The Upper Hand: Chuck & Chris Talk Hand Surgery

Chuck and Chris on Vegas, hand fellowship, research, and AIN Palsy

March 26, 2023 Chuck and Chris Season 4 Episode 8
The Upper Hand: Chuck & Chris Talk Hand Surgery
Chuck and Chris on Vegas, hand fellowship, research, and AIN Palsy
Show Notes Transcript

Season 4, Episode 8.  
Chuck and Chris record a second episode in Las Vegas during the AAOS.    We start by talking Vegas and Chris' dining choices.  We discuss research pathways recognizing Chris's amazing accomplishment of  winning the  Kappa Delta Young Investigator Award.  We share reflections on our recent fellowship interview day (and the remarkable candidates) before discussing a reader- submitted case on AIN palsy. 

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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, Hi, Chris.

Chris Dy:

Hey, Chuck, how are you?

Charles Goldfarb:

I'm great. We're back at it.

Chris Dy:

Good. Pretty good. You know, just it's nice to be across the table from you again. It's been a while.

Charles Goldfarb:

Yeah, we are recording an episode here in Las Vegas. And it's really a is something to not be on Zoom. It feels like we're in Vegas face to face. Life's open.

Chris Dy:

Yeah, no, I feel like we're probably gonna be back to doing zoom mainly because of our schedules. But it is nice to do. It's nice to have our podcasting equipment. It's been fun to lug that around. I'm sure it's not that bad. Actually. I'm sure it's nothing like being the guy in in a coat and with a backpack walking two miles on the Strip.

Charles Goldfarb:

No doubt I appreciate your sacrifice for the fine,

Chris Dy:

you know, and I'll do it for you. No, no problem at all. i She it's good to have a weight to do all this walking. You know, we were texting this morning about whether to when to come down here. And you said you're getting in a cab and I was like, No, I'm definitely walking.

Charles Goldfarb:

Well, so I walked. So I had my bag with me. I walked from the convention center to Caesars yesterday. And it took me about 40 minutes, right? Yeah, with my bag. And I have my bag today for a variety of reasons. And so I was like, I just can't do it again.

Chris Dy:

Right now. That's fair. That's fair. You know. So I've forgotten. I think the last time I was here was when the hand society was at Caesars. And that was nice, because I stayed in Caesars pretty self contained. If you wanted to walk, you weren't lugging stuff around. But I chose to stay at the Cosmo this time because I absolutely love the restaurants in the Cosmo. And my meeting commitments were relatively light, so it didn't have to spend a ton of time going back and forth. But I forgot how long it takes to walk around. I mean, when we talked on the last episode, we talked about the vagaries of navigating the strip. And I was supposed to be here for a picture taking ceremony and I was late by 15 minutes because I just got stuck on the wrong side of the strip and then they closed one of the walkways and it's just it was a mess

Charles Goldfarb:

you're sweaty and

Chris Dy:

right so then it was such a long walk that you know I walked back afterwards and I had to go back down for for an alumni reception for HSS that was it. You know what, this is a long enough walk I'm turning on my peloton. Outdoor walk half walk. It was the it was it was 2.8 miles to get from my hotel to the wind for the for the alumni reception, so at least I got credit for it.

Charles Goldfarb:

Wow. So a couple of things before we jump into why you are taking a picture. I would like to hear where you ate dinner because there are some foodies like yourself, I'm sure who are listening.

Chris Dy:

Okay, so I'm gonna divulge something here. Yesterday was not just what the last two nights were not just one dinner, there was dinner one and dinner too. So my sister was kind enough to join me for this trip. And because she's in LA, it's a quick flight. And I was like, well, he might as well come. And so we we ate off the strip, interestingly enough on the first night and went to a spot called the black sheep, which is from a James Beard finalist. Jamie Tran does a lot of really interesting Vietnamese food. That was delicious. But I also remember when I was at Caesars for the Pain Society eating at Beijing noodle number nine, it was kind of wanted to play the noodles as dessert. So back to the strip afterwards, add an extra plate of noodles, which was delicious, and then promptly woke up the next morning to work out and atone for all of that. And then have eaten that you know, I have a soft spot for Dave Chang Momofuku. So we ate there for lunch. And then dinner was at we went to Roy Choi spots. He's an LA based guy called Best Friend which is at the it's at the REI believe Park MGM. And then I went to the HSS reception walk two miles there two miles back, just so you know. And then finish the night with some Peking duck and red plate in the Cosmo. There was restraint. I told my wife I'm out of shape for eating like this. So you know, clearly there's some training to do, but I think I'm gonna need cardiology clearance to get back on the plane.

Charles Goldfarb:

That is incredible. Well, my story is much more simple. I eat to live I do not live to eat. But I had a wonderful dinner with a few friends at Nobu, which is always good, and I know they're probably better sushi places for true aficionados. But for me, it was really good.

Chris Dy:

I think Vegas is really interesting. I mean, it's like it's become for me such a Food City like you know, it's more of you know, it's weird to like think like, oh, yeah, you're gonna come here and eat at restaurants from other cities from chefs most cities but once you embrace you're like, great, I can do New York I can do la actually stopped by and got some some pastries, Dominique Ansel, which was We adored in New York. It was almost like basically New York City like early 2010. This theory did

Charles Goldfarb:

so well there was the urban legend, which I really believe is was true is that the orthopedic surgeons and the AOS were disinvited to Vegas probably 25 years ago because we were not the Ford dealers in America and did not spend all night gambling. But Vegas today is so different than Vegas then. And so those of us who eat a lot or drink a lot and may gamble some and spend too much money on hotel rooms, we are in demand. And so back we are in Vegas,

Chris Dy:

back we are in Vegas. I'm just happy that there's not a ton of smoke as you walk to the convention here. I know that was an issue at when the hand society was at at Caesars

Charles Goldfarb:

Yes, still still a touch but toe it seems totally different. I agree. So, Chris, why were you late for your picture? And what was the picture for

Chris Dy:

I was late for the picture because I didn't realize how long it would take to walk the mountain, you know, walk down the strip. But you know, I'm in been fortunate enough to to receive the Kappa Delta Award and the Young Investigator Award from the Academy in the IRS for our work on the brachial plexus injury, so that, you know, I gave a talk for that in Dallas a few weeks ago, which was great to to deliver that. And then here it's the presentation of the award.

Charles Goldfarb:

So amazing accomplishment, congratulations and a help those of us who don't know quite as much as you about the Kappa Delta. First, how many different categories are there for Kappa Delta awards in 2023.

Chris Dy:

So I learned yesterday during the ceremony that it's been going on for awhile Kappa Delta sorority, and they partnered with the academy starting I think, in the mid 70s. And their first award was$1,000 Research Award. recognizing excellence in orthopedic research, I think one of the one of the founders in Kappa Delta, had been working with somebody at the one of the hospitals for the for the ruptured and the crippled, this one in Virginia. And so they started that relationship. And Kappa Delta has been an incredible supporter of orthopedic research since then. So now they have three different categories. Two are named after, you know, some of the bigger founders and Kappa Delta. And those are given towards anybody who has contributed a lot towards orthopedic research, kind of like the injured a wildland metal that you received last year for the hand society. And then they have a young investigator category for those that are under 40.

Charles Goldfarb:

Are you still under 40 squeaked in and under

Chris Dy:

I think it's under eight years in practice. So for both of those criteria, this was my absolute last year of eligibility. And funny story, I had kind of forgotten about the young investigator category. But I was scrolling through emails when I was on a trip, visiting Mayo Clinic, for the F for the government scholarship doesn't go, there's my last year, I need to apply.

Charles Goldfarb:

So the other two are sort of Career Achievement Awards, right? This one is based on a singular investigative process.

Chris Dy:

So this is I mean, I think it's an expectation that you've developed a body of work over, you know, the your time as a young investigator that shows, you know, promise and potential and hopefully it has affected, you know, practice and change lives.

Charles Goldfarb:

Without boring our audience or boring your cohorts. Tell us a little bit about your research that is most recognized in this award.

Chris Dy:

You know, I think that one of the challenges that we have with Plexus patients is really focusing most on our traditional ways of looking at outcomes mainly like is this muscle and m two and M three and M four, and not really looking at like what goes on with this patient and how it really affects them. And when I was a resident, Scott wolf put me on to this idea that you know, that we need to broaden kind of our view of how we treat patients with brachial plexus injury. So he he and I started doing a systematic review of how outcomes were assessed. And we published that and JHS. And then he started working with Carolyn Cousteau and Steve Lee at special surgery on and developing an outcomes measure that encompass a lot of the psychosocial aspects and emotional aspects and social support. And then when I started as faculty at WashU, I talked with Scott and he said, Yes, you should run with this. And we started doing more work on kind of the economic impact of the injuries and a lot of the stuff to set up a study so that when we were writing grant, we could say, This is why Plexus injuries are important. This is why we need to study them. This is why you should give me X number of dollars to launch a big study. So it was nice that a lot of the preliminary work part of our grants, you know, serves as the crux for this for this paper that we wrote for the Kappa Delta.

Charles Goldfarb:

That's amazing. Congrats. You know, we've touched on this, but it's been many, many episodes ago. For the younger listeners, whether you'd be a medical student or a therapy or therapy student or in practice, especially if you're an academics, you know, when you start your career, I personally believe and I think you probably agree, you know, stay broad as you're figuring out what you want to do. Use the research process to understand different segments of orthopedics or plastic surgery more deeply. So for example, I had research in literally every area of orthopedics except for spine. And but once I started my career, I really have focused on two areas. Now they're not small areas, but they are niches I mean, there's congenital, obviously, and their sports, and that's where I would say, 90% of my research lies, and I feel most passionately about it. And it does allow you to tell a story about your research,

Chris Dy:

I think telling a story is great. And, you know, it was fantastic to see how your story came together, in looking watching your presentation for the wildland metal. You know, I think that, you know, doing this kind of research isn't for everybody, you know, people that aren't going into in academics are most likely not going to even think about this. But if you are going to go into academics, and you are going to try and you know, have an area of expertise, it is nice when your research area and your clinical area dovetail. And Plexus was a long shot, you know, for a number of reasons with NIH, because, you know, traditionally Plexus has not gone to the orthopedic portion of the NIH, the NIH AMS group, and we worked hard to kind of pull it in and get peripheral nerve back into the NIHMS portfolio at least a bit, um, which hopefully will help, you know, others going forward too. But I think that, you know, recognizing that, you know, at least orthopedic surgeons should have a role in in taking care of patients with these injuries has been a contribution to so it's been fun to, you know, to see how the work is developed, it's been motivating, to be honest with you to see that, you know, okay, we're making an impact we're getting there. And, you know, looking forward to getting the next phase of the work done.

Charles Goldfarb:

Yeah, and before we pivot, you know, I don't stand on a lot of ceremony and awards are nice, but they aren't what motivated me, but it is nice. And it does cause a little self reflection when you are awarded, and you are recognized for the work you're doing. And you're the main thing I have gotten out of those accolades. Now, I've never been a Kappa Delta winner, but it does motivate me, it absolutely makes you want to continue the process. Right?

Chris Dy:

Absolutely. I think it's important that people that are doing, you know, may at least for the Kappa Delta, that surgeon scientists are, you know, applying for these awards. And I look back at, you know, when I was applying, I looked back at the list of folks who have gotten in, and it is heavily basic, basic science. So, you know, I think we as surgeons, if you're doing this kind of work, you know, don't forget about these awards, because you have an opportunity to, to really set yourself apart from the basic scientists and nothing against them. But you know, you're a surgeon, and you have a skill set and a breadth of perspective. And to be honest with you, this little tip, the people reviewing the papers are surgeons. So keep that in mind. You have a leg up in terms of you can connect with them much, much better, I think, and more readily than some others.

Charles Goldfarb:

I love it. All right, we're gonna pivot now to another hat you wear in our department and in our hand division, that of fellowship director.

Chris Dy:

Yeah, it's, this was the second year that I've led the the fellowship interview process. And then within the last couple of weeks, we've had, we had, you know, 20, something incredibly talented. Young candidates come through our department for in person interviews, which you haven't done in, you know, three years.

Charles Goldfarb:

It was great. You know, when we interview resident applicants, it's really enjoyable. It absolutely is. But it's different. Because fellowship applicants, whether they end up in our fellowship, or another fellowship are going to be our peers, and we're going to see them in meetings, and it's nice to get to know them and meet them. And I think that's what Peter started many years ago, with literally bring in every single applicant almost on a different day. So became this six month slog of meeting applicants. That's really hard to do today. But I understand it.

Chris Dy:

I remember the stern interview very well. And this is before I got to know Dr. Stern, I still remember the two people that I interviewed with that so he brought three of us in and we you know, showed up for conference in the morning and then he just had his normal day so it was an hour I don't know if it was different when you interviewed but it was an Omar day and so you know you're in his surgery center with him. Your scrub looking over here or you're not scrub you're looking over your shoulder and the or, and then just questions start coming. And it's terrifying.

Charles Goldfarb:

So I totally agree. Totally remember, and I don't think I've shared this with you. So I had a lot of support from my residency and I was at Wash U and I didn't really know doctors don't know or his partners but we had a you know, had a conference in the morning which is amazing. We went over to the surgery center asking me questions like he asked you what I remember it this is this is a truism. I don't remember a single question I got right but I still to this day, remember the question I missed? And when I missed the question, I did stay composed. But in my head, I was like, You're just an idiot. But the question was, he was doing a carpal tunnel with a pretty standard incision. And the Palmaris brevis was clearly there and he goes Dr. Goldfarb, what is this muscle and I had no Yeah, but yet it still matched.

Chris Dy:

Right right. And I remember so first off, I want to say for those of you listening for the trainees, Dr. Goldfarb does get did get questions wrong at one point okay when he was a On the other side of the table episode, and so did I. So I just like anything I'm sure i There were questions I got right. But there was definitely a question I got wrong. And it wasn't the first level question. So we were I was watching him do a declared veins release. And, you know, he was asking me, oh, what are the potential complications of this surgery? And then, you know, I mentioned that, you know, the tendons could sub looks a little early. And then he's like, Well, who wrote that paper? And I was like, Sir, I don't know. It's like, it's one of your mentors. And he's like, it's Dr. Weiland, Dr. Weiland, your mentor wrote that paper was like, Oh, I will pack my bags and go home right now. The other anecdote I remember from, from that interview was that that's just a delicious sandwich. Like it was. I guarantee it was like a $4 sandwich. But it was a fantastic sandwich from your very local Cincinnati Deli. It was it was a good time,

Charles Goldfarb:

maybe the foodie and you started dancing. Exactly.

Chris Dy:

But our group that we had was great. I mean, it was incredible. So much talent. You know, I think one thing that we've noticed, I think now that we've taken a plastic surgery trainee for the last couple of years, maybe one a year, is that we're getting more plastic surgeons applying to our group. And it's it's refreshing to see, you know, different perspectives. And they've all accomplished so much as well. And I mean, it's a, that was one thing that I hope continues going forward is that we get to see the best of the best, regardless of the specialty.

Charles Goldfarb:

Yeah, absolutely. The we were fortunate that our first plastic surgery fellow was outstanding Brinkley Sandoval. And I think she's she you know, she set a bar. But she also gave us confidence that we could work with anyone and train anyone because before that, for reasons that are not entirely clear, we hadn't taken a plastic surgery fellow. But now we have 100% interest in doing so. And it's nice when there's a mixed background of our of our fellows. It really is helpful for everyone.

Chris Dy:

Absolutely. Did you like being back in person?

Charles Goldfarb:

I love being back in person, it is always about being back in person is great. But you know, how long can you commit to do an interview? And how much information can can you share in a 10 or 15 minute interview? It's just such a fascinating process process where you're really trying to get to know someone in a very short period of time.

Chris Dy:

Right? Well, how long is the right amount of time for a one on one it fellowship interview?

Charles Goldfarb:

I really don't know the answer to that. And I we did what, 10 or 12 minutes, and I think I guess technically 12. But I think 15 might be slightly better. 20 is too long, in my opinion.

Chris Dy:

Right. Right. Right. I think you can get most of what you need within that first 12 minutes. So yeah, I enjoyed the process. You know, it was nice to see everybody interacting again. You know, so hopefully everybody that came through had a good time.

Charles Goldfarb:

Yeah, I hope so too. I hope so, too. We probably should touch on at least one case. And I thinking back about Dr. Stern asking you complications for decware veins, I can't believe that first answer out of your mouth wasn't superficial branch, the radial nerve issues.

Chris Dy:

I think we covered that in the preliminary round of questioning during the initial approach to the surgery.

Charles Goldfarb:

But I think you had a case or a concept you want to briefly review, which I think would be interesting and educational for me regarding ai n policies.

Chris Dy:

Right. So we had a listener email us. So first off, if you have any questions, you can email them to us at hand. podcast@gmail.com. But the question actually came from and she may not realize this, somebody who was a rotating medical student when I was a third year resident on the peds service at HSS. Wow. And I've actually seen letters of recommendation from the surgeon come through for applicants from her program for fellowship. And I wonder whether she has fond memories of that or not, because I remember those very difficult service. The Pete surgeons at HSS are not as laid back as you know, maybe Dr. Goldfarb. They weren't at that point. So he's conference was these conference was intense. So there were there was a lot of there's a lot of PowerPoints, and there was a lot of consternation over PowerPoints. Right, exactly. Well, I came to fellowship very good at PowerPoints. But the medical students rotating through we're seeing, you know, the intense academic rigor of the pizza service. So Lisa King was the medical student, and now she's an attending hand surgeon at Henry Ford. And she has a question. So first off, she said some nice things about the podcasts that she really enjoyed listening to Chuck said the podcast, and our trainees don't enjoy it too. And it's led to some great discussions in clinic and in the ER, a question for you. What are your thoughts about the role for and timing of nerve exploration for ai n policies? How do we know which ones will get better on their own in which should be explored or decompressed? If patient has an EMG, with no motor units in the FPL, no clinical improvement over four plus months, and the ultrasound shows diffuse nerve enlargement in the forearm, but no signs of any focal compression. Would you offer surgery or just wait? Would you consider a nerve transfer for FPL? Thanks for your input. So wait Before you get into answering Lisa's question, I'm not answered. You're gonna answer we got we got to think practicing.

Charles Goldfarb:

We absolutely do. The upper hand is sponsored by practice link.com The most widely used physician job search and career advancement resource

Chris Dy:

becoming a physician is hard finding the right job doesn't have to be joined practice link for free today at www dot practise length.com/the upper hand. So yeah, we just did like a little teaser before commercial work a real podcast now,

Charles Goldfarb:

Rick, two or three years now? I don't think so. So before we jump into that, maybe educate us just about various policies AI in policy is the most common spontaneous nerve palsy, what's second or third?

Chris Dy:

You know, what I don't know if there's, you know, I think the spontaneous ones. I don't think they're really spontaneous, they just can't remember the mechanism. Sometimes you get the Saturday night nerve palsy kind of thing. And you can get a variant of Saturday night with the ulnar nerve, if somebody sleeps with their elbow bent for a long period of time. And then you see like this kind of rapid decline of the ulnar nerve and a young patient, but I think the eye and really takes the cake. And you know, you can have spontaneous ones, you can have ones associated with something like parsonage Turner, and then you can also have the weird ones after typically, honestly, after shoulder surgery, and, you know, it could be, you know, related to the block that often accompanies this, and usually for shoulder surgeries done before the surgery, or it's from, you know, the retraction itself. And I think that, you know, with the lateral cord being the most, you know, proximate portion of the plexus, when you're retracting on the, on the, the strap muscle side, you know, on the on the coracle, brachialis side, and kind of retracting over that nerve gets some pressure. And I think that the lateral cord contribution in the media and typically provides a lot of that aim kind of contribution, although there is a lot of crossover with the, with the medial cord part. So I think you see that after shoulder surgery, too. And typically, it gets better. And you know, the biceps, you know, isn't really affected. And honestly, they're not checking it that much. But the aim is a weird nerve reason.

Charles Goldfarb:

So we're talking we throw a lot of terms around, let's make sure to define them. So first of all, we have just a spontaneous policy, like an EIN to me. And again, you you live in this world, but to me that is a painless identification of weakness of the FPL and FTP to index finger as the presenting criteria. Is that fair? Right. Right. parsonage Turner differs, because there's pain associated. Is that right? Yeah. So it's

Chris Dy:

weird. It's kind of a viral, you know, associated with a viral procedure. And typically, it's a neuritis. There's a pain that comes with it. There's a very characteristic prodrome, usually following perhaps some kind of viral illness, there's an arc of pain and then then a loss of function, then you're left with function that doesn't recover.

Charles Goldfarb:

Do you think about this, this question that was asked by listener, do you think about parsonage Turner? And the AI and policy that she described similarly, as far as management?

Chris Dy:

I think so because I ultimately, it's still a big gray area. So there are no defined answers. There's not enough data or Gestalt out there to define an algorithm. I think, oftentimes the person is Turner patient isn't seeing the hand surgeon until later on. If the patient is Turner patient is identified early, there is a role for high dose steroids to help try to get that patient through. And some patients you I never see them, because they never they get better. But you know, if that hasn't been tried, there is a role for that if you catch them real early,

Charles Goldfarb:

perfect. So why don't you if you'd be willing to give your best answer, because mine is not going to be super helpful on how to address the patient described in the question

Chris Dy:

why I think, you know, I think that your your many, many decades of practice experience will be helpful here for historical context. But you know, would you have just kind of in the past just left this patient alone? It's interesting the way Lisa asked this question, because she asked if we would offer a nerve transfer, but what about a good old tenant transfer? And once you wait it out? I mean, you know, so that's, it's interesting that just that the contexts and the options have shifted so much towards nerve that we, you know, perhaps don't even think immediately about a tenant transfer, which could provide very, relatively quick recovery of function. Yeah, so

Charles Goldfarb:

I like the timing. And so for me and a patient with an isolate am palsy I give it three or four months and then I get a nerve study. I think that's safe timing, meaning even if the nerve doesn't recover, you still have time to act. If you decide to decompress or transfer whether nerves are attended. And then I do depend on the nerve study findings to base my treatment now for me, while certainly we can do or we can do tendon transfers to address a an palsy, honestly, even though I'm not a nerve transfer surgeon, I probably lean towards a nerve transfer rather than a tenant transfer for this situation.

Chris Dy:

Now, when you do a decompression, if you're looking at the nerve, do you would you would you stimulate the nerve and see if it responds Is that something that smoothie has its way and has a role in your treatment algorithm.

Charles Goldfarb:

Yeah, but honestly, given that, I guess I'm a generalist, when it comes to nerves, I would if I'm going to go the or to decompress, and that would depend potentially on some imaging findings, which don't sound applicable in this case where there was diffuse swelling, no evidence of a constriction point. But if I were to go the or thinking I would find a constriction point, I would just go to do a decompression and stop. If I thought there was not a constriction point, or area of greatest concern, I would send the patient on to someone like you.

Chris Dy:

Yeah, I think that the point of constriction, I think it's very hard to find points of constriction, where you have, you know, clearly inflamed nerve proximal to the point now that FDS arch is very tight, and pretty much everybody. So you know, you will have a point of constriction, it's just a matter of whether you're going to know that going into the case or not. I think imaging plays a different role in this patient, if you have access to really good Mr. neurography are really good MRI, or high resolution resolution ultrasound. Scott Wolf and Steve Lee have just done some interesting work here, where if you've gotten good imaging, you can actually see little, tiny undulations on the nerve that you know, potentially to reflect if an internal neural lysis would help like a micro neural license. So that's something that is worth doing. But only if you get with your imaging folks ahead of time and say, This is exactly what I'm looking for, check out this paper, you know, if you follow this protocol, do you think you can get me this information? Because that actually can help guide the micro neural lysis?

Charles Goldfarb:

Wow. And I don't think all institutions have that capability, nor the expertise from our MRI colleagues. But interesting. So how would you handle this patient?

Chris Dy:

So I think four months is enough time. And I think the challenging part is the counseling and getting to know the patient in terms of what they want, and their appetite for uncertainty. And I think that the thing that I wrestle with, with this stuff is, you know, is this patient going to be upset if you do nothing and observe them for 12 months, 14 months, 16 months? Because that's honestly, the timeframe you would give them if you're going purely observation, and then they still end up with a tenant transfer? Are they going to be upset with that? Or are they gonna say why? You know, why didn't you just do everything from the beginning. And if you do everything from the beginning, I think the nerve transfers here are pretty good, that we can go into the nerve, to the weeds about the different options, but you know, they're pretty good, they're pretty reliable. But they also take a long time to see recovery. So you're still looking at after nerve transfer, you reset the clock, and you're looking at nine to 10 months, to really start to see something meaningful. Whereas the tenant transfer, you're gonna get a pretty solid result within six to 12 weeks. How long do you think the tenant transfer gets you? So would you do like a biard FPL. For this?

Charles Goldfarb:

I guess I always struggle with a mismatch and excursion between the brachioradialis and the FPL. But I think it's a good option. And that's probably what I would do and whether you need to do anything at all for the index finger FTP, you know, I don't know, it depends on laxity and various other factors. But you're right, this is absolutely a patient decision based on appropriate education, and certain patients will be patient. Too many patients and others will absolutely not, and just need to move forward with something.

Chris Dy:

Right, right. And I think that, you know, one fun thing to do is for the index FPL, or the index FTP is to do a side to side Tina desus. And that one, you could even do awake. Yeah, I really, I really like doing the tendon transfers for this, for this condition, I think can be really effective. I do like to break your Radioss FPL tendon transfer, you know. And then also, I think that the index side to side, Tina desus, FTP, can be really useful. And that's a fun one to do awake. So sometimes, you know, I'll do that one, individually awake, because I think tensioning can be a little tricky to get right. Or we'll do that one awake, and then have the patient go to sleep for the Brd FTL, because that obviously involves more dissection.

Charles Goldfarb:

Wow, I didn't even think about doing part of a procedure awake and part of it. Asleep. Interesting.

Chris Dy:

You have the power, you are the surgeon.

Charles Goldfarb:

I love it innovative techniques once again. Well, there we go. We have a great answer to the question about AI and palsy. And hopefully we'll get more requests for case discussions.

Chris Dy:

Yeah, absolutely. So thanks for that email. And hopefully you're not scarred by your experience working with me when I was a resident. And yeah, if anybody has any other questions and podcasts@gmail.com

Charles Goldfarb:

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

Chris Dy:

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

Charles Goldfarb:

Mine is at congenital hand. What about you?

Chris Dy:

Mine is at Chris de MD spelled dy. And if you'd like to email us, you can reach us at hand podcast@gmail.com.

Charles Goldfarb:

And remember, please subscribe wherever you get your podcast

Chris Dy:

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

Charles Goldfarb:

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

Unknown:

Come back next time Hi