What's New in Hand Surgery 2024, part 1

Chuck and Chris talk through the 2024 JBJS 'What's New in Hand Surgery' written by Deb Bohn.  We discuss only two topics in our part 1- trigger finger and carpal tunnel release.  A few key citations from some really interesting topics:

1. Bookman J, Rocks M, Noh K, Ayalon O, Hacquebord J, Catalano L, Glickel S.Determining the optimal dosage of corticosteroid injection in trigger finger. Hand (NY). 2023 May 16:15589447231170326.
2. Bitar H, Zachrisson AK, Bystr¨om M, Str¨omberg J. Day-by-day symptom relief aftercorticosteroid injection for trigger digit: a randomized controlled
3. Wu RT, Walker ME, Peck CJ, Liu YJ, Hetzler P, Le NK, Smetona J, Thomson JG.Differential pulley release in trigger finger: a prospective, randomized clinical trial.Hand (N Y). 2023 Mar;18(2):244-9.
4. Blazar PE, Zhang D, Bryant JK, Benavent KA, Yeung CM, Earp BE. Patient perceivedoutcomes of recovery after trigger digit release. J Hand Surg Am. 2023May 3:S0363-5023(23)00167-3.
5. Koopman JE, Zweedijk BE, Hundepool CA, Duraku LS, Smit J, Wouters RM, SellesRW, Zuidam JM; Hand-Wrist Study Group. Prevalence and risk factors forpostoperative complications following open A1 pulley release for a trigger finger orthumb. J Hand Surg Am. 2022 Sep;47(9):823-33.
6. Matzon JL, Lebowitz C, Graham JG, Lucenti L, Lutsky KF, Beredjiklian PK. Risk ofinfection in trigger finger release surgery following corticosteroid injection. J HandSurg Am. 2020 Apr;45(4):310-6.
7. Straszewski AJ, Lee CS, Dickherber JL, Wolf JM. Temporal relationship ofcorticosteroid injection and open release for trigger finger and correlation withpostoperative deep infections. J Hand Surg Am. 2022 Nov;47(11):1116.e1-11.
8. Gray AM, Patel AC, Kaplan FTD, Merrell GA, Greenberg JA. Occult amyloiddeposition in older patients presenting with bilateral carpal tunnel syndrome ormultiple trigger digits. J Hand Surg Am. 2023 Jun 22:S0363-5023(23)00258-7.
9. Gannon NP, Ward CM.Results of implementation if amyloidosis screening forpatients undergoing carpal tunnel release. J Hand Surg Am. 2023 Jan 14:S0363-5023(22)00540-8.
10. Nelson JT, Gay SS, Diamond S, Gauger M, Singer RM. Warning signs: occultdiabetes and dysglycemia in the hand surgery patient population. Hand (N Y). 2022Dec 23:15589447221142893.
11. Meyers A, Annunziata MJ, Rampazzo A, Bassiri Gharb B. A systematic review ofthe outcomes of carpal ligament release in severe carpal tunnel syndrome. J HandSurg Am. 2023 Apr;48(4):408.e1-18.
12. Doi K, Marei AE, Mane SA, Hattori Y, Sakamoto S, Sonezaki S, Saeki Y. Reevaluationof the indications for the Camitz procedure in severe carpal tunnelsyndrome. J Hand Surg Am. 2023 May 12:S0363-5023(23)00171-5.
13. Piñal FD. Hand allodynia, lack of finger flexion, and the need for carpal tunnelrelease. J Hand Surg Am. 2023 Apr;48(4):370-6.

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Transcript

Charles Goldfarb: 0:05

Welcome to the Upper Hand Podcast where Chuck and Chris talk hand surgery.

Chris Dy: 0:09

We are two hand surgeons at Washington University in St. Louis here to talk about all things hand surgery related from technical to personal.

Charles Goldfarb: 0:17

Please subscribe, wherever you get your podcasts

Chris Dy: 0:20

And thank you in advance for leaving a review and rating that helps us get the word out. You can email us at Handpodcast@gmail.com. So let's get to the episode.

Charles Goldfarb: 0:29

Oh, hey, Chris.

Chris Dy: 0:30

Hey, Chuck, how are you?

Charles Goldfarb: 0:31

Good. Good. Good morning.

Chris Dy: 0:33

Good morning. Now we're changing up last time we recorded on a Saturday afternoon. This time. It's a Friday morning before everything gets started.

Charles Goldfarb: 0:40

Yeah, it biked into work, which I'm able to do again now, which I can't tell you the mental health benefits of doing this. So I'm happy. So did we three months post op? Three months post op? Yeah.

Chris Dy: 0:51

How's the range of motion?

Charles Goldfarb: 0:53

Range? Motion is great. The left comes and goes into the day it's back. I don't know knee knee replacement is I think everything you hear is true. It's not as easy as you think it might be. And it takes a while. Do

Chris Dy: 1:08

you think that? I mean, you had you had a partial, do you think the number is still 80% of or 20% of people who have a total knee are unhappy? Like that's the number that's often quoted based on the literature from the mid 2000s. I think

Charles Goldfarb: 1:19

it's funny, I was on my mission trip and people were you know, sort of laughing at me and talking about it. And I'm like, I thought everybody did well, eventually. They're like, No, they were quoting 30% of people are not particularly you know, not thrilled with their results. 30!

Chris Dy: 1:36

Yeah, I mean, that's that's a lot of people, right, as opposed to a hit total hip replacement, which you know, by and large people love.

Charles Goldfarb: 1:42

Yeah, like hips are like 95% Knees. I think these are are higher than that. But I don't know what the modern day numbers are.

Chris Dy: 1:50

Here. We are two hand surgeons talking about outcomes.

Charles Goldfarb: 1:54

Maybe I should have known before the surgery.

Chris Dy: 1:57

Maybe we should we should get your your surgeon Dr. Nunley. Back on the podcast to to discuss that for us.

Charles Goldfarb: 2:03

Yes, I'm sure his members look different.

Chris Dy: 2:05

All right, big day to day a lot of cases or clinic or what what's going on?

Charles Goldfarb: 2:09

Mixture of the above couple of cases. I have the CO H clinic today, which is busy before the holiday weekend and some admin What about

Chris Dy: 2:19

okay, all right. Well, I got another raging clinic before going out of town. It's always that like, you know, before you go out of town and after go out of town, the last every, every email I've gotten about having a patient come back, I'm like, just make sure it's not the week after I get back because that's going to be insane. So yeah, just clinic today and you know, get to fly out and have a good time. So yeah, it's always fun to have that kind of day went

Charles Goldfarb: 2:43

and you're gone for two weeks now. Just the week just was anyway, this weekend. Tonight. We got it. We gotta crank, let's get this episode. Done. So yeah,

Chris Dy: 2:53

I think this is a guest now an annual tradition. This is our what's new enhanced surgery. I think this will be part one of two. But let's see how far we get. You know, so I used to write this article actually a few years ago for Journal of bone and joint surgery. And it really kept me on top of the literature and, you know, in a, I guess, like a masochistic way I kind of miss it a little bit. Because I had all the articles from like JHS, JHS European hand, I had all the abstracts and everything pulled up. And it was just like this process every year of like whittling it down an incredible amount of time. So shout out to Deb bone at in Minneapolis for doing it for the last three years.

Charles Goldfarb: 3:31

You know, it is it is absolutely as you state it is a labor. But it is an important one both for everyone who reads the article. But for each of us individually. I've done something similar in two forums for pediatric congenital years ago. More importantly, every year for the last I think is 10 years now. We've awarded the Paul Manske best congenital manuscript. And that requires a review of seven major journals to identify articles. And then myself and Deb's partner Ann Van Heest and Michelle James, review them carefully. And award a winner each year with with, you know, recognition. So it's a valuable exercise. And

Chris Dy: 4:14

I think all three of you have junior partners that you maybe are going to be passing that on to at some point because isn't Michelle, semi retired or retired and, and you have an incredible partner who is now a full professor who maybe could help you out with that. Yeah,

Charles Goldfarb: 4:29

you know, I try to be careful not give her too many, quote unquote, opportunities. Michelle has retired from the Sacramento shrine and is working at UC Davis, I think trying to reboot their fellowship actually. Okay.

Chris Dy: 4:43

Well, you know, I think that's a that's task and that's going to be an exciting ride for her. Yes, classic. Dr. Gelberman reference to quote opportunities. Yes. So yeah, no, I love I love reading the What's New in hand surgery and, you know, I think it's something that is important. written to keep up with and I think there are a few articles I'm gonna pull from this after reading just this brief summary. Well,

Charles Goldfarb: 5:06

yeah, I love that. And there, there are some simulated articles. And, you know, I think you do a great job driving this conversation. So let's get to it.

Chris Dy: 5:14

Thank you for that opportunity, Chuck. But before we before we dive in lieu, we should talk about our friends over practice link the upper hand to sponsor my practicelink.com, the most widely used physician job search and career advancement resource

Charles Goldfarb: 5:26

becoming a physician is hard. Finding the right job doesn't have to be joining practice, like, for free today at www.practicelink.com/the upper hand.

Chris Dy: 5:38

So funny. I was talking to somebody about the podcast recently. And I was like, Yeah, essentially, it's 99%. One take and hopefully very minimal editing from Chuck's. And so yes to do the editing. So I don't know if you're gonna edit that part out or not. But and I will say dev i There is no nerve section here. So I know that you wrote this for the practicing orthopedic surgeon, but they seem nervous to just say, anyway, yeah,

Charles Goldfarb: 6:03

I think it's, it's fair enough. Because I'm thinking back at some of your year in some reason, I remember seeing a lot of peds and all of them. I put

Chris Dy: 6:12

as much peds in here, as she put in here, to be honest with you, it got three paragraphs in this year. So that's pretty much what

Charles Goldfarb: 6:18

I did do. Fair enough. Yeah, no nerve. Wow.

Chris Dy: 6:22

I know I kept reading waiting for it that didn't. So anyway, trigger finger, very common condition, as she states here, a straightforward condition to manage. They talked, there's one article that they pulled here that Deb pulled here about the dosing of steroid injections. So 5, 10, or 20 milligrams of catalog triamcinolone is the generic name, and they found a dose dependent response. Have you noticed a difference? Honestly, my, my cocktail for my injections is based on what I saw in fellowship. So how did you guys arrive at that cocktail?

Charles Goldfarb: 6:58

Good question. This is one of those things in answer to pass down. This is what I used in fellowship, and I use Depo Medrol. Which I believe is longer acting. I have, personally honestly, ashamedly, no reasoning behind my cocktail.

Chris Dy: 7:15

Yeah, well, I mean, it seems to work for us. We've never really needed to reexamine it. I mean, is this is this something maybe we'd want to consider adjusting the cocktail? And I know that we do I don't believe we buffer our lidocaine do we?

Charles Goldfarb: 7:32

You know, we went through a phase where we did buffer. I don't I don't think any one of us buffers anymore, because we just didn't find meaningful impact on discomfort.

Chris Dy: 7:41

Right. And it's just another step for the person preparing the injection. Just

Charles Goldfarb: 7:45

another step. And I think one of the things we do, it doesn't make it right. But one of the things we do is try to make things really easy on those helping us in clinic. So we like to be standardized because our Ma's and nurses rotate. And we have the same injection protocol for every single injection no matter where we're giving it right in for a trigger finger, we may give less of it, depending on the situation, but it's the same drop the same meds for every injection.

Chris Dy: 8:11

Yeah, the meds are basically the same. It's just I personally don't think I can get more than a total of a cc into trigger finger before causing discomfort. And that's kind of half half lidocaine with the with the steroid, I don't know what your sense is just kind of like a touch to it, where you know, you've filled and then you see the grimace when you've gone too far.

Charles Goldfarb: 8:30

Yeah, when I do a trigger injection, I give an injection, just a tiny bit under the skin go a little deeper right around the pulley. And then I tell the patient, they're going to feel fullness going out towards the finger, which happens about 80% of the time where you can always have a thumb on the finger near the Ag pole, and you can feel it. I tend to think that makes me feel better that it's going to work course there's no science there either.

Chris Dy: 8:52

Do you think you need to get into the sheath? No. And there is I think there is a paper showing you don't need to be in the sheath. Right?

Charles Goldfarb: 8:58

Yeah, yeah. All you need to do is be around the sheath, which is pretty hard not to accomplish. Right.

Chris Dy: 9:02

Exactly. And when you This is getting veering from the review article, but I think this is like practical aspects of injection. So where do you inject? So we're on YouTube? So show people where you put your injection. So I've tried

Charles Goldfarb: 9:14

every different way, I've gone all the way to the Palmo-digital crease and named proximately. I've gone a little proximal to the DPC, I inject right over the friggin a one pulley No, no, just just do it right there. What about you

Chris Dy: 9:28

on the same I think one of our partners injects at the Palmer digital crease. So when people come in and have had injections by somebody else in our practice, they're kind of expecting it to be a little more distal, but I tell them this is where it gets hung up. So I go there was a nice study that that Scott Wolfe would quote that when they were looking at percutaneous trigger finger injections or trigger finger releases. They found where the a one pulley is relative to surface landmarks and you know for our residents and fellows see that you know when you go from the distri in the Palmer digital crease in the PIP crease Can you translate that distance approximately, that's where the leading edge of the one pulley is. So that's where I go.

Charles Goldfarb: 10:05

I use that. I use that landmark as well, I think it's an important one. And then I'll say one other thing. I don't believe in two injections, because there definitely are people who will give a small lidocaine injection with a separate syringe and a separate needle, and then switch makes no sense to me at all. Well,

Chris Dy: 10:22

I mean, I fondly refer to that protocol as the government injection, because that's what I did with Dr. Gelberman, and there are certain people in our selling practice who still requested the way that Dr. Gelberman did it. So I'll do it. And some of that is our team members or staff who've requested government injection, it does add a lot of time to your workflow for sure. And

Charles Goldfarb: 10:44

I don't think any patient benefit. And then the only other thing is, you know, the cold spray, I will use ethyl chloride when the patient requested I don't personally think it makes a big difference. But some people swear by it.

Chris Dy: 10:57

I think it's the psychological aspects of it, but it is, you know, there's the pain from the needle going in, then there's the the true pain, I think, from the injection is when the injectate is being is filling the sheath or is filling the pot. And that's where I think you have no control over that, aside from the pace and the amount that you inject.

Charles Goldfarb: 11:14

Yeah, I Yes. I love the timeline discussion. Next that Deb hit on, I thought that's super interesting.

Chris Dy: 11:22

Yeah. So she, she mentioned an article that that was from a Bitar, et al. And, you know, what do you tell patients about how long it takes to see relief from a trigger finger injection? Because this is different than what I've usually tell people.

Charles Goldfarb: 11:37

This is different than what I tell people. So I guess, therefore, we should share. So what what this what she cites from the guitar at all, is that the timing of symptom abatement with pain relief at nine to 11 days improvement in stiffness, that 11 to 15 days and resolution of triggering at roughly three weeks from an injection. And of course, we don't know what we don't know. And if we don't ask the questions or see the patient back, we don't know. I tell patients that, you know, some will wake up in the next day or 48 hours later and have relief. I think others will take two to three weeks. And that's what I tell them. But I have never heard or personally recognize this kind of timing for symptom relief. Fascinating. Yeah,

Chris Dy: 12:23

no, I think this is great. This is really helpful for counseling, I'll probably adjust my counseling based on this. Because I usually tell people, you know, just roughly and you know, the steroid takes two or three days to kick in, start to feel better. And I've seen it take up to one to two weeks and a few patients. So clearly, I am wrong. And my counseling, or at least the patients that are in this RCT from Europe are different than the patients here in good ol son the week. But yeah, I, I have asked patients at times, you know, how long did it take to kick in? And, you know, I guess I probably should ask in more detail.

Charles Goldfarb: 12:54

Yeah, I think the the major take home is don't downplay this, don't make it seem like it's going to be three or four days, you're gonna you're gonna be fine in three or four days. That's not true. We know that's not true. And obviously, with the symptoms, they're describing stiffness, and, you know, these are more significant triggers that they're injecting and they're they're citing so you know, every trigger finger is not the same either.

Chris Dy: 13:15

You imagine randomizing patients to study for trigger finger that's gotta be at talking about adding time.

Charles Goldfarb: 13:22

As I've told you, I've done my last randomized control trial with the CMC paper.

Chris Dy: 13:27

Kudos, kudos to you, sir. Yes. So Deb then goes on to talk about trigger finger release. You know, it says in here that dogma suggests that the a zero fibres should be released along with the A one pulley. I always thought that was kind of a very WashU centric thing to talk about releasing the Palmer apron roses pulley that Dr. Manske described which I'm assuming is the same as the a zero pulley. So did you see elsewhere in Cincinnati where are they releasing the pulmonary fibrosis pulley and fellowship? Yeah,

Charles Goldfarb: 13:58

so first of all, I think that's a good a good shout out document as he did describe the PA totally the bomb references probably I assume this has to be that and like you I definitely do that you know, I release the entire a a one pulley I release at least the digital half of the people occasionally a few fibers from A to insist scenarios mixed. Some didn't. Some didn't. That is some did release. The PA pulley, the A0 some did not. Well,

Chris Dy: 14:25

this study shows that you should be doing both So yet another RCT for trigger finger patients but showing that you know half of them had resolution if you're least only zero, about half had resolution if you release only a one, but all of them in a resolution if you've released both these

Charles Goldfarb: 14:41

numbers are crazy. First of all, that they did trigger surgery and only released a zero. And again, I'm not being critical. I'm admiring what they were able to pull off. I don't know that we would have designed to study in a similar way. But this is really important information.

Chris Dy: 14:56

I don't think we I don't think we could have gotten this through our IRB to be honest with you because I I don't think there's enough equipoise. But clearly it's it's there are people interested in this that that have found the evidence suggesting that you could only release a zero and have somewhat similar results. But I think the RCT is the proofs in the pudding. So

Charles Goldfarb: 15:13

a zero and a one is the our continuing technique.

Chris Dy: 15:18

Correct. And then keeping on the theme of recovery taking longer than what we expect the group up at up at Brigham and Phil Blazers group, looked at how long it takes to recover after trigger finger surgery. The interesting thing to me is that patients, you know, the median self reported full recovery was six months. I mean, I mean, I honestly, I don't see him beyond two weeks. If that. So what do you think is? How do you think that reflects on your practice?

Charles Goldfarb: 15:44

Well, the first thing I think is it makes me feel better about my knee replacement. But wow, again, I mean, it maybe it's their 80%, better two weeks, like I said, and then they just takes a while to and it's always that when do you stop thinking about the procedure or the spot or whatever? This is incredible. And obviously, Phil Phil's group does great work. And this is a study I will obviously trust and absolutely, quote, this is important.

Chris Dy: 16:13

Yeah, no, I think it's helpful to tell patients, it's going to take longer than both, you know, you and I anticipate and once you know, what's cure, what's interesting to me is that, you know, four out of 50, so 8%, had not reported full recovery by 12 months. Now, that's shocking to me, to be honest with you. I don't know how much of that is, you know, the specific population that they're seeing up in Boston? Maybe that influences it? That has not been my experience? And I'll be honest with you, I don't think the self reported recoveries, six months in St. Louis.

Charles Goldfarb: 16:45

Again, we don't know we don't know. But I don't either. But maybe we've been burying our head in the sand or, you know, maybe your patient is coming to me and my patients are going to you.

Chris Dy: 16:53

Right, right. Well, incoming fellows, maybe you have a research project. I don't know if I want to do anything and trigger finger though. Yeah,

Charles Goldfarb: 17:01

well, let's have to beat a dead horse. Actually, clearly, this is new information. So it's not a dead horse. This study about the risk of complications is also interesting. And I will say this, I don't say this mirrors my experience, but I think we as hand surgeons tend to downplay the risk of less than perfect outcomes after trigger release.

Chris Dy: 17:21

So I would agree with that. I mean, what do you think are the things that we downplay?

Charles Goldfarb: 17:27

I think we downplay the risk of scar tissue and continued discomfort. And I think we I don't know if it's, I don't think we downplay infection, or, you know, things like that. But I just think it's not as simple of surgery. As you know, we can deceive ourselves into believing it is a simple surgery to perform. It's a safe surgery to perform. In my experience, there's a real population that has recurrence or triggering and it's probably in my hands 5% Because I really think it's that high where I either do another injection, or super rarely do another server. Yeah,

Chris Dy: 18:03

I think that's well said. I mean, you know, I think there are some patients beyond the recurrence of durian that just have ongoing discomfort. Some of that is you know, stratification of you know, who is more severe when they come in, you know, we read an article in journal club recently, our pan service Journal Club, about, you know, PRP contractors, you know, truly being a parkour prognosticator, as classically taught and, you know, evidence in the recent papers and I think the scar tenderness is a real thing. You know, it doesn't happen often for me, but I have been, I always counseled patients about the possibility of a painful scar just because of one patient I have in mind that's how to painful scar. And there's let me know in online reviews, that stays friend of mine, for me, a patient's

Charles Goldfarb: 18:44

painful scar is a surgeon or injectors painful scar as well. I mean, it is true. And you know, I as I tell patients all the time, this is something that we can't control, you know, Scar, massage and modalities can help, you know, eventually we'll be able to control the development of scar tissue right now. We just can't, right,

Chris Dy: 19:02

absolutely. So before we get into the best part of the the article, at least the one about compressive neuropathy, we should pause and thank our friends over at checkpoint.

Charles Goldfarb: 19:12

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Chris Dy: 19:21

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Charles Goldfarb: 19:36

To learn more, visit www.checkpointsurgical.com. Checkpoint surgical driving innovation Hansard what I love about checkpoint is they do change up the content, which is clearly evident to everyone listening right now.

Chris Dy: 19:51

Yeah, so I was when I was talking about the podcast a few weeks ago in Houston. I was telling him that I listened to the pod as essentially quality trouble just to kind of know. And then also so I know what I say, because sometimes I forget, but I listened to it at 1.5x. So maybe that pause right before you started the coffee? Doesn't seem that long when you're listening. Maybe some people listen to us at 2x Who sound like chipmunks? I don't know.

Charles Goldfarb: 20:17

Well, when I listen to regular podcasts I listen to typically 1.5 1.0 is just too slow. No one out there listens to you and me at 1.0.

Chris Dy: 20:27

I think there are people who don't know about the option of 1.5 I mean, to be honest with you, I like hit the button like, Whoa, this is awesome. In no part, my baseline for everything is 1.5. Which is weird when there's like music on podcasts. It's like very different. But the Go ahead, how does it say our jazz piano intro sounds, you know, it's slabs different. And while boy five,

Charles Goldfarb: 20:49

maybe the most important takeaway for those who are not familiar, is speed up. You'll learn more faster. Exactly.

Chris Dy: 20:59

So speaking of learning more carpal tunnel, so another common condition that hand surgeons treat, I found this section fascinating about carpal tunnel maybe being a harbinger of, of systemic medical problems. So we've read a lot recently about the association between Amyloidosis and carpal tunnel. How often are you thinking about this? You know, when you when you see patients?

Charles Goldfarb: 21:25

I'll be honest, I do think about it. I don't regularly biopsy this, you know, makes me think perhaps I should? I do think about it in older men with bilateral carpal tunnel. I think the value of these studies is that it is, I guess, unfortunately, a helpful reminder for those of us who don't continue to think about things like this regularly. What about you?

Chris Dy: 21:50

I don't I don't think I think about it enough. You know, when it comes, I've had people sent over for this specific reason. So clearly, that is different, you know, to send a biopsy, and I've had a patient who was a cardiologist in his 60s who requested that I do this too. You know, one of our partners yesterday, I was operating, you know, across the hall. And, you know, the fellow came in to mention that they had sent a biopsy. And I don't know, maybe they just read this article or not. But I mean, it was a patient, it was a classic patient like in their 60s and male bilateral carpal tunnel. And so they just went and sent it off. So this article that Deb mentions is from Ganon, and Ward, and they they sent a biopsy from patients who met certain criteria, so men over 50, and women over 60, with bilateral or previous carpal tunnel release. And not all of them had other conditions associated with amyloidosis. And they were offered screening, a half of them accepted having the biopsy, and almost a quarter tested positive for amyloid found that fascinating. Fascinating.

Charles Goldfarb: 22:55

And I haven't read the article, and I don't think we read something about amyloid in journal club. But there's this one. But yeah, I guess the next level question is what then happens is it become, you know, a systemic issue and all those patients are or not? And maybe the article didn't delve there. But that's the question.

Chris Dy: 23:14

Absolutely. And shout out to Christina Ward up in Minnesota, who was my co chair for the resident and fellows course a few years ago for doing that, for doing that work. And then also, there was another article that demonstrated that there's a higher risk of higher incidence of undiagnosed diabetes, or pre diabetes in patients undergoing carpal tunnel or cubital tunnel surgery. So I also find that interesting. I mean, I think it's probably a general trend in our American population. But do you think about this at all?

Charles Goldfarb: 23:44

I don't think about testing I do think about I mean, that one to me is almost more reasonable or more, you know, does it doesn't take that much of a stretch to believe that one, just because the relationships there and, and maybe we won't be talking about this, just like we don't talk about rheumatoid anymore, once all these weight loss meds, you know, take center stage are continuing to continue to advance but this is this, these numbers are crazy. I mean, it's really impressive.

Chris Dy: 24:11

Well, I found it I found interesting. I mean, they had a patient, a group of patients who had peripheral nerve compression, so carpal cubital, tunnel syndrome, half of them were pre diabetic, and 13% tested diabetic on a glucose challenge test that they had that they took, and that's double the control group. So people who don't have carpal cubital I mean, that's just interesting, you know, because oftentimes, I will have patients say, Why do I have this like referring to carpal tunnel or trigger finger? And, you know, maybe this is something that just adds to the counseling?

Charles Goldfarb: 24:42

Yeah, maybe we need to be more than just answers. And as Chris, I mean, we got to think systemically like we're back in med school.

Chris Dy: 24:49

I remember when I was doing my internal medicine, clerkship, and it was back in the day when we still had grades, and you had to you had to crush every workday. shouldn't write to really ace it and make the medicine people think that you would be the best medicine doctor and I did that. And I remember doing a debrief with the clerkship director, hardcore internist. And I was like, Yeah, I'm gonna be, I'm gonna be the orthopedic surgeon, those are medicine, and all this stuff. And that lasted for about a year and internship. And then after that, it was like, I tried so hard. I tried really hard to optimize things. And I was like, okay, console medicine.

Charles Goldfarb: 25:25

So this next study is a systematic review of carpal tunnel outcomes journal hand surgery. Myers at all. And it's that one I thought was is, you know, incredibly interesting as well, looking at recovery of APB. What were your thoughts? Yeah,

Chris Dy: 25:43

I mean, I think I've never routinely ordered postoperative electric diagnostics. Unless I believe there's an issue in onset for isolated carpal tunnel, I typically don't order preoperative electric diagnostics. But I do tell people if they do come in with lecture diagnostics, or I get it for other reasons that if you have an absent see map, it is a poor prognosticator. I mean, it's essentially that there is very minimal functioning at nerve fibers getting down to the getting down to the thinner muscles. What I found interesting about this is that there really was no difference for the folks who had a candidates done versus not having a candidates. And I actually believe that because, you know, we see so many people with advanced carpal tunnel syndrome. And I very rarely am indicating a candidate's, which is a transfer of the palmaris longus tendon to improve Palmer abduction. I very rarely indicate that surgery in somebody who has compressive neuropathy. It's usually for a traumatic injury.

Charles Goldfarb: 26:43

Yeah, a lot to unravel. I agree with you. I think one of our partners likes the candidates more perhaps, than I do. Some would argue it's not an opposition transfer, but it's really an abductor plasti I'm trying to show that to on YouTube, where essentially, you're maximally abducting the thumb to a resting position. So it puts it in a better position. It's not usually as dynamic as trans as other transfers can be. But the concept of see map recovery in patients who had lost see map is interesting to me, it's so unexpected to me.

Chris Dy: 27:18

Yeah, it's interesting. I also find it probably less clinically relevant to be honest with you, just because they're really not going to get the Feanor muscle bulk back. I think the reason, you know, and I'll pivot back to the thought and thinking that I thought was interesting about this favorite was the candidates thing, because, you know, so one of our partners thinks that it is a dynamic transfer, as opposed to it's classically described as a static transfer. So I think the reason behind why people don't really need to candidates, or the lack of benefit of candidates, is that patients over time develop ways to position their thumb as their carpal tunnel nerve, their median nerve is burning out, and they don't realize it. Because if you wouldn't, when I examined people, and this is what I teach our our learners is that you watch the patient abduct, and they will almost always extend their wrist and kind of flex, you know, and then they'll call for extension and flex it down. And if you really watch them, if they'll fire them, they're Palmeras as they're trying to position their thumb. So then if you stabilize or take pro flex their wrist down and take away their ability to use their their forearm muscles, including the specifically Palmeras, they will be much weaker when you when you test their Palmer abduction. So I think patients compensated for time. And then there's so many other ways they can compensate with their APL with their EPB, even to position their thumb. So that's why only makes a difference.

Charles Goldfarb: 28:42

Yeah, really well said and does resonate with me in a different population that is kids born with hypoplastic thumbs, some hypoplastic thumbs are really difficult to detect, it can be really a minor decrease in size, but there may be a decrease in the APB and thinner muscle size. And I'll see some of those kids at age eight or 10, who have not been previously diagnosed. And while occasionally we'll operate on them to give them an abductor. Many times we don't, because they figured it out. And it's not a real functional issue in ways that are very similar to what you describe. Right,

Chris Dy: 29:17

right. So as we bring this to a close, and I think we'll have to do another session on what's new enhance surgery to really get a full appreciation. The patient with a typical carpal tunnel syndrome, I really struggle with this. Because, you know, while I have a hunch sometimes that it is carpal tunnel, or you know, doing carpal tunnel release might help. It always makes me nervous. No pun intended.

Charles Goldfarb: 29:44

You're happy when you're nervous? Yes, you know, I do believe there's a typical carpal tunnel. I think this author doesn't believe in complex regional pain syndrome. And so The report on 35 hands and 22 patients over eight years with inexplicable hand Allah Dinya and lack of active finger motion. That's a typical for sure. And to me, it means something very different than the United States, we would potentially call that a type two CRPS. If there's the right background, etc, right,

Chris Dy: 30:21

right. But I mean it in a way, the way that the way, this author, which I always love a single author paper, so shout out to Paco Panella, for doing that again. But, you know, they had a painful to know. And, you know, positive feelings test. So I mean, that that is a strong indicator. I mean, I do pump the brakes on a lot of these patients, I will get testing in this situation, and I typically will do a diagnostic injection. I mean, what's your, what's your approach to that?

Charles Goldfarb: 30:50

Yeah, if it just doesn't strike me that I can reliably predict the results. One of two approaches, I will offer an injection for sure. And I'll you know, I'll lay more crepes, so to speak about expected outcomes, you know, I might share that I tell the classic carpal tunnel patient that there'll be an 85% cure or near cure rate 10% of people better but maybe not cured. I don't say the same numbers, I tell them, your numbers will not look like this, even though I'm optimistic the surgery will help you.

Chris Dy: 31:19

Right, right, I tend to tell them that I think we're gonna make a difference here. I don't think we're gonna fix everything. But I think it'd be a big bite out of the apple. So to say, you know, in pocalypse paper here shows that the patients who had these issues with limited finger flexion went from a DPC of 3.7 to 0.3, which is impressive, and, you know, their dashboards improved their pain and swelling resolved. I mean, that's impressive, and it's certainly something to keep in mind. And I agree, this is population that we would typically, you know, fall into CRPS, type two for in the right setting.

Charles Goldfarb: 31:49

Yeah, and I will say that for those of you who, you know, see the same thing and would call this CRPS type two, again, in the right setting, post history, radius, fracture, post trauma, whatever, the DPC improves, but it does not our experience is not what then what Pacos was, which is immediate improvement to a near perfect VPC. It is a slow process that takes time and therapy, and my patients do not typically get 100% of their DPC back. I completely

Chris Dy: 32:15

agree. And, you know, thank goodness for our therapy colleagues who are able to work with our patients so much to get them there. But I agree they typically will get there but it is not instantaneous. Wow,

Charles Goldfarb: 32:25

we did not get a lot of this article covered. We're definitely gonna have to come back. We

Chris Dy: 32:29

really veered off with the trigger finger discussion, we went off the rails. So yes, we will come back and do it again.

Charles Goldfarb: 32:35

All right. Safe travels. And I'll see when you get back.

Chris Dy: 32:39

All right. Sounds good.

Charles Goldfarb: 32:42

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

Chris Dy: 32:45

good. Well, be sure to email us with topics, suggestions and feedback, you can reach us at handpodcast@gmail.com.

Charles Goldfarb: 32:52

And remember, please subscribe wherever you get your podcast. And

Chris Dy: 32:56

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

Charles Goldfarb: 33:00

Special thanks to Peter Martin for the amazing music. And

Chris Dy: 33:03

remember, keep the upper hand come back next time