The Upper Hand: Chuck & Chris Talk Hand Surgery

Chuck and Chris discuss thumb arthritis and joint balance

September 04, 2022 Chuck and Chris Season 3 Episode 34
The Upper Hand: Chuck & Chris Talk Hand Surgery
Chuck and Chris discuss thumb arthritis and joint balance
Show Notes Transcript

Season 3, Episode 34.  Chuck and Chris discuss nuances of the presentation of CMC arthritis with attention paid to hyperextension of the thumb MCP joint.

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Charles Goldfarb:

Welcome to the upper hand podcast where Chuck and Chris talk Hand Surgery.

Chris Dy:

We are to 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 podcast.

Charles Goldfarb:

Oh, hey, Chris.

Chris Dy:

Hey, Chuck, how are you?

Charles Goldfarb:

I'm good. I'm doing doing back to back early morning podcast on the weekend.

Chris Dy:

Yeah, you know, I slept in today. I didn't do my workout before the podcast because I'm looking. I'm like, Yeah, I know. I know. It's crazy. It's crazy. I'm looking at some, some REITs for later on, but it's gonna be a fun day. Like we mentioned before, it's one of the last weekend's I'm in St. Louis Foley for a while. So gonna cook again, cooked again cooked yesterday. It was fantastic.

Charles Goldfarb:

We're so different. I definitely didn't get up early to work out. But I do have to, we do have a hard end because I have to go lead a congenital Journal Club, which I'm super excited about. It's a way we connect with our residents and fellows, and each month have a session and should be great.

Chris Dy:

Now you guys are doing it over coffee, you mentioned in your email, but the cafe used to go to as an open early anymore.

Charles Goldfarb:

Yeah, they changed their hours, they don't open till eight and I you know, eight o'clock is fine, except for starts to get into the day. And I don't want this to be a burden. And, you know, we're careful about making sure that everyone's in and there's no pressure to do this.

Chris Dy:

I remember fondly it's the journal club for my fellowship year. And I learned a ton I clearly knew because I knew I was coming to wash you already as faculty that I would not be doing any congenital, but the passion that you and literally will have for that is amazing. It's contagious. It's one of the things I love about our program is that you know, we all have our things pretty much and subspecialty stuff. And we just pursue it and we love it and you just hope that the passion is contagious, which I think it is not necessarily like you're gonna go do congenital, but you're gonna really want to be into something like you unless you're into congenital like I'm into nerve.

Charles Goldfarb:

It is an interesting sort of decision we have made because Lindley and I have had opportunities to set up a fellowship focused on the peds upper extremity. And we didn't want to do that. Because we value the our traditional hand fellowship and we don't go looking for applicants that are are you know, all in on peds upper extremity. Obviously we consider them like we consider everybody else because we want that someone who's interested in everything and eventually will hone in which I think has worked well for us.

Chris Dy:

Yeah, I think I think it has, I think it's a great thing that our fellows get exposed to it. You get me into this fellowship, you get exposed to pretty much everything you want to that's possible under the sun in terms of hand and upper extremity. You know, we're light on elbow. And we're very clear about that in our in our interviews. But aside from that, it's pretty awesome. Pretty awesome fellowship and you get the great elbow OCD stuff with you though elbow scopes, I saw more elbow scopes and risk of string fellowship.

Charles Goldfarb:

Yeah, we're light on I guess arthritic. I mean, advanced arthritic elbows really all I would say the soft tissue management around the elbow, the adolescent elbow, the young adult elbow, some ligament but you're right. We don't have that. We don't do total elbows, for example. But everything else you're right. I didn't used to be able to say that, right. I mean, we we used to have when I first started we didn't have great flexes. And we didn't have great soft tissue covers. So it's been it's been fun to watch.

Chris Dy:

Yeah, absolutely. And that's, you know, obviously the elbow thing is the byproduct of having probably one of the best shoulder and elbow services in the country next to us. So that that certainly is impacts it but yeah, it's our program has changed even in the last you know, seven years that I've been practicing.

Charles Goldfarb:

Yeah, well what's interesting is that our topic for today which we won't mention quite yet just to build the excitement, I feel like needs some sounds going on like all the good podcast or or at least we need lasers Yeah, like zooming in and out. But our topic for later is is definitely a general hand surgeon topic. But the beauty is you and I love this stuff like it's not like you know even though we both have our specialties wise I still love bread and butter hand as I call it.

Chris Dy:

Yeah, every now and then I'll get asked if I want a purely nerve practice. And I don't think I do it's just you know, first off it's educationally it's not as great for the trainees but I also love this stuff. You know, I love doing being the general hand surgeon now it will could probably get a little more selective about this stuff I will and will not see. But and maybe you can share some insight into how your practice your selection criteria for your scheduling has changed over time. But overall, I love the general hand stuff. I love the trauma. It's all good.

Charles Goldfarb:

Yeah, no, I think, ultimately time will do that to you, right? I mean, you just won't have time to do everything you want to do. And you're probably already there. But I tried to change my practice a bit by saying I wouldn't see patients over the age of 45. And that does fundamentally change your practice, I do fewer triggers and fewer cartels, not zero, fewer CMCS. But the reality is, I also am a pushover and patients I've seen before they want to come back, obviously, I lead them and direct referrals and patient, you know, so it's just a random person who calls WashU and says, Hey, I need a doctor from our carpal tunnel. I'm 73. The way our system works is our schedulers kind of find the first available and when they see I'm the first available if that happens, then they just get which which I think is great. It helps others build their practice to

Chris Dy:

Yes, I've been the recipient of many patients to see Dr. Goldfarb. This is only seeing children now. Right, right. Yes, that's that's what we're going with. Yeah, I'm too old to see Dr. Goldfarb. Okay, cool.

Charles Goldfarb:

I love it. We, you know, we we, as everyone knows, we appreciate our audience. And we really do, it remains the fuel that helps us. We are trying to gather more information. So if you look in the shownotes, there's a request to complete a new survey. We are asking for new reviews. Because that, you know, helps us build our brand. And we're still hoping we're still planning I'm hoping planning on doing a giveaway of Chris has signed textbooks. So lots out there for you

Chris Dy:

guys are one of chucks many assignment textbooks. Yeah, thank you for doing the survey. I don't want to belabor it too much. But it is really important to us. And then also the reviews are helpful. You know, I like hearing nice things about Chuck. So please feel free to write those and ask questions in the reviews as well. And we'll make sure to answer them. Have you had any interesting cases recently,

Charles Goldfarb:

I have I have how much detail to go into, but I'll say a patient who traveled from overseas great family, I saw them when they were quite young, and made the diagnosis of ulnar deficiency. And so I don't want to get into the weeds and congenital too much. But I tried something, which I've done before with some success, not perfect success. This patient had a when you have severe older deficiency, you can have a fusion between the radius and the humerus. And sometimes those patients still have a well formed all night at the elbow. So theoretically, if you didn't have that bony fusion, you could regain elbow motion with the bony fusion, your elbows are where they are. And so with this patient, we took down the the synostosis, between the radius and the ulna interposed tissue, and initially had regained some really good motion. And over time, unfortunately, bone re formed. Which, you know, I can't say it's 100% unexpected, and it's certainly a risk we talked about, but disappointing. Well, the patient came back years later. And what's interesting is, the diagnosis was only partially correct. I think the patient actually has a multiple synostosis syndrome, which is not something I've encountered a great deal but there are lower extremity issues at the foot level. There are some Falange ism issues at the hand where the joints didn't form. And so the fingers don't been all all the joints don't bend in the finger. And so I think that makes me feel a little bit better about why the bone reformed. So just super interesting. We did some genetic testing super interesting. I'll close by saying, you know, her elbows were essentially fused in a straight position. And that's difficult for a couple of reasons. One, you can't feed yourself easily or at all. Personal hygiene is easy, you know, toilet eating is easy, but can't feed yourself. And as your arms grow longer, your hands get further and further from your face and from the ability to eat. And so we did a surgery where we bent one of the elbows and it was tough, a lot of scarring. And we you know had to shorten and also flex through the bone and surgery technically went well but it's a it's a very unusual and interesting and I think successful surgery. But it'll be something we have to watch over time because she's not done growing and her arms will grow away further. So really interesting stuff for me.

Chris Dy:

Interesting case, never heard of something like that even through all the congenital journal cloths I went do probably heard about and forgot about it, but at least I learned it at some point. How do you make an elbow joint without making a joint?

Charles Goldfarb:

So in the first, you know when we treated this child as young and one of my principles is I believe that if you're going to try to do something where you restore motion or improve motion, that really redo it, the better because there's so much remodeling potential the young child and so six months of age or, or sometimes even younger, to me makes a lot of sense. And we do that with the other condition we do that, and we're getting we're getting in the weeds, but is with owner daimyo otherwise known as mere hand where some kids are born to own the bones. So they don't have good elbow motion. Same idea early, early intervention for this case, there was an older humeral joint, it just couldn't develop in function because the radio humoral sounds doses. So to

Chris Dy:

take down, you take the unready who will synostosis and allow the only hero joint to to move set correct to move,

Charles Goldfarb:

and the muscles aren't perfect. But you know, even if you just get passive motion or therapist listeners will appreciate this, even if you just get passive motion that's dramatically better than having

Chris Dy:

well, and especially, you know, in the era of, you know, active assist devices that are going to be much more helpful. You know, that something that one this patient comes, comes to be an adult, it's probably a nascent technology, it's gonna help her.

Charles Goldfarb:

Absolutely, that's exactly right. And we watch children with arthrogryposis, where they usually don't have active motion. And if we can restore some passive motion, the function is incredible. Watching kids adapt, is really remarkable. So cool case, challenging, technically, interoperability, ultimately, great outcome. But we should switch to some bread and butter.

Chris Dy:

Well, we should actually want to ask you a question about practice management. So if you have somebody coming internationally, first off, you know, when How long did it take you to develop that aspect of your practice, when people start seeking you out like that? And then how do you manage that? Do they contact you directly? How do they arrange travel? How often do they come back? What's done locally? What's done, overseas? And, you know, I know that you're a surgeon to the stars. But in all seriousness, we in our practice, we have had patients coming from, you know, all over the world to have, you know, spine surgery here. Hip scopes here, for example. And apparently, congenital Hansard are here.

Charles Goldfarb:

Yes. So it is a increasing, I guess, I would say opportunity, which I very much enjoy, I tend to deal with most of it myself, patients find me, at least been different things. My blog is one resource for patients, which i That's why I write it for congenital anomalies, you know, so patients and families have a knowledge source, but some of them that reach out for more. And I've done it, initially, I was just FaceTiming saying hi, and kind of learning a little bit. But recently, I've tried to make it a little more standardized and use some of the consulting services that are there online. The one I've used and I have no vested interest, I think they do a good job. It's actually from your residency institutions called BICMD. And actually, I was writing an email to a patient before we got on. And BICMD is allows you to do teleconsultations, which are really just educational opportunities for the family. And that's why it's legal. And they handle all the details. And so I've used that, I always offer patients the opportunity to come to St. Louis, in many do. The finances is where it gets tricky, right? Certainly you'll have some well off, and then you'll have some not so well off families. And I will say it's simply our institution doesn't make it super easy. Either to do the teleconsultations or to deal with the payment issues. And so it's tricky. I do use the Shriners Hospital for this with kids because it just, it takes that issue off the table.

Chris Dy:

Right. Right. And you know, we've had Ben Nwachukwu on the podcast in the past. He was talking about his NBA bubble experience, but then has been the driving force with with Riley Williams up at HSS for this BICMD. I don't know what you call it.

Charles A. Goldfarb:

service.

Chris Dy:

Service. Yeah. So but yeah, so people should check that out. If they're interested in developing that part of it. I thought that was interesting. So, bread and butter. I've had some interesting cases recently that I wanted to bend your ear about. So how do you handle how do you think about the MP joint in the patient with thumb advanced thumb CMC arthritis?

Charles Goldfarb:

Should we we should have gotten Macy on but should we talk about? Let's talk a little bit about what you look for in the clinic first, if that's okay, in a patient and I'll tell how I think about it, whether it's you know, exactly correct biomechanical and I don't know, but when I'm when a patient comes in, and let's do this stereotypical advanced CMC arthritis patient so we'll go back to that 73 year old I mentioned earlier, 73 year old A female who has severe CMC arthritis, what do you how do you think about that patient? What do you what is your examination look like? How are you better understanding what the thumb is able to do in this previously untreated patient?

Chris Dy:

first thought is usually, gosh, I guess I know why this patient didn't go to Goldfarb is can we find a way to not be surgery? Usually, you know, honestly, it's my default for thumb, CMC. You know, and I've, you know, as I've become more experienced with, you know, just surgery in general, you know, I think that I tried to minimize surgery, if we can on certain patients, and some patients just really want to get at it and do it, other people are going to be a little slow to recover, so to say. So I'm very honest about the conversation with them about how long it takes to get over the surgery. And we talked about that paper we've written in the past, about how long it takes, and it takes longer than everybody wants. And that sometimes scares people away. To be very honest with you, you don't want to scare them, but you do have to be honest. And then in terms of looking at the thumb itself, sometimes you can tell when they've got that really flexed metacarpal head, and that tipped over deformity, and then you start to see the Z deformity happen at the MP joint. And, you know, one of the things I always try to dictate and also talk to our residents and fellows about is what's going on with the MP joint. Did you look at the MP joint, you know, before we indicate this patient for surgery, because once you start to see some extension? posturing, I guess I'll call it at the MP joint, then I start to get worried about you know, if we address only the CMC joint, what's going to happen to the MP joint are we going to, are we going to potentially worsen the deformity?

Charles Goldfarb:

Yeah. And so I agree with everything you said, I guess I'll add a little more flavor, or I guess my perspective. So when I think about severe CMC arthritis, the base of the metacarpal subluxation dorsally, almost always, that's the pattern of the arthritis that develops that

Chris Dy:

because of the so called Peak ligament is intact and it's pulling the they're allowing it to escape what I deeply believe that or do we believe AB lads newer work showing that you know, it's not the big ligament that matters as much?

Charles Goldfarb:

I'm not sure it's the big ligament that just doesn't make enough sense. I do think there's, you know, there are obviously reasons that women develop arthritis more than men at this joint, although it's obviously not exclusive. I don't know that I understand it. And I'm happy there are people like me, lad that like to delve into the the why the what is as that metacarpal subluxation dorsally, what tends to happen is the thumb also at ducks, and is drawn towards the index metacarpal. So that creates its own set of problems in the way I try to keep things simple. And tell me you're gonna laugh at me probably. But the way I think about it is all of a sudden you have a thumb that is 80 ducted. And if you were showing this for YouTube, if you try to then grab that soda can with 80 ducted, thumb, you can't get the soda can in there. And so patients that have at least some degree of laxity will break at the MP joint, they'll hyperextend the MP join. So the metacarpal instead of being straight is now tilted. So the base the metacarpal is up, the head is down and you can get the Z deformity where the proximal phalanx then hyperextend at the MP joint and so you get this MP instability because of your CMC instability, which allows patients to sort of function while their arthritis is progressing.

Chris Dy:

Yeah, I think about it similarly. But I think that the way you described it is perfect. You know, what happens if you don't address the MP joint? And you just do say you do your standard CMC surgery, whether that's a suture suspension like Jeanne Delson yori or it's a lrti, Burton Pellegrini or your expensive suture tape suspension.

Charles Goldfarb:

The one thing is clear, if you don't address it, even if you help the pain, and you will help the paint that seems to join, most patients will not be happy. That is a significant can be a significant deformity. So I think one way or another, you have to address it, and you should start with therapy. You know, I think if some patients if it's not too advanced arthritis, but let's say as a ligament as the wax patient, their arthritis is in terrible, then I think you start as Macy has informed us on this before you should start with therapy and try to help with the position of the CMC joint therefore the position of the NP joint and maybe just maybe you can minimize this problem. But if you go to surgery,

Chris Dy:

well hold on a second. I do like a I agree with you entirely and our therapy colleagues are invaluable for that for that particular issue. And I like an MP joint customer orthosis Sometimes to really get the MP join into least neutral or some flexion. To see if you can control that. You know, are there are there? What's your threshold to address the MP joint in surgery? Versus just doing a thumb, CMC? So say you've gotten some reasonable improvement with therapy of the position of the MP joint? Are you done just doing your standard CMC surgery? Or do you do anything differently in that surgery to?

Charles Goldfarb:

I guess, first question is threshold, the literature would tell us 30 degrees of hyperextension. I think that's a an arbitrary number is just as good a number as anything else. But I like like most of our criteria in orthopedic surgery, I don't think that that's as you know, a line that cannot be considered. But it's a good play is a good number to have in your head, to understand whether you should think about it. But here's how I think about it. And I think I learned this doing CMC fusions, because when you fuse the CMC joint, you realign the joint. And when you realign the joint, it is not uncommon that you also take care of the MP joint as well. And so when I do soft tissue reconstructions, whether that's an lrti, or whether that's an internal brace, there are different ways to assure that you bring the base of the metacarpal, back down, and when you bring the base of the metacarpal, back down, if your soft tissue contractures aren't too severe, your MP joint will then assume a normal posture and you can skip intervening there. That's how I think about got it.

Chris Dy:

So then how do you bring the MP joint or the CMC, a base of the thumb metacarpal? I should say, back down? How are you adjusting your technique? Is it a tensioning? thing? Is it where you're putting? If you're doing an LRT? Is that where you put a tunnel? If you're doing a suture tape suspension? Is it you know, how you Where are you put those anchors? How do you do it?

Charles Goldfarb:

The two operations that I do are easy for me to talk about I don't do you know, other operations. But for the two I do, I think that for the suture type suspension plasti, which I continue to enjoy, I think it's a good operation, you were classically taught to create a, essentially a suspension bridge for the base of the thumb metacarpal. And you do that by putting an anchor into the radial bass to the metacarpal, and an anchor into the radial base of the index metacarpal, and you have a sling. The problem is the base and metacarpal can go sort of where it once supported by that sling. So I had a third leg to that, when I'm worried about this, and essentially, put a put a heavy needle through the dorsal base of the metacarpal and then pull it down. And so by doing that third kind of knot anchor, just putting the suture tape through the dorsal base, the metacarpal, and then tight and onto itself, you essentially bring the base and metacarpal down, bring the head of the metacarpal up and addresses the MP joint.

Chris Dy:

And so before you go further, let me just rehash summarize that yeah, clarify make sure that Yeah. So you've got your you've set your proximal distal kind of distraction, right with the suture tape. And you've already set that. So now you're then taking. So after you've got your anchors in your suture tape is in, you've got the free portion of the suture tape.

Charles Goldfarb:

And for me, that's, that's the residual from the base, right at the metacarpal.

Chris Dy:

From the base of the second metacarpal. So you go thumb metacarpal first, then you put it into the index, and you've got this long extra suture tape, and you're taking the free needle that is already in the package. And you're taking it going from the dorsal base of the thumb metacarpal.

Charles Goldfarb:

Yeah, I think you can go either way. I don't think it matters. But you're basically pushing the needle through the bone. I go from the article from what used to be the articular surface of the metacarpal through the dorsal bone of the metacarpal and then pull it back down onto itself.

Chris Dy:

And then how do you tie that back to itself? You tie it to the whatever the bridge is?

Charles Goldfarb:

Yeah, tied to the bridge. It's easy. Okay.

Chris Dy:

I haven't thought about it that way. Is that something you do for everybody?

Charles Goldfarb:

I always say I do it for half the patients. If there's any inclination that that metacarpal is not going to be stable. I go ahead and do it because there's no downside. The only potential downside is you creating a bulky knot. But if you try to keep your knot down, it doesn't cause a problem.

Chris Dy:

How would you how would you handle that? If you say for example, were in the real world and couldn't spend $1,000 on a thumb CMC surgery.

Charles Goldfarb:

I think in that case, it's not $1,000 But it's definitely not in that case is about your tunnels. And if you're doing an lrti really is the lrti should allow you to control that that Bass to the metacarpal. And so if you're trying to have your drilled tunnel really goes from dorsal to volere, and you pass your fcr tendon really from near its insertion to the base of the second metacarpal through the metacarpal. And bring it back on itself, it should accomplish the same goal, which is really magic when it happens. It's very cool.

Chris Dy:

Yeah, no, absolutely. And that's how I would. I haven't done a true lrti In a while. But that is the technique that I learned from mainly Dr. Government are doing a lot of LRTs with Dr. gelderman. And having a lot of anxiety because every step had to be perfect.

Charles Goldfarb:

Yeah, yeah, absolutely. And the reason I, you know, there's, you know, this makes sense. If you can avoid that second surgery at the empty joint, obviously, it's great. When I think about the empty joint, there's a few operations, I think about one just pinning it, which I don't think makes much sense, even though I've been guilty of doing that, because I don't want to do more. You can do the boilerplate advancement, which I've never been thrilled with, I think a soft tissue procedure there if you haven't balanced the forces, doing a soft tissue procedure like that is doable, but doesn't always give you the results you want. And then the fusion.

Chris Dy:

What about what before fusion? What about I've seen people talk about EPP anonomys, or tenant transfers, any experience with that?

Charles Goldfarb:

You know, I don't understand the EPB. I don't understand this insertion. I think it's it. You know, we It sounds straightforward, the BB and serves on the dorsal base of the of the proximal failings, it doesn't always and you can get an extension lag. But I don't have a lot of faith in the EPB. I do think it probably is a deforming force. It's hyperextending the joint. I've never done an EPB to anatomy or transfer. Have you

Chris Dy:

- in training? I saw it. In residency, there is a surgeon residency that would do this routinely for basically there, they would transfer the EPB. And over to the APL for pretty much every thumb CMC surgery. Now I'm not I'm not sure that's what works for me. And I don't know how much of that was a billing thing too, because you can build. Okay, believe I said that. But, you know, one of the fellows at that point, because I asked a fellow that I was working with, like, well, what's the deal? They're like, that's a building thing.

Charles Goldfarb:

Oh, man. But what it does raise the question of, Do you release the APL from the base of the metacarpal? When you do when you treat the CMC joint?

Chris Dy:

I mean, I guess conceptually, it yes, that would make sense. But, you know, not anything that I've done. So as we so when do you ever fuse the MP joint? Because this has come up for me recently, and some crazy deformities?

Charles Goldfarb:

Well, it's obviously much easier if you have arthritis at the NP joint. And certainly that happens. And then you should just go ahead and use it. And in to reiterate this, we've said this on the podcast before, but for the younger listeners, when there have been studies looking at the utility of different procedures in the citation about two providers regarding rheumatoid arthritis, but it doesn't matter. One of the best operations you can provide to a patient enhancer is np joint fusion of the thumb. It's a great operation, it takes care of alignment, it takes care of pain, and there's very little morbidity to doing it. So there's you shouldn't hesitate if there's an indication, and arthritis is a great indication, instability is a reasonable indication. But I offered if I don't think I can control the metacarpal posture through the CMC joint. And that absolutely happens is a vague answer, because I think it has to be a vague answer.

Chris Dy:

Is that an interrupt call? Because that kind of messes with your surgery scheduling, right?

Charles Goldfarb:

It does, but thankfully, it's a quick surgery. So quick addition, I think you have to consider that option when you meet the patient in the office. And, you know, I'd rather have them expecting that and my doing it, rather than not expecting it and my feeling like we needed to do it. So if you don't think about early, you're not going to think about later. So you should always think about it in the office. And then I do think it's an interpretive call, although generally my mind's made up beforehand, because I know what we can accomplish at the CMC joint.

Chris Dy:

So when you fuse it flexes, do you do a little bit of flexion? What do you like to how do you like to do that? Technically?

Charles Goldfarb:

Yeah, I like a tension man technique because like everything, Chris is inexpensive to $90,000 and I tend to put a little flexion intended 20 degrees, what do you do?

Chris Dy:

A little bit of flexion. I, you're gonna laugh at this headless compression screws. I like it, you know, spend some money. But to me that, you know, I think that the K wires can be a little bit fussy at times tension Manding, I think does work well. But you know, essentially, I'm using the headless compression screws as internal struts. Not necessarily in this patient population. You have the best bone and so you're not looking for tons of strong compression, but it's a nice way to have an implant in there that's not going to be prominent, but Hold it in place.

Charles Goldfarb:

You know, that's very fair. And I haven't done that. We were in peds conference on Friday morning and one of my partners was talking about doing putting a dorsal plate on a distal 1/3 of the radius fracture because he didn't show residents how to do it. No one's ever going to show him. And I think tension bands are really a wonderful orthopedic technique that is slowly disappearing from right, you know, from training. And so this is a great, reliable way to use it. I use it for PRP joints as well. What do you do for PRP Jones?

Chris Dy:

I you know, I'm honest with you, I haven't I would use the tension band, but I haven't used it in a long time. So I think I did one early in practice, but I can't remember the last one I did to be very honest with you.

Charles Goldfarb:

You're probably not missing them either.

Chris Dy:

Yeah, well, if it makes you feel better, maybe I'll slide some some stainless steel wire through the cannulated portion of the head this compressions group intention, pathway, complete orthopedic window dressing, it's important to

Charles Goldfarb:

the 2022 tension man technique. Yeah,

Chris Dy:

no, I think I think I agree with you. Tension banding is important. And it's a technique that we don't use enough anymore, just because we I think that the younger generation of surgeons thinks of other options first. So I think you know if you have the opportunity to teach it

Charles Goldfarb:

fantastic. Hey, Chris, that was fun. Let's do it again real soon. Sounds good.

Chris Dy:

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