The Upper Hand: Chuck & Chris Talk Hand Surgery
The Upper Hand: Chuck & Chris Talk Hand Surgery
Ulnar Shortening Osteotomy
Chuck and Chris review the ASSH meeting, preview the ASHT meeting, and discuss a few tricks and tips for ulnar shortening osteotomy through a case presentation.
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Chuck, 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, and thank
Chris Dy: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:Hi Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:I'm good. I'm missing you.
Chris Dy:Yeah, you know, I'm missing you too. You're uh, you're in your penguin suit, as they call it, you're all dressed up. I don't think anybody wears ties anymore, but you're that guy.
Charles Goldfarb:Well, you know my official capacity. I have to, have to look good, Chris, I have to look good.
Chris Dy:Yes, you are on the council of the ASSH. You're a featured presenter slash Dissector, and would expect nothing less from you, Chuck, nothing less.
Charles Goldfarb:I can tell you that your present attire, and that's a hint to those of you listening to maybe go check us out on YouTube, is way better than mine.
Chris Dy:Yeah, I actually followed the Marty Boyer rule to the extreme and took the early, early, early flight home. There was a lot going on at home, and just wanted to help out. My meeting obligations were very front loaded, so I did what I absolutely needed to do in the essentialist sense, missed out on some stuff at the meeting, very sad. I didn't get to see a lot of people get all the podcast love that you're getting, although I did get my fair share. Yeah,
Charles Goldfarb:for those of you who said hello at the meeting, thank you. It really goes a long way towards Chris and I's love for the pod, and we shared a little swag, which hopefully is appreciated. And it's been, it's been fun.
Chris Dy:Shall your loops never fall off of your neck again if you get my drift, or your sunglasses or your or your readers or your clicks or whatever they are, yeah, and it was great. It's always fun to see people. I was there the majority of Tuesday and Wednesday, and got to see a lot of people, and got a lot of love for the podcast. Thank you for everybody for coming up and saying that you like it and love it, because, as my daughter is learning in her first grade class, that fills our bucket and makes us happy and keeps us going fills our bucket
Charles Goldfarb:This is true. You know what filled my bucket, so to speak, was our washi reunion last night, which was on Friday evening.
Chris Dy:I'm sure it was a star studded event. Can you tell me more?
Charles Goldfarb:I can. We had a massive room, which tends to make the attendance look less than it was. And if Marty hadn't shared a picture with you. He will. It was, as always, fantastic. I don't this is not the most well attended hand Society meeting ever, but we had a really good showing. And true to form, we got in a big circle, we did not hold hands. We got in a big circle and went around the room and introduced ourselves and gave a little update on status. And really, really great, great.
Chris Dy:Always, always a fun event. And you know, our WashU pan family is very special, and it was, I think, some of our incoming fellows and one of our current fellows stopped by. And you know, some past fellows, of course. So always good to see those who have come through our fellowship and part of our residency, actually had dinner with Liz Graesser and Dan Hong. So both current fellows, Liz was a chief resident, and Dan is one of our current residents. He loves getting shout outs by name on the podcast, so I figured I'd drop one more time for him, just so he could really relish that while he is on his trip to India. Yes,
Charles Goldfarb:I know he's on his way. So Liz helped to write a really, really good paper that was chosen as the LIN shy Dobbins clinical I don't know what exactly it's called, the wrist and wrist,
Chris Dy:best paper and wrist, basically, right? Yeah, thank
Charles Goldfarb:you. And so as part of that, we get a little Award, which is great. But more importantly, we put on an ICL, and so I had some of the authors join, join me, and we have a we really had a good session on Friday morning, which was super well attended, and we had a great conversation. And I love it when I didn't even have time to show the cases, because all the questions and comments and the room, everyone just came forward at the end and wanted to talk more. There was at least 100 people for a 8am session. So it was great. That's
Chris Dy:super impressive. Now, this was a paper on inner observer reliability for wrist arthroscopy and grading. Was it hook and trampoline?
Charles Goldfarb:Yeah, basically just assessment of the TSCC and confirming tears and then applying classification to tears. And the bottom line is, we are really good at identifying central tears, and we are really bad at agreeing on all other types of TFCC tears. And so it actually the opportunity to have an ICL was perfect, because part of the takeaway from the from the paper is we need to we need to come together, and we need to educate and we need to talk about this
Chris Dy:So. What's the next step?
Charles Goldfarb:The group is going to get back together and try to over zoom and try to help define how one should think about confirming a tear, see if we can come to an agreement on some steps that a any risk arthroscopist could take, and then we may reapply, you know, apply those steps to a whole bunch of new arthroscopies.
Chris Dy:Sounds like a Delphi paper in the making. I look forward to to seeing the the outcome of that. Not surprised. Chuck Goldfarb, the workerman, hammering nails at all points with his hammer, just collecting awards in the process.
Charles Goldfarb:Its funny. You're so kind. It's funny, the I haven't been as deeply involved in research while this MBA thing is happening, but we've had a couple of really good papers come out. The CMC paper, the prospective randomized child will be lead author. I mean, lead paper in October. JHS, which is a nice talk to Brent about that. Yeah,
Chris Dy:no, that's great. That's so that's two months in a row for WashU, because my paper was our planet study group paper was the lead lead paper for the September edition. So you'll
Charles Goldfarb:forget. You'll forgive me if I didn't read it, but tell me, if not, the listeners, what it was about.
Chris Dy:It was about the most challenging issue we have in nerve surgery, which is pain. You know, we're not great at motor we're even worse at pain. And to be honest with you, the pain and the psychosocial aspects are the things that we can probably start to get in front of right away from Day Zero, whether you operate on patients or not, and while you're waiting in that very long regenerative phase, this is the thing that will limit your outcome, pain and psychosocial support. So I've focused a lot of my efforts initially, given that, you know, Plexus is a long term outcome kind of thing. So all of our efforts initially have focused on short term and pre op things like this to date, and, you know, we'll get to the point where we're looking at long term outcomes, but it's sobering. I mean, pain interference scores, you know, high don't change at a year, regardless of the functional outcome, the limited functional outcomes that we have at one year. So we talked about that with Brent, I think. And if anybody has talked to Brent about Plexus surgery, they know that he is somewhat of a skeptic in terms of the value of Plexus surgery, but he knows that it's a very attractive topic to many. So I think that there's a lot of work for us to do. So that was a gist of our article.
Charles Goldfarb:Nice, yeah, sounds really important. Did you do the little Skype interview with
Chris Dy:I did? I think Brent's the only one who still uses Skype, and I love him for that. It is like I almost expected him to take out his Walkman and just kind of start recording us, but it was a fun interview.
Charles Goldfarb:It was great. He said, Yeah, I'll do this over Skype. And I did a double take as we were talking in person. And then I had to go download Skype, which apparently I had downloaded in years past, but it was no longer on my phone. So with your
Chris Dy:with your rocket mail account from back into your yahoo.com account. Not hating on anybody who still uses Yahoo whatever, whatever you got to do. So it was funny. I have had the fortune of doing a few conversations with Brent over, over the years, and it's the, literally, the only time I log into Skype. So easy. He's the only contact I have in Skype. So it's, it works out. Well, you
Charles Goldfarb:know what this makes me think of? Again, as as people have, you know, generously come up and talked about their enjoyment of the podcast. I've had more than one, and maybe up to five people say, You know what? I did not know you could set the podcast speed.
Chris Dy:Oh, yeah. The Yeah, the speed thing is, so I came up a few times in Minneapolis. For me too.
Charles Goldfarb:It's so funny. I love it. So
Chris Dy:before we there are a few more things I wanted to share about the meeting, but I wanted to acknowledge our sponsor at practicelink, so the upper hand is sponsored by practicelink.com the most widely used physician job search and career advancement resource.
Charles Goldfarb:But coming a physician is hard. Finding the right job does not have to be joined practicelink.com
Chris Dy:or get a copy right. Okay,
Charles Goldfarb:joint practice link for free today. Www.Practicelink.com/theupperhand.
Chris Dy:I think Dan has placed that hex on us in terms of being able to to do this copy. It's been how many years now. So yeah, I really enjoyed hearing from people. I did the young surgeons boot camp on Tuesday, which is always fun. Got to be a table instructor and give a brief talk, you know, about fracture management, which obviously is something that we as hand surgeons all know a lot about, and it's a little bit out of the wheelhouse for me as a mainly nerve surgeon, but I think it's important to continue those skills. And it was interesting to talk to a lot of people see their experience. And every year it's like, it's my third year doing it every maybe my second year. Every year, it's different what they want to learn and what they want to do at the boot camp in terms of, you know, the things that are after disposal. I mean, there are people wanting to put in radial heads. One year it was all the rage to do. And to grade headless compression screws for approximate phalanx. Only one group tried it, or one pair tried it this year, you know. So I think people are, you know, coming in with different levels of experience, and it's fun because they get to choose your own adventure. Yeah.
Charles Goldfarb:Love that. Love that. I have not been in the lab yet, but I am going this afternoon and have a session, as I think we mentioned on politicization and tenant transfers for congenital anomalies. That should be fun. Other highlights for me, Steve Moran's presidential talk was great, really well executed, sort of talking about the value of mentors and personal relationships. I don't know if you were able to catch that. Thought that was really good.
Chris Dy:That's great. I mean, Steve is a fantastic person, dynamic speaker. You know, I think that we're going to miss him, but I know that we have a lot in store in terms of, in terms of the coming year for the hand society, absolutely,
Charles Goldfarb:The other highlights for me. So two other speakers. So his presidential guest speaker was a woman named Anne Bancroft, who, in 1993 was the first woman to reach the North Pole. And then she has traversed the South Pole several times, and hearing her story and her commitment to education was really great and and then lastly, the International guest speaker was Mike Hayton from the UK, who talked about sports. But what made it great was Mike is a really good, really good speaker, really funny, and talked about some of his interactions. The takeaway, I think, for those listening, at least my takeaway, who, for those listening who weren't present was, you know, you as he put it, you have to win the locker room. In England, they call it win the dressing room, but you have to win the locker room. You do that by showing the patient that you understand their sport and what's required for success. And there's different ways to do that. Was one really important takeaway.
Chris Dy:Usually, when I hear the term win the locker room, it's actually Converse somebody losing the locker room in terms of more of a leadership perspective, as opposed to a patient care but this sounds like great takeaways. You know, I think that there's a lot to learn from those guest speakers, and I sometimes they're not as well attended. So I definitely encourage people that go to the meeting to make sure to see those keynote addresses. I did want to shout out to one of our alums, Jeff Stepan, for winning the Richard H galverman award traveling scholarship from the hand society. That's obviously for, you know, for somebody coming from our fellowship, that's a very special award. I think Jeff was one of the last to train under Dr Galvin. Might have been the last class to spend time with Dr gelberman. Actually, in 20, 2019, and 2020, I believe. And, you know, he, he has a really exciting lineup of places to go. I was fortunate enough to write a letter for him for the scholarship. And it's, you know, I think probably the fourth or fifth person in our from our fellowship alumni to win that award. So I think it's a very special award for us, and I look forward to seeing what he's going to do
Charles Goldfarb:with it. Do you know his topic,
Chris Dy:nerf?
Charles Goldfarb:I knew that's what you were going to say. He's, I'm
Chris Dy:very proud. He's one of our Nerf surgeons that have come out of the program since David and I David Bergen and I started intensifying our focus on peripheral nerves. So, you know, he's going to be fantastic. He's got a great practice in the south side of Chicago, and I think he's going to focus his trip on ballistic nerve injuries, because that's what he sees. And I look forward to learning from him, because that's what we see.
Charles Goldfarb:Yeah, so true. Well, he's certainly a very, very worthy recipient. The other, the other WashU. I guess highlight from the meeting is that Lindley wall, our partner, is going to be the chair, co chair of the session, which is in Vancouver. So that is great. I know she's already very hard at work planning the meeting.
Chris Dy:Get your passports lined up. Now, Americans make sure that that is all at least you're I think there's a different kind of pass if you just want to get across the the north and south borders. But make sure those are in line, because it takes a solid six months ahead of time. I know that when Toronto, when the meeting happened in Toronto last year, that was a
Charles Goldfarb:big push. Yeah. PSA, apparently you can do that. You can renew online, completely online, and I think you can even get your initial passport now completely online. That's just in the last couple of days that that went live. And supposedly it's
Chris Dy:easy. That's very different than what, because I had to get my passport renewed before and at the post office go through the whole the whole process, whole process. One more thing. So I think one highlight for the meeting, for me was getting to chair a pre course on brachial plexus, which I know is not your cup of tea, but it was fun for me, because as the Chair, I got to pick all the topics, those just questions I wanted to know. And I got to work with my co chair, Johnny Lou, to pick the speakers, and she say, who would give a good talk on this? And did? Take the moderator option to not give myself a talk, because I figured there'd be somebody who would, you know, bail and I would need to fill in. But it was great. You know, the faculty were fantastic. There were actually more attendees than faculty, which, for Wednesday, pre course, on a very niche topic, is always nice. We had a really good discussion.
Charles Goldfarb:Oh, I love that. I love that. Yeah, I unfortunately couldn't participate in the peds or the arthroscopy stuff pre courses for because of other commitments, but there's been some really good content. There's stuff I really wish I could have seen but did not. Yeah,
Chris Dy:Nina and Eric did a fantastic Nina Sue and Eric Wagner did a fantastic job planning the meeting. You know, I think that was a great pick by Steve to have them lead the meeting. So a lot of work, they've definitely, you know, took the, you know, took over the readership from Paige and Megan, and, I think, added some really cool things and kept what worked in the past year. Yeah,
Charles Goldfarb:so I know we want to discuss a case. Maybe before we do that, we'll thank checkpoint surgical, yes,
Chris Dy:the upper hand is sponsored by checkpoint surgical, a leader in peripheral nerve surgery solutions with a bipolar stimulation probe. I call it the purple one. Checkpoint Gemini, bipolar nerve stimulator provides finely controlled simulation even at the fascicular level, allowing surgeons to take actions based on the most precise information available.
Charles Goldfarb:That is a hell of a sentence or two. Learn. I should ask them to
Chris Dy:cut that down. You're welcome. Thank you,
Charles Goldfarb:given my difficulties getting out. Learn more@www.checkpointsurgical.com checkpoint surgical, driving innovation and hand surgery. And
Chris Dy:it's interesting. I talked with them at the meeting. I think you did too. I think they're, they're in their investment in the podcast, as in wise, I think that they've gotten, I think what they want out of, you know, people listening and engagement.
Charles Goldfarb:Well, yeah, and I'm not, we're not trying to solicit more sponsors, but, well,
Chris Dy:I mean, but you know, if you want to, if it happened, it would
Charles Goldfarb:be okay.
Chris Dy:But we already have our nerve sponsor, though they wrote that in true
Charles Goldfarb:but it is a really unique opportunity with a very focused audience, which I you know, there's so many distractions in the world, but our listeners, Chris, our listeners to the upper hand podcast. I know they are locked in at 1.0 speed, and they listen to everything you say
Chris Dy:they might want to slow it down. I mean, point seven, 5.5,
Charles Goldfarb:yes, you can go down.
Chris Dy:You will, you will be proud of me. I think in some sense, the week before the hand Society meeting, I went full tilt on surgeries, filled every case that I could to get rid of a backlog that was unfortunately still growing, unfortunately, unfortunately, but I hit the hand surgery Triathlon The week before the hand society operated on a Wednesday, which is not normal for me, but did the fluoroscope, the microscope and the arthroscope in the same day, and I thought you'd be proud. I wanted to get your thoughts on on one technical aspect that often accompanies the arthroscope and ulnar shortening osteotomy. So I guess to set the stage, you mentioned that we're very good at diagnosing central TFCC tears. This is a woman who's closer to your age than mine, with pain on the ulnar side of her wrist, and she's had it for many months. We tried conservative measures, we tried therapy wrist widget, even a corticosteroid injection led me to get a MRR program, which demonstrated essential TFC seats here and signs of ulnar impaction. So briefly, you know, I actually had a plastic surgery resident who came to work with me that day, and we had a conversation about ulnar impaction right before the case. Can you tell me kind of your entry level description of ulnar impaction
Charles Goldfarb:I can and I would say, I'll start by saying that when I was in training and rheumatoid arthritis was more prevalent than it is today, there was a wonderful paper done which essentially graded different procedures and their impact on patients with RA, and at that time, it was very clear that thumb, MP, fusion was the best surgery for patients with, you know, severe disease. There is no doubt in my mind, and I was on a great panel yesterday which all of these speakers agreed the best surgery for wrist pathology, obviously, ulnar sided is ulnar shorting osteotomy. It is one of my top five surgeries, without a doubt, because it is so effective. Now, there's subtleties and there's important considerations, which we'll talk about, but it is a great, great surgery. Now to your question, yeah. So, yeah, that's
Chris Dy:a yes, duly noted. Great Again, but yeah, so okay, the surgery works, which is why even non sportsy surgeons like me will do that surgery.
Charles Goldfarb:Yeah, so classic impaction is not so hard to diagnose. Um. Um, patients who have discomfort with ulnar deviation, whether it's a neutral flexion or extension, but all types of ulnar deviation, and it doesn't have to be all three, but if you have positive impaction signs, you know you are always looking at the X ray to try to understand the radiographic appearance. And we classically talk about a neutral rotation PA, where your forearm is in neutral, because with supination, the ulna looks short. I'm sorry, with supination, the ulna looks long. With pronation, with supination, the ulna looks short. With pronation, the ulna looks long. And so you try to shoot it in neutral. But even that doesn't truly get at impaction like an MRI, where the lunate lights up. So imaging can be helpful, but honestly, it's not always necessary.
Chris Dy:Do you think that a contralateral film helps you understand the condition and prognosis, or if they have impaction on one side, they're likely to have it on the
Charles Goldfarb:other that's a great question. I know I had a great ped session yesterday about elbow, and I would say that contralateral films can always be helpful. I don't routinely get contralateral films when assessing for impaction, but absolutely can be helpful. Yeah, I
Chris Dy:think for me, it was helpful for surgical planning, but again, I was, you know, wasn't quite sure. So I do get contralateral films, and I do hear adhere to that zero rotation view that you've mentioned. Yeah,
Charles Goldfarb:and I would say that, you know, when I first started out my my goal was always to make the ulna a little short. I think almost any shortening that we do is what matters. And so while yes, neutral or ulnar minus variance is helpful. There have been good papers looking at the morphology of the DR uj and sigmoid notch. And you don't want to over shorten, but any shortening you do is going to be effective. And honestly, if you shorten to three millimeters, it's a much easier operation. Once you get to five millimeters, or seven or eight millimeters. It's just a little technically more tricky, although not terribly tricky, right?
Chris Dy:I mean, I find that, you know, I'm a simpleton. With regards to this, I will use the guide and I will shoot to shorten two, usually, and I end up shortening three, because the way that the guide is not perfect, nor am I, or the person whose hands are on the saw. So to say,
Charles Goldfarb:yeah, so you know, there's so many good systems out there, and using the guide with the oblique osteotomy maximizes your surface area. And it's a really simple, fun operation. If I use just a standard six hole DCP works just as well, I think, honestly, or close to it a little trickier sometimes, but transverse osteotomy. But that gets to an interesting point, and I'm actually going to, and I have been playing around with, and I'm probably going to try a distal metaphyseal shortening, rather than a standard plate shortening. The problem is, these things take a while to heal, and there is a risk of non union, and there is a risk you're gonna have to take the plate back out. So some have advocated for a different approach. Yeah. Do
Chris Dy:you think the metaphyseal bone is more apt to heal after an osteotomy, as opposed to the Diaphyseal or shaft?
Charles Goldfarb:No doubt, definitely more apt to heal. The tricky part is, how do you fix it? And, you know, do you know we could? We should talk about that. I'll say the other Yeah. I mean, it's really interesting question. I would say that one out of six of my patients have their plate removed, and I'll put it on volatly, which is not a huge number, but it's a real number.
Chris Dy:No, I think that that's, you know, I am. I was trained on using one system that was classically described. I mean, we can say it if we want to, but it was developed by Dr Geisler. In terms of the design, it's a very it's a thick 3.5 plate that is designed to sit on the shaft. And I put it on volar, and it's a chunky plate in a slander patient and in an area with not a lot of sub q, even if you put it vulnerably, you know, or dorsally, I mean, however you want to put it, but, you know, my experience has been similar, although I don't have the volume that you have. I tell every patient you might want this out if you know, if you might feel it when your forearm is resting on a table, that kind of thing. But I know that there have been at least two or three other companies that have come out with a different plate, and I know there's one set in particular that has that metaphyseal, more distally sitting plate.
Charles Goldfarb:Yeah. So one thing that came up in my session yesterday about wrist arthroscopy was, what is the role for arthroscopic wafer, or wafer in general? I'll start by saying one of the really important considerations is a wafer procedure can decrease impaction, but it doesn't increase stability. And so one of my favorite parts about a true ulnar shortening osteotomy, whether metaphysical or Diaphyseal, is when you hold the ulnar approximately, you tighten the ulnar carbo ligaments, and that increases stability. So a wafer doesn't do that. All of the panelists agreed that they don't love the wafer the arthroscopic way. For is not easy to do well is it is not. The results are just not as good. And none of us routinely do it right.
Chris Dy:And if you guys can come to agreement, and don't think that it well, you guys, you came to agreement that you don't like it, it's just not my, not going to be in, in my in my bag of tricks. Do you think that shortening through the metaphysis will provide you the same ligamentotaxis, or kind of that pull of the ligaments to stabilize the drJ as shortening, or approximately at the shaftwood. Yeah,
Charles Goldfarb:I would say that there's no literature on that. I you won't get as much shortening, and usually you're doing a little bit of an objective shortening, and also a closing wedge. So the answer is no. So if I'm shortening with any consideration for needing stability, then I would probably go with a formal Diaphyseal shortening. But the techniques are really interesting. I mean, some of the techniques from a tape seal that is freehand, you know, is a little closing wedge osteotomy, where it's more of a trapezoidal closing wedge. And if you have a big central tear, you just drive a couple of headless compression screws from distal to proximal through your tear, and that's a brilliant way to fix it. It's trickier, though, when you don't have a frank central tear, and then you have to have to modify your approach to put your screws in. But I love the simplicity of it, the speed of it, and the lack of need for hardware removal, and the literature supports a really, really high healing rate. You
Chris Dy:will not catch me doing that. That sounds way harder than anything I want to be involved in with regards to the arthroscope. Well, then
Charles Goldfarb:I have a new goal to convince you it's better. Yeah, no,
Chris Dy:I think I'll be sending that to you if the patient comes in asking for that. Do you think that a three five plate is necessary for fixing the shaft of the ulna. I mean, I think that honestly, a two seven plate does it for most patients, as long as you get good apposition. And honestly, if you get your inner frag screw too, because you can obviously use the plate to apply compression. You can get additional compression through your lag or interfrag.
Charles Goldfarb:Yeah, I may show my naivety here, all two seven plates do not feel the same to me. And I'll say, I'll throw out some manufacturers, just because I think this specific, specificity of that will be helpful. I love and I have no conflict. I love orthopediatrics and their small fragment set. It has a great three, five plate and a great two seven plate. And that two seven plate is for real. It is a DCP. And then I, if I flip and go and use a synthesis, modular hand, two, four or two, seven plate, it's not the same. So I would say yes to the ortho pediatric, and probably I don't know that I'd be as confident with others, right? Let me think
Chris Dy:they're all designed a little bit differently. You have your recon kind of plates that are, quote, flex in some sets, and then you have other plates, like the DCPs, that are your strength plates as they're described in other sets too. So agree, not every, not every two seven is the same. Yeah,
Charles Goldfarb:they're both DCPS, interestingly, but they're just not the same. I guess maybe I technically they're both two sevens, but maybe it's the width, in addition to the size of the screw that they allow to be placed. So
Chris Dy:to get back to our case, you know, introduce the arthroscope and evaluated. And course, there was this, just this bare spot on the lunate, which was, you know, telling. And I looked at the plastic surgery resident, was fantastic. And I said, that's what we're looking at right now. That's exactly she's like, Wow, that really, really drove home the point of why we're here. So that's a really good teaching point. We debrided the tear, and then we got on to the shortening. How do you proceed with you know? So this isn't about arthroscopy, but in terms of the technical aspects of the shortening, where do you decide to place your incision? What are you thinking about in terms of the surgical approach? Structures at risk, the intervals you want to be
Charles Goldfarb:in, just like you always do to me when you're talking about nerve let's talk a little about the arthroscopy first, so it won't take long, a couple of points when you debride your central tear. You can do that with a biter. You can do it with a shaver. You can do it with a heat shrinking device. I don't know that really matters. Some would advocate the heat shrinker, because if there are any nerve fibers innervating that TFC, and there may not be, because there's no blood supply that central TFCC, then they will take care of that. You can debride up to two thirds of the central TFC without worrying about stability. Really, real arthros. Arthroscopy geeks like me will micro fracture that big hole in the lunate and try to get some cartilage to form, not not saying that's necessary. Doesn't take much time. And I would say the final arthroscopic point is you do have to be a little careful. You can have a central tear and a phobial tear. So be aware of that, as I know you are. But for our listeners, look for that, because that indicates potential risk for instability, again, some of which can be restored with shortening, but not always. All of it.
Chris Dy:You'll be proud. We checked. We did the hook, we did the trampoline. We talked about your paper, your first paper, your second. Paper, award winning paper, the whole spiel. So we, we, we got everybody fully up to speed on the Goldfarb lexicon of wrist arthroscopy.
Charles Goldfarb:Perfect. Now back to your question. Well, no, I know what I was gonna say. What was it? But I know. So my incision, first of all, always make it too short. I try to try to minimize the incision. It's tough to minimize the incision. It's between the FCU and the ECU. It starts proximal to the ulna styloid. So you remove concerns about the primary ulnar sensory branch there can be that transverse branch. So if you're just proximal to drej, you work, you take away all worry, and honestly, pretty quickly down the bone.
Chris Dy:So the quote, easiest approach in orthopedics, but I've seen many people flail at doing this well in terms of, I don't like seeing muscle belly. I think it's a really good technical exercise to try to open the interval between the ECU and the FCU without opening the inner sheath of that fascia. So I like to give the residents and fellows a hard time about this. But I think when done well, this is an elegant, sharp approach. Do you keep them in the finger traps and the traction as you're doing this? Do you take them out of the traction tower entirely?
Charles Goldfarb:Yeah, it's a, it's a good question. I think it's just personal preference. I absolutely take them out. I do not find it easier. What about you? I take
Chris Dy:them out too because, I mean, your floor scan. It's just harder for me. I mean, I don't want to, you know, it's a, it's a pain in the butt to have, you know, to have to position a forearm for the osteotomy. This is when, like, if you have, like, somebody randomly around who can scrub and just hold, it does make the case a little bit shorter, so that, you know, one person can hold, one person can retract, another person could do the osteotomy. I've done it shorthanded as well. I mean, it's
Charles Goldfarb:fine, yeah, you're a little higher maintenance than me. We do just fine with two people. So I love that. For you, I'm just laughing. Also the microscope, the arthroscope, the fluoroscope, I would consider the microscope a net negative, but I do love that you got all the scopes. There's
Chris Dy:got to be something else that we can use to really make it a day like you got. There's got to be like the Grand Slam, or like the for the cycle and hand surgery. You have to think of that to see what else we can incorporate. Yeah.
Charles Goldfarb:So back to your case. You know, the the choice of implant affects whether you're going to put the plate dorsally volit or even middlely. When I first started doing these a couple of decades ago, the rahak system was the main system John rahax, first foray, I think, into innovation, was this shortening, and it was great. It was placement only, and patients did not like it after it did its job. So those plates came out. I really do think that a volatilely placed plate is less likely to need removal. And so what I do is I supinate the patient, put hominins around the ulna, and then elevate the pronator quadratus is the first step. Yep, I fully
Chris Dy:agree. And, you know, I don't do it any differently. I mean, I was, I learned how to do this from you and Dr government, and a lot of fond memories of that. So I haven't changed because I haven't had a reason to change.
Charles Goldfarb:Yeah. And I think the only other technical Pro I would say is, and I say this because I've been burned, is I do close the deep fascia on the way out, at least the proximal deep fascia, because if you're careless or or just closed skin, sometimes it doesn't matter, but sometimes you'll get some bulging muscle or muscle herniation, especially proximally. So a couple of I use monochrole, a couple monochromes on the fascia. I think makes a difference.
Chris Dy:Yeah, I run a monocro on a fashion if you've done the dissection in a elegant way. That fascia layer is very easy to re approximate nicely. I guess the biggest question I have is, how do you make your cut? I mean, are you? You mentioned a couple different ways going by the guide, free handing it. How do you what are your considerations for that?
Charles Goldfarb:I think for speed and accuracy and comfort level, I use a system. I'll say it. I am conflicted. I work with acumed but I use the acumed shortening plate, and it is a very quick way to take care of owner shortening with good flexibility. And I like it.
Chris Dy:Yeah, yeah. I used that set the other day. And, you know, the I was with a junior plastic surgery resident, so I was doing the, you know, the osteotomy, and it felt like a selling Dan, third shout out my name. It felt like I was in a boot camp because I was just going, like, like, I was, I usually don't get to do that case, like, physically do it hands. Was like, this is fun,
Charles Goldfarb:right? It's, it's, it's straightforward, and it's fun, and it, and again, it's so predictably reliable that I really like that case.
Chris Dy:So I like using the guide. I remember using the cutting guide with Dr gelberman, and it was, he would make you do the cut, and then he would make you check your cut. You know, obviously the cut, you know, the guide, accounts for the curve, meaning the width of the blade. So he would have you excise your piece, your wafer of bone that you osteotomized. And then would make you get a ruler and check your ruler to make sure that the thickness of the cut is what you intended. And then also. Check the evenness of the cut, which is a damn near impossible task. Anybody who's done this knows that right that area right underneath the plate is the hardest part to get the even cut, which is why I mentioned earlier that, you know, when I do it, I aim for two, I end up getting three, just because the cut ends up being slightly uneven. When I kind of do that area right underneath the plate, at least that's for me. You know, I have, I have made some fellows go through that exercise in the past, just, just, just for fun in education. But, you know, I think it's hard to make this perfect. I hope you are better than I
Charles Goldfarb:Well, that's why hazing still exists on college campus, hazing, hazing.
Chris Dy:That's that term so antiquated. We're here for education and maximizing the fellow experience motivating. I customize. It's personalized fellowship. I mean, I customize the experience to the fellow, and I try to get a sense of what they react to, right? Dan, absolutely
Charles Goldfarb:tell me if this analogy is apt, a wrist arthroscopy plus an ulnar shortening is gives predictably good results in a similar way to ulnar nerve transposition and carpal tunnel release. And what I mean by that is, I think you add the carpal tunnel, if it's needed, to an ulnar nerve transposition, and you add the ulnar shortening to a risk arthroscopy, if they're both needed, the results are better.
Chris Dy:I appreciate that you're trying to reach out to me and meet me in the middle here and talk your language. Yeah, I think there's a lot to unpack about that. Okay, yeah, it's true. Sure. No, it's kind of like adding a radial tunnel release to overcalcitrant tennis elbow. You're gonna be happy you did it. Okay. You don't know which one worked, but you'll be happy you did it. That's
Charles Goldfarb:fair. That's fair. What else do you need to unpack with your shortening case?
Chris Dy:I think the last part is just as you're going to close the post op protocol. So are you soft dressing? Are you, you know, forearm based plaster splint? Are you sugar tongue? And when do you start to let them what's your post op protocol?
Charles Goldfarb:Yeah, so if I perform an intra articular procedure, then I am immobilizing for five weeks. So that's a splint to start. Then I have cast, and in five weeks I start therapy. If it's just a shortening, which rarely, but occasionally it is. I still splint for two weeks, but then I get them in a removable brace and let them start moving. It's a look. It's a really good plate, and I think it's safe to let them move very early. When
Chris Dy:you say intra articulate, you would include even a debridemont in that. Yeah, I do personally. And then when you say immobilize, are we going sugar tongue? Are we going below elbow?
Charles Goldfarb:Only time I go sugar tongue is if I perform a phobial TFCC repair where I really do want to control rotation, and I'm not positive it's even required them but, but I do,
Chris Dy:and do you actively encourage them to rotate their forearm, or do you just kind of not mention it and see if they do it? Yeah,
Charles Goldfarb:I kind of either I don't mention or I say, Look, I'm not looking for you to rotate your forearm and your short arm splint, so don't go looking for doorknobs to turn, but I'm not going to torture you by including your elbow, because for all the therapists listening who can attest to this and mobilize in the elbow, is not fun.
Chris Dy:Yeah, true to that, I just admittedly will do a sugar tongue for the first two weeks and then transition them to a below elbow after that. I won't encourage forum rotation. I will tell them I want them coffee cup, kind of two pound limited as for weight bearing. And yeah, I agree the plate is the plate is super strong and can withstand the loads. But I do think that a a surgically created trauma osteotomy, is different than a fracture in terms of the milieu for healing. You mentioned earlier that some of these don't heal, and I think that's predominantly in patients with, you know, who are smokers and diabetics, and that's been shown over and over in the literature, especially for smoking. So that is one potentially modifiable risk factor that you could discuss before surgery overall. I mean, you know, I think that part of the rub of this surgery, for better or worse, is that you're holding them back for a while, and you're letting everything cool off, both in the joints, you know, and after that. So how long do you tell them, like, until they can get back to doing most stuff?
Charles Goldfarb:Yeah, especially in athletic population. And I say 10 to 12 weeks. Now I recognize that can be up to 16. If it's more than 16, I think we have a problem. But again, sometimes healing is very slow. But my party line. I usually say 10 to 12, but I think in reality, it's eight to 10. Got That
Chris Dy:sounds about right for me as a as a novice or non expert at this. Oh, by the way, as we bring it to a close, your boy, Joe burrow, he didn't look that bad against the Chiefs the other week.
Charles Goldfarb:He bounced back, as did a lot. It was interesting. A lot of people bounced back in a good way. But you know, the other thing we forgot to say, we should have started with this so. So for those who made it all the way through the podcast, Chris and I have essentially finished the A, S, S, H, American Society for Surgery the hand. But we both have another meeting coming up this week. We
Chris Dy:do the American Society for hand therapy, in which you. Do again, are the speaker, you can actually pay, you can actually pay and donate to charity to have a cocktail with Chuck Goldfarb. I mean, I don't understand. Like, well, I
Charles Goldfarb:mean, no, no, how
Chris Dy:are there even seats still available? Like this is probably sold out. I'm pretty sure we'll have to check with the media organizers. But you know, it is here in St Louis. Chuck is the Grand Marshal, so to say of the of the meeting. So make sure to check that out. We'll bring, we'll bring more things to hand out at the meeting, you know. But I'm looking forward to seeing the scene the world's eyes on St Louis for the Asht meeting. Yeah,
Charles Goldfarb:look, it's going to be a great meeting. I think you have a lot of us are speaking, and I had the coveted Sunday morning slot for one talk and the Friday evening for another, which will be really fun. So I'm looking forward to
Chris Dy:it. Well, great. So I have the because I took the Marty Boyer option and took the early, early flight home. I have a fun day with my son planned. We're going to go to Six Flags today, so we're about to get ready to depart for that. Wish me luck. I'll be joined by our partner, Dr Alexander alim, and his his son. So we will, we will see how it goes.
Charles Goldfarb:Now it's all coming clear foresight of the day Forsyth decided to give the kids a day off, and here it is all out there six.
Chris Dy:We're gonna have a good day. It is a Saturday, so I don't think technically it's a day off, but you're in the meeting time zone, the twilight zone of a meeting, where you don't know what day it is, but yes, wish me luck, and I'll catch up with you at the Ashe. Awesome.
Charles Goldfarb:Take care. Have a fun day. Hey, Chris, that was fun. Let's do it again real soon. Sounds
Chris Dy:good. Well, be sure to email us with topic suggestions and feedback. You can reach us at handpodcast@gmail.com
Charles Goldfarb:and remember please subscribe wherever you get your podcast,
Chris Dy:and be sure to leave a review that helps us get the word out.
Charles Goldfarb:Special, thanks to Peter Martin for the amazing music, and
Chris Dy:remember, keep the upper hand. Come back next time you