Episode 31, Season 2: Chuck and Chris introduce a new segment: The Wheel of Hand Surgery. And, the Wheel guided on discussion this week on SLAC Wrist. A bit on pathophysiology and more on treatment preferences.
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
Episode 31, Season 2: Chuck and Chris introduce a new segment: The Wheel of Hand Surgery. And, the Wheel guided on discussion this week on SLAC Wrist. A bit on pathophysiology and more on treatment preferences.
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
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:It's been a pretty good day. How you been?
Chris Dy:Doing well. I'm excited about the new segment we've got planned. I love the fact that you have no idea what's coming your way.
Charles Goldfarb:I'm a little frightened. You scare me a little bit with I'm giving up control here. I don't know if I'm comfortable with that.
Chris Dy:Yeah, I know. And this is why it's even better. Before we before we jump in, do you have any interesting reader or excuse me listener feedback to share with us?
Charles Goldfarb:I do see, you know, I was at a fellowship reunion a few weeks back, and it was fantastic. And I was asked to speak on social media. So I shared some thoughts on Twitter and Instagram. And I shared some thoughts on the podcast. And it was interesting that some people had heard of the podcast some people hadn't. A few of the people who had not heard the podcast since have logged on and listened in. So this is from one of my former co fellows. This is from Mike Dedonna, who was a year behind me. And he gave me permission to share his review. Chuck, it was so great to see you in Jackson Hole I've just completed a deep dive binge listen to the podcast. And here's the feedback I promised. The podcast is in all caps. Absolutely outstanding. You and Chris are fantastic. I love this. The two of you are unbelievably engaging, entertaining, authentic, honest, funny, and of course, extremely knowledgeable. I love the breadth of topics as well as the depth and clarity you provide on everything from patient presentation and indications to surgical techniques with great detail and specifics down to the number of sutures you use to close the carpal tunnel and love the kiefhaber box, which is what we call the retractor placement for the carpal tunnel, as well as discussion of complications therapy and everything in between. I've gotten my whole team to listen, with one caveat. They can't move to St. Louis, to join you guys. You're that good. Congrats to you. And Chris, thank you very much. And so Wow, Mike, that is really, really nice. We appreciate the kind words.
Chris Dy:That's, that's awesome. And you have now managed to mention that you did the Stern fellowship at least four times in the last four episodes. That is fantastic, great fellowship. We're very thankful to Dr. Stern for training. An incredible number of amazing hand surgeons. Well included.
Charles Goldfarb:It's interesting it I'm trying to feel young by harking, you know, back to those days, but it is amazing. You know, when you think about your legacy, what does that look like? Is it the patients you treated? Is it the articles you wrote? Or is it the people you touched and educated? And I think the older I get, the more realize I realize how impactful that process is. Looking in that room with all of those former fellows, it was really meaningful.
Chris Dy:Well, that's, that's great. And you know, perhaps we should get Dr. Stern on at some point just to talk about that topic.
Charles Goldfarb:I would love that. And he would love that I feel confident you would know better than I given your close podcasting relationship with him.
Chris Dy:Yeah, he's he's part of the side gig, the side gig's actually resuming again in October. So First Hand is coming back in October. We hope it's been long enough that you've missed us. And we're excited about that.
Charles Goldfarb:You've been renewed congratulations.
Chris Dy:It was it was a competitive process. So So here is our new segment. It's called we'll have hand surgery. So it speaking of engaging our listener community the topics for this we'll have hand surgery have been submitted by the current medical student on my rotation Ruba Socrab, who's going to be doing her away rotation at the University of Michigan shortly so anybody up in Ann Arbor look out for her. She's fantastic. Noel Palumbo current pgy three resident in orthopedics here at Wash U and Lauren Wessel current outgoing hand fellow here at Wash U so Chuck, six topics on the wheel of hand surgery, very high tech, six posts in a circle. Okay, so what I'm going to do is I'm going to spin a pin and whatever side whatever topic we fall on, we're going to talk about for 15 minutes.
Charles Goldfarb:Perfect. I love that. While you're about to do that, I do want to say that I looked at our reviews online and we don't we don't this is totally totally side gab I'm not just demeaning your wheel of hand surgery, but I do. I do want to say that I was reviewing the the questionnaire we asked listeners to fill out if you haven't done that, please do it. And they they were very clear that they liked the nerve talk. They want more sports, they want more technical, so we're going to do that but I also wanted emphasise that the mugs are coveted and there are people that really want our mugs. So we're going to send a mug to people who send in questions that we answer on air. And I'm going to send Mike a mug for his generous review. So sorry, Chris, I had to get that out. You know, I'm old. I forget things. I have to say it when it comes to mind.
Chris Dy:And I did want to say, Shohbit you're not getting a mug until your papers published. There's that current fellow class is dying to get mugs. And you know, Jeff Stepan you're finally getting your mug and we can't wait to have you back. So um, and oh, Micah Sinclair, we should get you a mug too. Anyway, so on the wheel of hand surgery.
Charles Goldfarb:Chris is being generous today.
Chris Dy:Micah listens every week, and we co chair the Government Affairs Committee for the for the hand society. She does great work. So I think she's earned what she has to work with me on a committee. So
Charles Goldfarb:Amen. Thank you Micah.
Chris Dy:The inclusion criteria are expanding. So let's see here
topics are:favorite instruments slash preference cards, preparing for new or unfamiliar cases. Didn't see that coming. And I'll elaborate more as that comes up. SLAC wrist. Never have I ever, and networking. So I'm going to spin this and I just want to know before I spin it, which topic Do you least want?
Charles Goldfarb:I think they're all fine. I'm willing to tackle any of them.
Chris Dy:Alright, here we go. Spinning. SLAC wrist, of course, the only clinical topic, but we can get into some technical stuff. So on this wheel of hand surgery, slack wrist is being removed, and shall be replaced by a new topic. It will be sports, I promise for next time.
Charles Goldfarb:Perfect. Well, this is great. Because those of you who can't really envision what this beautiful wheel looks like, just join us on YouTube, you can actually see it on our zoom podcast.
Chris Dy:We've been slacking on the social meaning I have been slacking on the social, I will post a picture of this amazing we'll have posted. But so this is what happens when you don't get your sports surgery on and, you end up with a slack wrist. So, Chuck, so let's talk about SLAC wrist. So how often does this actually come up? And what's the classic story? For a presentation of a patient with a SLAC wrist?
Charles Goldfarb:I guess I would, I would say it's a bi modal age distribution. And I use that term just because I wanted to work that into a sentence. There's there's the youngest-
Chris Dy:There's the Chris injury and the Chuck injury.
Charles Goldfarb:Fair enough, although I might spread us apart a little further.
Chris Dy:I will probably Yeah. Okay.
Charles Goldfarb:So maybe there's someone my age who fell a year and a half ago, had some wrist pain and went away. And now that wrist pain has come back with a vengeance. And then there's the patient who's 65 or 70, who comes in with wrist pain. And to me, it's super interesting, because you don't need an X ray on that 65 year old. You can look at that wrist and know what the diagnosis is. But I think for me, there really are two populations.
Chris Dy:So I think I know what you're talking about in terms of what that wrist looks like. And it's always that wrist that's just like a little swollen in the right spot. And it hurts, obviously, I mean, looking just looking at it, you can tell but you know where it's gonna hurt. You know, how do you do you ask them if they had any trauma in the past? Do you? Do you buy the story? Do you? I mean, do you believe them? Because most people don't know?
Charles Goldfarb:Yeah. So again, just just to make sure we are crystal clear. We don't want to be obtuse, but dorsal radial swelling at the radioscaphoid joint and point tenderness there is the tip off. But again, you can see it just by looking at the wrist. I always ask, I don't know if it matters, I guess it's just part of the discussion. But I always ask, do you?
Chris Dy:I do just to see what happens. I don't believe them. I actually, you know, this patient came in to see me recently one of my recent clinics. And you know, I immediately knew what was going on and was very curious to see what the X ray was going to look like. And lo and behold, it was a, you know, already a SLAC wrist. So for the listeners who are earlier on in training, let's talk through the progression of a SLAC wrist. So you have an injury to the SL ligament which leads to some element of instability. And eventually because that link between the scaphoid and lunate is no longer intact. The scaphoid will flex. So what happens there, Chuck in terms of you know, the contact pressure is yada yada yada?
Charles Goldfarb:Yeah, I think we could go deep we could go deep dive into the biomechanics of how the carpus works, but I think you said it really well. Without that scapholunate ligament the scaphoid is going to flex. When the scahpoid flexes the pressure between initially this styloid of the distal radius and the scaphoid waist, and subsequently, the proximal, more proximal distal radius and the more proximal scaphoid, the contact forces increase. And because that's not the regular load bearing pattern, and you get arthritis there.
Chris Dy:So maybe just for completeness sake, when we replace this on the wheel, we'll put scapholunate ligament treatment and go a little more into that. But let's say that ship has sailed. It's an irreparable ligament and you've already developed arthritic changes. How do you what do you tell that patient? You know, I tend to kind of give them you know, hey, this process has already started. We can't cure it, we can treat it but we can't cure it. I typically will start them with a brace and a steroid shot and a steroid shot if their pain is real bad at that point. Do you offer anything different than that right away?
Charles Goldfarb:No, I think that's exactly right. Because you can make a patient dramatically better I, I will say, I'm not one to give steroid injection after steroid injection after steroid injection, because I do believe there are negative consequences when you are potentially salvaging some of the articulations of the wrist. And so I think a single injection with the offer of a split works great, and give the patient a chance to see if they like it if they can work with the splint, and it solves their problem, either temporarily, or more long term. And if they fail that, then we have options. We have good surgical options.
Chris Dy:So but what do you you know, if you're putting in steroids, and you say you're doing some surgery down the line that preserves some elements of wrist motion? What are you trying to save? Really? Because I mean, if you're assuming your steroids in the right place, you're not really affecting the mid carpal joint. You know, so are you saying it's, it's the impact on the radius cartilage itself?
Charles Goldfarb:Yeah, I think they're, I mean, again, I don't know the science like some listeners probably do. And some scientists probably do. But I think it's pretty clear that repetitive steroid injections have a negative impact on the cartilage. And so the radiolunate joint, if you're going to consider, you know, scaphoid excision and four bone fusion, or we know that this gave when the ligaments intact and so the the steroids will migrate to the mid carpal joint as well.
Chris Dy:So what's what's your current thought process on procedures other than a four corner or? Or PRC? Do you see any role for like radial styloidectomy at all? Like, how does that or even arthroscopy some might argue?
Charles Goldfarb:Yeah, I mean, I guess it depends a little bit on the severity of the arthrosis. I mean, if you catch something really early, a scope in my mind has a role for confirming the diagnosis maybe. And I don't really believe in the whole cleanup procedure in this situation, although some might advocate for that as buying time. I don't do a lot of radial styloidectomies, you know, those can be done arthroscopically or open. I think they're pretty straightforward. There was a ton of research done in years past, especially after government quantifying what type of osteotomy made sense what angle the osteotomy was to protect the ligaments? I just don't do many in 2021. Do you?
Chris Dy:I don't thank you for triggering me. Just the insert the origin of the radius gave a cavity ligament so okay. Well, I guess in the short time that we have left in terms of the technical aspects, you know, how do you decide between whether you're going to offer a PRC or four corner fusion?
Charles Goldfarb:Thank I do it. Well, first of all, the literature has become more clear, right? the PRC is better, it's less revised, it's less expensive, patients are equally happy. And most of us like the PRC, I probably do more four bone fusions than I do PRCs. Having Having said that, of course, you know, everyone's like, what the heck is he talking about? I think they're both good options. I really do.
Chris Dy:So an interesting thing, I saw a patient as a second opinion very recently, who had a very straightforward issue, and was recommended to have a PRC by somebody else, and came in and was like, That just sounds ridiculous. So how do you explain this procedure to the patient of we're going to treat your arthritis by removing an entire row of bones. I mean, clearly, we have to have that conversation for thumb CMC surgery, but just seems weird.
Charles Goldfarb:It's a hard sell. So my hearing my conversation goes like this. If I'm selling a PRC, so you have this significant arthritis, we have to get rid of this arthritic bone. And thankfully, we can use other bones to support your wrist. There's an operation that's been around for 100 years, anything that's been around this long has got to work. And, and I draw a little picture, a terrible picture, we laugh at my art, and then I explain what we're going to do and I explained that I trust this procedure and usually that that convinces them. Are you sold?
Chris Dy:I love it. I'm learning here. This is great. So then how do you how do you sell the four corner fusion?
Charles Goldfarb:I do tend to use this stereotype if that's the right word for four bone fusions in that I think it does maintain carporal height, I do believe it probably has some advantages from a strength perspective, and it maintains more normal anatomy. And so for the patients that either a are freaked out by the PRC, or B, or a little younger and higher demand, I think the four bone fusion makes sense. And I do still perform a four bone fusion, you know, the concept of just fusing the the capitolunate joint has become a little more in vogue lately. But I like the four bone fusion and I still do it.
Chris Dy:So are you also taking down, you know, the side to side articulations? Are you just doing like a two bicolumnar kind of fusion?
Charles Goldfarb:Yeah, I like- That's a great question. I like that, I tend to really address the two mid carpal joints, so the capitolunate joint I decorticate. And I fuse that one. And I also fuse the joint between the hamate and the triquetrum. In a perfect world, I have two screws, one going from the lunate into the capitate and a second going from the triquetrum into the hamate into the capitate. And I really liked that. And I've been very pleased with the results that I get from that.
Chris Dy:So we were on our travel club meeting via zoom recently of the the younger generation of hand surgeons. And we were discussing this very topic and you know, I felt like an outlier. Because there are some of my colleagues are using plates more and feeling more confident in moving them earlier on with the plates. And you know, saying that, you know, there are some reports of construct failure with the type of construct that you just described that I use regularly with early motion. So, you know, if you could do four corner or four bone bicolumnar kind of fusion and move them early, would they you think that would make a difference in terms of the evolving literature between PRC and four bone fusion?
Charles Goldfarb:I fundamentally I don't believe that it's going to increase motion dramatically in the long term, it might make life a little easier in the short term. I guess the question is, would you trust your plate and screws in the lousy lunate bone? That's that's ultimately to me the riskiest issue, the lunate bone is not healthy, it's small. And we're trying to make sure it fuses because that is the key to the whole operation. So I respect that people are doing this, I don't feel a strong need to investigate it, I guess, is my response.
Chris Dy:And then the other. The other thing, I think that it's challenging about these sometimes if if it was getting the lunate correction, and getting the lunate correction, but then also being able to get your screw in the right position in the lunate because essentially, you've you've taken down the mid carpal joint, your capitolunate joint's taken down, you're having to flex down, essentially the wrist to get that lunate in neutral posture. But then also get your screw kind of in the center of the lunate, you know, volar to dorsal. Do you have any tricks for that because you know, whatever, you know, I tried to do that it's it's a little more challenging just because you end up flexing your wrist, but then it made carpal joint opens up and I try to keep it close. But it's challenging sometimes.
Charles Goldfarb:Totally agree. And it can be really challenging. I would say a couple of things, just to make sure we're following up on the biomechanics, without that scaphoid to tether the lunate, the lunate tends to go into DC. So it dorsal flexes. And so our goal with the surgery to create the greatest arc of motion is to get the new lunate neutral at the fusion site with the capitate. And so what I do is I decorticate everything, I flex the wrist, and sometimes I have to release that volar lip of the lunate, but I flex the wrist and to get the capitate and the lunate lined up, I place a six two K wire securing the capitate to the lunate and then I can put the wrist wherever I want to put my screw and I've been really happy with that technique and always start there and then go to the other joint for fusion later. So I like that I think it's probably easier putting a dorsal plate on in some respects for that very reason. But I hadn't been a huge impediment for me with that technique.
Chris Dy:And for your ulnar sided screw separate incision work through the same incision. If you're in a separate incision, how do you avoid, you know, the dorsal cutaneous branch of the ulnar nerve as as as it's coming from volar to dorsal?
Charles Goldfarb:Yeah, I'd be interested to hear what you do. I do make a separate incision just distal to the ulnar styloid I find the nerve or nerve branches and free them and then go right for that triquetrum to place the K wire and then the screw. What about you?
Chris Dy:I do the same. And it's funny because I did that. And that's how I remember learning it from from Ryan Calfee when I was this fellow. And then I was teaching a fellow to do I was like, Oh, this is how Dr. Calfee does it too. And they're like, Oh, no. Dr. Calfee just does it through the dorsal incision and I went for and I'm like, What the hell And he's like, oh, yeah I changed.
Charles Goldfarb:You can't just change.
Chris Dy:I guess, you know, and he's like, it just made more sense to me. So that's good.
Charles Goldfarb:So let's say you have do it. Well, I just put it out. There's a question in a classic SLAC wrist. Do you ever consider a complete wrist fusion? And do you ever consider wrist arthroplasty?
Chris Dy:I think I have a higher threshold to consider wrist arthroplasty. Just because I am not as well versed in if I have anybody that's interested in it, you know, I have a general sense of appropriate indications and, you know, expected outcomes I'll send them to Marty. Since Marty Boyer, our partner does that for our group. Although I admittedly want to learn more about it and then you know, total wrist arthrodesis I've done one for a SLAC wrist because it the wrist honestly looked really beat up on the X rays and I had some concerns about the lunate the radiolunate joint. So I ended up offering him a one and done surgery and we did a wrist arthrodesis and very happy.
Charles Goldfarb:I agree and disagree. I agree that there are certain patients that I think a wrist arthroplasty makes sense for. But for those patients, I have no interest in learning how to do a wrist arthroplasty and I'm happy to send them to Dr. Boyer. But it is an older lower demand population. There is another group that has very high demand and very bad arthritis and a formal wrist fusion a complete wrist fusion makes sense. And so I do think those two operations come into play although the vast majority of by SLAC wrist patients are treated successfully with either a PRC or a four bone fusion.
Chris Dy:Fantastic. Thanks for playing Wheel of hand surgery. I will replace SLAC wrist with some other sportsy kind of topic and we'll go from there.
Charles Goldfarb:Alright, so listeners if you like the wheel, let us know if you think it's silly. Let us know. Have a good one.
Chris Dy:All right. You better like it.
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 podcasts.
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.