Season 3, Episode 1. Chuck and Chris are excited for Season 3! We share some updates and then dive in with a case discussion for our classification- guided approaches to managing Kienbocks Disease.
Sign up for The Upper Hand Podcast Newsletter: http://eepurl.com/hH5qfT
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.
Season 3, Episode 1. Chuck and Chris are excited for Season 3! We share some updates and then dive in with a case discussion for our classification- guided approaches to managing Kienbocks Disease.
Sign up for The Upper Hand Podcast Newsletter: http://eepurl.com/hH5qfT
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 podcast 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 things hand surgery related from technical to personal.
Charles A. Goldfarb:Please subscribe wherever you get your podcasts.
Chris Dy:And thank you in advance for leaving a review and leaving a rating wherever you get your podcast.
Charles A. Goldfarb:Hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles A. Goldfarb:I am great. Welcome to 2022.
Chris Dy:Welcome, welcome, and welcome to a freshly recorded intro only took one take. Right?
Charles A. Goldfarb:You had just just one, just one.
Chris Dy:We'll see if that one actually worked out.
Charles A. Goldfarb:Yes, it'll be beautiful. So this is season three. Pretty crazy.
Chris Dy:Are you keeping track of seasons? How does this even work with seasons?
Charles A. Goldfarb:I don't know. I think it is our third year. Maybe our seasons are annual.
Chris Dy:We started what January of 2008. Okay, sure. So this is our third season. Okay.
Charles A. Goldfarb:Yeah, I think, you know, most podcasts don't get out of into double digit episode recording. So we've we've crossed a few barriers and, and we have done some soul searching about what we want this podcast to be. And here we are.
Chris Dy:Well, we can keep putting out episodes, I don't know if anybody's gonna keep listening. But it's not hard to get out of double digits. If you just put your head down and do the work, like one of my mentors tells me
Charles A. Goldfarb:that that is true. Just put your head down and keep on plugging.
Chris Dy:You got to put your hand up at some point and see the forest from the trees. But yes, it's been. It's been nice to have a little time off. He has you know, December is a crazy time from a practice perspective. And it's just a crazy time from a personal perspective with everything going on and certainly has not done us any favors.
Charles A. Goldfarb:Yeah, I think you and I had talked about taking a couple of weeks around the holidays. And then yet this this small COVID thing has interrupted our cadence a little bit, but we are back. And we are we have a good plan to move forward.
Chris Dy:We do and it's so it's the middle of January. And I'm supposed to be in California right now at the ASP and meeting. But I'm not so for those of you that did make it to the meeting, I'm sorry, I couldn't make it. It is one of those things where it's actually a meeting, I look forward to the most of the year because I get to learn so much. And I get to meet people that I want to talk to and clearly that was going to be stunted by the everything going on with with Omicron and then washy with for issued its own travel restriction.
Charles A. Goldfarb:Yes, interesting. I've never been to that meeting. I know that people who go feel strongly about it. And I really feel for the meeting organizers because I think in the fall, we all felt pretty good about where we were and prospects for meetings. And I still haven't been to a major meeting since I guess hand society 2019
Chris Dy:Feels like a long time. That said before you were a famous podcaster.
Charles A. Goldfarb:That is very true. Very true. I don't know what it'll be like, I may have to wear sunglasses, right?
Unknown:I think you'll be okay. So I you know, I have a really interesting case that came into my clinic recently. And I know that you've probably treated some similar cases, but I had a case of Kienbocks come in. And she is in her 60s. And was referred to me because, you know, the surgeon who was seeing her wasn't quite sure what to do. And she has wrist pain, that's dorsal and Central. She's had it on and off, but really gotten worse in the last few months. And you examine her so she was exquisitely tender over her lunate hurts whenever you passively move her wrist. And on her radiographs. She's got a little bit of sign of collapse. But the thing that was most striking to me is that her radioscaphoid angle is about 80 degrees. She came in with an MRI. So we reviewed it together. And she's clearly got no signal in the lunate relative to her adjacent purpose. So she's 60 ish. What did you do? I know that doesn't seem like you know, very old compared to you. But, you know, what do you do in that case? Oh, and I should say she's on their neutral? Yeah, well,
Charles A. Goldfarb:60 does not seem far away. It's right around the next bend. Actually. It's a great case. I think there are, if you this is one of those situations and I do say this in clinic to people. If you talk to 10 hand surgeons, you will very likely get three different answers to this clinical scenario. And then I would go on to say here's why I think this option makes sense for you. But I would share different options. And at
Chris Dy:that time that I would probably say if you talk to 10 Hand Surgeons is you're gonna get 13 opinions. That's what that's the line that I use and actually use that last week and click
Charles A. Goldfarb:through all that you want to talk through the options we would consider for this and then you can guys zero in on the one that appeals to you and I can share the one that appeals most to me.
Chris Dy:Sure. Well, I mean, the first one that's on the table is non operative treatment. You kind of know where this story's going. But at the end of the day, in my book, she's going to get the same treatment, whether I do it next week, or in five years. And I would include things like adaptive, you know, modalities and stuff with therapy, you know, my activity modification, and also steroid injection, I think that is clearly a reasonable way to go in a patient of this age, with keen box disease that's looking a little more advanced. So that's where I would honestly start, and I offer that to her.
Charles A. Goldfarb:I think that's very reasonable, it does raise the question of Natural History, and age based determination of treatment. And so, you know, I don't think I would start there with a 15 year old. And I certainly don't have much of a role for steroid injections in younger patients, although one to me is never an issue. But totally agree with that as a starting point for management in this patient, especially given that her SL angle, I'm sorry, her radio scaphoid angle is a degrees.
Chris Dy:So I mean, before we dive into the other treatment options, how do you think about the natural history of this condition? I mean, how do you think about the pathogenesis of this condition? One of our listeners and friends of the podcast, Rob Gray, told me on a tweet that he thinks COVID is going to lead to a bunch of ischemic related conditions like kidbox. And he thinks he's right. I mean, Rob thinks he's right all the time. I love your job. But you know, you're never wrong. Right.
Charles A. Goldfarb:It's a great question. I don't know that I disagree with Rob, I certainly have been seeing Kienbocks, but I haven't necessarily attributed that to COVID. I, I've been, you know, one a month, I think over the last six to nine months, which to me feels like a lot of keybox have not directly related to whether they've been positive for COVID or not. There's no great that there's no good natural history studies out there. I think our assumption is that whatever the ideology, and we can make all kind of hypotheses, I think it certainly there are some that are idiopathic that are some that are steroid related. And there's some potentially or post traumatic, but whatever the ideology. You know, the worry is when the loonie collapses, then you have essentially flexion of the scaphoid. And the biomechanics of the wrist change in arthritis ultimately develops. And so seeing that early patient, especially in the younger age group worries me that if I don't treat them proactively, I could regret it.
Chris Dy:Yeah, so I mean, I think that for those listeners that are not as familiar with Kienbocks, we're talking about, you know, in a vascular necrosis of the loonie, so blood supply for whatever reason gets cut off to the lunate. The lunate is dying, a slow death, usually a slow death, maybe a fast one sometimes. And you know, just like all the other conditions we talked about related to the scapholunate joint , anytime there's a break in the integrity of the scaphoid and lunate whether it's through a scaphoid nonunion or through an SL ligament tear, or through Kienbocks escape, little flex, and when the scaffold flexes, it does bad things.
Charles A. Goldfarb:I think that's well summarized, absolutely well summarized. And so, you know, some of our treatments are designed to save the lemonade, so to speak. And some of our treatments are almost ignoring the lemonade, and trying to take care of the pain only. And so that's why the suggestion of non surgical care is really trying to just modulate the pain without doing anything specifically different.
Unknown:How do you think about the the role of ulnar variants and Kienbocks? Because one of our mentors had, you know, Richard Gelberman had talked about had written some papers about the role of potentially have all their negative variants contributing to keen box disease. But there's also been, in decades later, contradictory evidence about all their positive variants contributing to the inbox disease. Now one of the underpinnings of treatment is radial shortening osteotomy in the setting of another negative variance. How do you view that conflicting literature in 2022? I don't think any of our listeners or anyone who knows the literature would argue that shortening the radius helps symptomatically with gearboxes, it absolutely helps with the pain. It's a very reliable treatments not perfect. It's a very reliable treatment. I certainly haven't. I wouldn't say that I truly understand the role of owner variants. In the development of Kienbocks, I simplify it for my own mind and for discussion with patients in that when I shorten the radius, I changed the loading of the lunate and therefore help pain and hopefully modulate the natural history. So yeah, I think you said it very carefully, which is important to distinguish. It helps with symptoms. I don't know whether it changes the natural history, I think that we have a good sense that, you know, you exam somebody with cane box. And if they're pre collapse, and they're tender over their lunate, you change the variance, however you change it. Usually they get better in terms of not being tender. And some would argue you don't even need to change a variance, you could potentially just do a metaphyseal core decompression of the distal radius. I know there's literature out there for that. I mean, what do you think about first off the core decompression technique? And then second off, if you have somebody on their positive, do you just shorten the ulna? Okay, so, yeah, so there's a lot there. So I guess I would say part of my challenge with Kienbocks, and part of the challenge of reporting outcomes is, at least in my hands, I often offer more than one treatment simultaneously. And so in a younger patient, who is ulnar negative, and so again, just to be clear, for those listeners who are not 100%, with us, all their negative is obviously that the ulna is shorter than the radius. And so you can then shorten the radius by a couple of millimeters, I don't think anyone's ever concluded that the amount shorten matters is just the fact that you are shortening the radius. And you can do so without risking on a carpal impaction, or owner side of wrist pain. But what I often do is I combined treatments. So in my in my, in the last year, at least a half dozen times, and some of it colored by our, our Outstanding Guest, Steve Moran, I often perform a radius shortening, osteotomy and a revascularisation of the lunate. I think that shortening the radius, a core decompression, and we should probably explain what that means. And traditionally, people talk about a closing wedge osteotomy to decrease the the inclination of the radius, all achieve the same goal, which is somehow or another, changing loading patterns changing vascularity in the area of ballooning.
Chris Dy:Feel very sportsy.
Charles A. Goldfarb:That's dangerous.
Unknown:That's why you like it. That's why you like it. Yeah, it works. Honestly, it works. And I think that if there's a bright young hand therapist or hand surgeon and wants to study this, I mean, it's it's a condition that'll it'll be around. And, you know, I think you can learn a lot about the carpus through with keen box as the lens. And it's very, you can tell a very compelling story with Kienbocks in terms of the images and pictures. I'm just thinking about writing how you could write a grant or something like that. But you could definitely tell a story with Kienbocks. For sure. One of the challenges that I think our group helped with was how do you even quantify whether the loon aid has collapsed and whether the carpus has collapsed around it, which was Dr. Gelberman impetus for kind of leading the effort to show that the radioscaphoid angle could be used as a proxy to understand whether the carpus was collapsing?
Chris Dy:Now, let's not be too humble, let's let's be honest, who the first author on that paper was it was a workman just hammering nails, none other than my co host. Chuck Goldfarb was the lead author on that paper.
Unknown:Well, thank you, I'm humbled, but I was just a worker bee, let's be honest. But that's a good example of why having a senior partner like Dr. Gelberman, who could, you know, had a had a vision. And I do think it was impactful paper certainly affected how you and I think about defining carpal collapse in Kienbocks. So looking for context, you know, prior to the paper that that Chuck and Dr. Gelberman wrote, you would look at various stages of collapse based on carpal height. So you would look at on like the PA radiograph of the wrist, you would see, you know how how much has the lunate shrunk how much as the carpus as a unit shrunk relative to something constant, like the length of the metacarpals. And that ratio was always a little bit tricky. And then on the lateral view, you would try to look at something like, you know, the interest scaphoid angle or the SL angle. But that was always messy because you're lunate. It's not normal. So how could you rely on your say your SL angle? So your Scaphoid should be relatively anatomically normal, although it's going to be flexed down and your radius is going to be radius. But if you're looking at the indirect effects, and the long term effects of this of keybox re escape what angles way easier to measure? And what was the number that you came up with in terms of you know, whether something was, you know, more advanced or not, was it something over 60 degrees, I think,
Charles A. Goldfarb:I think it was over 60 degrees. It's not a long time, but I think it was over 60 degrees. But the other interesting thing is one of the things that impeded research on this topic was the original requirement that you had to see the entire length of the third metacarpal. So right, right, in the olden days, when people like me would go look at the, you know, we'd pull all the X rays, we'd have a huge bundle of X rays, and we'd go pull out the we'd be Looking for a preoperative X ray, where you can see the whole third metacarpal and you wouldn't always see it so you could never calculate the angle. It's just interesting how very practical considerations affect our ability to
Unknown:move the field forward. Absolutely. So actually, you know, in preparation for this episode, I talk a lot with our residents and fellows about taking notes. I pulled up my Kienbocks disease notes from last edit was on March 25 2015. And it says here, the Stahl ratio, the modified carpal hightened scaphoid ring sign are not reliably different in 3A versus 3b, Goldfarb, JHS 2003. So there you go. This is the best measure radial scaphoid angle.
Charles A. Goldfarb:Thank you. I appreciate that. I don't know if it's widely accepted or not. I don't have a sense of whether people use that to help their treatment.
Unknown:Well, so how do you think about treatments? I mean, so when is you mentioned this big kind of is lunate salvageable, are you going to try to salvage the lunate? When is it just too far gone? When you no longer going to try radial shortening alone? When do you maybe need to bring something some blood supply in or when is that not even an option?
Charles A. Goldfarb:So, in patients with me, we just run through the the grading system real quickly. So the basis is the liquid classification right. So stage one is radiographs, may we can just go back and forth stage one is radiographs look fine. But on MRI, you can see changes in the loonie.
Chris Dy:Or if you didn't have an MRI back when things are being described, perhaps just a bone scan being positive. That's what I have in my notes here. Yeah, back in a day. So then I have here as a stage to being you're seeing some sclerosis on the plane films. And there's some more density and illuminate but there's no collapse and no bleak films can be helpful for that. Right And sorry, stage three, we start to get into some collapse.
Unknown:Right and stage three has lunate collapse. And the question is does it also have scaphoid flexion. Or some would say scaphoid rotation. And again, that's what Krishna just described how you decide. So three A is illuminate is collapsed. This scaphiod is maintained in his position. In stage 3 B's the lunate has collapsed, but the scaphoid has also flexed. And then stage four is the consequence you get whenever the scaphoid flexes when it's not supposed to. And that's when you get the pan carpal arthritis.
Charles A. Goldfarb:Right. So let's go you want to go stage by stage? Sure. Yeah, that's the thing. It's a good way think about it. Okay, which makes this a good classification, right? I mean, it does, it does help. Not all our classifications do that.
Chris Dy:The Lichtman classification as modified by Goldfarb.
Charles A. Goldfarb:Thank you. Thank you. So stage one is really radiographs look, okay, MRI or bone scan, if you know what that is, or can access one which most of us can no longer get bone scans. And those patients who fail conservative treatment, I think that is a fantastic candidate for vascularized ambassadors bone graft procedure,
Chris Dy:how many injections will you give them, you know, phrase in terms of non operative treatment?
Charles A. Goldfarb:Oh, I don't think continued injections are my solution to this problem. I would be given them one injection, then I would move on. Is this someone you'd consider something different?
Unknown:I don't know. I mean, you know, we talked about, you know, obviously, steroid injections and the local anesthetic that accompanies them usually are not benign to the cartilage. So certainly, you know, keep that in mind. But I think that, you know, somebody is doing well with injections, I'd be hard pressed to steer them towards surgery, I'd be probably, depending on the age would would influence me. I mean, I think in a 16 year old, if there's somebody with stage one disease, I probably would give them injections until the cows came home. Now 15, 20, 30 year old, maybe one or two?
Charles A. Goldfarb:Yeah, you know, I meant to I meant to share with our listeners that I received an email, which suggested that it was past time for Chris to, to hold himself out as a junior attending and a young professor. So they suggested that I'm not that old. And Chris is not that young. And so I just want to get that out there.
Chris Dy:I refuse to put my age in my file, because I'm getting close to 40. And I don't want to admit that
Charles A. Goldfarb:through funny. I totally agree. younger patients, less have an interest in giving any steroid injections or certainly repetitive steroid injections as patients get older. I'm much more comfortable with it.
Chris Dy:Okay, so we said already that if this was an owner swimming on their negative variance that you would shorten the radius. What if it was on their neutral or on their positive?
Unknown:Yeah, so for stage one and stage two and I often lumped them together if they fail conservative treatment. If they are older, negative, I will shorten the radius. I don't think the amount of shortening matters that much. I don't want to over shorten it obviously. millimeter two is usually something And that's what the volar approach, oscillating saw removal of a segment of bone, and then compression plating. And then I use a four or five vascularized bone graft, and insert that into the lunate, which has not collapsed. So basically, you're just creating a hole in the lunate. Inserting the bone graft, as we have discussed with Dr Moran do you really need to do that though? You really got to do that? I don't know. I don't know the answer. belt and suspenders. I feel like it is belt and suspenders, I think you're getting your immediate pain relief from the shortening. And hopefully you're getting your long term viability or improved viability with the bone graft.
Chris Dy:You think that your ability to offer the pedicle bone flap graft, whatever you want to call it in the future is affected by your radial shortening at time zero? Is it more of a psychological thing? I'm not the patient not wanting to surgery? Is you not wanting to have to do two surgeries?
Charles A. Goldfarb:I think it's the latter. I don't think doing the shortening affects my ability to do a bone graft. I just so I've always been a believer that if you can offer multiple interventions that same time is better for the patients better for society. So I'm a believer in bilateral carpal tunnel surgery for as an example. And I'm a believer and doing both of these procedures at the same time, would you stage them potentially?
Chris Dy:I don't know. I mean, you know, I think if you believe the data, and I think it's out of Argentina, accord decompression alone might be enough. So I think if you're looking for a relatively minimally invasive, quick thing you can do that might offer nice symptom resolution, that patient I haven't seen that patient in a long time, I would honestly consider doing a metathesis decompression. And then if things didn't work out the way that we expected, going to doing the combo procedure that you described.
Unknown:So Chris, when all your world is a hammer, everything looks like a nail. I know you know where I'm going with this. arthroscopy has a role in the treatment of Kienbocks disease.
Chris Dy:That's actually not where I thought you were going, I thought you're going to ask me about denervation. So what's the role of arthroscopy?
Unknown:There's a couple of good manuscripts that describe arthroscopic debris money and you know, it'll give you a good visualization of SL LT ligaments, you get in a sense of the cartilage both on the proximal surface and the distal surface of the loon eight you can understand loon eight fractures. And if you believe in fixing those, you could you know, you can arthroscopically assisted screw fixation of the luante. I don't ever truly understand why it seems to help. But it actually can be effective as an I think, as an adjunct treatment, perhaps, along with something else. And so, again, the literature is not unreasonable. It doesn't make enough sense for me to do it regularly. But I think it's, it's about as useful as your favorite procedure, which is innovation.
Chris Dy:I think that you can get all the information you just described from an MRI. So I don't know why you're trotting out the scope. Love yet love ya Conmed and your cool new tower and all that stuff. But I don't think you need the scope for this one. Now, I really want you to answer me on this one. I'm gonna ask you the third time if the owner is positive, are you shortening the owner?
Unknown:No, I am absolutely not shortening on I do not believe that has any role in the development of key inbox. Now let's be clear. And for some of the residents listening or fellows, we think of ulnocarpal, impaction and cane box disease as well, like a world of difference diagnostically. It is not always true. Sometimes the diagnosis is you know, the differential diagnosis is not completely clear. So in other words, if you have edema, in the owner aspect of the lunate, you have no collapse of the lunate, and you have a long owner is that impaction? Yeah, probably. But if that same patient, same radiographic appearance exists in a patient where the edema is in the entire lunate. All the sudden you're calling it Kienbocks. So it usually is clear, but it's not always. Yeah, I guess I haven't seen enough MRIs of patients with impaction to understand whether whether that edema pattern is purely along kind of that on their border of the lunate or whether you could see theoretically, edema within the entirety of the lunate with just impaction. I do believe that when it's impaction as the true diagnosis, it really is that volar owner will not say volar but it's the owner corner of the lemonade, and it really is typically discreet. But sometimes I think about it because it's not always in again. Sometimes it's clearly impaction and sometimes is clearly Kienbocks but there can be cases where it's not crystal clear what the diagnosis is. So when is it too far gone to try what you've described for your for your stage one and stage two. So stay, you say you get to stage three A, you don't have a lot, you have some claps present. But you don't have any scaphoid, flexion and rotation, still doing the same thing. I'm still doing the same thing. I'm still showing the radius, I'm still performing vascularized bone flap as you make me call it. But I don't know that I agree with Dr. Moran, who shared on our program that he felt like he could expand the loon eight with a laminar spreader or whatever, I've not been successful. So if the lunate is reasonable and its size and shape, I will absolutely do the same procedure for stage three.
Chris Dy:Okay, and then at some point, when is it just too far gone?
Unknown:depends a little bit on the patient. depends a little bit on the the relative length of the radius compared to the ulna. Dr. Calfee in combination effort, as you know, between WashU and HSS, I don't when were you involved with that effort?
Chris Dy:I was not. So basically, it was looking
Unknown:at stage shortening for Stage Three B. And I think our perception is it can be a successful operation, but it's not quite as reliable. And I think there can be a role for that in certain patients, given that the procedure is predictable, generally reliable and can be a good option. But once once you know, once the carpus collapses, I have less faith in revascularisation. I have less faith in shortening the radius. And I do think about salvage procedures. So um, I guess one thing before we get into salvage procedures, there is an increasing amount of literature, at least for the scaphoid non union group, and then you could apply some of this to Kienbocks for a free MFT like a medial femoral trochlear kind of free flap coming in. I know that both of us don't have personal experience doing that. Are there any patients that you see that you know, you might send to you know, for example, David Brogan, one of our microsurgery partners for that, I certainly would consider sending a patient if there was a I mean, really what we're what we're needing in those situations would be good cartilage, and a need for obviously vascularity to support the rest of the loony bone. I have a hard time envisioning that situation for Kienbocks for approximately the scaphoid. Maybe, but it it does enter my discussion with the patient. And I think an honest conversation with David can be helpful for some patients to see if that's the direction they want to track.
Chris Dy:Got it. Now as we come to a close, we talk about salvages. Are there any role in your practice for limited inner carpal fusions like an stt or an SC or something like that.
Unknown:So when I was a resident back in the day, and let's be clear, that wasn't in the late 90s, that treatment was regularly offered. I do not think there's any role for that treatment today. In my hands, I recognize that some people will still use a scaphocapitate or an STT. But it's so limiting for wrist motion. That for me thetreatment, which is not always a cure, let's be honest. But the treatment for phase 3 B or 4 is proximal row carpectomy. corpectomy. How's that not a cure? It does not resolve the pain and every patient. Unfortunately, I've been there. That's really that's really interesting, because you'd think by getting rid of lunate resetting the mechanics of the carpus that that's as reliable as it would come. But that's that's educational for me to learn, because perhaps I should set my expectations more appropriately. Yeah, I wouldn't. I wouldn't have a discussion with the patient, you know, suggesting that this will be a cure. I generally temper that when I discussed with the patient, even though to both sides of the table. We all think a giver, the lunate is going to be great. And hopefully it will be but it doesn't always work that way in my experience. So pyrocarbon lunate , what do you think?
Charles A. Goldfarb:Not ready for me?
Chris Dy:So you know, just to bring it to a wrap on this patient? You know, I have not, you know, we haven't gone down the road of treatment yet. But I ended up offering her knee supportive measures with a steroid injection and a wrist brace. And then when she's good and ready, we'll have a talk about a PRC.
Charles A. Goldfarb:I think that's fantastic. It's appropriate. And, you know, if you want to scope it, certainly there's a lot of good indications for it.
Chris Dy:Are there really though, are there so well, so let's talk one more. One of the things so you know, as we talked about our podcasts and reflected I think it'd be nice to end the episode on a positive note. So what's what's one win that you've had in the world of Chuck Goldfarb in the last week or so,