Episode 36, Season 2: Chuck and Chris discuss their approach to a scapholunate ligament injury. We discuss how we think about and approach these injuries with specifics on surgical approach and technique.
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theupperhandpodcast.wustl.edu. And thanks to Eric Zhu, aspiring physician and podcast intern.
Episode 36, Season 2: Chuck and Chris discuss their approach to a scapholunate ligament injury. We discuss how we think about and approach these injuries with specifics on surgical approach and technique.
We plan a newsletter launch soon. Subscribe here: https://wustl.us6.list-manage.com/subscribe?u=c6fe13919f69cbe248767c4e8&id=10e0c1dd85
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
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.
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:All right, Chris, Chuck, how
Chris Dy:are you?
Charles Goldfarb:I'm really, really well, how are you?
Chris Dy:I am fine. I am just hoping that our audio is better than I know, I have been bad in the last few weeks. And I'm trying to get better. We did a little interview for the plastics fellow for his for his website. And I did mention that I've tried three different mics in three different laptops. I can't figure it out.
Charles Goldfarb:Well, you sound good today. And I know it's really frustrating. I must have gotten lucky because it seems to have worked out well with a really old pair of quality but old headphones and my Mac Pro.
Chris Dy:Well, you know, that's how I would describe you Chuck, quality, but old. But no shout out to shout out to Eric Zhu, our podcast intern who has stuck with us for so long. And hopefully, you know, he's able to make me sound a little bit better.
Charles Goldfarb:Well, yeah, it's hard work. And so Eric, you got your work cut out for you. But we appreciate all your efforts.
Chris Dy:So Chuck, I have a nice little piece of feedback to get I got an email from Dr. Matthew Brown over he is a fellow in hand and wrist surgery in Wrightington in the UK. And he was kind enough to send me an email. And he mentioned that as an orthopedic trained hand surgeon with a record of multidisciplinary education, I would be most grateful for your participation, he invited me to help with a talk at the IFSSH meeting. He said he's a big fan of the excellent upper hand podcast, which has simultaneously supported his recent hand diploma revision and made his weekly four hour fellowship commutes between Edinburgh and Wrightington more enjoyable, he has highly recommended it to his UK colleagues. So another example of how we love our podcast community. And clearly, you know, I'm flattered and honored at the opportunity to come speak next June. And I'm sure we'll be plugging that meeting as things come along too.
Charles Goldfarb:Oh, we will for sure it is going to be a great meeting. And I've had a little insight, especially on to the pediatric and congenital side of the program is going to be strong. I wonder if I'm going to get an invite to try to make you sound better at this meeting, too. I mean, I don't know how you're gonna do it without me.
Chris Dy:You know, Chuck, uh, you know, the, you can keep following along on the bootstraps here. I mean, you know, I'll pull you along.
Charles Goldfarb:I'll take it.
Chris Dy:Well, thank you. Thank you to Matt, for the email, and you know, your kind words and for telling everybody about the podcast, we're really excited that it seems to really be having a foothold.
Charles Goldfarb:Yeah, we are grateful for all comments. And we've said this before, and we'll say it again, the emails and the questions, and the nice reviews really do provide fuel for us. Because while this is a labor of love, it is first a labor. And it does require us finding the time to do this, even though we always have fun doing it, just trying to carve out that little bit of time. So thank you.
Chris Dy:Yes. And that actually brings us to our next segment on the show. We're gonna do a detail episode today. And I got an email on the handpodcast@gmail.com account from Dr. Colin Kennedy, who kindly wrote us saying that he is a hand surgeon in Las Vegas and wanted to let us both know how much he enjoys the deep dive episodes, found it educational hear us go through Common Procedure step by step and to discuss the nuances to the case and the techniques. It's a refreshing reminder to pay close attention to certain steps of the case that we may gloss over. And certainly this is something where we have certain things that we pay attention to. And these are the things that matter to us. And if you guys are listening to this episode or any of the other detail episodes and have techniques and pointers that you want to share with us, please please email us and let us know. And Colin, thank you for that fantastic email. And I did respond asking if there were any particular types of topics you wanted for deep dive. And he requested one of two topics, acute SL repairs or drainage of flexor tenosynovitis. And I've heard I actually encountered this drainage of flexor tenosynovitis on my most recent call and a little birdie, Dr. Elizabeth Wall mentioned that you also encountered flexor teno on a recent call so maybe we'll table that one is that memory may be a little too raw for now. And we'll talk about acute SL repairs but here I am voluntarily presenting a sports topic to you Chuck.
Charles Goldfarb:Well, listen I while both are interesting, we should pick the more exciting topic which is SL and let's discuss that today. I do think there are some pearls about The flexor tenosynovitis drainage that I was, you know, it's just it for me it was an example of why it is important for the attending to be in the OR in the middle of the night in cases like this, because hopefully, and presumably, there's always something we can teach. And so those opportunities are important, but not the most glamorous of topics. Let's be
Chris Dy:Yes, I remember as a fellow here, Ryan Calfee, who is honest. excellent about coming to every call case. always saying there's always something that that we can teach you. So and he taught me a lot. So there's certainly value in that. So we'll save flexor teno for another day. But let's do a deep dive a Kobe style detail episode on technique for acute SL repair. So let me present a case to you. So you've got a 45 year old gentleman who had a fall on to his wrist about six weeks ago. And he was seen by somebody else was diagnosed with a wrist sprain. He comes in complaining of pain over the dorsal aspect of his wrist. His Watson test doesn't have any instability, or clunking. But it certainly hurts when you do it. There's no tenderness over his scaphoid proper, and there's no tenderness over here, his distal radius. His radiographs don't show any frank widening of the SL interval, they do show a little bit of DISI a little bit of extension at the lunate but no crazy, you know, deformity, you know, large increase in the SL angle. So how do you approach that patient in terms of imaging? And then let's talk a little bit about a lot about technique.
Charles Goldfarb:Yeah, start, I'm gonna start and I'm gonna hit on a couple of points that you made, which I think are really important. The first is the concept of pain, where it is how long I may last after an injury like this, and, and how to use just your physical exam to differentiate possible etiology. So for me, I use listers tubercle, to start every examination of the wrist, and I go about a centimeter distal to listers on the dorsal side of the wrist, and you theoretically fall into a little valley. And that valley is the SL. And it is remarkable to me that outside of the initial trauma, a couple of days, people will really localize to the SL area to the waist of the scaphoid to the lunate itself, but you can pretty quickly figure out where the pain is coming from. So that's the first thing. And I don't know if you think about the same way, but I start with just trying to really localize the area of pain, just distal to Lister's. Although let's be honest, it's six weeks, not everyone has pain. But in this patient still with pain. So do you think about it the same way as far as your exam goes?
Chris Dy:I do. But we were told the very beginning that we didn't disagree enough. I actually go to the the area where I think it's going to be most painful last, because once I've pushed on that area, I tend to lose some sensitivity of other portions of my examination. So I wouldn't start there. I would probably go there last but I agree 100% otherwise.
Charles Goldfarb:Yeah, very true. And then the second thing-
Chris Dy:You're, you're just you're just mean and you just want to jam on people and cause them pain. So that's fine.
Charles Goldfarb:Get their respect early. The second thing is the shift test. And I do it every time described by Kirk Watson. There's different ways to do it. But I do it a classic, classic way. And I don't know how good it is, you know, certainly there are times when the patient responds with discomfort if they're not guarding. And it can make me feel better. Other times I do it, I don't get much feedback, maybe because the patient is guarding. But for me, that's not a be all and end all test. How do you think about the Watson's scaphoid shift test?
Chris Dy:Um, you know, I think that it's a useful test, I always do it. I I think you very rarely see the findings that Watson described in its classic, you know, you're going to feel an actual shift or clunk as the scaphoid reduces back as you let go of your thumb. Because when you're what, you know for that maneuver, it's very hard to demonstrate to talk through the maneuver. But you know, with your thumb being on the distal pole, kind of on the palmar surface of the of the wrist. As you go from ulnar deviation extension into flexion, and radial deviation, what you're trying to do is subluxate that, subluxate that proximal pole of the scaphoid out of the scaphoid fossa. And as you let go of your thumb, in the setting of complete SL tear, in which the scaphoid is adopting a flexed posture. That scaphoid should clunk back in to the scaphoid fossa. And I very rarely will see that but I find it to be helpful because there's a little bit of a shift it moves a little bit or causes a lot of pain.
Charles Goldfarb:Yeah, again, hard to do over a podcast when we have points to that. So the first is that you are pushing on the scaphoid tuberosity at the base of the thumb. And if the patient has pain there, that's not a positive test, you are looking for pain and theoretically a clunk dorsally over the SL. And as you said, when you go from ulnar deviation, where the scaphoid should be extended to radial deviation, where the scaphoid should be flexed. Initially, your thumb is preventing the scaphoid from flexing and maybe pushing it out over the back. And the so you may get a clunk there, you may get a clunk when you let go. But I think it's a helpful test. It's just not all that reliable for me.
Chris Dy:Yeah, I agree. I think it's useful to go through with the trainees the theory, you know, the theory and the kinematics behind it as to why it should theoretically be positive, because that reinforces this concept of the in the setting of an SL tear of the scaphoid wanting to flex.
Charles Goldfarb:And then your next question is around imaging. And so for me, a scapholunate series is a little different radiographically than a scaphoid series. But a scapholunate series is a PA radiograph, a lateral radiograph, an ulnar deviation radiograph, and a supinated grip view. And those hopefully give me information. And the supinated grip, we usually do bilaterally on the same X ray plate to compare the gap. And sometimes we'll do a live C-arm, which can be helpful as well. It sounds like in this case, there wasn't major widening of the SL, which often is present, but that we can get to the secondary stabiliser issue but but even if there's a complete SL tear, you don't always have immediate widening.
Chris Dy:So do you use the ulnar deviation view to help you understand the correctability of the scaphoid? Say that it is you know, say, not in this particular case, but you have a flexed down scaphoid. Do you use that ulnar deviation view to say okay, I think I can get this one back. Or if it doesn't budge on an ulnar deviation view do you say there's no way we're going to get this scaphoid to sit up into a neutral posture?
Charles Goldfarb:I do use it for that reason. And I do use it gives a great view of the scaphoid itself, obviously because it's extended. But if it doesn't extend as much as you might want, that's a secondary signal of a problem. Because it really is that lunate and triquetrum, which bring it into extension, so the complete tear may not extend as much. And yeah, I mean, if it doesn't want to extend, it does raise alarm bells, although usually I think you can get it back into position. But at six weeks, as you mentioned, we're not terribly worried about our ability to correct this. If we end up going to the operating room for a scapholunate ligament injury.
Chris Dy:So I want to spend the majority of our time on the technique parts of it. But just a brief word about imaging, always an arthrogram for you in this setting?
Charles Goldfarb:I'm changing a little bit. Yes, I think an arthrogram for most of us is the right way to go even though patients don't love it. Because it's just so good when you have a potential ligament injury to see that contrast flow from the radiocarpal joint to the mid carpal joint. But a really good MRI, you know, like a three Tesla machine with good radiologist. Often you don't need it, but I think it's safer still in 2021 for most of us to order the arthrogram.
Chris Dy:Yeah, I was fortunate enough in residency to have trained in place that did beautiful wrist MRIs. And I remember coming here and fellowship being Oh, do we need an arthrogram? And you're like, of course you need an arthrogram like, Oh, sorry. Sorry, sorry. Sorry, sir. I will never question you again on the need for an arthrogram.
Charles Goldfarb:Yeah, but it's fair. I mean, it really does depend on your imaging capabilities. And we know we're very fortunate at Wash U. I don't know there's a huge difference between the imaging quality here versus your Mecca. But you know, there's nothing wrong with ordering an arthrogram.
Chris Dy:Indeed, so I will say now at this point, say we've decided that we're going to go to the operating room. So this Very young, very young. patient's MR arthrogram came bac with a full thickness SL tea. And he's a young person, he' 45. So even younger than you Chuck an Now the timeframe gives me pause and I intentionally made it six weeks. So what do you think Can you repair a ligament at six weeks? Can you repair ligament a three months when can you no longer repair an SL ligament?
Charles Goldfarb:So first of all, for those still learning about the scapholunate ligament, you know it's a C shaped ligament dorsal proximal and volar. There's nothing distally. And we always talk about the dorsal scapholunate ligament being the key portion. And when I think about it, you know if we're like in the lab or if we're excising an injured scaphoid to do a four bone fusion or whatever. If you're trying to cut through that scaphoid ligament, especially dorsal it's not easy. It's a stout ligament, especially dorsally, where you really need a sharp knife to get through it. However, if you are repairing it, it seems ridiculously difficult to do that it seems thin, it's unimpressive. And trying to stitch that ligament back together is tough. So that's what I'll start with, I want to say one more thing. And that is six weeks is really important. And I know you didn't pick that number arbitrarily. Historically speaking, we would either say, you have three weeks to repair an SL ligament, or else forget about it, or you have six weeks to repair an SL ligament. And after that, you're not getting it. And so forget about it proceed to a salvage procedure, like literally, that's what we would say. So proceed to a scaphoid excision four bone fusion. In 2021, I think most of us would not proceed to a salvage procedure, we would think about a repair or repair plus.
Chris Dy:Yeah so, you know, I think that the repair plus is the interesting part. And we've talked a little bit about on the Never have I ever episode about procedures that are published, but we probably wouldn't do. And one of those was the three LT, the three ligament tenodysis. But that is a reconstruction procedure, that stops shy of the salvages, the four corners, the PRCs, that kind of thing. Because we're assuming in this case, when I'm telling you since it's the case I'm presenting, no arthritis. And we're trying to prevent that formation of SLAC wrist, you know, the predictable pattern of arthritis that occurs with SL incompetence. Now, I will say nobody knows, and correct me if I'm wrong, because you are in this world, much more than I am. But nobody really knows the timeframe, how long it takes to get a SLAC wrist after an SL tear, but we know that it eventually occurs.
Charles Goldfarb:Yeah, what we know is that the flexed position of the scaphoid eventually leads to arthritis of undetermined time. And that likely is in my humble opinion, that likely is related to the exact injury experienced and so do is the tear only of the SL proper, or are the accessory ligaments injured because essentially, if the accessory ligaments are not injured, eventually they will fail over time and that scaphoid will truly flex and you get arthritis. And so I think it can be five years, it could be 20 years. So it's really unpredictable. But we've all seen. Well, you and I have seen that patient who comes in with no recollection of injury, that dorsal radial swelling, and you know the diagnosis before you get the x ray, which is a SLAC wrist. So yeah, it's an interesting thing. We don't have all the answers and that that that Brunelli type reconstruction is certainly the choice of many. And this patient would be a candidate for that, honestly, because repair is just so so unsatisfying.
Chris Dy:So let's change one important caveat here say it's two weeks. Patient has come to you for the original injury and original assessment. You're in the OR do you find that that ligament is often ruptured mid substance between the scaphoid and lunate? Do you find that it is often come off of the scaphoid more or come off the lunate? And then how do you talk me through how you would technically do this repair?
Charles Goldfarb:Yes, so I think it can be either my most recent event was a perilunate that I repaired a couple of days later on my elective day. And in that case, the ligament is most commonly torn off the lunate. Certainly that was my experience a couple of days ago. I think however, often the ligament remains on the lunate and is torn off the scaphoid especially in an isolated SL. So my goal is an anatomical reduction of the carpus. More than the SL but it's an anatomic reduction of the scaphoid and the lunate with considerations for the capitate. And I would say traditionally, I've done that with K-wire fixation. And then as good a repair as I can do with the dorsal SL and this is where I get to my disappointment. And this is this is why I think these fail is that you know we are hoping that we can get an intra articular ligament bathed in synovial fluid to heal with a suture anchor and a little horizontal mattress suture. It's just not a ligament that is amenable to a good repair. And I don't think to healing but hopefully enough scar tissue forms to prevent problems down the road. That's honestly how I think about it. Whether it's two weeks or six weeks, or whether it's an immediate repair with a perilunate, I just don't think that ligament lends itself to repair.
Chris Dy:So let's you made a couple of really interesting points I think we should elaborate on given that this is a detail episode. So you mentioned getting anatomical reduction. How do you do that? I know that you're you know if you're going to talk about joysticks, and you know K-wire fixation. What size K-wires do you use for the joysticks, what size K-wires Do you use for the fixation, are they percutaneous, are you leaving them out? Are you leave cutting them and burying them underneath the skin? Where are the wires going?
Charles Goldfarb:So the first question is, if we are going to use K-wires for fixation and try to do a repair, then.
Chris Dy:So, so joysticks. So-
Charles Goldfarb:Yeah, well, if we're going to use K-wires for fixation, and not something like an internal brace, which we can talk about, which may have a role here, then we are going for the anatomical reduction as judged by direct visualization of the scapholunate interval and you know, X ray in the operating room. And so I use 6-2 K-wires as joysticks. And so typically, you're taking the lunate out of extension into flexion, bringing the scaphoid out of flexion into extension, and often over extending it slightly to make your SL angle 30 degrees, 35-40 degrees, something like that. And then on my first K-wire, so my first K-wire will be from the distal scaphoid to the capitate. To hold the scaphoid in general where I want and then I use the after having used the joysticks to hold things generally together, the second K-wires from the scaphoid to the lunate.
Chris Dy:I found this to be much more gratifying to correct the SL angle, as opposed to correcting the actual gap. Does the gap matter?
Charles Goldfarb:I think the gap does matter. For the theoretical ability to repair the ligament, because you need it in close apposition, if not over reduced slightly to have any chance of getting that ligament to heal.
Chris Dy:So how, technically, how do you manage the gap? I've seen people kind of take those joysticks and cross them almost to hold it together and maybe use a big kocher something like that to keep it held depending on you know number of people you have assisting you etc.
Charles Goldfarb:Yeah, I like I like that concept. So I'll tell you what I haven't been overly successful with is trying to use like towel clips to apply a compression force. For me, I've been really happy with 6-2 K-wires, and you have to be careful how you place your 6-2 K-wires because they can get in the way of other things like your suture anchor. And some people will put their suture anchor in first and then put the 6-2 K-wire in. So you want that anchor placed appropriately. But if you have your K-wire joysticks in place, and you do the reduction mover from a dorsal volar standpoint, and then you cross your hands, for a mobile scaphoid, it's really effective in reducing or like I said even over reducing the interval slightly. Is that how you do it?
Chris Dy:Yeah, and I think that the joystick placement is super important. So you mentioned oftentimes that you're you need the joysticks to be out of the way of other things like your fixation, K-wires and your anchors. So it's important to think about where you're going to put those things. And then you're correcting the lunate from being in extension. So you want to make sure that when you put in your wire, you're a little more proximal on the lunate so that you have room to correct the extension and flex the linear speed Yeah, correct it and flex it into anatomic neutral position. And then vice versa for the scaphoid so that you have room to extend the skateboard. So you're almost dropping those wires in at different angles to correct them so that they sit next to each other and then you can bring your hands across like you mentioned. So I think about the same way do you use 6-2 wires and 4-5s for the joysticks?
Charles Goldfarb:For the joysticks, I use 6-2. For the pins that I put in, I use 0.045 K-wires and I do tend to bury those. If I use them. I will be honest that at the six week interval, I'm probably thinking about an internal brace and no K-wires whatsoever. But if I'm going to put in K-wires, I use 4-5s and I bury them, what do you do?
Chris Dy:Um, I will use 6-2s for all of it. And I typically will bury them if I am using K-wires. And I probably have a lower threshold to use K-wires than you since I probably do less sports surgery and I've less familiarity with kind of the comfort levels of you know when to let people move things than than you are. Now you mentioned one thing that the scaphoid that you can get the reduction. What do you do if you can't extend the scaphoid?
Charles Goldfarb:If you really can't extend the scaphoid because of scar tissue again, that would be a longer interval than six weeks, then I think you either have to do a sharp release of scar tissue typically at the volar distal aspect of the scaphoid or at the ST joint, scaphotrapezial joint. But in my experience has just been really rare that that is required, but I think you have to be prepared. Likewise, you know, most of the time you have to be prepared to do a salvage procedure. If you're doing something at six, you know three months or six months Don't think it's foolish to just tell the patient and go to escape when they repair, because it may not be possible. And so this is one of the situations where preparation really matters.
Chris Dy:That was to say the I like using in the office and using the live fluoro to get the the ulnar deviation view so that I can prepare myself and prepare the patient for what we are likely to encounter. And then I know we're going to save SL reconstruction for a different detail episode. So I will ask you, you know, what kinds of anchors, are you using relative size and manufacturer? If you want to say, and what kind of sutures are loaded in those anchors? How many anchors are using and where are you placing them?
Charles Goldfarb:Yeah, again, it gets to the point of what are you really accomplishing with these anchors and with the, with the suture, because it's not a strength repair. Your, the goal here is simply to get a close re-approximation of the anatomy and have that ligament laying back in place, put back in place. And I use a typically a two seven corkscrew anchor with a 2-0 FiberWire ethibond type suture, I happen to use Arthrex. As we all know, it doesn't matter what anchor you're using, I'm not conflicted. So that is that's my approach. And I put one anchor in and I try to do a little horizontal mattress, I've tried to do a little Krackow type suture, it doesn't work. To get that to get that, again, the ligament to lay nicely back in place to give it the chance to heal.
Chris Dy:Now that's a mini size type basically, anchor?
Charles Goldfarb:Yeah, mini mini mini anchor of some sort. Yep.
Chris Dy:Got it.
Charles Goldfarb:And and carefully positioned to keep it out of the joint, whether that be the mid carpal joint or the SL joint right at the edge of the articular cartilage.
Chris Dy:Well, so I mean, taking other orthopedic lessons of repairing ligaments back down to bone. What do you think about like a double row? Like why not another anchor?
Charles Goldfarb:Cuz I don't think it adds anything. I think all you're adding is the strength of the suture, which gets to the reconstructive concepts and gets to the internal brace. I think one of the interesting things that I struggle with that I'm certainly far and away, not the first, is that okay, so let's say you do have that isolated SL injury, as we do an open approach to the scapholunate ligament. We are cutting secondary stabilizers, assuming they hadn't been injured with the injury. And so that's why the ligament sparing approach, for example, was developed. I think it was developed at Mayo, but certainly the Mayo guys use it. And so that's, that's fundamentally problematic. And that's why people like PC Ho, who does really great work. arthroscopically have described arthroscopic repair techniques, not in an attempt to have technology triumph over reason. But really to preserve those secondary stabilizers, which makes a lot of sense, I'm just not yet convinced that I can effectively perform an arthroscopic repair, much less a reconstruction of the SL interval. And so I typically do an open approach, I will consider a ligament sparing approach. And if I'm not able to do a ligament sparing approach because of access, then I just make sure I do a really as good as possible repair of the dorsal capsule when I close.
Chris Dy:So when you do your approach, when you don't do a ligament sparing approach, are you doing the standard kind of inverted T dorsal capsulotomy?
Charles Goldfarb:I am I actually just make a straight line capsulotomy. So just for all of those dorsal incision, thankfully, you know, you're not really encompassing any any nerves typically in this in the midline right over the third compartment. Open the third compartment, I go ahead and transpose the EPL. I leave the EPL transposed when I close and I close the retinaculum beneath it. And then I'm working between the second and fourth compartments. So I incise the capsule longitudinally, if that's my approach for the day, and I as minimally as possible, take the capsule off the radius, and then you have great exposure, it does simplify your repair, there is no doubt I am not one, ok we'll work a little nerve into this. I'm not one who routinely performs a post interosseous nerve neurectomy. I want to hear if you do and then do the repair, I close well, and I'm done. What do you what do you think about that post interosseous nerve?
Chris Dy:I don't do the neurectomy. Although I see the argument. I know that Dr. Rob Gray is going to tell me that I should be doing it every time. Thanks, Rob. I don't I guess I could be convinced, but I feel like there is enough literature out there suggesting that that has appropriate deceptive function. And we're trying to preserve the native or restore the native anatomy. And I think there's probably more sense in keeping it in this particular case. And I feel differently if we were doing obviously some kind of salvage procedure. And I guess you know, the question I have for you just a little technical things. How much extensor retinaculum do you feel like you have to divide in order to get your access to the depth you need between the second and fourth compartments? You mentioned opening up a portion of it to transpose the EPL out. Are you taking down all the extensor retinaculum, you know, just a distal quarter, third, something like that.
Charles Goldfarb:I think you could do it either way, I tend to just open the third compartment and transpose the EPL. I think he could also leave the EPL where it sits, not transpose it and work distal to it. I just think it'd be it can be a little more of a flux factor. And I think if you're if you're going for a big exposure go for the big exposure. I think there are some reasons like an arthritis procedure, were taking out the post interosseous nerve makes all the sense in the world, because I don't think it really matters for the future. I do think there's a component of dynamic stability provided by some would say the FCR especially or, or the radial wrist extensors. And so to me, even though I don't think it's been proven conclusively, I think that post interosseous nerve innervating the capsule does provide some of that potential, which is why I don't take it out.
Chris Dy:Yeah, Elisabet Hagert in, in Sweden has done a lot of work on this and has convinced me that I think that it's important. So, yeah, I think that's one of the things about, for example, like an ACL reconstruction never feels normal, because you don't have the normal purpose of the fibers of the ACL. But again, I'm kind of, I'm not particularly well versed on this, I don't feel very strongly about it, probably the only thing in nerve that I don't feel strongly about.
Charles Goldfarb:I will second that not that I don't feel strongly about any of them, setting it up for you. So how long do you leave your pins in? And do you bury them or no?
Chris Dy:So I will leave them in as long as they'll let me stay in. To be very honest with you. I shoot for six weeks, depending on the patient, most patients I leave them, I leave them out of the skin. I don't like coming back to the operating room, I don't have to I know we have partners who will remove buried pins in the office. I'm gained from pretty much anything in the office, but usually not that like it's it's, it's a little bloodier than I like.
Charles Goldfarb:I agree with that I do go a little longer. So for an isolated SL, I will shoot for eight weeks and perhaps 10 weeks. And when I get to that duration, I typically do bury them. If I if I do a really good job, then the pins are deep enough not to bother the patient, but easily palpable, and I will consider an office removal if the patient would like. Otherwise, I come back to the OR, which I think is a terrible waste of resources.
Chris Dy:So how long do you think pins exterior to the skin will typically last? Do you think you'll you you mentioned you probably can't get eight to 10 weeks out of them? Do you think you'd get six weeks out of them?
Charles Goldfarb:Yes, I think if I was finally leaving for six weeks, for most patients, I would put them external to the skin. And then you know it's patient dependent. And it's the quality of the cast dependent because I think it's the the wiggling is also the putting the pins without tension on the skin. And so really doing a generous release around the pins can be helpful to mitigate pin sight irritability, which leads to a lot of the problems.
Chris Dy:So when you're burying the pins. Do you make a healthy incision to and given that you're on the radial side of the wrist? Do you find the SRN or anything like that?
Charles Goldfarb:I do. So little incision, right the level of the styloid. And just distal to it because that's where you want to be whether your pan is going proximal towards the lunate or distal towards the distal capitate. That's where you want to be so incision little Ragnell retractors just to protect the sensory nerve, and then you're down on bone. So it's a nice, it's a small incision, but it's effective and it kind of protects the against tertiary damage.
Chris Dy:Now do you do you make that incision before or after you fire the pins?
Charles Goldfarb:I actually make the incision and then place my pins. And then I make sure and then I make sure that once we're all said and done that the pins are not with I'm leaving them out, leave them in, I just make sure they're not causing irritation of the skin.
Chris Dy:And just one 6-2 across the SL? I've seen you know some people use two, 4-5s across the, or you said one, you're using 4-5s for that fixation. So just one not using two for rotational stability?
Charles Goldfarb:Yeah, I think if you have a pin going into the capitate and a pin going from the scaphoid to the lunate, one is sufficient. I'm certainly not against two I just don't think it's necessary.
Chris Dy:And then one other technical thing that, you know, when I before I got here, I had seen these repaired with two anchors and then double loading an extra suture through the anchor. I remember talking to you about that and you just kind of saying that that was not your preference. Probably different, different way. But you because you would believe that that would make a difference and probably is just more foreign material holding things in place as opposed to encouraging biology.
Charles Goldfarb:Yeah, listen, I mean, I think very few people would disagree with the statement that the scapholunate ligament injury remains the biggest unsolved problem in hand surgery. And it's kind of sad to say we've been saying it for 30 years and it remains unsolved and there are, you know, there are different ways to get around this problem and maybe get through get through this injury for patients with different techniques. But every single hand surgeon has his or her own philosophy on what they need to do with pin placement with anchor placement with double loading of anchors. It's very frustrating. But when there's 100 choices, it's because there's no clear winner.
Chris Dy:So let's say we'll leave the suture tape augmentation for a different day. But let's say that you have these K-wires, you've removed the K-wires, what's your protocol? Just bring us to a close with your protocol for rehab.
Charles Goldfarb:Yeah, so let's say we get to eight weeks. So eight weeks patient comes back, the pens are slightly palpable underneath the skin, we can successfully knick the skin and take out the K-wires. Then we send the patient to therapy for a volar forearm thumb spica splint. And we start with active motion and gentle, passive motion, at two additional weeks, we'll go more aggressively with the passive motion. And at 12 weeks I go to strengthening. How do you think about it?
Chris Dy:Pretty similar, not not anything different. I just know that we have a lot of therapy colleagues, if you have seen very different protocols that you've found to be beneficial, certainly let us know. And we'd love to share it.
Charles Goldfarb:Yeah, we've tried in our group to standardize our therapy protocols. We've talked about it a million times, we have wonderful therapy partners at Milliken hand center. And we are pretty uniform, we're not always exactly the same. But we've tried just to for many reasons, it makes sense. One, it's just more applicable. Two, there's more opportunity for research, if we are standardized with our protocols. And three, it's just easier. So I think we're generally pretty uniform because none of us dig in too much on this. If someone has a strong opinion, we go with it. And we defer to our therapy colleagues who kind of see things in action.
Chris Dy:Yeah, so I'm a little I most of my practices a little bit away from Milliken, I'm fortunate enough to work with the Athletico group a fair bit, and I've tried to adopt those protocols. One thing I like that we haven't mentioned that we should before we finish is dart throwers. So what do you think? Can you initiate earlier motion with dart throwers? Maybe you don't even have pins in but you know, can you start things earlier in that plane?
Charles Goldfarb:I buy the concept and if you want to describe it, you maybe able to do it better than I simply the dorsal radial to volar ulnar motion, I believe, and it's theoretically putting less stress on the SL interval. But we don't routinely use it. There's literature out of New York as you're well aware to support it. It's not been a principal of our rehabilitation protocols.
Chris Dy:Little secret I really like it and I use it. I'm a little further away and I guess I can't be in your your huge Chuck Goldfarb, Lindley Wall, Ryan Calfee, Marty Boyer, Dave Brogan study of SL injuries.
Charles Goldfarb:You are not welcome.
Chris Dy:I like the dart throwers, it makes sense to me. I obviously trained with Scott Wolfe, who'd spent a lot of time with with Trey Crisco on that idea. I think it makes absolute sense. It's just a matter of whether it's being implemented appropriately and understood by the patient. And that's where I trust our therapy colleagues to help reinforce that, but I do like dart throwers, I think it It allows me some elements of confidence that might repair or reconstruction in a different case is not going to be excessively stressed. But starting to patient on some rehab a little bit earlier on.
Charles Goldfarb:Look I would never argue against it. I just hadn't chosen to implement it. But again, that's where some of the variability comes in, which is the spice of life, unfortunately.
Chris Dy:Well maybe one day we can teach an old dog new tricks, Chuck.
Charles Goldfarb:That's true. That's true. I'm always happy to learn a new trick. All right, well, this is good. We do have we can do follow ups on this as well. But we appreciate the the listener requests, and hopefully we've satisfied, we've scratched that itch, and send more send more opportunities our way.
Chris Dy:Yeah, Colin, thank you for that suggestion. Hopefully, this, this helped you out as much as it helped us thinking about it. And then honestly, if anybody has any other topics they want, we've gotten a lot of really good reception for the the detail episodes. So if you want more deep dives, tell us what you want to talk about. And we'll try to work it in.
Charles Goldfarb:Yeah, and I would say most importantly, we love your comments. And on Twitter when Chris tweets about this episode, I am sure that some of you are going to comment on your approach. Please do we don't claim to have the all the answers. We have some of the answers. We don't have all the answers. So comment.
Chris Dy:Well, in the last episode, Chuck bragged about the reach of the podcasts and how nobody else could ever top this podcast so. He thinks he has a lot of the answers, so please prove him wrong. Please.
Charles Goldfarb:Prove me wrong. Prove me wrong. All right. Have a good day.
Chris Dy:All right. Take care. Bye.
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