The Upper Hand: Chuck & Chris Talk Hand Surgery
The Upper Hand: Chuck & Chris Talk Hand Surgery
JBJS What's New in Hand Surgery, part 2
Chuck and Chris talk through the 2024 JBJS 'What's New in Hand Surgery' written by Deb Bohn. We discuss a number of interesting hand surgery topics including: wrist and hand arthritis, distal radius fracture, scaphoid fractures, metacarpal fractures, pediatric injuries, among other topics. Great review of an important review of the literature from 2023.
Subscribe to our newsletter: https://bit.ly/3iHGFpD
See www.practicelink.com/theupperhand for more information from our partner on job search and career opportunities.
See https://checkpointsurgical.com or www.nervemaster.com for information about the company and its products as well as good general information about nerve pathology.
Please complete our Survey: bit.ly/3X0Gq89
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
Complete podcast catalog at theupperhandpodcast.wustl.edu.
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 rating that helps us get the word out. You can email us at Handpodcast@gmail.com. So let's get to the episode.
Charles Goldfarb:Oh, hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:I'm great. How are you?
Chris Dy:I'm well, I'm good. I'm finally trying to recover from some of this jetlag, you know, from the the old Singapore trip. That was rough. Usually jetlag doesn't get me but I guess in my old age now it's starting to starting to hit me harder.
Charles Goldfarb:Yeah, welcome to my world. You're not really in my world, you'll never be here. Yeah, jetlag while doesn't seem like you.
Chris Dy:It actually doesn't. Which is weird, because I like to think that I'm chronically sleep deprived. So it just kind of it's like being on call. But you know, like many people say, you know, it's harder to bounce back from the all night calls, the older you get.
Charles Goldfarb:So I'd love to hear about the trip. How was How was the trip, tell me about
Chris Dy:trip was great. Spent a lot of good time with the research teams that the different Singapore hospitals, they all kind of came together for this research course, which was great. You know, it was a pretty whirlwind tour of how to do research as a surgeon. So it was very dense. And I learned a lot honestly, sitting in the audience. There were some great lectures. And it was it was very fun. And we spent a couple extra days on the back end hanging out with the family in Singapore, which was very fun.
Charles Goldfarb:I can only imagine and you weren't the only American guest they brought over.
Chris Dy:I wasn't- it was nice. There was a another invited guests from the University of Michigan, Dr. Kevin Chung, who needs no introduction, probably for the majority of listeners, but fantastic clinician scientists. And we had a nice time discussing all things research related from tactical to personal.
Charles Goldfarb:Oh I love it. Well, that's good. What? Are you home for a while or when's your next trip
Chris Dy:home for a while. You actually did the old out and back to Chicago for a hidden society research grants review committee. Was it I guess Friday? Yeah, two days ago. So I don't know how often you do the Outback, but it was an early morning flight and a late afternoon flight back and I'm actually happy I didn't spend a night there. It was it was good to have the nighttime at home on Thursday and Friday.
Charles Goldfarb:For sure. I I did. I was in Minneapolis for Saturday for an Saudi council meeting. And those trips are tiring, though. Like you know, you can do it all in a day. But I think those are tiring.
Chris Dy:Yeah, they are. They are I actually have had a debate with one of our with two of our partners Dave Brogan and Ryan Calfee about whether it's more tiring or less tiring to, to go out and back because they spent the night in Chicago on Thursday, but I couldn't because it was our 15 year wedding anniversary. So I was I figured that was a higher priority. Yeah,
Charles Goldfarb:thank you chose. You chose well. Wow, you just got 15 I'm about to have 30- 30 years
Chris Dy:Wow. Congratulations to you guys. That's amazing. Yeah, pretty, pretty
Charles Goldfarb:crazy. Pretty crazy. Good what what else is going on in your world? Kids are go.
Chris Dy:Kids are good. Everything is good. You know, you had a lot of great feedback about the podcast eager to get back into this. So what's new in hand surgery part two. But anything anything going on in the world of Chuck Goldfarb that
Charles Goldfarb:Just keep my head above water. I'm actually looking forward to we have resident graduation this coming up by the time the podcast dropped. Jim Weinstein is in town who I think will be a really exceptional resident graduation speaker. So looking forward to that. Yeah,
Chris Dy:it's interesting. He's very famous in the spine and orthopedics world. I had no idea what he was doing. Aside from that, which is really impressive. I mean, kind of an AI guru. He's working at Microsoft now. And, you know, was, I didn't realize it served for two different presidential administrations really fascinating stuff for an orthopedic surgeon to be doing.
Charles Goldfarb:Absolutely, absolutely. So yeah, I look forward to look forward to learning about that. Well, maybe before we jump in, we can thank our sponsors.
Chris Dy:Yeah, so I think the the first one is Practicelink.com. And I'm gonna let you kind of lead on that one because it's not in the chat for me anymore.
Charles Goldfarb:the upper hand is sponsored by practicelink.com The most widely used physician job search and career advancement resource, but coming up position is hard. Finding the right job doesn't have to be joint practice link for free today at www.practicelink.com/theupperhand.
Chris Dy:I actually thought you were gonna let me try to go off of memory there because I would have tried to be that's the one I could have gotten off memories. I
Charles Goldfarb:would hope we both could, but I didn't have faith in me already.
Chris Dy:Alright, so you're back to one of our most favorite things to do reviewing what's new in hand surgery. This is part two. By the way, Agnes Dardes, former WashU medical student and friend to both of us a texted me saying that she also would only listen at 1x speed and didn't know there was a 1.5x speed until our last episode,
Charles Goldfarb:we have changed her world.
Chris Dy:So shout out to Agnes, thank you for listening. We love you. So this the next section was about arthritis. So the first paper that Deb talks about here is about PRC proximal corpectomy. And a conversion rate to total risks are three pieces of 5%. So one and 20 at a mean of 6.5 years. Does that feel right to you in terms of conversion rate?
Charles Goldfarb:I guess so. Probably seems a little high. Honestly, what what's your what's your take?
Chris Dy:I haven't I don't think I've done 100 of these to know, you know how many end up going on to total wrist. I think it's a nice number to quote it feels like a reasonable way to quote it. But that has not been my experience. So one in 5%. So, one in 20 Seems a little bit high. That seems okay.
Charles Goldfarb:You know, I really like proximal row carpectomy is I think it's a great surgery. I think that we know that you're going to see arthritis. Every single patient with a PRC develops radiographic arthritis. The question is how many develops symptomatic arthritis, and 5% is certainly higher than my experience. But I absolutely have used a number of these. And so it doesn't feel way off to me, is
Chris Dy:a fusion any harder and more challenging than doing a fusion off the bat? You know,
Charles Goldfarb:essentially my partner and I Lindley Wall discuss this a lot because one could argue that doing a PRC, she's
Chris Dy:my partner, she's my partner to Joe,
Charles Goldfarb:she's more of my partner. One could argue that doing a PRC in every risk fusion makes some sense. And I think Lindley really likes that, you know, she does a lot of we do a lot with spasticity. And so you're trying to shorten the skeleton to balance the flexors and extensors so we do a lot of risk fusions with a PRC, it's an easier operation. And so there's one less fusion surface. So I like doing risk fusions without the proximal row. Yeah,
Chris Dy:she did one the other day for for Plexus patients and you know, it's it's I agree, it's, it's just easier, does give you a nice source a local bone, depending on the situation if the if the bone graft is reasonable. But, ya know, and then when you do just, I guess vary a little bit away from the What's New, but when you do a total restore through desus, so not a PRC. Are you fusing? Are you trying to prepare the CMC surface as well?
Charles Goldfarb:Yeah, I've there have certainly been occasions when I do not I typically do. But I would say it's, it's an expenditure of three minutes of time. You know, I take a Roger, I, Roger, the surface, the base of the third metacarpal, the distal aspect of the capitate. And I pack a little bone graft. And so it's nothing fancy, which is why probably should do it. What about you? Do you routinely prepare that surface? Yeah, I
Chris Dy:don't know if I do enough restore arthrodeses to say I have routine I do enough. But yeah, I don't. Because I don't think that's where the the issue is going to be if if it were to go on to any issues with Union, but I found that to be a relatively reliable surgery, even without doing the CMC surface.
Charles Goldfarb:Yeah, well, it's hard to argue there. There are some long term follow ups where occasionally it's an issue, but it's just that it's pretty uncommon. So
Chris Dy:moving to a slightly different form of carpentry. So say you're not doing a PRC, but you're doing a Invercargill. arthrodesis, I guess is what we'll call it. Now. The next paper that Deb talks about and kind of summarize all literature's I think something that we kind of have thought for a while that it's mainly Neo, the Capitol illuminate Arthur desus surface, that's the most important as opposed to the kind of standard four corner. And I think that's based on the experience that Dr. Gelberman had with Calandruccio I think was the first author. So have you noticed any difference between when you go for a four quarter versus mainly going for the capitolunate.
Charles Goldfarb:You know, that study I was part of that study Jim Calandruccio at Campbell Clinic?
Chris Dy:Of course, you're working in hammering nails on how could you
Charles Goldfarb:forget that? I was the I was the fifth of 17 authors. Just kidding. You know, our paper actually was not totally supportive of that concept, but it's, uh, I totally agree with the idea that it's all about the capital donate and so I don't really focus on that I do add that your creature will handmade Orkestra quatro, capital handmade screw. Because it feels better. I think my fusion rates higher. But it is all about the capital. And and I will say it's interesting that there must not have been any articles this year, the years running together when you get old like me. And it's pretty clear that we should avoid for corner fusions. And I say that, as someone who really has done a lot of work on infusions, the literature is clear that PRCs have a far lower revision rate and requirements for secondary surgery. And I, to me, it's a very narrow indication these days young worker is really when I think about a full corner is that which
Chris Dy:does not mean how much does the surface, the base of the capitate matter? Because, you know, I think that most people, I think, still would say, Well, if there's arthritic way or Kandra, were at the base of the capitate, that maybe using that as your articulating surface and a PRC is maybe not best, or have you found it's okay.
Charles Goldfarb:Yeah, I just had a delightful who I think you met once or twice, delightful visitor from the UK, actually, by way of Auckland, Holly Morris, who will be in Darby next year at the polar tap center. So it's great to meet Holly, and we had a long conversation about this. I don't think the head of the cavitate matters. I think you have options. I shouldn't say it that. Absolutely. I mean, if there's really bad arthritis, that's different. But But I think you can do a capsular interposition, which at this institution has become a staple. And some people will will really singing the praises of the capitate resurfacing, which is a very slick operation, which I've never done. Yeah,
Chris Dy:no, I've, it's one of those things where I feel like I am there's a lot of confirmation bias for lack of a better term when I want the capitate to look Okay, it looks okay. And then I feel better if I put a little capsule in there. No doubt, it's an easier surgery for patients to get over. And I think there's enough as you stated enough literature out there suggesting that the results are not inferior and perhaps better with a PRC as opposed to a four corner. Yeah,
Charles Goldfarb:and it just for those who haven't technically done that, if you're worried about the head of the capitate, think about it as you consider your approach to the carpus. And I essentially make my longitudinal capsulotomy, a little more radio. And then I elevate the soft tissues off of the distal radius, and then make potentially a second longitudinal capsulotomy more own early so you have a nice flap of tissue that you can bring down resurfacing the capitate and suturing carefully into the bowler capsule.
Chris Dy:So this is a proximately base. So based off of the radius,
Charles Goldfarb:no, I'm sorry, if that came across wrong, it's a distally based the releases off the distal radius. Got it, I think you can do it any old way you want. Even if you're not proactive in your incision, planning, you can still figure out a way to interpose something. But if you are proactive, you can make a beautiful flat. Yeah,
Chris Dy:it's like when we're back, if you remember this, because he used to do too, but the black capsula thesis for SL, which I think is still a nice trick to have in your you know, plan, you know, ABCDE when you're doing an SL reconstruction, I still whenever I do an SL I will still raise my capsular flap in a way that I have the blat capsula desus as a as a bailout, dating
Charles Goldfarb:myself, once again, I've written a lot about the Blatt and Dr. Gelberman was a fan of the black. Therefore I was a fan of the black never made all that much sense. I mean, the concept for those who hadn't even heard about it is attaching the capsule still based on the distal radius and creating a check rein to volar flexion of the skateboard in chronic SL instability. I guess it makes sense theoretically, but the tissue never seems strong enough to me. Well, I
Chris Dy:mean, you know, I can like all of those surgical techniques for SL are trying to avoid skateboard flexion. So I've been known to use a blatte when it didn't work out the way that I expected it to. I think it's a reasonable thing to do. But yeah, I agree you unless you are truly very intentional on the way in the tissue quality can be suspect at
Charles Goldfarb:times. Yeah, very well said. Totally. So I guess back
Chris Dy:to the actual article, what to do at hand surgery. One thing that I found was interesting is that Deb one went on to discuss an article that talked about actually gaining motion after a PRC that has not been my experience. I've actually just maybe that's because I just counsel patients in a way where I'm setting expectations low but I've told them that they're not going to gain motion at the very most they're going to keep what they have.
Charles Goldfarb:You know, and one of the authors that paper is a mod journal in surgery 2022 one of the authors is Mark Cohen. He's, my guest is the senior author, but certainly just a small contributor to this paper. And Mark is the one who with Scott COEs and sort of did the original work comparing PRC and skateboard excision with For bone fusion, and my takeaway from that original paper is you do not gain motion. My real life experience is probably closer to this that you shouldn't promise again in motion, but you can get it. Is that fair?
Chris Dy:I think that's fair. I wouldn't promise it for sure. But I think maybe initially, there's just some pain limits pain base limits and their range of motion if you improve their pain by doing the PRC, you know, and you're aggressive with rehab, I don't know if you do any formal rehab after PRC. But I mean, I think that can certainly help your case in terms of gaining motion. Yeah,
Charles Goldfarb:I don't always do formal rehab. But I do end up patients who especially those are obviously interested in.
Chris Dy:So the next, the next article talks about our favorite topic in the world, and one that you are very well experienced in conducting original randomized controlled trials, CMC arthritis. So she talks about the results from the gene Delson, your procedure of suturing, the fcr and the APL together, and the long term results of you know, 12 to 14 years. So it's a simple surgery in terms of being straightforward with a low tourniquet time. Has that procedure kind of come into your come into your treatment? armamentarium? No,
Charles Goldfarb:it hasn't. But it's not for any particularly good reason, I guess I would say demonstrating the nature of a surgeon's mind. It does make some sense to me. I've said this many time. Any, I think almost any procedure works in the CMC joint, you need to have your favorite procedure. Hopefully, it's cost effective. Hopefully, it's times you know, appropriate. This is something that I should consider. I've been pretty happy with in general brace, suspension plasti. But I think this is very fair. And if I do fewer CMC treatments, I'll be happier. I
Chris Dy:think that you geared your practice towards doing fewer of them. But ya know, I still, you know, I will do the suture tape suspension. But then every now and then there are some technical issues with it. And I'm like, why am I still doing this. But again, like the track record of my practice, is that it's worked pretty well. So I just keep doing it.
Charles Goldfarb:Yeah. And that's for the younger listeners. I mean, that's one of the challenges we have, you know, you your personal experience plays a role in your surgical decision making, and that what you said is absolutely true. For me, the internal brace or this, the secret tapes, veggie policy has worked really well. And the literature that we have contributed in the last year to one retrospective study and one prospective randomized trial, which I think is coming out soon, basically show the results are very similar to anything else.
Chris Dy:Right. It's interesting, I've actually tried to kind of talk to patients about an old school lrti, mainly, because if I know I have a fellow on the rotation, I'm trying to get them in lrti. And even patients who have had an lrti in the past me like, Hey, do you want to do what you did before? And they just don't go for it. I do think there's something about the pain aspect of it, which, you know, going across the wrist crease and harvesting the tendon, there's something to that that is not a game changer. But it's notable enough for patients where they want the I think they want the something that is not in lrti. Yep.
Charles Goldfarb:And then the rapid initiation of motion is really nice. Even though I the longer I do the suture tape. And I assume it's very similar to the suture suspension plasti we shouldn't promise rapid recovery in the sense that I don't think CG tape makes patients get over the hump that much faster. But life returns to normal more quickly because you're gonna removable brace at five to seven days.
Chris Dy:I think that's fair. And then we had a whole episode if anybody's interested with Macy about rehab after thumb, CMC arthroplasty so you can go back and pull that from the, from the archives? And then
Charles Goldfarb:and then your favorite I know you're gonna love the next topic. denervation. Yeah, you
Chris Dy:know, I've I've done some of these and have had a mixed bag. So far. I haven't had to redo any operations. But I think that it's something where I think in the right patient, it's a useful surgery, but you have to counsel them appropriately.
Charles Goldfarb:Yeah, what is your what is your counseling for that procedure look like?
Chris Dy:Well, I think that there's, you know, I talked to them about that there's a very reasonable chance that they're going to have to have another surgery within the next two to five years. And, you know, usually I'll try to put them through a series of blocks ahead of time to simulate what this would be like. But I think it truly is hard to get a number of blocks that would truly degenerate the joint for especially for thumb, CMC. So I, you know, I guess you this paper that Deb talks about talks about quicker return to activities, it's probably because you're not protecting anything. So as a surgeon, you're going to let them do more things right away. So probably there is some bias in terms of, you know, what you will allow people to do afterwards, which will then influence when they say they're back to doing things.
Charles Goldfarb:Yeah. And in both of these studies, depth sites Have a less than 10% Revision rate at at least a year follow up. It's pretty good. It'd be interesting to see what happens long term.
Chris Dy:Yeah, I think that is pretty good. But I mean, I also think there's probably something in how you counsel patients and whether they're willing to sign up for another surgery right away. So there's probably something there that needs a little bit further exploration.
Charles Goldfarb:Absolutely. Absolutely. And then what about MCP joints?
Chris Dy:Yeah, you know, this, this is interesting. I mean, the survival rates for these MCP arthroplasties. In the Norwegian register, were pretty darn good. I mean, 84%, at 20 years in terms of you know, whether it needs to be revised. I find that to be quite good. I don't personally do a lot of MP arthroplasty. I send this to one of our partners, Marty Boyer. Because he's really good at doing MP and pap arthroplasties.
Charles Goldfarb:Yeah, I've taken the same approach I did a lot earlier in my career. It's funny, I saw a list of my most referenced articles from my career, you know, occasionally pops up on something he gets sent it. In Top Five is a paper I wrote during fellowship with Peter stern looking at outcomes from silicone MPR to plasti, for rheumatory, arthritis. And you know, it, it was one of this, there were a lot of articles like that when we just happen to have good follow up. And it talked about range of motion, etc. But these results are outstanding. It's
Chris Dy:interesting how well silicone does for you, because it's a relatively non sophisticated implant. I mean, it's a spacer. And it does pretty well both MP and pap joints. Yeah,
Charles Goldfarb:non sophisticated implant for non sophisticated surgeons that fits right up my alley.
Chris Dy:hardly the case. And then the next topic is mallet injuries. So the paper that that was read here talked about looking at patients treated non operatively. And follow them for mean of 12 years. Shocker. They do pretty well. Yeah,
Charles Goldfarb:it's, these are a part of my practice, for sure. And again, Dr. Wall, who we mentioned earlier, takes care of more kids these days than I do but take care of a lot of kids. And she has a pretty nihilistic approach. I have a hard time to join this subluxated. If there's a bony fragment is particularly large, I have a hard time doing nothing.
Chris Dy:So what is doing nothing mean? Does that mean not doing surgery? Or does that mean not splinting?
Charles Goldfarb:Thank you. Good point. So yes, I think you splint for pain control, basically. I don't know that you're splinting to expect it to change outcome, but you kind of, for me, if I'm treating whether it's an osseous injury or soft tissue only mallet finger, and I'm going to go the non operative route. And these are conversations which take me a while. It's a it's a custom splint for six weeks. 24/7, basically, very different, obviously, than the operative approach. Yeah.
Chris Dy:And I think conceptually is is very hard for patients to understand that, you know, in the indications for surgery are very, very narrow for me. But it's hard to explain, like I said, it's a conversation and like, Well, why aren't you fixing this? Why aren't we fixing the the tendon that's torn? Why aren't you fixing the bone that's broken? And it's just very hard to say, the papers show that there's really no difference. Yeah,
Charles Goldfarb:and in the adolescent population, which are where we find the majority of the bony mallets it's even harder, because you throw a parent in the mix. And that's why I don't have a problem with a close reduction and panning especially I did did one last week. And you know, the the fragment if we can improve the position of fragment, improve the joint alignment, I feel good about what we've accomplished.
Chris Dy:Yeah, no, I think that's absolutely fair. You know, it should be stated that this article demonstrated that patients go on to radiographic arthritis, but it doesn't lead to any clinical consequences, and it's very much similar to the distal radius literature that you contributed to. Yep,
Charles Goldfarb:I think that radiographic arthritis, and it's really interesting. I think we're going to learn more about the implications of that over time with some of these longer term follow up studies. But radiographic arthritis does not equal symptomatic arthritis. Don't
Chris Dy:sign us up for any long term studies on mallet fingers placed.
Charles Goldfarb:And no prospective randomized trial either.
Chris Dy:So before we move on to disagrees fractures, we should thank our sponsor checkpoint surgical and they recently hosted a webinar on nerve base surgery and the management of upper extremity spasticity with your buddies Dr. Scott Kosan, and Eugene Park. They review the concepts of nerve base procedures and managing specificity and its emerging role in the upper extremities. In case
Charles Goldfarb:you missed the live event I did Chris I missed it. It is now available to watch on demand. To view the recording and learn about upcoming educational programs supported by checkpoint surgical, please visit nerve master her.com
Chris Dy:I'm pretty sure that's bookmarked for you already. Right?
Charles Goldfarb:Oh my god, I love the more nerve the better once I've logged innervation
Chris Dy:anti nerve Come on now. So speaking of doing nothing for patients, this next article is really interesting. It's something I've always wanted to do it for this trial group called the appropriately called cast off group. What about one week of plaster and then going to an Ace wrap for minimally displaced this arrays fracture?
Charles Goldfarb:I love my patient population. I really do. I think we're lucky. We've talked about this in St. Louis, I do not think this would fly at all.
Chris Dy:I think it's are a hard sell. I think I probably could, I can't even do it for metacarpal, which is also good literature to go with just an Ace wrap. I think it's just hard. What about a kako? Brace brace?
Charles Goldfarb:Yeah, I mean, for the right patient, I just, you know, in the United States, that concept of loss reduction in the medical legal implications are just in the back of my mind fairly or unfairly. I want to treat the patient the right way. But I want to treat it in the, you know, the accepted domain medical legally,
Chris Dy:do you think that this paper gives you, you know, reasonable standing to say, All right, well, let's just you know, there's a chance that could displace, but no patients displaced in this in this series. I think it's nice. I mean, I think for the right patient for a minimally displaced fracture that has a very low chance of displacement in my mind, I like a cockroach brace brace. And, you know, kind of tell them where it like a cast, but it does change your quality of life. I mean, it allows them to shower more readily doesn't have the expense of going to therapy for a custom splint. I think it's a very reasonable thing. And I like having to study in the literature.
Charles Goldfarb:I think this studying literature is excellent. For me, it will help me move along the pathway, assuming additional literature supports this concept. It also gets to the point of with this type of nondisplaced, fracture or even others. I've been schooled that I see the patient that week one, week two, week three, week five, and I'm a new agent radiographs each time now there are certain fractures that need that, but I probably overdo it, I probably bring back patients more frequently than I need. Because the concept here is the initial traumas, always the worst trauma. If the patient is smart about not overusing the hand, he or she should be fine.
Chris Dy:I think that's true. And I tend to tell patients about the ones that I'm a little concerned about displacement. And I think that I don't see them serially after two weeks, kind of go to the one two, and then six weeks, you know, relative to the date of when I start seeing them. But I think it's absolutely fair. I mean, I struggle with the ones that I you know, trying to understand, which are the ones that are going to displace, because we have the kind of the classic LaFontaine criteria, but there was a paper out of Canada that kind of refuted a lot of that saying that really more, it's the age and the initial displacement, that are the bigger predictors. You know, there's this paper that Deb goes on to talk about here in terms of, you know, marginal, secondary displacement being a significant predictor of late displacement. This seems to be the concept of you know, if you see him back, and they displace a little bit, they're just going to continue to slide and continue to display. So has that been your experience? It has
Charles Goldfarb:been my experience, and I think it's true in this location, and potentially with other fractures as well. That and it's the classic, frustrating situation where you have a long conversation with the patient, operative, non operative, we decide on non operative, you say, I'm gonna see you back in a week or whatever the number is, repeat the X ray, and it's a little worse. And then you're on this slippery slope of do we change based, you know, based on their parents today? Do we watch it for one more week, and then all of a sudden you start healing gets really
Chris Dy:tricky. It's frustrating, because I think a lot of the if you're going to have surgery, the benefit of surgery is the earlier recovery, you know, earlier returned to function. And the longer you wait, you know, the less of that, you know, benefit you're realizing. So it's challenging, because, you know, you see him back, one, two, sometimes three weeks, and you're like, Alright, now it's dissuasive, wherever we should really talk about surgery. It's like, Wow, man, I just lost three weeks of recovery. Yep.
Charles Goldfarb:And I'm actually dealing with that exact situation right now. So not only do you have the long first conversation, you're having the long second and third conversations.
Chris Dy:It should be noted that Chuck talks about how long he has to talk to people quite a bit, but they are long conversations that will certainly change a clinic for you, for
Charles Goldfarb:sure. And then goes on to talk about the Frostfire Trial Group that combined randomized observational study in surgery for fractures in the distal radius of the elderly. I'm going to stop because I'm exhausted. Well,
Chris Dy:you know, elderly Chuck is over 60 years so you're not far from that apparently, at least I didn't call you geriatric. Sure.
Charles Goldfarb:I am. way away from that. I
Chris Dy:think that the dissonance between radiographic and functional outcomes is not surprising, but it's very frustrating as somebody who asked to counsel people about what to do.
Charles Goldfarb:I think that's right. I mean, the so just to be a little specific, because this is an impressive study, 166 patients randomized to treatment, and 134 were observed. And so 113 treaty with volar plates 187, close reduction only, significantly worse alignment at one year, although no difference in patient reported pain or function between plating and close reduction groups. Wow. I
Chris Dy:it's, you know, again, that that doesn't surprise me. But I think a lot of this has to do with and I don't, I can't, I don't know, where where was this study performed, you know, which country I
Charles Goldfarb:don't, maybe I can, because
Chris Dy:I think in at least in St. Louis, in the US, I think it's very challenging to, for patients to accept the appearance of their wrist. Even if you tell them about it, it's always going to look crooked, they hate the prominence of the ulnar head in most cases. And I really struggle with the counseling here. Because while I tell them kind of from a functional perspective, what the what to expect and how, you know, surgery might have a role. I think patients have a hard time seeing a crooked wrist and be okay with it.
Charles Goldfarb:I think that's true. And, you know, the patient population matters for sure. East Coast, you know, Mid America, where you and I are mate, we may have it even easier than our friends on the coast in the United States. And certainly I don't have a great experience with international patients. But all of this is relevant to the to the discussion we should be having with our patients. It
Chris Dy:is and you know, I think both you and I are guilty of the masochistic activity of reading our own online reviews, and I got torched in which I had this very, I think reasonable conversation about you know, non op versus operative treatment of disarray as fracture and just got absolutely slammed saying I came in and he asked me what I wanted to do. Why didn't he just tell me this is he's a doctor, why don't you just tell me what what I should have had done and Oh, my God, man, strategy, this kind of hippie dippie shared decision making Doctor based on evidence, and she's just taking the old paternalistic approach be like you need surgery, you don't need surgery. Yeah,
Charles Goldfarb:I think that only happens in Mid America, and only happens rarely even here. But you gotta read the room.
Chris Dy:Clearly, clearly, I was wrong. And I can't obviously can't do anything about that review, unfortunately.
Charles Goldfarb:Um, the next section is interesting. Dead discusses skateboard fractures. And she begins by discussing the whole concept of essentially artificial intelligence, both in the sense of diagnosing skateboard fractures. And then the concept of robotic assisted versus freehand placement of the guidewire. And we all know this is coming is one of the reasons I'm excited about our graduation speaker who we mentioned earlier. Really interesting stuff. I mean, we're going to be using AI for both diagnostic and technical purposes. It's just a matter of when.
Chris Dy:Yeah, no, I think the diagnostic thing is, I mean, it's already it's already here. I think that, you know, radiologists, I think, are wise to be on top of this, because it I don't think it's going to replace them. But it may, you know, expand their capabilities in terms of, you know, diagnostic diagnosis of many different things. I, I struggle with robotic assisted because it did show that it takes longer, but I mean, over time, that probably is going to, it's going to change. I mean, I can't think of anything worse than having a robot help me put a pin guide wire in for a skateboard. Skateboard screw.
Charles Goldfarb:Yeah, I think you and I are gonna be waiting a while before a point employing that technology. What
Chris Dy:else? What else? Am I going to harass our fellows? I mean,
Charles Goldfarb:put a little pressure on them, not the robot. Yeah, I don't know. This. Is this a little crazy? I think an experienced surgeon can typically do this pretty quickly from the dorsal approach. Yeah, I
Chris Dy:think so. But I think over time, it'll be interesting to see in hand surgery where the robot eventually gets used. It hasn't really creeped into anything, you know, what we do, but I have seen papers about, you know, robotic assisted nerve cooperations, which I think there might be a role for that. Maybe particularly in kind of some of the more difficult areas to do micro like when you're deep in the neck for plexes. And when you're when you're not when it's not flat on the table, like a digital nerve. So maybe there's a role for that. I've seen kind of robotic assisted. This is crazy, but phrenic nerve dissection of robotic assisted intercostal nerve dissection, which I think would be really cool, because intercostals are pretty frustrating stuff that you don't do on the regular truck. But it'd be interesting to see where robots land I will certainly will use this paper. You know, the next time I'm talking to a resident or fellow about when they're putting in their guidewire I'll tell them where we're About could do it better?
Charles Goldfarb:We'll say thank you very much. Yeah,
Chris Dy:exactly. This is this is part of my teaching strategy.
Charles Goldfarb:So the metacarpal fractures section is really, we already touched on it essentially, there are, there's a good study which looked at 37 metacarpal shaft fractures of the digits, not the thumb. They didn't meet surgical criteria followed over six weeks, and really only one had a change of alignment requiring surgery. So that gets to our point earlier, how to mobilize patients what what's the expectation, and then Deb talks about changes in practice over time and the increasing evidence about the need for following these patients and how it's just hard to change practice.
Chris Dy:It really is, I mean, I guess I want to talk about the first paper, I mean, I don't know the last time I saw metacarpal back that changed it to the point where it eventually was more of a surgical conversation to the point where I actually see them. And then I see them in six weeks, I don't see them back, you know, I used to like was starting out with see them at a week or so just to check alignment again, I've stopped doing it.
Charles Goldfarb:The only time I see them back one week later, and it's often in the adolescent population is if the radiographic alignment looks pretty good. But the finger looks a little deviated or rotated. I wonder whether it's just swelling. So then I Mobizen for a week and bring it back very different than what you're saying. I 100% agree. I don't think these tendons displace further overtime in the reasonable patient. So
Chris Dy:then when you see them say we see them a week or so after their injury radiographs look reasonable when you see them again,
Charles Goldfarb:depends on the patient depends on what our management is, are we casting? Almost never. Is it a removable brace? Is it buddy tapes alone? So the fracture pattern affects all of that. But yeah, I probably see him back twice. And that's probably it.
Chris Dy:You know, because one of these papers showed that one out of five never come back.
Charles Goldfarb:They're smarter than we are.
Chris Dy:I think that's fair. I mean, if you put them in, if it's if you're a patient, and your doctor just says put an Ace wrap on it, or you know, buddy take like you're like this is not a big deal. Why don't you need to come back? Most people would say I'm gonna let you drive on the peds section. Absolutely.
Charles Goldfarb:So, Deb, Deb is a pediatric cancers. And in large part, I know she does adult as well, like I do. But she discusses pediatric trigger finger. And she gets to a recent study, which looks at presentation, natural history and treatment of idiopathic pediatric trigger finger in a large number of children. And reports that 30% of those patients had resolution and the vast majority of those results within one year. And then the question in splinting did not affect things. And that is different than most of the literature. I certainly will use splints in an effort to try to avoid surgery in pediatric trigger finger. What's interesting, I think we're what's really interesting for someone like me is if you come to surgery for a pediatric trigger finger, is it treatment, just like an adult, a one polio release alone? Or do you excise a slip of the FDS? In my hands, I excise a slip of the FDS. I think it doesn't add significant to the surgery, the morbidity or the expectations, and I think it decreases the risk of recurrence.
Chris Dy:But that wasn't the case in this paper. That was not
Charles Goldfarb:the case in this paper. Very similar outcome. So really helpful.
Chris Dy:Yeah, I mean, this bottom line symptom resolution after surgery is very, very good. 98 99% Whether you excise a slip or not. I think it should be said that this is not trigger thumb. This is non thumb digit triggering. So, you know, do you think about those conditions differently? Clearly, there's a distinction there, right?
Charles Goldfarb:Well, yes, I think about them differently far, far, far, far more common sugar thumbs, there is good literature suggest that many of those will resolve and I certainly don't usually operate those at the first visit. Sugar fingers, I am less confident about the resolution. As I mentioned, I will use a splint and a pediatric trigger finger. And I typically see the pediatric trigger finger back at three months kind of see how things are going. And I think you're right, the the numbers are higher than I would have expected about resolution with or without FDS, slip excision. And another there's another institution that also practices that. So I think it's worth considering what what you hate though, especially in a kid and my experience has been without that slip excision. There's a higher risk of recurrence, but I need to respect the literature and have that conversation with families.
Chris Dy:And it's fair. I will say just as an aside, I was very proud of the return on investment from our private school education. Because I was in a pool throwing a ball with my son and I thought he jammed his finger where you know when he was 10 Catch the ball. He said is your finger okay? He's like, you know, Dad, the thumb is not a finger. So press so impressed.
Charles Goldfarb:Do you think he learned that at school and not at home?
Chris Dy:I think he learned that at school because we have not gone into that level of depth of human anatomy at home.
Charles Goldfarb:Bravo, bravo.
Chris Dy:So ganglion cysts, my favorite time, every time there's a ganglion on my schedule. One of the MA's looks to me says, your favorite ganglions.
Charles Goldfarb:Dammit. Yeah, giggling is not that exciting. You know, for some patients, they're just a bump. For some patients, there are pain generator, it's very hard for us as surgeons to distinguish what the what the reference was 150 for children, basically, in the hand, they're more likely to resolve than they are on the wrist. And they present with assist, it's been present for more than a year, it's less likely to resolve so there is a chance of resolution, so sending the patient away and telling them to try to live with it and see what happens is absolutely appropriate. Yeah,
Chris Dy:no, I think this is a good counseling thing for me, because you know, it's just more fodder to say leave it alone. To most patients. That is not acceptable to some patients, as you know, they conceptually have a hard time leaving something alone. If it's painful, that definitely steers my conversation in my approach, but for the non painful ones, this is helpful. The other topic that is a least favorite is the adolescent risk pain. So I'd like you to tell me what to do with patients with adolescent risk paid
Charles Goldfarb:ino is a difficult, difficult issue. There's so much that can be wrapped up into adolescent risk pain, I think our obligation as clinicians is to really take every complaint seriously. And do our darndest to rule out clear pathology and to address it, if identified. That still leaves a large number of kids that come in with this complaint, that have pain, which is difficult to explain. Sometimes it's generalized ligamentous laxity, sometimes you can't identify an issue at all. You don't want to waste a Washington say I don't like to waste resources, which means therapy, etc. But therapy is often a part of my approach to treating these kids. But I agree that, you know, we have to think about depression and anxiety, we have to have honest conversation with a family. And this review by Watson at all does do a good job with the topic.
Chris Dy:Yeah, no, I, I probably end up getting using more resources than then truly necessary. Mainly to say, you know, there's nothing that I as a surgeon can do in this particular situation. So it's MRI therapy, that kind of thing. And ultimately, it's it's challenging to tell the patient in the parent, there's nothing to do unless you have honestly an MRI that demonstrates nothing's going on.
Charles Goldfarb:Yeah, and that can be helpful, even though neither of us probably love that. All right, bring us home.
Chris Dy:So the last paper I want to talk about is actually one of my favorite papers in this whole section. My godchild, who's a friend of I think both of ours over at Emory and has done quite a bit with the you know, really revamping that hand surgery group in Atlanta. They did an RCT on patients for DISA radius fractures and whether they got a six day stereotypes like a Medrol dose pack when I asked Mike and it actually is just a straight up Medrol dose pack, showing significantly decreased use of opioids, which is really impressive. What do you think about this because I think dogmatically as surgeons, we tend to stay away from steroids because of the concern for wound healing issues. But steroids, I think, are pretty benign, at least at this dose, and may have some really nice benefits.
Charles Goldfarb:I think it's fair to say, I mean, again, I just had a conversation about Americans and the use of narcotics postoperatively, we clearly overuse them, we clearly continue to over prescribe them. Although I think we're far better today than we had been historically, it's pretty compelling evidence that a short course of steroids will decrease the narcotic use, and perhaps its most important, and those that were worried about needing narcotics.
Chris Dy:Yeah. So I texted Mike about this paper. And I asked him, you know, this is what you're doing now? He said, Yes. And for all of our shoulders, and he said it got the New Year Award from the, from the ACS, and I said, I heard it near. So it's a pretty big deal that they got that. And he said, no wound healing issues, no infections, anything like that. And he's doing in all of his CMCS as well. So pretty impressive. Yeah,
Charles Goldfarb:I remember we reviewed a paper I believe in this in this forum that looked at flexor tenosynovitis and the use of steroids in resolution and it didn't have any negative effect on healing and led to rapid resolution. So you know, steroids are super interesting topic. And this is one more piece of information for us to consider. Yeah,
Chris Dy:I do use it anecdotally to get some patients over the hump just seem to be struggling quite a bit. with pain more than most patients, and it's hard because I think until you've been in practice long enough to know what the bell curve looks like for most patients, which fortunately now I haven't. You don't know when when to pull the trigger on something like this, but I do like this paper and, you know, kudos to Mike and the group for for doing what seems to be a very challenging study, but it's very meaningful.
Charles Goldfarb:Before we close tell me how you think about the use of steroid dose packs in clinic, how often are you doing them, and what's the most common scenario.
Chris Dy:So actually, I end up seeing a fair number of people who I think have cervical radiculopathy, just by nature of my practice. So I actually will use the server, I will use that a steroid dose pack actually go a little bit higher than a Medrol, I'll do an 80 7060. So and so as you know, which is a big dose, but can really nip some of that stuff in the bud. So it ends up being people with like suspected cervical Riddick, because it gets takes a while to get them into physiatry. or patients who are kind of in that person to Cherner camp. And there's pretty good literature demonstrating if you start it early enough, which oftentimes patients aren't with me early enough. But if you start it early, may actually help quite a bit with some of those symptoms. When are you using them?
Charles Goldfarb:I think the way you said it's Well, I'd never actually do the big guns, big dose, you know, when I use is really a Medrol dose pack. And uncommonly I would say once or twice a year and I asked you interest because maybe I should be using it more just to help with swelling and just bouncing back. I need to I need to think about how to use it more efficaciously I guess. There
Chris Dy:we go. Some fodder for conversation and future discussion. All right. Well, thank you, Mike, for that article. And thank you, Deb for writing this. What's new enhancer? I'm excited to see who has this lovely honor and opportunity next year.
Charles Goldfarb:Yeah, looking forward to it. It's a great job. I debit. A big, big task as you well know and glad to have the opportunity to carefully review this manuscript and learn more about our literature.
Chris Dy:All right, until next time, take care. Hey,
Charles Goldfarb:Chris, that was fun. Let's do it again real soon. Sounds
Chris Dy:good. Well, be sure to email us with topics, suggestions and feedback, you can reach us at handpodcast@gmail.com.
Charles Goldfarb:And remember, please subscribe wherever you get your podcast. And
Chris Dy: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
Chris Dy:remember, keep the upper hand come back next time