The Upper Hand: Chuck & Chris Talk Hand Surgery

Chuck and Chris Talk Common Peroneal Nerve

October 23, 2022 Chuck and Chris Season 3 Episode 41
The Upper Hand: Chuck & Chris Talk Hand Surgery
Chuck and Chris Talk Common Peroneal Nerve
Show Notes Transcript

Season 3, Episode 39.  Chuck and Chris  talk about Chris' favorite topic, NERVE!  Today we discuss the common peroneal nerve. We discusse how patients come to us, how we assess preoperatively including workup, and the surgery- common peroneal nerve decompression.  

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Charles Goldfarb:

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

Chris Dy:

We are two hand surgeons at Washington University in St. Louis here to talk about all things hand surgery related from technical to personal.

Charles Goldfarb:

Please subscribe, wherever you get your podcasts.

Chris Dy:

And thank you in advance for leaving a review and leaving a rating wherever you get your podcasts.

Charles Goldfarb:

Oh, hey, Chris.

Chris Dy:

Hey, Chuck, how are you?

Charles Goldfarb:

I am great, because we're recording a pod.

Chris Dy:

Absolutely. I wish I could say I was full of energy. But it's been a rough. It's been a rough day.

Charles Goldfarb:

What too much cooking.

Chris Dy:

Now, though I did, I did do some cooking. And that was fantastic highlight of the day. But, you know, last night, I wasn't on call. But we're participating in this multicenter, randomized controlled trial for peg fusion for nerve repair, and duty called. And you know, when I got the call from one of our partners, it was early evening, and I said, Alright, great, that's perfect. We'll get the patient enrolled, if they want to do it. And we'll do the case. And I'll be in bed later. And you know, the case I was supposed to go in the evening got bumped for an emergency trainee, and then just kept getting bumped.

Charles Goldfarb:

Alright, well tell me a little bit about this. Because I know about this study. I'm not one of the surgeons, I haven't had the opportunity to pass one of these cases off, but I look forward to that day. But tell me a little about this study. And are we it's a multicenter study, as I understand it, how are we doing comparatively.

Chris Dy:

So you know, it's a, it's a peg fusion technology. For those that are unfamiliar, it's a newer, it's not new, it's actually been around for quite some time. So some of the old guard will say how it's come and gone. But there are some newer studies demonstrating that peg fusion in which you repair nerve as you normally would would suture and then you use a, essentially a chemical to help seal the nerve ends together after you've repaired it. And supposedly helps to facilitate and expedite nerve regeneration. Really impressive in the lab and really impressive preliminary papers. But this is a technology that's now being put to the test with a multicenter, randomized controlled trial. We are one of I believe at least eight sites, I think there still may be trying to recruit more. And we are in the lead.

Charles Goldfarb:

Nice, well done. This is you and Dr. Brogan, I believe,

Chris Dy:

yeah, so Davids the PI on the study, and we've got a great research team, who really are just handling the majority of the work it is a ton of of person hours, as we should say, that goes into you know, not only recruiting, enrolling, doing the randomization, and then all of the paperwork that comes with the follow ups. So we're very fortunate to have Carrie Burke, and you'll see to be more fantastic clinical research team. We had a we had a visiting scholar for the government scholarship, Avi Galadi recently from his center, at Curtis and he was saying how it's a hard study to enroll just because the criteria has got to be perfect. It's got to be a nerve injury that can be primarily directly repaired within 48 hours of injury. So it's very hard to thread that needle.

Charles Goldfarb:

Yeah, for sure. I mean, fortunately, with our population, we do have more opportunities for acute repairs, just because the nature of our center, but it's still not easy, still not easy. And you're right, you can't do these kinds of studies without the right team. It's hard enough on the surgeons, but having the right team behind you is really, really important. So congrats. Keep up the good work. Yeah.

Chris Dy:

So David and I are very proud, we are well ahead of our counterparts at other institutions. You know, and hopefully, you know, we're helping the advance the field in that regard. So I'm tired to be very honest with you, because that case went overnight. And then it just rolled right into a normal day, which included, and we talked about this on a prior episode, because I'm traveling next week, I added on the clinic this morning, and it just kind of went from there.

Charles Goldfarb:

Well, in respect of your time, let's do two things. One, there's a great review to share and then two lets, given that you're tired. The easiest thing for you to talk about is nerve. So let's talk about a nerve, the nerve we haven't talked about in a while.

Chris Dy:

Well, so here's a great review from Ani Stratzman, who is a early career hand surgeon in in Europe. He didn't say exactly where he is. Looks like Germany based on the email address. But he said Hey, Chuck and Chris, I usually listen to your incredibly interesting podcasts on my way to work. One morning not that long ago, I gave my 12 year old daughter a ride to school and after listening to you for a few seconds. She said wow, this guy sounds like Tony Stark- Iron Man for the Marvel Universe, you know? And that was you Chuck. Her comment made me laugh out loud and I hope it makes you smile at least.

Charles Goldfarb:

I wish I could say I'm a Ironman watcher so it doesn't really mean anything to me but it still sounds like a compliment so I will take it

Chris Dy:

that's a huge one that's that's big. That's big Tony Stark is good one. So and then he goes on to very kindly say your podcast is awesome. It's easy to list. Since you and every time I pick up something that I haven't thought or simply never heard or read about, I am deeply, deeply grateful that you share your knowledge. So generously, you make me a better hand surgeon. And I must mention, I'd love to hear more nerve.

Charles Goldfarb:

Well, well, let's give it to him. Absolutely. And

Chris Dy:

then on, he goes on to a request to be put on the newsletter email list. So we will definitely add you and then anybody who wants to please let us know, there's a link in the show notes. So you can always email us Handpodcast@gmail.com. Or find us on social and we will be happy to, to hear from you guys.

Charles Goldfarb:

I love it, that is a very kind review. And those words really are impactful. So thank you for sharing, and we will definitely add you to the email list. Alright, so I think we both delve into this lower extremity nerve at times, I have mentioned on previous podcasts that I work pretty closely with some of our sports surgeons. And so there has been an opportunity to work on this nerve. And likewise, they know you are a great resource, especially as this injury gets more serious. So take us into our topic.

Chris Dy:

Well, I mean, even though this is a hand surgery, podcast hand surgeons get called to operate, you know, all over the body, like any of our partners who do lots of flaps can tell you but for a nerve, you're oftentimes asked to help your at least orthopedic partners with dissecting out and maybe even decompressing the common perineal nerve. So you mentioned it in the context of you know, a knee injury in which maybe they're going to do a reconstruction of some sort. But I oftentimes see it in the patient who has a foot drop for an unknown reason, supposedly, or they have double crushing effects of lumbar spine issues. And, you know, they're still not recovering their ankle dorsiflexion. It's usually seen on the nerve study. So I've found this to be an incredibly useful nerve to learn about and a great procedure to, to learn and to teach. And I tell every resident that comes through, it'd be great if you came off of this rotation, knowing how to find this nerve, get it dissect it out safely, because you never know when you're going to need to do it. And then for our fellows, it's a great procedure to know how to how to do because then your partners can ask for help.

Charles Goldfarb:

Yeah, and those collaborative cases is you and I both strongly believe are fun. Although I will say I need this location or posterolateral corner injury to the knee that has been untreated for some time. That perineal nerve gets scarred in and your fun with your partner can go south really quickly. So

Chris Dy:

yeah, they they definitely this Emily wants your help. I don't know if they just wanted to say that you were there to dissect out the nerve. But those are hard. They're incredibly scarred. And I think those are, you know, multi legs and posterolateral corners. Those are really challenging injuries just in general. You know, during the beginning of the pandemic, I did a webinar for the American orthopedic Foot and Ankle society. And it was me, Jeff Johnson, Matt matava. So Jeff's Sports or excuse me, a foot and ankle surgeon who recently retired, he's now practicing at the VA, really well known in this field, an expert at the bridle procedure, the combination of tendon transfers to restore ankle dorsiflexion. And that Matava former, you know, sports or former team doc for the St. Louis Rams, and an incredibly well known sports surgeon. And then our last panelist was Susan MacKinnon, who obviously needs no introduction as a peripheral nerve expert. So I'm moderating this panel, which was super fun to do showing cases. And we agreed on nothing, which shows you just not even like, you know, what's the best strategy in terms of timing of each of our individual surgeries? How what to tell the patient to expect what's most important in terms of outcomes, it is wide open in terms of, you know, finding some way to unify everybody into figuring out what to do with these patients because universally they don't do great.

Charles Goldfarb:

So true. And that's no matter what the situation is, but especially with those sports injuries, so let's let's play some yes, no. Do you always get a nerf study in the setting of a traumatic perineal nerve injury?

Chris Dy:

Yeah, I do. And we can elaborate if you want me to or not, but I think it is useful. It gives us a good baseline. These are always such poor prognosis, you know, prognostically it's pretty poor most of the time just because of the force on that nerve that you know, if it's enough to disrupt, you know, give you a multi leg knee disruptive posterolateral corner ACL PCL, you know, it's going to be bad and typically that zone of injury to the nerve is incredibly broad and that is pretty much directly associated with their ultimate outcome because there aren't great options in terms of nerve reconstruction there if the if the zone of injury is really wide. So I like to get the nerve study just to establish you know, honestly, how bad it is. And then if it's you know, usually don't have the luxury of time in these patients because you'll you don't want to go after the knee surgery has been done and everything as rescored back end, so you kind of got one shot and that's when you got to negotiate with your partners as to when the right timing to do it is

Charles Goldfarb:

yeah, and as we all know, our sports surgeons will wha definitely get an MRI. Is that sufficient for visualizing the nerve? Or do you need an ultrasound?

Chris Dy:

I think it depends on where you are. You know, I think one thing that I like about the ultrasound not only in this context, but just in general is that for injuries in which you have a closed or a ballistic mechanism, and ultrasound can pretty quickly tell you is this a nerve in continuity or not in continuity, and that has been really helpful for us. You know, for example, for things like, you know, gunshot wounds, which we've seen St. Louis around the knee, getting an ultrasound has told us that nerve is not in one piece. And then why wait any longer than you have to get patient on the schedule, because you have a shot, you know, if you if you get there early, so I like the ultrasound for that reason, I think the MRI is useful, but I still like it in the ultrasound because it gives me the exact information I need. And I can't always rely on the quality of the MRI.

Charles Goldfarb:

Perfect, unless you have other preoperative considerations, I'd like to jump to just diving into the weeds of the surgery.

Chris Dy:

Well, I think what would be more useful than talking about it in the multilin context was just kind of a standard common perineal nerve decompression, because that's what most people are going to be treating. If they do treat this population. Honestly, it's not that different than many of our other upper extremity nerve decompressions. You know, so the, you know, the CPN, oftentimes, you'll see these patients with a foot drop either a florid foot drop, or just motor weakness in trying to bring your ankle into dorsiflexion. And oftentimes, that great toe kind of drags down, that's in addition to the classic paraesthesia, just like you would for any peripheral nerve, and this one happens to be on the dorsum of the foot typically. So there are a couple of pearls that I like on the physical exam, and maybe you can share your, you know, expertise in this too. But, you know, oftentimes, you know, patients are pretty strong with ankle dorsiflexion. And you kind of have to work hard to show them, you know, that they're particularly weak. Now, if they are, you know, you want to make sure that you're pulling real hard on them and show them on the other side how strong they are. Oftentimes, if they're strong enough, on the other side, you kind of pull them forward on the, on the chair, or kind of pull them off the exam table almost. And you can really find some weakness there. For the ones that have a florid foot drop, and you're looking to see if there's any recovery, I think crossing the leg over like you're making a figure four, it's very useful to take gravity out of the picture to really find that kind of m two. And that's one thing that I show our residents and fellows all the time.

Charles Goldfarb:

No, I love those I don't know, they have more to add, I really only do this operation in the context of a multiligament knee injury. But, you know, I now have the lingo down, Chris texted me earlier to suggest this topic and said, Let's talk about CPN. And I'm like CPM, CPM. What the heck is going on, but now, if I want to be a real nerf surgeon, I have to have the window down. So CPN, Common Peroneal Nerve, I've got it

Chris Dy:

nice, nice. And then the other, the other, the other pearl that I found on exam, and this is all stuff that I mean, I didn't see this in fellowship, but just kind of learned it along the way, you know, with with checking ankle eversion, which is the function of the perineum, longus and brevis. Oftentimes, when you do that, patients will use a lot of compensatory muscles to show you to basically try to evade their ankle. So if you're not careful, you will see they will compensate by externally rotating your hip by abducting their hip and activating their IT band. So you'll see these things I really tried to when I'm examining them how one hand on the outside of the knee to stop them from compensating that way, and then really see how well they can even get out. And I found that to be helpful, again, you know, demonstrating to a patient that there is something you know, what's visible and notable and examination, I think, is compelling it that a lot of times, you know, especially if you're in the context of you know, maybe we should talk about surgery.

Charles Goldfarb:

So, are these patients usually sent to you for surgery? Because I assume you're not commonly making this diagnosis on your own?

Chris Dy:

Um, no, I mean, they usually sent to me with, you know, evaluate for foot drop, where they've come from the foot and ankle surgeon because they were sent by the spine surgeon to the finagle surgeon for attended transfer, and they said, well, maybe there's something in between that we could do. And, you know, I think that, you know, our residents and fellows have helped kind of drive this too, because if they're rotating with me, and then they go and rotate with one of the other Doc's and are doing a tonnelle sign around the the fibular neck, super helpful for me, because they'll bring that up, I think with with the faculty that they're working with, and I think it's an outside is really helpful in this particular condition, because sometimes it's not necessarily foot drop, it's just a pair of features that bother them.

Charles Goldfarb:

Right, right. Okay. We've talked about exam, we've talked about imaging, is it time to talk about my favorite thing next,

Chris Dy:

the nerve study?

Charles Goldfarb:

I can't take it anymore.

Chris Dy:

The Ultra I think for for CPN. I think that you know, there's lingo again, and our physiatry colleagues will call it the fibular nerve instead of the perineal nerve. So just you know, we may be caught off guard. I think ultrasound is super helpful in terms of looking at enlargement especially compared to the opposite side, analogous to cubital tunnel, it's, you know, a nerve working its way around the bone. So looking for a conduction velocity loss is useful. And then also looking at changes in the motor amplitudes. But again, that's a topic for kind of really getting into the weeds. But I think surgery, it's it's a great surgery, I'll be honest with you, I think it's a fun surgery to do. You know, I think it helps patients a lot. You know, and I've even done it awake.

Charles Goldfarb:

I did an awake surgery today, which I should tell you about at some point. So is it time,

Chris Dy:

it's time we can talk about the surgery?

Charles Goldfarb:

All right, I want to start with your positioning, how do you position the patient on the table.

Chris Dy:

So this is a case where I don't know what it's like in other places. At least the culture here has been for these, you know, relatively short ambulate, outpatient hand surgeries, essentially anything two hours or less. We do everything on a stretcher here with a you know, a hand table kind of slid underneath the stretcher. For me, this is no exception. You know, I think that it's great to do a non sterile tourniquet, bump under the ipsilateral hip making sure that you're able to externally rotate or internally rotate them a fair bit. And especially if we're going to do a superficial perineal nerve decompression at the same time, putting a little that little bone foam wedge, sliding it right underneath the upper thigh on the posterior aspect, I think is super useful in terms of getting them exactly where you need them to be. How do you position them? Or is it mainly dictated by the sports surgery?

Charles Goldfarb:

Yeah, I don't usually get a lot of say I do my darndest to get a bump under the hip to give me some of that positioning. But usually I'm in an awkward position trying to that thigh

Chris Dy:

holder is the worst. They like that little you that they put underneath the post your thigh that just hoses you every time.

Charles Goldfarb:

Yeah, thankfully, they're not usually scoping. So it usually is just supine, but it doesn't make it any easier because their goals and my goals are not the same other than great care for the patient.

Chris Dy:

Right, of course, you don't quite think about that, if you ever are going to be in a case for somebody scoping you need to go first. Because once those subcutaneous tissues get blown up by the liters of fluid that get pumped through there, all your normal planes are gone. You take a surgery that would take you a much shorter period of time, and you can trip double or triple the time needed.

Charles Goldfarb:

Absolutely, absolutely. So usually what I have done again, in the context of working in one of my sports partners, whether that's pediatrics, pediatric sports, or adult sports, is sort of just a posterior lateral incision, sort of over the fibular head heading proximately I try to always just classic for me, I always start small and end up enlarging my incision. Tell me about your landmarks for your initial incision.

Chris Dy:

Um, you know, I think that that's pretty much how it goes, if you're working with somebody who needs to get to the you know, the posterolateral corner is that they're going to want to cheat the incision, probably more proximal, or I guess the technical term is cephalad than where you would normally put it if you're just working on the nerve. If I'm just working on a nerve, it tends to follow the course of the nerve. So it tends to sit a few centimeters distal to the very proximal end of the fibular head. Because that's where I know the nerve is going to be I do I make, I don't go straight transverse I know a lot of different ways to make this incision, you just got to find the nerve, and you know, the nerve is gonna wrap just below the fibular neck, you know, basically around the neck, at the head neck junction. And in Missouri, that's a little bit hard to feel that fibular head in some patients a very reliable landmark is a tibial tubercle because proximal to distal The tubercle tends to lie at the same level as the fibular head. So when you can't feel the fibular head in some patients just mark it off of the tubercle in terms of how far to where to put your incision. So I found that very useful, it tends to be almost a transverse but a kind of more oblique. And it goes all the way from kind of close to the tibial crest because I want to make sure I get over there, and then carrying it, you know just posterolateral to the fibular neck.

Charles Goldfarb:

So to clarify, I'm gonna translate for Chris Missouri, some of our patients are large, and those large patients it is so true can be it can be difficult to palpate the fibular head but that is a fantastic trick. I have heard that before. Use the tibial tubercle for your proximal distal or cephalad khordad. alignment. So you go to the neck slash post your aspect of Abraham to find your nerve, and then trace it proximally and distally working through scar tissue if it's a post traumatic situation. It's not post traumatic. I don't think there's any magic or difficulty in finding it. But in the post aromatics, if you haven't done this before, it can be a bear.

Chris Dy:

Yeah, absolutely. I mean, I think in the post traumatic so you're tend to be going proximately anyway, the short head of the biceps, if it's intact, is your home, because you know that it's going to be tucked right behind. So if you feel on yourself, if you're listening and you have you're not driving it you can feel your short head of your biceps on the you know the posterolateral aspect of your thigh just above your popliteal fossa. You can feel that tendon you can roll it around that nerve is going to be sitting tucked right underneath there. And if you're slender, you can actually feel your own perineal nerve. And oftentimes patients can sometimes get some compression there if they cross their legs, you know, in a certain way, but, you know, so I use that as home when I'm doing the more proximal dissections, because it tends to be more normal up there. Although sometimes with these wide zones of injury, it can be pretty rough, you know, in terms of that initial approach and the nontraumatic setting. You know, if it's a trainee that's starting off the case, just in terms of getting them oriented and setting their depth, I'll have them dissect and start with a knife. And they really get to the fascia on top of the anterior lateral compartments. Because once you're going from an anterior to posterior, you kind of fall off a cliff. And if you're obviously too deep with your, with your scalpel with whatever instrument you're using, you're gonna get close to where the nerve is really coming from the back and coming to the front. So setting depth on the fascia, and then after we've set our depth, then going back and finding nerve as it wraps around the fibular neck, I like to see the nerve all the way posterior, and then after that, then come from posterior to anterior,

Charles Goldfarb:

and how far proximately in a non traumatic situation, do you tend to decompress it, or trace it,

Chris Dy:

I don't think you need to go very far. Honestly, once you've seen it kind of wrapping around and coming from posterior to anterior, you inspect and you make sure there's there aren't any odd bands that are back there. I know that some are more enthusiastic about releasing all that fascia, I don't think it's particularly helpful. Because once I found that then I go from P to a from posterior anterior and I find that first clinic compression, which is usually the worst one that you know, the posterior cural septum, which is that kind of back edge of the perineum longest. And just start releasing there, because that usually is the point, the most offensive point of compression.

Charles Goldfarb:

Okay, and how far distally Do you trace the nerve into the muscle.

Chris Dy:

So then, you know, what I like to do with this decompression is that, you know, you see the fascia of this is pretty interesting, it really does wrap around the individual compartments and then in the anterior compartment between the muscles and it's almost like these, the fascia is coming up and you've got the muscle on each side of it. It's almost like an IV. So you know, finding the back edge and releasing that posterior lateral portion of the deep part of the lateral compartment fascia is the first step. And then after that, it's really retracting, and being kind to that lateral compartment musculature as you're releasing it, because unlike for example, like a flexor pronator release, if you're doing a, an older nerve sub muscular transposition, some of that nerve supply to the lateral compartment comes in proximal to where the fibula neck is crossing. So if you just were to take a bipolar or a bogey and just go right through the muscle to release the nerve, you'd actually be losing some of the nerve supply that you're trying to keep to the lateral compartment. So you really have to dance around the muscle and release to the fascia get over the top and then get some kind of like Dr. Mckennon called down curve attractor, other people call like a lagenback or you can use direct mail, get on the other side of the lateral compartment, release that anterior cural septum and then work underneath. And that helps you set your depth. And then it's just individually hopping over each of those little fascial vertical bands. And releasing them you know, you got a posterior septum, your anterior septum, and then the so called the nominate septum. It's usually not the innominate septum that's tight, but it's usually posterior and anterior that are the tightest

Charles Goldfarb:

two more questions. One, nerve stimulator, and in which situation, would you use it?

Chris Dy:

I think the nerve stime is useful, I guess, if you're having a really hard time finding the nerve. Usually, if you're having a hard time finding it, it's in a post traumatic setting. And you've already been digging through scar and tourniquets probably wind up a while. I don't think it's I don't use it routinely in a non traumatic setting or even in a dramatic setting. I think there's probably a role for nerve to nerve action potential like kind of two probes one on each side of a scar and seeing if something conducts across it if you're looking at a dense neuroma and continuity, but I have not used a nerve stimulator in this setting. Unless you kind of come across a funny branch. You want to see what it does. How about you?

Charles Goldfarb:

Yeah, I haven't used it. I've often wondered, you know, in that situation with a post traumatic, would it? Would it be helpful? I haven't ever thought it would be helpful in finding the nerve. And so I haven't done it. So I'm actually happy to hear that you haven't. And then the second question is, if one of our listeners who may have done this, but not done it recently, once you review some of the anatomy that you have alluded to, is there a best source and we can always put in the show notes if you don't recall it off the top of your head.

Chris Dy:

So Dr. McKenan has great videos on this. I don't do it exactly the same way. But whenever a trainee comes to the service, current generation of trainees tends to go to videos, by and large, so I send them to her videos. I think they're great. I think they're on YouTube as well as her education platform. You know, one of our residents who, who was matched at Harbor View for his hand fellowship next year. Nik Dwivedi, he and I wrote some review articles on this, which are in the orthopedic clinics in North America at some point in the last year or so. And then Pauline Glyn, who is going into sports, at HSS. Next year, he, he and I wrote an article that summarize the, the, the webinar that I mentioned earlier. So there's a bunch of stuff out there, those are good ones, they actually kind of include a lot of the anatomy resources, you know, and there's a lot to unpack here in terms of all the variations in the anatomy, and we don't need to get into all that detail. Um, one thing that I think is important is, you know, that I was teaching one of our fellows recently was that once you've released your CPN, I like to see the branching of the deep and the superficial perineal. And sometimes even, it's not so much a bifurcation, it's even a trifurcation. You can even see some branches, not necessarily to the joint, which is what's in the book, the articular branches, but there are some branches that go to the, to the, to the outside interior that come off more proximal than you think. So you really got to be careful about saving whatever branches come off, because they may be going into the muscle, and you can trace that if you'd like. But then I think also releasing products proximal to distal, releasing some of that posterior curl septum, along the course of the superficial parenting or perineal nerve can help because even though you've released the deep component, if you don't release that back apart, that can take it can hang up the superficial perineal nerve to love that. Sorry, this guy, this guy really jargony and really nerdy really quickly.

Charles Goldfarb:

No, I love it. But I'm going to take it to the basics. I mean, here's my two, you got to come up with two. But I of course have to, here's my two take homes. Number one, you got to know the anatomy. And in this situation, if you're not there all the time, you got to know it well. And so prepare for cases like this. Number two, if you heard Chris say, this was not something he got a great deal of experience with during his training. So you're learning and your potential for cases and even specialty focus. Absolutely should and can extend after your training is over. So it certainly has happened to me, you know, elbow arthroscopy is the example and and just a lot of work around the elbows and examples. So I love that. And and I think it's a good message for all of us.

Chris Dy:

Yeah, I mean, I think that, you know, obviously, I'm biased because of the fellowship director now. But I think that we offer a great fellowship, because we give you tools for your toolbox, you know, so that when you leave here, you can learn and teach yourself to do these kinds of surgeries, obviously, with the appropriate preparation, both reading videos, and even getting into the cadaver lab, but I remember, you know, doing this procedure as an attending for the first time and going to the lab and practicing and taking pictures and all that kind of stuff. Because it's technically pretty straightforward procedure. Like you said, you got to know your anatomy, but it's a great service you can provide for your for your patients and your partners.

Charles Goldfarb:

I love that. I think we should wrap this up and you should go to bed.

Chris Dy:

Yeah, no, I'd like to but there is some more stuff to be done tonight beforehand, but I thank you. I appreciate that.

Charles Goldfarb:

All right. Have a good night. Good night. 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@congenitalhand. What about you?

Chris Dy:

Mine is @ChrisDYMD spelled d-y. And if you'd like to email us, you can reach us at handpodcast@gmail.com.

Charles Goldfarb:

And remember, please subscribe wherever you get your podcast

Chris Dy:

and be sure to leave a review that helps us get the word out. Special thanks to

Charles Goldfarb:

Peter Martin for the amazing music. And remember, keep the upper hand come back next time