The Upper Hand: Chuck & Chris Talk Hand Surgery
The Upper Hand: Chuck & Chris Talk Hand Surgery
Technical Considerations in the treatment of Kienbocks
Chuck and Chris welcome 2024 and season #5 with a technical episode on the treatment of Kienbocks disease. We discuss patient evaluation and surgical considerations including radius shortening, vascularized bone flaps, carpal pinning, and so much more.
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Hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:I'm great. How are you?
Chris Dy:Its 2024, first episode of the new year.
Charles Goldfarb:It's an exciting time. Absolutely. This is year number
Chris Dy:into our fourth year,
Charles Goldfarb:fifth year,
Chris Dy:fifth year. No. Oh, yeah. into our fifth year. It's our four year anniversary coming up later this month. It was totally timed around some other world events.
Charles Goldfarb:Yes. Like COVID. For those of you not in the know. Oh,
Chris Dy:man. Yeah, no, that was that was a crazy time. Yeah, so it. Let's hope nothing like that happens anytime soon.
Charles Goldfarb:Yeah, did you? Did you have a good holiday with the family? Yeah,
Chris Dy:holidays were good. I traveled back and saw a family in Florida. Actually, when we left St. Louis. It was the same temperature in St. Louis than it was in Florida. But then quickly, things plummeted back home here in St. Louis. So I had to remind myself that it's actually January outside. And it's reasonable that it's this cold right now. Yeah,
Charles Goldfarb:must have been fun on the behind we, we got away to Charleston, with the family and for my family, what kids rolled or we have to go somewhere to be together. And it was great. It was it was really great. It's a cool town, and we had a blast.
Chris Dy:Great food hadn't been there in a while. But we need to go back. It's It's been a while. Yeah, great
Charles Goldfarb:food beaches are amazing. And we were walking on the beach, it was 55 or 60 degrees. And the architecture is really amazing. The homes are beautiful. It's a really, it was a good, you know, three day visit. So
Chris Dy:you survived the end of 2021 or 2023. Excuse me, I'm really missing hairs here.
Charles Goldfarb:I did had a good, had a good last couple of months. Actually. I looked at our division numbers for the last couple of months. And of course he did. And you know, it was a good month for the hand division. I'd say the last two months, were both super strong as we would expect. And what's interesting is, the numbers are yeah, there's differences between us, but we're all pretty darn busy.
Chris Dy:Yeah, yeah, no, I'm definitely feeling that I've got a rough couple of clinics coming up. You know, I've had the unfortunate, you know, every year it's weird, like either you lose our days, or you lose clinic days based on the holidays. And I've lost a few clinic days this month because of either holidays or travel. And I'm going to be feeling that in the remaining clinics.
Charles Goldfarb:Yeah, next year, I'll lose or days and I'm always convinced it's better to lose our days because we have to find room for the cases you'll find it but it's tricky. It's tricky.
Chris Dy:Yeah, absolutely. Well, I guess you know, I old me 2023 me would be stressing about which days I'm missing. But 2020 For me, it's just gonna go with it.
Charles Goldfarb:You'll say that now? Yeah.
Chris Dy:Exactly. Any, any resolutions, or affirmations, as they call them now, New Year's affirmations that you want to put out into the airspace.
Charles Goldfarb:You know, Talia had asked our family to each come up with a word that kind of summarizes what we want to do differently for the year, which I thought was kind of cute. Toys was, you know, be present. When you're present and all aspects of my word was, listen, be a better listener. You know, what's interesting is, especially as you're, you know, in meetings, and we're all doing all these zoom meetings, and hopefully, you know, hopefully I am focused on the meeting and that multitasking, but if I'm focused on the meeting, sometimes I'm trying to figure out what I'm going to say in response, and that makes me a bad listener. So I'm trying to do better with being present like Thalia, but also listening, really listening to people.
Chris Dy:I mean, I think that your Word of the Year actually corresponds with two of my New Year's resolutions here, actually went from I didn't make I was telling our fellow Emily's older sister the other day, I was not a New Year's resolution guy until the year I was a fellow. And I was so rundown, as they would say, Now burnt out in the middle of fellowship year, but I, I made my only New Year's resolution to that date, which was to work out three times a week, because I was just getting crushed as if it's different. Now. We've got more fellows, different faculty composition, but that year actually stuck to and haven't missed a week since then. And have actually elevated that number. But that was my first ever New Year's resolution. But this year, I went, I have some aspirational kind of immeasurable ones like you, but then also a couple of measurable ones. I said that I was going to listen more, it's actually number one. And then also to think before I act or speak, so it kind of combines those two kind of matches what you were saying. I need to leave a little more slack in the day. Just for my overall stress level. You know, it's funny, trying to you know, feeling like you're doing well in a lot of ways professionally but then realizing maybe to sustain I need to do a little less So that's a tough pill to swallow. So we'll see how that goes made here. And my measurable goals are kind of silly, but it's, it's to do yoga, to stretch and to do leg day consistently once a week each. So we'll see how that goes. That's measurable. And that's something I can actually check. Check off.
Charles Goldfarb:Now that those are those are excellent. I like both the aspirational and the measurable. I might have resolution guy I will say though, I don't know when I started, but I really have been good about exercising. I think you've motivated me in part, whether I'm having my knee replaced in one month, partially or partially replaced. Thank you. And one month, that's
Chris Dy:the total knee in denial surgery.
Charles Goldfarb:No, I just have medial arthrosis. But, but I I've been really good about working out and I've actually been lifting over the last kind of 10 months and I at least three times a week. I've been pretty consistent. I think I'll stick to it. Hopefully the knee was surgery done set me back.
Chris Dy:That's great. Good for you. Is that something you was your son at the age or you guys live together? Or your daughters Fred instance? Well,
Charles Goldfarb:Kylie, My middle child, who's the collegiate runner is really disciplined, like incredibly disciplined. And she was talking about how she, I think bench is 120 which is pretty awesome as a runner, and she's defined. My son is not a big lifter. So this is we kind of, it's gonna sound more impressive than it probably is. We put a home gym in. When my wife sold her business. She has the my cell belts business, which was wonderful for 20 years. We took the belt room in the basement and turn it into a gym, we put mirrors in a padded floor. It's really motivating. I was surprised how motivating it is. So that's been awesome.
Chris Dy:One of our partners has a really slick home gym. I don't know if you've seen Ryan Cathy's gym is pretty sick.
Charles Goldfarb:No, I did not know that.
Chris Dy:I've only seen pictures. It looks pretty awesome. So, you know, hashtag goals. Well,
Charles Goldfarb:it looks like he works out. But let's invite ourselves over for a lift.
Chris Dy:Ya know, Ryan's gonna embarrass me in another way too. So, anyway, why don't we thank our first sponsor, and then we can check in with a new review and then talk about kind of the year in summary for our podcasts,
Charles Goldfarb:that would be great. The upper hand is sponsored by practice link.com, the most widely used position job search and career advancement resource.
Chris Dy:Becoming a physician is hard. Finding the right job doesn't have to be joined practice link for free today at www dot practise lync.com/the upper hand. Alright, so
Charles Goldfarb:I think it's backslash. We
Chris Dy:always are, you know, practicing my locution, and I didn't get the backslash. I don't know which one it was. Anyway, we have a new review. And, you know, guys, it's the first review in many months. So thank you to Amy Pereira for leaving a review five stars, of course, the only option. And the issue, the title of her review is five plus, plus, plus stars. And Amy, thank you for writing is a fantastic entertaining and highly educational podcast, thank you for taking the time to do this. It is invaluable to me, and it's helped my practice in all aspects.
Charles Goldfarb:So nice.
Chris Dy:So nice. We're glad to help. You know, it's it's fun to talk about this stuff to talk about hand surgery and you know, randomly have gotten some emails, just you know, from people saying, you know, thanks for doing the pod is really helpful. In some of them. Some of them are patients. So you know, I think that that's an interesting component of what we do. You know, obviously, make sure that we have to keep things on the up and up in terms of what we say. But you know, some of the stuff I think for you, too, comes pretty easy just to talk about what we do on a daily basis and what we're passionate about.
Charles Goldfarb:Yeah, I think you and I can kind of both relate to the fact that this has been a labor of love and reviews like that, as we have continued to say really helped to inspire us to keep doing this. And you and I feel the same way. It's always hard to, you know, find the time to do this. But once we start, it's always super fun.
Chris Dy:Yeah, absolutely. So you know, those of you that are listening should know that Chuck and I did our annual check in and I've convinced him to re up for another at least year. So we'll see how that goes. But speaking of the podcast that our publisher Buzzsprout sends us a yearly and urine summary with some stats. So pretty cool. So Chuck, will you really did you realize we recorded 31 episodes last year?
Charles Goldfarb:That's interesting because we had gone bi weekly. So we
Chris Dy:by month by monthly bi weekly, I always get confused. Every other week,
Charles Goldfarb:which is the first year we've done that, but I have to say it has made it. I think each episodes a little more special and meaningful and hopefully energetic. So 31 episodes, let's go. Yeah,
Chris Dy:absolutely. And we are in the top 10% of all Buzzsprout podcasts. That's I think pretty. Pretty impressive given our humble setup here.
Charles Goldfarb:Yeah, I've thought a lot about that. You know, we have I have a obviously a wonderful audience. That is far more than and surgeons or trainees and there's therapists. And there's patients, as you said, and, and there's some that just listen randomly, but it's not as if we have an audience it is, you know, is as large as one can imagine. So we do have a finite number of people who might be interested. And I think the fact that we continue to have great download numbers 2000 plus a week is really awesome. So
Chris Dy:it but I totally agree. But if you're our one of a sponsor, or a potential sponsor, our audience is not finite and will continue to grow. So, speaking of audience, Chuck, where do you think our our podcast was most downloaded in 2023? City wise?
Charles Goldfarb:Well, traditionally, I know the answer has been St. Louis, Missouri.
Chris Dy:But you would be surprised that Chicago is actually our most popular City, St. Louis, coming in number two, Sydney, New South Wales, in as number three, good old New York. Number four. And I actually don't know where number five is. I'm gonna embarrass myself. But where's Omar?
Charles Goldfarb:I don't know the answer that there must be
Chris Dy:a big no, no, that's somebody who's really into the podcast, just, you know, just listening over and over and over again.
Charles Goldfarb:Thank you, Chicago.
Chris Dy:Yeah. Thank you, Chicago. Thank you, New York. Thank you, Sydney. We love having everybody listen. And let's just run down our top five episodes in terms of downloads. One number one was with Amy Morin DOM power about why mess with a good thing, diagnosis and treatment of carpal tunnel syndrome or collaboration with the British society. And number two was discussion a claw hand number three was habit times are changing. Number four was mallet finger made more exciting, pretty sure that was with Macy. And then the fifth was the What's New enhanced surgery episode. So super cool to see what what everybody's into.
Charles Goldfarb:You know what, when we go back to what you said before, because you were right, when I said our audience numbers are potentially finite. What makes this podcast different is the engagement. And I think that really does distinguish this podcast and sort of the maybe I'd call it a family of podcast listeners. And I think that's why our sponsors really do appreciate what we're doing
Chris Dy:here. Yeah, absolutely. And, you know, I think that we, we joke about the sponsor thing, but it is something that enables, you know, a whole group to, to be reached and to be spoken to, but also for us, you know, it's I have to say we probably still will be we would still be doing it even without the sponsors, but it certainly makes it a little more exciting to read, copy and do all those sorts of things. And I'll close with one stat 124 25.9 1000 downloads, so 125,900 downloads,
Charles Goldfarb:or 2023 2023 Thank you to everyone listening. That's amazing. I really, it's amazing.
Chris Dy:Yeah, it's pretty cool. I it's one of those things where it's continues to grow and it continues to be fun. Well, speaking of stuff, that's fun. I will mention our next sponsor, because the message is really cool.
Charles Goldfarb:Can I do the honors? Yeah, absolutely. I respond sponsor, checkpoint surgical is supporting the Washington University inaugural peripheral nerve course April 5, and sixth here in St. Louis. Faculty of this course will include Yours truly, Dr. D. Dr. Mitchell, pet from plastic surgery and Dr. Wilson ray from neurosurgery to say combined ortho neuro plastic surgery nerve course, you can register at the link in the podcast description or on nerve master.com. We really hope to see you here because this course is excellent. I've seen the syllabus and the speakers. It's fantastic. This is not part of the copy. But you got to be here. I
Chris Dy:think it's Thank you for saying that. And thank you for offering to read that I'm super excited about it. You know, Mitch and Zack and I have been working hard to put this together. Our keynote is none other than Dr. Susan McKinnon would have had no other way for the inaugural WashU portfolio of course, and hopefully this is something that resonates and finds an audience we've had a lot of industry partners step up to, to sponsor it knowing that it's going to be a great event. And I'm super excited to be a combination of didactics lectures and interactive sessions as well as cadaver dissections the opportunity to to do to do your own dissections to see processions done by by the faculty and it's pretty cool. All the faculty are either current washing faculty members or alumni in some way one of the peripheral nerve programs.
Charles Goldfarb:Yeah, it really is. I'm super excited to see how this goes and expect wonderful things and expect it to become part of our yearly calendar.
Chris Dy:Yes, let's hope so. So why don't we get to talking about some cases, or at least a clinical topic, whenever we we see fans on the road, they talk about how much they want technique and detail episodes. And I had a case recently that it reminded me of, we haven't covered kind of the nuts and bolts of key inbox, and some of the surgical techniques that come along with it. So why don't we do that?
Charles Goldfarb:I think that's great. I think it's great. We have taken some deep dives, and we can sort of hit on things. We don't want to be overly repetitive. But I think an overview is a wonderful idea. So let's do it. Tell us a little about your case.
Chris Dy:Yeah, so Dubya, let's say, mid 40s. woman who's had wrist pain for years, yes, a very, very young young woman has had wrist pain for you know, a couple of years on and off. But it's really started to get worse in the last couple of months. She comes in has some plain films taken. And their suspicion for key inbox disease based on some sclerosis at at the lunate, which is pretty much diagnostic. She had also come in with an MRI which was confirmatory before that I saw her. So I think you know, how do you start to think about that patient both in terms of you know, you've kind of gotten to a diagnosis, but physical exam, what do you do? And then how do you scrutinize the radiographs and the imaging to help kind of guide what you do next?
Charles Goldfarb:Yeah, I think it's, you know, we often have patients come in with wrist pain, but it's not common, that the complaint is central dorsal wrist pain. And so when we have that patient, you know, initially I'm like, Well, how could this be king bucks, because even in our practices, keybox is not all that common. I probably see five or six patients a year, maybe more, I don't I don't think dramatically more patients with keen box. And so that central dorsal pain for me is the hallmark. And you can almost put your thumb on the Luminate. So distal, and owner to listeners tubercle. And pain there. I won't say it's pathognomonic. But it really has to get us thinking about canines.
Chris Dy:Yeah, to me, one of the things that you taught me when I was in training and Dr. guldmann, same thing, I mean, point tenderness over the Luminate is keen box until proven otherwise, then the isolation the absence of any other clinical findings.
Charles Goldfarb:Along with that I try to you know, better understand the integrity of this case linen and linen trek, Rachel ligaments, I always check impaction testing, because what we know that's been proven in the literature, is there can be associated soft tissue conditions such as SL, LT or TFC. Pathology, but generally, it's isolated dorsal central resting. Yeah,
Chris Dy:absolutely. I mean, I think that the, the issues with the with the inner carpal ligaments are secondary, or the sequela of the main issue at the lunate. But certainly something that you should appreciate either in terms of how it guides your treatment, or how it portends a prognosis. So I mean, what's the for you somebody that's, you know, say you look at their X rays, and they don't have a lot of, you know, eventually with this condition, the illuminate will start to collapse. And as illuminate starts to collapse, you may see some loss of the carpal height, and there a couple different ways to measure that. But, you know, as you start to see these patients, if they have a relatively maintained carpal height, does that guide your treatment? Does that change your treatment more than if they have started to collapse? Yeah,
Charles Goldfarb:if I may, I want to take one step back, not for too long. So first of all, just make sure we're all on the same page. keybox is unexplained a bachelor in a process of illuminate it can be the entire unit, and usually is or sometimes it's not quite the entire unit. And it may be radiographically difficult to diagnose. And that's where an early MRI can sometimes be helpful. As you said, you can see a sclerotic line, and you can see collapse of the Luminate. And eventually, you see collapse of the corpus and arthritis. And so the case you're presenting sounds like a pretty maintained Luminate morphology, without dramatic collapse, but with pain and MRI changes. And so what we worry about is natural history. Now, to my knowledge, there's no wonderful natural history studies, but in this patient with pain, presumably a period of non operative intervention, which has failed to resolve the pain than I do think about surgery. Is that sort of where you are with this patient? Are there non operative steps we should discuss?
Chris Dy:I actually tried casting her because I thought that there might be a role of addressing the symptoms, we didn't have any signs of collapse. And at that time, the other thing that needs to be noted is whether there's any sagittal instability in terms of the Scaife illuminate interval, as you mentioned, the SL ligament can be compromised as Luminate starts to start to structurally deteriorate. And you actually have written a nice paper about the position of the scaphoid. I know that we all used to measure kind of the the SLA But for this, it probably is more important to measure the radius skateboard angles that not right?
Charles Goldfarb:It's hard. And so having a measurement of the the radius to the skate void is much easier to measure, we sort of have a break point of about 60 degrees. So if your skateboard is flexed more than 60 degrees, to us, it indicates inter carpal collapse, and then your real risk of arthritis. And so one thing that I know you and I agree on is we don't want to watch a patient go down that pathway. And so we know we want to do a couple of things. One, we want to address pain. And two, we want to hopefully change what is potentially the natural history of going down a wrong, you know, or unfortunate pathway. And, and I love the idea of casting first, because, you know, is this situation where surgical treatment is not always a slam dunk, I think trying to exhaust those options. As long as we don't take too long and exhausting those options, I think that is really important.
Chris Dy:Yeah, for me, you know, for a patient without, you know, any, you know, substantial carpal collapse in without any, you know, an advanced radio escape would angle that to me, as a patient, I'm going to try to go a little bit slower understanding fully that I'm probably not going to alter the natural history of this condition. But like you said, there is no really good natural history. So I didn't know when that carpal collapse is going to reach a tipping point. And you're going to see, you know, the accelerated path have arthritis. So I mean, tried casting, and, you know, still persistent pain after, you know, a couple of months of casting. So we have, we had a decision to make there. As you mentioned, you know, there are a lot of different ways to treat this surgically, I think our original understanding of treating this surgically was based on some observations about the ulnar variance in some of these patients. So what's what's your understanding of, you know, that literature in the past, and maybe how that thinking has changed or has not changed? Yeah,
Charles Goldfarb:I would say the single most, I'll say important, the single most important radiographic parameter for me, in assessing these patients is and remains on their variants. And so if the owner variance is negative, that is, the radius is longer than the all nine, and we are treating pain, then we have a very good, reliable surgical option, which changes the loading patterns through the carpus. And that is shortening the radius. And if I had to pick one surgery that I thought was most reliable, that would absolutely be it. If your owner is neutral or longer than your radius, further shortening the radius is probably not ideal. They're done different ways to try to change carpal loading, so such as capitate, shortening or other options that I can name a bunch, but they're not really relevant. But for me, if there is older negative variants, shortening the radius is my first choice for sure.
Chris Dy:Yeah, no, no, that was originally described by none other than the doctor government, I believe. And I think there have been some papers otherwise, that have said, you know, perhaps that's not as strong of an association. But certainly, I think that's what the experience that most hand surgeons have is that it is the patient with all their negative variants. And the idea of shortening the radius, just to reiterate, what you said, is to take some of that pressure off of the lunation you know, where that interaction that the lunate fossa is, and perhaps by shortening the radius to load the on the carpal joint more, and altra kind of the natural or, you know, the pre surgical distribution for that particular wrist. Yeah,
Charles Goldfarb:that's exactly right. It used to be said that you can consider that option for stage one, two and three A that is those without carpal collabs, but in three B or pan arthritis, stage four, you wouldn't I think people and there's an article out of here in HSS that really suggests that even in three B's absolutely can be considered especially when that radius is longer than the older so that is always on my mind is a personalized treatment.
Chris Dy:Yeah, you're reminds me of something I was telling Emily or fellow in the operating room for this case, because I have you know, it's not a common thing to do. I actually took out my notes from fellowship which are stored in a handy Google Doc and I was reviewing them and then I was talking to Emily about the condition and sort of the you know your paper about the raid escape one angle Ryan coffees paper that she mentioned about potentially treating three bees with radial shortening. And I was like, Do you know who wrote those papers? She nailed it. In the classic Goldfarb. contribution to literature like one of our listeners send a pass like a workman hammering nails just continuing to have an impact on our current generation of learners. Well,
Charles Goldfarb:I'm flattered and love that, you know, thinking back to our conversation with Steve Moran, one of the things that's frustrating about this diagnosis and treatment is part of the problem and defining the best treatment is treatment is not always I insulated. And so we often combined treatments, and I am guilty as charged. And so let's take your patient, if you have a 45 year old, young female who is older negative, and you say, I have a solution for you, I'm going to shorten your radius, I will often add a vascularized grabbed four or five vascularized graft. I think it is not a negative in any way and bringing the vascularity can be helpful. Yeah, no, I
Chris Dy:think it would be nice to approach this truly scientifically and do one procedure at a time. But I think the you only got a certain number of procedures in the can for this patient and any patient really. And, again, while you want to wear your, you know, academic scientific hat and say, Alright, well, let's do this. And if this doesn't work, we'll do that. I agree, I think this, this tends to be a condition in which we combine treatments, because we don't have a firm grasp of you know, which one really works. And we're not honestly that study is never going to happen, you know, in terms of getting it done from a rigorous perspective. So I think we end up combining treatments a lot. Before we jump into the surgical options a little more. Is there any role for injection steroid injections in this patient?
Charles Goldfarb:You know, if the patient said to me that she needed to do X, Y, or Z and couldn't think about surgery for six months and was having pain, sure. But as far as altering the course of the disease process, no, not whatsoever. So it's not usually something I offer, unless the patient has a real need to delay intervention.
Chris Dy:Right. And I think that's, you know, something that notes same way I would approach it. Before we dive into some technique details for the surgeries that I think we both would choose for this patient. What do you think about like core decompression of the distal radius? is, you know, there's been some interesting results particularly coming out of South America for that. Yeah,
Charles Goldfarb:I think there's three procedures we should briefly discuss coordinate compression is one and and to be very clear, quality compression is a minimally invasive procedure where we simply it's almost like harvesting a distillery is Bo Graf is the way I think about it. So you could take off listers to Brickell music correct, remove some cancellous bone sub Luminate in the distal radius, and whether that changes loading patterns or leads to increase vascularity in the area? I don't know. But reports are pretty strong.
Chris Dy:Yeah, and I think that's the kind of thing where if done in a, you know, a very thoughtful and deliberate way can be done relatively quickly, with with leaving opportunities for other surgeries down the line in terms of not creating a ton of scarring and allowing a quicker recovery. Yeah,
Charles Goldfarb:totally agree. The second surgery, I would say is interesting is arthroscopy. And of course, you know, it's my it's in my toolbox, and I enjoy arthroscopy. It's a big part of what I do. I have to say the jury's out a little bit for me. I think it's a certainly easy wrist to scope. Information is helpful. We learn about the SL LT ligaments TFCC, as we said, we learn about the status of the cartilage. If there's a fracture of the lunation, that coronal plane, we can see it we could theoretically guide screw placement, but I don't know that it's a definitive treatment. I think it could be an adjunct. But it's it doesn't really stand alone for me for most patients. Do you think about it differently? No,
Chris Dy:I, I don't use it. Part of it probably is the fact that I use it less frequently in general than you in terms of general arthroscopy. I think you mentioned one thing that I think is super important that coronal plane shear fracture or that coronal split, not always a shear, but that splitting the body of the lunette can be kind of challenging, and not knowing about that ahead of time can make surgical treatment quite tricky. I usually get that information on advanced imaging before surgery. So fortunately, this patient, you know, prior to coming already had an MRI. So that was helpful to know that that wasn't there, at least at that time.
Charles Goldfarb:Yeah, really well said I couldn't couldn't say it any better. And so I do I have mixed feelings on screw placement for that coronal fracture. I think it's just tough to think of nonvascular eyes Luminate is going to heal, but I have put screws in they never failed. I'm not convinced it always leads to healing. And then the final option, which I really, really, really want to hear your opinion on, because I've sent you a patient recently is what's the role for basically addressing the nerves of the carpus in a patient like this, so if you can do a neuro ablation procedure for keybox Have you done it? What do you think about it?
Chris Dy:Yeah, I haven't done it in particular for Kean box, but I think it depends on how you do it and the the way you set up expectations, you know, so you know if you do purely a PIO and Ayaan neurectomy I don't know if you're gonna get At the complete true deactivation of the wrist that you're looking for, but it might be enough to buy some time, in a way that's similar to the core decompression, I mean, you could do that in a pretty relatively quick and minimally invasive manner. And, and allow the patient to move on and maybe you get some good bang for your buck, you know, fully expecting that at some point, you're, you'll be back for a more definitive surgery, but maybe the timing isn't right for that patient to have the bigger the bigger surgery. Um, you know, my understanding of the results, at least, you know, from the Mayo series was interesting, you know, denervation in that manner of AI NPI and neurectomy, a partial generation did best for slack and snack was less predictable for kidbox. So, you know, that gives me a little bit of a little bit of pause in terms of how to utilize that surgery. But again, for the right patient is another thing to have in your toolbox. Is
Charles Goldfarb:it more therefore have a salvage type procedure for you? So in other words, let's say you go through everything we're about to talk to patients still a lot better, I might consider a PRC as a salvage procedure, would you instead consider a denervation? I
Chris Dy:don't think it's a salvage I think it's a bridge. And, you know, I probably would do the D innovation as part of the PRC, kind of a belt and suspenders approach, or the degeneration is part of one of the, you know, carpus preserving surgeries, like a radial shortening or a four plus five.
Charles Goldfarb:Excellent, excellent. So if we're going to talk about so why don't we, if it's okay, why don't we briefly talk about radial shortening. And we can say a few words about the basketballs grafting, but I think we've covered that pretty well in the past. So when you shorten, I'd love to know, dorsal or volar, hardware choice. Expected healing time, any tips or tricks to your to your treatment? Yeah,
Chris Dy:I mean, for me, because I was coupling list with a four plus five vascularized bone flap, I went ahead and did the dorsal, dorsal osteotomy and dorsal plating to keep it all through one approach. You know, I remember very vividly doing these cases in fellowship, and some of my notes were from a radial shortening with Dr. gelderman. And kind of doing it from the bowler side, getting out the three five LCP plate kind of more Diaphyseal as opposed to metabo seal. But clearly, this could be done with a volar locking plate, utilizing that oblong screw hole to help you dial in your shortening. You know, but for me, it was the convenience of already being on the dorsal side, I want to end to this from dorsal, how do you typically decide what you're going to do? Which approach? Yeah,
Charles Goldfarb:I have separated my incision. So I go volar I place a relatively distal DCP, I've definitely done volar locking plate, shortening osteotomies I have to say they're just not that satisfying. And so I get more joy out of using a DCP, six, oh, easily 3.5, maybe a 2.7 DCP getting good compression. And you're shortening usually a millimeter too. So it's not it's not challenging to shorten. And I just I like it and therefore I prefer to go volar my caveat is healing takes forever radiographic healing takes for ever in these patients. Yeah,
Chris Dy:you know, I think that I'm more looking at and feeling the illuminate and checking for whether there are any changes in that more than anything else. I, you know, I think if you're going to go the volar route and use the, you know, that six old DCP make sure that you've got a tabletop vendor, because not everybody's got the forums of Chuck Goldfarb, and convened a three five plate manually. So via the table dot vendors helpful? For
Charles Goldfarb:sure. Absolutely. Good point. And yeah, but you can do it dorsal you can do it volar, you can use hardware of choice. Thankfully, the radius metathesis, or even distal diathesis will heal. And so that's not part of the worry. It's just how much do you shorten. And again, I don't know that anyone has the answer dirty shortening going for neutral variants, or you just shortening a bit. I tend to shorten a couple of millimeters, but taking care of not to over shorten,
Chris Dy:right certainly don't want to overshoot, and I wouldn't want to go into a positive situation. And for me, this patient was we were shooting for neutral. The one thing I like about doing this dorsally also is that my worry is that, you know, when we're using our saw, we're not in a fracture situation. You know, so I worry about what's going on on the far end is that blade has come in through the the far cortex, I have more control of things going from dorsal volar, in terms of I've got my pronator quadratus buffering me on the volar side, you know, so I can I know exactly where my extensor tendons are because I'm doing it from dorsal, and I have the PQ on the volar side. So, you know, honestly, even when I do it a volere approach for a distal radius malunion. So a different indication but if I'm doing a male union correction, I tend to be a bit of a chicken and I make the dorsal Cateran session to look at my EPL and get it out of the way and you know, just because I know that you've got to fully release every periosteum cows, etc. In that setting to to fully get that thing hinged so you get the correction you want.
Charles Goldfarb:I think that's really well said and for the younger either you know, residents or fellows or younger attendings, I think that's really good advice. When you leave the or you need to be absolutely comfortable that you've done things in a way where you're confident you've done them, right. You do not want to lose sleep over, did I satisfactorily protect the tendons, there's plenty of things that are gonna cause you to lose sleep, don't let small technical things do that. And if you need to make a counter incision, make the frickin counter incision. And it's no big deal, right?
Chris Dy:It's not like it's a formal dorsal approach to the wrist. You know, it is, you know, and I warn patients, if I'm doing things, mainly from bowler that they might have a counter incision, certainly add some swelling. But you can do things in a way that, you know, allows you to feel comfortable. There was something interesting in this case, as we did our approach. There was and I think you've probably noticed this, there's so much baggy synovitis in the capsule, when we're approaching our illuminate. And then, of course, by the time that we have gotten to the or when we were taking our initial x rays, there is a you know, flexion of the skateboard. You know, that ring sign and our radius skateboard angle was elevated. You know, how do you at this point, do you prioritize correcting the position to the scaphoid? Before you do anything else? And how do you maintain that?
Charles Goldfarb:Yeah, I think it depends on why so it is an ESA is an SL pathology? Usually not, there's not usually a frank tear that can be as we've discussed, is it really the collapse of the loonie. And so if you believe Steve Moran and Steve's a friend, and you, thank you, when you when you open up the illuminate from dorsal, can you basically expand it to accept your graft? And will that help correct the SL angle? I honestly believe that wants to skateboards flex, I'm not sure I can do something to permanently put it back in position. Unless there's a tear. And I treat that, but I thankfully have not had to do that. Yeah,
Chris Dy:no, I think it's challenging. I mean, for me, we went ahead and put a joystick in the skateboard, got it out of flexion. And I put a pin across the distal skateboard into the capitate, to secure things and then kind of worked from there.
Charles Goldfarb:So I love that solution. I recently did a cane box in a 13 year old. And I always pin the carpus in those patients, because what you're doing, you're getting the skateboard back up if it's flex, but what you're also doing is you're unloading the Luminate, during the healing process. And so I think that's a very, very good technique and very reasonable approach.
Chris Dy:But it's a good thing. I learned it in fellowship, I went back and looked at all my notes.
Charles Goldfarb:So let's briefly talk about the four or five graphed I assume user four or five, yeah, four or five for this one. Yeah, my one complaint about the four or five, I do think it's a better graph than the one two. Because it seems to be just more durable. The problem with the four or five in my experience is it's very older. And so I'm usually finding I'm taking cortical bone on the owner side from the owner side of the radius. And so but there's usually good cancer cells bone, the the blood vessels are welded nicely to the bone. And I usually feel pretty good about it once I've elevated it. Yeah,
Chris Dy:to me, it's the elevation usually feels pretty good that the inset is the less satisfying part of it. In terms of you know, as you're trying to delicately put this thing in, you feel like you're probably being a little rough with it. But for this one, you know, the elevation went went well, well defined blood vessels, it was owner, like you said, which obviously can affect the way you how you can swing that and drop it in. But do you have any tricks on how you inset it and how you secure it?
Charles Goldfarb:Yeah, I have to say, when I first started doing this procedure, I would try to take the dorsal cortical bone with blood vessel and lay it in dorsally. So that all of the original dorsal cortical bone was sitting dorsally on the illuminate, I don't do it that way anymore. I generally inset it so that I kind of dunk it into the lunate bone. And ideally, I've dug a nice trough and in fact, as far as I can go vote early. And so I can really instead it nicely with the cortical strat, proximal to distal, and I think it sits better. I think it does provide a strat, I think it's more likely to stay in place. And I might add a little capsular indication over the top to minimize the chance of it popping out. But that's how I do it. How did you How do you handle it?
Chris Dy:I didn't like the way that you initially described it in terms of laying it on dorsally. And, you know, to me, it was like, well, it's sitting there pretty nicely. Again, this wasn't a case, fortunately, where we had coronal fracture, and we didn't have a substantial amount of collapse. So we don't really try to jack out to illuminate that much. So I mean, overall, pretty satisfied with how everything went. And then we did our shortening after that, and, you know, yeah, I'm curious to see how you would handle the postop protocol. On terms of length of normalization, and you know, when you would talk to the patient about when to expect something to change, either in terms of how they're feeling what their wrist or you know, healing of that, that osteotomy.
Charles Goldfarb:Yeah, you know, with vascularized graft, it's an automatic six weeks of casting for me, you don't need it for the fixation of your shortening, obviously, but for me, I do feel comfortable with six weeks of casting and then out of the cast is six weeks, and either some home therapy or some formal therapy with a removable wrist brace, usually for eight to nine weeks. It's interesting, I don't know if that's how you handle it at all. But I'm pretty happy by the time they come out of the cast and start moving. I think we're heading in the right direction.
Chris Dy:Yeah, no, that's been my experience. And and, you know, I'm not focusing overly on radiographs. You know, I'm kind of palpating illuminates and I remember being taught that that was, you know, the biggest measure of whether you have succeeded is whether you can take that point tenders over the illuminates and and take it down.
Charles Goldfarb:Love it. Yeah, I'm glad this I think this is a fun episode to talk about. You and I had mentioned talking about owner shortening osteotomy. I think that's a topic we need to hit on. I think it's a great topic, partly because it's probably one of my top five singular favorite procedures that I do. I'm
Chris Dy:glad you like it. I enjoy it too. But I'm glad it's in your top five. I have some others I'd put my top five we should actually do a little. You know, just a quick rundown of our top five favorite surgeries. I'm sure we've done it at some point, but maybe they've changed.
Charles Goldfarb:Yeah, we used to do a lot more than numbers up top five, top seven. So like those kind of said, We gotta do more of that and 2024, baby.
Chris Dy:All right, sounds good. Well, I hope that you enjoy the rest of your evening and I look forward to talking again soon. Thank you everybody for listening.
Charles Goldfarb:Thanks, everybody.