Season 3, Episode 32. Chuck and Chris discuss a case of central slip laceration before diving into cubital tunnel syndrome including decision- making for decompression vs transposition and technique preferences.
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theupperhandpodcast.wustl.edu.
Season 3, Episode 32. Chuck and Chris discuss a case of central slip laceration before diving into cubital tunnel syndrome including decision- making for decompression vs transposition and technique preferences.
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Please complete NEW Survey: https://forms.office.com/Pages/ResponsePage.aspx?id=taPMTM1xbU6XS02b65bG1s4ZpoRI9wlPhXnSF2MnEXxURVRNVDNBMEVSMU1CWFpIQVA4SEtMTFcyMS4u
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
theupperhandpodcast.wustl.edu.
Welcome to the upper hand podcast where Chuck and Chris talk Hansard.
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 A. 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.
Charles A. Goldfarb:Oh, hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles A. Goldfarb:I'm well, you got me up damn early this morning.
Chris Dy:I did. And for good reason. I have the the joy of that to hop in the car for at least a five hour drive. I'm actually not entirely sure how long the drive is. This is the kind of vacation guy that I am
Charles A. Goldfarb:Yeah. And you're, you're heading north?
Chris Dy:Yes, we are going to do a driving tour for a week of the wonderful state of Michigan, as they say driving the mitten.
Charles A. Goldfarb:I didn't know they said driving them. But how many days were you spent in any one location, or it's just constant movement.
Chris Dy:I think it's a 232 situation. So you know, it'll be super fun. I admit, I do not fully know the itinerary. So if you asked me to name where we're going, I couldn't entirely say but I will tell you when we get back. My wife is amazing at planning all these great trips. And she clearly knows what my strengths which is to show up and drive. And be in the moment. I'm really looking forward to I think it'd be super fun.
Charles A. Goldfarb:It sounds fun. So you know, when when when I was entrusted with young kids, there really there were screens, but they weren't like they are today. So what's your family screen motto in the car, you allow them?
Chris Dy:I think that we may have mentioned this in the past. But you know, we went when we're having our second child, my daughter who's now for when we knew she was coming, I went ahead and traded in my sedan and upgraded to the ultimate dad mobile. A Honda Pilot. And basically the thing is hopefully indestructible icon would. But yeah, so in that purchase, there is an entertainment system, you know, screen that pops down, etc, DVD player, the whole thing state of the art for 2017. And we did not tell them there was a screen in the car for at least three years. And then when the beginning of the pandemic hit, and we were just doing these road trips, because that's all you could do at that point. Were like, we should tell him about the DVD player. So first off, they didn't know what DVDs were, of course, so I went there. So we went to the library and got a book rented or borrowed, excuse me a bunch of DVDs, and they loved it. So it's a great because let's hope that the wireless headphones are working today so that I can listen to music, they can listen to whatever they're watching. It got to the point where when we would be just going, you know, for a five minute drive during these trips today. That's for the DVD to come on. So hopefully we can wean them off of that. That amount of screen time but for the long hauls, it totally works.
Charles A. Goldfarb:Yeah, I'm way less judgmental than perhaps I used to be. But I will say we should have a whole episode on the beauty of the library. I think the library is the greatest thing this country's ever produced. It is my favorite thing. I borrow books all the time.
Chris Dy:Is it like an American thing? My people are gonna laugh overseas. Is the library an American thing? I'm sure this is not an American concept.
Charles A. Goldfarb:That is totally fair. Maybe it's not. But I liked American libraries to the only ones I know.
Chris Dy:Yeah, the community aspect of it screams of European. It's definitely not individualistic American ideals.
Charles A. Goldfarb:Yeah, we could get political very quickly. But let's change the topic. Any cool cases?
Chris Dy:Yeah. So I had an interesting case I wanted to pick your brain about so I had a patient who had you know, a a tablesaw injury because it is the summer of doing awesome things like it always is in St. Louis. And tablesaw injury over the index P ij. was seen at an outside facility. told he had cut a tendon and they washed it out with quotes and put a few skin stitches in and he comes to clinic he was told to see a specialist so he comes to clinic within a week. Then you've got the classic you know, tablesaw jagged skin, kinda laceration over the PIJ and talk to him and say okay, so, you know, likely the tendon straightens out the knuckle is cut, probably the joint which is just underneath it is also open, we need to go and wash this out sooner rather than later and try to repair the tendon. So do you book is this for you? Is this a local only case? Is this Walant? Or is this somebody that you give some sedation to fallen anesthesia? What's your preference? At this point? Say it comes in like a day before your normal operative day? Do you actually happen to have time?
Charles A. Goldfarb:I would go either way with this one. I would. I wouldn't push for local only, but I would absolutely do it. Under local only, I would mention it as an option. It's not one of those cases where you're trying to get a chronically retracted tenant back in place, you know, or something like that. So I think he could do it in any capacity. Well, what did you do as far as anesthesia?
Chris Dy:Well, do you think that it adds anything to you have them awake? Does it help you surgically because that's kind of where I've shifted my threshold, I kind of went full on pendulum, like, do everything awake for a little bit, as you probably remember. And then I'm like, Alright, let's do the things that actually help in terms of you know, surgically.
Charles A. Goldfarb:I understand. First of all, thank you. That's a great point. I don't think it would help me and I sometimes these repairs are what's the right word precarious. And I'm not sure if I would trust a tenuous repair to stress it fully meaning Ask the patient to flex and extend. But that would be the rationale.
Chris Dy:This is where our personalities differ. I want to know how precarious It is,
Charles A. Goldfarb:yeah, what you could let things heal and mend.
Chris Dy:So I advocated for local lonely, and I'll be honest with you, some of it is logistics, it is easier to add it to the list if it's a local case at the end of the day. And I just didn't even want to have that discussion about whether there was anesthesia available, which I probably could have made happen but had already added on an anesthesia case, you know, for a fracture just before then. So I just started as local only because I actually do think it's helpful to know. So we get to the or, you know, do the block in the holding area, etc. And it's under Local. Open the skin. Lo and behold, you have
Charles A. Goldfarb:the lightning bolt this how did you there was already
Chris Dy:transverse lacerations. So yeah, I extended it on one side distally on the other side, proximately skin edges were pretty jagged, the skin was beat up. And then you have a zone three extensor tendon repair. So at least the classification, I know zone ones over tip, Zone Two is over the middle phalanx zone three is over the Piha, etc. So the jagged cut and tendon, the tendon is cut at the level of the joint, and you've got just a little bit of tendon slip distally.
Charles A. Goldfarb:And so when you say tendon, you mean central slip, lateral slips, and i.e. no lateral band on either side either. So the whole thing,
Chris Dy:the whole thing, you've got a little bit of the older sided lateral band coming up, that's okay. But the radial side, a lateral band is out the central slip just proximal to its insertion may be enough for a suture maybe not. And then the joint is open. And there's a nice scuff on the cartilage. That was my next question. And I know you sports guys care about the cartilage. So yeah, that white stuff is
Charles A. Goldfarb:important. Cool, cool. So you just stitch it back together, and you call it a win?
Chris Dy:Yeah. So if you have good tenant, what's your go to stitch? What kind of suit you're using what configuration?
Charles A. Goldfarb:So we had an extensor tendon this week, actually. But you know, I don't stress over any of that with extensor tendons, I think the goal is to get a great repair. And so at that level, you're not dealing with robust tendons, I'm probably using a thorough ethibond. And I might be doing horizontal mattress or figure of eight, something like that, trying to get as much suture to re approximate as much collagen as possible.
Chris Dy:Would you do good points? Well, I mean, before I say I mean, I think it's probably important for the trainees that are listening. This is different than a flexor tendon. Just think about them. morphologically. A flexor tendon is a much bigger, rounder tendon, whereas an extensor tendon is a flatter broader tendons. So you're not as you're not as able an app to get these big, nice juicy core stitches like you would for a flexor tendon that you see in literature. And like Chuck saying, I mean, it's the usually it says some kind of configuration of a horizontal mattress. I like a running interlocked horizontal mattress that's deeply published about from New York I happen to be there when he was doing it. We actually wrote a review article about extensor tendon locks. So whenever we have when I tell the resident This is all I know about extensor tendon repair circa 2000 Whatever it was 2007 but I like that configuration. i If I Can I like a 3-0 ethibond. Yeah, so a braided suture, I probably should say not the brand name. Braided nonabsorbable suture. I like a non cutting needle for this because I think that especially when you have a smaller tendon that is potentially tenuous quality, a non cutting needle important.
Charles A. Goldfarb:Yeah, all really good points. A brief aside and totally out of context. When I'm dealing with kids and I have a long incision to close. I often use viral doesn't pay me so I'm gonna say viral, viral repeat which is one of my favorite features I use a 4-0 or 5-0 a running if you to all the listeners. If you have not tried to Running Horizontal mattress on the skin. Try it. I love that stitch. It really really approximates the skin nicely. It's fast, and it's easy and I love that so anyways, going back to your case
Chris Dy:well yeah, well first I will say I just did a case recently at our Children's Hospital with our partner Dr. David Brogan and we were closing multiple skin incisions and a young child and have five over a peed with the running Chuck Goldfarb horizontal mattress suture was amazing. I have seen some foot surgeons call that the Texas Two Step which I think is super fun, but we'll call it the Goldfarb running stitch if you want to.
Charles A. Goldfarb:I thought I thought that was a St. Louis creation years ago anyways, I won't I won't claim priority on that one. The I guess the million dollar question is you said there was a small amount of central slip insertion remaining. How small and was it enough?
Chris Dy:six millimeters?
Charles A. Goldfarb:Maybe doubtful.
Chris Dy:So you know, wishful thinking, right. You know, at this point our our trainee had left for conference. So I'm with the first assist, who's fantastic, you know, great vertices. So he's holding the P ij. And extension after we wash the joint out I've mobilizes as much as I could, you know, from the incision that I had, in terms of the proximal aspect of the tendon. So I've got great purchase in the proximal aspect. I tried the running interlocked floors on the mattress suture. And it looks good. I'm happy with it. So then I say, okay, just bend your knuckle just let's see, let's test the repair. And it falls apart. And I'm like, I sigh and I'm like, You know what, I'm happy to have this information. And then I'm thinking Alright, what else can I do? I'm not going to do the same thing. Again, I start mobilizing the tenant a little bit more now or a proximal stump or a little bit over kind of mid p one, it's so expensive to license to get that tendon closer, and I was like this is not going to repair. Well. I've already passed a stitch through the distal stump. What do I do? So what would you do at that point because you know that you could try to repair it in the same way and split the pie and extension for six weeks pin it even in some circles, although I don't like that if we don't have to
Charles A. Goldfarb:think those are the questions I think, you know, number one, can you we approximate the tendon, and we all stress about like FDP insertion and shortening and all that we don't stress about it as much here. So if you can get the tendon back to the base of the middle phalanx. A suture anchor is definitely an option that some might even argue to, I would never do that. But you could consider a suture anchor. I think the pinning is a super interesting question. I'm sure some of our listeners have strong opinions, we'd love to hear them. And then your postdoc protocol is also super interesting, which gets to your original point about doing this local only. So if you can mobilize it, great if you couldn't, because tablesaw sometimes are rough and you don't have enough college and then I do something weird, like a turned down. But that's for another episode. But so would you do?
Chris Dy:So yes, I do want to talk about the turndown and maybe another episode because I think technically that's a really interesting technique that is super useful to have and it actually did cross my mind. You know what, that's what else do we do but actually then called for an anchor. And the anchor that we have on the shelf is an older kind of anchor. It's a I don't get paid by any of the sports companies. So it was a mini my tech suture anchor loaded with a two Oh, at the bottom suture, I don't get paid by j&j either. I should disclose I guess I'm doing something for Synthes at the hand society. So technically, that's j&j. But so, put the anchor in great purchase, obviously, aiming away from the joint anchor at the base of P two. Got my stitch ran a pseudo Krakow kind of suture up and down with one limb, and then use the other post to bring that tendon back down. Again, the pj's and full extension comes down nicely. I'm very happy with it. So then how brave Are you? Are you going to test this thing again? Are you just gonna make you know what good?
Charles A. Goldfarb:Well, the this is a tough one. I mean, the fact that you could the patient could demonstrate for you could see there was no gapping. And that looked great is really helpful. I often will mobilize these because the first principle has to be get this thing to eel. Whether I would immobilize the full six weeks, I certainly would not pin it in this situation. I don't know I might wimp out and mobilize for three or four weeks, probably four weeks not going to do it.
Chris Dy:So I ended up testing it gently. You know, so I ended up testing approximately 30 degrees of pap extension or PAP flexion and then splinting him and then you know he got a bigger splint than I normally would to be honest with you. Some of it was patient characteristics and trust, to be honest with you, so but I will get him going with therapy within the first within the first two weeks, like short arcs short arc active flexion no passive flexion at the PIJ, I do want to keep the DIJ moving and the MP moving. So it'll be a finger base splint short arcs PIJ motion.
Charles A. Goldfarb:Love it. Love it. We have new fellows. And I've been trying to share my philosophy room cubital tunnel, because we've had a couple of cases. And I thought it might be fun to talk briefly about how we think about not really when we do surgery. But if we have a patient who is surgical, how we think about decompression versus subcutaneous versus sub muscular transposition, and second of all, any technique pearls for any of those procedures.
Chris Dy:But I'm glad that you brought that up, because I will say, as we rounded the corner on 200,000 downloads, the cubital tunnel series is our most downloaded episode. So thank you to those of you who have downloaded it and listen to it. It's it's quite popular apparently, there's a lot in the first one at least there's a ton on diagnosis and workup and all that kind of stuff. And I don't think that's really changed a lot in the last few years. But it would be interesting to hear maybe how your philosophy has changed in the last few years. And when you use decompression versus transposition, what type of transposition I was recently at Children's Mercy in Kansas City, and they asked me to give a presentation on nerve injuries in athletes, which in my presentation I included on their neuritis cubital tunnel because of your landmark paper with Kurt Hene on the results of transposition in the people under 30, which includes a lot of throwing athletes. So we did have this discussion. And one of the slides that I show is a New Yorker cartoon that has a man and a woman at the dining table and a man saying Let me interrupt your expertise with my confidence. So that's the framing for this. So how do you how do you decide on what surgery to do? Like what's your in 2022? In August? What are you teaching our fellows?
Charles A. Goldfarb:Yeah, first I would like to echo your appreciation, we're well over 200,000 downloads and it's really again, remarkable I don't want to belabor that point. And we are going to celebrate that a bit and we would very much appreciate the listeners completing a new survey, which is in our show notes. And then if you haven't signed up for our email we are going to start sending some emails so that also is can be done through the show notes. So
Chris Dy:but But Chuck What well, they went
Charles A. Goldfarb:well Chris had the great idea to autograph a few books and send them to the lucky winners and you don't know which book we I guess you might be able to express preference and also there's mugs Chris there's mugs
Chris Dy:there mugs and I think there should be assigned to chuck Goldfarb series you know the the two Goldfarb books that I open when necessary or the tenant transfer book from the hand society which seriously I opened that recently I thought was a great book. And then also the the athletes book that you edited with Michelle Carlson, which I think is fantastic and I use that as a resource for our trainees on the regular so maybe you could get a signed Goldfarb series of books
Charles A. Goldfarb:or maybe maybe or the the series on nerves which I never
Chris Dy:you know, Chuck I will say my my athlete textbook is still unsigned because he refused to sign it. In very earnestly asked you to sign it during fellowship, and he refused to sign it. You laughed at me? Well, clearly,
Charles A. Goldfarb:I will sign it now. I will sign it now.
Chris Dy:Somebody else I will pass it on to somebody else.
Charles Goldfarb:All right. This is interesting, at least to me. So Paul Manske, who was one of my mentors was a big believer and cubital tunnel decompression when there were very few believers. I mean, very few. In fact, there was there's been a couple of times in my career where there's been real controversy at Washington University, orthopedics in our hand program. This was one going volar with this for his flights was another and how we treat do pigeons was another this one was the first one and I was a young attending, and even a resident. And Paul really believed strongly in this procedure. And when I came out, I started doing a lot of them. We shared our results early. And I've learned a lot since that time, I would say this. I'm belaboring this too long. I really liked the decompression, but it has to be in the right setting. It has to be for me, and the literature doesn't totally guide us on this. But for me, I don't do it in really young patients. So if I have an adolescent or young adult, especially an athlete, a thrower, I will do a subcutaneous transposition. If I have a middle aged person without severe disease, I will it has a stable nerve and that's clinically assessed most of the time by me, not necessarily ultrasound, I will consider a decompression and if there's advanced disease, I will typically do a subcutaneous, but I'll consider a sub muscular. So that was a lot but I'd love to hear your kind of overview as well.
Chris Dy:Think maybe one of these episodes. I want to hear more about the controversy aspect of it. I'm sure there was sparring between Dr. Manske and Dr. Gelberman in the most collegial and gentlemanly kind of way.
Charles A. Goldfarb:It was typically in our hour long sessions on anatomy which were weekly Yes.
Chris Dy:If I'm if the listeners want to check out a great article, the Goldfarb Manske article in all seriousness on insight to decompression and journaling and surgery is a great one. And that's an often quoted one in terms of the revision rate, you guys had a revision rate of approximately 7%. Is that right? Yes, yes. So that's, that's a number that often gets used. For context, you know, the more recent papers that were published even one out of here, and clearly these are setup methodologic very different because you looked at the series that Dr. Manske did and then looked at the revision rate, whereas Ryan Calfee pulled the cases that were done else, many of them which were done elsewhere, and then looked at the revision rate after an insight to and those were that was upwards of 20%. I think it's somewhere in between, to be honest with you. That's an important consideration I have when I think about what surgery to pick. And largely, my indications are pretty similar to ours, although I like to use data and objective tests on like you.
Charles Goldfarb:Like, why the ultrasound?
Chris Dy:The ultrasound is far superior to clinical exam, although I think clinical exam is very good. I think the ultrasound is much better in terms of predicting a nerve that's going to be unstable. You have you were involved in a great paper with Ryan and I think, again, Dr. Manske on looking at the how to assess stability of the ulnar nerve, how frequently patients have symptomatic or asymptomatic subluxation, or mobility of that nerve. I think for those that are listening, it'd be great if you could tell them how you assess stability, because I think that that's something that I went back and read the article, again, recently was put together a talk and I think it's really well explained in that article.
Charles A. Goldfarb:You were kind this was one of those studies that I did a couple of studies when I was young that I would not repeat now. But we got a large number of patients, these were siblings, or really honestly parents of Shriners patients largely that we just because we didn't want anyone coming in with an issue, we wanted asymptomatic individuals, and we talked them into participating. So waiting room study, and it's the waiting room study for sure.
Chris Dy:But genius, right. It's genius. It's great. It's great use of of resources.
Charles Goldfarb:It is and I love that you brought up the instability issue, because that is the issue. And first of all, for those who don't know, all this literature, then the nerve does not Well, I would say, around a third or more of patients have a nerve that slides up now whether it truly dislocates or purchase. That's the that's the tougher part. So for me, when I don't always have an ultrasound to really answer the question, what I do is I flex the elbow fully. And then I put my finger on the posterior aspect of the medial epicondyle, and then I extend the elbow. And if you feel nothing, obviously want to make sure the nerves not in front of your finger. But if you feel nothing, the nerve is stable. So the nerve has not perched has not written up at all. If when you put your first put your finger down, you're on the nerves, that obviously tells you something. Or if the nerve really has dislocated, or subluxated anteriorly your finger is preventing it from falling back in the groove. So for me, that's a helpful test. And I don't know if that's still how you think about it. Chris, are you do you totally depend on the ultrasound.
Chris Dy:I mean, I think it's important to assess that you have to feel it, I don't, well, I trust my exam, I think an ultrasound is better. And there's a there's a paper we talked about a couple of years ago about that. You know, so I think that for me, it's also on top of what you described before starting that I feel the nerve in the groove and try to get a sense of its mobility just by palpating it back and forth. And then I flex the elbow up and then tried to you know, put the put my finger exactly where he described and see if I can trap the nerve. You know, it's not always, you know, patients have may have instability on one side and not on the other. So it's not all here, if you have an unstable nerve on one, that doesn't mean you're going to have it on the other side. So that's important. And I'll be honest with you, my left side is unstable. And I oftentimes will show that to patients. Or yeah,
Charles A. Goldfarb:and that's super cheap, or you're unstable on both sides, and one side symptomatic. But it's helpful for patients to understand that and see that whatever the case may be, yeah, and examining the nerve in the group is super helpful unless the patient wants to kick you when you're doing that because you're nervous, so angry.
Chris Dy:Right, there's a there's a funny Instagram post I have from maybe six months ago with my own nerfing ultrasounded by Greg Decker, because I was putting out their talk and I was like I'm gonna have it slide out the ultrasound of a neuro subluxated. So as Greg just to examine my elbow, other ultrasound. So if you want to see that it's out there, and maybe we will try to put it into the show notes or something. But I think the instability is the key because I do not think that a patient with an unstable nerve that is getting to the point of surgery for ulnar neuritis or cubital tunnel syndrome, if you leave their nerve unstable or potentially exacerbate that instability with a decompression, I think you're gonna have an unhappy patient. Now, that being said, you have some patients who you know, or you have people that get on the podium at the meetings and say, people don't mind you know, mechanically unstable nerve after decon. impression I, I've seen that go the wrong way.
Charles Goldfarb:You're rolling the dice. And I will say one of the first patients that I remember their name is because it was one of our fellows, Dr Manske decompressed and unstable nerve, because he didn't want to miss fellowship time. And he was great. It cured him. But the problem is, and this is what Ryan Cathy's paper showed, is that if you have an unstable nerve, after decompression, so a failed decompression, the results of then transposing that nerve are not as good as a primary transposition. So it gets really complicated. What which patient for you is perfect for decompression.
Chris Dy:So perfect for decompression. To me as somebody who has isolated cubital tunnel symptoms, or we've had carpal tunnel, we treat the carpal tunnel to they've failed a prolonged effort and non operative treatment, including night splinting, ergonomic adjustments, they've got a stable nerve on clinical examination and proven by ultrasound ideally, not always, but ideally, they have a nerve study that doesn't have any signs of denervation. In the ulnar intrinsics, or extrinsic musculature. They've got normal two point discrimination. They have no atrophy. And on the nerve study, they've got normal snap amplitudes, but they have a decreased conduction velocity across the elbow. So thread the needle, but it comes up honestly, it comes up and that patient does really, really well with the decompression in my hands.
Charles A. Goldfarb:Yeah, and their recovery is so incredibly fast.
Chris Dy:What do you tell people about recovery after a decompression versus a transposition, so you have an isolated insight to on their nerve, or another nerve with a carpal
Charles Goldfarb:tunnel. With a decompression, I almost treat them like a carpal tunnel, I just ask them to avoid hyper flexion of the elbow. So really small incision, I made my incision a little anterior to the medial epicondyle. I don't like to put it right on the middle of a condo, just to think that can be irritable, I don't like to put it right over the nerve, because then when they put in their elbow on the table back can be irritable. So little anterior, not just drag the skin back, do the decompression, and I allow them to move right away, I might put a little bit bulkier of an elbow dressing on just to discourage a ton of movement to start but I let them take it off pretty quickly. And I wouldn't want them doing like curls or triceps for six weeks. But I let them get back into activities almost right away.
Chris Dy:Is that dressing
Charles Goldfarb:off? For me for these type of simple surgeries three days they can shower in three days can't soak or scrub for at least a week, if not two weeks. But showers in three days. What about you?
Chris Dy:I've stuck with five days, although with some patients, you know, three days depending on them, I've actually gone become more liberal with that after I think we've discussed this in the past either on the podcast or in one of our other venues. But I live gone to using Dermabond a little more, which allows which makes me feel a little bit better about letting people get things a little bit wet and everything early on but has to be the right decision at the right place. I don't like it in the palm.
Charles A. Goldfarb:Yeah, I don't like it because the cost but you don't worry about things like that. So
Chris Dy:why wouldn't I?
Charles A. Goldfarb:Alright, so how
Chris Dy:do you so one of the things that I come up against with you know, when I indicate a patient for a decompression is it decompression is saying look, I'm gonna make the compression part better. But what makes cubital tunnel different from carpal tunnel is that you've got this traction component across the medial lateral condyle. So how do you counsel them about the future health of their nerve after a decompression because, you know, if they continue, like you said, doing normal kind of activities for young active people, they are at risk for having traction across that nerve and having issues come back.
Charles A. Goldfarb:I don't, you know, my philosophy in general is my goal was surgery is to allow patients to do what they want to do. And that obviously comes up in athletic population. And so I would not do a decompression about thought I had to permanently change their lifestyle choices. So I will let them get back to doing everything just not immediately. You know, the best possible case is a patient with an ache and he has hypertrophy areas where we have an explanation beyond the Kubota retinaculum to explain why there's compression. But I do think the compression component is enough in some patients to explain everything and the traction component won't be a problem. But if I'm really worried about the traction component, then I transpose there.
Chris Dy:Yeah, I think that is in that throwing overhead throwing athlete. You know, the pressures, the strain in that nerve is so high during those crazy cocking wind up, you know, I'm not going to pretend to know the throwing motions anymore. But that amount of torque on the medial aspect of the elbow is tremendous. And it puts a ton of pressure on that nerve. So I think that's probably the rationale for you wanting to do a subcutaneous transposition in those throwers. Is that right?
Charles A. Goldfarb:Yeah, that's exactly right. Absolutely. And how do you think about deep transposition either subcutaneous or sub muscular.
Chris Dy:I think that once we start getting to the point where you have atrophy, you've got two point changes, and you're starting to see some real sea map amplitude loss and deactivation on the EMG. I do the most definitive surgery at that point, which to me is a sub muscular transposition. You know, I think it's important to know how to do a subcutaneous because that's my go to for the patient who has an unstable nerve that meets the otherwise otherwise meets the criteria for decompression. Then we can talk I think we've talked before kind of in detail about technique for that subcutaneous transposition, I don't like the fascial flaps kind of thing anymore. I my go to is the technique that Mel Rosenwasser described using a pedicled pedicled. Add a professional flap, essentially.
Charles A. Goldfarb:Yeah, a lot. A couple of things to unwind there. I agree with you. I really liked the subcutaneous in my population skews younger. But I'll say this in a work comp patient, I will lean towards some muscular almost no matter what just to do the Lasser first, and I agree with you, once it's more severe, I think it's the best place to put the nerve. So totally agree with you there. Let's talk a little bit about that. adipose flap, I have to say, I don't know why I started doing this in the near future. I know we've talked about it, but like to rehash and just hear your technique a little bit. It has been I think one of the best changes to my surgical practice that I've done. It is so much better in my opinion than the Eaton you know, flexor fascial flap to keep the nerve anterior. I love it. I think it's fantastic. So can you briefly describe how you do it?
Chris Dy:Well, I know why you did it, why you started doing it, because we talked about it on here. And he said, that's a really cool technique, I'm going to try it. So when you in February 2020, when the first episode draft, he said, Hey, it's a really cool technique, I want to try that. Thank you, I want to go back into your amazing surgical log, which you keep for you've kept for however you been practicing 30 swings. And go back and see why they changed. So I'll be very honest with you, I have no idea if it's a billable, flat, but it is based on a distinct pedicle. So it's based off of the inferior honor collateral vessels. So that vessel that you see kind of right when you're getting close to the insertion of the septum on the medial epicondyle, that vessel that always bleeds if you go down there boldly without taking a lot of care. So that's a great vessel. And usually there's maybe two or three branches that supply the fat in the fascia over that area, which clearly, you're usually going to elevate if you choose to expose the median nerve during your Ellner transposition, which not everybody does. But if I'm doing a sub muscular release, I always do that. Because I want to protect it. But that pillow there have fat and fascia is beautiful. And what I love about it, and this is a technique described out of Columbia University in New York, it's you can make it very broad. What I don't like about the fascial flaps that are described classically is that you know, it's short. It's a short segment, which to me almost reminds me of the cubital retinaculum in terms of you know, something that could press back down on the nerve. Now clearly, that technique has worked for many for many years. And but when you take that fascia, and you tether it to the subcutaneous tissue, it just seems like it's going to scar back in. So what I liked about the added professional flap is that you can make it as nice and broad as you can. Sometimes you have a nice pillow that you can then put the nerve on top of and then sew the flap down to either the remaining septum or the posterior skin. Sometimes you have to kind of split the fat, and then use that as a pocket for the nerve. It kind of depends on what the patient's habitus gives you, I will say in Missoura we tend to be pretty, pretty good with the amount of fat and fashion that we have to use. But you always have to be ready to pivot and adopt a technique. How do you do it?
Charles A. Goldfarb:Yeah, I think that's right. We generally are blessed with plenty of fat in our patients but not always. And I think in especially in those patients where I'm a little worried i From the minute I make this decision, I start planning this flat, and I really go as posterior early as possible to release all the fat. So I think about it literally from the minute I cut skin and I just aim more posterior early than I normally would. So instead of dividing the fat, it's almost as if I'm releasing the fat up the posterior leaf of the skin and then elevating it obviously continuing to pay attention from cutaneous nerves. Elevated anteriorly not you know not maximum or anything just enough so that I can have a healthy view of the flexor pronator mass. I can see the neuromuscular septum to take it out I can find the vessel the inferior owner collateral vessel protected even though I'm positive we have to maintain it I like to and then I then I go ahead and in a perfect world I just suture that down on to the most medial aspect of the flexure printer mass or even the little fascia remaining on the on the medial epicondyle So it really kind of covers the nerve. Obviously, we don't want to constricting the nerve. I again been I've been thrilled with that approach.
Chris Dy:So what's your what's your postop? protocol for that right now? Are you? Are you allowing them to move right away? Are you putting Are you splinting them right after surgery? And how are you handling it from there.
Charles Goldfarb:So that's evolved as well. And you know, Paul Manske to use his name twice, in this episode, always put his patients in slings and let them move right away, I was too wimpy to do that I splinted. For many, many years, I do not splint anymore, I might suggest a sling for comfort, but allow them to come out and start moving right away, I'm more comfortable with the quality of my repair. I see them at two weeks, if they're really struggling for some reason I motion which doesn't happen, often I might some of the therapy. But otherwise, especially in a young, healthy patient, I just get a moving. And then at six weeks, I let them start really advancing quickly. And by eight weeks, athletes are typically back doing their thing.
Chris Dy:So for a subcutaneous transposition, I'll do the same posterior splint that I would for a sub muscular, just for protocol reasons. But both of those groups of patients come in at three days, in a sub muscular, I'm leaving a drain, and not always for a subcutaneous. But that first visit was is usually just for drain removal and to start therapy. So I see him back at three days, start them on motion right away. You know, so I tend to move them along a lot faster than our son musculars. And they love it, you know, allow them to come out of the the long orthosis that the therapists makes them to, obviously for motion, but then also sleeping. Yeah, I think that's some that's a change that I made within the last, I don't know, 18 months, and patients have really liked that because they hate sleeping in that long arm orthosis.
Charles A. Goldfarb:So here's my hope, when this podcast is done and gone, and it's you know, 10 or 15 years from now you're gonna you're gonna go, Ah, I wonder why I put the drain in were all those nerve transposition. So well, is that really necessary? I did that for so many years.
Chris Dy:I've never did that. Yeah, and I remember I know exactly why, and we're not going to talk about it. I know exactly why I leave upgrade after some transpositions. But I don't want to ever be there again. First year in practice, lessons you learned where we are unduly influenced by, by adverse events and by things that you don't want to that you don't recall fondly. And maybe in 1015 years when I'm the old guy like you, in your in your rocking chair somewhere. Maybe I will go back and say, Gosh, Goldfarb was wrong.
Charles A. Goldfarb:I'm sure you'll say that about a number of things. All
Chris Dy:right. Doubt it. I doubt it. Well, this was fun. And maybe the next time we we come back we talk if if your technique has changed at all for some muscular but we should definitely continue this conversation about things that may have changed since we first talked about them. Yeah, I
Charles A. Goldfarb:think it's a great topic. It's almost the Journal of retraction Chuck and Chris style. All right, have a wonderful week.
Chris Dy:Yes, I will enjoy and thank you to everybody for obviously listening, spreading the word and then filling out the survey. Again, you can get your personally inscribed Chuck Goldfarb series of textbooks if you if you enter into the survey,
Charles A. Goldfarb:and maybe even one of these hats, Chris can sign the St. Louis soccer club MLS team coming to St. Louis shortly. I'm super excited about that.
Chris Dy:Man, that stadium has come up really quickly to vote. Yes. Anyway, have a wonderful week. You too.
Charles A. 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 at hand podcast. Hey, Chuck, what's your Twitter handle?
Charles A. Goldfarb:Mine is at congenital hand. What about you?
Chris Dy:Mine is at Chris de MD spelled dy. And if you'd like to email us, you can reach us at hand podcast@gmail.com.
Charles A. Goldfarb:And remember, please subscribe wherever you get your podcast and be
Chris Dy:sure to leave a review that helps us get the word out.
Charles A. Goldfarb:Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time