Season 4, Episode 9.
Chuck and Chris take a deep dive into Deborah Bohn's What's New in Hand Surgery in JBJS. The article covers key new articles into our favorite research topics in hand surgery. This is Part 1 of a two part series.
JBJS 2023; 105:428-34
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As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
Complete podcast catalog at theupperhandpodcast.wustl.edu.
Season 4, Episode 9.
Chuck and Chris take a deep dive into Deborah Bohn's What's New in Hand Surgery in JBJS. The article covers key new articles into our favorite research topics in hand surgery. This is Part 1 of a two part series.
JBJS 2023; 105:428-34
Subscribe to our newsletter: https://bit.ly/3iHGFpD
See www.practicelink.com/theupperhand for more information from our partner on job search and career opportunities.
Please complete NEW Survey: bit.ly/3X0Gq89
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
Complete podcast catalog at theupperhandpodcast.wustl.edu.
Welcome to the upper hand podcast where Chuck and Chris talk hand surgery.
Chris Dy:We are two hand surgeons at Washington University in St. Louis here to talk about all things hand surgery related from technical to personal.
Charles Goldfarb:Please subscribe wherever you get your podcasts.
Chris Dy:And thank you in advance for leaving a review and leaving a rating wherever you get your podcasts.
Charles Goldfarb:Oh, hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:I'm really good. I'm back. I want to show you something.
Chris Dy:Oh, boy. I hope people are watching on YouTube because there's something really funny going on right now. What what are you wearing?
Charles Goldfarb:This is a reason for our listeners to go to YouTube and watch our video. So this hat, which my wife threatened to kill me if I wore on the podcast, much less out of the house is I actually love it. It was a gift. I participated in the Australian hand surgery Society meeting. I did it unfortunately, virtually. And there thank you was this awesome hat. And I think we need to wear more hats. And I usually wear baseball caps. But this Outback kind of hat is awesome. And you can be honest, should I wear this to work? Dr. Dy? You know, I
Chris Dy:think that it would generate some interest where I actually thought it first off, I think it looks great covers your dome, which is criterion number one. But I thought where you were going with this is I thought you were going to use this as a promo for the AOA annual meeting in Salt Lake City where perhaps you were wearing that kind of hat because you're a cowboy ranchero kind of situation.
Charles Goldfarb:Well, the subtleties of hatsmanship would say that this looks nothing like a cowboy hat. Dr. D. This is a classic. I don't even know what it's called. Maybe it's more of an Outback hat. Anyways, I love this hat. But I guess I want to stay married. I can't really wear it out in public at least too often. I wish I lived in the era where men wore hats like that.
Chris Dy:Yeah, I think you know, I remember there was a there was one trip that we had that Tiffany I took when we were in residency to Charleston, a friend was getting married in Charleston was fantastic city. And there was a great headshot. And I bought this sweet hat. And I just never wore like, we're not in an era where you know, like, I just, you know, at least in the circles, I travel, I would be that guy wearing a hat. So I have the hat. And I love wearing it. The only time that I bought a hat was recently about a year ago, we were on spring break in Puerto Rico. And fantastic hat shop like just great hat. And I wore it because it was like, you know, it was the right time in place to have a great hat. And then I brought it home. And then I was in Florida and my father loved the hat. So he just wanted it. So when he saw the picture on it sent him a family picture when we were in Puerto Rico. He's like, can you get me one? I was like, we just like left San Juan like we can't go back. He's like what just give me one sec. I'm looking for one I couldn't find it. So eventually when I went to Florida, I just surrendered the hat to him because it was just easier than trying to find a new one for him.
Charles Goldfarb:Well, that's one of my rules. When there's a great hat store in a city where we visit I have to go I wish our pod had a greater listenership so that I could you know restart the trend. But I would love for listeners to comment on that, which means you have to go to YouTube.
Chris Dy:But I took a picture of his I'll post it don't post much on social media anymore for the pod but we will post that because that is totally worth it.
Charles Goldfarb:Perfect. And I should say thank you to Sarah Torrington, David McComb, and Richard Lawson for both the invite and for the hat. I gotta figure out a way to get Talia to approve this.
Chris Dy:Yeah, well, I cannot match your swag. But I do have some swag from the global nerve Foundation. The very nice Yeti coffee tumbler which I have to say I think this may be my new go to I gave a talk for their Esser Master Master chorus recently on peripheral nerve and I was supposed to go in person to Birmingham to give the talk which would have been fantastic. But it overlapped with the time that my son's youth hockey team was playing the intermission at a blues game. And that was probably the best three minutes of his life. I absolutely had to be there for that. So I gave my talk virtually. They were kind enough to let me do that. And hopefully next year they'll have me in the UK or one of their other spots. But I swag is not as fantastic as yours, but it's definitely appreciated and loved.
Charles Goldfarb:Yeah, it may be more usable. I will say to your assumption about why I was wearing the hat. I do have two meetings which I'm helping to host and I will be really happy when both of them are over. I'm really looking forward to both of them. But these are within the span of like two months are there in the span of four weeks? Yes, there's the end is the pandemic affected this but there's the world congenital Symposium which I'm hosting with Anne van Heast and Michelle James I'm in it is in Minneapolis because we thought it is a world meeting. And there's a great international attendance and, and if you haven't registered, the hand society has this on the website that the program's incredible. And if you do anything congenital, whether you're a surgeon or a therapist, this meeting is fantastic. So I hope you will join us. And that meetings in mid May, and then I am in charge of the American Orthopedic Association's annual meeting in Salt Lake City, which also will be good, more of a leadership team, obviously. And hopefully, you're going to be the well, I know you'll be there. But that should be a good meeting, too.
Chris Dy:Yeah, no, that's fantastic. I mean, I'm always impressed by the the numerous responsibilities that you were able to juggle, it's, it's amazing to be honest with you. And, you know, those are both going to be great meetings, I hope people are able to, to attend them. Especially that that congenital one is gonna be fantastic. And then the topics that you have lined up for the symposia at the AOA look look incredible. So I know that a lot of people will be joining.
Charles Goldfarb:Yeah, for sure. For sure. It'd be great. We have I think one of our both of our favorite I guess, thematic discussions, and that is the article that you used to write for the general bone and joint surgery on what's new in hand and wrist surgery. And you gave that up.
Chris Dy:I actually was asked to do it for it's a three year period actually asked to do it again. And I was told no, but I knew that would be the case. But I emailed the editor in chief marksman kowski. And I was like, Hey, I would love to do this, again, be honest, honestly, because it's a huge pain in the butt to do and it's a lot of time, but it made me read. And I felt really good about my command of the literature for those three years. And I still obviously try to keep up with Journal Club. We read the journals and stuff but I was really good those three years so but one of our colleagues, Deb Bohn, who I think does some work in the in the pediatric adolescent congenital world as well, and is actually at the University of Minneapolis has done a fantastic job. I think this is her second year doing it.
Charles Goldfarb:Yeah, University of Minnesota, Deb is actually along with Lindley wall and Claire Manske, the program chairs for this congenital meeting coming up in Minneapolis. And she this article, again, is super well written and hits the high points, and there's so much that we can unpack that. We'll see how far we can get with one episode, but it's probably gonna be two episodes. And it really is a great, you know, conversation starter, so to speak.
Chris Dy:Yes, absolutely. It actually brings back some memories of having all this article strewn about on my desk here in the office, trying to figure out how to act to incorporate all them in a way. But like most of the like most of the jbjs What's new in handed wrist, it starts with carpal tunnel syndrome, it actually touches on some of the controversies not controversial, but I guess, evolutions that we talked about in our episode with the BSSH. With Amy Moore and Don Power.
Charles Goldfarb:It sure does. I thought for sure you're gonna say it starts with the most important topic and answering that is nerve.
Chris Dy:Yeah, there's I see the peds section back there. And, you know, I don't know if people are gonna make it all the way back there. It is. The peds section by way of space on the page is I think, tripled the size of what I did. And those sports funny and funny how that works. So the first article that you'll see opens a little bit about talking about the CTS 6, you know, some of the background articles for that. But she did talk about an article in which you know, using the CTS 6 for both experienced and inexperienced providers, and I say providers, specifically over telemedicine that CTS 6 is easy and reliable to administer, suggesting maybe that the CTS 6 could be used as a screening tool because I think most hand surgeons have accepted the CTS 6 we've been doing it anyway. Whether you formally calculated or not, you have this kind of internal calculus anyway. What do you think about using this, this really the CTS that should be disseminated to primary care providers? And perhaps the physician extenders?
Charles Goldfarb:Yeah, it's always a question how do you spread that knowledge and you know, we tend to speak in an echo chamber a bit amongst hand surgeons but you are right. So you and I are both believers in the CTS 6 I think both of us during the pandemic applied it over telemedicine and found it to be successful. And so this was a nice validation of our personal experiences and, and I really like it and I agree with you it would it would decrease the frustration of patients being sent in either with too much information like they've already gotten nerve studies when they didn't need them, or confused patients who clearly don't have carpal tunnel but have been told that they probably do have carpal tunnel.
Chris Dy:Yeah, I would love I would love to hear from listeners about how they've incorporated the CTS 6 for those of you that have physician extenders, you know, NPs and PAs in your practice, that's not something that we have at this time, but something we're probably looking at doing, and I think this would be a great tool for that. For that part of it. I need I'm going to make a public March New Year As resolution, I need to put a dot phrase in my carpal tunnel counseling thing for the CTS six just to make it easier for whenever we go back. So I'm doing so many ultrasounds now just be so easy and I can send us some of the sites we're about to talk about. But I don't know if you've got Fraser CTS six for every carpal tunnel patient or not.
Charles Goldfarb:I, we have a dot phrase for it. But I don't do it. And you're right, it just makes you include all that information. That's a really good point, let's do it.
Chris Dy:Maybe we'll I have a have a consent dot phrase that I use for carpal tunnel, maybe I'll just put that in for carpal tunnel release. Maybe I'll just put that in my dot phrase for carpal tunnel release. So yes, we're practice managing right now live and on the air. It's
Charles Goldfarb:a good suggestion, no better no better time than the present to talk about it.
Chris Dy:So ultrasound, are you going to come around and just use an ultrasound? Because I guess we're already been told that maybe we don't even need nerve studies. But clearly, people still get nerve studies. And we'll talk about that in a bit. But the ultrasound has seemed to continue to supplant the nerve studies in the isolated carpal tunnel syndrome patient.
Charles Goldfarb:Yeah, and I'll be honest, I typically obtain ultrasound as part of a nerve study, when I feel the need for a nerve study. It's becoming increasingly clear that it should be the primary go to unless there's, you know, extenuating circumstances which we can talk about. The literature is becoming really clear.
Chris Dy:Yeah, I think the missing piece before was, you know, I think a lot of people needed to know, because I think I'm the reason a lot of people still get nervous studies, not necessarily to confirm the diagnosis, it's to exclude a competing diagnosis or to know about a competing diagnosis. And also, and I've heard, you know, pretty prominent nerve surgeons status and national meetings. It's because they want something some objective evidence to show that this was severe carpal tunnel syndrome, or something along those lines and before embarking on a surgery that is highly reliable, but not perfect. And some patients will be, you know, perceptively or subjectively not better or worse after surgery. And they want something to fall back on in terms of objective measurement. I think this study that they are discussing here, you know, looking at the cross sectional area of the median nerve and showing how that corresponds or correlates to severity of, of electro diagnostic findings is very helpful. And that was a study that John Fowler did.
Charles Goldfarb:Yeah, these are good. The other the, the one that is also a Fowler study, maybe it's the same one, they were the first author is Charles and that's in the journal hand surgery 2022. This sentence is powerful. Patients who had a carpal tunnel syndrome diagnosis confirmed by a surgeon, by the surgeon using ultrasound, had 1.8 fewer medical visits and underwent surgery, a surgical procedure three to four weeks earlier than those who had a CTS diagnosis confirmed by EDS. And then it goes on to comment on what you just stated. So really impactful work.
Chris Dy:So we've talked about this a number of times, do you think this is something where you would just send them maybe only for an ultrasound if you needed is does what's come out in the last few years? satisfy your desire or need to have something even like in a work comp population? Do you think more conflict come around to some people ordering for work comp just to have the evidence?
Charles Goldfarb:Yeah, I think so for me, and I guess I'm actually this sounds crazy, another practice management discussion, personal discussion, but I think it'd be helpful for our listeners. So for me, if the CTS six is clear carpal tunnel, you know, highly likely, with based on all the points and the like, I don't always feel the need to get a nerve study in a work comp patient, I might still get that nerve study. I don't even know the mechanism for just getting an ultrasound for carpal tunnel syndrome diagnosis, is that something you currently do, you will send a patient to our physiatry colleagues for an ultrasound assessment for carpal tunnel syndrome.
Chris Dy:You can I just do the ultrasound. So I'll walk over and if the ultrasounds available, I'll all graduates sometimes it's not available, which actually is becoming an issue in our facility where I primarily see our patients. But I'll do it myself. To be honest with you, I'm pretty comfortable with that assessment. But if I'm not able to, and then there are other situations in which I'll send, say, outside of carpal tunnel, but safer cubital tunnel in which they've already had they've come in with a nerve study, I have a high suspicion for a subluxation or dislocating ulnar nerve. I've sent them only for an ultrasound of the cubital tunnel. So yes, that's something that we can do with our system you could clearly send them to in our system to diagnostic radiology. But I'll be honest with you, it's easier and I'd like to support our department. So I send it to our physiatry colleagues just for an isolated ultrasound.
Charles Goldfarb:I know we're going down a rabbit hole I'm not intending to but I would think that if you are considering a cubital tunnel decompression, you might get an ultrasound, just to make sure that nerve is not purging or subluxated.
Chris Dy:Yeah, same situation too. So if they've come in, they have a nerve study. Everybody gets anybody who's going to get an insight to We'll also get an ultrasound, just to make sure it's not going to subluxated because there was a study we talked about, I think it was actually what's new in hand surgery a couple years ago, demonstrating just that the ultrasound is so much better at predicting stability or instability of the ulnar nerve than clinical exam.
Charles Goldfarb:This this next section in this paper is, I mean, the first two sentences are you might be they're really strongly stated. And I think they're really important ultrasound and the CTS six have both been shown to be more sensitive, and specific in diagnosing carpal tunnel syndrome than electrodiagnostic sighs that's a really strong statement. And then the next one is in a database study, eds represented nearly one half of the cost of the preoperative care in nearly 400,000 patients with CTS, those are those are both really important and powerful statements.
Chris Dy:Yeah, that makes a lot of sense, though. I mean, you know, the, you know, the the nurse study is a procedure, and you know, it's gonna cost some money. And I think if we're trying to make things really lean, I think it's pretty clear that you really don't need to see, I mean, honestly, you probably only need the ultrasound in many cases, but I think that it's the bang for your buck is much better on the ultrasound than then a nerve study. Let's be clear that I think there still is a role in some patients for a nerve study. And again, it's if you're looking for, you know, a competing diagnosis, you want to make sure you have absolute diagnostic clarity, but it should not be the default to get a nerve study. But as they go on to talk about in, in the next article, they mentioned, a lot of hand surgeons still will either require a nerve study, you know, prior to an appointment, granting an appointment for carpal tunnel based on a survey of hands society members, or will go in the majority will go ahead and get it so over 50%. That's an article that one of our current fellows just below wrote when she was a plastic surgery resident at the University of Michigan.
Charles Goldfarb:Change takes time. But let's be honest, this conversation has been going on 10 years and in the it has accelerated for because people like John Fowler have really made a difference. It really should be for the younger research interested, surgeons and therapists out there. So unless you had to be patient as an investigator and be willing to put in the work over time to see your message grab hold, but it is clear that John's work with others, has really started to make a difference because we are close. So let's be very clear about our indications for a formal nerve study. Number one, revisions for me get potential revisions or recurrent carpal tunnel syndrome get one a patient where the diagnosis is just unclear, but I remained suspicious. And maybe that's it.
Chris Dy:So we skipped the study, which we should go back to because of what you just mentioned. So revisions, do you need a What's the nerve study? And I'm not disagreeing with you. I just want to probe you a little bit on this. What's the nerve study going to tell you? You know about this other than, you know, if you you can probably diagnose a nerve injury on either clinical exam, potentially on imaging. If you don't have a preoperative nerves study, what what good is a post operative nerve study going to do and then the paper here that that they described in the first author was Kurita. And found that you know, carpal tunnel ultrasound is very good for the failed carpal tunnel syndrome or carpal tunnel release patient and that, you know, there is usually an 86% of the patients that they looked at there is some kind of persistent compression, and that usually is incomplete release. And then for the 35 patients that they studied, only one patient had no abnormality that on ultrasound to potentially explain it persistent symptoms.
Charles Goldfarb:I think it's a really important study. And I think your comments on it are accurate. I am a pragmatist. And we live in a litigious society. And honestly, that's probably the strongest reason and hopefully that fades. But having data in these situations is important to me.
Chris Dy:I completely a hard data, I guess I should say, I completely agree. And actually in in patients who have had, you know, persistent symptoms or a quote, failed carpal tunnel release, I'll get a nerve study, but also get the ultrasound for this exact reason. Because I think the ultrasound does provide information that a nurse study cannot the nurse study, I don't think can provide you information about an incomplete release. Although we know that is typically the case if you're dealing with somebody who has persistent symptoms, not necessarily recurrent symptoms.
Charles Goldfarb:Yeah. And we still need those studies. And maybe you're gonna tell me they're out there and shame on me for not knowing um, you know, we still need those studies that look at outcomes after primary or revision, carpal tunnel. And preoperative diagnostic tools. Those are harder, because everyone responds differently, but that's the goal that we need to really change practice.
Chris Dy:Right, right. And I think that especially like in the setting of, you know, again, straying a little bit from I don't think Deb covered cubital tunnel in here, unfortunately, and there's no nerve injury section. Bravo, bravo. Come on dad. But yeah, the Uh, with the cubital tunnel, and I think that we really need to as we push for ultrasound in that setting, too, we really need to understand what a, quote, normal and happy normal ulnar nerve after transposition and a happy patient, what that ulnar nerve looks like sonographically in a transpose bed in order to help us understand the patients who are not doing well,
Charles Goldfarb:I think that's right. I think that's, that's really well stated.
Chris Dy:So I guess one thing I wanted to ask the other part of the Jess bellick study that that Deb touches on here is that only 38%. So less than four out of 10 of hand society members thought that the the CPGs, the recent, the most recent clinical practice guidelines, so 2016, which had a change in terms of not requiring nerve studies that only 38% thought those were appropriate. And, you know, four out of 10, were also unaware that they existed. So how do you feel about that having worked on a prior version of the CPGs?
Charles Goldfarb:Yeah, it's it. On it? Well, it's just frustrating. I mean, honestly, when people put hard work into really compiling the literature for these recommendations, which are imperfect, but they really summarize what we know. And they shouldn't be referenced. And we should each of us as hand surgeons should understand them. But I think it's the reality of the world we live in. I don't, I don't think it means we shouldn't continue to do work like that, because that work matters. But it's a little disappointing.
Chris Dy:Who, which version? Did you work on 16 or not? 2009 2016 2009.
Charles Goldfarb:I don't remember my exact role. Again, I'm getting old. And that's been 13 years. But i There were, there were a couple of things about work comp and about nerve studies that were really important in both and each of these that had, you know, again, an impact whether that was directly on patient care or on their the attorney view of our care, there's some important work in there.
Chris Dy:Yeah, and it's a ton of it's a ton of work to do something like that. And it's expensive. I mean, to be honest with you, the academy puts a lot of resources into these, and I think the hand society has contributes to that in terms of, you know, providing experts in everything, you know, but the academy puts a lot of money into this. So it is a little disappointing that a lot of people aren't aware of it. But you know, I think it's, that's the challenge of implementation science. So moving on. So do you use steroid injections for the treatment of carpal tunnel, I feel like depending on which specialties literature you read, you can either find evidence to dam or to dam it or to support it.
Charles Goldfarb:Well, this is compelling research. Now, it's not to say anything negative about the paper, which I need to dive more deeply into. It's in hand is not in general hand surgery, or jbjs. But that the data that's reported are really on believable. So Lee pen, and that's li dash P and report the long term results of a randomized clinical trial of steroids versus carpal tunnel surgery. And the results are incredible, equally effective results in one year, surgical procedures slightly superior to yours. And then with 90% follow up from the original cohort and a mean of 6.3 years therapeutic failure defined as any further treatment occurred in 11.6% of the surgical group higher than I might expect, and 41.6% of the injection group. So that means that 58% of patients randomized to steroid injection needed no further treatment that is really surprising
Chris Dy:to me. That is, that is surprising, honestly, and I think that to look and again, not to nitpick without going into details, but this is where looking at the details will matter. And I think both of us, oh that these articles, a more of a review. But if you look at these three studies that this group has published, you know, they reported their one year results, their two year results, and then their three year results. There one and two year results were in fantastic journals. They were in very high impact journals. They were not surgical journals, but they were Arthritis and Rheumatism and rheumatology, which are incredibly competitive journals in those specialties, and I don't know whether they put the the three year or semi the long term follow up the 6.3 year mean follow up in a surgical journal and specifically in hand because they want the surgeons to read it or because it couldn't get into the other journals.
Charles Goldfarb:Yeah, it's a really important question and for better or worse, I think if they wanted to and you and all that people would read or see regularly, they might not have chosen that particular journal. Not to say anything negative about that journal. But yeah, it does speak to likely structural issues with the paper and you and I will read it and we can come back circle back with this group and discuss.
Chris Dy:Yeah, we should definitely deep dive into that into that topic. I guess we're we talked so long for carpal tunnel and nerve I mean, it's it's great, you know, but we probably should, I don't know how much you How do you feel about the Amyloidosis topic because we do have a review do that in journal club in terms of, you know the the potential role of the hand surgeon in screening for this condition because there is a higher higher incidence of Amyloidosis in patients with bilateral carpal tunnel syndrome.
Charles Goldfarb:Yeah, it's you know, there's there's only a few diagnoses where we as hand surgeons can make a difference. Big picture. We certainly feel you know, I feel really good about what I do every day. But as far as larger systemic issues this is this is one of them, I see something congenital where I can make a difference and, and trying to understand the relationship between trigger finger carpal tunnel and Amyloidosis is really important and it can be helpful for preventing heart disease down the road or delaying heart disease down the road for the patient.
Chris Dy:Do you at this point? Are you a few? Because you know the the studies that we've seen have demonstrated that in patients who are with bilateral that carpal tunnel that you know that's the population potentially to, to investigate. I've had you know, one patient come in after the New England Journal came out, he was a cardiologist specifically asking me to send Tina synovium. But I think that was because he's cardiologist and he just knew. Do you ever send any samples?
Charles Goldfarb:If there's any family history or anything else that makes me think amyloid? Yes. But that means the vast majority of people No, and I don't think the recent work tells me the best way forward. And again, if any of our listeners feel differently, I will hope you would write in but I think there is a growing body of evidence, but there's just still not a clear indicator for me about when to do that biopsy and send it for Congo staining.
Chris Dy:Absolutely. So before we close with trigger finger, we should thank our sponsors.
Charles Goldfarb:Of course we should because you know, where would we be?
Chris Dy:Maybe we are doing the same thing. The the upper hand is sponsored by practicelink.com, the most widely used physician job search and career advancement resource.
Charles Goldfarb:Becoming a physician is hard finding the right job does not have to be joined practice link for free today at www dot practicelink.com/theupperhand.
Chris Dy:Alright, so let's keep rolling with What's New in hand surgery for 2023. So trigger finger. You know, the dogma is that, you know, at least what I was taught is that, you know, patients who have VIP contracture are going to have a worse outcome after a trigger finger doesn't mean you necessarily don't do the trigger finger release. But you know, Deb's talking here about a tenet in hand surgery that you know, when the PIP is contracted that you should excise a slip of FDS in addition to do the trigger finger release? Is that something that you were taught and follow? I it didn't strike
Charles Goldfarb:me as dogma that had been reinforced to me. And so while dogma can exist across institutions and in the literature, sometimes it's it's not that way. And and I, you know, I take out a lot of f partial FDS is so FTS slip excision in kids with trigger finger is not been a routine practice of mine in this situation, what about you?
Chris Dy:It's the same. So I was actually a little surprised to read that sentence. Not that I'm questioning it at all, because I think like you said, that may be many, many hand surgeons may do that. The the role for me for an FDS excision is somebody who has persistent triggering on the table. And or afterwards, but and in the salon setting somebody who has it on the table, you've already done a very thorough release, and you're wondering why it's still triggering.
Charles Goldfarb:I totally agree. That's exactly the setting where I would immediately do it an adult. And I wouldn't do any pap contraction releases. So I don't think it's crazy, but it's not been part of my protocol. But the bottom line is Dr. Baek, demonstrated by six weeks, there were no differences in the degree of contracture, pain or function between the group either treated with a trigger release at a one pulley alone or also with an FTS slip excision.
Chris Dy:Yeah, and I think that that makes an absolute a lot of sense. And I think it's something where I will still counsel the patient, you know, probably a little more cautiously if they've got a preoperative pap contracture. But I'll be honest with you that preoperative pap contracture has probably been well tolerated up until the surgery, but you will make them you can still make them better by releasing their trigger finger.
Charles Goldfarb:Absolutely. Do we want to wrap it up? Or do you want to touch on duper trends? And then we can come back later for the rest of this?
Chris Dy:Now, why don't we go ahead and wrap it up? I will, let's touch on a dupe of trends. And we'll get back to everything. I'm curious to see your role, the role of collagenases in your practice. You know, I guess this is something that's evolved over the last 10 to 15 years and has been a lifetime's of work for a lot of people in terms of getting that product to market and then seeing how it's, you know, its use has been unfolding and how the long term studies have shown it to work.
Charles Goldfarb:Well as as I think we've discussed on this pod, I respect the work that has been done in the development of the collagenases product. I was when it first came out, I was trained and So you know, certified to do it. And it's never been a practice of mine. I've been really, really happy with the needle app anatomy procedure. I do it regularly. And it's not perfect. There is no perfect treatment for this disease, because we cannot cure it. But I from the cost perspective, I've been especially happy with needles, and I believe you feel the same way?
Chris Dy:Yeah, I do. I mean, I think that, you know, one of the prior versions of this article I really reviewed, you know, looked at at Mayo Clinic article that was retrospective, that looked at, you know, the, the different treatments, you know, collagenases versus, versus needle versus surgical treatment and the subsequent prospective RCTs that Deb includes here, found the same result is that collagenases and needle are not significantly different in terms of their recurrence rate about 50% at long term valuation, and the cost is just so much more. So you know, in this saw patient, you know, the other day who had clashed and Ace and just ended up didn't like the process ended up having a recurrence and wanted something different done. And again, I think, to be fair, both of us are, have been experientially and training wise has been sort of led towards needle laparotomy. A lot of people still use collagenases. I think it's still a treatment that may have a role. It's just not in my personal practice.
Charles Goldfarb:Right. And to be clear, and my messaging is also clear with the patients. When I think about a needle ORCL alginates versus open Fashi ectomy there's no doubt that the open Fashi ectomy remains the gold standard for delaying recurrence. But in these articles have shown that that the sentence is both treatments have a similar five year recurrence rate of around 50%. In comparison, the rates after surgical Fashi ectomy is much lower. And then to close this, there was an interesting paper that looked at the use of IV dexamethasone with a six day oral, oral methylprednisolone treatment that at that short term follow up really did improve outcomes after Fashi ectomy.
Chris Dy:I have not used that. And I think that one of the biggest things that I talk about with patients is not getting stiff. I mean, I actually haven't go to therapy, usually within the a day or three days of surgery to get properly splinted. Much better than what I can do in the operating room. But mainly to work on motion. And I think that I do have some concerns with regards to wound healing and some of these patients, you know, especially with the early motion, and you know, the contracted nature of the skin beforehand. So that would give me a little pause with regards to the steroids. But you know, I think this is something that I want to think about a little bit more with regards to potentially using, you know, that high pulsed steroid taper.
Charles Goldfarb:Yeah, perfect. Perfect. Love it. Thank you. I look forward to getting part two of this done in the near future and sharing it with the listeners have the upper hand.
Chris Dy:Yeah, absolutely. And if you're looking for the article, so it's in the obviously get online if you go to jbjs but it's in the March 15 2023 issue of jbjs. And Wonderful job. Deb on on this, and I look forward to unpacking more of it.
Charles Goldfarb:Absolutely. Have a good day. You too. Bye. 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@handpodcast. Hey, Chuck, what's your Twitter handle?
Charles Goldfarb:Mine is@congenitalhand. What about you?
Chris Dy:Mine is @ChrisDyMD spelled dy. 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 and
Chris Dy: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