The Upper Hand: Chuck & Chris Talk Hand Surgery

Chuck and Chris discuss ethical conundrums

July 03, 2022 Chuck and Chris Season 3 Episode 25
The Upper Hand: Chuck & Chris Talk Hand Surgery
Chuck and Chris discuss ethical conundrums
Show Notes Transcript

Season 3, Episode 25.  Chuck and Chris on the road again before we head back home.  This is another episode recorded in Providence, Rhode Island during the AOA Annual Meeting.  We share a few cases and discuss ethics.  Specifically, complications from an outside surgeon or repeated less than ideal outcomes.  Join us and share your thoughts!


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Charles Goldfarb:

Welcome to the upper hand podcast 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 things hand surgery related from technical to personal.

Charles Goldfarb:

Please subscribe wherever you get your podcasts.

Chris Dy:

And thank you in advance for leaving a review and leaving a rating wherever you get your podcasts. Hey, Chuck, how are you?

Charles Goldfarb:

Oh, hey, Chris.

Chris Dy:

Switching it up here with who goes first.

Charles Goldfarb:

I guess that's what happens when you're in, you know, episode number, how many episodes?

Chris Dy:

I don't I don't know, man. But you know, I was feeling a little bit insecure about our downloads stats when we were at the AOA meeting and hearing them talk about all of the podcast downloads that the JBJS podcast gets.

Charles Goldfarb:

I know, but I think you know, we I think we're sort of at one of those plateaus where each new episode is getting around 1600 or so, and each week we get around 3000. Feels like we've been here for a bit.

Chris Dy:

No, actually, the numbers are creeping up. So every time I get that email from Buzzsprout, I actually put it in my podcast folder. And then I go back and look at last week's and we are creeping up although the growth has been a little bit slower. You're gonna need to be a little more energized and engaged and perhaps as engaging as Mo Bhandari or something like that.

Charles Goldfarb:

Seriously, seriously, I guess we need we need a broader audience. Maybe with the hand stuff maybe too narrow.

Chris Dy:

Exactly. I did listen to Mo Bhandari on an ortho hub podcast. And he was pretty engaging. I've never met the man. But he sounds really interesting to talk to.

Charles Goldfarb:

I have no doubt. I have no doubt. So we have an ambitious brief podcast planned. We have a couple of cases. And then we want to talk about some ethics.

Chris Dy:

Yes. So don't stop listening. Now it is it really interesting ethical question. Okay, because the topic of ethics may turn some people off. But I think it's something that you know, most people are going to deal with in practice one day. So, Chuck, why don't you lead us off with your case,

Charles Goldfarb:

My case is not a huge discussion. But it's just an unusual situation, where I had a 12 year old male come in, who had previously fractured his third metacarpal and had pain at the MCP joint, he had maintained motion, although motion of the MP joint was painful. And on radiograph, the head of the metacarpal was flattened. He came in with an MRI, which confirmed that there was avascular necrosis of the metacarpal head, which has an eponym. Therefore it's real. It's called Dietrich's disease. But it's, it's AVN of the metacarpal head, really uncommon, really difficult, at least in my mind diagnosis. And I just thought it was interesting, because I've seen I see one of these every five years or so.

Chris Dy:

Difficult to diagnose or difficult to treat?

Charles Goldfarb:

I actually think we have good treatment. But in this case, as an example, the family wasn't ready to go to what I think is the definitive treatment. And so we agreed to stepwise approach. And so I performed-

Chris Dy:

Wait, hold on, hold on, hold on before we go there. So I have never seen this condition may have seen me as they say. So can you talk me through, you know what the classic textbook case of this is? And in particular, in your patient? Is it somebody who was treated without surgery? Where they treated with surgery? Is somebody who how many years out? Were they from the fracture? What was the nature of the fracture? Where was it that kind of thing?

Charles Goldfarb:

Right, so thank you, in the case of the adolescent is almost always post traumatic. I think it is most common in the third metacarpal, third metacarpal head, and it seems like just a random unfortunate event. It can be seen in others, patients with autoimmune conditions, patients on high dose steroids, like every other type of AVN. But in this case, it was in my practice, perhaps the more classic situation of sort of an idiopathic, avascular necrosis. And so the problem, of course, is that a large portion of the central metacarpal head dies, doesn't have the subchondral support the cartilage collapses. And then you just you just have a void and you have a major problem.

Chris Dy:

Is it usually a distal fracture? Or is it a neck fracture? I honestly I will admit I'm failing to remember where exactly the blood supply comes into the metacarpal head.

Charles Goldfarb:

I don't know that it necessarily follows I think the fracture can be anywhere in this case, the fracture was subtle and it was it was metacarpal shaft.

Chris Dy:

Oh, wow. Okay, and what's what do you have any you said you see this once every five years?

Charles Goldfarb:

I think so.

Chris Dy:

Okay. All right. So then how do you talk to what does the patient usually come in complaining of?

Charles Goldfarb:

I think the classic presentation is pain, sometimes with decreased or difficult motion and interfering with sports activities, as you might expect, and the problem of course, is you're not going to give a steroid injection based on age or based on the fact that he was that can help. I'm not sure what conservative treatment looks like when you truly have cartilage loss and lack of support. But you can certainly try to rest this. But I don't think that those things are typically successful.

Chris Dy:

Maybe just put some PRP in there what happens.

Charles Goldfarb:

PRP might be successful. I haven't tried that approach. I don't want to get too sarcastic on the podcast. PRP would not be my first choice.

Chris Dy:

For the low low price of.

Charles Goldfarb:

That's right. That's right. And so I gave the patient two options. Maybe this is overly simplistic, and if there are listeners that have seen and treated this differently, I would love to hear about it. The options I gave the patient were arthroscopy of the MCP joint with debridement and confirmatory information versus an open oats procedure, which I personally think is the appropriate treatment. And while it sounds daunting, especially to a patient, it actually is relatively straightforward, and I believe would give a great outcome. And in the past when I've done this has given a great outcome.

Chris Dy:

So is this an issue where the metacarpal head cartilage is actually there's defects in the cartilage? Or is it something where you have collapse of the subchondral bone?

Charles Goldfarb:

I think you have death of the subchondral bone and the cartilage above it collapses. And that's what we found on arthroscopy in this case.

Chris Dy:

So how, what kind of, I mean, if you're going to do an oats, do you have strong enough subchondral support to keep the piece where you want it?

Charles Goldfarb:

Well, I think that's part of the beauty of this. If we take a 10 millimeter plug bone with the intact cartilage above and I usually take it from the knee, and then plug that in. You can also take other you can take costal cartilage, you can take other things, but if you have a good supportive bone straight, then I think you get by the area of unhealthy bone and you can get this thing to heal.

Chris Dy:

And so are they. So, when you talk to this patient about arthroscopy, what do you tell them to expect if you're only doing the scope?

Charles Goldfarb:

I try to be as honest with them as I can. Excuse me. And I believe that the debridement like many things can help for a period of time. But I also tell them, I don't think this is going to be a long term answer for them. But if they're not ready for the other surgery, I think it's reasonable. I think the information gained from the scope is helpful.

Chris Dy:

Is it, does it give you much more information than an MRI?

Charles Goldfarb:

Yeah, I think it does. It may maybe not. Maybe the MRI told me what I needed to know. I think showing arthroscopy pictures is visual evidence for a patient that the MRI doesn't necessarily give, it's just more impactful to see that one centimeter hole in the head.

Chris Dy:

Right, right. I think a picture is very impactful on patients, which is you know, we were doing a teaching session yesterday with our fellows on ultrasound. And we're talking about how sometimes just showing a patient something on a screen, even if they have no idea what they're looking at, can be very impactful for the doctor patient relationship. Now honestly, ultrasound has that advantage of like, actually you putting a probe on somebody and touching the patient. And I think that for sports, you know, the arthroscope. And the pictures are so valuable when you talk to patients?

Charles Goldfarb:

Absolutely. The question for this patient will be is it an autograft from the knee? Is it a allograft? I think in a non, you know, load bearing joint like the MCP joint, and allograft might be just the right answer for this patient. So less downside less morbidity.

Chris Dy:

Now when you do that surgery at some point in the future is that dorsal approach? How do you get access to what part of the metacarpal head really needs support? Because we know it's more the fuller part that's going to be more important for articulation. But how the hell do you get to that?

Charles Goldfarb:

This is center center. And so is the absolute dorsal approach maximum flexion. And usually you can get this done pretty straight in a pretty straightforward fashion.

Chris Dy:

And are you what's what's your fixation strategy? Is it purely interference fit of that dowel? Or are you putting any hardware in there?

Charles Goldfarb:

Purely press fit.

Chris Dy:

Okay, little little carpentry?

Charles Goldfarb:

Just a little bit.

Chris Dy:

That sounds that sounds like a fun case. I'm sure I'm never going to see that or I definitely, definitely will be sending that one to you.

Charles Goldfarb:

All right, I want to hear your case. I'm guessing it's nerve, but I still want to hear it.

Chris Dy:

You know it is nerve. But the interesting parts about the case are not directly related to the nerve. So patient comes in with a digital nerve laceration actually comes in because I saw a different surgeon that's retiring and referred the patient to our group. And, you know, at this point, it was a few weeks out already from the laceration, confirmed to be a radial digital neuroma and was painful. It was at the level where it was just proximal to the tip crease it was before the trifurcation of the digital nerve. So something that is theoretically repairable. And I said okay, I think that we can help you. I think you'd benefit from, you know, us exploring this, we're probably not going to be able to repair it and end but I think he'd be a good candidate for using a nerve allograft. So, you know, we went about our day, got them ready for surgery, and booked it for the next week. And then the challenge started.

Charles Goldfarb:

What could that challenge possibly be?

Chris Dy:

Well, you know, the good old American Insurance conundrum. So the nerve allograft is actually on this patient's insurance company's list of experimental procedures. So despite an abundance of literature suggesting that neuro allografts are at least equivalent to a nerve autograft for this particular indication, it would not even be considered for a for use. So then I had to, I said, Okay, well, I guess I'll just do a peer to peer. So a couple days pass, I get on the line for this peer to peer, which was with a family medicine provider. And so then I did this peer to peer, but only to be told that this was not even Peer to Peer-able. So it's not even something that we could have even discussed, it wouldn't have changed the outcome at all. So then I, I'm a little I get a little upset. But I say, Okay, what's the next step? So they say, to file for an expedited appeal. So I write a letter to the insurance company for my patient, of course, I'm informing the patient the entire time of this craziness. And you know, he appreciates being updated, that we're trying all this stuff. Mind you, this is all not to be too dollars and cents about it. This is all uncompensated time for us, right? So I write the letter, I send it. And then we get an email back saying, well, this isn't even an expedited appeal, it's gotta go through a standard appeal, which, you know, it's not, this is not a motor nerve. It's not as time sensitive, but it's still kind of time sensitive. I mean, it's not like an completely elective surgery. So we go through that process. And then we're told that it's not even eligible for a standard appeal. You can't use the nerve allograft unless the patient pays for it.

Charles Goldfarb:

Wow. And you use what nerve?

Chris Dy:

So then we eventually get to the case. And now it's like two weeks after three weeks out, actually, after we tried to schedule the case initially. And it's as expected, there's a 18 centimeter, 18 millimeter gap. So you know, I think that the textbook says maybe a conduit I don't even know if the conduit would have been approved by the insurance company. We've talked about a nerve autograft, and I harvested the posterior interosseous nerve. And true to form. When you need it, the posterior interosseous nerve is very small. When you don't need it, it's huge. So actually, I can't remember the last time I had to harvest the PIN, because I've gone to the nerve allograft so much for this, but actually ended up cabling, the PIN and it worked really looked great. But I was like, Man, I can't believe I have to cable this.

Charles Goldfarb:

I was gonna predict it at that level, the PIN one way or another would work. But wow.

Chris Dy:

It's just it's just painful to have to go through that process. You know, so I think for anybody that's listening, you know, it's, I'd love to hear how people deal with this. I think it's a fact of life in the American system, for better or for worse. You know, there are some efforts, I think, for each, you know, device or implant or biologic company, they always try to get their devices on the approved list. But it's not always successful.

Charles Goldfarb:

Well, and of course, this resonates with me, getting back to our first case, that I fight the insurance companies every time I want to do an oats for an elbow, OCD for capital or OCD in a young patient, for it is absolutely the best treatment. I do lots of micro fractures, and for small lesions that can be very appropriate. But you know, if it's a centimeter lesion, there's no better treatment than a oats. It's a faster recovery. It's reliable recovery. And insurance companies fight me or just frankly, say no, because they considered experimental, which is total Baloney, because there's good literature to support it.

Chris Dy:

Including some that you've written, right?

Charles Goldfarb:

Yeah, but forgetting about our junk, there's there's good literature from elsewhere, too.

Chris Dy:

Right. Well, it's interesting, in that appeal letter that I wrote to the insurance company, I included several citations and some that we had authored, and it just doesn't matter, it seems, it's really, really frustrating.

Charles Goldfarb:

It's frustrating. And again, as Chris said, if you guys have tactics or thoughts on this, you know, email us or, you know, tweet us share your thoughts.

Chris Dy:

Yeah, no, I've seen some really interesting, you know, usually there's the physician who just got off of a peer to peer and goes on Twitter to vent, but talks about different strategies to, you know, they actually document the peer to peer conversation and the NPI of the person who that they did a peer to peer with and name in the chart. And that somehow has led to some, some stuff being reversed. Because if it's documented in the chart, and you show it to the patient, you know, clearly has had some effect potentially.

Charles Goldfarb:

Interesting. Yeah, I do let the peer to peer reviewer know that I'm gonna share this with the patient. And I think that's the least we can do. But, you and I are spending time I was gonna say wasting time, but we're certainly spending time and one one could easily argue wasting time on this process.

Chris Dy:

Right. And I think that, you know, when you do these, make sure you tell the patient what's going on. Um, because you know, you want you are their advocate and you believe you're doing the work, you might as well you know, get the credit, so to say in terms of telling the patient that you're trying. So I think that we try to be good stewards with our resources. We're understanding our system, but sometimes this is just maddening.

Charles Goldfarb:

All right, in the last couple of minutes, and we don't want to rush this topic, it'll take as long as it takes but share an ethical conundrum that you've recently encountered.

Chris Dy:

Yeah, so recent case of a patient who had a carpal tunnel release done elsewhere. You know she had both sides done and by the same surgeon one side did well the other side not so well. So I'm seeing the patient for the not so well side. You know, preoperative numbness and tingling did not, did not improve after the carpal tunnel, which was an open carpal tunnel release. It was a healthy size incision did not cross the wrist crease and not the old school, extended carpal tunnel release. And she, the patient was actually complaining of a lot of sensitivity in the distal forearm close to the wrist, but had perfect nerve studies had perfect EMG and had a perfect motor sensory examination but exquisite amounts of pain. So this is not an episode about that. The nerve parts of it but you know, my suspicion was for an incomplete release or potentially nerve injury.

Charles Goldfarb:

Excuse me. And when you say perfect, you mean nerve study is an exam consistent with carpal tunnel

Chris Dy:

No, no, the nerve is actually working really well. syndrome? Okay. So this may have been in a quote electric diagnostically normal, patient probably met CTS six criteria was indicated for surgery. And the nerve was working well in the nerve study and had great two point discrimination. So I was less suspicious for nerve injury, more suspicious for an incomplete release. And ultrasound confirmed that the nerve measured cross cross sectional area was 18. And, you know, just before the incision is, that's big, and then a normal value is 10. And this is not a patient who's a giant. So you know, that's, that's a big value. So we went into the surgery, and I crossed the I worked holder to the prior incision, I crossed the wrist crease with the Brunner zigzag, and I'm looking directly at intact volar interbrachial fascia, it's like nothing had been released, at least at that point, just proximal to the wrist crease. So I'd like to find the nerve proximally. Before this, the the area of the prior surgery and then march my way in going distally. The volar interbrachial fascia was completely intact, the nerve was swollen and looked very angry. And then we went distally to do the release. And all of the transverse carpal ligament was intact. It Like It hadn't been released. And I don't know what happened. I mean, I liked that I was pretty close to where the other incision was. So if they had released a transverse carpal ligament, I would have seen it and it wasn't that long ago that the surgery was. So I had to, I guess, how I rationalize in my head is that the carpal tunnel was never released. And then the patient's having more pain, and I wouldn't you know, I think it's right to label this a complication. But what do you do? Yes, I talked to the patient, I told them what I found. But what do you do with the, do you talk to the other surgeon?

Charles Goldfarb:

Yes, it's super interesting question, what is our obligation to our community? And to, you know, hopefully not in the medical legal sphere, but what's our obligation to other patients, to our health system to get this right? I thought about it a couple different ways. And sometimes this is a complete one off, where if you consider so this has come up for me as a pediatric orthopedic surgeon, on occasion, there'll be a patient managed elsewhere and then sent to us for, you know, a higher level of care or treated one way and then sent to us for advice. And in those situations, it really feels like a one off, I think a senior surgeon reaching out to that surgeon to discuss this particular case, makes a lot of sense. That surgeon a surgeon discussion in a non threatening, supportive way, if it feels like a one off, is appropriate. Does that have you done that? And does that resonate? Or would you consider if you had a case like that maybe suggesting I call them or you know, someone who's been around a lot longer.

Chris Dy:

Right, I mean, so, you know, I'm not trying to throw stones or anything. I think that all of us have difficult cases and cases don't go the way that we expect it to and none of us are perfect. But you know, if it's a one off I still think it's it's probably good to reach out but definitely better to reach out if it's more than a one off. It's interesting you say a senior surgeon because you know, I've only been in practice I think seven years now. And you know, I don't know if I'm even I'm even though I feel comfortable in what I do. I don't feel comfortable making that call yet. And so I'm curious to see to hear why you said a senior surgeon.

Charles Goldfarb:

I just think it's easier. I think the more your name is established, the less threatened or, I guess potentially A resistant to critique another surgeon might be, you know, we're in a unique situation, because we're in academics. And we are, I think, the senator of last resort for many, many hundreds of miles. And so we tend to see these kind of cases. And so what I tend to do is, you know, if I see, I see one case that didn't go so well, from a surgeon, and maybe I, you know, think about it, but sit on it, I've seen more than one, I tend to discuss it with my peers. And if the six and the seven of us have, or all have the same belief and have seen similar poor outcomes, that's a whole different discussion.

Chris Dy:

Right. Right. You know, because I think that they all of us have patients that are unhappy after surgery, even if everything went according to plan for us. And I know that there are a lot of hand surgeons in our community that see patients that have seen us before and had surgery by us as well. And it goes both ways. You know, but yeah, I really struggle with this one in terms of what to do. So I'm glad that you volunteered to reach out. So thank you.

Charles Goldfarb:

Well know for sure. And I do think health systems, I think care about this, it always becomes the classic of you know, if you are a rainmaker so to speak for a hospital or health system, will they protect you? Or do they really want what's best for the patients, and if there is a repetitive challenge from a surgeon, it has to be addressed. And in the state board is one option, the health systems and other?

Chris Dy:

Well, you've given me a lot of things to think about. And I would love to hear how people who are listening and would have handled that whether you're much further out in practice. And then we have a lot of surgeons out in practice for a while whether you're early on. And then also a hand therapist perspective would be really interesting on this because you guys spent so much more time with patients and have helped coach patients through the recovery so much. So, you know, let us know, you know, handpodcast@gmail.com or online at at hand podcasts and your feedback on this would be really valuable.

Charles Goldfarb:

We aren't offering many solutions, but we are offering one potential angle, or maybe two potential angles. But this is this is tough. And I think you know, ignoring it is not the right answer, although that's certainly the easiest approach.

Chris Dy:

So that wraps our first episode, perhaps our last ethics episode with Chuck talking about just you know, ignoring it.

Charles Goldfarb:

Don't ignore it.

Chris Dy:

All right. Well, you have a wonderful day.

Charles Goldfarb:

Yeah, you too. Thank you. Hey, Chris, that was fun. Let's do it again real soon.

Chris Dy:

Sounds good. Well, be sure to check us out on Twitter @handpodcast. Hey, Chuck, what's your Twitter handle?

Charles Goldfarb:

Mine is @congenitalhand. What about you?

Chris Dy:

Mine is @ChrisDyMD spelled dy. 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.