Chuck and Chris on the Radial Nerve. Part III Tendon Transfers

Season 3, Episode 48.  Chuck and Chris  continue with this 4 part segment on radial nerve injuries.  In this podcast, we discuss tendon transfers as treatment for the radial nerve injury.  We discuss the three key transfers including wrist extension, thumb extension/ retropulsion, and finger MCP joint extension.  We plan one additional episodes on therapy before and after radial nerve palsy treatment in this series. 


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Transcript

Charles Goldfarb: 0:03

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

Chris Dy: 0:07

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: 0:15

Please subscribe wherever you get your podcasts.

Chris Dy: 0:18

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

Charles Goldfarb: 0:27

I am doing really well. I am in a new

Chris Dy: 0:30

Yes, it looks like a very different location than location. your posh normal basement looks like a basement that is perhaps sparse or Spartan. Some would say.

Charles Goldfarb: 0:40

I wouldn't call my typical basement posh. But I am. I'm in a basement in my childhood home in Alabama. We are recording on the Saturday after Thanksgiving and I escaped to the basement early this morning to talk to you.

Chris Dy: 0:56

Excellent. Thank you. Thank you did you have a nice Thanksgiving down in Alabama?

Charles Goldfarb: 1:00

We did have a nice Thanksgiving we my pretty much my entire family lives here. And so we had a great Thanksgiving. Saw some other people and spent nice it's always nice nice to be on.

Chris Dy: 1:14

Is there a one irrefutable indispensable Goldfarb Thanksgiving tradition, either with the meal or anything else that they think is special or maybe even unique?

Charles Goldfarb: 1:25

It used to be well, two things. Chris, of course, used to be that we would play a family soccer game. And that went on for many, many years instead of a traditional football game. We haven't done that the last couple years. That was super fun. And then I guess from a food item. There's two dishes that I think really characterize our Thanksgiving one is yams. They are prepared in a I don't know I think a little bit of a different way. Heavy on the butter heavy on the brown sugar. Very, very, very sweet. And then the stuffing is more bread light and less sort of dry. Which I think all of us have gotten used to maybe it was unintentional to start, but it's part of the tradition. Now what about you?

Chris Dy: 2:14

Well, I guess the tradition now is me struggling to find a way to cook Turkey that everybody will eat and inevitably ends up being the same people eating turkey no matter how I cook and how delicious or not delicious it is but so this year was chicken fried turkey, which was amazing. And makes amazing leftovers. I'm not gonna lie it was really good. But only a couple of people got this right. But it's been fun. You know, the yams sound delicious. They sound traditional in terms of tons of butter, tons of brown sugar in terms of at least how I've had yams in the past.

Charles Goldfarb: 2:46

So wait a second who doesn't like turkeys it's the kids don't like turkey or

Chris Dy: 2:51

I think my wife just doesn't like the taste of Turkey itself like the texture of the bird the meat so it tends not to be a hit. So then if nobody else is eating, it's just me and my father a lot and the kids that tend not to eat it they go heavy towards the mac and cheese.

Charles Goldfarb: 3:07

You know Thanksgiving dinner is really interesting. I think everyone can talk about having the same type of dish. But it is very different family to family. And I think it's hard going so you know Talia, we have always done Thanksgiving in my house or in so funny house so called my house at in Birmingham. I don't live in Birmingham. I live in St. Louis and I've lived there for a lot of years. So your tie is Thanksgiving is less important to her family. less consistent. Her family tends to disperse for Thanksgiving. But for the Goldfarb is Thanksgiving with our typical dishes, and I really enjoy it.

Chris Dy: 3:43

I will say before we move on, I do love stuffing. And we had three kinds of stuffing this year. One is an actual stuffing like inside of bird. I've roasted a chicken just because you have to roast some kind of bird. And it was delicious. And there is one stuffing that was inside the bird and the bird was sitting on top of it. There was another kind of stuffing which was cooked completely separately. Then there was a third stuffing that our friends brought and it was it was heaven to have so much stuffing was great. How many people did you have at your house? How many No, I just another one other family. So it was a total of 10 people, which was super fun and enjoyable because that was on call. We did it for lunch. So I was up at five ish, getting the ovens ready. I worked out while the ovens were preheating one of the roasted pork shoulder so that was going while I was working out and then it's basically five until noon was just like it's kind of like a day at the office just like you know, non stop going, going going and then I actually took my apron off and looked at my wife and I said done, which I don't think I've ever like just been like I'm done. But I was done. I was gifted an extra half an hour because our guests forgot something at their house so they had to run backs. got everything done perfectly on time which was great

Charles Goldfarb: 4:57

for any listener who does not know about Chris is excellent in the kitchen. All you have to do is follow him on Instagram because there are regular almost daily posts

Chris Dy: 5:10

I probably should post on hand surgery. I mean

Charles Goldfarb: 5:14

I'm not here to tell you how to handle your Instagram account but your foodie accounts pretty good

Chris Dy: 5:21

it's just so much easier to post about the food so we should finish our series on on radial nerve palsy. But before we do we have to talk about our friends over a practice linked I got a text the other day from a friend and fellow listener Micah Sinclair saying you got a sponsor. So super excited that that you and I have been sponsored by practice like,

Charles Goldfarb: 5:43

Absolutely, it has been fun relationship thus far. And we hope it's been mutually beneficial. We certainly have enjoyed it. The upper hand is sponsored by practice link.com The most widely used physician job search and career advancement resource.

Chris Dy: 5:58

Becoming a physician is hard finding the right job doesn't have to be so joint practice link for free today at www.practicelink.com. But you should get all your radial nerve palsy tips from Chuck, particularly for tendon transfers.

Charles Goldfarb: 6:13

Absolutely. But I do have to slightly correct you, we are going to have one more part of the segment because don't forget Macy and the therapy that follows tendon transfers and nerve transfers,

Chris Dy: 6:24

or the decision making that precedes their attendant transfers and nerve transfers. I remember one particular moment I probably she'll kill me with her test for saying this but in nerve clinic, may see pulled me aside and said thank you for, you know, fully treating me as a colleague in this clinic. And I was like, wow, I was like really, you know, it's like, of course, she's like, you know, we were in this clinic together. We're doing this together. I'm seeing patients with you. And you know, you're, you know, I'm a therapist here. And I'm like, I love that like that makes me so happy to like you, you know that we're working on this together. And I think a lot of is because like, there are times where I'll say I don't know me see like go in there, let me know what you think because I don't want to put this patient through a huge reconstruction nerve faced and then at the end of the day, they're either going to have once a tendon transfers or don't have the wherewithal to complete all the therapy that comes with the nerve transfer. So that piece of it's really, really important. So I'm looking forward to discussion not only about how to do the therapy afterwards and pearls about that, but it also helped the decision making that goes through their minds, or at least Mason's mind, from a therapist perspective.

Charles Goldfarb: 7:28

Yeah, for sure. It brings up an interesting point, I guess I can't even conceive of a relationship with a therapist. that's any different than the one you described. That is completely collaborative. And I think I was raised on that principle with Dr. Umansky. You know, as a congenital hand surgeon working at the Shriners, where we absolutely valued is not good enough, but value the opinions and followed often the recommendations of our therapists regarding appropriate surgeries. And that's certainly true for cerebral palsy, but for many other diagnoses. A little known fact for those of you who are bigger fans of Macy, then chuck and Chris Macy is also from Birmingham, Alabama. And we are out for the turkey trot. And I was watching the turkey trot because I'm having surgery this week on my knee. And but my kids were running and family were running and I saw Macy's husband and adorable son, I met her father. So they were out for the turkey trot as well, which was super fun. Macy was not there. But I got to meet I got to hang out with their family at least briefly.

Chris Dy: 8:35

That's amazing. I thought you you have all people right before your surgery, probably try to stir up a little inflammation. I thought about it last time you tried to get a really revved the milieu for your surgeon to work with. So we left off we left off at the last episode with with a lot of pros about nerve transfers, actually, I've been thinking about a few more. So you could do a wrap up at some point as a bonus popery. But you know, I think that ultimately, the the tenant transfers are what a most people should get. I think my ratio is probably higher, it's in terms of doing tendon over nerve. But unfortunately, you know, a lot of trainees that don't bias but many will go throughout their fellowship without actually seeing a lot of tenant transfers, just because many of those cases that would have been automatic slam dunk, tennis transfers are now shifting towards more of a nerve basis. And a lot of that's based on who you're training with and what you're seeing, but a lot of people I think, do want to come see the nerve stuff with us. We do a fair bit of it volume wise. So I'm happy that we do it. But I think that there are people who are going to go into practice that aren't going to do nerve that should know how to do radial nerve tendon transfers.

Charles Goldfarb: 9:42

That's interesting. It's I'm not suggesting we do a survey but I would have thought that I would guess it's at 2010 and transfer. Am I just that far out of the loop? Do you think it's if you look at all hand surgeons What's your perception of what percentage are doing nerve transfer, preferentially over tendon transfer

Chris Dy: 10:05

Probably is close to 80-20. And even if you look at individual surgeons like in my practice, like I remember when I talked to I was doing hosting some kind of pre course for the hand society on nerve and versus tend to transfer. And I was on the podium with with Dr. Mackinnon. I, she asked Dr. Mackinnon, this was probably about four or five years ago now. And I said, What's your ratio in terms of tendon versus nerve. And at that point, which was, you know, again, not recent, but she said it was four to five to one in terms of tendon to nerve. So while the nerve phasers, get a lot of, you know, airplay, and like, we talk about it a lot. At the end of the day, you're probably going to do more attendant transfers and nerve transfers. For some of the reasons we stated earlier, and then also, because of timing, patients oftentimes get to us a little bit late, unfortunately. But I think if you took a survey of practicing hand surgeons all over, you would see more tendon, the nerve, it's just, you know, the stuff that gets published now and talked about and presented about is more nerve patients, because it's newer,

Charles Goldfarb: 11:01

for I totally agree. Yeah. And in academic centers, maybe there's one of those situations where, you know, the trainees are seeing a bit more of the nerve transfer to your point, rather than attend insurance or when they get out to practice, they may choose the tenant transfer. In my practice, in general, as I've said, I don't do a lot of nerve transfer, okay, occasional selective nerve transfers, but I do a fair amount of tenant transfer, much of it and my pediatric population with cerebral palsy, and with congenital deficiencies, but, you know, I think all of us unfortunately, for better or worse, or do tenant transfers related to destroy us plating, etc. So it is an active part of my practice, and I like it.

Chris Dy: 11:46

So before we dive into details is for standard regular palsy, is there ever any advantage for you to having the patient awake for the tenant transfers?

Charles Goldfarb: 11:57

No, there's not. I understand why you might like that.

Chris Dy: 12:03

I, you're assuming that I like that. I said, I just asked the question, I'm assuming.

Charles Goldfarb: 12:11

I don't think it's super helpful. For me, the tensioning part of tenant transfers is obviously important. But it's not helpful for me to have the patient awake, at least in 2022.

Chris Dy: 12:24

Right, right. Well, I think tensioning part is appealing. But you know, oftentimes it does, some of it involves some free education, which they may not have gotten right away. So it's hard for them to actively fire something, you know, it's not like it's a teen license, where they already know how to do it. And it just takes you longer. Having being awake for surgery that long can is unnerving, you know, to a certain to a vast majority of people, once you're beyond like the standard 1015 minutes or whatever. It's interesting, we're in the process of working with a company that makes a virtual reality headset for some of these longer surgeries, which would help a lot. But um, you know, I have not found it particularly helpful for this. I just figured I'd ask because a lot of our listeners are into wide awake surgery. So but neither of us are doing that for radial nerve tendon transfers.

Charles Goldfarb: 13:11

No, no, no. One day One day, so when we should we should, why don't you want to talk about the nerve transfer stuff now? No, let's

Chris Dy: 13:20

save it for the future. Let's talk about tendons. So let's, yeah, well, I mean, you know, like that's, you know, we'll sprinkle it in at some point, keep people keep people wanting more Chuck. Don't give them everything. So, are you ever using anything other than pronator teres if it's available to restore wrist extension?

Charles Goldfarb: 13:38

Yes. So maybe just to briefly highlight that we can go into the three segments we're working on. So the three goals I think you will agree are number one, wrist extension? Number two, control the thumb or thumb retro portion? And number three finger MP joint extension? Is that fairly said?

Chris Dy: 13:59

Absolutely.

Charles Goldfarb: 14:00

I like the way he broke that down. Perfect. So totally agree. Of those three, the most reliable, and I think universally pretty much accepted as the gold standard is the pronator Terry's any pearls on how you do that?

Chris Dy: 14:17

Well, I was gonna ask you because every time I do this, this is one of the more because I do in the book, tenant transfers. And then also when we're doing our selective nerve transfers. This is the one where you kind of tell the trainee, you're like, alright, we got to keep this as broad and long of a periosteal tail as possible. Don't undercut it the letter thin out and then the entire time. I'm letting them do it. I'm watching them. I'm holding my breath, waiting for them to undercut it waiting for them to shortchange me. Last time I did with David Wright, our fellow right now who you went to on a trip with recently to, to work internationally. And he was fantastic. It was it was a beautiful tale of periosteum it was so so good. it. So it was just one of those like app affirming moments, you're like, alright, this is why you you have the trainees do it, so they can learn. But there was a lot of talk the whole time, like, all right, don't remember, this has got to be perfect. So one thing that I do, and I don't know how much of this is the nerve thing, but I will release the br and decompress it at the level of this superficial radial nerve. So that essentially its anatomy, the br for the recovering SRM, but then also, so I can get really far on the kind of mid, middle, third, distal third shaft of the radius to get that part at Terry's periosteal tail.

Charles Goldfarb: 15:33

Interesting, I have not approached the br That way I leave it alone. You know, for What's always interesting, every time we're in the O R, it's really easy to find the printer Terry's but it's always surprising. It is directly in the midpoint of the radius, the insertion that is and it finding it mid radially works really well. But anatomy is always a little different. And so you have to work, you know, figure out how to get down to the bone, isolate the tendon, as you said, really, really preserve as much of the tendon and periosteal insertion. And that makes the younger patient a little bit easier and have a good length of tendon to work with. Because you don't have a lot of links to play around with as you transfer to ecrb. But it's a great transfer, and I tend to weave it into the ecrb the classic pullover tapped I don't always have enough but you know we're we want when I'm in the O R, I don't know about you, when I'm in the O R, I am looking for tension at neutral. Even if it's slightly flexed, I don't mind but really neutral. Green classic talked about tendon transfers with a wrist really extended. And for some patients that can be appropriate for most of my patients, I'm not looking for that much attention tensioning

Chris Dy: 16:53

the tension with the wrist and neutral and do you go end to end in terms of the tenant or you put it into the side of ecrb wondering whether something's gonna come back regenerate anyway.

Charles Goldfarb: 17:04

I do I basically a classic pullover tapped if I can get two passes through the tendon, so I'm not cutting and realigning. I am passing it through the intact tendon. Do you do it differently based on your patient population, okay,

Chris Dy: 17:19

I do the same, I do the same. You know, and then also, so I tension with the wrist cocked up in about 30 degrees, because side tennis so it in that way, and then I take it off. And when I'm looking for tension, you know, because inevitably it drifts a little bit, I'm looking for a little tension a little bounce in the neutral position. And then I'll spend some backup and extension. You know, so in terms of we talked about this periosteal tail for those of you that are less experienced with the surgery part of it, you're looking for the pronator teres tendon insertion on the bone and it's a broad insertion. But if you only took the pronator teres tendon itself, when you went to Trent, when you go to transfer to the wrist extensors, it will be short and you will not reach. So what many of us do is extend the insertion with the periosteum. And I tend to go to kind of the distal third of the radial shaft with it. But I inside is very hard with a knife on the dorsal aspect of the shaft and the volar aspect of the shaft and make little rectangle. And then I'll use I don't know what you use, I'll use a combination of of a knife or a number nine for your elevator to the sharp portion, and then that wider blunt portion to really get a nice tail of periosteum up to essentially increase your working length of that pronator Terry's tendon

Charles Goldfarb: 18:33

all well said, The only thing I would add is the other benefit of having as much length as possible is it helps your line of pool or moment arm. You know if you if you have a short pronator, then you theoretically have to tie it in more proximally which makes it a more transverse pool versus a longitudinal pole. And the other issue is you're always sort of right around the outcrop or muscles and just finding that sweet spot for where to tie it in can be tricky for certain, but I really did like how you described your tensioning assessment.

Chris Dy: 19:07

How do you how much how proximal Deigo on the part of your Teres musculotendinous junction in terms of mobilizing next sometimes you're tempted to just trim a little bit of muscle off of the musculotendinous junction to get a little extra length off of your PT so you can't land in the sweet spot. Is that a no no for you? Or is that something you occasionally will do?

Charles Goldfarb: 19:25

I don't usually address the muscle. I do try to you know put an Army Navy retractor parallel to the muscle and just release some of the fascia adjacent to the muscle to increase the excursion of the muscle it's not a high excursion muscle in general. And but I don't I haven't done much with this one. That's some of the other ones we're going to talk about. I will try muscle but for this one I haven't

Chris Dy: 19:50

done a lot. So one other tensioning thing that I found helpful is to make myself a little bump out of blue towels and COVID to keep the wrist and extension Um, you know, during the surgery, so I'll hold it manually while we're tying in. But then after that, I'll take a stack of blue towels and then make it bigger distally. So balled up and then put the wrist in a position, I want it with the blue towels over the wrist and the wrist kind of cocked back and then co ban all that to the wrist and sometimes also to the MPGs, to keep the MP joints an extension. And again, you can play with that to get into more extension if you want while you're actually sewing in. But that just holds the position of it during the rest of the cases, one less thing that I have to worry about, although it's not exactly where I want it, it's better than letting it completely droop. I don't know how I evolved to doing that. But it's always somebody that the trainees like to see. And they're like, Oh, I didn't really think about that. It's like, that's just makes my life easier. It's less things I had to keep track of.

Charles Goldfarb: 20:43

Yeah, I liked that, too. I, I really try to control the ECRB with maximum proximal force to really assist with that extension posture, you really have to pull pretty hard both on your transfer pronator and your recipient ecrb. Yeah, but it's just such a reliable good transfer. And that's why pretty much every series of tenant transfers includes it. How do you think about the thumb?

Chris Dy: 21:15

So for the thumb, I think that the if you have it, I like using a polymer as long as if you have it, not always present. But if you have it, it's fantastic. You know, I think that I end up selling into more of a combination of the EPL and EPB. Just because I know although I know the EPL is to tends to be more responsible for for retro pulsion. If they're an MP extension lag, as we talked about in the last episode is a little bit bothersome to the patient functionally. So I tend to kind of sew into that as a group. What if you don't have a polymer is what do you like to use?

Charles Goldfarb: 21:52

I have done it different ways. And thankfully, you know, we know the stats on absent Palmeras 10 to 15% of the time, it is so easy when it's there. Because it does everything you want to do is an easy technical transfer, and it does retro pulse and abduct the thumb. It's a beautiful transfer, and certainly strong enough and you don't think about the plumbers is having a great deal of strength, and it probably doesn't have the same strength as the muscle it is replacing. But I go in that, you know, I just use just the EPL. I like what you said about the PDB though, just use EPL, when absent, I have done it different ways and sort of depends on what else I am doing. I have used FDS. And I have used what I would say bigger transfers like the FCU. But I tend to prefer the FDS when palmaris is absent. What about you?

Chris Dy: 22:49

I've used the FDS. But I also know there are a lot of people that will honestly just include it with the finger extensors at that point. Because sometimes you're in a situation from trauma or whatever else where you don't have additional options or you don't want to mess up the fingers, you know the finger flexors for other reasons because they're stiff, or because they're not perfect or whatever. Whatever the reason. So fts. Occasionally, it just feels like a big thing to take, you know, in terms of finger flexors, but certainly expendable, if you need to.

Charles Goldfarb: 23:18

Yeah, and when we talk, I mean, I guess we probably should just mention. Classically, when we talk about radial nerve tendon transfers, we sort of have three groups of transfers versus the brand transfer, pra and D, and that that includes the fcr as the main transfer for finger extension, we have the FCU transfer, which is more can be more associated with the green transfer. And we can use that for wrist extension in kids. But I think when we talk about it here is the FCU series of transfers. And then the superficiality transfers, were advocated by boys. So really, boys is superficiality and brand is fcr.

Chris Dy: 24:02

And so what and that with that in mind, what do you prefer in terms of using for your extrinsic finger extension, your MP joint extension? Assuming median and ulnar are pristine?

Charles Goldfarb: 24:13

I think most would say fcr is the transfer of choice. The tricky part for me is because in the pediatric population with CP, we're looking to increase supination FCU helps accomplish that goal. And again in the pediatric population for I don't mean to confuse things, but in the pediatric population, we're often using FCU to ecrb to help with wrist extension. But I think if I'm doing an adult, radial nerve palsy, it is absolutely pronator teres to ecrb when available Palmeras long as to EPL and then fcr to ECRB. That is my go to and I really like it I certainly had to be flexible and be able to go in different directions. But that's my preferred

Chris Dy: 25:05

any pearls for harvesting fcr? I know that we all we've harvested fcr for many other things, including lrti as et cetera. But do you have any pearls on how to do that in the most efficient way?

Charles Goldfarb: 25:15

Well, one thing that's important to say, I think, for all of these Tennant transfers, is that no matter how much you like little incisions, this is not the operation. To use small incisions, you really need to change your moment arm, change your direction of pole, make sure the transfer muscle is fully released. And so a big incision. Now, if you're doing if you're doing Palmeras, and you're doing pronator, and you're doing fcr, you really are all on the radio side of the wrist. And so a mid Low, Mid radial incision can be really helpful as far as just having great exposure, and you just want to go as distal as possible. And so, you know, when you're taking the FCU, you're taking it right off the PISA when you're taking the fcr you're going right up to where the fcr disappears around the skateboard, please, I am.

Chris Dy: 26:04

I agree. And I think that the big incision is key. And, you know, for me, like for example, the last time I did this was purely attendant transfers, I use the standard big volere approach. And then after we had tunneled everything through to the dorsal Lun, then we closed the volar approach. So we wouldn't have to go back and I think that's a pearl that many talks about, you know, closing as you go, so you don't have to try and manipulate the wrist and the fingers to close but only after you've tied in your tenant transfers. And we did last time we actually sutured or did our we've from fcr. Actually our pronator Terry's to ecrb was done kind of through the volar incision, just because we were we had the exposure of the second compartment through that and we did a more dorsal midline incision to suture into our, our finger extensors and

Charles Goldfarb: 26:51

our thumb extensors. Yep, love that. Exactly. Right.

Chris Dy: 26:55

So then how do you how do you get the tension just right for your, for your EDC recipient?

Charles Goldfarb: 27:01

Yeah, so I'm constantly so you can over tension these, let's just say that I've been guilty. But you'd rather over tension, assuming that over time, there'll be some creep and some stress relaxation. And so you tend to over tension slightly versus under tension. And I'm constant. So I put I basically do the first limb of my pullover TAF, we, and then I check what things look like. And so what I'm looking for, for the fingers, and I do think that's the trickiest is I'm moving the wrist and I've already done my PT transfer, she can't You can't get too much information. But you can understand what wrist extension does the finger posture and what the tDCS effect is. So you're really looking for slightly over tension with the wrist and slight extension. Hopefully your fingers are up, meaning your MP joints are fully extended. That's what I'm looking for. Is that how you think about it? Or do you do it differently?

Chris Dy: 27:58

Yep, very similar. For those of you that are not watching the YouTube feed Chuck is showing a wonderful example of almost like a hook fist. So the MP joints kind of up in near hyperextension. And then holding them there and then checking the team to desus. So even though you've already seated in your PTCRB, flexing the wrist and kind of seeing what that initial posture is going to be for the MP joints of the of the fingers as that wrist is passively flexed. Do you tend to set your cascade on the EDCs by suturing them all together before you insert your weave from your donor? Or do you just kind of get them one at a time?

Charles Goldfarb: 28:39

Great point. And absolutely. So I sue them all together to start because that tension in some ways may be more important. It's more important, but it's a different importance than your actual tenant transfer. So I set the attention of the EDC tenants all together, and then I add the tendon transfer. Great point.

Chris Dy: 28:57

I think that if you're purely there are some cases like a cervical radiculopathy or something where I'm doing purely something for the EDC and I think that's a great one to do awake to set the tension on those. And it's a smaller surgery. But I think setting the tension is key. What suture do you use? If you can avoid using a brand name? That'd be great unless you know j&j wants to sponsor us. What do you use calibre wise and needle wise? You remember?

Charles Goldfarb: 29:27

It was? Yeah, I'm using a braided so I'm using a nonabsorbable, two Oh, or three to depending on the size of the patient and his or her attendance with I do like a cutting needle, although a taper cut is also fine. And a braided. Whatever it's called polyester. I don't know it's not polyester.

Chris Dy: 29:50

Does it start with an E?

Charles Goldfarb: 29:52

It starts with an E and ends with a bond.

Chris Dy: 29:57

I like using a tapered needle here in this situation. For the, for setting tension side to side, I'll use the three Oh, if you know for example, for the PTCRB, I'm using typically an O or zero caliber suture. And then if I if it looks like it's always be auguin with the three Oh, for the for the weave, I usually put to figure of eight sutures for each weave. And I try to get three leaves if I can. And then usually if we're doing for like the, it'll be three Oh, caliber suture for the thumb. And then for the finger extensors. There'll be an O and A three Oh, like, you know, for each of those weaves. That's worked for me, it's always fun to try to guide our trainees through making sure that the sutures pass through each of the donors and recipients without cutting the prior suture. But our attorneys are fantastic. And they do a great job with that.

Charles Goldfarb: 30:50

That's right. And I one thing, so of all of this stuff is for the residents and fellows who are listening, when you go out to do a case like this is not going to be a case you do every day. And so you may review and read the array we read about the incisions and the muscle tendons, you're going to transfer the part that will keep you up the night before and stretch you out until you get done is the tensioning. And your choice of suture, your choice of incisions, all that stuff's important that tensioning is what's going to stress you out. And so videos online can be helpful for that. But it's also common sense. And using tDCS. To assess positioning, I think you get more comfortable with the concept. But the first time you do it, that's gonna stress you out,

Chris Dy: 31:34

potentially still stresses me out. And then we'll talk about this with Macy. But before we bring it to a close, I mean, when when do you initiate therapy after these kinds of tendon transfers? Do you think it's, there's a camp that will go very early, and there's a camp that follows the standard six weeks of immobilization that are probably some people that fall in between,

Charles Goldfarb: 31:54

again, depends a little bit on my patient population, with my younger patients with CP patients where spasticity of the muscles is an issue, I tend to go six weeks in a cast. In a younger, I'm sorry, I shouldn't say it that way in a more typical radial nerve palsy, from trauma or whatever. I am not against early mobilization, I'll be really interested to hear what Macy has to say. But the flip side of that is I've never seen a patient develop long term issues secondary to casting for six weeks. And so it's all about the convenience or inconvenience of casting for six weeks, which in the grand scheme of things, I think is not that big a deal. And so I tend to immobilize a little longer for these, although I'm not against early mobilization and the right patient.

Chris Dy: 32:42

Yeah, I agree. And I think that I tend to err on the side of mobilizing for the full six weeks or at least a month. You know, that's pretty dogmatic. But it's worked. And I think that if you include that in a preoperative conversation in terms of expectations, it's not a hard sell. You tell them that, you know, you want the the tension is the hidden tendency to heal, you want the tension to try to set as much as you can, it softens a little bit early, and it will stretch out over time. But as you know, even though we say that these verses relative to nerve, the tenant transfers will get you going quicker. You got to make sure you build in that, you know, we're not going to move it right away. We're going to let it set for four to six weeks before we do anything else.

Charles Goldfarb: 33:20

Yeah, exactly. Right. Exactly. Right. All right. Well, this is fine. But I definitely am looking for the fourth part of this wonderful series getting Macy on we'll we'll, we'll find a time we'll get her on. There's a lot of different things that have come up that you and I want to talk about. But it's not going to all happen before the Christmas, New Year's holidays. But we got a lot of things to talk about. I'm excited.

Chris Dy: 33:41

Yeah, it's gonna be heading into 2023 with a full head of steam for the for the upper hand. And we're excited to to hear from any listeners that have any other questions. We have had a little bit of a dry spell on the listener email account. So please send your questions, comments, rants, to chuck at hand. podcast@gmail.com. And let us know what's on your mind and what you want to hear about. Okay.

Charles Goldfarb: 34:05

Perfect. Perfect. All right. Well, have a good day. Have a good day. Enjoy your family and I will see you soon.

Chris Dy: 34:11

I hope you do the same safe travels back. Thank you.

Charles Goldfarb: 34:16

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

Chris Dy: 34:19

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

Charles Goldfarb: 34:24

Mine is at congenital hand. What about you?

Chris Dy: 34:27

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: 34:35

And remember, please subscribe wherever you get your podcast

Chris Dy: 34:38

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

Charles Goldfarb: 34:41

Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time