The Upper Hand: Chuck & Chris Talk Hand Surgery
The Upper Hand: Chuck & Chris Talk Hand Surgery
Positive Energy, Cases, and End of Year Discussion
Chuck and Chris with a bonus, year- end episode with listener questions, CMC fusion case discussion, and an HBR review on the importance of positive energy. This was a really a catch- up episode and we catch up on Chris' travel, Chuck's b-school, and other timely topics.
HBR: The Best Leaders have Contagious Positive Energy. Emma Seppala and Kim Cameron. April 18, 2022. Reprint HO6ZUL
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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 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 podcasts.
Charles Goldfarb:Oh, hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:I'm great. How are you?
Chris Dy:I'm good. So weekend, we're keeping track of our time for a sneak preview for a future episode. But things are good hear. How about you?
Charles Goldfarb:Yeah, I now you tease me I kind of want to talk about our new endeavor where we're tracking how we spend our time. I'm into I'm into day three. And it's super fun. Yeah, it is a total tease for listeners. But we will share how Chris and I spend our lives become
Chris Dy:highly scientific study, only the most rigorous of methods. But there is an app involved. And I think it's going to be super interesting. And I actually was curious if we could get our entire division to do it. Because I think it would be very, very interesting.
Charles Goldfarb:It would be interesting, I have to say tracking one's time. So what we're talking about, we're probably going too far down this road, where we're talking about just you know, you know, how much time do I work? How much time do I sleep or spend time with my family? And and when I'm working? What am I doing? It's it's really tedious to do this?
Chris Dy:Yeah, absolutely. And I have to do some retrospective entry. So put it that way. It's highly remember, I was really good until about noon yesterday. I promise I will get them back in. And I think it's kind of like locking cases when you're when you're a resident or fellow like you don't stay on top of it. It's kind of like mountain of work to do down the line. Right. Anyhow, that's for a future episode in 2024. So it's our last part of the of the year we get a little bonus. Episode drop.
Charles Goldfarb:Yearh, this is a little earlier than we typically released an episode but we wanted to share one final go. And we have some good stuff to talk about. Just as a quick preview, we have a couple of listener we at least one listener comment and listener question. We have a couple of HBR articles to talk about. And we have a great case. But I want to start by hearing about your journey across the world with your family. What about six weeks ago now?
Chris Dy:Yeah, it was a while ago, but we haven't gotten a chance to talk about it. So that I was invited to speak at the Philippine Orthopedic Association, which, as a Filipino American, young man say it was an incredible honor and very meaningful. I mean, I've only been in the Philippines once I was born in the States. I had been once when I was in high school. So to get the opportunity to go back was amazing. So thank you to those that invited me, St. Australia and Nats, Zillow, a couple of Filipino surgeons I've met at various points, including in there a couple of podcast listeners to nats is a big congenital guy. So he's always asking me for more of that, and I have to politely decline.
Charles Goldfarb:That's we got here. We'll come back in 2020 for more congenital,
Chris Dy:but it was it was cool. So we decided, You know what, let's go for it. We brought the whole family. And so my wife, two kids and eight year old, the five year old traveling all the way across the globe. And then my father in law came and my parents came they met us there. So it was a big crew. But we had a fun time. Thread the needle in terms of time off with coupling it with the Thanksgiving week. So an extra week before so it was it was an amazing trip. incredible honor, great conference, a great opportunity to network and meet surgeons. And that was fantastic.
Charles Goldfarb:Oh, it sounds great. It sounds great. You know, those, it's always daunting to consider and plan those trips and think about time away from work and all that. But you I'm sure you will not look back and regret that time. In fact, you'll look back fondly and your kids hopefully will be even more kind of in touch with family and Heritage Center. Yeah,
Chris Dy:I think I think that was part of it. You know, my kids met cousins that they would have never met before. You know, so that was fun. And they're already trying to plan the next time that we can go back and stuff so incredible. You know, a couple of odd things that happened. I mean, so we never we don't have a cab tablets for the kids. But because we were like we have these crazy flights, like the longest one was 14 hours. Okay, like if the seatback entertainment goes down like we're toast. So we went ahead and got couple iPads for the kids and you know, kind of got them set up and everything and it was great. They didn't really use them like that much and it was like okay educational stuff, educational unquote, like on the iPad, and then like videos and watching was only on like the seatback entertainment thing. But then my son decided he wanted to learn how to text. So, of course the iPad has iMessage and I'm sitting at a conference and I'm actually texting my eight year old son which is super cool. You're but it's so cute and it's just like, you know, the intentionality that he has with each word that he's typing and what he wants to say and it was it was the best. Yeah,
Charles Goldfarb:you know I continue to evolve with my texting skills my my youngest is 18 She is a bullet texture so she's the most emotional Goldfarb and so you can feel and hear with these text after text after text instead of you know, me, I text to it punctuation. They all give me grief. And, you know, old school texting and there's no punctuation. There's no capitals, and it's text, text, text, text sex and like my phones blowing up and I'm like, What the hell is going on? He's so funny.
Chris Dy:There's such a thing as an emotional Goldfarb.
Charles Goldfarb:There definitely is
Chris Dy:just the latest product release.
Charles Goldfarb:This version, the highly most highly evolved Goldfarb is the youngest Yes.
Chris Dy:Better watch out future generations a Goldfarb is going to take over the world more than than they already have. My goodness.
Charles Goldfarb:Yes, no, she's amazing. And yeah, we know exactly what she's thinking all the time.
Chris Dy:Yes. Okay. Perfect generational shifts here. So you've been busy though, too. I mean, you know, this has been a busy semester for you. First, first semester and business school, right?
Charles Goldfarb:First semester, and B School Check. It was fantastic.
Chris Dy:It was really everything, how many?
Charles Goldfarb:Thank you very little for that. I have three more, three more. This was our, I think, our longest break. So my last classes were beginning of this December of this month. And we had a major marketing presentation. And again, this is all in the Executive MBA Program. We had a major marketing presentation and business plan development. And then we had a Take Home Final and business analytics, which was super interesting, a little daunting. It was a advanced statistics utilized for the financial side of the world, whether it be Monte Carlo simulations, or regression analyses now, clear overlap with what we do in our world. But I would never claim to be an advanced statistician, but I am better today than I was. So this is kind of funny. So we had our Take Home Final. And these takeoff finals are 10 to 15 hours or so. And so we had class Thursday, Friday, Saturday, I worked on it Saturday night for a bunch of hours and Sunday morning for a bunch of hours, I just needed to get it done. It tested the endurance a little bit, but I'm so happy I got it done. While it was fresh. And it's just an interesting way to learn these finals are learning opportunities, which sounds corny, but it's really true.
Chris Dy:Well, I think, you know, the game is different. When you're at, you know, your state in terms of an earring Executive MBA Program. It's not like you're, you know, college student anymore. So you're learning you learn differently, you value and relish the opportunities to learn differently, because it has much more direct implication on what you do now. So yeah, that's great. Your comment about the advanced statistics stuff is interesting, because, you know, my approach to that is like, yeah, you're not going to be an expert in actually doing it. But you know, the language, you know, what's possible, you may not have ever heard of some of these things before, and you're gonna pull that into your, you know, your, for lack of better word, daily practice, you know, and it's like when I talked to students about whether to do you know, certain classes as part of a master's program or something and say, Hey, you're not going to be doing all your own stats, but you'll know how to have a better conversation with your statistician, you know, how to read the literature better. I mean, Monte Carlos and advanced regression analysis show up in our medical literature, too. So yeah, that's great. That's fantastic. You know what, so that your whole experience with the Executive MBA didn't even come up in your recent installation as the Richard H government professor. So they're going through all of your amazing accomplishments. And when you were had this incredible honor, being installed that as a an endowed chair, the government professorship, they didn't even talk about the fact that you're going to business school. That's crazy. Yeah, well, thank
Charles Goldfarb:you for the kind words, I'll share one lesson from business school Data Wise, and then, you know, we don't want to belabor this, but love to acknowledge that the installation. So the, the point from business school regarding data is, and this was kind of strongly suggested and is so true, is if you have a stream of data, always graph it, always plot it. It's so telling. And that was demonstrated to us over and over in class, and I don't do that enough. You know, I may have some data that I'm thinking about and ask someone to analyze it, but plotting the data is makes all the difference in the world. And then yeah, the installation was something I you know, it was it was out there for a long time years. finally happened. My family came in from Alabama, which was super special. I think they know I'm a hand surgeon, they really have no idea what I do. So now they have a little more of a taste. And really the other thing that was special was the other people who came in town, Peter Stern, Terry light, my good When Kirby over flew in, I didn't know he was coming from California. So, and then, you know, Larry lanky from Columbia, and Ken Yamaguchi, who's now at Northwestern, a lot of people came in. And you know, this was not just for me, this was a recognition of Richard government as well. But really amazing turnout. The lesson I take away aside from the really, it was fantastic. And the dinner afterwards was amazing. And people were learned a lot. I talked a lot fantastic stuff. My take home is don't miss events. It was so meaningful that Peter stern came to St. Louis to be there for Richard and I, it just doubles down that principle, don't miss important events, whether they're important to you or important to someone you care about. Don't miss them.
Chris Dy:Yeah, it was a it was honestly, it's an orthopedics Hall of Fame. I see the people that were there. So yeah, I mean, I think that, you know, there are things that are meaningful to for so many reasons. And you know, if you, if whatever, you can make it and I did bend my schedule a bit to make it there for you. So, I'm sorry, I missed the dinner. But yeah, there was an event for my kids. I wanted to be at too so yeah, there's always work, you know, yeah.
Charles Goldfarb:There's always challenges touch out no doubt. Anyways, super fun. All right, shall we jump in. So
Chris Dy:I love it when we get reviews. And we're fortunate enough to have a great review from RJR Cannell via Apple podcasts from the UK. Thank you for listening over across the pond, best orthopedic podcast five stars. If you haven't left a review, when you go to leave a review, the only way to leave a review is with five stars, entitled best orthopedic podcast, beautiful presentation of a variety of topics, from clinical controversies to technical pearls, we'll get into some of that today, which would be fun, totally approachable and engaging style and like the majority of orthopedic podcasts, really useful for preparation for ortho exams. So they give you get everything yet prep for your cases, prep for your exams, you get to hear about Chuck and all of his amazing accomplishments. Good stuff, good stuff. So thank you for leaving that review. Please leave a review, Spotify, iTunes, wherever you get your pods. And then feel free to email us at hand. podcast@gmail.com.
Charles Goldfarb:Love it. Thank you. Thanks for the review. Thanks for sharing that. And let's see if it's okay, I'll pivot for a listener submitted question from Cal sharp. Here's cows comment and question. I've had a couple of patients with older sided wrist pain after distal radius fracture that are treated with ORIF. And some that were treated non operatively. I would love to get your thoughts on how you approach owner risk pain and treat it At what time do you start intervening? After a period of observation? advanced imaging question mark? Oh, no carpal injection question mark surgery, perhaps this would be something to consider on the podcast. Indeed, we are considering on the podcast. So Chris, I'll paint a scenario, we have a 47 year old male who falls off his bike as a district his fracture, he did a beautiful open reduction internal fixation from a volere approach. You test it as DRUJ intraoperatively and found it to be stable. And now he's four months out, the radio side of the wrist is doing great, but he's still complaining of owner sided wrist pain. How do you think about it?
Chris Dy:Well, I mean, I guess I was prepared for you to give me a case of a 67 year old woman. Because honestly, that is the patient, that demographic tends to be the one that I find having to have this conversation a lot more with. I usually, you know, I guess we can answer your question in a moment of how you might handle that patient. I think it is important, again, to assess stability as DRUJ and I'd love to know your ways on doing that. I do tend to try to blot the owner head and try to manipulate it volar and dorsally in different form positions and see if there's any increased laxity compared to the other side. I also do a try to manipulate the corpus as well relative to the illness and then stabilizing the distal ulna, and then essentially rocking the corpus back and forth to see if that generates pain. These are all things that I like to use to look at potential TFCC issues. You know, I'd love to know what I'm sorry, intraoperatively. This is stuff I do in a clinic. I do it intraoperatively too. But you know, that's kind of the if this conversation is happening after surgery, and we're still having on their side of wrist pain, which happens a lot of people. And those are the things that I'm doing briefly in clinic while trying to assess, you know, talk to the patient a bit more. I'd love to know your thoughts on how you assess that. And also what you think the pain generator is. Patients who have continued on their side of wrist pain after disarray, so if
Charles Goldfarb:yes, so first of all, I think one of the points I need to make to the Fellows is always perform the intraoperative exam after you fix the radius and do that in supination, neutral and pronation. And if you have concerns about stability and hopefully you've tested the other side, so relative stability, then you know most commonly if you have concerns, long arm splint and supination. And it does change the patient expectations afterwards, right? Because we all talk about, we'll fix your history radius, and we'll get you in therapy right away. But it's worth it. So that's number one. Number two, I do the same thing. postoperatively, once the, you know, not the two week visit, but maybe the six week visit. And ultimately, most are stable. We don't really know what's going on with the TFCC. And then, of course, if there's an illness, styloid fracture, patients will focus on that, and really be concerned. But the reality is, as we've discussed before, and I think, as all of us know, is that older set of risks, pain persists, while the distal radius heals, whether it's treated awkwardly or not.
Chris Dy:Yeah, I think that, you know, it's that's important messaging to, I have that conversation from the beginning, when we're talking about surgery, especially if there's no other style of fracture. Because, you know, like you said, like, the patient sees that they have two fractures, why are you only treating one, which is a very reasonable, you know, thing to ask. So we talked about that. And I tend to, you know, at least when I was in training, there were a number of studies that had been published, looking at whether or not to fix the on their style of fracture, and, you know, essentially demonstrating that, you know, at a year comes, and then you do have the chance for prominent implants in that may need to be removed, given. There really is no subcutaneous tissue there.
Charles Goldfarb:Yeah, it's been an interesting evolution, as you said, when you were in training, we were talking about fixed or not fixed, I think all of us believe, don't fix the oldest thyroid unless you really feel like you 100% have to. So it's not even really part of the discussion anymore. For me. Whether or not there's a fracture, the pain can persist. Of course, I'm always thinking TFCC and arthroscopy. But but don't jump to that too soon. I think my messaging is probably the same as yours is, I tell people when preoperatively that owner saw their wrist pain can persist for a year. It's a good, it's a good landmark to have for them to consider. And then hopefully it helps manage it better after surgery.
Chris Dy:Do you think that that the likelihood of having pathology to the TFCC is higher, what that merits actual intervention is higher in that patient that's 47 and likely had a higher energy impact injury than somebody who had a standing level fault?
Charles Goldfarb:I 100% do. And of course, fracture pattern can tell you something, whether it's that radial shift at the distal radius fragment or whatever. But the higher energy injury makes me worried more. And certainly a relatively small percentage, honestly of the wrist arthroscopy as I do today, are related to a previous fracture, but most are not related to a previous fracture. So as we know, from back in, what 9095 Bill geysers original
Chris Dy:were late, the late 1900s. Yeah. So
Charles Goldfarb:last century, we know that that soft tissue injuries happen, but the vast majority just get better for patients.
Chris Dy:When do you at what point do you pull the trigger on doing something more than counseling, either injection, which I use in my practice, or getting advanced imaging.
Charles Goldfarb:I'm not a big fan of advanced imaging in this situation. I think there can be a role for it. But my first step, let's say we get to nine months, and the patient's just not happy, not happy with you, not happy with their wrist, and you got to do something. I think our corticosteroid injection is an incredible tool. I don't repeat it typically is sort of one and done. And I give it with the concept of I felt a patient I think it'll make you better. If it does make you better, we learn something. And if it makes you better, only temporarily, then that's when I personally think about arthroscopy is the next step. But it's a great anti inflammatory, and it usually helps people.
Chris Dy:You wait nine months, you're so mean, like usually, if it's I'll go further. I honestly if it's if it's three months, I just go ahead and do it. Oh,
Charles Goldfarb:wow. I don't go better. I tell them to suck it up. Why
Chris Dy:wait, though, just out of curiosity, I think I'm out of the woods there in terms of potential concern for infection, etc. Way out of the woods. So if they're struggling in may unlock, you know, the ability to work through things a bit more with therapy. You know, it's honestly it doesn't come up that often that I'm giving a steroid shot, but you know, I've been happy with it. Yeah, so I don't make them wait. Yeah,
Charles Goldfarb:three months feels early to me not not because I'm trying to hold out and I agree with your points. I don't think it is at that point, you're not going to really worry about healing impact of the steroids and, and infection is not really a concern. So I don't think I wouldn't disagree with it. I just think so many people get better, better between that three month and six month interval. That is probably not necessary. But what it does do is it makes it look better. Yeah.
Chris Dy:It's funny, I used to, you know, I think it's important to obviously understand literature, where this is not a huge area but I I'm for tennis elbow for injections, I have become more lenient about giving injections. Although I used to stand on principle about the literature and know how to make a difference and sector and like, there are some sometimes it just does help. And I tell them that it might not help based on what the later on, you know what the literature says. But I found it to be useful. There is some elements of patient satisfaction. And you know, even though there is obviously risks with any injection, this is one where I think the, you know, the upside is much bigger. Listen,
Charles Goldfarb:and I may have said this in the past, I may not have my dad's end down in Alabama recently retired, he stressed to me that patients want something. And it's incredibly important. Now, I quibble a little bit more with his approach, which is they came in with a likely a viral, whatever, you know, infection, he would give antibiotics. But they got something and when they got better, who got the credit, and patients want treatment, and so we don't want to do something that could potentially be a negative for them. But I agree with you. The literature is really important, and we try to be you know, science based, but I don't fight so much anymore about injections for tennis elbow. Yeah,
Chris Dy:isn't. Yeah, I totally, totally agree with that. Perhaps not the antibiotic part. But yeah. So in terms of cows question, you know, how often how many times in your decades long career, have you performed in arthroscopy after distal radius? Or if so,
Charles Goldfarb:this is the beginning of my third decade. Where are you? You're in the middle of your second decade? We're not that far apart. I'm at
Chris Dy:the end of my first decade in practice. Are you towards the towards the end? Not even at the last year towards God?
Charles Goldfarb:You're only in your ninth year?
Chris Dy:Is that right? Yeah. I mean, I'm currently in the ninth year.
Charles Goldfarb:Oh, wow. Okay, we're a little further recall. What was it? Well, you
Chris Dy:were you were recruited as a resident in the late 1900s. I believe.
Charles Goldfarb:It's true that century. What was your question?
Chris Dy:How many times in your decades long career Do you think that you've done a scope after? After disarray? Sorry, if? And what do you what have you seen in that arthroscopy and how have you intervened? Is it a debris mint? Is it repair? What do you think? So?
Charles Goldfarb:It's a great question. And I would say this of the patients, and this is not about me, but of the patients I've treated for destroyed is fracture, the percentage that ended up going to or for arthroscopy is probably 1%, maybe 2%. I mean, something incredibly low. If you look at kind of all patients that I take for an arthroscopy and look and see what percentage of those patients had a fracture at some point in their past, maybe that 7% or something, but both are low, but I don't think it's too in regards to cows question. We ended up doing scopes on many of those patients. And maybe because injections when required are helpful enough that
Chris Dy:you quickly mentioned. So I think it's super important. And that concept of the radial shift, or the coronal shift of the into fracture pattern, you know, so that's one that when I was in training, Scott wolf was really hot on and you know, I think it was, I think the surgeon in Australia, as Mark Ross, who has published pretty extensively about it, too. Did a couple of projects related to it. And I learned a lot in doing them, you know, there can be subtle shifts in the coronal plane, that can make a difference for drJ stability, at least in the lab. And I think I've seen that in patients too. But I've also been endeavored to really get that coronal alignment of the metathesis over the shaft during surgery. So what's been your experience with that? And then do you have any pearls on how to to get that alignment? Correct? Yeah,
Charles Goldfarb:it's a really important point. And it is a sort of a different reduction maneuver. Now sometimes it just comes back in place. But other times I have struggled to align things coronally, and there's different tricks. You know, some people will put a laminar spreader between the shaft of the radius and the ulna and you open the laminar spreader and that helps the reduction I think that's a perfectly reasonable tool when necessary, and by doing that you bring the distal aspect of the radius back on top of the shaft. I don't know that that technique other than something like that if you have to matters all that much, but I'm interested in your take. But I do think you wanted anatomical to help the soft tissue healing process.
Chris Dy:Yeah, I like the laminar spider technique and use it occasionally. I have some concerns about being too aggressive with that because you are you know, introducing some potential for scarring and interosseous membrane, that kind of thing. So it's that and then also, you know, honestly getting a lobster claw type fracture clamp on the shaft and using that to manipulate. Some of the newer implants do have a kind of oblong hole in the coronal direction so that you can shift in that manner which is super helpful. It honestly, it depends on the fracture depends on the day in terms of who you have with you, and whether you have to do that maneuver yourself, or whether you can, you know, have somebody else put the screw fixation in while you're holding the attending maneuver. You know, you're about to get some cramps, because you're holding the reduction for so long. But I think that it's important to do, I think it's becoming increasingly recognized, you know, so I think, when you're looking at the fracture pattern, make sure you recognize that and potentially even talk with the patient about the, you know, the issues with, with homicide risk pain afterwards. The other one that becomes a little bit concerning to me is that the fragment of Bergen as I call it, because our partner has published a couple of papers on it, looking at that dorsal on their corner piece, I think that's useful to understand the implications that might have on on their side of risk paint on the line, too.
Charles Goldfarb:I think that's well said, both of those points, and you know, the drnj configuration if the fracture extends to the drJ can matter. I haven't been as impressed with brokens fragment, but I think it's a relevant consideration, especially when there's combination.
Chris Dy:So Cal, hopefully that helped. And you know, I'd love your thoughts on it. I know Callie, you see quite a number of patients and you've recently been in training. So if you want to share your thoughts, please email us back. Hopefully that answered your question. Which by shout out our first sponsor. The upper hand is sponsored by practice link.com, the most widely used physician job search and career advancement resource.
Charles Goldfarb:Being a physician is hard. Becoming a physician is hard to finding the right job doesn't have to be joined practice link for free today at www dot ATT practice lync.com backslash, the upper hand, how
Chris Dy:many times you think you've read that copy? And now you're still you're flooding it up?
Charles Goldfarb:Loving it, you know, it's interesting app just tired. It's been I'm ready for a little time off. And I'm tired. No excuses. No excuse.
Chris Dy:That's yeah, we talked about the things we'll talk about briefly. Laters energy. And it's it's such a hard thing to bottle to really harness. And I mean, I think when we one of our first leadership talks, when, when Rick Wright was in charge of this series was about managing your energy. And I think that's super important. One of the things that when I talk about this, it's just knowing when you're at your sharpest, but kind of on a weekly daily basis, but then also on, you know, sometimes you're gonna have deviations from that and recognizing that and saying, you know, I can't do that today. It's just not the right thing to do right now. Yeah,
Charles Goldfarb:that's really well said. Before we jump into that we were we, you know, we've had some good, good discussion. Do you want to do a brief case? Yeah,
Chris Dy:I'd love to hear your thoughts. I mean, so I've seen some patients recently, you know, and still trying to figure out the best way to manage them CMC arthritis surgically when it comes to it. And I think that your recent paper has been very helpful in terms of comparing outcomes after, you know, a lrti, the Burton Pellegrini type technique with the fcr suspension versus the suture tape suspension, which is all the rage nowadays. Or at least it was. much difference in terms of outcomes. We're still searching for, I think, the ideal technique. Do you have any? What's the role of a thumb, CMC, Arthur desus fusion in your practice,
Charles Goldfarb:CMC fusion, got a bad rap, maybe 20 years ago, and it did, because of the rate of non union. And it's a fair it's a fair consideration. Because the last thing in the world you want us to have to go back and do another surgery? I think CMC fusion is a great operation, and done in the right patient. I strongly believe they will be happy. And they will come back for potentially other side if it when that is necessary. So I really like the CMC fusion. I think we have a few advantages today, versus 20 years ago in obtaining healing, but I think it's a really good surgery. So
Chris Dy:you mentioned how it got a bad rap. I mean, there was that study in the UK was, I think it was the UK, at least it was published in the British Journal, but it was, you know, a randomized study that was actually halted early and stopped early because of the unacceptable, quote, unquote, rate of non union in the CMC, Arthur desus group. And you know, that I think, really set that procedure to the side for a long time. But I think it was Dr. Gelberman and you were the big believers in this surgery. And I think during, you know, last few years of his practice, you guys had a series that was published with was a KJ Hippensteel Back in the day, we're happy to present in our program, looking at you know, you know, cmcr through desus, and there were some nonunions, but the rate of symptomatic non union was very, very low.
Charles Goldfarb:Yeah, I'm not even sure I was on that paper. But yeah, I think that the, the two things I think about one is the hardware utilize, obtaining compression I believe matters. And two, I always used history as bone graft. But those are the technical things, which I believe matter, the indications matter to do you have a patient population where you think about this operation and and also, how many times a year do you think you do it?
Chris Dy:I probably do three or four years, it's probably five to 10% of my thumb, CMC surgeries. You know, I think it's, I think I've really liked the surgery. My indications for it tend to be the labor, classic indications for it. Honestly, it's a person with bigger hands too, because doing an Arthur desus on somebody with the smaller trapezium is honestly, just kind of hard, once you've cut back on the on the arthritic bone surface, so it's technically more challenging. So but, you know, the person with the bigger hands, who is either a laborer, and has years to go on that, or if they have activities that are kind of relatively, you know, heavier. So in terms of like, aggressive yard work kind of thing. You know, that, to me, is a great patient for it. And, you know, the patients who do well are very, very happy. And, you know, that's been my experience so far. What are your indications? And then also, you know, technically how do you, you know, how do you prepare the joint surface? Are there any pearls that you have in your decades of experience?
Charles Goldfarb:So my volume is not much different than yours is, it's five or six a year, maybe less? It is the younger labor type population. So I would say less than 50 for sure. And maybe closer to 40 is my typical patient. I've done too recently. You know, it's, so my preparation of the joint the base of the metacarpal is easy. Simply because the bone is not so sclerotic, and obtaining great cancellous bone and that is a key that I don't think I realized earlier in my career, you want great cancellous bone, not just good bone. So great consoles bone, I like the cup and cone technique, where the cup is the distal aspect of the trapezium, the cone is the base of the metacarpal. So you repair the metacarpal make it as as cold like as you can, so as rounded as you can. And then working on the the distal aspect that trapezium is a little trickier because it's just dense sclerotic, and you have to get past that sclerotic bone. So for me, it's usually a sharp Roger, and with a streak down the center and work on either side, like Dr. Gelberman taught us and perhaps a burr although I'm not a lover of the Burr, what about your Yeah,
Chris Dy:similar similar technique? I had a fellow I won't say when, who was all about using the software these and you know, I don't love it, to be honest with you. So, you know, I do the Roger technique. I think one of the tricks on the trapezium is really recognizing how you have to get out to those radial and ulnar horns on the trapezium and getting those down, because those can be a little bit tricky because of the sclerotic nature of the bone out there and the osteophytes that are there. So in recognizing that you know, if in terms of you know, who has the angle to use a Goldfarb quote, you know, in terms of who's doing which parts of the surgery, I prefer to be the one doing the trapezium unless I'm very comfortable with the person on the other side of the table, because you have less chances. With the trapezium that quickly, it can quickly evaporate with an overly aggressive preparation, so to say, more chances on the metacarpal.
Charles Goldfarb:Yep, exactly right. And then again, I add cancellous bone graft, even if I have a perfect fit, if the cup and cone is perfect, I still had cancellous bone graft. And in my goal, usually it sits where it's supposed to sit. And of course, we didn't mention the one warning to patients, the one thing you have to tell them is you can't put your hand flat on the table after this surgery, if they know that before the surgery, they will be fine with it. But resting posture is thumb should lie over the middle phalanx of the index finger people talking about 30 degrees of abduction and etc, etc. But I just think it's simplistically have it rest over that middle feelings. Yeah, lining
Chris Dy:up for pinch, right? So you know, it's it's a different. I've found the thumb cmcr 36 to be different in the arthritis population versus the plexus population. Because for the plexus population, I'm really trying to get their thumb completely properly abducted in more than a position for opposition. And pinch. They just wanted out oftentimes, I don't know what your experience has been for using it for other indications outside from arthritis.
Charles Goldfarb:None I really don't think so. Glad you're doing those patients instead of me.
Chris Dy:And then technically, you mentioned that we have advantages now. I mean, I'm sure we had the technology back then. But we didn't use it. So what's your fixation of choice? So you've K wire guy? Yeah,
Charles Goldfarb:not a K wire guy. Even though there's nothing wrong with K wires in this situation. And I think if things go arrive for whatever reason, be comfortable and confident using K wires. I think there are some specifically designed plates for this that give you a couple of advantages. The one advantage I think is most important is it gives you the potential for compression in a low profile plate is not likely to bother the patient. And the second is a plate that also allows you to place a compression screw, either in or outside of the plate, and adds another point of fixation to fight toggle, I think is really important. And so there are a couple of options out there. The one I use with with absolutely no conflict of interest is the Met artists plate. It is expensive. But I think it's well designed.
Chris Dy:I do like I think it is important to get some compression, you know, my experiences, I don't use that plate, just because I don't use any of the other things in their in their lineup. And again, no, no conflict with met artists. The thing that the plate that I've used is kind of a standard 2024 kind of plate, depending on the size of the patient, and I use a two column plate. And then I'll usually cut off, you know, one of the rows and then cut it in a way where I can actually bend the proximal part to kind of hug the bottom of the trapezium, and then put some compression through the plate on the metacarpal side, just with kind of a standard ao technique. So I found that to be helpful. And then I think it is important to keep a low profile if you can, when you're doing your approach elevate the sleeve periosteum you know, off of the metacarpal to try and you know use that to cover the plate down the line if you if you think about it ahead of time.
Charles Goldfarb:Well said well said You know, this is a fun surgery, and patients get great outcomes they heal in a timely fashion. So all good. It's a good it I would say it's a mandatory tool for you to have for certain patients. Because the lrti or the gpz activity or the internal brace, those are not always right for every single patient.
Chris Dy:Right. It's good to have things in your toolbox for sure. So speaking of things in your toolbox, a shout out our next sponsor, are you heading to the Bahamas for the AHS, ASP, ASRM annual meetings later this month. If so, stop by booth B 14 to visit our sponsor checkpoint surgical. They're also hosting the ASPN lunch Symposium on Saturday, January 13, where a guy named Chris Dy will be presenting alongside Dr. Steve Lee and Dan Zlotolow about nerve injury reconstruction challenges. So you get lunch, you get nerve, all good. You can find the registration at the link of the podcast description or on nerve master.com. I hope to see you there.
Charles Goldfarb:All right, fantastic. So it's going to be a great meeting. I know you're going down I think brokens going down Dr. Wall is going down. So a good chunk of our faculty are going down. Yeah, so
Chris Dy:as Dr. Morris so I hope you're back to take golf.
Charles Goldfarb:I will be holding down the fort. No,
Chris Dy:I think it's a fun meeting. You know, I love the ASPN meeting as well as the association meeting but they're for the ASPN have had a really good time being on their on their executive committee learned a lot about the organization. And and I love sitting in on those scientific sessions I learned so much being there. So excited about being down and you know, Bahamas doesn't hurt either.
Charles Goldfarb:Is just a family that Dy family vacation? Or is this just the just Chris Dy, himself
Chris Dy:so no, no, the family is coming. And I am going to I told my wife like, look, I'd love it. If you guys go, like I'm actually really busy at this meeting, like I'm gonna be at the meeting like, really at the meeting, those meanings
Charles Goldfarb:are tougher, unless, you know the sick, your significant other can handle it and enjoy it and be with the kids perhaps happily on the beach.
Chris Dy:But I think that's the key of having the broken and while families are as well as that becomes a group affair. So yeah, it'll be it'll be fun. It'll be good time. I'll catch them at dinner. Maybe Maybe.
Charles Goldfarb:Oh, all right. We had talked about maybe discussing a couple of HBR articles. But I think let's focus on one if that's okay with you. And the article that we'd like to briefly discuss was actually shared with you and I by Marty Boyer, and it's entitled The best leaders have a contagious positive energy. This article was written by Emma Cipolla and Cam Cameron. And I'm not sure what year it was published.
Chris Dy:2022 Yeah, in HBR. So if you want to pull it up on the the HBr thing to reprint is h 06 ZUL. For those of you HBR nerds.
Charles Goldfarb:Yeah, so this is these are articles I think are helpful because what they do is they sort of either validate or educate us around things we think we believe are true, and provide a little more evidence for success, honestly.
Chris Dy:Yeah, well, so what they're talking about here is, you know, kind of the energy that somebody brings in, you know, anecdotally I mean, you you are totally in charge of the energy in the room, when you walk in, you can change it, you can shift it, and some of us are more conscious of that and try to try to affect the dynamics of a room others are more passive, if that's
Charles Goldfarb:right, and you know, this article like many others in this kind of type of HBr present pation are based on a lot of work, a lot of interviews. And you know, in this case, two decades of research on positive leadership, and it's really incredible that they focus on extraordinary performance. And they have found that one person is usually at the center of networks that are most responsible for forward motion, and well being. And the the authors call those people positive energizers.
Chris Dy:Yeah, I think it's the way that they did their research is that they took the group, and then they asked people in the group, when this person want to interact with this person, what happens to my energy level. So it could be a group of, for example, in this case, you know, vice chairs or division chiefs, and you're saying, you know, when Chuck Goldfarb walks into the room, what happens to my energy? You know, I thought that was super interesting that they were able to, you know, to look at the people with more positive energy versus those with lower energy, or negative energy, and, and see how that affected performance. I mean, how do you how do you interpret this in terms of how you think about, you know, your leadership in our department, group of surgeons group of, you know, because I trust neuro rehab folks, and does that. Does that resonate? Does it make sense? And then, you know, how do you? How do you think about your own energy?
Charles Goldfarb:Yeah, it's, I've thought about this in a couple of different ways. I'd love your take. There are people that are leaders that walk into a room that immediately get attention, and immediately, maybe get deference. But those people are not always these positive leadership people. And I think increasingly in 2023, and tomorrow and 2024, we will see that it is positivity and collaborative leadership, more than the kind of old school leadership, which is, you know, takes the day. But this type of leadership. I, I've seen it, I know it works. And you know, hopefully, it's not a type of leadership that requires conscious effort. Because the best leaders probably don't have to do that. But those of us who are aware of this, even when we aren't at our best, or at our most energetic, I think we can find something if we recognize these principles.
Chris Dy:Yeah, absolutely. I mean, I guess they mentioned early in the article about how this is different than something like charisma, and you seem like a very high risk guy, as they're saying nowadays, how do you think about this as different from charisma and is positive energy always kind of what we think about, you know, the cheerleader rah, rah kind of thing?
Charles Goldfarb:I think, and they make the point of discussing those who deplete energy, and we know that type of person, right? It's kind of the law person. And I don't think those those people, no matter how smart they are, can be effective leaders. And so I do believe that people who are positive energy leaders often have charisma. But I think if you are supportive of those around you, if you give back with what other people put out and amplify that you don't have to be charismatic. Do you think you do?
Chris Dy:I think there's, there's an association, like you're saying those people that have are more charismatic, tend to have higher positive energy just in general, I think, but there are ways I think it's as, as people have been saying recently, it's context dependent. But I think it's situationally, you know, where you are, you know, that, that matters, like your, your positive energy you can bring to a to the or is different than the one that you bring to the clinic. And it's different than the one that you bring to the boardroom meeting.
Charles Goldfarb:Yeah, that's exactly right. And this article makes the point with a personal example, that you have to be at your best to be able to reflect the positive energy around you. So you know, you need to take care of yourself, to be in the right frame of mind, to be that positive leader. And to me, positive leadership has a lot of different things, most of which are addressed in this article. It's making people around you feel good, it's not stealing ideas is amplifying the ideas of others. And there's just so many examples. But when you do that, or when the group does that, honestly, is the best situation where there's a lot of positivity, people are happier, and we talk so much today about well being and, and feeling a sense of belonging, all of those things go together. Yeah,
Chris Dy:totally, totally agree. And I think that that's probably some of the, you know, the the emphasis on getting back to meeting in person again, is that you are more likely to To get that positive energy, you know, in person than on a zoom screen or whatever, you know. So I think there are some people that do that better than others, then you have to work so much more intentionally if you're meeting remotely than if you're in person just because it feels more organic, and you're just honestly happy to see people. When you're together.
Charles Goldfarb:I think that's really well said, and I don't, I don't, you know, you can work really hard on a zoom. But as you say, I don't think you can, you can do it, I think in person is required for some of this. And so trying to find the time for in person conversations that build a team, build a department build a practice of, you know, however you want to think about it, a practice that, you know, will be innovative, a practice that, that will kind of move the field forward and create happy patients, if it's a medical practice, all of those things matter so much, and zoom is convenient. Zoom doesn't do it. Yeah, I
Chris Dy:think zoom can work for some situations in terms of like, sometimes a one on one meeting with somebody that you know very well, you can that can work. But if you're trying to lead a big group, it is incredibly challenging. As we wind it down, I, I'd love to hear your thoughts on how you bring examples of how you bring positive energy in three different situations. One, a leadership meeting to the O R, and three, the clinic, I can start since I kind of sprung that on you. But I think for me positive energy for the or is really getting the team on the same page from the very beginning. If there's somebody new in the ER, making sure to introduce everybody, I did that recently. And that was a big hit. And somebody actually told me that like that was really nice, I felt very included. So I think that's one example for me, and er, how about you? Yeah,
Charles Goldfarb:that's really good. And I was a little taken aback that you were putting me on the spot for three examples, but I think they're the right ones. So I think about, you know, when I'm in the or, in, let's face it, I think probably most of us are like this, especially first thing in the morning, we may not be at our best energy wise. And if you have the same team with you week in and week out, that's okay. But when it's not okay as if you have new people, a new team, which increasingly is happening in our laws, and as similar as across the world, I think then you have to bring your A game and your energy when you start. Because if you are that one wrong person at 730, in the morning, when your car is starting, it just it really risks having your own car go in the wrong direction all day. And so it is what you said, it's involving everyone in the room, it is bringing energy about, hey, we got a busy day, we're gonna get this done, we're gonna take great care of patients, it is being a little rah rah is just bringing energy.
Chris Dy:Yeah, you are. It's, I think, as a surgeon, you are disproportionately in charge of the energy and the or, I mean, anybody who walks in the room can change the energy. But as a surgeon, because of the de facto leadership position. If you're having a rough day, everybody will, that will shift the outlook on the day. So it's I've told this to trainees before, I mean, the only to be very honest with you, the only person that usually knows that a case is a trickier and more challenging than expected, or you're getting into the problem is the attending typically. And sometimes it's even understands what's going on. So if you keep your cool, and you keep good energy, the rest of the room won't even notice if you all of a sudden are dealing with a technical issue. Now, if sometimes there's a moment for this, and you have to kind of get everybody's attention, but if you start freaking out, everybody's gonna start freaking out. So you got to really keep your cool.
Charles Goldfarb:I think that's a really, really important expense, especially for those in residency or even in medical school. It's critically important and you can, let's say, and this has happened to me, I'm doing a procedure, you're taking out a volare. scalenes simple surgery, you know, not a lot of stress involved. And you notice there's a nic in the radial artery. If you, you know, freak out and talk about blood spurting, and then everyone's aware, it's a negative, it's gonna affect the energy for that case and cases moving forward. But if you can't really ask for, you know, a nylon and a, you know, maybe microset no one bats an eye, it's unbelievable, as you said, no one bats an eye. So if you keep your cool and just address the issue, it'll be fine. So the
Chris Dy:for good for clinic stuff. I mean, how do you, you have you have busy clinics? I mean, how do you keep the energy going in the clinic? You know, from the jump and then throughout the day? I
Charles Goldfarb:think the hardest part of clinic is not the typical patient because we're lucky right? We are an orthopedic surgery, patients are typically happy and if we can address their issue, they will come in happy and they will leave happy. The problem or the difficulty is the problem patient. The patient that's not happy, for whatever reason, it comes in, and those, those individuals are energy to Peters. And we all know that one patient like that can honestly ruin the whole day. Whether it takes the time takes our energy, and then we have less energy to put out in the world. And so I think it's really important in those situations that we have to, you know, we, the surgeon, the main person need to address then work with that patient, not let the whole team be drawn in negatively with that patient, and try to just deal with it the best we can and then find more energy to move forward. What do you think? Yeah,
Chris Dy:no, I mean, I think that there have been days where clinic has gone surprisingly well, in terms of efficiency of time and happiness. And then it's, you know, I look at my MA and like, that clinic was awesome, like, what happened, and she's like, you didn't have any nerve patients. It's like, okay, or like the challenging neuro patients, you know, I've tried to structure templates. So that complexity of patients and the people that are likely to to be longer and more involved visits, I'm not necessarily ng deplete years, but just things that can slow clinic down, I tend to put them during times where we have a little more leeway. And then knowing that patients sometimes can be more challenging in terms of their situation, their happiness, their demeanor, etc. Some of those patients, I intentionally say that patient needs to be the very last appointment when they come back next time.
Charles Goldfarb:Yeah, that's really smart. It's also not easy to do. But it's really smart to handle it that way. And I like you, like everyone listening, understand, understands that there is no way to look at your schedule, on the morning of you can have the same 60 patients, three weeks in a row, and that clinic flow, that energy level, that enjoyment varies from week to week, and there's simply no way that I understand you predict it, and you just have to hope the next day is going to be a good one. Yeah,
Chris Dy:absolutely. Honestly, there, there are things that we do during clinic to kind of keep things keep the keep some levity, we have a little whiteboard that occasionally people have been known to draw or leave comments on use of the whiteboard is fractured, like, you know, a grid with the rooms. And you know, that was a I think that was a Dr. gelderman thing that I've incorporated, you know, in terms of having a board where to write like what to do, because sometimes there's a lot of asynchronous communication in clinic, like if the MA is in the room already, and I'm walking out, I want to do an injection, etc. Alright, on the board, but there have been various tallies of things or drawings, or you know, that just kind of keep the mood light. And I found that very fun. Yeah,
Charles Goldfarb:I think that was a Rick right thing. Maybe government even got it from Rick. Right. But I think that's good. And your last scenario was a meeting, a leadership meeting. And I think there's a couple of principles, number one, don't have a meeting unless you need to have the meeting. We're all meeting out. And so there's really good reasons and really important reasons to have meetings. But if there's not a compelling reason to have a meeting, send the email is dead. So that's number one. Number two, as you said, in regard to the or lay out what you need to accomplish in that meeting, and do that at the beginning. And then summarize it at the end. And then thirdly, it's the same thing, bring positive outlook and energy, and a positive approach to dealing with the issue or the opportunity or the strategy, whatever you're there for. But that energy is palpable, and can get you off in the right direction.
Chris Dy:Well said, I don't have much more to add, I'm trying to get better at listening and not thinking about what I'm going to say next. And I think that indirectly relates to what you're saying about, you know, giving support to somebody. Because if you don't listen to them, you're not actually going to be able to support them. And if you don't agree with them, taking a minute to process it, and think about it and consider their perspective before they're refuting them or trying to ask, you know, clarifying questions. Yeah,
Charles Goldfarb:and that's, that's a whole episode in and of itself, of course, I agree with you. It can be hard to listen, and process and figure out what you're going to say next. But I love what you said. I mean, when someone says something that you don't agree with, there's there's a couple of different ways to respond. One of those is to state your disagreement, which can be okay, if you have a strong reason why and how you think about it differently. More and more, I'm doing what you suggested, which is try to understand why the person feels the way they do. And that will help inform you to make, you know, a better decision and response.
Chris Dy:So last episode of 2023, we're jumping into the New Year. I hope, you know, we'd love to thank everybody for listening to us. If you made it this far. You're very loyal listener. But you know, feel free to send us emails. Communicate with us about things you want to hear about on the podcast as we jump into 2024.
Charles Goldfarb:Yeah, I mean, there's so many topics. Thankfully, we aren't at as there's no shortage of topics, but we want to talk about what matters to you. So the more you communicate with us, the better we can be at that task. From the hand society coding app, to HBr articles to technical We enjoy it all. And we look forward to 2024. That'll be our fifth season. So we are looking forward to it. Happy New Year to each of you. 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 at hand podcast. Hey, Chuck, what's your Twitter handle?
Charles Goldfarb:Mine is at congenital hand. What about you?
Chris Dy:Mine is at Chris de MD spelled dy. And if you'd like to email us, you can reach us at hand podcast@gmail.com.
Charles Goldfarb:And remember, please subscribe wherever you get your podcast
Chris Dy:and be sure to leave a review that helps us get the word out.
Charles Goldfarb:Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time