid surgery trying to avoid injections. And I do recommend this 2018 study for those of you who are interested and I'll put it in the show notes as well.

Macy Stonner:

Thank you for educating us on that paper. And I don't want to get into this but I'd be curious to know if they how they operationally defined therapy like was does it just go to therapy? Yes or no or what was done in therapy? I'm not really sure if you know that but it's something that I would be interested in looking at the future.

Charles Goldfarb:

Yeah, so basically They all got general custom made or prefab orthosis. They had two sessions of hand therapy per week, which is what you said you didn't like to do for an-

Macy Stonner:

It depends on what's done.

Charles Goldfarb:

For an average of 25 minutes. And basically, the therapists controlled what was done. And when it was done. Some patients only got the orthosis. Some patients, you know, went over a course of multiple weeks. And so it was there was a sounds like a fair amount of variability and what exactly they did. But that number is remarkable. It's remarkable that only 15% converted to surgery after seeing a surgeon for CMC arthritis. And two years later, only 15% answered. It's great. It's fantastic.

Chris Dy:

What do you think your number is? What percentage do you think your patients that you see, since the therapy then cross over to surgery?

Charles Goldfarb:

You know, if I don't know the answer to that question, I, the ones I know are the ones that come back for injections until they fail. And my pattern, I assume is like everybody else's the first injection, and especially in a patient who doesn't have terrible arthritis is good, you know, maybe nine months or a year, and then it slowly declines. And when patients are seeing me every three months for an injection, they get tired of it and they scheduled surgery. Is that your experience?

Chris Dy:

Yeah. But I mean, I feel like the 50% feels about right to me. Yeah, but our practices are at very different points in maturation. You know, so I think, you know, I remember and I've said this on the pod before, I mean, my first year, when I was in board collection, I didn't do any thumb CMC surgeries, because my practice was just starting. And it's not what I jumped to right away. But it took a while to even get a reasonable clip. And I was certainly not one of the highest rollers in your study, mainly because I didn't do a lot of it and still don't do a ton. And maybe that's just the nature of the practice I have, because I see so much nerve and other stuff, too. But I'd like to think I have a pretty robust general answer to your practice. And I think 15% feels about right in terms of conversion, maybe it's even a little higher than what I see. Again, me I'm not as passionate about this in terms of like jumping to the bar. But I'd like to think I have reasonable indications.

Macy Stonner:

So I've worked with both of you in your clinics and Dr. Goldfarb, I know No, well, either you there's a patient coming in for like routine injections, obviously, like they've probably been done therapy route before, that's not going to be somebody that I know that I need to go write a referral for. But do you feel like somebody coming in as a new patient never been to therapy, kind of that same case you described in the beginning of this podcast with both of you? 100% And that person therapy? Maybe like depends on what your mood is that day? Depends if you have a therapist in the clinic, I'm just curious to know like, Are you always gonna send that person?

Charles Goldfarb:

100% of time I offer and push gently towards therapy. I mentioned the other treatment options, which may be a mistake, because sometimes they'll be interested in injection at the same visit with me.

Macy Stonner:

Yeah.

Charles Goldfarb:

I always suggest therapy.

Chris Dy:

I try not to put needles in people the first time I meet them if I can avoid it, because our needles tend to hurt. But I will mention it like Chuck and sometimes you know, they take you up on it. If I have a head therapist and clinic with me and usually in that clinic I do. I will say I want you to talk to so and so either usually in the south county clinic, it's Kathy or Jamie, they talk to Kathy or Jamie. They'll determine whether how frequently you might need to come for some therapy. And or if you're in clinic with me down the main campus, talk to me see, let's see what she thinks. And we're very fortunate to have that environment where we can do that. And it's not automatically a prescription and like you said for some of our patients, you know, transportation resources are a challenge. And you know, insurance stuff is a reality and that can be very tough.

Charles Goldfarb:

Let's, let's pivot for the last few minutes if that's okay, and let's just talk about postoperatively. First of all, may see what is your favorite surgery favorite CMC surgery to help a patient with postoperatively Do you have a preference? Is it is it the standard LRTI? Is it the intro brace? Is it another procedure? Do you have a favorite or do you feel like they all recover about the same?

Macy Stonner:

It just goes back to my gender point. I think it's a guy. I like the intro brace reconstruction. I feel like they come out of that postop dressing just rock solid. They got a really good posture their thumb I just look at their thumb and like, that's a good outcome. The CMC joint is nicely positioned their MP joints flexed they just look good. And they typically don't need a ton of therapy for me because they're pain free. Their range is good. They can start strengthening early. They do great and again anecdotally speaking for a woman a kind of feel like an lrti Because you're casted depends on the provider but typically for maybe six weeks and so they just have a little bit more opportunity to stiffen up and they don't come out of that post operative dressing. Just kinda like unstable and weak and scared. They're just like rock solid and that nice thumb position. Again, the LRTI obviously, you have a little bit more rehab to do regarding the wrist, their wrist, it's a little bit more stiff and painful. But I think they're both very reliable. And it depends on the patient. Obviously, if it's a revision surgery, I think that my mantra for this is less is more, I see so much more recurrence of pain or recurrence of a collapsed posture, rather than stiffness. So if I had the opportunity to have a say, and how long they were mobilized, I'm always going to be a little bit more conservative and have it longer. Because you can't go back, you can always work on motion and stiffness, but can't tighten up that joint even more if I just hate to see somebody start moving too early.

Charles Goldfarb:

It's an interesting point, because there is no doubt that trend is earlier mobilization, even for LRTI. And the study out of Salt Lake City, by Hutch and others really describe that and eight compared, you know, two weeks versus four weeks and get the same results. But I am with you. I mean, I don't find any harm and immobilize no longer with a soft tissue reconstruction.

Macy Stonner:

Exactly what's the harm in it, I it's just very rare that I would see somebody that gets too stiff. And sometimes there are those cases where you can tell they might have a little bit of a CRPS vibe or a lot of anxiety about a cast or you know that they're super swollen, their their fingers are stiff, likely a good idea to get them started a little early, take them out of the cast, put them in a custom brace that they can take off to breathe. But obviously, it's a very case by case basis.

Charles Goldfarb:

What do you when you educate LRTI patients? How long do you believe? And it may not be a fair question, because I don't know if you see them long enough. But how long do you tell them, it's going to take them to get over the surgery and get back to you know, back to a situation where they're not thinking about their thumb. So really get over it.

Macy Stonner:

Eight to 10 weeks, I would say typically strengthening isn't initiated until 10 to 12. Again, depends on the provider depends on how the patient's doing. But if you need a ballpark, I would say 10 to 12. Let me know if you disagree. But to get over it to where you're really just kind of living your life not thinking too much about it. I feel like probably eight to six weeks they meet you. They're freaked out, you make him a brace, teach them how to move to them, or I would say twice a week, by the eight week point met them probably six times, and they're getting a little bit more confident. They're not thinking about as much they probably have full motion, maybe starting to do some live activities without the brace on life just a little bit better for them.

Charles Goldfarb:

Chris, what do you tell them for LRTI till they stop thinking about it daily?

Chris Dy:

Six months. You know, I used to tell them three months. And then we had Jeff Stepan one of our former fellows and now superstar faculty at the University of Chicago, he did a qualitative project, interviewing patients who had thumb CMC surgeries. And they all said and a lot of these were my patients. So I took this pretty personally that we told them it was that the recovery was shorter than it actually was. So I tell them that it's going to take six months until they start to feel like you know, they don't hate me every time they use their thumb. But eventually they will get there. And I'd love it. I don't know maybe is it 10 to 12 weeks from when they start therapy? Or is it 10 to 12 weeks from surgery?

Macy Stonner:

10 to 12 weeks from surgery, being able to do some like resistance type thing. So like actually pulling your pants up with your thumb and index finger like that kind of thing. So that's when life gets a little bit easier because they can actually they're allowed to use it to different stories, they have recurrent pain. So we obviously share very different timelines. But I think it depends on what exactly we're talking about here.

Chris Dy:

I'd rather under under promise is I guess there's a term for this. But I mean, you also don't want when you talk to patients about this, you have to be very careful because you don't want to you don't want to over promise. You don't want to under promise because also want to scare him away from what you know is a good surgery that can help a lot of people. But there are some people that are on the fence reasonably so about surgery, and the amount of time it's going to take but that number seems to have worked for me recently. Chuck, do you tell them something somewhere in between are you closer to Macy? Closer to my number?

Charles Goldfarb:

I say four to five months, but what I'm telling them is my thing is four to five months until you are back doing all your activities and you're not thinking about your thumb. I think at eight to 10 weeks people are back to most of their activities, but they are still thinking about that thumb. It's like-

Macy Stonner:

That's a good point.

Charles Goldfarb:

It's like it to me it's like any painful situation. You know you can start using the painful joint or the injured joints sooner but it's really when they aren't thinking about it that that means they're over the hump. So it's just definitions. I think we're all saying.

Macy Stonner:

I agree.

Chris Dy:

How about golf? I've had some patients recently, obviously, with the time of the year asking about golf.

Charles Goldfarb:

With an internal brace, I would let that let them start pitching and putting in five to six weeks and progress as tolerated. From there. I honestly think it's like 10 to 12 weeks before they're getting out the big driver and going crazy.

Chris Dy:

Maybe I want to ask one more question about this. Because it's a surgery that in the right situation works incredibly well. But it's not universally used. What about a CMC arthrodesis?

Macy Stonner:

They do great depends on the right patient. I anecdotally speaking again, I feel like the classic patient would be like a 40 or 50 year old guy or woman who are a little bit too young for the board reconstructive procedures. Rarely do I have a complaint. It's like slam dunk pain is zero. I have strength and good. The only complaint I would say is if like the thumb was brought out too far into palmar abduction, where it's a little bit in the way. But other than that, from a pain perspective and a function perspective, I think that they do quite well.

Charles Goldfarb:

I'm a fan too. I think you know that, Chris, I don't I don't remember the last time I did one. But in a young patient with high demands, I really like it. I think it can really provide a good outcome. And certainly, you know, I just see a very young population that sounds can benefit from it.

Chris Dy:

I think that's that procedure has been has gotten a bad rap mainly because of that RCT that was stopped prematurely in Europe, because of the high non union rates. But, you know, radiographic non union does not necessarily equate to a symptomatic non union. And I think that was the experience that I think it was it was the KJ Hippensteel, one of our residents who wrote that paper with Dr. Gelberman and some of the other partners. Yeah, the the non union rate is real. Now, the symptomatic non union rate was quite low. So I think with some changes in the technique and some of the newer implants specifically designed for that arthrodesis. It's a surgery that works really well. And I don't use one of the special implants but I love that surgery in the right patient.

Charles Goldfarb:

Yeah, totally agree. All right, Macy, final thoughts on your favorite joint in the body?

Macy Stonner:

I guess my final thought would be to remember that less is more in a postop patient, and in a conservative management patient. You just have to approach it the right way. Doesn't require a ton of therapy. Just give them a really good education session and got to find the right patient. And, yeah, that would be it. I appreciate y'all having me tonight.

Charles Goldfarb:

Oh, the pleasure is ours. This will be a highly rated episode for sure. I've learned as I always do when we when we chat and we'll have to figure out the next topic to dive deep on.

Chris Dy:

Questions for Macy, handpodcast@gmail.com. Send them

to Macy. Attention:

Macy.

Charles Goldfarb:

Alright, y'all have a great night and we'll see you soon.

Macy Stonner:

Good night.

Charles Goldfarb:

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 time.