The Upper Hand: Chuck & Chris Talk Hand Surgery

Cubital Tunnel Syndrome with Ulnar Nerve Pathology: A Case Discussion

August 28, 2022 Chuck and Chris Season 3 Episode 33
The Upper Hand: Chuck & Chris Talk Hand Surgery
Cubital Tunnel Syndrome with Ulnar Nerve Pathology: A Case Discussion
Show Notes Transcript

Season 3, Episode 33.  Chuck and Chris catch up and review an interesting case with severe elbow arthritis and ulnar nerve pathology.  We discuss the role of the AIN transfer includes Chris' technique as well as treatment of the elbow arthritis while treating cubital tunnel syndrome.

Subscribe to our newsletter:  https://wustl.us6.list-manage.com/subscribe?u=c6fe13919f69cbe248767c4e8&id=10e0c1dd85

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.  

Charles Goldfarb:

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 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 Goldfarb:

Oh, hey, Chris.

Chris Dy:

Hey, Chuck, how are you?

Charles Goldfarb:

Fantastic. Saturday morning here with you early. What can be better?

Chris Dy:

You know what I'm feeling good. Just got up a little workout. I'm very excited. This is probably the best. The best you're gonna get me this weekend. Maybe not. But you know, I love I love getting up early and getting stuff done. So this is great.

Charles Goldfarb:

Absolutely. So you already jumped on the peloton. Oh, yeah.

Chris Dy:

It's better off if I get it done early in the morning. I feel better in the morning. No, it's done. You know, honestly, so I we were laughing at one of our last podcast we were talking about my trip to Michigan. I did a lot of running in Michigan, which was interesting and weird, but super fun. I used to run a lot and I think I clocked over close to 60 miles in Michigan for a week which was which was good for me. I liked being outside again.

Charles Goldfarb:

That must have been to get you out and running. I mean, you didn't have a peloton, obviously, but the weather must have been idyllic. Is that fair?

Chris Dy:

It was it was perfect. There was a peloton and one of the places we stayed at one hotel after like for the Grand Hotel Rafi is here with me. So we stayed at the Grand Hotel one hotel at the the entire trip and they had a peloton but actually opted to run instead because we are in Makena. And Island has a loop that's like just over eight miles. So I clocked the loop every day I was there, which was super fun. Yeah, it's

Charles Goldfarb:

great. I don't have to talk to you because I just look at your Instagram posts. I know exactly. I can see your run because you've posted about it. I love it. Now this is particularly painful for me because I can't run right now. Because my damn knee so I am forced to either peloton or ride my bike to work or around which is fine, but I miss running. I really do.

Chris Dy:

So I did run into you in clinic the other day and you did mention hitting a PR on your peloton.

Charles Goldfarb:

Yeah, when you know, old people don't hit PRs as many times Now granted, I hadn't been riding the peloton too long. I don't know about you, and how often you try to PR or whether you're just you know, riding to get the ride done. I ended up only competing with myself. And it's just one of those days where it looked like it was possible. And then I went forward and it was pretty satisfying. I have to say

Chris Dy:

good for you. I'll be honest with you, I guess I've been riding for on the peloton thing for over two years now since the pandemic started. And I don't hit PRs anymore, because I was in beast mode back in the peak of Olympic and now I just do it for the ride. But there are, you know, few orthopedic surgeons on the skeleton crew that keep me honest. There's one pediatric orthopedic surgeon that I pursue, pursue a lot. And she's always faster than me, and I she does keep me honest. But enough peloton talk, we're going to alienate a segment of our audience. So what's what's going on in your practice you mentioned or something changing.

Charles Goldfarb:

So I guess it's I don't know if it's Be careful what you wish for. But I think you realize how much I enjoy the adolescent elbow. And again, the challenges that exist, whether that be congenital issues or post traumatic issues. And I recognize that I am in the minority of people who enjoy it. And the reason is, at least partly because the challenges of having good outcomes. But I had a brief afternoon clinic and I wasn't at refills. I had about 25 patients, but five, five of the 25 or new referrals for difficult adolescent elbow issues. And it was great. And it was exhausting at the same time. And it just gets me thinking about how niche this this group is this problem is and how to better explore it. I definitely talked about these cases with a few selected people. But I'm brainstorming how to you know with rare problems coming to consensus on treatment and things like this is tricky. But I just thought it was interesting is the first time I've ever felt like wow, that was a lot of adolescent elbow.

Chris Dy:

How you described your adolescent elbow is how I feel about Plexus great but overwhelming. I love it though. And I think that it's going to be fun to see you explore you know how that niche aspect of your practice grows or doesn't grow I'm sure it'll grow just knowing you. But yeah, that's those are tough. I mean, are you gonna establish some kind of case conference or you know, something in which you can, you know, bring these cases to with Zoom and everything. It has made it a lot easier just to conference with people from different places.

Charles Goldfarb:

Yeah, it was debating a case conference and putting it out there and seeing who might you When I was debating doing a webinar with one of the societies and getting a few good people and just make a case based as a starting point is kind of see what happens. I need to make sure that there are others out there that want to, you know, grow, grow that segment of the practice. And certainly I'm sure there's people want to discuss, but these things are hard to write about, because there's so much variability in patient presentation. But I assume themes will present themselves over time.

Chris Dy:

Well, you heard it here. First listeners, Chuck's gonna have a webinar and a case conference and in classic Goldfarb fashion is turning this into academic productivity, like a workman hammering nails all the time.

Charles Goldfarb:

And as my wife says, Say it out loud, and you are committed to making it.

Chris Dy:

You know, we did commit you to the fitness thing, and we're closing the loop on that. So congratulations on that. Yeah, absolutely. So

Charles Goldfarb:

sounds like you are going to be really traveling a lot. Now you have been traveling, at least to some degree this summer. But what are your upcoming trips? They all work are they family what's going on?

Chris Dy:

But we talked just to close the loop on that episode we had on national society. So I'm finishing my travels for the government traveling fellowship for the hand society, which has been super fun, obviously challenging because of the pandemic. The travel started in February of 2020. And are now finally concluding in September of 2022. So a much bigger spread than I think the the borders of the government fellowship originally intended, but getting it done. I'm traveling to Brazil in a couple of weeks to see Jai Maver tele and to talk with him about his work in Plexus and nerve injury. So super excited about that. Just a bunch of trips coming up. This is honestly my last weekend. We're recording this the last weekend of August. And this is my last weekend in town until honestly the beginning of October, you know, fully in town. So there's in and out that kind of stuff. But so I'm just going to relish this wonderful weekend. Wow.

Charles Goldfarb:

Howlong are you in Brazil?

Chris Dy:

I shortened it. So it was supposed to be a total of nine days, it's going to be six days just because of the way that the travel show shook out. Trying not to be away as much on the weekend. So kind of shortening the trip helped me with that.

Charles Goldfarb:

Yeah, understand. Speaking of travel, let's talk through one thing I don't want to say struggling with but I think is really interesting. So I know you have recently traveled to do a grand rounds. And I've recently and we'll do more upcoming doing a virtual Grand Rounds. And it was really fun I did for University Chicago, talked about wrist arthroscopy, one of my passions, and it was super fun. Within the confines of what can be fun on Zoom, you know, you don't get the audience engagement. I didn't get to see people I want to see and it did remind me how great a group University Chicago now has. I mean, from the attendings to in hand to the attendings in other areas. So I was excited to at least somewhat connect, but it's really interesting. I'm not you know, I, on the one hand, it's easy, and it's fun, on the other hand is painful as travel can sometimes be I think I would have, you know, have enjoyed it more.

Chris Dy:

I agree entirely. So we did very similar grand rounds in terms of I traveled to University of Missouri, Kansas City, so approximately a four hour drive which Chicago would have been for you. I went in person and Micah Sinclair, dear friend and a podcast listener. So hi, Micah, was kind enough to invite me to do the Grand Rounds and gave me the option of doing it virtually. And I told her I was just gonna go because it is just so much better. Everything you said is true, it is so much better to do it in person to have those interactions and, you know, giving a talk in front of people you've never met before and you're kind of it's kind of a blank slate is It's tough. It's something that I haven't done in a while, but it was good to you know, dust off, dust off the the talk and kind of get the cobwebs off and and to do it. So I'm thankful that I was able to go and do it. Although the drive was a little bit long and I almost died on i 70. But it was

Charles Goldfarb:

the flip side is you know, it's 7am on Wednesday morning, I did Grand Rounds for an hour and then I started operating at 830. So

Chris Dy:

I hear you man, I totally hear you. And yes, shout out to the University of Chicago group. Megan Conti mica and I are thick as thieves. And one of our future fellows that we matched this past May is is Jason is coming from Chicago. So we're super excited and Jeff Stephens there. Jennifer Wolf, great, great hand group.

Charles Goldfarb:

Yeah, absolutely. Absolutely. So yeah, it was fun. It's interesting. I and I I'm looking forward to traveling more I guess I gotta be careful what I wish for.

Chris Dy:

Yeah, especially you, you're gonna get looped Do a lot of travel with all your responsibilities. So let's talk about some cases. I think that we should follow up on our recent cubital tunnel episode with at least some case based discussion. Have you had any challenging cubital tunnel cases recently,

Charles Goldfarb:

I have, I'm going to say I'm going to share a case from about three months ago that I considered sending to you. And you might roll your eyes and say you should have or you might say, I'm glad you didn't. So this patient is a 61 year old, very active male, who has noticed decreasing elbow motion for the last couple of years, not painful, particularly, but also kind of a stoic guy. But more concerning has been over the last four months, has noticed difficulty with hand function, difficulty with grip strength, and some changed appearance of his hand. And so, an outside hand surgeon sent that patient to me to evaluate and here's what I've found. And before I tell you what I did, obviously, I'd be curious as to what you would do. First of all, the patient really did have decreased elbow motion, elbow motion was about 40 degrees. shy of full extension to about 110 degrees of flexion. bilaterally, not painfully accepted by forced terminal extension. patient had a just a difficult to palpate elbow. radiographs demonstrate a lot of arthritis, it was actually hard to feel for the older nerve. The ulnar nerve was irritable for certain, but was sort of almost encased and there was atrophy. In the first dorsal roseus Two point discrimination was greater than 15 millimeters FCU strength was good, maybe a touch decrease but not not dramatic dorsal owner hand sensation was decreased as well. So with that limited information, should I have sent the patient to you?

Chris Dy:

I would have loved to see the patient but clearly this is your wheelhouse as well. So bilateral elbow are are limited motion but it's also bilateral ulnar nerve symptoms.

Charles Goldfarb:

No ulnar nerve symptoms only on the right side. Yeah, only on the right side. I'm trying to think of how to present this further. So the patient was sent to me, in part and there was a very talented outside surgeon who said I you know, combination is weird. You have that bad elbow, not weird, but it's just not particularly common. Difficult elbow arthritis, notable ulnar nerve pathology with intrinsic atrophy. I'm sending the patient up, because I think perhaps there's an opportunity to deal with the elbow, arthritis, transpose the nerve, and consider a nerve transfer distally all at the same time. Yeah,

Chris Dy:

so their transfer thing is the thing I was thinking about once you start to say atrophy, you know, the first thing I thought of is just to make sure it's not the neck, which is why I asked about the bilateral elbow thing, certainly a patient of that age, I think it's appropriate to consider. So my evaluation would have included that in terms of the C spine. Just to make sure it doesn't mean you wouldn't address the cubital tunnel. But you know, for me, that's an important thing.

Charles Goldfarb:

Yeah, I love that. Certainly, we clinically examined the patient. And I wish I could provide the details of the nerve study too. But I do not recall, I know you are much more, you know, precise regarding nerve study. To me, it just confirmed that we have a serious cubital tunnel pathology, and need to address it.

Chris Dy:

Well, before I get into details of how I decide on whether to include a nerve transfer. How would you determine how you would include a nerve transfer?

Charles Goldfarb:

Yeah, and that's why I considered sending it to you, I absolutely would have sent it to you, because I know you, you know really engaged in this type of case. The reason I didn't was because of the elbow arthritis. And while I know you're more than capable of shooting that I thought that it would make sense for me to do that. And it was a bear. So I enjoyed it.

Chris Dy:

I am very happy that using that Center Station. Because also the other thing is that trying to feel when I tried to coordinate a surgical date, I think it would be well into December.

Charles Goldfarb:

That is true. That is true. I guess simplistically, and you have more of an algorithmic approach. It's implicit simplistically for me, patient with a relatively acute onset of ulnar nerve symptoms with some atrophy, and you know, to me means an AI N transfer is reasonable. And I was pushed to do it honestly by the referring physician.

Chris Dy:

Got it? I think that makes sense in turn have, you know acute onset? I think that, you know, full disclosure, I like doing the nerve transfer. People say that it's you know, it doesn't really add any morbidity, but that is a bigger dissection you're adding, you know, as opposed to if you didn't do anything at the wrist, or if you just did a Guianas canal release. You know, I think there's a lot of surgeon driven utilization of that procedure. And I'm guilty of it too. Because we feel better that we're doing something to try and address the atrophy and doing something that's going to potentially expedite the recovery. The literature is not great methodologically. You know, I know that there are people that advocate for this, even locally here in St. Louis, Susan MacKinnon is very strong advocate of it, she developed the procedure. And I think that is good procedure, and it works well in the right population. But if you had to randomize people to own their nerve transposition alone versus the nerve transfer, I don't know what what the outcome would be to be honest with you. There are some very good retrospective case series demonstrating improvements objectively, in the motor amplitudes on the nerve study. Particularly, there are some studies from Canada that have demonstrated that that are compelling. And I think really interesting for future work. For me in terms of determining the nerve transfer, I like to see that there's a decrease in the C map amplitudes, that is substantial, perhaps under the 30% threshold, that of normal, and that there is acute denervation on nerve steady, like you mentioned. So acute innervation, meaning fibrillation is in sharp waves. Then looking at the recruitment pattern in the motor units, I just like to bring some objectivity to, you know, my indications for it. Because I've had a few cases even recently, where the fellow or resident has asked me why aren't we doing a nerve transfer? I say, Well, look at this data. This is why I don't think we need to, although it is super tempting, because it is a fun transfer. Technically, it's pretty straightforward. And, you know, I think that it makes you feel like you're doing something more for the patient.

Charles Goldfarb:

I love that. I love that. Thank you for sharing that. I mean, we've talked about that before. I don't recall if we've specifically talked about your technique, and without spending 30 minutes on it, just briefly describe, you know how you think about this procedure.

Chris Dy:

Happy to do it. And I also want to hear how you address the elbow arthritis component to it. Because I also, when I think about my type of transpositions, that transposition, I consider what is going on in terms of the elbow joints and deeper work is done. So let's get back to that. You know, I think that it's important to have careful indications I use this and use the nerve transfer and patients that have active deactivation, as we just spoke about to that have a reasonable drop in or C map amplitudes. I do look and make sure that they've got a good median nerve and a good pronator quadratus. And a good aim. That's obvious on clinical exam, but also because they typically go for a nerf study, I have them needle the pronator quadratus. There was one case that we wrote up that David and I broken and I wrote up, in which we had the needle, the pronator quadratus. And then I went and looked for the PQ and it was completely atrophied, which was a very fun surprise to have in a case. And I learned how they needle the PQ and most places is that they actually go from dorsal. So they put the needle in dorsally, they pop through the IOM the interosseous membrane, and then they assume that they're in the PQ. And then they check the the needle characteristics when you know they asked patients pronate. So now, because of that, every time that I sent somebody for a needling of the PQ or an EMG of the PQ, I have them do it on their ultrasound guidance, because I don't want that surprise ever again. That's probably a harsh overreaction. But I think it is super useful. So that case reports out there. So technique wise, I tried to get everything done in two hours of tourniquet time transposition, nerve transfer, in my routine because for that is to do the transposition, then go distally do the nerve transfer, do the micro close the distal wound, get it wrapped up dressed and then put a blue towel over it so it doesn't get messed up when we take the tourniquet down. And I like to look at my transpositions after the tourniquets down. So then you know we get all that done in two hours. We let the tourniquet down, I put the drain in for the transposition and we finish up there. We're pretty good usually about getting it all done in two hours. Sometimes you got to run a little bit over but to me that's a good goal to keep the case moving along.

Charles Goldfarb:

All right, so we have some differences which we should take a poll and I know what the poll would say 80% agree

Chris Dy:

I know the drain is great. I know the drain is crazy. Okay, I know the chair to get down as crazy. But I get it I get it.

Charles Goldfarb:

I love it. No but specifically once you so I let me tell me what you do you release vocally maybe half of the pronator quadratus to go more distally to where the nerve starts branching, I presume and then tell me how you insert your aim into your older nerve.

Chris Dy:

So when we do our distal incision I do sometimes I'm doing in common and carpal tunnel release. Basically the incision is curvilinear in the palm part, it's centered over the hook OF THE HANDMAID'S. And then if I'm doing a carpet common and carpal tunnel, I'll basically cheat the skin window radially it's kind of like you're doing a carpal tunnel. If you've made your incision to owner do the carpal tunnel part, and then my skin incision across the wrist creases in Bergner zigzag, and then it's parallel to the FCU. longitudinally for approximately six to eight centimeters, sometimes a little longer depends on the patient's anatomy. At that point, I typically try to find the ulnar nerve in the forearm, which makes it a lot easier to walk into Guianas canal, I release scans canal, I look for the ulnar artery. And there's a pretty characteristic branch of the ulnar artery that comes off at the near the origin of the ATM. And that branch runs perpendicular. And that's a very good clue as to where the ulnar motor branch is coming off, there was a resident and current shoulder fellow Ryan Hill, who worked with me who we did a lot of these and he was really, really good about finding that branch of the artery. And every time was like, this is totally a clue. We talked about writing it up. Obviously, I don't think you'd get in anywhere. But that branch is a clue as to where the owner motor branch is going to originate. You know, I know that everybody watches Dr. McKinnon's videos, and she talks about how you know you can't really see the on the motor branch until you decompress it. That doesn't really jive with my personality, I like to find it before I decompress it. So I will then decompress the owner motor branch, the hypothyroid fascia, and then I will normalize it back. So I don't do a complete visual neural license. Although I know many talk about that I do a skip neuro lysosome, which I will check and see I don't love neuro lysing the entire internally normalizing the entire motor branch off because I think that could potentially do some issues. But I like to be super short of what I'm doing. So I'll do a skip neurolysis into the forearm. There was a paper I'm trying to remember where it's from, I think in South Philadelphia, that demonstrates that you can use the dorsal cutaneous branch as a clue as to where to put you know where your motor branch is going to be. That's typically where the doors cutaneous branches coming off is where your nerve transfer is going to be in set. So that cadaver study was I think about 20 cadavers that showed that every time in those 20 cadavers, the owner murderer branch was, you know, adjacent to the Dorsky taneous branch just like Dr. McKinnon talks about in her videos. I trust that but I don't completely trust it. So I end up doing my Scrivener. lysis. After I've gotten my location for where I think I'm going to insert it, I elevate the plane between the long flexors and the PQ isolate my aim, I fully acknowledge that at some point in the case, whether it's at the beginning or the end, I'm going to get into branches of the answer interosseous artery so I usually play defense and cauterize those with the bipolar. After I've gotten a looper on my AI, N, I will then address the PQ itself, I usually end up getting releasing two thirds of the PQ, I usually will do that by putting a like a brochure or some kind of writing clamp or something underneath the PQ and on top of the AI n and then releasing that initially the top layer with the Bovee on a low setting and then eventually with the bipolar just for defense hemostasis that kind of thing. And you know, the arborization of the peak of the PQ branch ends up being about halfway. And I think there's a study about that. But I will release it about two thirds. And after I've you know, I think one thing to do is to make sure that you after you found it distally and gotten as far as you want to go distally to then release it as proximal as you can within your wound before you cut it distally because once you lose that tension on the nerve, it's a lot harder to get the neural ISIS. So I release approximately, if I haven't cauterized the AIA at that point I usually do because I'm cursing myself for not doing it earlier. I will cut it distally and then bring it into the field for the into the ulnar nerve field for the transposition, I usually end up putting a thrombin so gel foam there at the PQ bed in order to get some better hemostasis. And just leaving that in there. And then I'll do my insets create a paired Nouriel window within the within the aim or something within the ulnar motor branch and then doing the the micro.

Charles Goldfarb:

So that was super detailed and super helpful. highlights the difference between Chuck and Chris. And talk more about the window. You said a parry neural are you creating an EPA neuro window and talk specifically about how you do that, please.

Chris Dy:

So you've got your motor branch isolated off of your own nerve, which at that point is still you know, because you're inside the ulnar nerve, you've already kind of created your abnormal window. So it's total semantics, EPA neuro perineal but in your own or motor components. There's a little trick that Dr. McKinnon talks about that one of her former fellows kind of innovated I guess, is that I like to take the marking pen and put it on the the On the remoter component, which I guess that point is apparent Areum efinor. And whatever you want to say, I like to use this as a total nerding detail. But there was a study that demonstrated, at least in the ACL tendon harvest, when they're harvesting tendon for an ACL reconstruction, the skin marker that you've used to mark, the skin is already contaminated. So I will use the black marker, the permanent marker, the Sharpie that has not touched the skin and put a.on The window and then use two jeweler forceps to two dice to open up the window. And once I've seen that the black is has been pulled off, that's when I'm ready. And it is nice to do it under the microscope and kind of see the fascicles of the older motor components.

Charles Goldfarb:

Do you have to do it under a microscope?

Chris Dy:

Yeah, I think that's a really good question. I think that you don't have to, I think that our principal, you know, the literature shows that a micro a micro cooptation is better, at least in the digital nerve world based on categoric studies of micro versus loops. I don't think you have to as long as you're technically doing it, well, there are many people who will do it under loops, and then check it under the microscope. I'm not sure how much of that is, you know, it's ease and then you can bill for the microscope component. But he said it said what I said. But, you know, I typically will do it on the scope just because I have it available to me, I don't think you have to as long as you're doing it. Well, I think the details of that, you know, co optation are important, I like to make sure that I'm able to get the owner, the aim to kind of stand up and sit without a lot of tension. And you know, how you placed your sutures in the configuration can make your life very easy or very hard. If you do the back stitch first. That tends to make it easy. To put the front stitches, I usually put three stitches. Now I know nylon spaced 120 degrees apart. And then I make sure after I do that computation, and I look at under the scope and I have the trainee or or I do it myself, extend the wrist and make sure that there's no tension on that CO optation as the wrist is extended, that still protect the wrist initially for the first three weeks, just because I'm OCD. But I like to make sure that that is all set before I do put some glue that's an off label use for nerve repair.

Charles Goldfarb:

Why three weeks?

Chris Dy:

Nobody really knows I've talked about this with multiple people and multiple places. Most recently without action at Mayo, we don't know how long it takes for a nerve coaptation to really set up and take you know before the micro sutures don't need to be there. In it's obviously the suture stay. But you know, we think it's three weeks. We don't really know, I don't know if anybody's ever going to do that study. David Bergen and I have talked about doing that study. But honestly, it would be a one off and I don't think it would be too much more than that. So if there's any interested young, bright minds that want a cool study to do, please tell us how long it takes a nerve to heal in a human because everything is based off of animals.

Charles Goldfarb:

So that's fantastic. I think that's a super helpful summary of your approach to the transfer. I won't belabor that. I do want to get back to the elbow briefly. And then we should I want to hear your case. Because

Chris Dy:

how do you do your transfer? I'm dying to know because I think I just dropped. I talked for a very long time, my soliloquy on nerve transfer,

Charles Goldfarb:

one that I enjoyed your soliloquy, and it wasn't very long time. But I think the principles of what you said or what I follow, but I do it in a less nerve surgery way and I would say is we you know, we divided half of the PQ, we found the arborization of the aim, we divided it just divided a and just proximal to that arborization. We did not cauterize the artery, we you know, our inset was pretty similar to what you described it, we did it without a microscope. We did it with 3.5 loops, I was operating in our offsite location. While we were doing it, and I've done this before, without loops, you know, we did actually discuss looking at this with a microscope, I would love to see how we did. And I think next time I probably will do this under a microscope. Not because I question how well we did because I think we did well. And I liked how it looked. But I agree with you that microscopic approximation. In some ways, it has to be better. But yeah, I was very happy with our transfer.

Chris Dy:

Me and that sounds sounds great. You know, I will say one technical thing that I have started to do more because others have told me about it is I've taken sometimes a Cobb or a key elevator and release some of the FTP muscle off of the owner shaft. That kind of sits there because that does help if you're having a hard time getting your donor nerve to reach without tension. You either can go more proximal on your inset, which you know it's not ideal but that's what you got to do to avoid tension but releasing Some of that FTP muscle off of the PQ or off of the owner shaft with an elevator can can certainly help, at least with the actual coaptation. But we know that as soon as you take tension off of everything in close, though, that everything's going to settle down, but just technically that that has helped me, I'm curious to see how you think about the elbow arthritis component of this whole thing, because I think that that makes it more challenging. It's going to have implications for post operative swelling, how you manage the post operative course, because it's not just about nerve at this point, expectations. And then also, technically, I don't love putting a nerve right on top of capsule that's been released and then addressed in that perspective. So while my go to usually would be a sub muscular transposition, if there's any sort of capsular or elbow joint work, sometimes I just go with a sub fascial or subcutaneous transposition.

Charles Goldfarb:

I agree with everything you said before I jumped to there, I have to go back because I was smiling when you were describing the our, the arterial branch to the abductor, digital enemy as an important landmark for the Moto branch of the ulnar nerve. And that is your worldview. My worldview is that branch is critically important to the Hueber to maintain the viability of the muscle, if you're going to do a Huber opposition transfer, which I don't do anymore. But I have seen when that surgery goes wrong, and you get the muscle basically, but you know, essentially dies, if you don't protect that branch. So soon, if

Chris Dy:

it makes you feel better, I use it as a landmark and I keep it every time I don't cauterize it or you know, a tie it off. So I keep it just in case, I thought about a Hooper and somebody that I saw recently, I was like, I could do a Hoover. And this was like nobody does that in adults come

Charles Goldfarb:

on. Well, it's not often long enough. And adults. Interestingly, that's why, and you have to take it off the peace of mind. But that's a whole, that's another podcast. So I think your point about the elbow is really important. And ultimately, in this patient, we did a sub muscular, and the patient is just doing really well it just you know, the right patient has pain is well controlled, you know, they're going to move and I worry less about those patients and the patients that might be a little slow. The concept of putting the nerve down on the bone, with an open joint totally worries me. But I, you know, the right operation for this patient as a sub muscular. And so essentially, we did that. So tons of osteophyte formation, a number of loose bodies, we work just for immediately, I thought we may have to go laterally to we did not. And we, you know, really worked hard on the carpentry part of the operation. And the patient was not overly concerned about his motion. But by the same token, I felt like that was one of our goals. So our motion at the end of the surgery was 10 to 135. And I was really happy with that the nerve actually rested in a good spot, if that makes any sense at all. Usually, I just like you I think I put it sort of right next to the median nerve. It was a little more media alized. And I was pretty happy with both the results of the elbow debridement and the location of the nerve after the transposition.

Chris Dy:

I think that's great. And yeah, the motion result sounds fantastic. I mean, how much motion do you tell people that they need in terms of a functional arc? We talked I think we talked before maybe isn't a podcast for it was on conference. But you know, what we think is a functional arc is not always what patients think is a functional arc. So what did you tell them?

Charles Goldfarb:

Well, two things about that. First is,

Chris Dy:

of course, ther

Charles Goldfarb:

down, of course. I told him that I want to improve his extension. And I would hope to get him you know, we classically say 30 degrees, I hope to get him you know, closer to 20 and a final product and up to 130. What I also typically tell patients is I hope I can improve you 50% in each direction. Because I think that's a pretty reasonable goal is obtainable and full motion is not.

Chris Dy:

Yeah, no, I think that that seems like from a patient slash consumer perspective, the 50% goal sounds really reasonable. I try to tell people just with any contractual release type surgery, whether it's elbow, wrist finger, whatever that you know, we're not going to make it perfect. Some people when they bat an eye at that I kind of back off on surgery to be honest with you. And I say well, I think we need to be really aligned on expectations here. You know, where I think it's harder as patients who gets stiff after non operative treatment, because they feel like you know, they're there. They should be better than they are. That's an aside for your elbow treatment. You know, did you go into the surgery thinking that you were going to address? You weren't going into address this the actual arthritis you were going into address kind of the symptoms of the arthritis. Do you have any future plans for any other surgery? As as somebody who may end up with an arthroplasty down the line or is just kind of putting the lid on the arthritis.

Charles Goldfarb:

Yeah, it's a really important question and the fact that I could go immediately with a sub muscular, you know, Bob Hodges is over the top approach really was not what we did, we simply did a I lengthen the flexor pronator mass, and we had a great visualization of the joint, the patient was not complaining about his elbow and his lack of motion and didn't have pain. And so by take by a, you know, essentially I took off the overgrowth of the coronoid and the electron. I took out multiple loose bodies, debris did some bone formation on the anterior humerus and in the electron fossa. What I didn't do was a lot of bony contouring of the rest of the humerus because that wasn't his complaint. That's why my motion wasn't perfect. I, you know, sure this patient could end up needing further elbow surgery. I don't think he will. I think he's going to do really, really well. From especially from the elbow standpoint, and hopefully from the nerve standpoint.

Chris Dy:

Sounds great. The, I guess the question is how much aggressive capsule release? Did you have to do? Did all the things that you described meaning the loose body removal, the flexor pronator, lengthening, the Bodie, the limited bony work? Did that do it? Or did you have to really get into the capsule?

Charles Goldfarb:

Complete capsule ectomy anteriorly. And posteriorly, was sort of just part of the gig, because there was only way to remove the bone that needed to be removed. Figured, yeah, and I don't do a lot of big open elbow surgeries anymore, meaning that a lot of these patients, you know, an arthroscopic approach would be effective. But nerve nerve surgery aside, this was an open approach all the way that guess the question would have been if I wasn't addressing his older nerve, how would I've addressed it immediately, laterally, both. But fortunately, medial approach only was pretty, pretty effective. Not perfectly effective, but pretty effective.

Chris Dy:

So how, just from a practical perspective, how long did you book this case for? Because it says, I mean, I've been talking about when I'm doing a transposition and doing the neuro transfer and trying to get alternative time and two hours, you're much more efficient than I. So how long did you book this case for? And is this the kind of case he put at the end of the day, or though it had us logistically scheduled this one?

Charles Goldfarb:

Yeah, so this is booked for two and a half hours. And I did, let the tourniquet down

Chris Dy:

wheels in and wheels that time or

Charles Goldfarb:

two and a half hours, wheels in and wheels out, patient was blocked. Patient had an indwelling pain catheter. So three days of pain relief and allows early motion to start. And I think that surgery was less than two and a half hours. There's so much nice overlap in those procedures, because the hardest part about the elbow debridement is the exposure which is required for the nerve. And so thankfully, there was synergy there, I put this case, at the end of the day, except for some local only cases. And it's a big case due at the end of the day. And in some ways, cases like this may be best done on a different day, not a crazy toolroom day, I think about those things a lot. And I guess in a perfect world, I might, I don't think there was any compromise for the patient doing it when I did it, but it does change the efficiency of the day.

Chris Dy:

Ya know, as I've navigated this process of learning how to use two rooms, I've tried to put those cases those longer cases, either on a different day, or at the end of the day. Because it doesn't make a difference in terms of workflow and efficiency, you know, to room day with eight medium sized cases is very different than a two room day with, you know, 14 to 16 small cases. And unfortunately, my practice is weird. And, you know, I've got, you know, the combination of the two as you do as well. You know, so yeah, I think that's I think that's a great case, I guess, for our therapy colleagues, how did you navigate the therapy part of this afterwards?

Charles Goldfarb:

So we did and I, I'm not even sure it's the right approach. But we, you know, we were assured of hemostasis there's a little bony bleeding from the elbow, but basically, no problems there. So I did splint him for 24 hours before having him start therapy really early, while his block was still working. I'm not sure Add discipline to him, started started motion early at 24 hours, and did have a resting splint to utilize for protection. And, you know, we'll see, he has done quite well, to this point.

Chris Dy:

So no, no disclosures for this. But did you use the on cue pain catheters at the indwelling catheter that used? Absolutely, yeah. And how have you found patients managing that because that's something that I tried a couple of times. I didn't have a great experience with it. But you know, what's been your experience with that?

Charles Goldfarb:

I don't use it regularly. I know some of our colleagues use it very regularly. I found it to be effective when I do it. And it's always in cases like this typically bigger elbow cases where I want early motion or where or the patient has, I guess known pain issues, and even a few patients that have had CRPS where I like that blockade proximately I feel like it may help us in those challenging patients and honestly, those risky patients where you're operating in a situation whether it has been CRPS before.

Chris Dy:

Now, are you putting the is the pain catheter placed proximal to your incision? Are you putting it in and having it in your field?

Charles Goldfarb:

I'm sorry, this is anesthesia placed in the supraclavicular. area.

Chris Dy:

Got it. I didn't know if you were putting the bupivacaine directly on the cartilage to kill the rest of the remaining cartilage or whether you know, whether you are Nuray practicing the nerve proximally with the bupivacaine,

Charles Goldfarb:

I left the synovial fluid do the damage on the adjacent nerve these days.

Chris Dy:

Well, that was that was a great, that was a great case discussion. You know, I'd love to see that you're, you know, getting into the nerve transfer world. I think that's fantastic.

Charles Goldfarb:

No competition, these patients are still coming your way. Trust me.

Chris Dy:

No, no, that's okay. I will, you can definitely have that because I don't want the arthritis component. I send all that stuff to you. That's a great case. I think, you know, there are a lot of technical points that if listeners do it differently, please educate us because we certainly are not the end all be all on this stuff. And it is always great to hear from people. I think at our next episode, we're going to have a great guest coming up. Is that right? Yeah, we'll

Charles Goldfarb:

leave it a little bit of a mystery. But we have a guest who hosts her own podcast, which is super interesting. That'll be the next episode. And we actually have a couple of guests planned for the near future.

Chris Dy:

Okay, well, people fill out the listener survey, you know, at the, either the next episode or the one after that, we're going to start giving away some stuff. So let's, let's get some feedback on how Chuck and I are doing. We've passed him great milestones and it's been super fun to do this it honestly, once we get it on the schedule and get it done. It was one of the highlights of my week.

Charles Goldfarb:

Well said I couldn't agree more. Have a wonderful Saturday with the fam and safe travels. But I look forward to talking to you maybe or just seeing your travels on Instagram one or the other.

Chris Dy:

I eventually at some point will have to post about hand surgery on Instagram, but it's rather right now about travels and food and there will be food pictures from this weekend. So

Charles Goldfarb:

they'll take care. Alright, take care. Bye. 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 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 Goldfarb:

And remember, please subscribe wherever you get your podcast

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