Chuck and Chris share Current Strategies for Dupuytrens,

Season 3, Episode 43.  Chuck and Chris  discuss their current strategies in treating Dupuytrens disease.  In an update from our previous Charlie Eaton interview , we describe our indications, treatment strategies, and outcomes with various procedures.  We focus on open fasciectomy and needle aponeurotomy.

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Transcript

Charles Goldfarb: 0:03

Welcome to the Upper Hand Podcast where Chuck and Chris talk Hand Surgery.

Chris Dy: 0:07

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 Goldfarb: 0:15

Please subscribe wherever you get your podcasts.

Chris Dy: 0:18

And thank you in advance for leaving a review and leaving a rating wherever you get your podcasts.

Charles Goldfarb: 0:24

Oh, hey, Chris.

Chris Dy: 0:25

Hey, Chuck, how are you?

Charles Goldfarb: 0:26

I am good. We're back at it.

Chris Dy: 0:29

We are back at it. So, funny story about last week's episode. You know as soon as I said the word candy stash my son started freaking out and was panicking that I was going to steal all of his Halloween candy. So somebody might have heard some background noise there as that was going off.

Charles Goldfarb: 0:45

That is kind of awesome. We have those discussions in our house all the time because Macy sometimes will purchase her own Nestle Crunch bag and occasionally disappear and I've been accused of being guilty.

Chris Dy: 0:56

Yeah, you know, it's interesting this the trunk or treat situation went to was definitely there are some parents flexing with the full size candy bars.

Charles Goldfarb: 1:06

What did the Dys bring?

Chris Dy: 1:07

The Dys brought a cake because of the Dys also forgot to get some for trunk or treat and we're at the grocery I was like, alright, this and it was a hit because we were the only cookie cake. Which you know, many of you know that cookie cake is a is prized in our household. So

Charles Goldfarb: 1:21

yes, in fact, I may need to pick up one for tomorrow for a birthday celebration and clinic. But I have to, to, I guess I would say hands society activities that I want to plug in. I feel very strongly about both of these. The first is I received my copy in the mail of the new hand society, ASSH surgical anatomy series. I believe you may have contributed to this series. Dr. Dy, did you

Chris Dy: 1:49

I believe the debut perhaps the first book in the series with the cover art from none other than Mr. Frederick Stivers, the husband of our partner Dr. Lindley Wall. But yes, I was the co- editor on the first book in the series.

Charles Goldfarb: 2:04

Excellent and the series survived, your addition. And it may have culminated here with ulnar sided wrist disorders, Edited by Sanj Kakar and Jeff Yao. And I got mine as an author of a chapter in the mail. And it is fantastic. It is absolutely comprehensive. And it is well illustrated, both with line drawings and with photographs. It's well described any and everything on the owner wrist is is caught in this book is nearly 500 pages. And I cannot say enough good things about this book. Now, I haven't obviously read it all in a couple of days. But I've skimmed it all and read a few chapters. And it's great. So I want to plug that for all you older sided risk pain interested people?

Chris Dy: 2:53

Yes, because that topic clearly has been figured out. So maybe that's why it deserves 500 600 pages. That's great. Is there anything in particular that makes the book so good is just a list of authors, you know, that that have come together? Because Sanj and Jeff are so great at pulling people together?

Charles Goldfarb: 3:09

Yeah, I think that's part of it. They got a good group of authors they have, you know, there's a lot of chapters, I mean, you could imagine, oh, let's come up with five or six chapters, there's I don't know how many there were there, probably 30 chapters. And so they really took a look at it from every angle. And so I think it will serve as a Bible for many. And I mean that when I say it, I was super impressed.

Chris Dy: 3:29

So for those of you that are going to be at the next hand Society meeting, which is going to be in Toronto, make sure you bring your book Chuck will be signing them. He'll be placing inscriptions doing personal dedications, maybe taking pictures that might be an author booth, like that kind of thing.

Charles Goldfarb: 3:45

I'm not the editor of this one. I'm just saying he'll

Chris Dy: 3:47

Sign, he'll sign your, your chapter. For sure. what else what else is going on what else you want to talk about?

Charles Goldfarb: 3:54

So the other thing and I may have mentioned this to you, I part of what I enjoyed about the Hand Society was I found, this is a weird thing to say I think I found enjoyment in some of the committee meetings. One was the Touching Hands Committee, which we talked about. But the other was the Business of Hand Surgery Committee, which I've been on intermittently for a lot of years. And I think the young leadership is great. And there now is the you know, the hand- P which is modeled after Hand e. So Hand e is the you know, electronic hand surgery education platform with videos. It's you know, phenomenal. And hand p is a similar concept. Jeff Greenberg supported this where there are practice and life lessons on economics and all those kinds of things that really matter to all of us. And so that is a great resource. And it is supplemented by the Hampi podcast. And so listen to it. It's good. It's very good. And it's a worthwhile use of your time and I just want to say that

Chris Dy: 4:55

so I've actually had a couple of people come up to me asking me how I feel about there being enough other podcasts in the hand surgery space is great. You know, I think that they're gonna have a hard time keeping up with Chuck and all of his charisma and the magic that he brings to this this show. But in all seriousness, I have listened to a couple of the episodes and they're fantastic. David way, is that a great job with it, the production is fantastic. It's not as good as Chuck's production quality, but it's pretty darn good. So, yes, please check it out. Please listen to it.

Charles Goldfarb: 5:27

Yeah, for sure. And we were going to, I think, just dive into a critical topic that, you know, we haven't really talked about it since an early three part episode, which was one of our most downloaded maybe, was one of our certainly our top five downloaded episodes on Dupuytrens disease.

Chris Dy: 5:46

So yeah, we had the fortune of being joined by, by Charlie Eaton for that one. And, you know, she knows so much about it that I feel like, it might have been hard for some to kind of get a high level view on deeper trends. So, you know, I guess what I'd asked you, Chuck is, you know, where do you see, you know, your go tos? What are your go to treatments for dupuytrens in 2022? And does that vary based on kind of how, which, which components of the finger are involved? And, you know, has your experience changed even since when we recorded that episode a couple of years ago?

Charles Goldfarb: 6:17

Yeah, it's actually crazy to say that I think I've been doing and favoring the needle apponeurotomy procedure, or I just call it the needle procedure. I've been doing that operation since 2008. In the office, and have had what I feel is a lot of success with it. And I really like it, I do not. And we should talk about each of these, but I don't use Xiaflex. I don't see the point really, when I when I enjoy and have had good success with the dental procedure. And interestingly, over the last six months, I've done more open fasciectomies, big open fasciectomies. And, you know, in a training situation, there's nothing like it. I think it's fantastic for trainees, and thankfully patients are really happy with it just comes with, you know, conversations about recovery period. But you know, I don't know that anything has dramatically changed since we interviewed Charlie. The literature hasn't dramatically changed, but we should we can touch on that. But do prisoners are remains a disease, which is interesting. And I believe hand surgeons can really help patients.

Chris Dy: 7:23

Yeah, 100% agree. And, you know, I guess before we get into the details of a needle and your indications, when you think it's great when you're pushing the indications and technique and the logistics, I would agree with you on the collateral base. You know, I don't have a role for it in my practice, for completeness sake, when I started actually looked into offering it, just because I think it would have been good for our group to have somebody that offers it. But just looking into it logistically financially, in terms of you know, our practice would have had to buy and hold the product, which I think is can be good for some practice environments. So for example, like a private practice environment, I think financially, there can be some benefit there. But for us with me not knowing exactly how much I would use it, to have to hold on to inventory and spend on buying it, storing it, etc. It was a deal breaker.

Charles Goldfarb: 8:11

And that's right. And that's exactly the hurdle I also faced. It just didn't make sense. Now, thankfully, one of our plastic surgery colleagues, Ida Fox continues to offer collagenase. And I send patients to her if they really are sad, you know, if they see the John Elway commercial, and they want, they plant collage, and I say okay, you know, we have a great friend who does this, and you'll be happy with their care. But for me, it doesn't doesn't make less sense. I will say there is one intervention that I am absolutely against. And that is radiation therapy. Have you encountered or worse? Have you had to operate on patients who are post radiation treatments?

Chris Dy: 8:54

I have not, you know, I will say that I've actually treated somebody who offers that treatment in a different context. And, you know, we talked about the pros and cons of the radiation and we agreed to come out, you know, if we have patients that want a specific thing to refer, it's just hasn't come to that yet. But I have not had the the opportunity to treat a patient who's already had radiation. That was actually the next question I was gonna ask you, before we get into the needle was what are your indications for radiation? Why do you feel so strongly against it?

Charles Goldfarb: 9:23

Well, I did review the literature and in preparation for this, as I know you like to do in preparation for this conversation. And the literature is not supportive. It's not necessarily against it. There's just not supportive literature. My problem with that treatment is if you have to go back and do a fasciectomy, it is a bear because not only are you fighting dupa trans disease, you're fighting an incredible amount of scar tissue. So I for that reason, I'm not a fan.

Chris Dy: 9:56

Yeah, it's it sounds like something that is done by somebody who doesn't have to take care of the the end result if it ever comes to a tumor recurrence or treating it surgically. So I guess my question for you is, can you just at a high level for somebody who might be early in training or isn't familiar with the concept? What is a needle aponeurotomy.

Charles Goldfarb: 10:16

So this is a procedure that originated in Paris, as I understand it by a group of rheumatologist who have been doing it for a long time. And Charlie was one of the first United States surgeons to go over there and train. And he brought it back to the States. And I believe it was in 2006 or so he gave a great talk at the hands society. I'm not sure you were a physician, then Dr. Dy. But maybe you are. And that's where I got motivated. And it was one of those scenarios that just the chips fell perfectly. I come back to St. Louis, I'm like, That's intriguing. And then one week, two patients come in, not surgical candidates because of cardiac issues, beautiful pre tenderness, cords. And in the office, you inject a tiny bit of lidocaine just to numb the skin because the cord is aneural, so it doesn't hurt to divide, the cord is just the skin. And you don't want to put a lot of numbing medicine in because you want everything awake around that you want to know if he gets you close to the nerves. And you essentially take a relatively stout needle, and you move it back and forth, and you divide the cord and the first stick of lidocaine patients hate. And after that, they kind of get through the little lidocaine injections when you're done with a 25 or 27 gauge needle. And I use a 22, sometimes a 20, with a really impressive chord. And I think it's safe. And it's incredible. It's incredible to take a patient, especially with an isolated MP contracture, divide are pretending to score and in the office that patients fully straight. It, there's nothing like it. It's incredible.

Chris Dy: 11:56

So that was a rave review, five star review from Chuck Goldfarb about needle apponeurotomy. So question do you put it in? Do you divide the court in multiple places? Is it two or three spots? You know, because I know you could theoretically just do it in one but I've you know, lead, the way I was taught was to try to do in two or three different spots.

Charles Goldfarb: 12:13

Yeah, a couple of I guess I can say their pearls, at least from my own experience. Number one, I do try to do it in multiple spots. Now, certain courts don't actually allow that. Because when you divide it once you're done, and it's not this really stout, thick stuff that requires multiple, multiple different levels of division. But I generally try to do it in more than one location. I do counsel the patients that we're not taking out the stuff, you know, we're not taking out the do portraits, that's really important that they understand, because you don't want them to be disappointed that there's still lumpiness in their palm. And then sometimes I can try to work to decrease some of the skin tethering. And Charlie would talk about that separating the cord from the skin when it's been tethered. That can be a little trickier to do. But I think the the immediate results are just there's nothing like it.

Chris Dy: 13:09

Now, do you also, will you use this for only isolated, pretendinous cordswith MP involvement? How adventurous are you with getting to contractors that affects the PAP joint.

Charles Goldfarb: 13:19

So very, I've become very comfortable, for better or worse, with a tackling almost any cord that I can palpate I don't use ultrasound. And I think you may be someone who eventually uses that modality to help you. I don't use ultrasound. But if I can palpate a chord, then I'm willing to try it. Now I do lay a lot of great about risks. But I think if you get close to a nerve patient is going to tell you, and I think you can be pretty cautious. Now, a spiral core can be tricky. But I will tackle different chords in the finger itself. But I do have I guess I would say a low threshold for calling it if the patient is getting any kind of tingling or sensory feedback, which thankfully has been rare.

Chris Dy: 14:06

When it started in practice, this is one of those procedures where I never got to physically do it, like my hands doing it until I was in practice because the attendings would always do it. So I was obviously I felt comfortable with the indications felt comfortable with the theoretical aspects of the technique, but not the actual manual aspects. So I started saying I'm only going to do MP contractures. And I'm not going to do anything else any pap contractures. And that was I guess, now seven years ago, and I still am only doing MP contractures. I'm not doing pap contractors just because I'm not comfortable with that. And I think that you know, for me, there's still a role for going to the operating room with anything that involves the PAP joint. I absolutely get what you're saying. I think that it's if you're comfortable with that and you can palpate the cord. I just would rather have access to what I need access to so i haven't gone there yet. Technique wise I think that Charlie described it as using the needle attached to a syringe When holding the syringe what I've done is just honestly hold the safety hub of the needle and not had to use a syringe I usually I go with the Marty Boyer quote of telling the patient ahead of time, it's gonna look like a crime scene, because of all the percutaneous kind of bleeders, you might get into and you know, have a healthy amount of four by fours, the stack with alcohol on the stack that's dry, have the dressings ready for the end? You know, and I, you know, I've been very happy with, with the results that I've done. I, you know, depending on the day in clinic, I'd be curious to see how you handle this, I'll see them and if the clinic is going perfectly well, I might offer to them on the spot. But most of the times I'll say, once you, we can do this, let's just schedule a time usually it's at the beginning of clinic or at the end of a clinic and an on a different day, are you just doing it right up right at the time.

Charles Goldfarb: 15:47

I tried to if the patient wants but but if it's like you, I think I've had really really busy clinics lately, and, and depending on the needle procedure, now some needle procedures literally take three minutes, and some of them could take 10 or 15 minutes, but 10 or 15 minutes, as you know, can disrupt a clinic entirely. So I have scheduled patients in you know, down the road, and thankfully some patients are would rather be scheduled down the road, I like your pearls there those are those are really important things. And I would I would ask you, you know, there are pre tendinous chords that are simple, then, and you see that patient are like wow, I can help you, this is not going to be a big deal. You're going to love this. And then there's preachiness cores that have nodularity and are super thick. And I My experience has been we can be successful. But it's just it can be tough,

Chris Dy: 16:41

right? Absolutely. There's that you know that nodular clumping kind of thing. And especially for me, if it gets beyond the Palmer digital digital crease, I get super worried, not because I don't think he can do it. It's just it's log. And you know, I think patients have a certain amount of time in them when you're picking at them to you know, in which they will allow you and tolerate it and still be somewhat happy. But because you know you're in a clinic setting the vibe is different than if you're they've amped themselves up to go to the operating room. I think that has to be a super, I have to be super confident that this is going to work and work quickly. I don't have all the time in the world for that one. Curious how you handle post op or post procedure, splinting and mobilization, anything like that descendant therapy for a splint? How do they? How often you ask them to wear it, that kind of thing?

Charles Goldfarb: 17:29

Yeah, I have to say I have mixed emotions, there is some literature saying it's not particularly helpful. It is interesting to me that patients who are coming back for a second need a procedure, which is obviously fine and great. And, and they know what they're getting into. Most of them don't want another split. But when I do a splint on a patient that may have a couple of fingers that are involved, maybe more severe contracture with successful needle procedure. I want them at night for at least six weeks. That's my general protocol. What about you?

Chris Dy: 18:00

I do nighttime for two to four weeks, depending on how severe it is. And then daytime ad lib and then you know, finger range of motion, you know, flexion, etc during the day.

Charles Goldfarb: 18:11

Yeah, and I'll say that, and we should talk about open fascia committees, I'll say with open fascia committees, I don't send all those patients for a splint either, even though most of them by definition are more severe. I just have I mean, some of them I do if it's a very severe case, but not all of them. Just because I think it's the mechanical solution. And I think splinting as Charlie Eaton said may not have much of a role.

Chris Dy: 18:33

Right, right. So what are your when do you indicate somebody off the bat for going to the operating room?

Charles Goldfarb: 18:41

The first indication is a patient that don't think would do well with a needle procedure, which is remarkably rare. I've only regretted I think two people having tried to needle and just it was too much for them,

Chris Dy: 18:52

like personality wise emotionally. Is that what you mean? Or the court itself?

Charles Goldfarb: 18:55

Yeah, personality emotionally. I think I lay enough crepe that even if we're not successful, and that's thankfully been uncommon, that patients are okay with that. Yeah, let's try the needle. If it doesn't work, we can always go the or that's kind of the crepe. So I think the indications regarding the operating room are a severe pap contracture. So more than, you know, 45 or 50 degrees, a nonpalpable cord, a severe recurrence after a needle whether that's, you know, a year later or five years later, and in a patient who's had a needle and understands what that means and why you know repeating it may or may not make sense so I always presented as an option. But for some I certainly guide the patient towards an open Fashi ectomy.

Chris Dy: 19:41

Now, is there any role for well launched in this case I mean for doing an awake in the operating room or purely going to at least some level of sedation.

Charles Goldfarb: 19:51

So I have done a couple and I have to say I don't love it, it this these can be super technical. really challenging, which is why they're great for residents and fellows to experience. They can be frustrating. And you know, protecting the nerves and arteries can be tricky. And so I don't know that I'll unless it's something really straightforward in which case, I probably would be doing a needle, I don't think are like well off for this procedure, but I'm guessing you do

Chris Dy: 20:28

know I've used it and still would use it if a patient feels very strongly. But I usually, you know, for the same reasons, you stated, you know, the window in which we'll launch is going to make a difference and add to the surgery is very little in this. So while I've used it in the past, I'm using it less just because you know, if it's something that can be done awake, it's usually something that can be done with the needle. And, you know, I know that you like to drop a lot of F bombs at times, and you know, it's kind of hard to entertain the patient and do the surgery safely with this kind of thing. We've talked about the showmanship aspect of the launch, at least in my experience. And, you know, I think that it can be quite challenging. So I typically, if we're going to the operating room, this is something that, you know, sometimes can be done under IV regional or beer anesthetic, if you feel like it's something that would be within that window of time in which your anesthesiologist is comfortable with that. But other times, it's done on a regional with a tourniquet.

Charles Goldfarb: 21:16

Yeah, totally agree. And I guess I used to be of the belief that Bruner, zigzag incisions were the only way to go. And let me be clear, I do not. And I'll say this strongly, and I know there'll be listening to disagree, write us and tell me why I'm wrong. I do not like straight line incision is that after you've completed the procedure you create Z classes with, I just don't think that works particularly well. So I like either zigzag incisions which is all I used to do. I've done a lot more mid lateral kind of combination. Bruner, plus mid lateral, and then maybe bring it back over the middle phalanx or something. But I found that to be really successful.

Chris Dy: 21:58

Do you think it's just if the spiral cord is sitting along that side where you're going to make the mid lateral component of your incision?

Charles Goldfarb: 22:05

Yeah, I think you can get better exposure. And I think you have a nice flap to bring over it just it gives me nice exposure. And again, I still like the zigzags, I just try to you know, there's not one standard way for me to approach this it just based on what the disease looks like and having enough exposure. What principles do you follow? So let's say you have a little finger cord that affects the MP and PRP joint? How do you think about your incisions and where do you find the nerves and talk through it,

Chris Dy: 22:38

I tend to do mainly Bruners, zigzag incisions, I will incorporate a mid axial especially if it's an area that's not going to be where they're resting on it. You know, I've been taught by my therapy colleagues that patients really pay attention to corners. So during the closure, I tried to make the corners look as nice as we can, especially if they're coming out and going to a splint and they're going to see their incision pretty early on. Corners can look really gnarly to patients. So you got to make sure those look great. And on these, I tend to err on the side of putting in more sutures, which I usually don't but I've been told by my wonderful therapy colleagues that that is more patients don't like seeing anything that looks like it could be exposed deep tissue. So those are little pearls for incisions, you know, for me, my you know, my principles are that I typically will find the neurovascular bundle proximal and distal, doesn't mean I automatically go out and find it distally I'll find it proximately kind of see where it's lying relative to the pathologic tissue. And then as soon as I'm no longer comfortable knowing exactly where it is, then I'll go find it distal to that area where I'm working. That's probably the biggest thing for me. And also knowing where the tendon is the flexor tendon.

Charles Goldfarb: 23:44

Yeah, it's well said I mean it, I feel strongly about finding the nerve and artery proximately tracing them distally. And if it goes well, you just trace them digitally and take out the duplications. If you really get into you know, a concrete situation where you're the nerve disappears, then I go more digital and then trace it backwards as well. I think that's really important. Protecting the tendon sheath and you know, taking the duplications off the tendon sheath, off the skin really important. I like what you said about closure, because you know, really what we're doing with these patients is we're insulting the hand in a major way with this big excision And then when I send them to therapy pretty early. I operate on Wednesdays primarily for this kind of surgery. So either Friday or the following Monday they start therapy, because I want them working on flexion. So I do put a lot of stitches. But one major change in my practice is I put 4-0 nylon as my corner stitches. And then I use an absorbable stitch in addition to that, so that we're not completely torturing the patient at the time of suture removal, and you still have strength when you take your stitches out at 10-12 days. So that's been a nice little pearl, which the therapists have appreciated. And the nurses that I work with in clinic have also appreciated.

Chris Dy: 24:58

Sure is that a 5-0 rapide like you do for a kid or is that a 4-0 monocryl or chromic or something like that?

Charles Goldfarb: 25:04

It's been a chromic has been a 4 or 5-0 chromic simply because that's available. I don't know that it matters too much. But I've been using a 4 or 5-0 chromic.

Chris Dy: 25:16

Interesting. Okay. Yeah, no, I think for, for me absorbable sutures and on the polymer surface of the hand and digit have not gone as well. So I'm reassured by your experience, and maybe I'll incorporate that because again, nobody likes to take more sutures out, no patient nor our medical team, I actually have started to send patients directly to therapy right afterwards, mainly, so they can get, I think, a much more comfortable orthosis than I can provide. It's lighter. You know, I think that it, then they get plugged into therapy, and I start motion three days after surgery. You know, but, you know, having them in a smaller orthosis is, I think, helpful. As long as they're able to go on the same day, I usually have been asked by my therapy colleagues to make sure they eat something light before they go over there. Usually the pack, you will make sure that they have some a nice selection of snacks before they before they leave anyway. So

Charles Goldfarb: 26:07

yeah, I like that. I don't spend everyone use me, I guess you just said you don't because you send them right to therapy. I used to split every single patient with you know, for about 15 years as a kind of volar supportive splint. I don't do that anymore. I do if it's a really severe case, I will splint but I usually do it in in transit plus, and the other patients I'll just do a soft dressing and tell the patient that when you go to therapy, they they if you go to therapy, when you go to therapy, they will make you an extension.

Chris Dy: 26:35

Yeah, no, they with me, they leave the operating room in a four by 15 plaster extension splint, usually foreign based, but they'll go to therapy, you know, they may have it taken off within a few hours or you know, if there's an issue getting in the least I know that they've been there immobilized, but with the expectation, and they're not hanging out in that for two weeks, like they're getting out as quickly as we can, and we try to arrange for that. I guess to bring us to a close, I'd be curious to see your experience with you know, recurrence rate, not that it ever happens to you, but your experience and kind of how you've seen that come about and your interpretation of the literature, both with needles and with with surgery.

Charles Goldfarb: 27:12

Yeah, I mean, look, you do this enough, you absolutely have recurrence. It's just it, you know, we're, it's I feel like we're sort of, you know, we're patched treating these patients, we're not treating the root cause of duplications, we're treating the symptoms of duplications. And so Charlie Eaton was, of course, correct, we need to find the molecular answer, not the surgical answer to this problem, kind of like we've done with rheumatoid arthritis. And so there will be recurrence by definition. The reason for an open surgery is, and I say this to patients directly, it's the longest disease free interval. And so the patient can rest assured that if we do an open procedure, while the disease is almost certainly going to come back, it's going to be down the road five years or more typically, and with a needle, it may be much sooner and with collagenases, maybe much sooner. That's my basic speech. I think, you know, collagenases and the NATO procedure are pretty similar depends on which articles you read, but pretty darn similar. And so that's where it gets to cost for me. But the open Fashi ectomy is remains the gold standard, in my view.

Chris Dy: 28:20

Yeah, there's a nice paper from a retrospective paper from Mayo Clinic. I believe Marco Rizzo was the senior author on that one, that demonstrated results are very similar in terms of recurrence rates between needles and in calamities and the expenses hugely different and much more expensive with collagenases. Perhaps that is different based on where you practice in terms of whether in the US or elsewhere. But that I think matters a lot to patients, you know, especially if like, you know, they're being asked to pay for this medication out of pocket if it's not covered by their insurance. So that can be a difference maker for sure. And yes, the the disease free interval and the recurrence rate, these disease free interval is longer and the recurrence rate is less with surgical treatment, but it comes with the upfront investment both in time and cost for the patient and their insurance company.

Charles Goldfarb: 29:09

Yeah, the last thing I'd say is, I always let the tourniquet down. I always try to make sure we have good hemostasis because nothing compromised results like a hematoma. This is one of the few procedures where I do that. And you learn what white is what a really white finger is. And a finger this sort of white and sort of white I've learned to just immediately ignore really White gets your attention and for all those surgeons listening you know when you see really white you know what you don't forget it

Chris Dy: 29:41

and that gets to you ever pin the finger still I know some people talk about pinning joints. You know because then that's the point where you see really white maybe you kind of backup that pin.

Charles Goldfarb: 29:52

With with almost zero exceptions. I do not pin VIP joints anymore, whether that's treatment for a camp that actually PRP contracts are related to trauma, or dupa trends, I did that in my youth, which no longer is with me, I do not pin joints anymore, I don't think it adds an advantage. And I'll say this, this is actually important. I almost never do volar plate releases for dupa trends, I believe if you excise all the do purchase tissue, generally that does it. And then occasionally I'll do some soft tissue, I'll do a manipulation of the PAP joint. But I cannot remember the last time I did a PAP volar plate release. And so I feel good about that. And I feel therefore because we know the results when you do a formal pap joint release. age old results say you only keep 50% of that improvement. But I think if you do it more standard DuPage ones excision, you can expect better results in that,

Chris Dy: 30:48

then I'm assuming you're not when you talk to patients at a time you're not counseling them that full extension is the expectation is that correct?

Charles Goldfarb: 30:55

I don't promise that I say that's our goal. And we might have it in the operating room, whether we can keep it will depend on you, you and your efforts with therapy.

Chris Dy: 31:06

Yeah, and they're honestly, they're usually happy that they can put their hand on the pocket and get their hand in the glove. If you get them something that's reasonable in terms of less than 30 degrees at both joints. So that's kind of what I counseled them for. And usually that's what they're looking for is I want to be able put my hand in my pocket, I want to be able to get a glove on in the winter. So that's that has worked out for me. So I'm, I'm, I'm excited to hear how other people feel about this. If you are a staunch collagenases advocate, please let us know. And also let us know your conflicts of interest if you have any budget. The John Elway commercial is great, and it is very powerful education tool. And then I just redirecting to a needle.

Charles Goldfarb: 31:46

Yeah, I don't think we're gonna get to get any offers to sponsor the podcast from the collagenases, folks, but hey, we're just being honest here with Chuck, Chuck.

Chris Dy: 31:56

Chuck will listen to all offers and we'll continue to

Charles Goldfarb: 32:00

Awesome, thank you.

Chris Dy: 32:02

All right. Have a good day. Thank you.

Charles Goldfarb: 32:04

Hey, Chris. That was fun. Let's do it again real soon.

Chris Dy: 32:07

Sounds good. Well, be sure to check us out on Twitter at hand podcast. Hey, Chuck, what's your Twitter handle?

Charles Goldfarb: 32:12

Mine is@congenitalhand. What about you?

Chris Dy: 32:15

Mine is @chrisdyMD, d-y. And if you'd like to email us, you can reach us at handpodcast@gmail.com.

Charles Goldfarb: 32:23

And remember, please subscribe wherever you get your podcast

Chris Dy: 32:26

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

Charles Goldfarb: 32:29

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