The Upper Hand: Chuck & Chris Talk Hand Surgery
The Upper Hand: Chuck & Chris Talk Hand Surgery
Listener Mailbag: CMC and UNT
Chuck and Chris catch up on with listener submitted questions on technical aspects of two procedures: a deep dive on CMC arthroplasty with suture tape suspension and the indications for subcutaneous vs submuscular ulnar nerve transposition. We close with a brief discussion of medial epicondyle fractures with ulnar nerve pathology.
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Welcome to the upper hand podcast where Chuck and Chris talk 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. And
Chris Dy:Thank you in advance for leaving a review and leaving a rating wherever you get your podcast.
Charles Goldfarb:Oh, hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:If fantastic, here we are again.
Chris Dy:I didn't realize we were dressing up for the podcast. I'm here in a nice long sleeve tee. You know, but some of us are wearing ties, apparently.
Charles Goldfarb:Well, I'm trying to up our game. You know, if we can't do it verbally, we got to do YouTube, apparently. Exactly.
Chris Dy:But I guess we're on YouTube. So I keep forgetting that. I told you how my son asked about Yeah, I think we talked about this a few episodes ago about finding me on YouTube. And he had another fellow a fellow dad at his school Pull me up just to confirm that it was indeed on YouTube.
Charles Goldfarb:Well, he needs verification, he can just believe you. Yeah,
Chris Dy:he also told me he wants to be a YouTuber when he grows up. So I'm not sure we're going down the right path.
Charles Goldfarb:Hey I think he's probably smart. It's funny. I you know, you I'm sure you get the same email. Those are all our listeners get the same emails about different things. But Chris, and I get a lot of podcast emails, saying you know, we can help you optimize the ones about how to optimize YouTube always catch my eye I have yet to click on them feels like clickbait. But
Chris Dy:yeah, absolutely. You know, I think we put out a call to the WashU undergraduates, but if there's anybody that wants to be a marketing, social media intern for the upper hand, please step up. Or if you know, pre med who might be interested, let us know.
Charles Goldfarb:Yeah, that is true. We did have an intern for a while was that year, too?
Chris Dy:Yeah, that was year two, that was back in the day. So why are you so dressed up?
Charles Goldfarb:So I was I don't think it's top secret. I was the dean. You know, it's interesting. I feel a little old school because first of all, I don't I don't usually dress up anymore at all. And, you know, when the Dean asked you to do something, you do it. And here at Washington men, and as the dean asked me to be part of a small group, in a chair Evaluation Session. So what the way it works at Wash U as it works in many academic academic institutions is every five years, a department is reviewed. And in doing so you review the chair. And it's very, very informative. And there's usually a few visiting chairs from other departments. And so I won't give too much information about this because so I dressed up, I wore suit yesterday, and I dressed up today, it was fascinating process, you really learn a ton about your own institution, and about this process. So I liked it. And I was laughing because I got I got there this morning. Yesterday, I wore suit. And I had to prepare the night before because you know, I'm sneaking out of the bedroom. Try not to wake my wife. And so this morning, I was less prepared. I got in the car and realized I didn't have a belt. It wasn't the shoes I intended to wear.
Chris Dy:Did you at least have matching shoes, because that's happened to some people.
Charles Goldfarb:I wasn't it wasn't terrible. I was laughing to myself. So others joined him. But I don't know that anyone would have noticed that I hadn't said anything.
Chris Dy:Oh my gosh, there was one day when I was a fellow. I always kept a spare set of clothes in the car. Because you never know on call. You never know what's gonna happen. So I thought I had it ready to go. And I had to do a case overnight. And I had clinic with Dr. gelderman the next day. Oh, and I had to close didn't have the shoes. So then it all the entire clinic was about how I was wearing joggers in the clinic. I mean, I just And if you've ever been in clinic with Dr. Gelberman, and you know that he knows how to push those buttons. You can push him. Dr. Gelberman. It was his medical assistant at the time, just kind of and she still reminds me to this day about about that experience. So yeah, you want to make sure you have everything laid out.
Charles Goldfarb:You know, I think a lot about this, and hopefully talked about it but doesn't really matter. You know, there is something to dressing the part. And if wearing scrubs is dressing the part then I dress the part. But if it's if if that doesn't qualify for administrative roles, I just don't dress the part and there is no doubt when I dress nicely. It's different. It makes you feel different, I think interact a little differently. There's something to it. Yeah,
Chris Dy:absolutely. And, you know, I think I still have trainees who come to clinic in between cases and they're like, is it okay, if I'm not dressed up? I say it's totally fine, you know, but that would not fly with other attendees. And if so when I say it's totally fine, I totally mean it's fine. Gentlemen, I'm just happier there.
Charles Goldfarb:Yeah, I totally agree. And then, you know, but the flip side of that is we can't complain about the casualisation if that's a word of our field. You know, I know they're, you know, there's a little taboo around ties and infection and stuff but we can't make it okay, which I agree with you I do as well. Well, and then complain about the lack of formality and some of the things that we're seeing because some of those other things bother me. But you kind of take it all or take it or go back to the olden days,
Chris Dy:times are changing. So have you been pretty busy? Otherwise? I've had quite the week to be honest with you.
Charles Goldfarb:Yeah. Tell me about your week. And then I'll fill you in. I know you have, I think there was a flight cancellation somewhere in there and you had to make on board
Chris Dy:last two weeks were a little tough. You know, I loved going to the American Society peripheral nerve meeting, which was in Nassau this year. And it was great meeting had a great time connecting with everybody gave some talks, the lab presented some research, I really impressed with what our partner David Brogan has done in terms of getting the lab off the ground, and then on our side, doing some great clinical research multicenter stuff, much along the lines of what you've done with good. So it was awesome, great time, got some time to hang with the kids and everything, which was really fun. And we were super excited to come back on Monday MLK Day, which was a holiday, at least for the clinics. And then that winter storm, I can't remem The name was a winter storm Heather, or whatever the name was totally hosed us in terms of getting back. You know, I was supposed to come back and have a two room our day on the day after MLK Day. That got cancelled because I could not come back. And it's really fun calling patients from an airport on Monday night saying your surgery on Tuesdays canceled, some of which were super understanding and said, yeah, just get home safe doc. Others were saying, So when are we going to do it? You know, it all worked out. You know, fortunately, there was some time, you know, this this week, which is the following week. But that added to some stress levels. And then there was this ice storm that happened, at least in St. Louis on Sunday night going into Monday morning, which and I happen to be the lucky chap on call with our fearless hand fellow Adam Mosa, who is just sitting there triaging all of the distal radius fractures that were pouring in on Monday night. So yeah, we you know, like the clinics, at least in St. Louis, when you have ice clinics, you never know who's gonna show he start with a certain number, you end up probably about 20% lower than that, and a bunch of rescheduling things. And so anyway, that was the start of the week. I can go into it more but it was it's been a week.
Charles Goldfarb:Yeah. So it is interesting. So it was it was a real it was a real ice ice event and I was up early I'd clinic that day. And I was up early. I'm a Southerner I make gives me a little anxiety. My wife laughs at me being a Yankee. But I got up early. And you know, my driveway was a sheet of ice. And it was absolutely the classic black ice, you couldn't see it. So I'm like, I know what's going to happen later today. I made it into work. And I had 60 some odd patients on it a little more than half made it at the half that made it super grateful. And it really is the effort you know, to go to work that day rather than staying home it means something and the patients that were there I connected with felt felt really good. I don't like being that slow but felt good. I I did overhear my my neighbors clinic where one of the patients was just berating the poor medical assistant about the other doctor not being able to get in because he couldn't get in. And it's just it's like I get it. You know, it's these appointments are hard to come by and, and it's a big deal to come in to the doctor. But you also got to be saved. But I think you were you were super busy. It sounds like
Chris Dy:yeah, so that rolled into Tuesday, which is the to room or day and then Wednesday was a makeup to room or a day, which included some of those fractures. I've now we had to destroy these osteotomies on the books for one last week and one this week, which is uncommon. He and do one every few months or whatever. And then on top of that we had seven acute fractures. Next, that just rocking and rolling. So we were like, do we have enough plates, I was like, Let me spread these cases out so that the poor rep has a little breathing room.
Charles Goldfarb:The poor, the rep was having the best day of his or her life. Yeah,
Chris Dy:I don't know about that. It's a contracted plate. So it's not that great.
Charles Goldfarb:It is, you know, like we all you know, hopefully we all have an internal barometer that says with this fracture, I operate or I don't operate, but there's a little gray area and my guess is you were probably searching for reasons not to operate rather than do 10 or 12 fractures.
Chris Dy:I sure tried to triage and tell you that. Yeah, it's been busy. But, you know, it's not a sustainable pace. But it's sometimes you got blips that you just got to get through. And I'm excited actually, you know, I've been really excited about some of the research stuff that we're doing. Oddly enough, there was one weekend one morning this weekend where I woke up wanting to write a grant, which
Charles Goldfarb:I exactly can't say that's ever happened to me. The
Chris Dy:clinical work this week surely cured me of that need right now but I've got some work carved out for the coming week. So anyway, we should get in the episode before we do probably should think Get our first sponsor. Absolutely.
Charles Goldfarb:The Upperhand is sponsored by Practicelink.com, the most widely used physician job search and career advancement resource.
Chris Dy:Becoming a physician is hard finding the right job doesn't have to be joined practicing for free today at www.practising.com/the. upper hand.
Charles Goldfarb:So we love it when you the listener write in to us. And we've got a number of super interesting questions, clinical questions that we'd like to respond to expand upon. So please email us anytime. And Chris is gonna tell you the email address
Chris Dy:Its not hard. Its handpodcast@gmail.com. But yeah, the let the mailbag stuff is super interesting all that Chuck kind of lead off with the first one, because it does pertain to a paper in which he was the senior author.
Charles Goldfarb:yeah, so we a little background, we had been using, and I am not aligned with any of these companies. I have a distant history of working with arthritis, but we have been using the internal brace for as a suspension plasti for CMC arthritis, and started doing that 2017 Maybe, and a lot of a lot of folks in our group had been using that same technique. And so we started two projects. One was a retrospective look, and we started that during COVID. And the other was a prospective look, prospective randomized trial, which you know, we all know is not very common in hand surgery, and is challenging to do. So we submitted our retrospective look comparing the two groups that is standard lrti versus the trapezius ectomy with suspension, using the internal brace. And then we also have recently submitted our prospective randomized trial between the two groups and, and the first paper was published in JHS Go,eExcuse me. And you know, there are flaws in the manuscript, and I was grateful It was published in JHS Go, and there was a good question sent in.
Chris Dy:So why don't you if do you want to talk about the question first, you want to tell us kind of a high level summary of what you what you found in the paper?
Charles Goldfarb:Well, what we found the paper was there really weren't fundamental differences in outcomes between the group and I think that's a fair summary. And those of you who have done or read about CMC arthroplasty in the various techniques will not be surprised by that finding, because it seems like about everything we do, provides good outcomes. When I see a patient today, I give them the two options, and I say the lrti and I do a classic Burton and Pellegrini. lrti where we obviously fcr, excise the entire trapezium, use the entire tendon, through the base, the metacarpal, to suspend the thumb metacarpal, and then create an anchovy or kind of ball tendon to place where the trapezium used to be, I give them that option, and I give them the suspension plasti. And the question, I don't know that we necessarily need to read the question, but the question was around that technique we specifically use with the suspension plasti with the intro brace. And so what's interesting is, as much as I try not to bias the patient, I think the conversation biases the patient and 80% of patients choose the suspension plasti with the internal brace. I'm curious as to your conversation and and do you even offer an LRT?
Chris Dy:Yeah, I mean, I think well, first off, I'll offer an allergy, if that's what they've had on the other side by me, or more likely somebody else, and they're happy with it. You know, I tend to say there are a lot of different ways to do this. I give the caveat that some of it depends on the bone quality and surgery. I tell them, you know, sometimes we take a tendon and use that or we use the suture tape suspension. And if one for whatever reason doesn't, you know, last or we have an issue in surgery, you always have the other one as a backup typically. And that that obviously is making sure that you're mindful and careful with your fcr as you're doing your trapezius activate. So I honestly had they asked me, you know, what, what I prefer what I do I tell him, you know, I think the secret he has mentioned is faster. I think I tell him that the results essentially are the same. But it is faster in terms of the aren't. And you know, I think that if you truly ask people about harvesting and fcr I don't think they love it. I think there is some soreness, some additional pain in the short term. And for some people, that's enough to kind of tip the balance. I think we have to be good stewards. And I think cost is an important part of it. Particularly if you're operating in a surgery center that is freestanding and where the implants are technical coming out of your overhead. It's probably a little less directly influencing the surgeons that are in a bigger institution with more of an academic practice. Yeah, and
Charles Goldfarb:we get and then we get into the book, how you truly calculate costs because oh our time matters and then the second issue is returned to work returned to activities. And so the fundamental difference, which always is the factor that captures the patient is how quickly you can get out of a cast and right or wrong. I cast patients for four weeks after lrti. And there's been studies suggesting that number could be shorter, and it absolutely could be. But I cast patients for four weeks with a seizure tape suspension plasti. I get patients in therapy five days after surgery, they are moving in using their thumb doesn't mean all their pain has gone. But they're moving and using their thumb and taking a shower. And that's that's a really big selling point.
Chris Dy:Yeah, absolutely. I think, you know, in our last podcast with Macy, we talked about the post op rehab after something like a suture tape suspension. And then she mentioned like, for all these, like, you don't want to push it too much in terms of generating pain, because this is a surgery that is largely geared towards pain, and I feel like she is probably slowing down our patients more than they want to, because she understands the benefit that we'll have in a long term for them. I don't know. I mean, I guess, you know, one of the limitations of the work that that you've led for our group is that, you know, the, the therapy protocols are very different for the two and like you said, you know, there's been work from other groups saying that even for an lrti, you know, the classic Burton Pellegrini. Like you could go a little bit faster with the rehab, but I think that our group chose not to include that as you know, an earlier rehab protocol, because it would vary from our clinical standard of care. And ethically, it was kind of like, you know, we didn't want to get into that for the RCT. But I mean, why do you think that you can move people a little bit earlier after a suture tape suspension.
Charles Goldfarb:So for me this, the times zero strength is there for the suture tape, and I if I'm going to create an analogy to another surgery, it is excision of the trapezium and K wire pinning of the thumb metacarpal to the second metacarpal, which we don't do, because patients hate that pin. There are certain patients of instruments or there's certain pins that patients hate. That's one of them and pinning the DOJ is another one. And it's super interesting that not too long ago, one of our partners Marty Boyer went back to the concept of pinning after trapezius ectomy that did not last long, I'll tell ya. And so I think the timezero strength is there for the suture tape suspension plasti, I don't think is there with a tendon. And that's why I tend to mobile I don't think is there for weeks either, to be truly honest, but but I think you're starting to develop scar tissue which, which supports this suspension.
Chris Dy:So the question from our reader, and again, we don't need to read the whole thing. Listener excuse me, Colin, Dr. Colin Kennedy, out in Las Vegas, had great questions about the technical aspects. So I think there are a couple of different ways that you could do this surgery, if you are using that Arthrex suture tape. So one way would be to insert a swivel lock on the base of the index metacarpal. And the other way would be to use kind of a fibertech all suture anchor into the index metacarpal base. And I actually think there's a third option, which is the kind of metal version of the soul lock, as opposed to, you know, the the plastic bow composite version. So why do you which one do you do and why do you do it? And do you typically fix them to the index first? So do you fix it to the thumb metacarpal first,
Charles Goldfarb:yeah, I mean, our group standardized before our trials, but I'll tell you what I do today, which may or may not be different than what you do today. I put the swivel lock suture anchor into the radial base of the thumb metacarpal first, and I try to align it it's basically halfway dorsal bowler so that that suture lies in a little sulcus, I bring the thumb metacarpal directly adjacent to the index finger metacarpal I distract the thumb metacarpal and I put the second swivel lock, just distal is the articular surface of the second metacarpal. So that's where the second and first articulate. I then often do another step I leave the needle on the suture tape, and I often will put a stitch through the dorsal base of the metacarpal and what that does is it actually brings the metal it basically extends the metacarpal by bringing the proximal metacarpal down it extends the distal metacarpal which can get it helps any problems you may be having at the MP joints. I like that combination and I've been quite pleased with it.
Chris Dy:So we're gonna have like a fulcrum against the shouldering
Charles Goldfarb:correct and a fulcrum against the shouldering proximately but control the metacarpal head distally
Chris Dy:right right yeah, no I because I my Oh, ours got switched I was doing my last week so our yesterday at the Orthopedic Center, which is not my home court. So I was all my best favor promisee Thank you, but the the rep there was a different rep that I normally cover and you left the needle on and we were passing it through and I said hey you trying to kill me is needle and he's like others like to leave when I was like I know. I know a guy. So I actually go I've changed so i She think that for Me technically, it's easier and more straightforward to fix into the index metacarpal base first, you know that insertion point is just dorsal to where the SER is kind of running by. I don't you know, I think it's be very clear where it is, I don't necessarily check it on, on imaging unless I'm trying to make a point to the to the learner, that's with me. But can I really making sure and feeling that I'm on, not the trapezoid not, but on the index, metacarpal base and kind of feeling and just kind of giving some push, I think that's the bone theoretically, that has a harder time in terms of bone quality, although I have not truly found that to be the case, based on where I've been putting my swivel lock. But I have kind of asked in the past about if we have any backup options, I know there is a kind of a metal type biocomposite, because I've found with those biocomposite anchors, this swivel lock. I think and I have no ties to Arthrex. So if you're an Arthrex rep, forgive me if I'm getting this wrong, my personal experience is that you have to be 100% Perfect with your, with your trajectory when you're inserting that wire or the foot block. After I after drilling, I actually asked the learner to kind of piston through one or two, once or twice with against the hard stop to really clear that channel of debris. I learned that from a former resident who was going into sports and that's what they would do. Dr. Paul England. And I think that's a good idea. So called out the England maneuver. And then I while we're kind of swapping out and before putting in the anchor, which is coming from the back table, I'll take a forceps or free and just kind of pop it into that tunnel so that you know, hey, I can feel it, there's a back end of the bone and be the the person putting in the swivel lock understands the trajectory because you got to be perfect. Got to see that kind of fork parts sit down, and the screw part of it really sitting against the surface of the bone. Because otherwise, if you don't have that, and you start turning, it's not going to advance.
Charles Goldfarb:I think that's well said the other technical Pearl is you want to apply maximum tension to your suture tape. And then you basically line everything up with the two prongs over the suture tape at the entrance to the hole. And as soon as you start to put the anchor into the hole, you release the tension on the suture tape. And you're right, it has to be perfectly aligned. I will say that it's not a difficult maneuver. But unless until you do it right a couple of times and actually probably do it wrong once it's easy to screw it up. Yeah,
Chris Dy:no, I actually find the thumb, at least from I do is from a dorsal approach. I think you also go dorsal, you know, I think doing the that doing the anchor insertion for the thumb metacarpal actually, I think can be a little bit tricky sometimes in terms of getting the exposure and getting the angle because I do that second. And then kind of canting out the thumb metacarpal base radially in order to get the cleat or the fork of that thing lined up and push down. And then I'm going in and getting it into the position of you know, traction and at duction, which can make it a little bit harder for the person who's putting in the anchor to follow that move as I'm getting started. And then I move it. And you know, we have to kind of be in sequence which is great towards the end of a rotation. The beginning of the rotation I'm putting in it went to the point where our amazing current fellow, Dr. Emily's oldest has said, Alright, it's the other rotation I want to put in that anchor now. And I've let her do it the last couple of times, because she's kind of understood the sequence there. And I think that one can be really finicky in the self tensioning part. You know that anchor is supposed to be self tensioning I have not found it to be a self tensioning as a as it's told to us. So I actually typically will hold attention until it's exactly the time to let go
Charles Goldfarb:of grief and have nothing to add. So to our you know, question writer, thank you for the for the question. Hopefully that provides a little clarity. If it didn't, please follow up with us and we can talk on the phone or something involved
Chris Dy:one follow up question to bring that the closer look why put you put the thumb metacarpal first, I put the index metacarpal first, so why do you do it that way? And I can tell you why I think I do it my way.
Charles Goldfarb:It's the way I've always done it, which is a lousy answer. I think it's very straightforward. And I've had no troubles doing it that way, which is the main reason I don't see an advantage of switching things up. So I've just got I had no difficulties.
Chris Dy:I just like working from outside in or inside out. Excuse me. For services I got to and then so then I can you know I like to see, you know, the very end kind of where things are going but you can do it a lot of different ways. Have you had any experience with using the kind of metal version of the swivel lock?
Charles Goldfarb:I'm not I've only used the composite and like, like you said they have worked well for me. I've not had an issue with strength, no matter how osteopenic so yeah, but the only the
Chris Dy:only thing I'd say is you know in terms of osteopenia, I tend to check the bone before we open the kit. There has been a time where we've opened the kit. I've gotten something good in the index and I'm not happy with my thumb metacarpal and I've had to pit it. And I think that it'd be good to know how you would kind of handle that situation. You know, what I've done in the past is that, and you may not have come across this, but I've had to use an interference screw, which has been good to at least know that that's on backup in order to get the suture tape to kind of cinch down because you already drilled, you know, reasonably big hole there. So you need something in there, that's going to hold it if you can't get that swivel lock to sit.
Charles Goldfarb:Yeah, I think that that's a very good option. You could also probably, if you left your needle on, you probably could literally put a needle through the bone. It's a big needle. And unless the bone is super wimpy, I think you could make that do and even if you had to go through your hole and out there articular surface and then tie it to itself. I think that would work as well.
Chris Dy:Right? Right. Always nice to have a free needle around too if you've already got it off. So sure. All right, so we beat the topic of technical aspects of suture tape suspension, I think to the point of submission,
Charles Goldfarb:I think we beat the topic of doing research on the CMC join to submission as well. I think that is my last article about CMC joint of my career,
Chris Dy:we just had journal club this past week and it was a great article about fat grafting and PRP, CMC surgery research that'll never feasibly get done in the United States. But you never know there's always latest and greatest I'm sure we'll see more and plant arthroplasty stuff come in. You never know what's whatever.
Charles Goldfarb:And as much as I try to keep old people like me out of my own clinic I still they sneak in the door sometimes with CMC arthritis, so they're not going away.
Chris Dy:Oh man So one quick, why don't we go to a nerve related topic. But before we do let's Why don't we talk about our friends over at checkpoint?
Charles Goldfarb:Oh absolutely. The upper hand is sponsored by Checkpoint Surgical a provider of innovative solutions for peripheral nerve surgery.
Chris Dy:Checkpoints next nerve master education program is titled upper extremity acute nerve injury management cadaveric Course. That's a mouthful, guys. It will be held in Scottsdale, Arizona. Ooh, that's nice. On March 15 and 16th where it'll be super warm I'm sure Yeah,
Charles Goldfarb:wow. I we're learning as we read the course faculty includes Dr. Deanna Mercer, Amber Leis and Brooke Baker. To learn more about this program and to register please visit Nervemaster.com Checkpoint Surgical driving innovation in hand surgery. You don't miss a warm weather meeting?
Chris Dy:Oh, no, I you know what? I'm actually going to be in Scottsdale this coming weekend for a different warm weather hand surgery meeting. So our travel clubs getting together. So yeah, well, I'm gonna go check out the environment. Make sure it's good for everybody who's going to be going to this awesome meeting from checkpoint?
Charles Goldfarb:Oh my God. Now this is a family meeting also.
Chris Dy:No, this is a me and my wife are going to this meeting. Her kids are staying at home with my father in law, which will be nice. Yeah, I mean, this course is looking really cool. I saw some other material for it. I think there's gonna have some really cool intraoperative ultrasound stuff to look at zone of nerve injury, which will be fascinating. Checkpoints also been kind enough to sponsor our WashU peripheral nerve course which is coming up but not officially part of the copy. But I want to plug the course. It's going to be April 5 to sixth here in good ol St. Louis, in in Missouri in the middle of the US. It's going to have you know, speakers from Washington faculty here right now plastics, orthopedics, neurosurgery, as well as the alumni that have come through this program. So folks like Amy Moore Jana Dengler coming back, it's going to be a fun course. It's going to have didactics and cadavers. And you know, if you're registered, now you get a better price. And if you're a trainee, you get any better price. So and the social is going to be at the home of none other than Dr. Susan MacKinnon. So you get to see how Dr. MacKinnon lives.
Charles Goldfarb:Nice, very nice. And I will say April 5 and sixth in all likelihood is going to be a spectacularly beautiful spring day in St. Louis. Of course our fingers are crossed it. That's true. But Dr. Mackinnon knows how to throw a welcome social.
Chris Dy:Yea, I t hink it'll be a good time. So make sure you check that out too. So we got an email an email to to the pod about cubital tunnel surgery. And this is from Dr. Archit Patel, who is in in New York State and he said that he's enjoyed listening to us on the podcast. He's saying he was a med student at Wash U. So he must have had a great experience with either you or Marty at some point. or Ryan, maybe. And interestingly, it's because of this stuff that you say versus stuff folks hear. From listening to the podcast. It sounds like you and Dr. Goldfarb leaned away from doing so Bosco transpositions and prefer the insight to or subcutaneous transpositions if needed. Is that your understanding? Is that what you do, Chuck? I mean, I actually emailed back because I actually I think I do things a little bit differently in that.
Charles Goldfarb:Well, first of all, thanks to Archit for writing, and asking us to clarify because clearly we needed to clarify. Here's my you know, and it was funny, we were having our monthly research meeting and we're doing a group project on cubital tunnels. And I don't know about you, Chris, or are listeners. There's a limit to how many cubital tunnels I want to do in the day. There's a limited number of carpal tunnels as well, but it's just more because they're just simple and fast. Keeble tunnels are still, hopefully simple and relatively fast. But I have an incredible number of cable tunnels coming up. I think it's for one day and five the next and that's too many for me. So, I've spoken to my nurses.
Chris Dy:I'm sure your nurse is going to be here.
Charles Goldfarb:But anyways, the question the question, my population tends to be adolescent to young adult. Rarely do I believe in insight to decompression is the right surgery for that group. If, in a slightly older patient, the nerve is absolutely stable, as demonstrated clinically, by palpation, as well as by ultrasound, as well as intra operatively, I will start out and plan to do a decompression and stop that is less than 10% of my current patients, I would say 80% of my current patients are subcutaneous transpositions. With that fasciocutaneous flap, and 10% are sub muscular. I rarely have the older patient with more severe cubital tunnel. I have had a couple of recently did a nerve transfer recently for that, but the vast majority of my patients and I look forward to hearing Chris's clarification, the vast majority of my patients are subcutaneous. So
Chris Dy:what's your threshold to get into that 10%, where they get a sub muscular as opposed to a subcutaneous.
Charles Goldfarb:I am a believer in patients with severe cubital tunnel doing everything I possibly can to help the patient. Even though the literature in my reading is not completely clear that submuscular is better. I believe it is I think it is the best operation. But I believe it comes at the highest cost. And it's not. It's not just inter inter operative time. It's not just discomfort or recovery. I just think I don't love that concept of cutting muscle. But if a patient has more severe findings, and certainly if they have atrophy, or static two point discrimination changes. For me, that's an indication to really think hard about doing a sub muscular.
Chris Dy:Yeah, no, I've tried to I think those are, I think that's a great algorithm. And I think a lot of people probably have similar thoughts to you. I mean, you know, the price of a sub muscular is there, I do think that the the additional discomfort of that surgery is substantial. To the point where, you know, people ask me how, what the recovery feels like, you know, I've learned it's kind of to get over the cord cutting and sewing and the surgeries, probably four to six weeks for some muscular, and inside two is much shorter, and subcutaneous is someone in the middle. You know, for me, the algorithm I've come to is that somebody who gets an insight to decompression is somebody who has somebody who's, you know, refractory to conservative measures. Somebody who has a nerve study that is completely clean in terms of no see map amplitude loss, there's a conduction velocity drop across the elbows, one would expect but no deviation changes on the EMG. And the ultrasound has demonstrated the nerve to be stable, because I think there are some studies showing that the ultrasound is better predicting it. And I honestly don't want any surprises in the operating room, I'd rather kind of know exactly how to book a case for and how to counsel the patient. Although every time I talked to him about it inside to talk about the possibility of a transposition that's happened to me twice so far, in terms of not being not being fully prepared. But if you have any findings of either an unstable nerve on examination or an ultrasound, then you get a subcutaneous transposition. If you have any advanced findings on clinical examination in terms of weakness, as you're stating, certainly atrophy, elevated two point discrimination, then you're and then on your nerves study, if there's a sea map amplitude loss, that's anything more than you know, you know, a value that's less than about 60 to 70% of normal of the same amplitude or there's the innovation findings with abnormal recruitment patterns, then you're getting a sub muscular. So that's my algorithm. And then I think I'll add the nerve transfer part. I mean, I think at the same amplitude value is probably less than 30, or 40% of the normal value for that older, intrinsic, whichever, whether it's the ADM or the FDI. Then I'm thinking long and hard about doing a reverse at the side, quote, supercharged nerve transfer.
Charles Goldfarb:What do you tell patients? Let's take the patient with a an unstable nerve, but a relatively clean nerve steady. What do you tell that patient regarding expectations? How many get a cure what percent good are cured? What percent are improved, but perhaps not cured? And what percent are hopefully neither better nor worse?
Chris Dy:I actually don't use the word cure. I think ever in my practice, you know, in terms of how I counseled people, I tell people, I think I'm gonna make it a lot better. I tell talk to them about how this is a mechanical thing. The nerve is flipping back and forth or wanting to move out from behind the elbow. And that we're going to talk it and secure it and about To replace in front of the elbow, and you know, those patients who have unstable nerves that are relatively slender, they actually do get a sub muscular as opposed to a subcutaneous, I think our experience in the Midwest is that our patients tend to not lack adiposity. So to say, and, you know, they've, they've got some thickness on that side,
Charles Goldfarb:possibly.
Chris Dy:They, at least they at least got something to work with there. But yeah, and I tell them that I think this has got a really good chance of, of keeping the nerve for being irritated. I tell them, there's a chance of having to redo the surgery. At some point in the future, I've had one patient who have had to revise their subcutaneous because she had a bad trauma to the medial side of the elbow, and that certainly dislodged her her nerve or at least irritated again, when I went into surgery, it wasn't actually flipping back posterior. But you know, the literature would suggest that there is a risk of revision for subcutaneous. And that's why I think it's important to really take care of that nerve when you're doing a surgery.
Charles Goldfarb:Yeah, I don't I feel really good about how my patients are faring. Recently, I don't think I'm a better surgeon, I think one of two things has happened. One, my population really has veered to the younger patient with an unstable nerve. And those patients typically really do well. Or to this concept of the fascia cutaneous flap, I really do think it's a dramatic improvement compared to an Eaton fascial flap alone, which is what I did for 15 years. And so I am really happy with the ulnar nerve treatment in 2024, I feel really good about it, it's pretty uncommon that I worry about a less than optimal outcome.
Chris Dy:Yeah, and I think it's just about catching the patients at the right time. And then making sure that you're, you know, like you're saying, like, the technical parts of surgery are non negotiable. And that's probably not not what's changed with you, it is more kind of maybe the procedure selection or your ability to counsel patients, or it set expectations or just the fact that your patients are very younger. I do. I mean, honestly, by because of what I do, and the population that I see, I get a fair number of these patients who have really burnt out nerves, so to say, kind of the cold burned out nerve. And that's an uphill battle. And the counseling is really hard. I mean, for a patient who's got severe enough, on their neuropathy, where we're talking nerve transfer, and even papers, patients who don't get a nerve transfer, but have you know, quote, severe on their neuropathy, I tell them that, you know, I'm not going to judge the surgery as a success, or not a success until about a year after surgery. I tell them, it's going to take that long for the nerve to mend itself. For things to grow back. You're going to get a fair bit of recovery early on in the first few months. But you know, we're not going to know whether this worked until about a year from surgery. I
Charles Goldfarb:think that's really, really well said. We're running out of time. But I would like to just briefly touch on the third email that we got, if that's okay with you. Yeah, absolutely. So this is this is again, I emailed the person who wrote us and they did not get back to me. So I don't want to say their name. But essentially, they wrote about a 12 year old female with a history of bilateral medial epicondyle fractures, which I have seen. And on one side, everything went great. On the other side, they are left with with with what appears to be a non union, but discomfort and what appears to be co contractions. And that's what we talked about, from the paper that we had written where the older nerve doesn't act like a classic, irritated, older nerve. But in the young patient, they have these contractions where the patient may attempt to flex the elbow and you feel the triceps firing, they may attempt to extend the elbow, you feel the biceps firing, and ultimately, especially in this 12 year old female population is often the older nerve. And so I just I can't state strong enough how big a deal this is that we have the thought of the older nerve being the culprit in these patients, and I've been so happy with treatment of those patients.
Chris Dy:So what's your How do you approach this? How do you make the diagnosis of these co contractions is there like kind of buzzwords that they say are things you see on examination?
Charles Goldfarb:Yeah, it's it's often accompanied by X rays that aren't that satisfying for being healed. That is, with or without previous surgery, maybe there's an appearance of a medial epicondyle non union said the tendency, especially of Orthopedic Surgeons, is to immediately blame it on the bone. And of course, I hope we all would also assess the ulnar nerve, and it may be irritable, but never classically they're not. It's rare that patients are complaining of numbness or tingling, they don't have any weakness in their hand. If you have bang on the nerve, maybe there's some irritability but it's the complaints are more vey. They typically lack flexion and you really can feel the co- contraction is basically the muscles firing at the wrong time, and it's sometimes that's all it is. There's no more nervous, irritability, signs. And then when the patient comes back on post op visit one, they are already better. It's really satisfying. So
Chris Dy:what is your treatment of this? Is it a transposition as we discussed? Is it a neuro lysis? And leaving a bead, what do you do?
Charles Goldfarb:Definitely transpose. And I haven't had the courage not to address the medial upper condo, I just I'm going to I'm going to have the courage to not address the middle of a condo because I don't think it has anything to do with anything. I think if the medial epicondyle doesn't heal, it often scars in we have a fibers union, just don't buy that. That's the problem. And most of these patients, and my theory is these painful medial elbows where the X rays don't look perfect. might always be the nerve, and that's a little out there. But I would just say be aware of the nerves.
Chris Dy:We're getting into Qanon unknown territory now. Here we go. So is there any way you any way you could test that theory? I mean, could you block the ulnar nerve before surgery? Would that just kind of anesthetize that area too? Would that go? I mean, is that one way to think about how to do it and how quickly does co contraction stop after you've transpose the nerve?
Charles Goldfarb:Good questions Spoken like a nerve surgeon. I wonder if I mean, this is not the population to anesthetize in clinic, unfortunately. So I don't know that while it's a good idea to lidocaine, you know, around the nerve, I don't think that's probably something I would choose. I do think postoperatively the coca directions are gone at the first visit. So I don't try to mobilize those patients immediately. I tend to just let them rest for two weeks and then come back and start mobilizing, and it's usually immediate improvement in
Chris Dy:typically a subcutaneous or sub muscular transposition, change the younger group, so
Charles Goldfarb:I just don't like go and some mastering the younger group, especially without real nerve finding.
Chris Dy:Right, and especially if they're younger, inactive and potentially going to compromise that good old flexor pronator mass. Yeah, well, that was a fun episode. So if anybody made it to the end and wants to submit some questions, happy to do another mailbag episode. So hand podcast@gmail.com And then let us know if if it's cool, we share your your question on the air. And yeah, go leave a rating and a review. Hey, Chris,
Charles Goldfarb:that was fun. Let's do it again real
Chris Dy:Sounds good. Well, be sure to check us out on Twitter@handpodcast. Hey, Chuck, what's your Twitter handle?
Charles Goldfarb:Mine is@congenitalhand. What about you?
Chris Dy:Mine is @ChrisDyMD spelled d-y. And if you'd like to email us, you can reach us at handpodcast@gmail.com.
Charles Goldfarb:And remember, please subscribe wherever you get your podcast
Chris Dy:and be sure to leave a review that helps us get the word out. Special thanks to Peter
Charles Goldfarb:Martin for the amazing music. And remember, keep the upper hand. Come back next time