Flexor Tendon Avulsion

Chuck and Chris have a good discussion on FDP tendon avulsions and repair options.  We discuss whether the FDP should always be repaired in the setting of an intact FDS (a great deal of therapy is required and results are rarely excellent) and we discuss how we each repair the FDP.  We also reference a few items:

1) Carroll Tendon Pulling Forceps (this allows easy passage through tendon sheath)
2) Tendon weaver (passer).  Sharp instrument used for tendon weaves with tendon transfer surgery

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Transcript

Charles Goldfarb: 0:00

Chuck, welcome to the Upper Hand Podcast, where Chuck and Chris talk hand surgery.

Chris Dy: 0:09

We are two hand surgeons at Washington University in St Louis, here to talk about all things hand surgery related, from technical to personal.

Charles Goldfarb: 0:17

Please subscribe wherever you get your podcasts, and thank

Chris Dy: 0:20

you in advance for leaving a review and a 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: 0:30

Oh, hey, Chris,

Chris Dy: 0:31

hey, Chuck. How are you?

Charles Goldfarb: 0:32

I'm great. How are you? I'm

Chris Dy: 0:33

good. We just keep recording at different times of the day and week. This is us on a Thursday afternoon. You're fresh out of clinic.

Charles Goldfarb: 0:40

Oh yeah, I'm riding high right now. Clinic was fantastic.

Chris Dy: 0:45

That's always when I'm at my peak energy is right after a day of clinic.

Charles Goldfarb: 0:49

Yeah, thankfully it was, it was just a half day, and it was one of those clinics where it didn't seem like that many patients, but we started off with a bunch of new patients that were a little time intensive, and all of a sudden we're behind. And I don't, as you know, I don't really care for getting behind. And so thankfully, we caught up, and it was a very productive clinic as far as booking. So

Chris Dy: 1:10

that's good. Yes, I had a morning half day clinic at one of our satellite locations, and then hold myself up in an A in a touchdown office to work on a grant. So there was, it was, I'm coming off of a different kind of quote high, but my clinic experience was interesting this morning, because hit it very hard. Did you know half three, just over three hours of clinic slots, saw over 30 patients and zero bookings?

Charles Goldfarb: 1:36

You know that was actually before you, before you just got into that? That was gonna be my next question. And you probably know the data, or can look at the data. First of all, I would say those days happen and they are difficult. I remember.

Chris Dy: 1:48

I remember one of those days happening when I was in your fellow in clinic. You were not the happiest. I remember that,

Charles Goldfarb: 1:55

no, it just feels futile. I'm on a good run. And I was going to say, what do you think your hit rate is? I mean, we we have data available, which is basically surgeries poor, you know, new patient visit to surgery ratio. But overall, what do you think your hit rate is? If you have a clinic of 60 patients, how many surgeries

Chris Dy: 2:16

I vary? I mean, I vary all over the place. I mean, there are days where I think I break the system in terms of trying to get my my team to book cases, and they just look at me, and I walk out of a room, and I grab a sheet, I don't say anything, and they just say no. And then there are days like today where I was like, cleaning up my pile of paperwork, and I was like, Oh, I didn't book a case. And I mean, I, you know, obviously, like, you know, surgeons like to operate, but I think we have pretty reasonable indications. And, you know, I don't push indications by any means. It just wasn't a day of that, of that. So I think I remember, and I'd be interested to see what listeners have in terms of metrics they follow, just like the gross, you know, surgery or new patient visits to surgery bookings. I think mine hovers into low two point somethings. I don't know if that feels right or not. I may be completely pulling that out of left field. Now

Charles Goldfarb: 3:06

I think yours probably does, and so does mine. I think we're both probably lower than our partners in a lot of respects. I do it is funny when I have a really busy booking day, I apologize to nermina, and I just feel like you can only book so many cases without going crazy, and thankfully, she's resilient. But yeah, I it's an interesting metric, and it's certainly not the only one that matters, and you can have a great clinic without scheduling any cases. But ultimately it's sort of, sort of the goal. My question for you is, can you book too many nerve cases in a single day. Meaning, if you had four cubic tunnels and a perineal decompression and a nerve, can you do too many or is that impossible? That wasn't completely clear. Let me try that one more time. Is it possible, not from a time perspective, but from a Chris Dy enjoying the day perspective, is it possible to put too many nerve cases on one day?

Chris Dy: 4:07

I think it depends on what it is. Because I actually, when I come out of the room, I actually don't specify dates, unless it's like a time sensitive thing. So, you know, I have, actually have told, you know, our my team, when we're scheduling cases, I can't do more than four or five. Will launch cases in a day, both for my own stamina and also to make sure I don't lose the second anesthesia team when they have two rooms. Because if I have a if there's enough local cases, they will just move them all into one room, which is not an ideal setup, because, you know, as in our place, I have to go out and do the blocks between cases, which can really slow things down. And then also, I just don't have the energy on an or day to do eight while on cases. I know a lot of our listeners do. I just, I can't, like, I just can't, because you're, you know, it's a bit of a showmanship aspect on top of the teaching part of it. There are days where I can't do more than three, or I probably can't do more than four on their nerve transpositions in one day. I mean, I can, and I have done it occasionally, but I look at the schedule like, oh, well, I guess it's a high rep day for the resident or the fellow, which is a good thing for them, but it does get a little bit tedious. Yeah. And like, months monster nerve transfer cases, probably just because the amount of time you're not booking three or four of those in a day usually. So

Charles Goldfarb: 5:25

yeah, it's interesting. I ulnar nerves are one of those that I try to cap, but Nermina doesn't listen to me, so I have done four or five in a day, and that's it. Just, it's not that my favorite case, as you know, and that's a lot. And then, honestly, as much as, you know, I like wrist arthroscopy. I would say three is too many and four is definitely too many a day, not too many. It's just that I kind of, when I see that on the schedule, I'm like, wow, that's a lot. Yeah, it's

Chris Dy: 5:53

like, the fourth piece of chocolate cake. You're like, yeah, I can do it. I mean, I can do it, but, you know, I don't probably, you know, not enjoying it as much as the first second or third piece of cake or a piece of pizza or whatever it is that you're enjoying. Yeah?

Charles Goldfarb: 6:07

Why don't we thank our sponsors? Would that seems like a good time? Yeah,

Chris Dy: 6:11

we should thank Practicelink. The upper hand is sponsored by Practicelink.com the most widely used physician job search and career advancement resource.

Charles Goldfarb: 6:19

Becoming a physician is hard. Finding the right job doesn't have to be joinpracticelink.com I'm sorry, join practice link for free today at www.practicelink.com/theupperhand.

Chris Dy: 6:33

Alright, yeah. So after I finished in clinic, I did hold myself up an office, and I forced myself to write a specific aims page that I've been procrastinating on for a while, and this is going to resonate with very few people who are listening. But I mean, I've written so many grants in the last two or three months, for whatever reason, I decided this was the moment to chase different grants. So I think since April, from April to August, I'll have written six grants various sizes, some for very small mechanisms and some for big mechanisms. So that includes one NIHR, one grant going for another one. And you know, it's various foundation grants, both internal grants and kind of national grants. So it's, I'm tired of writing, but I keep realizing there I was, like, this actually fits this mechanism really well and we can make this deadline. So here we go again. It's

Charles Goldfarb: 7:24

well, you clearly have a talent for writing a good grant. No doubt about that. What would what hit rate would make you? Would you be satisfied with? I mean, obviously, you know you want the r1 of course, but excluding that one, if you got three of the five, would you be happy? Oh,

Chris Dy: 7:39

yeah, for sure. Three out of five is great. I mean, honestly, one out of five is pretty solid. Two out of five is pretty good. So it's almost like baseball stats, in terms of your batting average, if you're hitting 300 you're doing really well. So, I mean, it's really hard, and it's an interesting thing, because it's like, once you get one grant, you become a safer bet. And then just like, keeps kind of coming, as long as you know how to write a grant well. But it's a, you know, it's a very good exercise to think about what you're doing academically, research wise, it's the ultimate BS Test in terms of, you know, if you can't explain what you're doing, you know, in a very clear way to smart people that aren't well versed in your in your specific field, and show them that this is a good return on investment, then you shouldn't be doing it. So, you know, it's, it's a challenge, but you know, one that I persist on, and I'm happy that I just put my head down and got the work done today. So I did an interesting case that I was hoping could be kind of the crux of our conversation today, it's the hand surgeon and hand therapist, favorite diagnosis of Jersey finger. And we talked about, you know, kind of alluded to this on prior episodes about how, you know, the the classic teaching is that that's a surgical indication for a jersey finger, and there are different, different implications on timing, but we talked about how, how you know, your paper, your case series that you worked on with one of our former fellows, Jocelyn Compton, demonstrated that perhaps there's a role for non operative treatment. So it can you before I launch into this case. You know, can you kind of tell me your current indications for surgery? Yeah.

Charles Goldfarb: 9:20

So. And just for background, who those, for those listeners who haven't listened to the entire catalog of the upper hand podcast, first of all, shame on you. And second of all, kid, I kid, here's how I think about it. Most of us consider, most hand surgeons considered FDP avulsion, an absolute surgical indication. And I'm not here to say that's wrong. I'm here to say that it's incumbent upon us as surgeons to make sure patients understand what they're getting into because it's a lot. It is. While the surgery itself, I would never call huge. It can be bigger than expected if you have to trace the tendon back into the palm. Thread it back out to the distal phalanx, and it can be a ton of therapy, and results are not guaranteed to be fantastic, and so all of that matters. If you happen to hit a home run, patients will come away thrilled. Otherwise, I would say most patients are happy after the surgery, assuming we avoid complications. Thrilled is probably uncommon, at least in my personal experience. So I always have that conversation with the patient. I try to be honest with them. I don't try to talk them into surgery, although I explained that that's, I guess I would say, still, the standard of care is to repair the FDP. Yeah. I

Chris Dy: 10:36

talk about how that's the textbook. Yeah. You know, how long do you tell them it takes to get to, quote, happy, 16 weeks, four months, so four months of therapy and to get to happy. And then what's the rough method, understanding that not all the cases are the same. What's the rough PPC that you get?

Charles Goldfarb: 10:57

I think if you get a distal Palmer crease measurement of one centimeter, you should be

Chris Dy: 11:02

happy. I was thrilled. I'd be thrilled with one centimeter if

Charles Goldfarb: 11:07

I mean, honestly, I think that's one way to think about the other way to think about it is maintaining PIP full motion and getting a 30 degree arc of distal joint motion would probably make me pretty happy. So

Chris Dy: 11:18

if you had PIP motion. If you had somebody that had good superficialis, motored, active flexion, would you tell them to leave it alone?

Charles Goldfarb: 11:30

I would give them the option of leaving it alone and explain why. If it was my finger, I think that's what I would request. I really do, especially if it was the ring finger. And we know the ring fingers, most common because of vascularity and the like, I think, for the ring finger, I mean especially non dominant ring finger, but probably even dominant ring finger, if with my occupation and my difficulties going to therapy recently, you know, strengthened with my lack of therapy for my Knee, I would, I would not have mine repaired, would you

Chris Dy: 12:07

so, I mean, if you what about this? So what if it was your small finger? Does that make a difference?

Charles Goldfarb: 12:15

I think it does make it. I mean, I think both ring and small matter for strength. And you know, we both occasionally need strength in the or and in life, that's the reason to repair the FTP, so a dominant hand, FDP, ring and small finger, to me, are more important than index and middle finger. Is that what you're getting at? Yeah,

Chris Dy: 12:36

yeah, no, I would agree. And, you know, I guess, you know, usually the way that I've approached this in the last couple years is that, you know, if there's somebody who has reasonable, you know, Pip flexion, I really try to tell them, like, Let's optimize that. You know, as long as your you know, stump hasn't retracted and come very painful. I mean, there's probably not a role for surgery. And if it becomes painful, that's a different kind of surgery with a much different kind of outcome. So this was an interesting case, though. So this is an very active person, perhaps chronologically older than you, physiologically, pretty young. And this person injured themselves playing soccer, grabbing a jersey. It's interestingly enough. Wow. So you know, it was the, it was the small finger on their dominant hand, still working, still athletically, quite active. And came to our Injury Clinic, and I the, you know, the physiatry colleague of ours came over and said, Can you see his patient? I said, Of course. I went in. I was like, well, started going into the spiel of, here are the options, blah, blah, blah. And then I looked at his X ray, and of course, the piece had retracted back to guess where, right at the PIP joint, to the point where it was a it was interfering with superficialis function. So what do you do then? Because he's got no PIP flexion either.

Charles Goldfarb: 14:03

Yeah, I think that's totally different in the sense that a bony avulsion, and I think, to me, bony avulsions are different, because if it's a sizable enough fragment that you're actually looking to repair the bone, I think it heals in a very different way. Am I was this a big enough piece that you think you could get the bone to heal? I

Chris Dy: 14:23

didn't think so. I mean, honestly, it's a, it's, it's one of those pieces where, like, I don't think I can get solid fixation in that piece, but it was, it was a piece, like, a sizable piece, but not sizable enough where I was, like, we could fix that, and it'll, you know, reliably do well. Because I think, you know, for those that aren't as well initiated. I mean, you know, so bone to bone healing is much more reliable. Tendon to tendon healing, while finicky, is is reliable. But I think that tendon bone interface, as we've seen with like rotator cuff and everything, is just, you know, it's really tough, you know. So I think when you've got a purely avulsion injury without the bone fragment, I think that's a real, real challenge. Much. I mean, what's your What are your thoughts on

Charles Goldfarb: 15:01

that? Yeah, so I think the scenario you present so small fragment, bony avulsion, approximately migrated to the PIP joint, means you need to do surgery, because you got to give them some finger motion. So your options are, go in and just take out the bony fragment, ie cut the FDP tendon short and leave him with an FDS only finger, and I think he would rapidly get back PFP motion, or if you're going to the or do you go ahead and do the repair? And my my gut here would be, if I'm going to the or I'm going to do the repair, right?

Chris Dy: 15:33

So I agreed with that, and started to have that discussion. What's your sense on timing,

Charles Goldfarb: 15:40

if An avulsion is into the palm, I think you absolutely have to do that in the first three weeks, if you don't, and I've been guilty of that, and that's in the literature. But if you, if you try to be aggressive, even in kids, three weeks is, you know, it's a pretty good landmark. I think what you can do is just make the whole finger stiff and so it but in this situation, I think you probably can go even a little bit longer. I don't know how much longer, four weeks, maybe, because you're not asking that much of the muscle belly, but I don't think I'd go longer than four weeks.

Chris Dy: 16:16

Yeah, so this was interesting. I mean, I really like this guy, and identify a lot with him. I mean, I like all my patients, of course. I mean, I identify with him in a lot of ways, in terms of, you know, just really wanting to, you know, grab in terms of life. So I start talking about surgery, and you know what that looks like, and what the options are, and he's like, Well, you know, that's great, but, you know, I'm leaving tomorrow on this trip. And I won't go into details for privacy reasons, but it's one of those, like, trip of a lifetime kind of things where it's like, yeah, that sounds awesome. I was like, Well, I'm supposed to tell you that you should have surgery within the next few weeks, but that sounds like a great trip. So what would you tell them in terms of, would you immobilize him at that point? Honestly, my thought was like, well, maybe that piece will dislodge and we won't have to do anything, so I'm not going to immobilize you.

Charles Goldfarb: 17:07

Well, I think, you know, I never mind these scenarios. Because A, yeah, maybe the maybe it dislodges and retracts more approximately, or he comes back at four weeks, five weeks, six weeks. And you don't, you know you probably, you go in potentially with the option of repairing the tenant, but, but doesn't really stretch to where you need it to. You just take out the FDP tendon and leave him with an FDS only finger and and maybe you can manipulate him in the or to get his VIP joint moving again. Yeah.

Chris Dy: 17:37

So, I mean, so we come to the conclusion, we've agreed that we're going to let him go and come back when he's back from his awesome trip. Would you give him any mobilization or any particular exercises to do?

Charles Goldfarb: 17:50

Sure? I would. I would probably have him see therapy. I don't think he needs a splint, but if you wanted one, I'm not against it, but I'd have therapy. Either I or I'd ask therapy to instruct him on how to try to get some at least PIP motion. I don't really care about VIP motion, but at least and try to get some PIP motion back in flexion.

Chris Dy: 18:06

Yeah, that's what we did. So, you know, before we get to the next part of our we should thank our next sponsor.

Charles Goldfarb: 18:15

Absolutely we should thank our sponsor, checkpoint surgical, along with SSH, are hosting a live webinar on july 24 at 8pm Eastern Daylight Time, join doctors Michael Houseman, Steven Kohler and azul Shah as they discuss nerve disaster preparedness, prevention and response, how

Chris Dy: 18:41

to handle the unexpected. Iatrogenic injury. Look at that dramatic pause. So to learn more and register is nerve master.com so before we get into the rest of that this case, first off, I think that's gonna be a great webinar. And Second off, the number of people that have randomly texted or sent me a whatsapp based on the speed in which people listen to our podcast. Is hilarious. I don't know if you've got any feedback from that. No, tell me more. Yeah. So our former our former medical student, believe it or not, turned eventual hand surgeon, Agnes Dardis, texted me talking about the speed in which she listens to the podcast. And I haven't heard from Agnes in a while. She was a med student here. Rock star ended up going to Penn for her residency, did a hand surgery fellowship, and is now in practice so and I see her every now and then at the meetings. And then I had one of our good one of my good friends from the Philippines, who invited me over to the orthopedic meeting there. He texted me saying he did. He had no idea there was anything but 1x speed. So, yeah, you know, it was just a funny reminder about how little things affect people. It's so

Charles Goldfarb: 19:51

it is so funny that I personally am selective. I mean, I don't ever listen to anything at normal speed. But is it a certain podcast or a one point? Two, 1.5 is probably most common. And if I really just need to get through something, I go like, 1.822 times speed can be hard, unless it's like a work required listening, and then I may go two times speed. That's

Chris Dy: 20:13

aggressive. I mean, for all of our required trainings, I look for the speed up button, and it's never there. Time to open the second laptop so I can click through. You didn't hear me say that? HR,

Charles Goldfarb: 20:23

the, it's very funny. The Chris and I, full disclosure are, it's we're doing our podcast, obviously, but we don't have our video on because we're having internet troubles. And that the, you know, the internet is such an interesting thing. I'm, you know, it gets so frustrating where I hopefully we're succeeding with the podcast without being able to see one another, and we do play off visual cues, so it is a little awkward.

Chris Dy: 20:46

Yeah, this is weird. I mean, looking at the black Charles Goldfarb box, they make eye contact. No, that's not that weird. But, you know, it definitely makes a difference. So we are, we are truly mastering the art form of radio at this point.

Charles Goldfarb: 20:58

It is radio. It's taking us back. Take us back. So should we talk about how we would fix an FTP avulsion? Yeah,

Chris Dy: 21:06

I think that's, I think that's probably what I wanted to get to with this episode, is that people, when we get feedback about the pod, really like the technical aspects of it. So, you know, why don't we dig in and kind of talk about the different options here? So surgical incision planning. I mean, yeah, so, I mean, I think there are different ways to do it. You could do a Bruner zigzag just across the entire, you know, volar aspect, or polymer aspect of the finger. For this one, I chose to go kind of a zigzag across the dip crease and then between the dip crease and a pip crease. I did a mid axial along the radial side so as to avoid the being on the ulnar side of the small finger. And then did a zag across the PIP crease. So it's a combo zigzag, kind of mid axial approach. How do you typically think about

Charles Goldfarb: 21:51

it? I like that. I try to minimize, you know, I don't feel like I have to open the whole finger sometimes. And so if we've gotten an ultrasound for some reason, or we can feel the A vols tendon more proximally. I don't mind doing a sort of a zigzag across the D, I P flexion crease, and then making an incision more proximally and trying to pass the tendon through the sheath without exposing everything. Now, of course, I don't mind exposing things if I have to, but I think in principle, I agree with what you said.

Chris Dy: 22:22

No, I totally agree. I mean, if you don't have to make the extra incisions, you know, don't make them, you know. So I knew where the piece was parked, and I knew I was going to have to thread it through. So I just went ahead and saved myself the frustration of trying to be cute on this one so exposed to skin flaps and lo and behold. I mean, you can feel the peace just kind of parked right over the the FDS insertion, you know. So I, I think I've tried to become more judicious based on your what we've talked about and what, you know, others have told us about kind of when, when and where to open your pulleys. I mean, that's more appropriate or relevant to, like, a, you know, zone two injury. But I decided I was going to have to open the a three pulley in order to get this, this puppy out. So, so I got the piece out. And, you know, it was stuck down to the superficialis slips right when they are, you know about to insert on the base of the middle phallic. So, you know, what do you do at this point?

Charles Goldfarb: 23:20

So first of all, yeah, I think if you either for the case you're describing, or if the tendon is a vulst all the way into the palm, you know, it's tricky, passing tendons back under the various pulleys. In this case, you know, I think I would basically, the first thing I would do is put a tagging suture, which really would be my core kind of stitch, potentially, and I would excise the bony fragment. And then the next step would be, probably using a mosquito of some type, just gently dilating the pulleys distal to where I was, and then make an effort to pass the tendon beneath the pulleys in hopefully a very simple fashion. But it's never easy.

Chris Dy: 24:11

So what makes you decide to remove the bony fragment is it when you know it's just so small you're not going to be able to repair it, or, you know, do any sort of bony apposition, and just be able to, you know, kind of say, alright, call a spade a spade, use the core stitch, dilate the a four and get it underneath.

Charles Goldfarb: 24:27

Yeah. I think if there's any chance there's enough bone that I think the bone is to our advantage and will heal, then either a I'll concentrate on bony fixation and, and that's the, you know, there's a classification for the type of bony fragment, you know, fracture. And I can't cite that off the top of my head, but, but if there's enough bone there, and you can put a couple of screws in, that's great. If there's enough bone there, where you think it will help the healing, and you even put a suture anchor beneath the bone, and then weave the tendon, using the suture anchor to really have the tendon support the bone. But a. The bone healing to be there, then I would do that. But it's really, yes, it's the size of the fragment,

Chris Dy: 25:06

yeah. So for me, for this case, I mean, it was the latter of what you described. I mean, so, you know, trying to think that, you know, trust me, I would have loved to put some kind of even teeny, tiny screw in there, you know, to help but I was thinking that the bone heat, the bone would help with healing. So I ended up opening the proximal aspect of a four and then being able to get that bony fragment underneath, actually, you know, came to length pretty easily. So I had, I had it opposed, and at this point, you know, what are your technically, what's you've, you know, we talked about using an anchor. So what kind of anchor Are you calling for? And not to go with trade names, so like, roughly what size or what kind of sutures loaded into it.

Charles Goldfarb: 25:43

Yeah. Let's talk first about passing the tendon under the pulley. And so, you know, when I was a trainee, Dr government, you know, described using a pediatric feeding tube as the ultimate solution. You'd always have a feeding pediatric feeding tube. I think if I asked for a pediatric feeding tube today, I would get, you know, a look of disdain. I

Chris Dy: 26:04

don't know. So even at the peds hospital,

Charles Goldfarb: 26:07

even at the pedshospital, I think I would. I like those tendon passer I guess, devices which have the long, curved,

Chris Dy: 26:21

I don't even know what's call it. Your passer is not a very expensive thing, right? So it must not be trademarked. But is that what you're talking about? The thing that's got a long loop on it?

Charles Goldfarb: 26:31

No, not so that I would call it Houghston suture passer. That is not what I was thinking. Although I think that could work if you put suture on the Hougston suture pasture I like, but they're more expensive than you think. No, it's like a mosquito, but has a long bill, or whatever you might call it, that it's curved, that allows you to it just gives you the curve is helpful, and that can be helpful for passing. Maybe

Chris Dy: 26:57

I'll look it up and

Charles Goldfarb: 27:01

put it in the show notes. So that we don't come across as complete idiots to everyone. So

Chris Dy: 27:06

I think I know which one you're talking about. I, you know, whenever I do a tenant transfer, I call for two different instruments. One of them, I think they call that the tendon passer. That's got that nose on it, you know, that usually pass the tenant through. That's, you know, the sub q tunnel, or whatever. Then the other one, I think, is called the interlacer, the interweaver, and I usually affectionately call that one the pig sticker when you're doing your pulvertaf weave. So I know which one you're you're talking about. Yes,

Charles Goldfarb: 27:30

for sure. And then there's also the tendon stripper, which I have no idea if that's the appropriate name or not, to harvest a tendon graft. Very different. Yes,

Chris Dy: 27:38

sometimes used to harvest nerve graft. And I do not like that modified. Some people have modified attendance driven a harvest seral nerve. And I don't love it. I think it's too high stakes. And that when you get into those anatomic variants and then you lose this nerve graft, I mean, no way, anywho. So we that's how you would pass it through.

Charles Goldfarb: 27:59

Yeah. So I do always put a core type stitch. And again, sometimes it's very easy. I think it's very hard to go from a one through a four. So usually you have to get something at the a three level, pass through the first stage, take it out, pass through the second stage. And then what I typically do is, once you're past a four, I do use a 25 gage needle through the a four pulley, through the tendon, through the a four pulley, just to hold it there. While I think about my repair, they're so sad

Chris Dy: 28:27

if it doesn't, if it retracts.

Charles Goldfarb: 28:31

Yes, refeeding work is not my favorite thing, although I, you know, like we all, I occasionally have to do it. Do you?

Chris Dy: 28:37

Do you ever have to go back to the A one pulley to get that thing out of there, or are you not, typically not operating and trying to re trying to get these tendons fixed. If somebody has is retracted back to the

Charles Goldfarb: 28:47

palm, no, I think absolutely, whether it be avulsion, or whether it be a zone two injury, absolutely back at the A one level. Sometimes I it, you know, it is what it is. If you're going to repair it, you go find it and do what you got to do, and then to your question on anchors. So I think if we're thinking about how we can repair FTP avulsion, with or without bone to back to the distal phalanx, I think there's sort of two basic options, either you're going to use a suture anchor, or you're going to try to pass past the tendon, I'm sorry, pass the suture through bone and secured in some form or fashion on the dorsal side of the bone? Is that those two groupings fair? Yeah,

Chris Dy: 29:32

I think that's the broad category of groupings.

Charles Goldfarb: 29:35

I went through a stage where I still don't like buttons. Occasionally I'll use them, but I don't like buttons. And for those listeners who haven't used a button, the idea is that you take a Keith needle or some kind of process to drill through the distal phalanx, bringing your suture dorsally, whether it be through the nail or proximal to the nail, and then you basically tie the tendon through its suture down to the button, and. The button prevents the tendon. I'm sorry, oh, the button prevents the suture from being on skin where it won't do well. Instead you're tying on the button. And that used to be really popular. I just think it's hard to those buttons are hard to deal with.

Chris Dy: 30:15

I completely agree, and my neuroses make sure that there's always a button around at the surgery center. So last time I had asked for a button was probably two or three years prior, and then I walk in in the morning, I was like, you also have that button, right? Just making sure, but yeah, no, I agree. I think that's that's not the first option for me.

Charles Goldfarb: 30:37

No for me either, but That's old school hand surgery. It was always a button. I went through a stage where I passed the suture through the bone, and I made a small incision, and I tied the suture down to the bone, proximal to the germinal matrix and sort of distal to the terminal tendon insertion. And I thought it's a great solution. The reality is, it's not. And because it seems to the suture there seems to cause problems. And I had to go back and take suture out occasionally, even though the tendon will heal, it just to me, seemed like it caused problems,

Chris Dy: 31:16

right? It'll be a suture of any sort of caliber that's going to be strong enough and not absorbable, enough to get a tendon to as a core suture for a flexor tendon. I can see how that was going to irritate things,

Charles Goldfarb: 31:27

right? Which leaves us with the last option, which is the expensive option, but I think it honestly is the best option, which is a really small suture anchor, right?

Chris Dy: 31:37

So, I mean, you know, I thought about this, and you know, you have different kinds of small suture anchor options, some of which are loaded with like a 2o type stitch of caliber, and others that come with a 3o type stitch. And they're small, though, and then you honestly your quarter of bone, especially if you've already had a bone fragment, is very small in terms of the robustness of the bone. And you certainly don't want to have an anchor tickling the the germinal or sterile matrix. So you the room for error here, and you're into small finger in this case. So it's a small bone.

Charles Goldfarb: 32:13

Yeah, I would say that historically, sutrankers were tough because you had to put them in obliquely. They were just too long. Now there are small drinkers with good holding power, 2.2 millimeters. For example, that generally okay, but with a little finger and with the with the bone issue, like bowler bone being absent, it's trickier, no doubt about it, it won't always work. In that case, I probably would drill through and use a button, I guess is that what you ended up doing.

Chris Dy: 32:39

So you know, this was not the most cost conscious of cases you did. So I well, so I went and I tried to use an anchor. And, you know, when you put the anchor in, you, and I was in the bone bed, right, the the cancellous bed, where the the fragment had evolved, I put the anchor in. And, you know, we do all tests. You know, everybody hands off of the hand, and you pull on the anchor to see if Is it strong enough, and it passed the test. Was thrilled, you know, this is perfect. I'm gonna have a great repair and not have a button. So then we go and start passing our core suture, you know, using the sutures that are loaded in here, kind of weaving around the bone fragment leaving the bone so it could kind of tuck down and cinch down to heal down. And as soon as we start doing that, the acre just falls out. And then, you know, the F bombs come out, and, you know, whatever, whatever. But you know, so then I'm like, All right, go get the button. And then as they're getting the button, I look at the rep. I'm like, you have that other one that we talked about. It was the smaller one that I was let's just, you know, see, so while they're retrieving that, they went ahead and get the button. I'm like, Alright, let me just be reasonable and say, Alright, let's just get the button and, you know, see how this holds. So I'm starting to process for the button. And, you know, I don't know how you do it, but, you know, it'd been a while for me, I used the Keith needles, and I actually used the K wire driver to get the Keith needles in position. I like to go over the nail plate itself. And we didn't have the felt that, you know, sometimes the children's hospitals will have to sit between the button and the nail. So we used a couple of telfas stacked together and then tied it down, and we had good apposition. I was very, very happy with it, but yeah, kind of knew the patient was probably going to test the limits a little bit. So before I really tied everything, you know, perfectly down, I was like, let me just see that small anchor. So the small anchor actually held pretty well, and then I use that to just be a belt and suspenders, you know, because I figured this, this could get a little bit dicey in terms of apposition and making sure the tendon heals well down the bone. So, again, not the most cost conscious of things, but, you know, I was really happy with the fixation at the end.

Charles Goldfarb: 34:57

Yeah. I mean, it sounds like one of those cases. I will. Say it is frustrating as those events are, you are much happier it happened in the operating room than when the patient first goes to therapy. So no doubt about that. Oh yeah for sure. And do you try? You may not have much of a choice in this case. Do you put your anchors in heading distally? Do you put your anchors in at 90 degrees to the bone, or do you try to do the dead man's angle? I think we may have talked about this in the past, but I don't recall what you

Chris Dy: 35:25

do. I like the dead man's angle. It wasn't a great option for me. I just basically took a, I think I ended up taking, like a small gage needle and just kind of sounded out the bone. And I was like, Alright, this is probably the best place. So it ended up being kind of somewhere in between the first two options, not a dead man's not, you know, full on perpendicular. And I definitely checked the nail and I couldn't see it. So, you know, that's a good thing. And I guess I had a question for you for the last thing. How do you, you know, I've opened a three and I confirmed that, you know, the superficial slips were intact. How do you keep the glide there. Do you just leave the pulley open? Or, you know, what else can you do to ensure that you get good glide between your Profundus and superficialis?

Charles Goldfarb: 36:11

I don't think I've thought of that as a significant issue. I think you know, you know I have occasionally, have occasionally used the pulley underneath the FDS and or FDP if I worried about a gliding surface with a fracture or something. In this case, I think it'll be okay. Are you concerned that they won't glide against one another? I

Chris Dy: 36:35

mean, that's just I, you know, my my concern is, honestly, for a lot of this case was, let's just make sure we keep His FDS moving. So that was the biggest thing for me. So I actually used when I elevated, when I, quote, vented or opened the pulley. I did it with the bias so that it was almost like a like an L shaped window, or not an L shaped but like a window, so that I could flop it back down. And I actually ended up tucking it between the FDS and the FTP, kind of like you described, just to get some kind of glide. And you're definitely making a sacrifice in terms of sacrifice in terms of acknowledging that you're going to get some Bose triggering there, potentially. But again, at the end of the day, if I'm getting getting them gliding, I'm much happier.

Charles Goldfarb: 37:12

Yeah, I haven't done that particular trick here. I think your therapy would be focused on your PIP flexion, for sure, and then obviously a gentle progression of your distal joint flexion. But, yeah, I think that in all likelihood, would would help decrease scarring, especially given that the bone was rubbing there, most likely, and obviously blocking your FDS. So doing something different makes some sense, and certainly easy enough to do

Chris Dy: 37:36

therapy we have so post op mobilization. I mean, I went with a dorsal blocking splint, form based ring and small finger. Do you do anything differently? Yeah,

Charles Goldfarb: 37:44

and I would agree completely for this. I probably would do active PIP motion. I probably would not, especially given the bone issue, not do a lot of aggressive, active DIP joint motion initially. So be a passive protocol for the first six

Chris Dy: 38:01

weeks. Yeah, that's the protocol that that we're going with. So, I mean, I honestly, it was one of those cases where, like, all right, you know, one of the things I think is hardest when you're starting as faculty, and even now, like, you know, I still, you know, trying to figure out, like, where's the sweet spot on when to do, when to stop, and when to just say, alright, we're going to accept the result that we know is going to be good. And, you know, I think that's where it definitely gets tricky.

Charles Goldfarb: 38:27

I think that's really important, and it's something that only time can teach us all. And you know, when is meticulous perfectionist the right approach, and when will that actually potentially not be the best thing for the patient is really tricky. I would add that this technique of using a suture anchor for bony repair is obviously not isolated to the FDP, and I have used it for recently, in the last two weeks, for bone avulsion from the medial epicondylar epithesis, so a functional UCL injury in a 11 year old. I've used it for a UCL of the thumb, where there's a small bony fragment, and I left the bone in both of these situations for the reasons you said, because it'll bony healing is only a good thing. And you can really make a beautiful X ray with this.

Chris Dy: 39:18

Yeah, you definitely can. If you lasso that thing and kind of walk it down. It looks great. Can look

Charles Goldfarb: 39:22

great. So, yeah, it's funny. You know, it's some varieties of spice of life. That's

Chris Dy: 39:27

right, that's right. Well, no great discussion. Hopefully. You know, those of you that were listening enjoyed that. If you have any other suggestions for kind of technical topics, please feel free to email us handpodcast@gmail.com

Charles Goldfarb: 39:41

Awesome. Thanks for sharing, and that was fun. Other than the internet challenges,

Chris Dy: 39:46

all right, it's 2024 that's the way of life. That's right.

Charles Goldfarb: 39:49

Alright. Have a good evening. You too. Hey, Chris, that was fun. Let's do it again real soon.

Chris Dy: 39:55

Sounds good. Well, be sure to email us with topic suggestions and feedback. You can reach us. At handpodcast@gmail.com

Charles Goldfarb: 40:02

and remember, please subscribe wherever you get your podcast,

Chris Dy: 40:06

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

Charles Goldfarb: 40:10

thanks to Peter Martin for the amazing music. And

Chris Dy: 40:14

remember, keep the upper hand. Come back next time you