Episode 32, Season 2: Chuck and Chris revisit the Wheel of Hand Surgery. The spin of the wheel generates our discussion and this week we talk 'Never Have I Ever'. Tune in to learn about dogma, what we do in practice that the literature may not support. Including tennis elbow amongst other topics.
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 32, Season 2: Chuck and Chris revisit the Wheel of Hand Surgery. The spin of the wheel generates our discussion and this week we talk 'Never Have I Ever'. Tune in to learn about dogma, what we do in practice that the literature may not support. Including tennis elbow amongst other topics.
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:I'm good. Thank you. How are you?
Chris Dy:Oh, just saying that you've got a little peloton swag on right now.
Charles Goldfarb:This was my birthday present this year. I'm not a big gift. I like to give gifts I don't always you know, I don't need to receive gifts and I'm not the peloton master that you are but I do enjoy a good peloton.
Chris Dy:Was that a? Was that a subtle hint by somebody that you need to get your ass on the bike or?
Charles Goldfarb:No, you know what's happening is because I currently don't have a car because of an adverse event on the road.
Chris Dy:Car misadventure as they say.
Charles Goldfarb:And I do have a car on order but it's gonna be a while I am biking a lot to work. And I have to say I am enjoying it. Although biking in the dark in the morning is not my favorites. And so I've been on the peloton a lot less lately.
Chris Dy:I will say that terrifies me. As you mentioned in prior episodes, I know we have some listeners shout out to Sam Moghtaderi who biked to work. But that that terrifies me to do that on a regular basis.
Charles Goldfarb:But you are in a good spot too I mean, you can really just go through the park, but we're getting off top.
Chris Dy:Yeah. Well, you know, I think that it's kind of you know, it'll depend on the day. You know, sometimes there will be days that will allow that to happen. And other times not. We'll see. We'll see.
Charles Goldfarb:You have other issues too, which is little kids running around the house, I just get up and go. So less encumbered, so to speak.
Chris Dy:So we have another great review. So thank you to everybody the reviews are pouring in and we love it. We will say the last episode, we read a review and answered a question from Matt, medical student at Mayo. Matt, if you're listening and you want a mug, send us an email. We don't have your email address and address and all that kind of stuff. So handpodcast@gmail.com to collect your mug. And when we were talking about dishing out your mug, Chuck was like Well, let's see if he really listens. That's your first Chuck Goldfarb WashU test.
Charles Goldfarb:Absolutely. And then we'll get in touch with our shipping boy. Oh, that's me. That's me. I'll get that out real quick. If you
Chris Dy:I don't know if you guys realize the imbalance of labor here between me and Chuck the podcast editor slash I don't I never heard this term shipping boy.
Charles Goldfarb:Well, shipping boy is a derivation from one of my previous non hand surgeon duties which was belt boy. So let me explain what that means. And this is a subtle or not so subtle plug. So my wife has an incredible business called myself belts. We should have her on as a guest. Maybe or is that awkward anyways. Anyways, myself belts is a one handed belt, which she developed and patented and started a company around many years ago, when my oldest was potty training and could not keep his pants up. And so the belt business has been great. She was on Shark Tank. It's a really interesting story, I think objectively, and so early on, she would go to the lake during the summer. And that's when there weren't a ton of belt orders. But I would come home every day after work, and there'd be 10-12, whatever orders and she would say okay, let's you know, we'd be on the phone, maybe not even cell phone back then. And, and I would ship belts. And so you know, it was kind of satisfying, you kind of just get the work done. But I got tired of being the beltboy.
Chris Dy:I'm pretty I'm pretty sure that the belts were shipped with maximum efficiency shipping two belts, it's staggering the room so that the belts were shipped appropriately.
Charles Goldfarb:Excellent point.
Chris Dy:Never overlapping but perfectly sequenced those belts.
Charles Goldfarb:Well, the problem was, I would go down, we had a little belt storage area and I'd go down to the belt storage area because I wasn't, you know, in that room every day, I didn't know where they all were because there's multiple different styles. And so I'd called Talia, cursing about where's the where's the sailor belt or whatever. And she would laugh and we would yell at each other. It was great. Good times.
Chris Dy:Yes, the old days. So yeah, I think that would be great to talk to Talia. I've always wanted to talk to her about her Shark Tank experience. I think that is such a relatively unique, you know, not many people know somebody who has who has been on Shark Tank. So that's pretty awesome. And maybe if you recall off the top of your head the episode, we could point our listeners to it at some point.
Charles Goldfarb:Yeah, no, it's season six is all I know. It's brutal. Let's just say I'm not a fan of all of the judges. The teaser, though, is if you're a shark tank fan, and many are Mr. Wonderful is a good guy. He plays a character for reality TV, and it is reality TV, but it's kind of hard to watch. But she got a deal not to be a spoiler. So all ended well.
Chris Dy:So we have a great five star review from Mark Grayson. So thank you, Mark. Terrific podcast, guys. I just graduated from the UCLA hand fellowship and wanted something to listen to, on the long drive to my first job in Colorado and what a find. So thanks for finding us and good luck with that job. I crushed about 15 episodes and enjoyed your thoughtful insights and good humor. And I almost felt like many of the episodes were tailor made for someone in my shoes. I will be tuning in regularly. So awesome.
Charles Goldfarb:That's that's really nice. And I say congratulations. I don't know, there's a lot of jobs to be had in the state of Colorado, given how popular it is. So congratulations and enjoy it.
Chris Dy:Yes, yes. Enjoy the enjoy the new job. Good luck settling in and, you know, as questions come up, if they do in your practice, and you want to, you know, kind of talk to Chuck about it, because he's the seasoned OG send us an email hand podcast@gmail.com
Charles Goldfarb:Yeah, please do please do we would look forward to it. It keeps it lively here. Because you the listeners have different challenges and different questions. And Chris and I do we live in a somewhat insulated environment. And we like to think we know all about different practice environments and practice challenges. But the reality of course, is that we do not. So write us.
Chris Dy:Yes. And feel free to address your questions to shipping boy. So today, Chuck, we're back with the wheel of hand surgery.
Charles Goldfarb:We're turning off listeners left and right.
Chris Dy:Oh, no, no, I will read a comment that we have at some point from a listener who loves the wheel of hand surgery, and actually requested that we filmed a segment little audio segment based on the wheel of fortune, you know, where people are chanting wheel of hand surgery. So if anybody's listening wants to contribute to that we can mash it up. It would be great. I'll get my editor on that one.
Charles Goldfarb:That would be me. unlikely to happen. But if there is a tech savvy audience member that is definitely mug worthy.
Chris Dy:Yes. Oh, that would be great. That would be great. So if you remember we have our wheel. And for those of you watching on YouTube, here is the high tech wheel, incredibly high tech. So we did replace one topic that we covered last time we covered slack wrist, so that went by the wayside, and we've replaced it with the sportsy topic because I know that's what you and the listeners supposedly want. But we have topics here that have been contributed by former fellows Shohbit Minhas. So thanks Shohbit if you if you still listen, I know you listen before the fellowship and during the fellowship we'll see if you listen after the fellowship. And Lauren Wessel and Ruba Sokrab as we mentioned last time have contributed to this. So I'm going to spend my pen on this again high tech and we'll go from there. No, no, I'm not closing my eyes. I can't find the pen and close my eyes.
Charles Goldfarb:I don't know what all the topics are. I couldn't see.
Chris Dy:Alright, so let's Okay, so again, the topics to review, networking, favorite instruments slash preference cards, prepping for new cases as we kind of alluded to last time. Didn't see that coming. Acute SL injuries and Never have I ever with blank.
Charles Goldfarb:Guy there's certain ones I'm hoping aren't picked in this wheel of hand surgery.
Chris Dy:What do you what do you what I haven't spun yet? What do you not want to discuss? Because I'm having like communicate with my wheel saying pick that topic.
Charles Goldfarb:Never have I ever I'm just not sure where to go with that one and didn't see that coming kind of violates one of my internal credos of Don't be surprised, but, you know.
Chris Dy:Well your your the fellow that was with you on your service at the time of creation of the wheel is the one who picked that topic. Alright, here we go. I will close my eyes spinning the wheel. Okay, so it's kind of in between. I think it's more Never have I ever wait I'm actually gonna take a picture of this. So that we have
Charles Goldfarb:Perfect, I need evidence.
Chris Dy:proof. And hold on a second Quick Edit here. And I will show this to you. Can you see? No, probably not.
Charles Goldfarb:Not really. No, you can, hard to see. I trust you.
Chris Dy:Alright, so Never have I ever with blank. So what I meant with this was what are the things that are considered taboo in practice, you know, save for common conditions. And this came from one time where we were on Twitter and we were talking about what we do for tennis elbow. And people were talking about whether they do steroid shots, whether go to the OR, PRP, all this kind of craziness. So I guess there are a few topics we could address here. Can you think of anything that in your practice that you don't love to truly fess up to, but you actually end up doing?
Charles Goldfarb:So these are things I do that maybe I keep on the down low, or things that I don't do, because I really object to them.
Chris Dy:Either one, but probably more the first, this is the insider knowledge.
Charles Goldfarb:Sure. And this is not the-
Chris Dy:Stuff that stuff that's maybe considered taboo in the literature, but you're like God, it works.
Charles Goldfarb:Well, I think just building on what you already said, this probably is not going to come off as controversial, but it does violate my reading of the literature, is I do give steroid injections for tennis elbow, I will say that they are never my first choice, I always send patients to therapy. And let's be honest, therapy may work. But I'm not sure if it's therapy or just time, and I send patients away. And if it three months, or six months or longer, they still have symptoms, they are really unhappy. They're asking me to do something, I certainly don't want to go to the operating room. And so I offer a steroid shot. And as we all know, there are times when it's a home run, I warn patients that it's likely to come back, and they should use their pain free interval for stretching. And I warn patients, they could come back worse. But I don't lose any sleep over that decision. And I don't know what your reading of the literature is, and what your personal practice is. But I'd be interested to hear.
Chris Dy:Getting into literature is that it's time and that. I don't know if it's the steroid shot, or the fact that something is being injected. Because there are plenty of papers and high level studies showing that injection of a placebo is effective. And I don't know if that's again, the fact that the psychological benefit of somebody is doing something to you. Or maybe it is hydrodissection. You know, maybe that is useful. And I don't really know, I have given more I tried my hardest when I came out in practice to follow the literature. And the literature has really piled on to the fact that it is time. But that's a really hard discussion to have with a patient because, you know, tennis elbow sucks, like it is a condition that is bothersome in every aspect of your life. You know, the only time I'm not old enough like you Chuck to have tennis elbow. But the only time that I had was close to tennis elbow was a substantial amount of yard work one weekend, and I was like shit, this would really suck if I had this condition. So I don't know. I mean, I think that I tried very early on not to do things like steroid shots and not to operate. But I give steroid shots now, but I still feel weird about it.
Charles Goldfarb:I absolutely feel weird, feel weird about it. I absolutely discussed the literature with the patient, it makes it feel more appropriate to me if I share why I'm hesitant, because most people come in saying, Give me a steroid shot, please. And I talked them out of it. And most people are minimal to that to start. That's the benefit of being older and we could do an episode of On on all my ailments like tennis elbow. If that's interesting to the audience, let us know, my wife would definitely not tune in. What about-
Chris Dy:Talk about reality TV.
Charles Goldfarb:What about PRP? Or what about dry needling? What about do you send any of your patients to our partners or anyone else to consider such injections?
Chris Dy:So I think that if anywhere in the sports, orthopedic, musculoskeletal world, there is a suitable indication for PRP, it is tennis elbow. I think there are a number of studies that would support that. I have I think I saw one patient for PRP one time, because we actually in our department do have, you know the setup to do that. It's just honestly, it's expensive. And most patients don't have the means to do it. Because at least my impression of it right now is that it's not typically covered under most insurance plans. Do you have any thoughts on that you're a little closer to that in terms of the finance part of it than I am?
Charles Goldfarb:Well, we first of all, we we should do an episode on alternative treatments and some of the challenges in the St. Louis Community and in all communities I know about charging patients for unproven therapies. It's really super interesting the FDA is I don't want to go down to go down the rabbit hole but the FDA is gonna come out with some recommendations about this and there's some really, you know, concerning things that go on, I think PRP is very reasonable for the patients that I can't get better with We are lucky that we have Dale Colorado doing injections and trying to create a center. And for appropriate use alternative therapies, and he's done a great job with it. And I think that I feel very comfortable sending my patients to him, one to be evaluated for appropriateness, not just a knee jerk reaction, and to to do it under the under the guidance of the best literature.
Chris Dy:Well, I mean, you said, you know, unproven therapies, I guess I would probably not put PRP for tennis elbow in that category, that would put it in the alternative treatments category.
Charles Goldfarb:That is totally fair. And I didn't mean to convey that there are lots of other things going on out there that are unproven. But you are correct that that is not, I think PRP is, you know, a reasonable approach.
Chris Dy:So where does this fit in your algorithm, you know, for injection, and then maybe PRP and then surgery or who skips the PRP? I mean, how routinely Are you recommending the PRP and then how many injections before you consider surgery for this condition?
Charles Goldfarb:I will I'll share my algorithm without great confidence. That is the algorithm may not have great comments and other things that I do. But I would say that patient walks in, he or she may have six or eight or 12 weeks of discomfort, I recommend one visit to therapy. I go over some things myself, I let the therapists go over things I talked about activity modification, supinated lifting, and lots of stretching. I asked him to come back eight weeks after the first visit, for a reassessment, if they are not getting better, if they are getting better, I tell them to come back if they need me. If they come back, and they have failed therapy, and they're not making any progress whatsoever, I will do a steroid injection. And I typically only offer one however-
Chris Dy:Do you bring? Do you bring that injection up? Or do you let them bring it up?
Charles Goldfarb:On the first visit, I bring it up to explain why I'm not doing it. It's pretty rare that people walk in not knowing about this steroid injection option for tennis elbow in my experience.
Chris Dy:And then if they if they've already done, quote therapy, do you investigate further as to what they've actually done? Or ask the therapist that's with you and clinic collaborating with you? Do you ask them to investigate more? Or do you give them a pass and give them credit for having done therapy.
Charles Goldfarb:Depends on the patient, but I absolutely try to learn more about what they have done. And again, it's a I want to say a negotiation in a bad way. But I'm not going to let this turn confrontational. If a patient comes in feels that they have done therapy, and are asking for something more and a wrist brace hadn't worked and a counterforce brace hasn't worked. You know, what else do we have to offer? I don't think I'm doing harm with a single steroid injection, I do think we can do harm with multiple steroid injections. But I don't think it's some great crime. And I think there's a chance you knock it out of the park with a single steroid injection.
Chris Dy:So where you'll do one steroid injection, and say they come back, I don't know, two or three months later, they got some partial relief, but it's still nagging them and still bothering them.
Charles Goldfarb:I do investigate on to whether they did use what I call a pain free interval to work on therapy exercises and stretching and strengthening. And if I'm comfortable with everything, I probably discourage a second injection, I will admit I will do a second injection, I will not do third, fourth or fifth injections, unless circumstances are highly unusual. But that's when I start talking about the other options out there. Surgery being one option, PRP being another option, but I wouldn't think about surgery for most patients to at least six months of failed intervention.
Chris Dy:Do you bring up PRP, in terms of you say, here are the other options? And how do you tell them about PRP and also balance that with the estimated cost that comes with that?
Charles Goldfarb:I just lay it out there I kind of briefly describe that it is supported in the literature, at least somewhat, that we have one of my partners does it although you can also get in the community. It is out of pocket because insurance companies don't buy in. And it's just another choice. And for some patients, they've heard of it and it resonates for other patients, they have no interest in paying significant out of cost dollars for a treatment that's not you know, frontline, so to speak, at least for me. It's not my line.
Chris Dy:So, imaging. Are you getting an MRI at this point?
Charles Goldfarb:No. It you know, as long as everything else lines up. I don't I want to say I don't think my I don't think my treatment has ever been modified by an MRI in the situation because some patients you know, work comp will get the MRI or they'll demand an MRI and again, if I think there's potential I don't always find it. I don't think an MRI has ever changed my treatment. You know, there could be problem with the extensor mechanism that can be a political rupture of the extensor. It doesn't change my treatment.
Chris Dy:You know, in terms of the Never have I ever realm, I have acquiesce to patients who feel like some imaging would be useful for them, even though I know that it's not going to be useful. And I again, like you're saying like the literature would support not getting any additional imaging, and certainly from a societal cost level, not getting in addition, additional imaging will be useful, but not wanting to get into a confrontation with a patient, I try to stand my ground, I tell them the reasons why. But in some patients, it's they really, really want it and I will admit, I give in some times.
Charles Goldfarb:Yeah, look, I mean, we would it would be interesting to see if our payer model was different, whether we you and I would give in, I do often negotiate and say, Okay, let's give therapy six more weeks. And if you're really not turning the corner, call before your visit, we'll set up an MRI and we'll go from there. So I do try to push it out and potentially make it disappear. But let's be honest, tennis elbow is not a complex diagnostically. And people like you and me are a diamond doesn't mean there are lots of providers out there that will take care of a patient with tennis elbow, and I want to take care of patients, I want them to value our practice. And I want to have a good relationship. And there are people listening, a few at least two will shake their head and disapprove of our choices here. There are many others where I believe this is how they would approach it as well.
Chris Dy:I think if we you know, you mentioned this bit, but I mean, if we were in a bundled payment for tennis elbow, I think there would be much more streamlining and how we took care of these patients. But reality is we're not in a bundled payment for tennis elbow. And I think there's a lot of nuance in how you manage some of this just mainly getting the patient through this process. And like you're saying, the longer you kick the can down the road, the more likely the patient will, quote, regress to the mean, as many of the papers have said.
Charles Goldfarb:Right. All right, so we got to do a Never have I ever for you, what is something that you do? Although maybe cover your eyes when you do it?
Chris Dy:Um, I will. I don't know, this isn't that isn't that taboo, but I will denervate for tennis elbow. And I think we talked about that a little bit. So that'll be one thing I'll give you for tennis elbow. And then I will you know, if I have a patient in whom I have done a trigger finger before the trigger finger will on surgery, I will let them skip the steroid shot, if they've already loved their surgery, and honestly, a lot of times they tell me that the WALANT surgery hurts less than the steroid injection for a trigger finger. So I will allow them to bypass the, you know, the traditional, I'll give you 1234 steroid shots for your trigger and just go straight to surgery because I feel very good about the predictability of that surgery.
Charles Goldfarb:Well, for your second one, I don't think that's crazy at all, patients. Many patients do not want to go down the trigger finger injection path again, especially if it has led to surgery and other fingers. And so I agree with you, especially office based trigger release. But even if it's in the OR, I don't think that's crazy at all. I have zero experience with your other point which was denervation for tennis elbow. And I know we've discussed it before. So again, I don't go hunting here having your head in shame on that one. Remind me exactly what you do for that. I'm curious.
Chris Dy:So, you know, Delon described, I think it was in journal of hand surgery late 2000s, probably around the turn of the decade. And while the last decade, the 2010s. So there is a small cutaneous branch coming off of the radial nerve that you can find pretty reliably. Some people actually describe that branch when you're finding the interval for a for an anterolateral approach for radial tunnel release. So that puts your cutaneous nerve in the forearm that sits between the BR and ECRL. That will oftentimes also provide a branch to the lateral epicondyle. So if you keep tracing that nerve up, you will, you'll see where you can denervate it. So that in the you know, the paper has some very interesting kind of anatomic maps. So I think that that is useful. I find that branch, I actually will send them for an ultrasound guided injection of that branch to see how they feel about it. You know, and usually this is for like the recurrent case, maybe a failed prior tennis elbow surgery, which we could talk about too. And I have an like we mentioned before, I have a low threshold to release the radial tunnel. And again, probably the longest kind of can't be Never have I ever. I like doing that surgery and I think that for these patients you want to be dun dun dun. So my predisposition towards addressing the nerve issues has led me to pretty much in most tennis elbow cases, you're not getting an isolated tennis elbow surgery with me you're getting a tennis elbow radial tunnel release, and in some severe cases, the deactivation. So I cut that branch going to the lateral epicondyle, and I bury it within the head of the triceps, tuck it into the triceps, very loosely close the opening and the muscle with a 3-0, monocryl on each on each side, not to create a point of compression, of course, just to make sure it doesn't displace, and then I'll tuck it in with some fibrin glue.
Charles Goldfarb:Interesting. Yeah, I got like I said, zero experience with that. I don't see tennis elbow surgery the same way. Although again, my results are not perfect. So maybe I'm missing the boat here. But I will absolutely perfect. First of all, I don't do many tennis elbow surgeries, it is definitely less than five a year. And I see a fair amount of tennis elbow. And if I do five tennis elbows a year, probably two are with a radial tunnel. And those are patients that have in order to pain over the radial nerve or regular tunnel, I guess I should say, as well. And so I will do is a tennis elbow if there's no radial tunnel pain.
Chris Dy:Conversely, do you do isolated radial tunnel?
Charles Goldfarb:I do? Yep. Yep. Again, super rare. Again, a couple of year, I would say at most.
Chris Dy:I feel like you know, if you're doing an isolated radial tunnel, it's just so easy to do the tennis elbow part of the surgery to and in most of those patients, they have just some elements of that anyway. So admittedly, I will probably end up doing, you know, the tennis elbow part. And to me that involves, you know, debridement and sometimes tenotomy of the ECRB as it comes off at a lateral epicondyle. Is that how you approach it? Or do you do it differently for the tennis elbow part?
Charles Goldfarb:For the tennis elbow, I don't specifically perform a tenotomy. I generally ellipse out what I consider visually unhealthy appearing tissue. And I try to stimulate kind of a bleeding or healing response on the lateral epicondyle lateral aspect of the capitellum. So a little different. I know some people will truly tenotomize the ECRB origin, which I think is fine. I just don't always do I don't routinely do that.
Chris Dy:Do you simulate that healing response? Are you using a curette or something like that? Or
Charles Goldfarb:I use a curette and sometimes a raunger. I'm not opposed to drilling but it's just easier to use whatever is on the set.
Chris Dy:Okay, scope?
Charles Goldfarb:Yes, yes, I've said this to fellows before, when I was starting my practice when I was clinically not as busy as I wanted to be. And the literature certainly is supportive of arthroscopic treatment for tennis elbow, I did a fair number of arthroscopic tennis elbow treatments. And I will do it today. And I have in you know, in the past year, I've done a few the negatives of that are it takes more time, it's a bigger deal for the or both the setup takes more time. And the procedure takes more time. But the benefits are, you know, you can rule out intra articular pathology, if you have a reason to think there might be intra articular pathology. And that's the patient that I will tend to do it on today. And you can really effectively treat tennis elbow, I think and I've had very good results with it. As you're building your practice. It's just a nice way to do elbow scopes. If you want to build a practice that includes elbow arthroscopy, this is a great way to increase your comfort level with the procedure. Obviously taking great care during the process to not have adverse events, but it's a great way to build that skill set.
Chris Dy:Elbow scopes always make me so nervous about the nerves. I'm just seeing it go there. Because of the I see the other end of it. And you know, fortunately, it's great that our fellows get that experience. I remember going into the rotation with you and seeing way more elbow scopes than I ever thought I would see you on one of those tears where you were doing a lot of the you know, osteochondral defect stuff, which is really cool.
Charles Goldfarb:It's funny, you know, Elspeth is Elspeth Hill is our one of our fellows this year and she has started her rotation with me for two months and she is a plastic surgeon and she has a wonderful attitude and has very little experience with elbow and I have to say I don't know that elbow is her true interest and I seems like I've been seeing in clinic and in the or a lot of elbow so I kind of feel badly even though it's what I one of the things I enjoy. I have the other direction for Never have I ever is procedures I really don't like to do and really try to avoid and sticking on their arthroscopy course I may have said this before. I don't really like and rarely do diagnostic arthroscopy. I just think in 2021, it's almost never indicated. Now, it's not to say that I know what 100% certainty every time I do a scope, what I'm going to find and what I'm going to do. But for the patient with vague, unexplained pain, it is pretty darn rare that I offer a diagnostic arthroscopy to solve the problem. Thoughts?
Chris Dy:It's interesting, I had a patient who came in to see me recently who has kind of vague wrist pain. And we were talking about it. And she had, I think I was a third opinion. And she was saying that, you know, somebody had said, Well, I can't explain why you have this amount of wrist pain. But why don't we just go ahead and explore and see what see what it is. And I think probably the procedure they were describing was a diagnostic arthroscopy, and it gets to the kind of sports magic of, you know, the therapeutic lavage. Probably helping quite a bit. And you know, the splinting after surgery, and I guess, at the end of the day, if it's what makes the patient better, fine, but I don't love the idea. I'm with you on that. You know, I, our worlds are different. But the diagnostic exploration of a nerve, I think is, you know, something that I don't think we do, but I also know that we go to the or, and the our information gives us diagnostic value. So confirming the extent and location of the nerve injury, but all this stuff has been really assessed very thoroughly with serial physical exams, with electro diagnostics, ultrasound, all those things. So it's just adding another element to the to the workup and trying to figure out, you know, the prognosis.
Charles Goldfarb:Yeah, that's interesting. I want to hear more about that. But I will say, the patient for whom a diagnostic wrist arthroscopy makes sense for me as a patient who has vague pain, I have given a diagnostic slash therapeutic corticosteroid injection to and who responded really positively to that intra articular injection. But the injection wore off. If I give a if I don't know what's going on. And I give a steroid injection and it doesn't help. I am, I am going to tell the patient, I can't help you. If I've really exhausted everything, and it doesn't happen often. But I don't think a diagnostic scopes are appropriate in that case. So going back to your scenario, I guess I might say for radial tunnel, you said you will use injections to help with the diagnosis. And so if you've exhausted everything to make a nerve situation better, what will you find? And what percentage of patients where you do an exploration for nerve, you know, diagnosis? Do you find pathology?
Chris Dy:I mean, it's not for compressive neuropathy, it's in a setting of a nerve injury. I see. And for example, in a brachial plexus, you know, one of the big differences the based on who you see is whether they would explore the Plexus at the level of the neck. And whether it is to find you use it as a treatment to you in terms of finding a viable nerve root that you can use for grafting. But you know, one of the things I was big when I visited ChangGung in Taiwan was the exploration is part is the last part of the diagnosis. I mean, you think you've honed in on your diagnosis, but that's everybody knows the ways that we assess nerves are really imperfect. So there is no 100% perfect way. But if you know you find that truly there is a five level devotion and you see it with your own eyes, and you weren't able to confirm that, that's just helpful to tell the patient we looked or you find one nerve or like look, here's how bad the injury is, we did find one nervous. So I think there is the exploration and the surgery is part of the treatment. And I have a good sense of what I'm going to do. But you know, confirming my diagnosis is essentially what's happening or for example, say like we've had a run of recently sciatic perineal tibial nerve gunshots, we had a really interesting case where, you know, we talked about and we do this really cool conference where we have people from ChangGung, and people from London and our group in St. Louis login. We talked about a case where there was a gunshot, essentially to the sciatic nerve right at the bifurcation of the tibial and the perineal nerve. And there are two gross types of nerve injury you can have from a gunshot one being, you know, the fascicles actually being disrupted by the bullet and then the other being the sort of concussive injury blast zone injury to the nerve. And it actually went through the perineal nerve, but then had a blast injury to the tibial nerve. And the discussion and debate on the call was do you manage those differently? You know, do you get the tibial nerve time to recover? Just do a neurolysis or do you excise and graft both of them knowing that, you know, the concussive injury to the nerve is far worse but you know, that's an information that you can't really glean from New preoperative electro diagnostics directly. ultrasound helps and was really helpful in this particular case. But there's nothing like an exploration to say, look, this is what what is actually happening.
Charles Goldfarb:I love it. And did you explore this patient?
Chris Dy:That's a great case. I mean, I know we're on a hand surgery podcast. It's exactly what we suspected based on the clinical exam, and the electrode diagnostics and the ultrasound. And the bullet had gone through the perineal nerve and had a concussive injury to the tibial nerve with, you know, essentially a high grade axonometic injury to that tibial nerve. So they both ended up being excised and grafted.
Charles Goldfarb:Gotcha, awesome. All right. Well, let me flip it back on you. I gave the wrist scope example. So Never have I ever what procedures and I can if you don't have anything that really comes to mind, what procedures Do you not regularly perform that you know, are performed in the community?
Chris Dy:I'm trying to think of things that come to mind. I mean, I, I don't do Darrach's a fair bit, it's still still makes me feel a little weird to do the Darrach it's a hard thing to explain to the patient. Well, why does this hurt so much? What can we do? Well we could cut it out. And I'm still baffled a bit by how that surgery really works as well as it does. And I still I admit that I have struggled in my practice with the instability of the stump. Although we have partners, everybody manages it differently. Some of us are very intent on using things like hemi slips of ECU to stabilize it from the jump. But others are like, yeah, just let it go. And it's fine. It's just I struggle with that surgery, I that doesn't really quite fall into the Never have I ever, but as the surgery I was reflecting on recently, because I just indicated somebody for because I think it's a good solution for that problem. But it I don't do you have any thoughts on the Darrach?
Charles Goldfarb:You know, I have been around long enough to see all kinds of different solutions proposed for issues at the DRUJ and match resections and stabilizations and Darrach's. And Sauv Kapandjis, all kinds of different things. I would say right now my solution is the DERA. But I totally feel the same way you do. I don't love it. I have a difficult time explaining it to the patient. And I really worry about instability. And the other thing I tell the patient, though, is that it's been around for 100 years. And there's a reason for that, I think. And so I typically do two things. One, I release the pronator quadratus, as Paul Manske taught us. Sometimes I'll bring that and interpose it between the radius and ulna. And I do almost always stabilize with an ECU Hemi slip. And I would say the technical pro I have for that. One is you always need a longer strip of ECU than you think you do. And so you cut the ECU as far proximally as possible where you can get tendon or at least a Hemi slip of tendon, because you need every bit of it to get a good sling for that stabilization.
Chris Dy:So I will say the one procedure I know that is done in the community that I probably will never ever ever do is an interosseous membrane reconstruction. That for sure i that is a hotly published topic at least was a few years ago. And I I just feel like that's craziness. And then the other one that I did a lot of as a medical student, mainly because I was studying it in the lab is the distal radioulnar ligament reconstruction as described by Bryan Adams, I find that that is a surgery that it's very, it seems very technically difficult to make it work. And I don't think the papers ever reflect the level of enthusiasm that was originally there.
Charles Goldfarb:Well, I like both of those. And I know there are constantly updates on how to best reconstruct the interosseous membrane. I'm totally with you. I don't believe it's possible, honestly is too complex of a structure. But I know there are techniques and newer techniques continuously being reported. And here's what I'd say to the to the the Adams-Berger reconstruction. I have done it. It is very rare even in my wrist heavy practice. And I would say that for me. The foveal TFCC repair, I don't want to say has replaced the need for that but my understanding of the DRUJ and my need for a structural repair of the tfcc that that has increased I more commonly do that with a foveal TFC repair which I think has decreased the need for some type of you know tendon graft reconstruction not completely obviated it but definitely decreased it.
Chris Dy:I think the ability to tension that TFCC Through the through the ulnar tunnel technique has taken the learning curve out of that treatment of that side of the wrist a lot. And I've by no means am I as an expert in the wrist, you know anywhere close to you, but that surgery has helped me as somebody who does those surgeries but doesn't do them a ton to, you know, stabilize that side of the wrist and help treat pain. What I would say is maybe one more surgery we could briefly discuss before we close out is the three ligament tenodesis for SL reconstruction. Again, a hotly hotly published topic as recently as five to 10 years ago, but as we talked about in the literature update this year, has fallen a bit out of favor in terms of the ability to reproduce those results. Have you ever done that surgery? And would you ever do it?
Charles Goldfarb:I have done the surgery. I do not do the surgery. And I think we have institutional bias against the general concept of this surgery. And it's been modified, but the basic Brunelli so to speak. And there will be a lot of listeners who don't understand our institutional reluctance, whether it's the original or the modified, or the modified, modified, but I have not seen good results, whether they be my own, or others. It is a very complicated surgery. I like simplicity. But that doesn't mean simplicity is always the right approach. So yeah, I think it's a great example. Perhaps it's just something that we need to learn better, but I don't buy it. I just don't think it's the solution. I'm looking for.
Chris Dy:A lot of tunnels.
Charles Goldfarb:A lot of tunnels little bones.
Chris Dy:All right. Well, thanks for playing wheel of handd surgery, I will take this Never have I ever with off, high tech wheel going away. And then let's have a listener send in a topic. Handpodcast@gmail.com you can hit us up @handpodcast on Twitter. Just let us know what you want to what you want to replace this little post that with. And if it really is more sports, we can find a sports topic, but the sports topic that's on here has not been picked. So we'll see what happens next time.
Charles Goldfarb:It's not been randomly selected by Dr. D. For some reason.
Chris Dy:My wheel, we did pick a sportsy topic last time. So
Charles Goldfarb:SLAC wrist is sportsy?
Chris Dy:That's what happens when you don't do the sport surgery.
Charles Goldfarb:So I have one favor to ask. Please take good care of that wheel of hand surgery during your upcoming move. I mean, God forbid something happens to that.
Chris Dy:This this stays in my work bag. So you know it's tucked in a manila folder. Maybe we'll get I can't get it laminated because I gotta keep changing these post-its. Maybe one day, I'll get somebody to build us an actual wheel.
Charles Goldfarb:Perfect. Alright, have a nice day.
Chris Dy:You too. Take care.
Charles Goldfarb:Bye. Hey, Chris. That was fun. Let's do it again real soon.
Chris Dy:Sounds good. Well, be sure to check us out on Twitter@handpodcast. Hey, Chuck, what's your Twitter handle?
Charles Goldfarb:Mine is@congenitalhand.
Chris Dy:What about you? 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 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.