Season 2 Episode 43. Chuck and Chris review 3 new journal articles pertinent to the practice of hand surgery. Two are focused on steroid injection and the role this treatment has, especially in the treatment of carpal tunnel syndrome. The third focuses on complications with local only surgery in a large database study.
Yoshiaki Yamanaka, MD, PhD, Takafumi Tajima, MD, PhD, Yoshitaka Tsujimura, MD, et al (Department of Orthopaedic Surgery, School of Medicine, University of Occupational and Environmental Health, Fukuoka, Japan)
Molecular and Clinical Elucidation of the Mechanism of Action of Steroids in Idiopathic CarpalTunnel Syndrome J Bone Joint Surg Am. 2021;103:1777-87
Nikolas H. Kazmers, MD, MSE, Kate Peacock, MPH, Katelin B. Nickel, MPH, et al (University of Utah and Washington University Data Center) Comparison of Complication Risk Following Trigger Digit Release Performed in the Office Versus the Operating Room: A Population-Based Assessment
J Hand Surg Am. Vol. 46, October 2021
Manfred Hofer, BSc; Jonas Ranstam, PhD; Isam Atroshi, MD, PhD. (Department of Orthopedics, Kristianstad Hospital, Kristianstad, Sweden (Hofer, Atroshi);Department of Clinical Sciences–Orthopedics, Lund University, Lund, Sweden (Ranstam, Atroshi).) Extended Follow-up of Local Steroid Injection for Carpal Tunnel SyndromeA Randomized Clinical Trial. JAMA Network Open. 2021;4(10):e2130753. doi:10.1001
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.
Sign up for The Upper Hand Podcast Newsletter: http://eepurl.com/hH5qfT
Season 2 Episode 43. Chuck and Chris review 3 new journal articles pertinent to the practice of hand surgery. Two are focused on steroid injection and the role this treatment has, especially in the treatment of carpal tunnel syndrome. The third focuses on complications with local only surgery in a large database study.
Yoshiaki Yamanaka, MD, PhD, Takafumi Tajima, MD, PhD, Yoshitaka Tsujimura, MD, et al (Department of Orthopaedic Surgery, School of Medicine, University of Occupational and Environmental Health, Fukuoka, Japan)
Molecular and Clinical Elucidation of the Mechanism of Action of Steroids in Idiopathic CarpalTunnel Syndrome J Bone Joint Surg Am. 2021;103:1777-87
Nikolas H. Kazmers, MD, MSE, Kate Peacock, MPH, Katelin B. Nickel, MPH, et al (University of Utah and Washington University Data Center) Comparison of Complication Risk Following Trigger Digit Release Performed in the Office Versus the Operating Room: A Population-Based Assessment
J Hand Surg Am. Vol. 46, October 2021
Manfred Hofer, BSc; Jonas Ranstam, PhD; Isam Atroshi, MD, PhD. (Department of Orthopedics, Kristianstad Hospital, Kristianstad, Sweden (Hofer, Atroshi);Department of Clinical Sciences–Orthopedics, Lund University, Lund, Sweden (Ranstam, Atroshi).) Extended Follow-up of Local Steroid Injection for Carpal Tunnel SyndromeA Randomized Clinical Trial. JAMA Network Open. 2021;4(10):e2130753. doi:10.1001
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.
Sign up for The Upper Hand Podcast Newsletter: http://eepurl.com/hH5qfT
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. It's a beautiful day in St. Louis, you know, recording a podcast, what could be better.
Chris Dy:It is at the very least, I mean, we're doing it inside. But both of us have sunlight in the background, which is awesome. So that's, that's a win. That's a win.
Charles Goldfarb:Yeah, it won't be the case at 5pm when it's pitch black out, but we'll enjoy it while it lasts.
Chris Dy:That's okay. I'll take that. I mean, you know, so in the new neighborhood now, we go to the same church we went through before, but now we're able to walk to the church. So that was our morning time out to the outside time in the morning, my son's got a a soccer game coming up in about an hour and a half. So I'll be outside as well. It's a beautiful 60 degrees here in St. Louis, and sunny. And it's amazing.
Charles Goldfarb:That is awesome. Although if I'm remembering correctly, it's pretty much straight uphill to get to church, I imagine the walk home is a little more enjoyable.
Chris Dy:Oh, it's not that long. I mean, you know, so we have this mantra in our family that's at your, at your urging, I read that book that Clayton Christensen book, how you measure your life, and he talks about mantras. So we developed a mantra about two years ago, whatever, a year and a half ago, that's we are kind patient and respectful in our family and the number of times that the kids have heard us say that. And I honestly have to remind myself that when I'm having a tough time at work, that I am kind patient and respectful as part of this family. But you know, we were doing something yesterday, and Rafi didn't want to do something because it was hard. And my wife was like, you know, we do hard things in this family. She's like, maybe we should add that to the mantra. So we are kind patient respectful, and we do hard things. I don't know if we can change the sign that our nanny last year made us.
Charles Goldfarb:That is really funny. Bring in a little Peleton.
Chris Dy:You know, I guess that's where it came from. It's got to have come from there. But yeah, so the walk uphill is not bad. It was a beautiful day. I actually was thinking on the way home, I was like this might be kind of painful. Come February, if there's ice and snow. I was like maybe will drive then, but it really isn't very far. So it's nice.
Charles Goldfarb:I love it. I love it. I'm glad you're settling into the new hood and hopefully met some neighbors and the like. And.
Chris Dy:Yeah, Halloween was great for that. They do it big here. I mean, I had never seen anything like it in terms of you know, everybody out with fire pits. And you know, that whole deal, which was nice and welcoming. And you know, the kids really enjoyed Halloween. They obviously our three year old really took to running everywhere to get candy. She tired out after about 40 minutes. But you know, the first 30 minutes she was sprinting to every door just yelling Candy, candy candy. It was cute.
Charles Goldfarb:For a while.
Chris Dy:We had to remind her about her manners a couple of times. But.
Charles Goldfarb:That is good. I do have to say most listeners, this will not resonate. But I do love the St. Louis tradition where you just don't go get candy in St. Louis, you have to typically tell a joke, which is there's nothing better than five year olds or 10 year olds telling jokes and Knock Knocks. And I think it's a great tradition. I think it's great.
Chris Dy:Yeah, I had never seen that until coming here. So our daughter took our son's joke. And she got to the point where she was so excited. We had to remind her about the joke thing. She'd run to the door while yelling candy. As soon as she got to the people, she would just blurt out the joke immediately without being prompted. No pause for the punchline, that kind of thing. And just hold out her bag. And I'm like, well, at least you told the joke.
Charles Goldfarb:That's part of the joy, part of the joy. All right, what do we got lined up for the show.
Chris Dy:Well, we're going to talk about some articles from our recent journal club, you know, so those of you that follow us on YouTube, we've noticed that the journal club sessions have gotten a lot of traction and have been very well reviewed. So we're gonna bring that back, and would love to hear some feedback from listeners, whether you think that's a useful thing. I mean, we won't make it strictly about the articles will include kind of the context and how it may inform or not inform our practice. So hopefully, you'll tell us if it's useful. Send us your feedback handpodcast@gmail.com or@handpodcast on Twitter. And I wanted to read an email that was sent to us by Brittany Mitchell. She is a working towards her CHT and she is a hand therapist in Salem, Virginia. And she gave us a bunch of questions and great feedback and I want us to just take a piece of what Brittany had told us or asked us. So here's one steps taken for assessment and treatment of the arthritic patient How do you know when to perform surgery versus conservative management? And do you prescribe therapy first? Or does it depend on severity of arthritis? Now, Chuck, these questions are usually for you, because you're the OG, you're the, you've got all the wisdom. So I want you to take a stab at these.
Charles Goldfarb:Well, for better or worse, in my practice, much of this is patient driven. And I think most of the listeners can appreciate that. That is different, necessarily than the rest of the world. And patients do drive their care here, which of course, important they should, although I think it's our responsibility to guide them to, you know, the concept of value based care and really, the best care and certainly jumping to surgery is not typically what we do. The value of things like therapy, honestly just simply hasn't been proven, especially for diagnosis like arthritis, there are a couple of good manuscripts looking at the role of therapy and CMC arthritis with some pretty good results. And I do share that with patients, and absolutely make that an option for patients, especially earlier in the arthritic process. And my experience wants you to go down the path of using steroid injections to modify symptoms from arthritis. At that point therapy is typically less helpful, and then it becomes purely a patient driven decision. It is almost never. And I can think of a few exceptions, but almost never do I push for surgery in situations for arthritis. And I you know, we've talked about this, I don't know if I captured well, your thoughts on the topic, but that's where I stand.
Chris Dy:Yeah, I think duration of symptoms. And, you know, attempts that other treatment are what drive me towards surgery for a lot of my patients. I don't use radiographs as much, mainly because we see it routinely that not only in the thumb, but also in the knee and the hip. For those of you that are orthopedics trained, the X rays don't correlate with symptoms. I've seen awful X rays in patients who aren't bothered at all. And I've seen pristine X rays and patients who have terrible symptoms. So I don't use that to drive my management. One thing I do make a point of is eventually if I do get X rays, and I don't get X rays initially on many of these patients, I usually get X rays only if we're kind of heading towards surgery, mainly for surgical planning, and also to show patients their X rays. I think that's very illustrative and helpful thing. I tell the trainees this, you know, I try not to I try not to indicate surgery on the first visit. Now there are exceptions to that if somebody is, you know, had a treatment for a long time, for example, I see some of Dr. Gelberman's old patients now who have had lots of therapy and lots of injections, and they're ready. And then I also, you know, I think I'm probably in the minority on this, I try not to put needles in people on the first visit. It's silly, but the needles hurt. And I don't want that to be their first impression of me. That being said, if they're in misery and lots of pain, I will offer the injection. But, you know, usually we have the privilege of having therapists, colleagues in our clinics most of the time. So that's one entree into therapy. And sometimes they've seen the patient before me and kind of told me yeah, they're there. They're ready to person for an injection, or they want to do some form of therapy.
Charles Goldfarb:Yeah, like everything you said, it's interesting. So earlier, and definitely more than 10 years ago, I was involved in a clinical practice guideline development process for the Academy on CMC arthritis. And you might think yourself, that's Chuck, I missed that one. And that would be because it never, it never was completed. I think likely because there was so little literature to guide us. But I remember sitting in this conference room being on the younger side, way back then, and listen to a couple of the older hand surgeons say, well, we don't even get our we don't even get X rays. You don't need X rays is a clinical diagnosis. X rays don't help you in any way. And I'm thinking to myself, but of course you have to get X rays. And now I'm like X rays don't help me at all. It is a clinical diagnosis. It is easily reproducible. In almost every case, there are exceptions, but almost every case, you know the diagnosis, you can see the pathology, whether there's a contraction of the CMC joint or, or just pain, and it was an evolution and and I don't, I don't get X rays along the way, unless like you said, I need them to talk to the patient. Or sometimes when I'm considering surgery, I'll get X rays, but it's not a priority.
Chris Dy:It's interesting. There are some times where it's totally patient dependent and even you know, we've gotten our Press Ganey patient satisfaction surveys back recently. And I admit I'm not perfect, and there are times where patients are unhappy and usually the patients that are unhappy that are the ones that are more vocal and have more apt to leave comments. And one of the comments I got was he didn't even get the X rays. And I'm like, Listen, I don't expect the patient understand that that's not you know, you know, that test is not going to change my management but I feel like sometimes there is a fear pubic components, you know, to getting an x ray in terms of having not necessarily going through the X ray with them, but knowing that you cared enough to get an x ray for them.
Charles Goldfarb:Yeah, it's really interesting. And clearly communication wasn't ideal. And often find that sometimes I'll go ahead and suggest X rays because you just see the patient may not say it, but you just see that they want something more in the X rays can be that something more. And you're right sometimes is just a almost necessity for the patient to leave your office satisfied that you did what you need to do. It's also the the other mantra of they like to leave with something, leave with advice, or leave with a handout or leave with a link of I think that really matters to some patients, but which patients and is always the tricky part.
Chris Dy:Let's just say in my, in my practice, or my clinic, we have a whiteboard in which I write kind of everything that I asked our team to do. The term x ray, OWO meeting X ray on the way out, and not coming back, as become much more frequent than the last year. Because it's just easier honestly, to send them for X rays to have them understand that we did it for them. I review it and I'll call them if there's any issues or anything like that. But again, you get the sense some people just want something to leave with.
Charles Goldfarb:Yeah, couldn't agree more. Couldn't agree more. That's a great, great conversation piece this, the questions.
Chris Dy:So yeah, Brittany, thank you for the fantastic email, we will get some more of your questions. And I know that you wanted to come to the to the ASHT meeting, but couldn't, you're busy, you got two very young kids, we certainly will send you something in terms of swag, because of your great questions and engagement. And, you know, thank you for listening. And again, if anybody has questions, please submit them through the through the email account, and let us know. And then also sign up for the upcoming it's been upcoming for a while but the upcoming newsletter, and in this newsletter, we will also include links and details about the articles that we're going to talk about now. So Chuck, what does the number 2000 mean to you?
Charles Goldfarb:Yes, we have about 200 people signed up for the newsletter. Granted, we have about 1200. And growing it's really super satisfying, we continue to get about 1200 regular listeners, but 150 of you have signed up for the Number 2000. newsletter. And hopefully that momentum grows. So we're close In the year 2000? No, no Conan O'Brien fans? it's on my list of things to g t done. I hope it gets done th s week. And I do think it'll ma e for an interesting forum f r discussion. And we again, we' e never looking for one w y discussion despite our choice f podcast format. So we lo k forward to feedback, of cour e on this and other things that e d Yeah, that didn't help me. Tell me what should it mean?
Chris Dy:So we have over 2000 downloads a week for the podcast. So thank you, everybody, for checking us out. Telling your colleagues um, you know, it's a, it's something that we're very proud of, I had to update a an educator portfolio recently. And I did it one time before promotion, and had to do at one time since then. And it was very nice to change the number from over 1300 downloads a week to over 2000 downloads a week. So thank you, everybody.
Charles Goldfarb:Yeah, it's fantastic. Yeah, it means the world and it's why you and I are sitting here on a Sunday afternoon talking to each other.
Chris Dy:Well, let's, let's jump in. So we should probably should tackle the intimidating article first, that basic science article that amazes me, but also is very, in some ways difficult to interpret. So this is a from the group, Yamanaka et al. and out of out of Japan. And this is in the in the October 6 edition of jbjs. So it's molecular and clinical elucidation of the mechanism of action of steroids in idiopathic carpal tunnel syndrome. That's a mouthful, but how does steroids work? For carpal tunnel? So Chuck, before you read this, what was your thought of how steroids work in those who you choose? chose to give steroids to?
Charles Goldfarb:Yeah, I would completely buy into how I think steroids work everywhere as an anti inflammatory period and kind of end of story. It's it's the explanation I give for the wrist when we're doing you know what, potentially with the TFCC tear, but it's absolutely how I conceived of steroids working for carpal tunnel syndrome. about you is that it was your impression as well.
Chris Dy:Yeah, my normal shtick is you know, when you have carpal tunnel, there's some swelling in the carpal tunnel it presses on the media nerve cuts off the blood supply to the median nerve because it's a confined space, and the nerve starts to get aggravated and irritated. And when it goes through this kind of dynamic ischemia, that's when you start to get the pain and paraesthesia as then, you know, this is kind of on the earlier side of the Earlier side of the condition, so yeah, the same impression that you injected there in in the carpal tunnel, you would cut the swelling presumably from the synovial, surrounding the flexor tendons. And as you cut that swelling, the nerve would have, quote, more room to breathe. I didn't think it was swelling in the nerve itself, though, but I thought it was swelling in that confined space.
Charles Goldfarb:Yeah, absolutely. And the authors here kind of did really did two studies in one and I don't know if this was related to feedback they got during the editorial process, I actually didn't think it was necessary. They kind of looked at, you know, outcomes with steroid injections in a group of patients. But that's not what you and I are focused on, we're really focused on the part where they it's really interesting, they, they collected fibroblasts, from the sub synovial connective tissues, during carpal tunnel release for patients with idiopathic carpal tunnel, and they incubated them with or without triamcinolone for for one, three or seven days. And then they looked at expression of fibrosis related genes and expression of inflammatory cytokines, which is just a super interesting thing to do. So kudos for thinking about an age old question in a very 2021 kind of way.
Chris Dy:Yeah, I think it's interesting. So for the listeners that, you know, my simplistic understanding of the basic science of carpal tunnel syndrome is that initially, you will have some inflammation. And as the process goes from this dynamic ischemia and becomes more of a sustained and prolonged compression of the median nerve, there will then be fibrosis within the nerve, that can lead to some of the longer term findings that you see the more advanced findings. Now, they were not studying the nerve itself. So they did not sample the nerve, but they studied the tissue immediately surrounding the nerve. So what they found was interesting enough is that when you incubated, you know, the, the sub synovial tissue with the steroid is that it wasn't really the inflammation that was cut, it was an effect on fibrosis related genes. So you know, this was super interesting, and way beyond me in terms of the basic science, but I thought it was interesting that it was more about the steroid working on the fibrosis as opposed to the steroid working on the inflammatory components.
Charles Goldfarb:Yeah, I mean, I think you're pointed, this is not the nerve, this is the surrounding tissues is important. But it's really dramatic findings that really change how I think about this. And the next paper, we're going to talk about clinical outcomes from steroid injection, which again, I think is more is, is better done than then what they did in this paper. But it's an important thing for us to process, it's important probably to share with the sophisticated patient. And really, I think it's important for us to consider, you know, think about this as we move forward with additional investigations.
Chris Dy:So for me, I mean, I don't know it doesn't, it changes a little bit how I think about does not change what I do, because we know that the steroid injections in that patient in the certain population will work. Now the longevity is what we'll get into it in the next article, and whether it makes the true difference, but it will work temporarily. It doesn't change what I offer patients, I guess I've changed how I talk to patients about it, I kind of go back on the whether it cuts inflammation around there. I think it may have some really interesting applications in the future. Say for example, we did gene based therapy for carpal tunnel syndrome. Now we know where to really target. But that is, you know, far away from where we are right now. And far away from what we do is hand surgeons I think.
Charles Goldfarb:Yeah, and the other thing, which, you know, resonates with me is another diagnosis, which would be tennis elbow, because we talk about tennis elbow as not being an inflammatory condition. And one of the justifications, some use to avoiding steroid injections is just that. And yet, this article shows that steroids can have an effect even beyond or maybe instead of the anti inflammatory effect. And don't get me wrong. I'm not advocating steroid injections, because while I do use them, occasionally, there is pretty good science out there that they're not the be all end all for tennis elbow, but it just makes me think about that diagnosis as well.
Chris Dy:So let's get into the next article. So this is from Hoffer at all and this was from Lund University in Sweden, and this is extended follow up of local steroid injection for carpal tunnel syndrome and RCT. And this was in JAMA Network open and it was published and we look at the publication date, October 22 2021. Again, this will be in the show notes and then in the newsletter. So they did an RCT here, and this was amazing five year follow up after steroid injections. So there's a lower dose of 40 milligrams of methyl prednisolone and then double that dose and the second arm of the study, and then a placebo and a third arm.
Charles Goldfarb:Yeah, this is great. And this is actually this paper this. This group of patients has been previously studied and reported on so this is almost a follow up study. But man, this is super well done. and really gets to the heart, it is interesting on perspective, it gets to the heart of why we think about injections. And just briefly to summarize, so they had they had more than 100 participants. And the bottom line is that steroid injections were effective in the sense that they decreased symptoms for a mean of about six months. And they slightly, but not dramatically, in my mind, decrease the number of patients that went on to carpal tunnel. So as a surgeon looking at these data, essentially, it confirmed what I already thought, steroid injections buy you time, but do not fundamentally change the benefits of surgery. And most patients come to surgery. And often it's not very long from now. However, the way the article reads is kind of like, well, steroids are great, they're a great option for patients to consider. It's just not the way I think about it.
Chris Dy:Yeah, I think it's really interesting. So in the plus, let's look at the actual results here in the placebo group, the number of percentage of patients that went on to have surgery was 97%, within five years of the injection, in the low dose steroid injection group, the percentage that went into surgery was 92%. And then in the high dose, it was 84%. So 84% of people still want to have surgery. Now that is significantly lower than you know, the 97% of the placebo. But again, 84% went on to have surgery. But the way that the conclusions and relevant section of the abstract reads, you would think that an insurance company potentially who may not read the entire article, somebody from an insurance company, may say, you know, what, why are we paying for surgery and all these patients?
Charles Goldfarb:Yeah, and that would be a huge error. And the other I think, all this is interesting and helpful. To me, the most important take home message is the time to surgery, which is pretty consistent at 180 days. So this says, Look, on average, you can expect six months of going down your current course, but then on a you know, on average, that's when you will consider surgery to be the right approach for you, which is pretty disappointing, because that means that if it was six months until surgery, presumably they're thinking about surgery as early as three months after an injection. And so to me, this means that injections again, don't really have a strong role in my practice, unless there's a specific patient driven thought process around delaying an intervention.
Chris Dy:Yeah, so in the placebo group, they had the meantime to surgeries for months. So you know, like you're saying, I think my take home on this is that it works by the time probably gets you about six months. And I think that, you know, this kind of segues us into the next article, the article from Kazmers, and the group out in Utah, that looks at you know, complications, potentially whether you did this surgery for this is an example of a trigger finger release, but probably very similar findings for carpal tunnel. Nice. So, you know, with for me, the advent of local only surgery without a tourniquet has changed, I think my threshold to indicate surgery, both on a medical basis as well as on a hand surgery basis.
Charles Goldfarb:So Chris, I could not agree more, is just so simple. And I don't want to be a naive and be in come across as unaware of risks, even in a in a local only type procedure. But the local only procedures really are so much less demanding on the patient. There's so much less demanding on the system. And they're just easier in every way and less expensive and greener in the sense that, you know, we're saving the world from the all the rigmarole that goes into a or based procedure. This study is timely and really is impactful. It took the simple example of triggers. But really, it's it can be extrapolated, as you mentioned, to certainly carpal tunnel, if not further.
Chris Dy:So this is from our WashU residence, the alum, Nick Kazmers, who has been doing amazing things with the group at University of Utah. And so this was published in JHS and the date of publication let me pull this up here. I don't know if so yes, so this was in the October issue of JHS. So the article title is comparison of complication rates following trigger finger release performed in the office versus er, population based assessment. And they actually worked with our administrative data group here at WashU, who I've worked with a lot. So methodologically, I think, among the most rigorous of all of these groups who use administrative data, so I immediately knew that it was a well done study. I actually remember connecting Nick with Margie Olson to do this study, and then forgetting all about it and then reading the study and think oh, so they finally did it. So these MarketScan which is a commercial insurance database, the US to know Medicare and no Medicaid, but just Commercial insurance in the US. And they looked at almost 28 to 38,000 cases 7600, which were done in a procedure room and 30,000 that were done in the OR. And they looked at the risk of medical complications, which was significantly lower in the procedure room setting. And they also looked at surgical site complications, which was not significantly different, although they're just those of you that want to know the absolute percentages, there was point six 7% in the procedure room cases and point 8% In the or cases. And there were very few atherogenic complications, you know, less than point oh, 7%. And in the, to me, point oh, 7%. And procedure room and point oh, 9% in the OR. So, you know, this was really interesting. To me, it showed that procedure room cases can be done quite safely from both the medical perspective as you would expect. And from a surgical perspective.
Charles Goldfarb:It is timely in the sense that there is a group of us and I will put myself in that group in the past, but I think I'm a, I'm a convert, but there's a group who says, Look, I don't know about the infection risks. And I don't know about complications, I don't know about lighting. And I don't know about can my can my group handle it? The reality is, you know, local only surgery is a win. And yes, it absolutely requires system based thinking. It requires coming together on processes and doing things differently. Now, let's be honest, you and I are still on that path to figuring out how to do this efficiently, safely and effectively. But this is the future. It's just it's not it's right in every domain. So why aren't we doing more of it?
Chris Dy:One would argue that it's not the future, and perhaps we are behind, because clearly, you know, this is happening in a substantial number of trigger finger cases. So you know, 7600 out of 38,000 cases, you know, that are going on. So, you know, we should be doing this more. One thing, you know, I this is a fantastic article. One thing I wish that Nick and the group had compared were the local the procedure in cases with the local only in the OR cases. Because I thought that would be an interesting comparison. And I'm sure there there were reasons why they didn't do it. But I, I think that that would give me a better sense of the complication risk, more apples to apples.
Charles Goldfarb:I think that's a great point. It is a nice segue. It's a nice intermediate step to go from traditional hand surgery to local only in the OR to local only in the clinic. And I think you and I are sort of on that spectrum of more the middle group and growing local only group.
Chris Dy:Yeah, we we've talked about it on the pod in the past, but when we had our second wave of our closures back in December of 20, you know, when they closed our ambulatory centers, you know, I did, I think 20 cases in the office triggers and carpal tunnels and the queer veins. And you know, we informally administered a survey, and now we're waiting for it's in peer review at a QA journal. But the patients overall were incredibly happy and knock on wood. I mean, I think I'm out of the window of complications from those cases, at least the ones that you worry about the most, and, you know, patients did really well. Now, again, like he said, it took a lot of work to make that happen. But I think that's the way that we're gonna end up going.
Charles Goldfarb:Yeah, it you're right, it is the future, but it is now and you are you and I have to catch up with jackets.
Chris Dy:Again, it's not the future, we're just behind.
Charles Goldfarb:Alright, well, I loved all three of these articles. I think they're all impactful. And we'll be cited in years to come. So it was fun reviewing and but you?
Chris Dy:Yeah, absolutely. I mean, so it is, you know, I have to put on my fellowship director hat and say that, you know, this is the kind of stuff that you're going to get if you were to check out our fellowship program, you know, applications throughout right now, Marty and I actually did our first ask me anything. session yesterday, it was incredibly well attended for being this far away from interviews. So we had 15 people on including some PGY threes and that aren't even applying yet, which was really cool to see. So we're really thankful for everybody that participates. I'm sure some of you also listen to the pod as well. And my son made a guest appearance and insisted that I use a zoom background that was a tiger, which was a little bit weird when he like actually stepped away and I had this like Tiger King thing in the background. But anyway.
Charles Goldfarb:Yeah, a little weird, little weird.
Chris Dy:Well, I enjoy the rest of your day. And Chuck, thanks for chatting about these articles, and we look forward to the next pod.
Charles Goldfarb:Absolutely. Have a great day.
Chris Dy:You too.
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 dy. 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