The Upper Hand: Chuck & Chris Talk Hand Surgery

Deep Dives on Surgical Technique: Cubital Tunnel Decompression

May 09, 2021 Chuck and Chris Season 2 Episode 19
The Upper Hand: Chuck & Chris Talk Hand Surgery
Deep Dives on Surgical Technique: Cubital Tunnel Decompression
Show Notes Transcript

Episode 19, Season 2.   Chuck and Chris continue the new segment: deep dives on surgical technique.  We continue with another key procedure- the cubital tunnel decompression.  The focus is the exact technique that we use, from skin incision to treatment of the nerve to handling of the FCU.

Let us know if you like this segment and we welcome suggestions on other procedures to dive into.

As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
theupperhandpodcast.wustl.edu.  And thanks to Eric Zhu, aspiring physician and podcast intern.

Survey Link:
Help Chuck and Chris understand better what you like and what we can improve.  And be entered for drawing to win a mug!  https://bit.ly/349aUvz

Charles Goldfarb:

Welcome to the upper hand 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 aspects of hand surgery from technical to personal.

Charles Goldfarb:

Thank you for subscribing. Wherever you get your podcasts.

Chris Dy:

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

Charles Goldfarb:

Oh, hey, Chris.

Chris Dy:

Hey, Chuck, how are you?

Charles Goldfarb:

I'm doing very well. How are you today?

Chris Dy:

I am fine. We are on Instagram Live. Hello, Instagram Live and we're also doing a podcast. You know, it's gonna be a fun day. Let's see how this goes. I sprung this on you at the last second.

Charles Goldfarb:

Thank you for keeping me young man. I didn't know you could multi zoom. Instagram podcast. Awesome.

Chris Dy:

I'm not sure we might break this. So

Charles Goldfarb:

Who broke the internet? I don't know.

Chris Dy:

Yeah, those those two hand surgeons with five people watching. So anyway, it looks like we've got you know, obviously our number one guy, Dr. Sam Moghtaderi on there, former guests for WALANT. And Sam, we're gonna talk a little bit about some of the WALANT issues on the podcast. So anyway, Chuck what's going on in your world today?

Charles Goldfarb:

You know, it's one of those days it's an admin academic day, which unfortunately becomes more admin and less academic. But no, good day, a lot to catch up on and looking forward to getting some stuff accomplished.

Chris Dy:

You know, I had some academic time yesterday, and it was the first time in a while that I actually had time to think, that was awesome.

Charles Goldfarb:

It's so easy to get caught up in checking the boxes. And you know, we love seeing the patients, but man, it is setting aside time to think is a prerequisite for the real world for CEOs of all varieties. And we you know, we don't we don't set aside that time. And I think for big ideas, and for do things, doing things for ourselves or to advance the field. You have to have that time.

Chris Dy:

Yeah, and I think one thing that I probably could get better at is actually just reading. No, I think that the temptation naturally is to figure out how you can do more. But I think many, many clinician scientists have told me that you can save yourself four years by spending four hours in the library.

Charles Goldfarb:

Wow, that is strong. Yes.

Chris Dy:

So do we have any actually I think we have a new review. iTunes five stars the only option if you're putting a rating on iTunes. So this is from ET calverts from April 29. Thank you for the review two thumbs up. Great. Chuck, good. Did you give her one of those thumbs?

Charles Goldfarb:

Well, I would be happy to I will, I will do anything I can.

Chris Dy:

It's such a great idea to listen and learn with a conversational tone and totally entertaining. So thank you for that review. We really appreciate it again, go on the iTunes and leave us a five star review. And nobody has actually taken us up on this Chuck will answer anything that you write as a question in there. So please, please leave a question. Let's incorporate from the Instagram Live. Dr. Sam says the problem is that when I take my academic time to think I fall behind on my charts, that's pain that we all feel, so.

Charles Goldfarb:

That, there is no doubt there is truth there. I do want to take a second to thank our partners QXMD with the read app. I continue to use this app it's really interesting that I I try to stay up with the literature and with publications in different ways. Google Scholar does it for me, I get emails about publications. But the read app is really helpful because I get a once or twice a week, I think you can set it however you want. I get an update on what's been published in the fields that I have requested on whether that be cleft hand or OCD of the capitellum or the best hand podcast out there. I get the updates every week, Chris.

Chris Dy:

It's easy to be the best when you're the only actually the only hand surgery podcast shout out to hand therapy heroes, hand therapy podcast, colleagues. So um, you know, funny story about the QX MD thing I was chatting with Micah Sinclair, a pediatric focused hand surgeon over in Kansas City. And she asked me she's like yeah, do you remember you said something about how what you use to help keep your journal articles so you can read them? Like, I don't remember ever having that conversation in person, but I'm pretty sure we had it on the podcast. And I can't keep track on what I say in various modes of my life. Whether it's email, conversation, zoom, or podcast.

Charles Goldfarb:

No, that is true. The podcast confuses me even more, much less Instagram Live, what is gonna happen? We're gonna we're gonna implode i think i think that's the only future I see for us.

Chris Dy:

Well, you know, to keep us going if anybody wants to sponsor us, give us money. Let us know. This has been a wonderful experience with the podcast and you know, we have a lot of people that listen every week. So we're we're trending in terms of downloads. So get it on the ground floor. I mean, you know, get in early.

Charles Goldfarb:

It is interesting to watch our numbers. The numbers are stunning. And we are so grateful for those who download and listen in every week where, you know, it's around 1200 expected downloads and listens a week, which the great thing is that number continues to elevate every week and it really is remarkable, remarkable to see. So, we were talking earlier about our lack of time and I do enjoy other podcasts but it's difficult to find time to listen to other podcasts. I was listening to one of my favorites which is called the old man and the three which is JJ Reddick's, I that resonates on a number of levels to me. It is really good. And it's really funny and they had Duncan, JJ Reddick had Duncan Robinson on who is a really excellent long range shooter also.

Chris Dy:

Is this the white guys who shoot threes podcast?

Charles Goldfarb:

There may be something to that, but Duncan Robinson is best known, despite his NBA career and estimated new contract he was undrafted three years ago, and he's estimated to sign a five year $80 million contract coming up which is really stunning. But he went to Williams College for one year.

Chris Dy:

I was going to say, played ball at Williams right?

Charles Goldfarb:

He did it's a pathway to success.

Chris Dy:

I mean, that's basically Jake Goldfarb coming your way, right?

Charles Goldfarb:

If only if only but what i what i took away was they have a segment about kind of, they were talking about being a fanboy of different people and different things. So I was thinking that I wanted to ask you know Who? Who and, and I can go first if you want but who in hand surgery, have you met hand surgery, hand therapy, the greater world of academic medicine. Who have you met that really made you feel like a fanboy and wanted to like get their autograph, or, or whatever, like, just talk through that if you have any one that comes to mind? If not, we can stall and I'll give you one.

Chris Dy:

I don't have anybody that comes to mind. The only time that I've asked for an autograph was when you turned me down. When I asked for you to autograph my book. But you know, that's that's fine. Actually, I do want to hear your fanboy story. But shout out to Shobhit Minhas one of our current fellows who is a podcast listener has been since prior to his fellowship, I see that Harrison is actually on Instagram Live. So Harrison is coming to join us from Los Angeles next year. Anyway, Shohbit had this great idea, which maybe we'll play this out over a series of episodes of who would you put on the Mount Rushmore of hand surgery. So I want to plant that seed. And then we'll get back to this maybe in another episode, but I don't have a automatic fanboy moment. Because I guess fortunately, I've been around, you know, some of the people that I admire the most in terms of, you know, legends in hand surgery, even here at WashU. So somebody like Richard Gelberman, Susan MacKinnon. So I've gotten to know them and perhaps, you know, those are people that I would have thought of as thinking of as a fanboy type affair. What about you?

Charles Goldfarb:

Yeah, I think that's true at our world is accessible at least I like to think it's accessible. Most people don't stand on airs or, or have expect some differential treatment. And so part of it for me was not being familiar with this person. But I the one experience I've had that most felt like a fanboy experience was with Adrian Flat. So Adrian Flat for those of you who don't really know the name, was a Brit, who tells the stories of surviving the the German raids in the you know, 39 and 40. You know, how hiding in the subway really remarkable stories. He became one of the fathers of congenital hand surgery in this country for sure, was in Iowa for many years, and then ended his career working, and really advising down in Dallas, Texas Scottish Rite. So I spent some time down in Dallas with Marybeth Ezaki and Scott Oishi learning a bit and I had lunch with Adrian Flat one day kind of out of the blue. And he was he just felt like a larger than life figure and he has written one of the one of the books that one of the books in congenital hand surgery, the care of the congenital hand which has been gone through several editions, and Marybeth actually just rewrote it to update it for modern times. So meeting Adrian Flat, who passed away, not in the not too distant past was really one of those moments for me, which was just really exciting.

Chris Dy:

So there is photo evidence of that lunch of you and Adrian Flat that gets shown pretty much at every resident fellows conference, which is the fittingly the Adrian Flat resident fellows conference at ASSH meeting. And when they introduce they show the picture of you and you had a just a little different haircut back then.

Charles Goldfarb:

I was waiting. I didn't know that picture was shown but I do know that I look-

Chris Dy:

Every year, every year.

Charles Goldfarb:

Well, it was something I I still remember that that lunch. So it was pretty, pretty neat.

Chris Dy:

I guess maybe a more practical fanboy ish moment is I remember when I was a resident at special surgery. And I had never worked with Michelle Carlsen before in a case. And it was one of the things where I was about to apply for hand surgery fellowship. So I needed all of the faculty to know who I was, and hopefully know that I could operate. And I'd worked with Michelle a lot in research, but never in the OR or in the clinic. And I remember scrubbing a case with her and my hand just started shaking. Like I couldn't like, it was almost like a Ricky Bobby moment, where my hands just the loops felt all out of focus, but fortunately, I think I got it together. But I'm pretty sure she thought was pretty weird shout out Alison Kitay, a former HSS resident who is seeing us on the Instagram Live. But we're doing a podcast recording right now.

Charles Goldfarb:

We are. So just, I just was talking to Michelle, we you know, she and I share the strong interest in the care of the professional athlete. And she has built really a thriving, remarkable practice treating that population and for good reason. She does a wonderful job with it. So we were just catching up about an athlete this week, but I really admire what she has built at HSS. For the care of

Chris Dy:

This is what happens on the deep interwebs of the these athletes. professional athlete, hand surgery. Are you guys like Illuminati? Like you know, there are only a few of you. It's like you, Michelle and Steve Shin, just, you know, talking about cases.

Charles Goldfarb:

Well it is interesting how people ascend in this world, and I think not to get too personal or too direct. But you know, what has hampered my growth in this field is the fact that the St. Louis Rams are no longer in St. Louis. The NFL is so dominant in so many different ways. And while each league is different in different physicians may specialize. When the Rams left St. Louis, I think I was feeling really good about where I was. And I had a good network of agents I worked with, and that has really diminished. And so well, I do have the opportunity to care for many professional athletes, I think in St. Louis without an NFL team has really hampered my growth in that field, while Steve Shin in LA has taken off, and he seems to be the name that's mentioned as much as any, if not more than any. And five years ago, that just wasn't the case.

Chris Dy:

Don't follow the Rams Chuck, stay here in St. Louis.

Charles Goldfarb:

And don't worry. Don't worry. It's interesting watching what's happened with the English Premier League. Speaking of rams and Rams owners. You know, the three American owners of Premier League soccer teams, and they are under a lot of heat because of the attempted exit for the Super League.

Chris Dy:

Apparently, it's not a good idea to follow the money that typically doesn't always pan out.

Charles Goldfarb:

Apparently not, you and I are proof of concept there.

Chris Dy:

Yeah, we are not following the money right now with a podcast. So staying in the realm of sports. The detailed deep dive segment that we did a couple of weeks ago was pretty popular. And Shohbit, I was actually surprised that you had never watched an episode of Detail given how much of a basketball nut you are. So perhaps we'll have to sit down and put on one of those.

Charles Goldfarb:

That would be fun, my son texted me last night and said, because I always talk about all these subscriptions we have and all these different polls on our time as we've been talking about. And we subscribe to NBA Live or NBA, whatever it's called the I get every game at home and this year pandemic year, we have watched a ton of NBA, but I need to watch this segment of Details and we need to talk about another segment.

Chris Dy:

So let's I think we've covered some of this in some of the prior episodes. But clearly some of our thinking may have changed since we recorded the initial cubital tunnel episodes because that was honestly I think it was one of the first episodes that we dropped. But let's talk about the detail on an in situ ulnar nerve decompression. So skip indications say you decided you are doing an in situ ulnar nerve decompression. And before I asked you to get into that, I will say if anybody is on Instagram Live and wants to, you know, text some comments on how you do it. We'll try to roll that in as well. So, Chuck, um, how big is your incision, I'm actually going to get out a ruler this time and measure my incision.

Charles Goldfarb:

It's so, before I jump in, I have to say that Leo Cho, who was one of my chief residents texted me earlier this week asking this exact question and of course it's on Leo for not listening to the podcast but but I will I will push him on this one. So you know when I make a carpal tunnel incision, as we discussed, my incision is two centimeters, give or take depending on the size of the hand. And so for a standard cubital tunnel decompression.

Chris Dy:

I did have something here to scale it.

Charles Goldfarb:

For a standard cubital tunnel decompression, I would say it's basically five centimeters is is my and I make it in this will be interesting. I make it just anterior to the medial epicondyle. And the reason I do that is that people complain about incisions posteriorly when they rest their elbow on the table. So five centimeters, just anterior the skin is so mobile it's no problem getting back to the cubital tunnel retinaculum. What size incision do you make? And where do you make it?

Chris Dy:

So five centimeters? Two inches. I think that's about right. Clearly, I am not good at understanding how long the incisions I make are. But you know, yes, the skin window is pretty mobile. I agree with you on the prominence and bothersome ness of the incision, the healed incision site if it's posterior. So for an ulnar nerve transposition, I actually, you know, move the incision more anterior because you taught me that. But honestly, for the cubital tunnel decompression, I keep it relatively simple and keep it essentially over the area where the nerve is going to be perhaps that has some implications for scarring over the nerve too. But I said a little more posterior, just, you know, along the posterior border of the medial epicondyle.

Charles Goldfarb:

But I think for those on Instagram Live, and maybe they'll comment or certainly for our audience, if you want to reach out to us, cubital tunnel decompression for some people is a good three inch incision. or bigger, it means something different to different people. And so, for me again, the idea is very simple. I don't excise the intermuscular septum. All I do is I release the roof of the tunnel. So the cubital tunnel retinaculum, Osborne's ligament, I released the superficial what I call the deep fascia of the FCU. And I release anything obviously constricted proximately I don't touch the nerve. And that's all I do.

Chris Dy:

So this is detail. So let's rewind. So say you've made your five centimeters. I mean, you're you said it was five for this one, right? Yeah, five centimeter incision, just anterior to the medial epicondyle. Well, what do you use to help get down to where you need to go? So is this a couple of senn retractors Are you looking for the M ABC and its branches here are you just if it shows up, it's great, are you going to spend some time you know perseverating over it?

Charles Goldfarb:

Two senn retractors, I do assure that the MABC is not in the field. I pull obviously harder on that posterior senn retractor. And as blunt spreads down to the retinaculum. So I think the approach obviously depends on the body habitus, but the approach is quick. And I'm pretty straightforward.

Chris Dy:

So one thing that I like when you know, so in terms of finding the MABC, if it is in your field, it tends to rest right on top of that fascia. So I after the initial blunt dissection with the senns, I will typically take a rag or a raytech and kind of roll it around my thumb and bluntly dissect with my thumb, working over the medial epicondyle to clear all that space off. And typically that will push a branch of the MABC anteriorly. And then if I see that branch, and I'll switch that to the blunt end of the retractor, and work from there. So I like to find the nerve proximal to the medial epicondyle. And I do a fair bit of ulnar nerve surgery. And I still think especially if you're sitting on the other side of the table, and the trainee is the primary surgeon, this can be a little bit trickier to find that nerve than we give it credit for just because of the angle of the approach. If you have the arm up kind of like this, that person who's sitting in you know, in the driver's seat needs to really understand where that nerve is and where to dissect because you can easily glance over it if you don't go in and behind that medial epicondyle.

Charles Goldfarb:

Right. And I think the anatomy is different for each person. And so the depth of the groove varies. And so for some patients, it's very easy to feel the nerve, for others it's not. And obviously that has implications for instability of the nerve, and so theoretically, I guess the way I think about it is if I'm thinking about doing a decompression, it is an absolutely rock stable nerve. And so theoretically a nerve is sitting a little further in the depths of the groove. But you're right, it seems like it should be 100% easy to find the nerve every single time. And I think it is, but it can be a confusing.

Chris Dy:

So do you find the nerve at the medial epicondyle just proximal to it before you proceed distally? Or do you release the FCU fascia and look for it there first?

Charles Goldfarb:

I go right at the cubital tunnel retinaculum right behind the medial epicondyle and I've been happy with that approach. You know, when we do things like De Quervain's decompression, I'd make a big effort to create a flap, which theoretically helps prevent those tendons from subluxating. I don't do anything similar with the elbow, I don't know that I can create a flap strong enough that if I did believe in that, I would incise, the cubital tunnel retinaculum and Osborne's ligament as far posteriorly as possible. That's not been my approach. I don't know if you've if you've taken steps like that.

Chris Dy:

I don't take that step. But when we are you'll say we've gotten the ulnar nerve isolated, which to me is the biggest part of the surgery at this point. Once we've gotten a lock and a read on where the ulnar nerve is, I tell the trainee if they're the one primarily doing the dissection that what you don't want to do is destabilize it posteriorly. So the more posterior tissue that you take, the more likely it is that that nerve is going to want to drift anterior now like you, if I indicated in situ, it's almost always rock solid going to mean in situ, because I have gotten an ultrasound ahead of time, mainly because I don't want to wreak havoc with my day. And also I want to talk to the patient about counseling because they're very different surgeries to get over, you know, an in situ even versus the subcutaneous transposition. So I typically will have them avoid dissecting excessively posteriorly on the nerve and staying really right on top of the nerve A to avoid the stabilizing the nerve, and B to avoid those FCU branches that start to come off.

Charles Goldfarb:

I think that's well said. And then we do have a couple of comments or questions coming in. You're the one who can multitask and deal with the comments from from Instagram. I'm struggling,

Chris Dy:

I can read off of my phone, Chuck. Yes, I can. So Sam, podcast friend, former guest how far proximally and distally do you release for an in situ so he says he finds himself going fairly high on the humerus with an Army Navy. And that makes me go more than three inches plus with the incision. So Chuck, you mentioned earlier you are not getting the septum out and you know, obviously the septum is not a point of compression unless you transpose the nerve. How far proximately are you dissecting? And then in terms of where your incision is placed? How much of that five centimeter incision is proximal to the medial epicondyle? Or is it mainly all at and distal to the medial epicondyle because that'll tell you how far you can get up without extending your incision.

Charles Goldfarb:

Yeah, my incision is just at the medial epicondyle, and I create subcutaneous tunnels and feel my visualization is perfect. So this the length of the incision, I don't think dramatically affects how far I decompress the nerve. And so I can access three four inches above the medial epicondyle and distal to the medial epicondyle, I still split the FCU muscle belly when we're talking about distal to make sure that I decompress that deep fascia. So I feel my access is not limited by the size of the incision, as long as I can get my senn retractors in and mobilize the skin two again max three, three centimeter incision is sufficient for me.

Chris Dy:

Do you? Do you believe that the Struthers needs to be released?

Charles Goldfarb:

I do not. Unless on preoperative exam. There's marked findings clinically there which I don't usually see. I think Struthers and again there we're talking five. I think it's the literature says five inches proximally I don't know, but it's significant.

Chris Dy:

We keep switching units.

Charles Goldfarb:

So confusing. My head hurts. I think it's eight centimeters proximal to the medial epicondyle is where we classically say Struthers is, and if there's dramatic clinical signs preoperatively that I make I probably would consider transposing. But I also think that when you transpose you put more tension on that proximal tether. So I think a decompression really is not necessary to fully release Struthers.

Chris Dy:

So then to say we were going distally we've released the cubital retinaculum, which is really the roof of the cubital tunnel and then you're getting towards Osborne's ligament which at least I understand that to be defined as the fascia that connects the proximal aspect of the two FCU heads. And I think that is a distinct structure from the cubital retinaculum. And I will release that. And as we proceed distally How do you manage the FCU muscle belly?

Charles Goldfarb:

So different people do different things? Obviously, it was why you're asking, I actually take the blunt ends of my senn retractors one or both, and I simply pull distally if you're in the right plane, the muscle separates. There's nothing to cut. I think it's incredibly safe. So you've released the superficial fascia taking care to avoid any cutaneous nerves. Now you bluntly spread the muscle you're looking at the deep fascia and I use scissors to dissect that deep fascia. How do you do it?

Chris Dy:

So I like to incise the superficial fascia that covers the FCU muscle bellies. I like to look at the individual muscle bellies and I've maybe it's because I like the I like doing it or like torturing our residents and fellows but I like to incise that rafe between the two heads of the FCU with a scalpel initially, you know not just tearing through it like you do.

Charles Goldfarb:

It is such a precise movement.

Chris Dy:

But I like doing that and then you know as that dissection progresses, taking the blunt and a senn retractor, or even just a ragnell, or a baby Army Navy, depending on the size of the patient, and pushing those FCU heads away. And that gives you free reign on that kind of deeper fascia of the FCU. Kind of almost some people will call it almost like a mesoneurium along the the ulnar nerve itself and releasing that. And I don't know if there's a right answer on how distal you go there. It's got to, most people would say about four to six centimeters is maybe even excessive, but that will be sure that you're released. And you can do that through that relatively small incision because you're working through those skin windows, and you're able to work quite distal even with a five centimeter incision.

Charles Goldfarb:

Yeah, I think the windowed approach is key you are, you can mobilize so much because you're focusing either directly posted in the medial epicondyle and proximal or distal, but let me be clear, only people who see the world as a nerve centric place would call it a mesoneurium. No one calls it a mesoneurium, except for you. It is the deep fascia of the FCU.

Chris Dy:

Sure, sure. Agree to disagree, agree to disagree. And then the biggest thing is, you know, like we talked about earlier, I think of sparing the branches to the FCU, even though you're not trying to transpose this nerve in this setting. I think one anatomic probe that I picked up is, you know, I think it was from trying to remember the classic anatomic textbook that lists every kind of variant that's out there, it's got a maroon cover. But there are some variants in which of those branches to the FCU will come in and supply the FCU and then come back up and supply the FDP to the ring and small side, I like to preserve those as much as I can. I guess that's maybe more relevant to an ulnar nerve transposition. But it's good to know that those branches if you look at the nerve as a tube over here, those branches are coming off of the side. So if you stay right on top of the nerve here, you should be safe.

Charles Goldfarb:

Yes, you should. But they're absolutely and you've seen it. There are absolutely times when those motor branches come interior. So I do now preach, be careful and thankfully knock on wood. I don't believe I've injured but when the nerves come in here, you're right. It is it is surprising, but it happens.

Chris Dy:

So basic question that might help some early trainees. Do you even set up a the setup a bovie or bipolar for this case? And what settings do you use?

Charles Goldfarb:

Interestingly, I do not set up a bovie or bipolar for a carpal tunnel release, I do for cubital tunnel decompression. And it's usually at eight to 10. The one vessel that gives me trouble is the tran- I call it transverse it's really an A to P vessel, right as the nerve enters the FCU. So when you've released that superficial fascia, and you go release that you spread the muscle, you're looking at the deep fashion, there's always that transverse vessel. And if you buzz too hot, the nerve jumps and people like you don't like that don't like it when that happens.

Chris Dy:

So do you use a bipolar or bovie?

Charles Goldfarb:

I look I'm not a nerve surgeon. I use a bovie.

Chris Dy:

Oh, no, you didn't say that. Alright.

Charles Goldfarb:

No, I hear you.

Chris Dy:

I like the ulnar nerve. But personally.

Charles Goldfarb:

I will use either. I do use a bovie on occasion. But you're right for that particular branch in close proximity to the nerve. I think I'm bipolar makes a lot of sense.

Chris Dy:

I think I know the exact branch that you're talking about. And I've even heard Dr. McKinnon talk about that as a vessel that almost acts like a bracelet over the nerve. You know, so that one is always there. And that one, if you don't get that can make your life challenging. And maybe not so much for this. But more for transposition, which maybe we'll get into in a subsequent episode is just posterior and hugging almost the floor of the cubital tunnel by the medial epicondyle. More posterior than the nerve is this cluster of vessels, that if you don't get it first, it will get you. So that's one thing to keep in mind. Mainly, if you're doing a transposition, I wouldn't be working that posterior if you're doing an insight to decompression alone.

Charles Goldfarb:

Yeah, well, we can talk about that. Now that I think that's interesting, because, you know, Paul Mansky, and originally the the Is it the macay monkeys, the study out of Boston, or maybe it was Pittsburgh, where they looked at the lack of vascularity to a transposed nerve. And so the recommendation was, you should bring vascularity with the nerve when you transpose it. And what ultimately gets you are the vessels you're talking about. Now, we have beautiful longitudinally running vessels until you get to roughly the medial epicondyle level. And then you get this this sort of plexus, but a bunch of vessels coming together, whatever that's called a flock, a flock of vessels. And you're in trouble, you can no longer take the vessels. And so that's where I use the quarter as vessels for a transposition.

Chris Dy:

So Sam is mentioning when he transposes, there are juicy vessels by the septum, perhaps a flock of vessels. Those are different than the ones I think we were talking about. So those vessels, I believe, are the ones described by Ken Yamaguchi, when he wrote that paper with Dr. Gelberman. In those branches of the inferior ulnar collateral artery are always there by the septum. And that's actually the reason why when I do a transposition, I don't have the trainees or myself. I don't take the septum all the way by the medial epicondyle, because that's not the point where you need to take it. And that's where you're going to get into trouble with those vessels. Now, I inevitably end up seeing those vessels in more detail once I you know, as part of my surgery will release the service to find the median nerve and keep it safe and out of the way. So, when I'm doing that, I want to make sure it's not hanging up there. But those are always the vessels that once you get into it, I sigh I get out the bipolar. But I'd rather stay away from them.

Charles Goldfarb:

Yeah, and they do vary. And let me apologize, guys, I'm going to correct you is this superior ulnar collateral artery, that pierces the intermuscular septum that does provide vascularity to the nerve. So I do try to protect that vessel as i transpose the nerve. But like you There are times when I get out the bovie and turn it and turn it up to deal with bleeding in that area, because it can bleed for sure.

Chris Dy:

Yeah, and with those kind of vessels, I'd rather get ahead of I'd rather get them before they get me I think the points will take in about wanting to preserve vasculature to the ulnar nerve if you're doing a transposition. But you know, there's obviously some more work that's been done recently demonstrated, you can take a substantial amount of that extrinsic blood supply to the ulnar nerve, and it can survive even without a robust extrinsic supply for a long segment. So I think that that is, you know, the literature is such where you can make it fit to whatever your preferences in perhaps we can get into the technical details about ulnar nerve transposition, which probably should do subcutaneous and sub muscular. I know that we have different ways how each of us does a subcutaneous so that would be good to dive into the next episode.

Charles Goldfarb:

Yeah, that would be fun. What's been fun about the Instagram Live is I see people come and go, like, Dr. Tarabadkar and Dr. Galvez and, and I don't know, whether they're like in the middle of a busy clinic, and they just flipped open Instagram, and they like, what's this going on? Or if they turned us on? They're like, Oh, God, I don't want to hear Dy and Goldfarb again. I gotta get out of here.

Chris Dy:

I think they all recognize what's going on here. And they cannot be a part of it. You're either with us or against us. So thank you to our hand surgery fellow from Chile. Who has a question. So let's wrap up with a question.

Charles Goldfarb:

Perfect.

Chris Dy:

Wants to ask when do you decide to release or transpose an ulnar nerve? Now the easy thing is to say go listen to episodes two, three and four. For me, oh, Niel's in clinic by the way. And so for me an in situ decompression-

Charles Goldfarb:

Busy clinic, busy clinic Tarababkar.

Chris Dy:

Hey man, you know, those those people in private practice, he's probably got 80 people lined up to see him right now. And they're all probably listening to us talk about him, he's probably walking in and out of rooms. Anyway, so for me an in situ decompression is a patient who does not have any advanced motor or sensory findings on clinical exam, so no atrophy, no elevated two point discrimination. They've gotten a nerve study that does not demonstrate any EMG findings in terms of denervation and does not have any, I will say notable loss in motor amplitudes on the motor portion of the study, they typically will have a conduction velocity drop across the elbow. And then I will get an ultrasound at the same time as that nerve study to demonstrate that it does not subluxation. And again, mainly that's so I can counsel the patient about what to expect in terms of which surgery and the recovery. What about you, Chuck?

Charles Goldfarb:

Yeah, that is a very detailed and good kind of plan, I do think each of us have to have our own indication. So that will be a little different for each of us. I agree with a nerve study. So if a patient despite the fact that the literature says and this is neurosurgery, early literature, the neurosurgery literature says that you can decompress successfully with an advanced digital nerve that has caused some EMG findings. But my personal belief is early cubital tunnel that is failed conservative treatment with an absolutely stable nerve is the perfect indication. Now, do you have to have an ultrasound to assess nerve stability? I would say no. And maybe I'm overestimating my abilities. And maybe that's a study Chris and I need to do we've talked about it.

Chris Dy:

Already been done.

Charles Goldfarb:

To assess my no one's assessed my ability.

Chris Dy:

Maybe not your ability, but the Royal ability. Somebody's already done that.

Charles Goldfarb:

And is it and what were the findings?

Chris Dy:

We are only about 30% accurate when we assess things before surgery, and an ultrasound is over 95% accurate compared to interoperative inspection after a decompression.

Charles Goldfarb:

Let me tell you how I do.

Chris Dy:

Evidence be damned.

Charles Goldfarb:

Here's how I do it for those of you who might not have access to ultrasound, how about that. So I am increasingly using ultrasound By the way, but I what I do is I flex the elbow all the way up. I put my finger on the most poster aspect of the medial epicondyle and I try to extend the elbow. If the nerve is perched that is lying on the medial epicondyle, I'll feel it under my finger. If it's anterior to me, so maybe not even truly subluxated but anterior to my posterior finger, then I trap it anteriorly and I feel it So I feel comfortable with my abilities. But I wouldn't argue with the literature. If we're not good at it. We're not good at it. And that's part of the problem. It's why you always have to be ready to transpose in case your decompression creates an or magnifies an unstable nerve.

Chris Dy:

Yeah, and I think that one thing to note is that subluxation and instability is a physiologic variant. You know, some people have that, you know, and some of the studies out of here, you know, one of Ryan's paper shows it's about 30%, or 1/3 of people have that, at least in our population here in St. Louis. So that's something to keep in mind and clearly will have implications on how you plan surgery. So this was fun. I enjoyed it. Thank you to the five people who have hung out the whole time. Live we have had a lot of people come and go, but this will be archived and you know, we'll we'll make sure to save it for everybody as well as the podcast episode.

Charles Goldfarb:

Perfect.

Chris Dy:

So one more I saw here. Sam, however accurate the ultrasound I feel like I really care about the stability of the in situ released nerve, not the pre-op nerve. Amen. I agree with you on that. That you always got to check.

Charles Goldfarb:

That is very true. Alright, have a great day. Good to see you. This was fun, with Instagram, contributing to the craziness.

Chris Dy:

Alright, have a wonderful day.

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 hand podcast@gmail.com.

Charles Goldfarb:

And remember, please subscribe wherever you get your podcast

Chris Dy:

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

Charles Goldfarb:

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