The Upper Hand: Chuck & Chris Talk Hand Surgery

How the Times are Changing

January 29, 2023 Chuck and Chris Season 4 Episode 4
The Upper Hand: Chuck & Chris Talk Hand Surgery
How the Times are Changing
Show Notes Transcript

Season 4, Episode 4.  Chuck and Chris discuss major technical changes to their surgical practices as well as a few practice management changes.  Learn how we now approach ulnar nerve transposition, cmc arthritis, and other procedures differently today compared to 5 years ago.  We also share a MAJOR announcement- tune in and learn what's changing about our release schedule!

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As always, thanks to @iampetermartin for the amazing introduction and conclusion music.

Complete podcast catalog at theupperhandpodcast.wustl.edu.  

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 podcast.

Charles Goldfarb:

Oh hey Chris.

Chris Dy:

Hey, Chuck, how are you?

Charles Goldfarb:

Fantastic. I just finished clinic.

Chris Dy:

Nobody ever says that after finishing clinic. Was it a good clinic?

Charles Goldfarb:

No, it was a good clinic. And it was great, because there was just you know how one patient can make your clinic like one really, really good interaction

Chris Dy:

in a good way or in a bad way?

Charles Goldfarb:

Well that's true. Both directions. This was good. It was just actually a woman who works at Barnes that main hospital we work at that has known me since I was an intern. And I've seen her intermittently over the years, and she's just delightful. It was really, really

Chris Dy:

Did you wish her a happy 100th birthday.

Charles Goldfarb:

What was funny was we're sitting in the room, you know, we have the work room that I kind of fly in and out of like you, I'm sure. And I sat down and the resident Dwayne, who's working with me said, Wait a second. I wasn't born when you started working here.

Chris Dy:

Yep. Yeah, sounds about right. It's crazy. I was in the ER today. And so what we started to do for these long cases, I did a plexus. We decided to just do a decade's progression in terms of music. So we start in the 80s. We go to the 90s. We go to the 2000s and go to the 2010s. At some point, I had to ask the resident I was working. I was like, So what year were you born? Oh, you were a toddler when the song came?

Charles Goldfarb:

It's perspective building.

Chris Dy:

Yes, indeed. Yes, indeed. But while I'm glad you had enjoyable clinic, because I actually saw somebody the other day who you had done a surgery on but they obviously couldn't get in to see you. Because the age age issues. So the age, the age daddy or clinic.

Charles Goldfarb:

It's a classic example of be a little pushy. And I never say no. But if you don't have to be pushy, to just a nice person, sometimes they don't they it happens like that, which is unfortunate.

Chris Dy:

Well, then they ended up with me. And hopefully I can live up

Charles Goldfarb:

to their expectations. low bar low bar Doctor Dy

Chris Dy:

So any good cases recently?

Charles Goldfarb:

Yeah, I did have a relatively interesting case. Just for, you know, this was an adolescent case, who traveled a bit to see me patient had a distal radius fracture four years ago, not a bad one. It healed on eventually. And he's noticed this progressive deformity on the pinky side of his wrist. And not to belabor the issue, but he had a growth arrest, and had about a 25 millimeter difference. And now, he is skeletally mature.

Chris Dy:

For those in America. That's an inch right.

Charles Goldfarb:

Yeah, so I was trying to appeal to the worldwide audience. But yeah, it's roughly one inch, which is a huge difference. Right? Right. And so he was having pain. He's an athlete and wanted just to get back to sports. But the way it's interesting to someone like me is Do you lengthen the radius? Or do is shorten the order?

Chris Dy:

Now is how much is 2.5 centimeters? Is that a lot to ask if you lengthen?

Charles Goldfarb:

No. So I would if I was going to lengthen it would be a gradual lengthening with a unilateral External Fixator and getting two and a half centimeters would be fine. It's a it's a great bone to lengthen. It's well tolerated complications are low.

Chris Dy:

Just like a bone transport situation you like crank it a little bit every day or like,

Charles Goldfarb:

yeah, you you first surgery is basically an incision down to bone, create an osteotomy then put foot four pins in to four chance pins in to proximal to distal, the osteotomy. Put your frame back on, like the bar, the bar that's sitting outside of the skin, you let it sit for five to seven days and they come back and you start turning a quarter of a millimeter I only do three times a day for the radiator for the hand. And you know, doesn't take long to get 25 millimeters or one inch. And then you got to let it consolidate as you recall from your orthopedic surgery days, and so you're looking at probably four months or you shorten the ulna.

Chris Dy:

Right Well, I guess is this is this a unit planar deformity? Or is it say by planar multi planar kind of thing?

Charles Goldfarb:

This is Uni- planar. When they get really complex, I send them to our ski old partners who do the circular frames, but I am quite comfortable and enjoy the unilateral frame procedures.

Chris Dy:

So before we get to the question of lengthen radius shorten the ulna. Is there anything that could have been done differently with his original injury treatment that would have minimized the chances of you know, if I seal arrest?

Charles Goldfarb:

In this case? No. And I think it's so interesting how sometimes the most innocuous appearing fractures ended up closing on the growth plate and some that are really devastating do not. Now if they had been followed closely, this would have been picked up earlier. But then the question becomes, would you really stop the growth of the owner in a 12 year old? To a no, because then you're, in retrospect, sure, that would have been a great thing to have done. But it's really hard to do that in a young patient, because you're just you're dooming them so to speak, for one inch differential side to side, which, honestly, is not a big deal.

Chris Dy:

Yeah, I think whenever I get fitted for shirts, I remember my one side being quite longer than the other. I think it was just my poor posture.

Charles Goldfarb:

So your custom shirts, Dr. Dy, you are you.

Chris Dy:

This was this was back in a different life when I lived in the the old New York City, the old Big Apple? I don't know, I don't think I've been since becoming a parent, I don't think I've taken that much time to select my clothing.

Charles Goldfarb:

That is fair, that is fair. So then how do

Chris Dy:

you decide what to do here? How do you decide whether to lengthen the radius or shorten the older?

Charles Goldfarb:

This is one of those situations where I say that is patient centered care. But in giving my spiel, I, you know, I think we can take the patient wherever we want to take the patient in most situations, and this kid just wants to play ball. And so it's certainly a faster recovery without any negatives to my view. And so we shortened the old nine. What's interesting, though, is it's not an easy shortening. A big that's a

Chris Dy:

lot. A lot. Yeah, that's approximately 2.5 centimeters

Charles Goldfarb:

is approximately 1 inch

Chris Dy:

So don't put haven't hasn't technology evolve where we don't need to do X fixes for bone transport, haven't the spine, scaly folks figured out ways to use magnets to, you know, to do guided growth, that kind of thing?

Charles Goldfarb:

Well, if you follow the paediatric literature for radial deficiency, Dr. D, you would know that they actually there is a report on using the magnetic lengthening devices for the radius in a setting of radial deficiency to help balance the corpus.

Chris Dy:

Well, since I no longer write the What's New in hand surgery for JBJS I must have missed that in the Journal of Pediatric hand surgery slash Chuck's blog. Yeah.

Charles Goldfarb:

It's interesting. I don't think that's ready for primetime. But it in for two and a half centimeters, it's probably not worth it. But it is fair question. I think that'll that'll be here for all bones at some point.

Chris Dy:

Now, if you're doing guided growth and lengthening the radius, in general, how do you think about that with response it, of course, I want to know about the nerves. Because I know that there are case reports of doing you know, for addressing a big sciatic nerve defect to actually shorten do an osteotomy, shorten the femur, and then do guided growth or progressive distraction, lengthening through the femur. So how do you think about like the pace at which you, you know, have them grow, and whether that's going to stretch nerves, etc.

Charles Goldfarb:

So I've never seen a nerve problem in lengthening. And that's because we don't lengthen at a rapid rate, you know, quarter millimeter three times a day or four times day is just not going to bother the nerves, unless there was a situation where there was significant scarring or other issues or something like that. For those who are truly interested in this, the only time I slow lengthening down is with soft tissue preparation for centralization. And the reason I think that's interesting, and maybe the only one who thinks that's interesting is that if you rapidly lengthen for soft tissue to try to bring the hand over the end of the ulna, you can injure the growth plate, ironically. And so in those cases, there's no race against time for lengthening bones, it is a race against time, because if you go too slowly, the bone will consolidate too soon. If you go too quickly, the bone doesn't consolidate at all. So it's a balancing act. But for soft tissue only stretching and that does stretch the nerves, then you have to be a little careful.

Chris Dy:

Right? Right. So then I'm assuming you decided to shorten the ulna based on your prior statements,

Charles Goldfarb:

shorten the ulna took a big chunk of it out, and then it's a little bit of a fight to get those bone ends opposed. We ended up having to place a screw outside of the plate. And then we elevated one of this was that we put three screws in distally one screw out of the plate proximally and then we use a massive bone clamp like a pointed bone, tenakee alum, and we're able to get it In, you know, an unreasonable position and then compressed and it looked beautiful, but I don't think we could have done much more than that that little over two centimeters that we did.

Chris Dy:

Now, when you decide to do that, and that amount of shortening, do you still use the standard kind of shortening plate and Nia that many of us use? For all the shortening? osteotomies? Or do you freehand this osteotomy? And do kind of ao technique? Because maybe you have a little more customer? customizability? With the latter?

Charles Goldfarb:

Yeah, I think our freehand makes all the sense in the world, you can certainly use anyplace you want, but you're not getting the costly advantages of the systems.

Chris Dy:

Right, right. Well, do you think that that if you use kind of a standard ao kind of plating technique, that would not have saved you money compared to using a older shortening specific,

Charles Goldfarb:

it does, the benefit of the older shortening systems is you do the oblique osteotomy, I think, which is a bigger surface area, and then you can put that lag screws. So that is the advantage.

Chris Dy:

I fully believe that you could do that for you hit I think you would do just fine. But you know, those systems are great. And I what I like about those systems is that they are designed in a way where it is easy to get compression through your various techniques of compression, it's easy to get your inner fragmentary screw through how they've designed it.

Charles Goldfarb:

For sure, should we talk about our sponsors?

Chris Dy:

We should and then we have a bit of an important announcement to make as well. But we should talk about our friends at practice link. The upper hand is sponsored by practice link.com, the most widely used physician job search and career advancement resource.

Charles Goldfarb:

Becoming a physician is hard. Finding the right job doesn't have to be joined practice link for free today. That means today Dr. Dee, at practice www.practicelink.com/the upper hand.

Chris Dy:

So I was mentioning to somebody about the podcast. And they were asking, we're talking about how we finally had a sponsor. And they're like, oh, yeah, it's like, do you guys record that every time and like, I was wondering whether you just kind of like plugged it in differently, like, you know, kind of pasted it in and splice it in? And I'm like, No, we actually record it every time.

Charles Goldfarb:

Yeah, because they're always on our mind, because it's such a great service that practice link offers.

Chris Dy:

Well, yeah, now I remember who I was talking to us talking to Holly Power. Holly is in practice in Alberta. She was a former fellow in the plastic surgery service here at hand. She's doing big things in terms of peripheral nerve. And she's a big fan of the podcast. And so in it was great to see her and Johnny Lou, who I talked about in the last episode, a bunch of other podcast friends at the meeting last week in Miami. I'm glad to be back.

Charles Goldfarb:

I bet you are. Before we make our important announcement, the meeting was good.

Chris Dy:

Meeting was good learned a lot. You know, there's a lot of really interesting stuff going on in the field of nerve. We're still trying to figure things out in a number of ways. But I think some of the emerging technologies would be interesting. I think there's a lot of perspective on how to measure outcomes, which obviously is important for our work. A lot of agreement that we don't have that part figured out and a lot of agreement that that's something that will be important. So it was good to it was good to see that that's still an area of interest.

Charles Goldfarb:

Excellent. And I'm sure, I'm sure that sunny southern Florida was pretty nice this time of year,

Chris Dy:

they'll coming back to Snow was a little bit of a rude awakening. But I do like the fact that you know, we're recording right now. It's just before five o'clock and the sun is still out. So that's a good thing.

Charles Goldfarb:

Yeah, we have past the nadir of short days and every day is a little bit longer. And that is beautiful.

Chris Dy:

Makes a big difference. Well, speaking of changing, we are changing, we are making a big change for our podcasts. So our listeners and we want to tell you that we are going to switch to releasing episodes every two weeks.

Charles Goldfarb:

Yeah, I have to say that we haven't come to this decision lightly. We want to make sure that when we get together we give this everything we have and we want to make sure that we are addressing timely topics with energy and with gusto and with new ideas and they're certainly a never ending source of ideas but we thought to do our best for you valued listener that we were going to change the cadence now. I would like to put a plug in if this makes you happy email us if this makes you sad email us let us know communicate. There's been a little bit of some radio silence from the from the listeners at least virtually you know by interaction maybe in person we see we see people but I'd love to hear more.

Chris Dy:

So you know, we've had enough good stuff from the email account to put together one grab bag episode, which we'll do next. But yes, please let us know What's your thinking? What's on your mind what topics you want to cover? I know that a lot of folks really like the radial radial nerve series, but then others are looking forward to the Sport series coming up. So, yeah, let us know. It's, it's tough to switch. But I think is we want to continue doing things with panache and alacrity as one of our former ministers would say, and I think this will allow us to do that. So that's something that is coming your way. I think after this episode drops, I will start doing every two weeks after that.

Charles Goldfarb:

We appreciate your understanding, and we appreciate your continued listenership we hope this is is not a negative in that respect. And hopefully, it may be even a positive. So thank you. Thank you. Thank you. Thank you for listening in. And we appreciate all the support and love that we have gotten over the years. Because Dr. Dy, I think this is our fourth year, is that right?

Chris Dy:

We are in our fourth year, I guess it's we've passed our three anniversary, I left the gift I got you at home, I think I have leftover rice krispie treat and hear from something that I could give back and walk over and give you. But what do you want to talk about today?

Charles Goldfarb:

I want to talk about for years, I didn't think we'd make four episodes.

Chris Dy:

You know, somebody asked, like, you know what, how it started and the story behind it. And you know, it's crazy, like we started at the beginning of a pandemic, or no, before the pandemic, and I'm sure the pandemic was already kind of started. But, and then things popped off. And we were left to our zoom existence and just kind of rolled with it. It's crazy to think about everything has changed in the last three plus years. The resident I'm working with was still in medical school. I realized that today.

Charles Goldfarb:

Did you I have to share a couple of things. Did you share? Or did you see the end of the year summary for our podcast? I think we should share some of the stats. I think the listeners who are you know, to whom we are imminently grateful would find this interesting.

Chris Dy:

I think they would too. I would love to pull it up here and see if they can come up for me. Do you have it pulled up already?

Charles Goldfarb:

I do. Or some of them I've memorized. The first is that

Chris Dy:

Lana that says that you've ever

Charles Goldfarb:

it just stuck in my head. We have 125,000 reasons to be proud.

Chris Dy:

That's really cool. I'm sure that is a number of total downloads.

Charles Goldfarb:

Yeah, so we had 50 episodes last year. We had 125,000 downloads. We our most popular cities, St. Louis somehow it's never

Chris Dy:

that's all it's all of us all the residents working with you that just clicked and downloaded the entire time.

Charles Goldfarb:

Number two, Chicago number three, Sydney, Australia.

Chris Dy:

That's really cool. I think that's a that's, that's exciting. I think they're all just listening for more of your stories from your Australian and surgery friends,

Charles Goldfarb:

maybe and then 114 countries. And really cool. That's very cool. And then do you know what the most popular episode I hate to give you kudos? Do you know what the most popular episode was?

Chris Dy:

You know what? I'm not sure I'm sure it was a discussion about peds or sports or something like that.

Charles Goldfarb:

It was the jbjs hand and wrist surgery update episode.

Chris Dy:

That's not I mean, it's if you think of it, it's a great way to get your literature update clearly with a ton of bias. We should do that again. When that after when that article comes out this year. We definitely should that I have here that I think was interesting is that if you listen to all the episodes in 2022, you listen to us talk for 1727 bits, which I'm sure was on at least at 1.5x speed.

Charles Goldfarb:

I wonder how many days of life you wasted.

Chris Dy:

I think that you you probably were a great commute, buddy. For a lot of people, Chuck. I'm sure they really appreciated that.

Charles Goldfarb:

Oh, that's so good. I have a good idea for our discussion today, which you have already heard because I know you prepared. Let's speaking of time and how things change over time. Let's talk about things we do different operatively today, compared to in the past now your past is not as long as my past. But let's talk

Chris Dy:

you said five or 10 years ago, I was like I was barely in practice five years ago and 10 years ago, I was stuffing it with your fellow that's the biggest difference I think for me. But ya know, I think that you know, the biggest change and one that immediately came to mind was just the bringing in what launch so wide awake local anesthesia, no tourniquet surgery into into our practices.

Charles Goldfarb:

I think that is a really really good one and it's changed the way my day works. So the instead of having all these little, little cases carpal tunnels triggers whatever first thing in the morning where I bounced and get a bunch of done there. Now at the end of the day, it changes my whole day just how the cadence works. But I would say universally, patients have been really happy with that option. And I was worried about anesthesia. And I was worried about kind of those relationships. No one cares, it's a great thing for patients is a great thing systemically

Chris Dy:

love it. Yeah. I mean, I think that, you know, I think it, it can be threatening to some anesthesia partners. And I've heard this, you know, when people talk about, you know, incorporating Volant into their practice, and getting blocked from doing so, you know, I think at the end of the day, if you were to have one of these surgeries, you probably would want it done this way too. And I think people remember that, because, you know, you hear about, you know, some kind of like, freak issues with anesthesia every now and then, which you know, are not related to the surgery. That stuff can happen. And you know, honestly, most people, you know, want to get back to the, you know, getting back to doing what they love without that, you know, hangover from anesthesia. Yeah, I

Charles Goldfarb:

call it a brain fog when I talk to my patients, but I think

Chris Dy:

maybe maybe yours just just you're just slightly more elegant with your conversations.

Charles Goldfarb:

Sure, brain fog sounds very sophisticated. Alright, here's mine, that you will very much appreciate. My treatment of cubital tunnel syndrome has changed, I guess it's changed sort of in two ways. If you look back 10- 12 years ago, I was doing a lot more decompressions that I'm doing today. And it's not as if I'm, you know, my patient population has changed so much. But I think I'm just more selective. Given that we understand that a decompression that doesn't go well can affect long term success rates for the treatment. And so I do have a lot of patients that have instability, I do have a lot of patients with could be with other surgeries at the same time. And I do look for the option of decompression, but I would say 75 to 80% of my cases are transpositions generally, subcutaneous and I can talk a little bit more about technique, but I would like to hear your reaction to my statements.

Chris Dy:

Yeah, I think that's about right. I mean, my approach to cubital tunnel treatment has changed to I'm not I came out of training. And for the first couple of years, I was very much, you know, no, decompression is only some muscular transpositions. And you know, upon visiting others and some reflection, I've incorporated decompressions into my practice, but it's not a common thing, I think because I, I become algorithmic with my treatment of cubital tunnel, for better or worse, but it seems to have worked out for me. You know, I think that there is a definite role for decompression, but it is limited. I'd be curious to know what your what you think the revision rate is on a decompression say, within five years of the first surgery. What do you think the revision rate is because I know that way back in the day, when I was I think maybe like in grade school, you and Dr. Mansky published his original results and your revision rate was was like 7%, or something like that 7% that a recent series from here, which was kind of an all comers and not apples to apples, you know, showed a 20% rate, which I also think is a little high. So where do you think that real revision rate lies?

Charles Goldfarb:

I have not recently done a revision for a decompression, but my guess is seven to 10% is accurate in a carefully selected population.

Chris Dy:

And then, you know, what do you think the true advantages of a decompression in 2023?

Charles Goldfarb:

Oh, I think it's I think it's so nice to get away with doing that. A you can do an under local only if you're really ambitious, but but it's just a simplicity, and bulky soft dressing, immediate gentle motion, get back to activities faster, get in the shower faster. It's just the recovery time, even though you still have to be careful and aware so that you don't stress them or too much. It's a game changer if you're able to do it.

Chris Dy:

They are completely different surgeries to get over even a revision or a decompression versus a subcutaneous, let alone a sub muscular, but I mean, they're very different surgeries to get over it. I use it when I can I think there's definitely a role for it. Have you done any of these? Awake?

Charles Goldfarb:

I have not. I mean, I think if I had the perfect candidate I would offer by the perfect candidate. I mean someone who is not too heavy. And where I was really 99% confident I was doing a decompression only because as you know when we commit to the local only we sort of lose anesthesia is involvement. There's no pre screening.

Chris Dy:

Right, right, right. Well, I think the ultrasound is helpful for that. I've only seen the ultrasound be wrong once. And, you know, it wasn't one that I was doing under local, I've done a handful under local and, you know, the shoulder is gotta be real flexible to make that happen. It's going to work you have to really check that ahead of time and I've learned To any clinic just be like, okay, so if you had to lay like this for like a solid 15 minutes, could you do that?

Charles Goldfarb:

That is interesting. That is a really good point. Well, there

Chris Dy:

there are some people who do it under local in the office and do it prone. Just to minimize that, you know, the movement and stuff.

Charles Goldfarb:

I would think that's not a bad idea.

Chris Dy:

And lying prone for 15 minutes while you're having surgery is not also not easy.

Charles Goldfarb:

No, let's talk technical because I think I say this regularly to the trainees. I, how I used to do a subcutaneous with a standard eatin flap. And for those who don't know the terminology, tick, eat and describe taking a strip of fascia from the flexor parameter mass, and elevating it, and suturing it into the anterior scan to prevent the nerve from succeeding posted early, it's easy, it's somewhat elegant. And it works to prevent the nerve from sub luxating. I don't do that anymore. Almost ever. But this fasciocutaneous Flap is awesome. And for those of you who haven't tried it, try it. It is really slick. You elevate all the fat and and at you know fascial tissue off the flexor pronator mass, excise your muscular system as you usually do. And then you have hopefully a nice reasonable size padding to cover the nerve and also to suture into the middle of a condyle to prevent them there from succeeding posterior Lee. And I think it's fantastic. I haven't had a single revision after using that technique. And I have revised several others that have used the eatin flap that weren't mine. And you just see what happens sometimes with that flap. It's not always great.

Chris Dy:

Yeah, I think there's a real risk for some tricky adhesions, especially if patients don't get started early with the Eaton flap or the V sling, which is something that others have described that any kind of sling coming off of fascia. If you're not talking to nerve all the way deep. I know that there's some folks have a role for a sub fascial transposition. I'm not in love with that just because I've had to do the revisions. But I think that you know, do whatever works for you. Obviously making sure that you avoid those extra kinks in the nerve as it takes us downslope, getting rid of the septum where it can come across. So a little plug. I've been I'm going to do one of the acsh Fellowship debate webinars I'm going to moderate on I think it's February 9, if you guys want to tune in, but the topic is cubital tunnel syndrome, and one of the topics that's going to be presented is the adipur fascial flap that Chuck adores, and that's going to be presented by one of our colleagues from Duke University so that'll be an interesting if you want to see all the technical details I'm sure that he'll mythologies fella, Wola will have some great slides. So yeah, please listen to that or follower. Watch that if you're interested.

Charles Goldfarb:

Love it, love it. All right, I got another unless you got one to share.

Chris Dy:

I've got one to share. I'm, I think I'm maybe 30 Something cases into doing ultrasound guided carpal tunnel release. And, you know, I've it's been I think I went and did the training in November of 21, initially, and it took a while to kind of get the process through, so that we could actually start doing cases along while Now obviously, there was a lot of training I did in terms of follow up cadaver workshops, etc. So I believe I started doing that procedure in the fall of 22. Kind of early fall. And you know, 30 Something cases in and it's been really interesting. You know, because of the way that I trained here, I did not do a endoscopic and training. I know a lot of listeners will do endoscopic as opposed to a mini open. And I think it's been refreshing to see how patients do after it. I'm not exactly sure where it's going to land in my practice. I'm learning a lot about how to counsel patients about it. So I don't want to go into too much detail here yet, because I want to be fair to, to the technique. But it's been it's been interesting to have to implement, getting a device through the approval process, trying a new technique in practice, and kind of comparing it to something that I've done many, many, many, many, many more times.

Charles Goldfarb:

Yeah, it is interesting. And I guess ultimately, at some point, you have to decide whether it's a value add for your practice and for you, and for your patients, of course, and I ultimately decided that it was not when I went through this process and inch I look forward to your ultimate decision about whether you will continue to do this. I think it's interesting and it's different. Whether it's the right thing for the long term, who knows.

Chris Dy:

And what was the this was slightly different with the device. I saw that you were ago that you were using right?

Charles Goldfarb:

Yeah, I use the I don't mind saying it the am surgical, I guess retrograde approach whereas incision in the palm and you work from distal to proximal. And I liked the technique, I liked the technology. But ultimately, I didn't leave the or as happy and Skippy as I do after a regular carpal tunnel, it just added an element of stress that I never got past. And I talked to Dr. Government about it. And he said, Why are you taking a simple, safe, effective surgery and adding that to it? Do you really think it's worth it? And ultimately, I decided, for me,

Chris Dy:

it was not never seen you skip. Don't

Charles Goldfarb:

skip regularly, but I have skipped.

Chris Dy:

So I want to see if you skip after a carpal tunnel of all the things. That was my recent addition to my practice, anything else that you've changed in the last five years?

Charles Goldfarb:

Well, I don't want to belabor because we've talked about it. But how I approach the TFCC is completely different today than it was five, seven years ago with the understanding of phobias, TFCC tears, and I'm speaking about that tonight for the SSH webinar. But it's just totally different. And I feel as though I didn't understand the TFCC as well as I could have, even though I'm not sure many did. But the faux vo insertion of the TFCC matters. And it's remarkable how often I am repairing the TFCC with a phobia in mind. So big deal and totally has changed my practice.

Chris Dy:

Yeah, it's changed mine to listening to you. I mean, I, it was scoping a risk recently, and you know, was telling our trainee all about your papers about you know, hook test and everything. And it really has changed kind of how I evaluate stability. And think about it in terms of what what a specific repair technique could do what the role of shortening would be subsequently. Super interesting to hear. And And honestly, like, I think that if people, by the time this episode drops, your webinar will have been done, but it'll be available to view on online for the hands signing, I'm sure it's going to be a great one. So make sure to check that out. I have a question for you, Chuck. Sure. So in the last five years, or so 2023 versus 2018, do you think you operate more or less on adult distal radius fractures?

Charles Goldfarb:

Is a fair question. I don't think I've changed honestly there. You know, there certainly hasn't been a change. I don't know that my approach has changed. What about you?

Chris Dy:

I feel like my approach hasn't changed a whole lot. But I find myself doing less surgery. And I don't know whether that's because maybe subconsciously or unconsciously, the way that I present the options is different now. Although I think the purely radiographically my indications haven't changed,

Charles Goldfarb:

I think you're probably right, I think I probably operate less for that reason I, I don't push surgery as much as maybe I might have subconsciously or consciously in the past.

Chris Dy:

So another big change for me, has been having to rooms regularly. And that I think has brought it's just another element to you know, the day in terms of planning things out, and having to figure out how to how to navigate that. And I think I've gotten pretty good at it for my setup. But you know, as soon as you think you have something set up well, you never know what's going to happen next.

Charles Goldfarb:

It is a skill as we've talked about. It's a it's a really a It's not easy to do it right and to do it. Well. I think that's that's exactly right. I'll share my last one. And if you have another one, please share we'd

Chris Dy:

love for you get to your last one, I just do you have one pearl, you could share with somebody who is in the stage of their practice where they're getting real busy, and they might be trying to run two rooms.

Charles Goldfarb:

Yeah, the curl is easy. Do it yourself that is plan out which cases go in which room and what order and how you flip flop. You cannot trust that to anyone else for maximum efficiency. A lot of thought goes into it because you have to think about a multitude of different factors, including equipment, including how much time you can potentially overlap the rooms, not the cases. It's very tricky. And I think that's the that's the secret sauce. What about you?

Chris Dy:

I think that's really, the other thing I'd say is to consider who's with you, and how to maximize their education while balancing that against efficiency. Because you know, the reality is, is that you're going to in a place like ours where you have trainees of various levels it is a fellow to room day is very different than a PGY two or three to room day. And both have fantastic things that you can get from each of them. And you know, I think that that's an important thing to consider.

Charles Goldfarb:

Well said well said my final I change. And again, we've talked about it is the CMC joint. And I had a patient come back today, that was 10 years out from her lrti Happy as a clam, and wanted surgery on the other side. And we talked about the options. And she chose the newer option, which is the suture teacher takes

Chris Dy:

suspension. Yes. And

Charles Goldfarb:

I gave her both options. And it's hard when you're very happy with one side, but she didn't like the recovery.

Chris Dy:

You know what I think the that is that brings me to a point that is different. I think I counsel patients differently in for a number of procedures, but mainly for thumb, CMC, about the duration of time. And that ultimately ends up that the time it takes to recover and that ultimately, I think, ends up turning off some patients, but I'd rather err on the side of accuracy of what that recovery is like. And that for me, stemmed from an actual paper that one of our fellows wrote after interviewing my patients after they've recovered from from CMC surgery, and how long it really took mine. And some of you, I think, maybe some of yours and some of our partners. So it's not a quick it's not a quick surgery to get over. But you know, using the suture tape, I think does speed that recovery alone.

Charles Goldfarb:

I think it does. You want the final word?

Chris Dy:

No, I never want the final word. I'm gonna give it to you.

Charles Goldfarb:

I like this. This is fine. Here's my here's my plug for another episode, we're gonna do a grab bag. I'd like to I think we should both take stock of what we say in clinic often our little colloquialisms that we use and why we use them. We've sort of done that in the past, but I think we could do a better job of it in the future.

Chris Dy:

Yeah, and I've definitely got a couple of analogies. And then a couple of things that I things I use with patients and things I use with our team are very different. But you know, anybody who's been in clinic with me knows what the TI protocol is. And I'll leave the teaser for that.

Charles Goldfarb:

Teased. All right, have a good night. All right. Take care. 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 @Handpodcast. 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.

Charles Goldfarb:

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