The Upper Hand: Chuck & Chris Talk Hand Surgery

Unsolved Problems in Hand Surgery: JHS European based discussion on Kienbocks and CMC Instability

May 14, 2023 Chuck and Chris with Mireia and David Season 4 Episode 12
The Upper Hand: Chuck & Chris Talk Hand Surgery
Unsolved Problems in Hand Surgery: JHS European based discussion on Kienbocks and CMC Instability
Show Notes Transcript

Season 4, Episode 12.  
Chuck and Chris welcome two amazing guests: Mireia Esplugas from Barcelona, Spain and David McCombe from Melbourne, Australia.  Our guests join us to discuss the March 2023 special issue of JHS European, Unsolved problems in hand surgery.  David McCombe was the guest editor of this special journal.  We chose two articles to discuss with our guests.  Tham and McCombe authored "Trapeziometacarpal joint arthritis in the young patient" and Salva-Coll, Esplugas, Carreno, and Lluch- Bergada authored "Kienbovks disease: preventing disease progression in early- stage disease."  We enjoyed this collaborative effort between The Upper Hand Podcast, Journal of Hand Surgery European, the British Society for Surgery of the Hand, and FESSH

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Charles Goldfarb:

Welcome to the upper hand podcasts 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. Okay, Chris. Hey, Chuck, how are you?

Charles Goldfarb:

I'm doing pretty well. How are you?

Chris Dy:

I'm good. It's a beautiful weekend in St. Louis. Well, it was until it wasn't last night.

Charles Goldfarb:

It has the weather has been fantastic. And then all hell broke loose. Oh, my God, you weren't going to that soccer game where you?

Chris Dy:

I didn't that made it to the cards game and the Cards game was great. And then we were doing some stuff in the afternoon and we slowly watched the weather just deteriorate. It's pretty, pretty rapid and went from a beautiful day and the 60s to hail.

Charles Goldfarb:

Yeah, you were kind enough to share tickets for the soccer game with one of the residents and he was so grateful. But it turned into just like a good start time was delayed two hours, but they got the Win St Louis City.

Chris Dy:

Yes, I know. I saw that. You know, it's uh, they're, they're pretty impressive. You know, they're certainly doing better than the cards.

Charles Goldfarb:

Yeah. So we have a special episode. This is a joint episode with the British Society for Surgery the Hand and we have some great guests. Do you want to give the audience intro?

Chris Dy:

Yeah. So this segment we did one a few a few months back and you know, at some great guests, Dominic Power and Amy Moore. And you know, there was clearly a high download hit rate. So people were pretty excited about it. So it's really fun to collaborate with this group. You know, so we're gonna we're gonna have two guests joining us. And we're going to talk about CMC and Kienbocks . I think it's going to be fun. Mareia Esplugas is going to join us and we can formally introduce her when she joins us. And David McCombe is going to join us. So we're crossing continents here we've got Mireia is from Barcelona, and David's from, from down under. So this will be really fun.

Charles Goldfarb:

Yeah, David's from Melbourne. And he was the guest editor for this European journal in hand surgery volume, which was entitled Unsolved Problems in Hand Surgery. It's really good. We picked a couple of them to focus on. But really everything that you and I talked about and stress about is hid in this really interesting addition, I guess you'd call it.

Chris Dy:

Yes, I love I love when journals take the time to do special editions and we don't see it enough, I think. But it's a nice way to get some topics out there. And honestly, for people that are looking for things to study, it's a great way to pick up some new ideas just kind of like what's new enhancer is always a fun one. Just be like, Oh yeah, that would be an interesting thing to study. We should thank our friends that I practice like you said that I provided tickets for Andrew to go to the soccer game it was on me it was actually practice link. So 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 doesn't have to be joint practice link for free today at www.practicelink.com/the upperhand. All right, I'm super excited.

Chris Dy:

Yes, thank you practice link for sponsoring us and thank you British Society for Surgery the hand and the team at JHS Europe for this opportunity to have some fun to interview folks from Barcelona and Australia. So without further ado, why don't we jump in? Well Chuck, here we are. We are joined by two fantastic guests I wanted to welcome them First off we have Dr. Mireia Esplugas is a has spent 25 years at a hand in research and so making me feel very young. Thank you. Mireia as a member of the Spanish Society for Surgery behind the European Wrist Arthroscopy Society and FESSH, friends of us friends of ours on the podcast. So welcome and thank you for joining us from Barcelona.

Mireia Esplugas:

Thank you very much. I'm very happy to be with you today here.

Chris Dy:

Very excited as we are to

Charles Goldfarb:

Yes. And David McCombe is our other guests who actually is the was the guest editor of the particular journal Hand Surgery European that we're talking about today. We have picked a couple of articles, but the entire journal is excellent. It's looking at unsolved problems at hand surgery. And David is works in Melbourne at St Vincent's Hospital and the Melbourne Royal Children's Hospital. He's in private practice with Victorian Hand Surgery Associates and his clinical interest are adult and children's hands surgery and that's where our pads have overlapped with the treatment of the kids as well as peripheral nerve and brachial plexus which is exciting for Chris and reconstructive microsurgery. So we are super excited. Welcome to both of you.

David McCombe:

Thanks. Thanks, Chuck. It's great. Great to be here and very honored to be asked to participate.

Chris Dy:

Well, we'd like to have some fun on these episodes. The last one that we did with Amy more and Dominic power was a well received and was a nice conversation. I would love to start with the keen box article. And today I'd like to say that I think this was an incredibly nicely written article very much laid out the evidence of or the lack thereof, in terms of what we know and what we do not know about cane box disease. So congratulations to you and your co authors for writing such a nice comprehensive article.

Mireia Esplugas:

Thank you very much. It was a struggling to to write it, but we enjoyed it. And we enjoyed that you have enjoyed the article. Thank you very much.

Chris Dy:

There was only one thing that I would have added and I probably would have cited Dr. Goldfarb stature, on the staging of gearbox disease. But otherwise, I think that it was an incredibly comprehensive and it made me think a lot because I struggle with this condition and maybe Chuck and David can share their thoughts too, but the early stage cane box disease, knowing what to do and how to counsel patients it's a lot easier once you get to the salvage procedures. But you know, I don't make any money off could start with your thoughts. I mean, you know when in your practice when you see a patient who's got an earlier stage disease, what is the role for purely a metaphyseal core decompression of the distal radius?

Mireia Esplugas:

The program that we keep of diseases that we don't really know what will happen in the future. And we don't really know if this radiological funding that we found is only a moment in, in the in the timeline of the disease, or it will be in this way, for many, many times. So I think this is the most important aspect of the article. Because we don't really know if whatever we plan to do to the patient will improve the disease, or the disease would improve by itself alone. And the patient would be clinically correctly for many, many years. So we, we think that we must avoid any treatment as much time as possible. If this is able to live, the patient is able to wear a good life with his disease. And if we cannot control his symptoms, and we plan, a surgical treatment, we really like to do the less aggressive as possible. And the decompression is an extra tickler easy to perform an easy to recover, procedure. And then if you see the meter, you can find good results, good clinical results, which is not perhaps good radiological results. But if the patient is good, is good with its disease and can have a good life, this is a good treatment for him. This is our idea.

Charles Goldfarb:

I like that. David, maybe in a similar way to Maria, What's your general principles as you think about key box? And we can maybe maybe Chris, and I'll present a case and hear what each of you think about, but what are you how do you think about Kienbocks in general?

David McCombe:

I agree that we are operating in a sort of relatively evidence for his own in terms of progression. But yeah, we see we capture the patients, either when they're way down the track, and it's too late for anything or else, you know, often it's this group that have got this the pain and some restriction relationship inside of artists and, and but still have a salvageable or have an intact Lunate. There. They're the uncommon ones, in our experience, you know, we see our patients often they've got a fracture through the night, they're too far gone. And so when, when you see them, it's tempting to want to, because you're familiar with what we perhaps believe is the long term result of deterioration. You want to avoid that because it's difficult, you know, there's not not a lot of great solutions for the bad back end loss event, stage three, threes and fours. So it's tempting to try and do something active. But I agree that doing articular procedures, is going to stiffen the wrist, it's tempting to want to put a escolares graft in because, yeah, that makes some sense to correct the problem. But I guess I will be doing shortening osteotomy is I haven't got a lot of experience with just the metaphyseal decompression. But can I get an arthroscopy? I'm not exactly sure that I know, a great plains and a good friend and colleague, and he's written extensively on this and the assessment of the integrity of articular cartilage, I think it's a really difficult problem. And I think we, you know, when it's bad, it's bad. But there's a big gray zone where we're not quite so sure what we're dealing with. So I think the principles of trying not to do harm, it's makes a lot of sense, an extra articular procedure, particularly shortening of the radius, if that's feasible. I haven't got a lot of experience with the wedge for the neutral variance. But yeah, I think it's hard. That's why That's why we chose it as a topic because this dilemma is how hard you go. How aggressive should you be? Are we really changing people's outcomes by doing whatever intervention we're planning to do? So there was no I really appreciate Maria's and her colleagues, Alex genkos contribution to that addition. So I thought was really good as well. So that doesn't give you any air today, Chuck, but I guess we're all you know, to a degree, gives you a bit of flexibility and you can sort of do provide and you don't do a lot of harm. You may be doing what everyone else is doing. Perhaps

Chris Dy:

I am scared yet reassured that we are operating in an evidence free zone as the state the question that I wanted to ask each of you and get your thoughts and I think, Chuck, I'd love your thoughts on this too. Are there any radiographic findings? For you to say, I can't salvage or we have to go to a salvage procedure. I cannot save this lunate anymore. Maybe start with Mireia your thoughts? When do you say we can't do anything In like an extra particular procedure like a core decompression, we cannot do an osteotomy we cannot do a dennervation we can this lunate needs to go.

Mireia Esplugas:

I think that perhaps the most useful way to decide this should be to have different controls in time. And to check if it ever, ever evaluates quickly if he or if he doesn't, or if he's become an unstable or he's having a perhaps we should not only focus on static explorations, but also dynamic explorations. And if you see that, the carpark kinematics is changing because of the lunate is, is changing his shape. Perhaps this would be the moment to decide that it's the time to take aggressive or more aggressive surgical procedure.

Chris Dy:

Thank you for that. David, I'd love your thoughts, you know, when can you no longer do any sort of graft or flap or anything like that? When is the lineage done? Well, I

David McCombe:

think once you that once there's a coronal plane fracture, I think that's difficult. It's very hard to, to, if you were to contemplate bone grafting the night once it's quite applied fracture, I think that's pretty hard to capture the brunt of it, try and unite the bowler component to that. I think, you know, the concept of the intra articular procedures. So they're trying to salvage the night that's already lost, its high. If you're trying to expand that back, or if you're trying to fit a bone graft, it's actually got some sort of blood supply still in it, and you're trying to squeeze it into a low note that's reduced its proximal, distal high. That's pretty challenging. It's a it's not a very big bar. There's a lot of real estate in that Luminate at the best of times, let alone if it's already started to collapse. I think you can still do procedures like derivations and I think you can still do even if the illuminate this non salvageable. I think you can deactivate a wrist, I think that's a reasonable thing to do. It's, you know, it can provide some relief and it's not doing harm. Whether it for that loon I'm doing a leveling procedure is worthwhile, perhaps. But I think once you've got that those changes in the winnowed structure, I'm not sure he can say that. I know people have tried to unite and Jim Higgins with his MFT is trying to rebuild Illinois from scratch. I've not got a lot of experience with that. I use the MFT for skateboards, but I haven't been courageous enough to tackle the night with one of those yet.

Charles Goldfarb:

That's very helpful. I would agree. I really liked what Mireia said about the kinematics and the motion. It's very important to think that way, there's not always a simplistic evaluation tool of the loonie. But the coronal plane fractures are difficult. And there is literature to suggest that one can fix those with a small screw and get them to heal. And I have certainly tried, but I don't believe I have been routinely successful. So I really appreciate that that comment, maybe Chris, if it's okay, let's let's do a very quick case scenario and just ask how each of you would approach it and then we can switch our topics if that sounds alright to everyone. Okay. So, go ahead.

Mireia Esplugas:

today something because of this current fractures are very difficult to really treat. In fact, we are we are moving to think that perhaps, we should substitute this this unit to, to read re return to the normality, the carpal kinematics and we are moving to try to to substitute it, for instance by 3d printed to donate. And we are focusing there, how to stabilize it. And we are we are engaged. We are starting many projects and this in this way. And because perhaps the most important thing is to restore the carpal kinematics and kinetics not to try to to get healthier to donate with a good shape.

Charles Goldfarb:

Thank you. Well, we all will look forward to your reports. Not an easy problem, for sure. So here's a case for everyone's consideration. A 35 year old male laborer who has had central wrist pain for five years. You have been following him for two years. And the illuminate by X ray and an MRI was obtained is basically a stage to illuminate so it's not truly collapsed. The older variance is slightly negative, and he is frustrated with his wrist pain. He has failed conservative care and wants something done. So David, maybe we'll start with You, how do you think about this patient? And what would you consider offering him?

David McCombe:

So I think he, I think a joint leveling procedure, if he has gotten at variance to a degree, I think that that's a good operation. And that can form a component of your plan that he's going to end up having a scope and having these articular surfaces examined and make sure he hasn't got that sort of shifting, shifting sand type of osteochondral fragment that's just loose on the surface. I think that would be a poor prognostic sign. The question, I guess, here is whether you believe that doing a four or five draft and plugging it into the back of his lemonade, and this is the situation I was talking about before this, this is the guy who's 35, it's a laborer he needs, he's got another 20 years of manual work in front of him, he's not going to be as good at that if his wrist is poor. If he ends up with a partial total risk fusion, so yeah, he might be the one that I would do. The trouble is, I think that that guy, he's the minority. So to build up a feeling as to whether you're doing the right thing by these patients, you really need to aggregate a lot of experience with that, I think, because it's, it's not an easy operation. And, you know, if you have a bad result, is it the technique? Is it the principle the surgery, that doesn't work? As well as a we not? We may be reversed lysing the bone but are we restoring the height and maintaining kinematics and, and normal mechanics? So, but you asked me the question, and my answer is I probably would, he would be the guy that I might do this for. So I'd shortened him. And I'd take the full five graft, and then do the osteotomy through that donor site, bring that down a little bit. And I would just carve out a little carve out my slot in the back of the lunate and plug it in there. Perfect. And then I would then I would, I would wait.

Charles Goldfarb:

Thank you. That's how well this every before I turned to Mireia, does every patient get an arthroscopy as part of the procedure to assess the articular cartilage?

David McCombe:

I think if it's a stage two, if he's, if they're not just having a splint, and resting and observation, if they're, if I'm contemplating doing something, I want to have a scope, I want to scope it. And part of that diagnostic part of that is gaining experience, it's you're trying to learn what the MRI finding really, really means I think it's we're learning with the arthroscopic distal radius fixation and arthroscopic Skyforge fixation, everything else now that we're the scope, the scope is really just part of the diagnostic sort of algorithm really, rather than necessarily being an operation itself.

Charles Goldfarb:

Perfect. Mireia.

Mireia Esplugas:

I think that the arthroscopy is not the only good valuating tool, but also, it's good for the patient, because you always find a sign of it, it's there, which is perhaps the one of the reasons of his central pain, you'll find the cartilage flaps that you can you can the bride and this may also be at the source of patient's pain. So, yes, I think that we should always scope a keen book mixing it with other treatments. And in this particular case that you have explained, I would scope I would evaluate and treat intraarticular as in the radiocarpal as inter metacarpal. And then I would add, but would ask I would add an extra articular osteotomy. Because many patients with only with the osteotomy get better with their pain, you do not perhaps modify the disease evolution, but the patient is is better. And I think that if in this particular case, which is a manual labor, which is certified, which is which the only thing that he wants is to have less pain, and without interfering in his mobility because he has to have a good wrist. Only with this, you can improve him and wait, if in the future, there are more benefits to offer to him surgically. You can.

Charles Goldfarb:

Thank you. Thank you. Alright, Chris, I'd love to hear your thoughts. And see if you would approach this any differently.

Chris Dy:

Well, I'm gonna bring some sanity to this discussion as somebody who's not. I'm happy that this is a liquid stage two, which means our unit is still in reasonable shape. I'm going to stay out of this gentleman's wrist and leave that for when I have to inevitably come back because we will all be coming back for this patient for future surgery. So I'm going to leave the risk of I've

David McCombe:

The vascularized bone graft cures the problem, right

Chris Dy:

now because according to the evidence or lack thereof, a joint leveling procedure into denervation will do very well for this patient. So that's all I'm going to offer this question. Do a leveling procedure from the volar side, do the deviation from the volar approach that we already have leave the dorsum of the risk completely intact? So I'm going to close it there Just so that you can't disagree with me and then we can talk about our next topic. David, you authored a really great review article for treatment of early stage thumb, CMC arthrosis. And I, again enjoyed this thoroughly because it really walked us through all the issues, you know, for for you, when, when is early stage truly early stage? Is it purely radiographic? Because we know that sometimes the radiographic findings don't correlate with you know, patients actual symptoms?

David McCombe:

Well, I think the focus of this was really the that troubling group where you you don't want to proceed down the road of trapezium, traverse ectomy or with whatever variation of stabilization we're doing, because this is the 40 year old patient and the prospect of a suspension plasti or sorry to drop his ectomy lasting, another 40 years is daunting. So this this work was done by a lot of this was done by my colleague, Steve Tam, who's worked with me and he has done a lot on basal thumb. Kinematics and, and this problem with the early patient with the idea of that subluxation if you truly can identify it. And I think in the article this is described the role of CT scan in accurately defining what is and is not subluxed, then there's a role for stabilizing it is provided the majority of the articular cartilage is intact. So, again, a little bit like we were talking about before with the keybox. In the role of arthroscopy, there's again, there's a role for actually visualizing that cartilage and you can be pretty things that look okay, on X ray can be somewhat disappointing when you actually visualize the articular cartilage itself, you see, can see be bare areas on the on the base and metacarpal and trapezium. So they do sort of that's a very long winded way of not really answering your question, Chris. But patients with persistent pain, don't settle down with simple splinting. And those those treatments, we all use cortisone injection maybe. And then it's an ongoing disability for them, they've got pain at rest, payment, mental activity, then they that sort of triggers the investigation with the CT and then scope plus minus ligament reconstruction if you if you're confident that you actually have true and true subluxation it sounds like such a little bit of a difficult thing clinically, it's a hard thing to see if I think you know, a lot of people who are a little hyper mobile can comes around and have pretty significant range. So trying to be accurate about what you define as subblocks I think it's important is

Chris Dy:

I have not used I love those comments and I obviously thought about this quite a bit. I have not used a CT scan in my early stage patients, perhaps because I have not thought about going to more of a soft tissue based or you know, reconstructive type surgery in that particular population. Mireia are you using a CT scans to evaluate your thumb CMC patients at all?

Mireia Esplugas:

I usually use ultrasound we why because I have an ultrasound equipment in my consultation. And because it helps me to check if there is any joint effusion you can also see the loose bodies. And I come back to two, two dynamic pathology has to keep up before I think that early CMC disease is a Synovial disease is a sign of disease, which can be which can have mechanical or biomechanical basis during grip. So, with my ultrasound, I put my proper underwater aspect of the joint and I asked the patient to pinch and to grip and and I can compare with the other time and I see if it's too hypermobile or if he compresses too much, oh he or or if there is an any effusion there or if the metacarpal bone dorsally subluxated during the pinch, and, and this for me this is a definition of the early stage of a CMC pathology.

Charles Goldfarb:

I know that Chris loves that he has recently become an ultrasound fan I am not very I assume that you share David's thoughts on the benefits of arthroscopy as well.

Mireia Esplugas:

Yes, I think that arthroscopy allows you to remove the loose body that you very very often lead found in every aspect of the joint and you can check you can do a sign of a mechanical sign of Atomy which could be compared with the good corticoids injection that you can do under on your ultrasound. And you also see the joint and the surface and the the osteophyte the joint surface and you can act there. I do not recommend the electrocoagulation of the ligaments to tighten them because because I I really think that they can reset There's no proprioception helps in that to stabilize the joint. So, electro electro burning of the Meccano receptors. I don't think that it's a good point to that. But the SAIC I scoped them. And I think it's benefited from the patient.

David McCombe:

Can I ask Mariah and Chris, how long do you think the learning curve for an ultrasound to become so comfortable that what you're seeing is actually pathological and not just part of the normal variant?

Mireia Esplugas:

I think that you can always compare with the other hand. So it's not yes, it's difficult to learn, but it's not so much difficult. And if you have any depth, you go to the other CMC data and compare, and you can think, realize it do this pathologic or it's normal for the patient.

Charles Goldfarb:

Chris, have you used I know, you, you know, everything is nerve nerve nerve and use your ultrasound to assess the nerve? Have you used ultrasound to assess joints?

Chris Dy:

I haven't. I think also I want to make sure I'm the right size Pro for that. But now I'm intrigued, and maybe I will. I will say that the limits for me right now are honestly just time in not having that built into my workflow yet. But I'm intrigued and maybe may start to explore this. There was I think, Chuck, you had one question. I will I wanted to piggyback off of Mireia's comment about the thermal capsular fee, and the importance of proprioception. I know that Elizabeth Hoggart has published a bit on the thumb CMC innovation, but there are some proponents for innovation. So I guess I wanted to quick thoughts on that. And then I know Chuck wanted to close with one more question. So today and David, what are your thoughts on dennervation? For thumb, CMC?

Mireia Esplugas:

So I'm doing a revision in advanced CMC joint pathology, I believe that it's a good point to to restore good life for the patient. Because in the in the lab, biomechanical receptors, studies that you refer, we participated in that. And we found that with age, the mechanoreceptors, density gets down. So you are not damaging proprioception, if you generate when the patient is not young.

David McCombe:

Right, can I ask you a question? I'm supposed to be answering questions, but I'm fascinated that definitely the say the 30 year old woman who is who's hyper mobile? Do you believe you can, by virtue of strengthening the thumb with the proprioceptive arc intact and can use can we stabilize? Can we produce a stable thumb CMC underload? Or is that unrealistic? And do we need to be doing reconstructive surgery or what what do you think about that?

Mireia Esplugas:

So we collaborated with Natalie Merida in the in the article, which provoked pro promotes first loss of interest is strengthening an opponent struggling to stabilize the joint work in the left hand, we really saw that they are the main stabilizers because they're so interested and opponents and in Spain, we do not have hand therapists. We we do not have, we have few friends service. So we, our patients do not have a hand therapist, the team to go, and we learn them how to stand and their first or second interests and their opinions, and we follow the patients. And yes, we see that many. I don't know, I don't know, which is the best advantage. But I feel that patients who really do well, their exercise, many of them get improved. So yes, I would recommend to strengthen photosynthesis.

Charles Goldfarb:

Perfect, perfect. Well, where are we? This has been an amazing conversation. I'd like to close with one question or one is a comment. But it is a question as well. So like you, I enjoy arthroscopy anywhere and everywhere. And I believe for early CMC, it can be very helpful. My question is, and this article included it, we always hear that closing wedge osteotomy of the base of the metacarpal can be helpful. And I always look for the opportunity to do that procedure. And I just never find the right patient. So what am I missing? And how often is that closing wedge osteotomy appropriate? Very well, you want to start?

Mireia Esplugas:

I think as you I haven't performed I only have one or two in my life and I have scoped many, many CMC joints, because I really do not know which person the job surfaces the good to indicate a semi permanent a couple of students. So I think I am asking you shall

Charles Goldfarb:

David teach us?

David McCombe:

Well, I'd love to extract but I I, again, exactly the same. I haven't. I haven't got much experience with that operation. We put it in our algorithm of treatment for the patient with early arthritis without subluxation. But to be honest, the group that you see they're either too far gone, or there is this subset that we talked about in our article who got the subluxation that Billy arthritis symptomatic subluxation. And they, they do pretty well with the ligament reconstruction. And I think in part, that's because they get stiffer. We're reducing the range of motion. And maybe that's what, what helps with the pain we sort of making the very stable. But I haven't got much experience with extension osteotomy I guess, the tibia for the arm, a plastic surgeon and the concept of doing a causing wedge osteotomy in a tibia for a bit of arthritis seems pretty terrifying to me. But then I guess it's the same. Same idea, but I haven't seen that patient. I see this group of patients with the instability, who've got pain and severely arthritis. And then the next group, the ones where it's eaten three and eight and four, and they're too far gone. And then it's just a matter of managing the symptom and then doing the operation when they're when they're ready. So yeah, I'm with you. It's the unicorn.

Chris Dy:

Yes, I've only seen that patient on a test question. So in my clinic yet, David, Mireia, thank you for joining us for this great conversation. It's it's fascinating that we've had the opportunity to interview you for this you know, David, you being in Australia and Mireia being in Barcelona, thank you to the British Society and the European Journal for the for collaborating with us on this and you know, honestly, this unsolved, unsolved problems and hand surgery. Journal edition is fantastic. So we encourage anybody who's listening to please check it out. So David, Mireia, thank you and we look forward to having you join us again sometime soon.

Unknown:

Thanks very much. Thanks, man. Thanks for asking us.

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@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 and be sure to leave a review that helps us get the word out. Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time