The Upper Hand: Chuck & Chris Talk Hand Surgery

Chris and Chuck Talk Innovation with guest Jorge Orbay

October 10, 2021 Chuck and Chris and Dr. Jorge Orbay Season 2 Episode 38
The Upper Hand: Chuck & Chris Talk Hand Surgery
Chris and Chuck Talk Innovation with guest Jorge Orbay
Show Notes Transcript

Episoe 38, Season 2.  Chuck and Chris welcome guest Jorge Orbey to discuss his pathway to success.  Dr. Orbay has started two success companies and, more importantly, has directly impacted patient care with the volar plate and now with the internal elbow stabilizer.  He reflects on his path and provides thoughts for future innovators in hand surgery or any field.  We also learn technical pearls on the volar approach from Dr. Orbay.

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Charles Goldfarb:

Welcome to the upper hand, where Chuck and Chris talk hand surgery.

Chris Dy:

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

Charles Goldfarb:

Thank you for subscribing wherever you get your podcasts.

Chris Dy:

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

Charles Goldfarb:

Oh, hey, Chris.

Chris Dy:

Hey, Chuck, how are you?

Charles Goldfarb:

I'm doing great. How are you?

Chris Dy:

Great. I am super excited about today's show.

Charles Goldfarb:

I am as well and I think we're gonna have plenty of content. So we're gonna jump right in and welcome our guest. Our guest is an innovator. It's a name known to I would say most if not all hand surgeons. And that is Jorge Orbay. Welcome, Dr. Orbay.

Jorge Orbay:

Thank you, Charles. And thank you, Chris. Glad to be here.

Charles Goldfarb:

Well, we're really happy to have you. I'm going to give a very brief biographical background and feel free to emphasize or correct me if I don't get everything exactly right. Dr. Orbay was born in Cuba. His medical school was done at the University of Puerto Rico. His residency was done at the hospital for joint diseases in New York. And he was a hand Fellow at Jackson memorial in Miami. He's been in South Florida, I believe his whole career, and has, you know, done a lot of fascinating things with the development of implants and different ways of thinking about orthopedic pathology. Dr. Orbay, I know you've had different people influence your career, but how briefly tell us how you came to be an orthopedic surgeon? What was your pathway? I know engineering was an interest at one point. But how did you go from, from a medical student, to a resident at a wonderful place to having such an impactful career?

Jorge Orbay:

Thank you for the last one. I always liked science, I always thought I was going to be a scientist, like a physicist, or something very basic and logical. But I ended up being a doctor, which is a great profession. And the nice thing about being a doctor is that you are in contact with human beings. Well had I followed my original pursue of pure math, physics and logic, I would probably have not enjoyed this aspect of life. So going to medicine was a great thing for me. And I really, when I went into medical school, I thought I was going to be a psychiatrist. Because the human mind fascinated me. And I thought, well, I know it's very complex. There are many problems we don't understand. But maybe I can give a hand on this. But I was a third year medical student, I realized this brain problem, nobody can solve, and I'm not going to be alone in this. So I decided, let me do something practical, that gives good results and makes patients happy. So I'm not too sad. And that was orthopedics. And that was exactly up my alley. Because engineering, physics, math, that was my thing. I was fortunate I went to medical school in an obscure part of the planet. But it was actually quite a nice medical school it was a beautiful thing to study medicine in a nice tropical island made great friends. And it was an enjoyable experience. But of course, when you tried to apply to a residency in the US, they thought you're crazy. But I crossed paths with Dr. Victor Frankel who was the world's leading biomechanist at that time, and he hired me on the spot, at joint diseases, he said, We want you to stay here with us. So I didn't even go through the match. It was very fortunate. And then the residence was hard work. And you know, residencies are tough that and that Joint Diseases residency was stuff. I did a fellowship with Bill Burkhalter, who was the best teacher ever had, he was a true mentor. And then I was in private practice. I wanted to be an academician that didn't pan out. And I was alone in private practice. For several years, all I did is work very hard, very hard, build a big, very successful practice, created a group. And when one day I said it's time to do it, let's do it. Let's make the world a better place and solve problems that nobody has solved.

Chris Dy:

So interestingly enough, I have my three University of Miami degrees on the background here, saying I actually was a former patient of one of your groups. I had a fifth metacarpal fracture that one of your partners treated non operatively and no i did not punch Anybody, but certainly I have heard your name throughout the halls of Jackson memorial and University of Miami, you're a legend down in South Florida and it's incredibly wonderful on one island to the next Island, then to Manhattan, another island. It's a great story. And I know that your daughter, I believe, is an orthopedic surgeon too so you clearly have influenced her in a very positive way.

Jorge Orbay:

Thank you, Chris. Yes, having my daughter become an orthopedic surgeon was a blessing. And I cannot have been such a bad dad.

Chris Dy:

Well, that's, that's I have, I have two young kids, Chuck has older kids. And I think, you know, certainly seeing how your your daughter has progressed makes me very aspirational, hopeful for my kids.

Charles Goldfarb:

Well said. So Jorge, one of the things I am most proud of, and Chris is gonna roll his eyes and maybe laugh at me a little bit, but I have to my name, a patent. And really, I say that quite quite, almost jokingly because it's really my wife's patent. But she started a business, a belt business, it's been, it's been great. But as I was preparing for this conversation, I searched the patent registry for your name. And to say that I was overwhelmed would be would be an understatement. So it's really remarkable. I didn't I didn't count how many patents you have. But I was intrigued, especially by the first two. And the first was essentially a, I believe, a metacarpal fixation process with a with a way to position a K wire and put a K wire and I remember that that product. And the second was your, essentially your volar plate with a peg device. And so so talk us through those a little bit why those two issues was about an unsolved problem. And I think all will be intrigued as to why and interested in just hearing more about one or both of those products.

Jorge Orbay:

The metacarpal flexible nail, it was something that I thought out when I was a fellow, the we see all these metacarpal fractures, and we're putting plates in them. And I thought it was excessive surgery for such a silly problem, because Dr. Burkhalter really wanted you to leave him alone. He said put them in an MP block cast hold the fingers down like this, tell him to move early. They might have a bump. But Did that ever take off? Was that a success for you? And for the they'll have perfect hand function. And he's right. He's absolutely right. But patients don't like bumps in their heads. So I at that time there, there was this great surgeon, French surgeon, Guy Foucher, who have published that article on what he called the Bouquet technique being French, he's an artist. So a bouquet is this long, vase and you will put the flowers into it, and the flowers would kind of go down and follow the neck of the vase. So that was his theory you have you get a metacarpal fracture, and you put three 0.45 K wires anterograde into the metacarpal. And they'll do great fixation, I thought that was a great idea and worked very well. But it was kind of you know it was an operation, you had to make an incision go down to the bone drill holes, make a window with the three K wires. So why can't we just do this percutaneously. And I started doing that as a fellow, you can get a K wire, bend the tip and then put it in a chuck and then jiggle it down, make a percutaneous hole, jiggle it down through the metacarpal. And that really, it makes sense. It really made the the you still had to mobilize them and then MP block cast, but they didn't get the angulation. So that was the that was the first pattern. So it was a way of percutaneously doing Guy Foucher's technique. hand innovations company? Great question. had that been the only product, we would certainly have crashed and burned. Because it didn't, doesn't hold water. There was not enough revenue per case to be commercially successful. But what did I know I was just a doctor trying to solve problems. So I had that idea. And I put a lot of effort into making it into a product. And we did have started this company called hand innovations. That was our first product. But I also had this volar plate thing that I was developing at the same time. And it just happened. I got old enough that I said I better do what I always wanted to do now that was about 10 years after I had been in practice. So this is now or never. So the story with the volar plate is that, that was a really big problem. So we were treating distal radius fractures with external fixators which could you know handled most of the deformity in extra articular fractures but it was really very cumbersome and difficult for the patients and it produced a lot of stiffness because those those things going through the skin when people make a fist they hurt, the skin pulls on them and of course people place them with too much distraction and so on and so forth. Jesse Jupiter at that time came out with a pi plate, that was his solution to the wrist fracture was a beautiful idea it was a pelvic recon plate made small and adapted to the wrist. There was a lot of interest at that time, there was fragment specific fixation also taking off. But when I used that pi plate for the first time, I said this is brilliant. These screws they thread into the plate not into the bone, they give you a great fixation, they just unfortunately, are very irritating to the extensor tendons. And on the same pi plate said that Jesse Jupiter and Hill Hastings had developed there was a little volar T plate though would accept this, this pins this, they call them pegs, which is a great name for them. They screw into the plate, and they simply serve as a buttress of the articular surface. So this volar T plate was designed for volar fractures, and I use it for a dorsal fracture. I did the first case was a an older lady with a simple Colles fracture, very displaced, she was very swollen and very miserable. And I just put this little plate on with a little local and regional block. And the next time I saw her, she had like four finger motion, she had no pain, she was the happiest person, I never, I thought if I had put an external fixator on her, she would not like me as much. And I knew from the first patient I did with that volar T plate, that this was the solution to the distal radius fracture. And we're talking about 1996 probably at that time, that's how I came up with the volar plate. Then I put the volar plate and the flexible intramedullary nail together. And that was hand innovation. And hand innovations was a very successful company. I didn't know anything about business at that time, I was fortunate to have met Ernie Hernandez, an engineer that had work work with Cordis Corporation, a cardiac company that had been bought out by Johnson and Johnson and closed and taking all the manufacturing down from Miami to Mexico. So he was out of a job. And he started repping Arthrex. He came to my office one day and told me there's a good friend of yours that told me to talk to you. Do you have any ideas you want to develop? And say, of course I do. But I have no idea how to do it and he said, well, let's try it. We became partners in hand innovations. He put a lot of work and a lot of understanding of the market and understanding of product development. And I put all the money and all the ideas on how to solve the wrist fracture. And we were very successful.

Charles Goldfarb:

So Chris, I apologize. I don't want to monopolize this, but I have a lot of questions. And so I'm gonna follow up with one and then I'll let Chris try to squeeze in a question here or there. So Jorge, we met in either August or September of 2002. And I want the listeners to understand this because those who know hand innovations from the past, and certainly those who know your products, probably understand the hard work it took to build the company and get the plate right. But what you, the effort that you expended to make it successful and to have hand surgeons like me, adopt the technique is remarkable. So I started practice at Washington University in August of 2002. And shortly thereafter, a guy I did not know named Dr. Orbay said, Hey, do you want to meet? And I'm like, at that point, of course, sure. I you know, a nice hand surgeon. And so I met you and you described your plate. And you described the concept and I was sold. Because both you're personable, and I thought the concept made a lot of sense and I hated external fixtures. And so slowly I began to use the plate. And just so you're aware, my partners were a little taken aback. And these are you know, Richard Gelberman and Marty Boyer and others. Well, I thought maybe my job would be short lived but you know, eventually like you I shared the successes of this concept and eventually they bought into it as well. So as I imagined it, you crisscross the country. Meeting no one, nobodies like me, sharing your idea and sharing the technology behind your idea.

Jorge Orbay:

It was a lot of work. But it was a lot of fun too. In fact, I will not call it work. It was just very enjoyable to meet other surgeons, and to be able to share these ideas and to try to solve a problem that we all were facing. And there was at that time, a lot of people would throw eggs and tomatoes at my team, that it is true, but we knew we were right, so it wasn't difficult to keep on moving forward.

Chris Dy:

So we have a lot of therapists, hand therapists, physical therapists and OTs that listen to the podcast, and may or may not realize, you know, what a game changing innovation, your product was, and continues to be. When did you change or when you first put in the volar plate in that patient you described? And then your subsequent patients. What was your rehab protocol? How did it change? I mean one of the biggest advantages that I see in my practice with you know, a volar locking plate in a in this patient population is the ability to move towards early motion and earlier recovery.

Jorge Orbay:

Yes, I totally agree. Well the first cases we had to take more care of them because that voter T plate was so weak, it would break all the time. It didn't have a volar buttressing surface. So it held the dorsal fractures well, but not having a volar surface, you will get that problem with a volar marginal fragment all the time, it was very serious. So we would put them in a cast on a short arm cast for weeks religiously, everybody got that cast. And I would do encourage them early motion. So at that time, we were not very sure of the rehabilitation protocol in the sense of how much activity or weight or force we would allow them to perform, we really had no idea. And we did have problems with failure of fixation we had particularly problems with the volar marginal fragment, as those original plates did not have a good volar buttressing surface, though, so the pegs would hold the dorsal fragment. But there was not a good volar buttressing surface, as it as the plates evolved, and we understood the problem better, we corrected those problems. And that's when the term watershed line came in, because we realized we must buttress the volar surface as far distal as we can. And the limit is the watershed line.

Charles Goldfarb:

Perfect, perfect. What What do you do with your, if you have a, just out of curiosity, if you have a relatively standard Colles type fracture, and you elect to treat that patient with a volar plate, what do you do these days with your post op? Do you splint them for a week and then haven't seen therapy? But just curious, what's your protocol?

Jorge Orbay:

It's exactly that. I give them a post operative dressing with the wrist in extension, a volar slab, that holds the wrist in extension but the finger's free. And I tell them, you have to start making a fist immediately. As soon as your hand wakes up from the block, start moving those fingers. And I tell them now that I trust the fixation, and you can do activities of daily living, you can lift up to five pounds, and I promise you fixation is not going to fail. The fracture is going to hold fine. It's like you're broke, bone's not broken anymore. But please don't move the sofa, I tell them and then at four to six weeks when the bone heals I let them do whatever they want to do. Right now loss of fixation after distal radius volar plating is extremely unusual.

Chris Dy:

What was it like seeing your product, your baby go to the masses and seeing everybody putting this plate in and then seeing subsequently the issues that that may develop with tendon irritation either on the flexor side or the extensor side because everybody's putting it in, they may or may not be following your technique. And there may be using slightly different products. What was that process like for you to see that happen?

Jorge Orbay:

You use it you hit the nail right on the head. Every time I see a complication from a volar plate, I think it's my fault. I feel miserable about it. I feel miserable about flexor tendon ruptures. I feel miserable about you know, loss of fixation with volar marginal fragments. I think the the main problem is if you don't get an anatomical reduction, the plates are designed for an anatomical reduction. So if you don't get an anatomical reduction the plate is sticking up in space and the flexor tendons are right on the surface of the plate. And many of these fractures come to the doctors say 10 days or two weeks after a closed reduction, and they collapse, or they just took time to get to the surgeon from the initial treatment treating physician. By that time, if you just do a simple volar approach, and try to pull as hard as you can, you won't be able to reduce the fracture, because there's a hematoma on the dorsal side that is now organized, and the periosteum is intact. So you can't really get the length back can't get the volar tilt, it's impossible to reduce a fracture. And that's why we have problems with flexor tendon ruptures to this day. So the proper technique is the debriding the hematoma. And for that they have to pronate the proximal fragment out of the way, which is my extended FCR approach. That is my thing. My biggest contribution more than the plate is the approach. But people think it's too aggressive and they don't want to do it. And they end up struggling.

Charles Goldfarb:

Do you release the brachioradialis in every volar approach for a distal radius fracture?

Jorge Orbay:

Great question. You don't have to in every case, because in some cases, you can actually pronate the proximal fracture without releasing the brachioradialis. It's just easier to the important thing is to debride the hematoma to allow the fra- the dorsal fragment to get down to its anatomical reduction. But in young patients that come in relatively early, I won't release the brachioradialis I will just pronate the radius, aspirate, curette, irrigate the hematoma out and supinate it back into place. And then the anatomical reduction comes in automatically.

Chris Dy:

Now, I think there are a lot of surgeons that will use this fixed angle device to you know, to help get the reduction. Now, does that technique ever have a place in your in your toolbox? Or are you very adamant It sounds like you are about getting an anatomical reduction before you apply the plate.

Jorge Orbay:

Yes, I I am very insistent on getting anatomical reduction. But I do understand that in some cases, it's very difficult. And those would be the nascent malunions. You have a patient that is six weeks down the line, there's already some early bone formation on the dorsal aspect. And you pronate the proximal fragment, you debride the hematoma you excise the dorsal periosteum, to try to eliminate all the soft tissue restraints to regaining the length. And still, it's very difficult to get a reduction because everything is contracted the fascial planes, even the muscles and the skin might be contracted at that time. So there is a place for the distal fragment first technique, you apply the plate to the distal fragment and then you lever the plate down to the radius, that helps you get the volar tilt. But when it's that tight, it's very difficult to get the length. So it's not only regaining the volar tilt, it's also regaining the length with which we do with a bone holding clamp and using that first screw that we put into the oblong hole, often you use a clamp as a mechanical advantage tool, like a lever to push the proximal part of the plate up. And it's not trivial, it's really difficult to do. And you need a good assistant to go and drill your hole and put your screw when you have down to like. But I think like 99% of the time, you can always get the reduction angle and the length.

Chris Dy:

I have one more technical question about how you approach these fractures before we move on. Did you when you started repair the pronator quadratus. And did you change? And what do you do now?

Jorge Orbay:

I still repair the pronator quadratus. I don't think you have to repair it for any other better reasons than that is where God placed the muscle and put it back where it belongs. I mean, I cannot demonstrate that the patients get a better result when I repair. But I think it's it's just the right thing as a surgeon. If we restore the anatomy the best we can we're doing what's best for our patients.

Chris Dy:

And do you have any technical pearls in terms of how you either elevate the pronator quadratus to facilitate the repair later on or how you do the repair itself?

Jorge Orbay:

Oh yes, for sure. So one very important thing is when we do the brachioradialis release, don't cut it just across but do a step-cut tenotomy So you can repair it side to side. With a mattress suture when you repair the brach-, the brachioradialis side to side. Now you have somebody to suture your pronator to, you can't structure the pronator to bone. And if you don't mobilize the flexor carpi radialis, it will not bow string and, you know, release the tension. And the sutures will rip up from the pronator. But if you have released the brachioradialis, from the distal part of the radius, got a step-cut, and you can repair it kind of loose as you repair the pronator there is not enough tension on the sutures to rupture your pronator off. And the other point is distally, when we elevate the soft tissues from the watershed line, the first centimeter or so is not muscle, it's that thick periosteum that we call the transitional fiber zone. So that tissue is very strong, so you can always put it back exactly where it belongs. And then that will cover the distal edge of the plate, which is where the tendon ruptures occur. So I think you get the biggest bang for your buck by repairing the transitional fibers zone. And then the repairing the muscle is a great thing to do if you can.

Chris Dy:

That's fantastic. Thank you.

Charles Goldfarb:

So we mentioned your first company was hand innovations and your I believe your second and I don't know if it's your last or there's other companies down the road is is skeletal dynamics and you have a number of products. I have two questions regarding your products for Skeletal dynamics. The first is your volar plate. Do you think we've pretty much gotten to the point where the volar plate is, there are a number of options out there. Yours is beautiful. Are there more advances to be made with the technology for the volar plate? Or are we pretty good. And then the second thing I do want to touch on is your elbow internal stabilizer. But I'd love just to hear your thoughts on the future of the volar plate first.

Jorge Orbay:

Thank you. So on the volar plate I think the current paradigm has been developed to a point in which there's still room for improvement. But we're pretty much far into it. And I don't think you can make a volar plate much better. One thing you can do is come up with a way of allowing the surgeon to apply the plate to a mal-reduced fracture and then reduce it correctly. Some sort of levering device for the surgeon who doesn't want to do the extended care approach, we could do that I just don't think it's the best way it's not necessary it's not the best way to do it. People do learn how to do the operation while teaching is the most important thing if I can get to the surgeon and teach them the technique, then they all should get just wonderful results with the currently available plates. There's also place for improving the hook plate, the plates that are designed for the volar rim fractures. Interestingly volar plates were introduced to treat a dorsal fractures because we thought we had the volar fractures are, you know covered with volar buttress plates. The reality is that nowadays, the more difficult fractures to fix are still the volar fractures that are comminuted. Because the plate has to be pretty distal to obtain off buttressing, and then you cross the watershed line. That's why we now are banking on the hook plate. The hook plates are an extension that cross the watershed line, but they try to minimize the irritation to the flexor tendon. And there's a place for a radial sided hook plate, there's no volar marginal fragment on the radial side. But sometimes the the scaphoid fossa requires more fixation that can we that can be provided by dorsal buttress plates. So to have some sort of buttressing a plane that is that creates a concavity underneath the the subchondral bone of the scaphoid fossa would be of benefit for some of these volar, volar comminuted unstable fractures. So we can still improve volar plates a little bit. But there might be other solutions to the volar fracture that still have not been developed properly. And a minimally invasive form of fixing extra articular fractures, which are so common in the elderly. A frail patient will come in very handy as something that can be done to a very small incision and very little time and at least stabilize 50% of the distal radius fracture, which which are completely extraarticular. I think there is room for that.

Charles Goldfarb:

Makes sense. Makes sense. So talk to us. Again, you saw another clearly unsolved problem, also a problem that the external fixture had a outsized role in caring for and that was the, you know, unstable elbow injury. And many of our listeners, I would guess, are not familiar with the internal joint stabilizer that you've created, can you just talk us through identifying the problem, how you thought about solving it, and then what things look like today.

Jorge Orbay:

And that's one of my favorite things that internal joint stabilizer is one of my passions. So the unstable elbow has been a problem for a long time, we, we tried the hinge fixators, it seemed like a great idea. But it proved to be impractical, because they were very difficult to apply. And it was very difficult to pre-produce that axis of ulnar humeral rotation, so didn't really work and the pins going through the ski- through the skin just like in the external fixator, they inhibit motion, because they hurt when the patients move the elbow. So after, after seeing all the difficulties with the hinge stick, external fixators, we realized there was placed to develop something simpler and better tolerated by our patients. But it really is just an internal, external fixator. The original hinge fixator was designed by Mori and it had an axis pin, it was a Steinman Pin that was drilled through the elbow, it came up through the skin and was attached to this fixator on the ulna and on the humerus. So it really was not that a innovation. It was just a very small fixator under the skin, but it, it really was a step forward for the elbow surgeons. What was interesting about this product was once we had realized what we need is a very small fixator under the skin. How can we guide the surgeon to always get that true axis of ulnar humeral rotation? Because if you don't get it right, the elbow doesn't really move? It will, it will, as you flex, it might distract, or it might compress the articular surface and you won't get the motion that you want. And that was the most difficult intellectual challenge in the internal joint stabiliser story. It was how could we do this. And we experimented with several different techniques, some of which was really quite amusing. So one required pins on the ulna, pins on the humerus and some Gizmo that would self align as you flex and extend the elbow and then you drill the K wire through the gizmo and it would reproduce the axis that would work but it was so cumbersome, it would make no sense. And one day, it just dawned upon me, why don't we just give him a guide that centers on the medial trochlea. So as you center the medial trochlea, you have one point on your axis of rotation, then just look at the lateral aspect of the elbow, find the center of curvature of the capitellum, mark it and drill the K wire through both points and that's the the guide on the internal joint stabilizer that was the most fun part of the whole project.

Charles Goldfarb:

And how do you so this is a rare problem. And clearly you can test it in the lab. But how long did it take you to be convinced that you'd hit on a solution?

Jorge Orbay:

Not long

Charles Goldfarb:

Me neither. It was, it's great.

Jorge Orbay:

So there was an article we published in around 2013 on I believe it was a it was a magazine was clinical orthopedics and related research. And it was about the use of a bent Steinman Pin as an internal joint stabilizer. So the first 50 or so cases that we did, were actually bent Steinman Pins. I would get a Steinman Pin, a 2.5 millimeter Steinman Pin. And then bend one eight- sorry, one end into a figure of eight. We will do this, I would do this in my garage. It's very simple. Just bended some pliers, something to bent around it and cut it. And then I would have that figure of eight, which was the plate, and then the long rest of the Steinman Pin. And so in surgery, we would find the axis of rotation 2.5 millimeter drill, and then cut the Steinman Pin to length and bend it until it worked until it fit that particular patient. Used two 3.5 millimeter AO screws to fix the figure of eight down to the ulna. And that worked. So when we already had a significant experience with bent Steinman Pin, before it was a commercial product. So in my mind, there was no question that the commercial product will work, it will just make this accessible to all the surgeons that are not necessarily willing to bend the Steinman Pin the way I was. It took a lot of work.

Chris Dy:

I can I can just imagine you in your garage and your pliers. And I'm really impressed. So you know, this has been a ton of fun. And I think very inspirational to many and some great technical pearls. But for those surgeons and our therapists who have ideas, do you have any general advice about how to pursue their ideas? And how to go, you know where to start, really?

Jorge Orbay:

Yes, I do. I think follow your passion. If you think your idea is worth it, give it 100%. Many times, the first step is actually to protect it with a patent. And this is something I didn't know. And I learned by experience, I could have obtained a very broad patent on volar fixation of dorsal fractures. But I did it because I had no idea. And I just did the cases and presented it in a meeting. And then I completely obliterated my chance of getting a patent on that concept. But that's fine. You know, cannot complain about anything. So do protect the idea, it takes some money about 10 or 15 grand to do so but it's worth it. And after that, then you have two choices. You either develop the product with a company, and that is probably the most common way of developing ideas or do it yourself. I chose the doing it myself, because I was very bad dealing with big companies and didn't have the skills to do that. And it worked for me and might not be the solution for everybody. So I think the best advice is give it 100%. And trust yourself. And you'll succeed.

Charles Goldfarb:

I think that is a that is a great way to end this interview. Jorge, I can't thank you enough for joining us. I really do mean it when I say that you are an inspiration to many of us. And you really we all aspire to obviously help our own patients, but to have a bigger impact and your impact has been immense and continues to be immense. I don't want to make it past tense. So thank you for what you've done for the field of hand surgery and wrist surgery and elbow surgery. And really remarkable. Thank you.

Jorge Orbay:

Thank you, Chuck. Those words really inspire me to continue forward. Thank you. And thanks, Chris.

Chris Dy:

Thanks for joining us. We're looking forward to seeing what's next for you. We're always excited. So thanks again for your time tonight.

Jorge Orbay:

Thank you.

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 podcast

Chris Dy:

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

Charles Goldfarb:

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