The Upper Hand: Chuck & Chris Talk Hand Surgery
The Upper Hand: Chuck & Chris Talk Hand Surgery
Considerations on the Darrach Procedure
Chuck and Chris discuss the Darrach procedure including our indications, alternatives, technical considerations, and more. We also share our amazing experiences at the ASHT!
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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,
Chris Dy:And thank 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:Oh, hey Chris,
Chris Dy:hey, Chuck. How are you?
Charles Goldfarb:I'm great. How are you?
Chris Dy:I'm good. I'm good. I'm in a different location than our usual. Those of you watching on YouTube. See this lovely Embassy Suites lay out in the background here.
Charles Goldfarb:Nice. Yeah, you look very nice. Tell us about where you are.
Chris Dy:I am at the what's been, I think, my third trip to the orthopedic research society's clinician scientist development program. So it's actually a, it's a really cool program, I think, for the people that are interested in in working as a clinician scholar when they're out in the wild, and I attend this in 2011 Wow, as a resident sponsored by the American Foundation for surgery the hand. So thank you. Afsh donors around that time, and have come back on the faculty for three years now, it's an honor to be invited to come back and to talk about wonderful things like how to start as a clinician scientist, how to get promoted, that kind of
Charles Goldfarb:Yeah, and is it every year this conference is held...
Chris Dy:it's every year and its in the same hotel? And I've learned a lot of things about the Embassy Suites in Rosemont, Illinois, including that their gym is quite limited in terms of what's available, number of machines available, and what number changes is that orthopedic surgeons want to work out in the morning. So it's always a bit shuffle
Charles Goldfarb:Yeah, I can imagine. I can imagine. Well, good. Well, we have a, I think, a very robust set of things to discuss. And I'd love to start with both of our experiences at the American Society of hand therapy, hand therapists and therapists.
Chris Dy:Yeah, I was, I really enjoyed the meeting. I was I was a participant. I was able to watch our our research team, two medical students, gave fantastic podium presentations on their research. So thank you to the program chairs for accepting their abstracts and allowing to present podiums. One of them was on our initiative to understand how we contemporize and contemporize outcome assessments after like a plexus injuries using things like video goniometry, which is interesting, try to automate some of this process, or at least make it more objective down the line. And Steven dimartini gave great presentation on that. And then Ishaan sane gave a great talk about our work trying to understand how to implement a navigator position for patients with brachial plexus injury. So a new thing for us that is long overdue, somebody who can kind of be a flex player and incorporate some of the elements of social work, you know, some medical aspects of things patient education, essentially be a closer or somebody who brings goes the extra mile and gets people across the finish line for things like disability insurance applications, etc.
Charles Goldfarb:Yeah, navigator positions are interesting. And I'm sure some of our listeners have experience in that there is no question of the value of that role. It helps the physician, it helps the patients, helps everyone in between. But it's not a revenue creating position, and so it's it's yet another person in the team, and it sounds it's hard to justify, even though everyone understands the value
Chris Dy:Yes, and that's a long history in things like oncology and cancer, obviously. So yes, the way that we're able to get this done is that we were fortunate enough to get a grant from the foundation for the Barnes Jewish Hospital to at least get us started, and hopefully we can very clearly demonstrate value and try to find a way to fold this person into the team on a more permanent basis. Yeah,
Charles Goldfarb:I love that. Love that. What I really enjoy about the ASHT and I guess I would say hand therapist in general, is their passion for what they do is really cool and it, you know, it's, it's demonstrated in many different ways, attendance on Sunday morning would be one example, and not just attendance. So we had a couple of things Sunday morning. And not only were people there, they were engaged. And really it's just a great group of people who really care about what they do and how they you know, make patients lives better. So I had a great time, and always enjoy the sht. And it's the second time it's been in St Louis in recent memory. And I think they, they like St Louis as a hosting city. Yeah,
Chris Dy:I think it's, it's the the size of the meeting fits pretty well for the size of our city. And there's obviously a rich legacy of hand there. Purpose and expertise in hand therapy in St Louis, so it's great to have them. So I hope they come back, because it's always nice to have a meeting at home. It's interesting to have a meeting at home. I had a special companion for the afternoon portion. On Saturday, my daughter's soccer game was canceled because the fields were wet, so she came and my six year old daughter was sitting front and center as we watched our medical students give a talk. They were so kind. They printed out a name tag for her American Girl doll. It was, it was fun. She got to see kind of a piece of what, what I do at work. So she got to meet daddy's work friends. End quote, and had a great time. Yeah, I didn't, I didn't have her stick around for the IC or for the course that Macy and I were, we're teaching together. I would have been a little bit more challenging, and the meeting organizers were on high alert when they saw a six year old was around. Then they're like, you're gonna be with her the whole time around. Like, yeah, absolutely no problem. I can't let you get away without telling us about your cocktail reception. People bought tickets to have an evening with a scholar like yourself, so you were the feature for this ticketed event, and I heard you gave a great presentation.
Charles Goldfarb:Thank you for saying that. Yeah, it's a it's the major fundraiser, I guess, annually, for the foundation. And it was Friday evening from around 630 to eight, and I came down after business school and hadn't had a good time, and I talked about impact, how we consider our impact, and how we should think about our impact. And again, audience was great. And so I spoke for, I don't know, 3540 minutes, and then we talked, there were questions for another 20 or 25 minutes. So really thoroughly enjoyed it. And, you know, hopefully it, I think it was positively received. You never really know, but I enjoyed it.
Chris Dy:Multiple people from various factions of the hand therapy world commented to me about how great the presentation was. So congratulations. I heard that you had some tough questions that you handled very well, you know. So kudos to that. That's always the wild card about you know, you know what your talk's gonna say and probably how you're gonna deliver it, but you never know what the question is gonna be coming from, the coming from the audience of a group that you're not as familiar with, say as if you were presenting to a group of hand surgeons or residents or fellows or medical students.
Charles Goldfarb:Yeah, that's exactly right, and I think I don't mind looking silly and making fun of myself, which I think is always helpful in the Q and A and so no no hesitancy to say something silly and laugh at myself.
Chris Dy:Well, thank you to the as HD for always welcoming the hand surgeons to come to your meeting and we I had learned a ton personally, both from watching the podiums that I was in in the audience for and also hearing, you know, the questions that were asked of Macy and me when we were giving our our course. And I've always learned a lot from Macy too, as everybody does. I hear she's a bit of a celebrity among the hand therapists, for very good reason, given her recurring guest role on the pod, we should have her back. We have it's been a while. It's
Charles Goldfarb:been a while. So on Sunday morning, I walked in a little early before my session with Stacy. Stacy and I, on Sunday morning, talked about medial elbow injuries and the role of the ulnar nerve. You could have learned something, and, yeah, in adolescence. And it was great, great session. So I walked into Macy's room beforehand, and she was in the big room, and there was good attendance. And she's up talking about, you know, rehabilitation after free muscle transfer. And I walked in, and then she immediately just stopped and waves. It was hilarious. Bill Birmingham. Hello the Birmingham. Hello for those of you not aware of Macy Stoner and I met in St Louis, but we both grew up in Birmingham, Alabama, so
Chris Dy:that's great. I heard that talk was awesome too, for so rehab after a free functioning muscle transfer. Very niche topic, but super important, if you're investing that amount of time and effort into a procedure like that, to make sure that you can get it across the finish line.
Charles Goldfarb:Yeah, what I heard, what I heard, was great. Should we start by thanking one of our sponsors? This is brand
Chris Dy:new information, folks. The upper hand is sponsored by practicelink.com the practicelink.com the most widely used physician. Job searching, career advancement resource,
Charles Goldfarb:becoming a physician is hard. Finding the right job doesn't have to be joined. Practice link for free today@www.practicelink.com backslash the upper hand. All right, let's get into it.
Chris Dy:Yeah. So I had a I've had, you know, as just like anything in clinical practice, things come and runs, and I've had a run of patients who are undergoing distal ulnar resections. So the so called Dara procedure, a very, I mean, like any surgery, like a PRC, that's been around for the better part of a century, if not longer, and we're still doing it probably works for some good reason, even though it sounds kind of ridiculous when you're talking about to a patient. So for example, one of the patients that I performed this procedure on recently had been kind of, I think probably the one of the most common indications is, at this point, is a patient that is in their seven. Who had a disarray is fracture that we went through extensive shared decision making and counseled her about her fracture, and she ended up with what I've called now, and I think others do too, an expected malaunion. And you know, it counseled her about the appearance of the wrist, both coronally and sagittally, but the ulna, while it was prominent, it wasn't the prominence that was bothering her. It was the limitation in forearm rotation. So this is a patient I talked pretty extensively about performing this ulnar resection. What's your talk with patients? Just to start the conversation about what to expect or when to do the surgery, like, you know, for that reason, and what reasons to do the Dara, or just to say, you know, it is what it is.
Charles Goldfarb:So a dare in the setting of a distro radius fracture, and whether it's post operative pain or limitation in motion or deformity in the setting of a distraught fracture, yeah, I think it's a really important question. And concept, I'll say that I was taught don't ever think about a second surgery after a distro radius fracture for at least one year. I don't think many of us accept that to be true any longer. I do think the message, though, is important is be patient before jumping in after a distro radius fracture. I'm not saying wait a year, but be patient. Give give patient, give the patient a time to get better, and don't rush, because some things just take time.
Chris Dy:Do you think that there's a threshold where you kind of know it's not going to get better?
Charles Goldfarb:Yeah, I would say the pain component is most likely to get better over time. I would think that we and our therapy partners probably about know by three months whether we're going to see improved motion. Is that your sense? I think so. I
Chris Dy:think the die is probably cast by three months, and then you get a sense of where their motion is going to land, and then also how they can compensate. So if it's truly limited form rotation, you get a lot of wiggle room through the shoulder to compensate, or if their shoulder is not great, and that clearly limits their abilities to do that, the pain part of it, I think, is more of the wildcard. And I think pain is what would push me to potentially consider intervention a little bit sooner. But yeah, I think you kind of know, and I think you start laying the crepe in terms of planting the seeds for discussion at future visits. And most of the times, I'm not seeing just patients with dissaraeus fractures beyond three months, to be honest with you, unless they've got an ongoing issue, like something like this.
Charles Goldfarb:Yeah, I think that's, that's, that's great. That's really true. What's interesting about range of motion, in my mind, I want to hear more about your experience with this patient is we usually get pronation back pretty quickly after, I would say, a standard distal radius fracture and treatment with a volar plate, for example, and we might struggle to get supination back. Pronation far more important for daily life, even though patients want their supination back as well. What's your what was this patient's complaint regarding motion?
Chris Dy:So this patient's complaint with motion was actually trying to get both pronation and supination, so she was kind of limited in both both ranges. And I think it's interesting that we've shifted now to a pronated world, right? With keyboards. I think the teaching before with supination was better for grip and function in daily life, but now with, you know, our you know, being behind keyboards for a lot of things, not just for work, pernation becomes more important, perhaps with devices and texting and using, you know, those things more than keyboard may be less important, but she was just all around bothered by it. And I think it's a different ballgame when you've got expected deformity of the radius, as opposed to the situation where you've got a vulner plate and you've got hopefully anatomic or closely anatomic alignment, both coronally and sagitt of the radius. Now
Charles Goldfarb:how do you decide whether to address the distal radius versus addressing the distal ulna, or potentially addressing both? But in this case, it seems like you were totally focused on the distal ulna, which must mean the distal radius, while not anatomical, was still in the realm of acceptable. Yeah,
Chris Dy:I think motion, arc, flexion, extension was acceptable for her from a grip perspective, which I think honestly, at the end of the day, is probably the most important thing for the radius. She was doing well, she wasn't having any signs of some the carpal tunnel syndrome that can occur in about 15 to 20% of patients after just a radius mal Union. It really was the illness. And to be honest with you, and somebody in their 70s, I'm hoping to do one surgery and be done and keep it simple and not have to rely on a protracted rehab. And
Charles Goldfarb:how do you think about Dara versus Dr uj release? Now, drej release is not an operation we talk a lot about. You know, Marty Boyer may, in our practice, may be the most likely to to provide that intervention. I will do it rarely. I mean super rarely every couple of years. But. How do you think about that procedure versus simply the excision of the distal ulna?
Chris Dy:To overly simplify it, that's a surgery for a younger person. And I think about it. I've done it, and I've also sent people to Marty to do it. That's a tough case with somewhat, not somewhat, with less predictable outcomes, I would say. And you really got to hit it hard with therapy. You know, the surgery is just the beginning salvo and the whole thing. And I think it's the ability to know that they're going to go to therapy and that they're actually going to do whatever it takes to get what is likely to be improved, but incomplete recovery of forearm rotation. What is your take on it?
Charles Goldfarb:Yeah, I think that's right. I mean, what we what we know, is that drej doesn't typically get stiff, and so there usually is an extenuating circumstance, whether leading to prolonged immobilization of the forearm, because most patients start moving at least a little bit right away. And so it's uncommon to have isolated druj stiffness, and it is less predictable of an intervention. And while the Dara is far more predictable, it does carry some risks, which I'm certain we're going to talk about. So
Chris Dy:if we just kind of veer away from form stiffness and we think more about drej instability, is there a role for a Dara in that or and then, what's the role for an ulnar shortening in your practice, for in the instability setting? And let's take the TFCC out of the picture. Because I know you're going to bring up the fovea,
Charles Goldfarb:yeah, we'll take the TFC out of the picture. There. There is, I mean, obviously the TFCC is in the background, but I would say there is a reasonable intervention, which is a formal ulnar shortening with platen screws, where you migrate the ulna proximally, and therefore you tighten the ulna carpal joint and the drej and so some degree of drej laxity is corrected with a formal ulnar shortening osteotomy. And so it is absolutely an option in the setting of a non arthritic joint and reasonable bony alignment, and it's a really good surgery in those situations.
Chris Dy:Do you think that a shortening can improve rotation by getting the ulna to sit more appropriately with an acquired notch?
Charles Goldfarb:I would say unlikely, unless the Mao union of the distal radius allows it, but usually a malunion is a three dimensional malune unit, even if it's say, for example, primarily dorsal tilt of the distal articular surface. But I don't think we usually see improved rotation with an ulnar shorting osteotomy.
Chris Dy:Maybe we also probably underappreciate some extension of the fractures into the sigmoid notch as well, which potentially could predilec to drJ arthritis. Do you think the, you know, the ulnar shortening still an option if they've got drJ early arthritis that's developing? Or do you pivot at that point to the Dara?
Charles Goldfarb:So I would pivot to a Dara 100% now, others would pivot to survey kapanji in our institution that's not been a primary intervention. At the hand, meeting a few weeks ago, a well respected dystrodias authority commented that she particularly prefers surveys, and I just hadn't had the results with that intervention that I've had with Dara. So I don't usually do a survey.
Chris Dy:So can you, for the audience, summarize what a Solvay kapanji is, and thank you for clarifying that it's not a suave kapanji, which is a pet peeve of our partner, Dr Boyer.
Charles Goldfarb:That is true. So in the sovey, you take the distal radius and the distal ulna, so the very distal aspect of the ulna, and you essentially fuse the drej. So you remove the cartilage between the radius and the ulna, the sigmoid notch, you fuse the distal ulna to the distal radius, and then proximal to that fusion site, you take out a segment of ulna, and so you created a long, wide platform for the carpus, and then you allow rotation proximal to that. And so it's again, a procedure has been around for a really long time. It's not laborious. It doesn't take much hardware, but it does move your mobile segment more proximally to allow rotation.
Chris Dy:What's the patients bring this up and they ask, why can't you just replace the joint? So what's been your current indications to send patients to one of our partners for drJ arthroplasty? Is there any role for that? And what's your role for that to practice in general? Yeah, I
Charles Goldfarb:listen. I think that is increasingly accepted as a really good operation for patients of all ages. You know, it's not the same as a wrist replacement, and we probably should have a guest on to talk about some of this would be interesting as someone who does it all the time, but a wrist replacement or arthroplasty is different, and it's low demand patients only. And lifespan is not great, but the druj arthroplasty can really be long lasting and highly effective. I just tend to attempt a simple approach first, and that's the Dara. And for me, the the druj arthroplasty is a bailout for a failed Dara. How do you think about
Chris Dy:it? Fame, and honestly, I'm guilty of not learning as much about the drej arthroplasties and the risk arthroplasties because we're spoiled. Marty takes care of all these people, and he's a pretty well recognized authority in this area, and he loves it. And I also recognize at some point, I'll need to learn about this, and we'll need to share the load a bit more at some point. So yeah, I think about that in the same way. And just now getting circling back to the Dara, what do you tell patients to expect in terms of either motion or how long it takes to get over the surgery, that kind of thing?
Charles Goldfarb:Yeah, I typically maybe, and I might do it differently than you. I typically have mobilized for about four weeks to allow the soft tissues to stabilize, tighten up a bit. I don't necessarily put them in a monster or a long arm cast. I just ask them not to intentionally rotate, and they tend to self regulate in that regard. And then I get them out of immobilization and start rotating. I do think. And maybe we're going to circle back, we should talk a little about technical, yeah,
Chris Dy:absolutely, I think I just, I'm thinking about the talk to patients, and I'm, I'm a little less restrictive in terms of immobilization, you know, I try to keep it simple. And honestly, if her issue was rotation, I kind of let her rotate right away, because I think that most patients are going to be self limiting in terms of not overdoing it for activity before we jump into kind of technical aspects. I think we should acknowledge our other sponsor again, brand new information, checkpoint. Surgical,
Charles Goldfarb:absolutely the upper hand. Sponsor by checkpoint surgical, a leader in peripheral nerve surgery solutions with a bipolar stimulation probe, checkpoint Gemini bipolar nerve stimulator. Mouthful provides finally controlled stimulation even at the vesicular level, allowing surgeons to take actions based on the most precise information available. Learn more@www.checkpointsurgical.com
Chris Dy:checkpoint surgical, checkpoint surgical, driving innovation and nerve surgery and giving Dr Goldfarb a whole lot of stuff to read. Geez,
Charles Goldfarb:that was a lot of anxiety trying to get all that out. But you
Chris Dy:got it, you're good. So back to the back to our case. Approach pretty simple for me, at least. I try to keep it simple, I go essentially on the ulnar side of the dorsal distal forearm, kind of over the prominence of the ulnar head at the distal aspect. I'm looking out for the dorsal cutaneous branch of the ulnar nerve as it starts to make its way from volar to dorsal to mid axial line anatomy is a little bit distorted, given the fact that you're on the carpal joints, distorted with the prominence of the ulnar head, and then I visualize my ECU and use that as my guide.
Charles Goldfarb:I like what you said. I will say that I you know, it's very satisfying to me when I take a little different teaching approach. So I had a very strange ganglion cyst emanating from the ulna carpal joint, and so I asked the resident to draw the path of the ulnar sensory nerve. And she's an excellent resident. And she drew it just dorsal, like it was just a straight line, dorsal. And I it just feels good when you like. I don't usually do that. And I'm like, she's gonna that is something I do. That's exactly right. That's exactly what I was thinking. Is something you would do. And I realized the value she had drawn it perfectly, I would have felt silly and never done it again. But making them draw it on the patient is really impactful.
Chris Dy:The other time that I'll use the marking pen, I'll either make a game plan on the drapes, in terms of like, if we need to simulate certain nerves in a certain timeline, and here are the goals, etc, or if we're cutting fascia, either in a setting of an ulnar nerve transposition, and we're, you know, releasing the fascia overlying the two heads of the FCU. I like to see if they can see the rafae between the ulnar and humeral heads, and have them mark it out on the fascia. Again, total teaching point. Doesn't change what we do. Makes it look slicker, though, and then also releasing a perineal nerve, you know, kind of tracking the course of the deep perineal nervous that goes underneath all the lateral anterior compartment musculature, putting dots on the fascia with the marking pen so as to see where they think they need to release. Because for that, when you do have to be kind of dead on with your fascial cuts to make sure that you're able to decompress the nerve without excessive exposure. So sorry for bringing nerve into our talk, but yes, that's when I use that. So
Charles Goldfarb:I love that. I like your approach using the ECU as a guide. And then, quite simply, I try to take my sagittal saw, which I don't always use in different osteotomies, but I use a sagittal saw. I use it just proximal to the articular surface. And I would say that's step one. How do you take out the ulnar head?
Chris Dy:So, yeah, actually, when I was doing this, a very astute resident, Dr Ryan Wilbur, is working with me right now. He's fantastic. And we were talking about different approaches to this. And he was mentioning that some folks preserve the ulnar styloid, you know, as part of this, that has not been very helpful to me. And I, honestly, I find, you know, I release the periosteum, and then I just kind of work my way around the ulna and going distally, and try to keep take everything right off of the bone, and I don't do much handling the TFCC, and I make my cut more proximal.
Charles Goldfarb:Yeah, look, preserving the ulna might sound good, but ultimately, the styloid insertion of the TFCC is not the stabilizing portion of the TFC, so I don't think that helps. So like you said, I sharply dissect circumferentially and then make my cut, and I'm done.
Chris Dy:Is this a metaphyseal cut? Diaphyseal somewhere in between. Like, how far proximal to the sigmoid notch Are you going for your cut? Are you just
Charles Goldfarb:just a little bit right proximal? Are you making it more proximal than that? I'm more proximal
Chris Dy:because if I'm trying to gain rotation, I want to leave no question that I'm going to be able to get the rotation. So I tend to make my cut proximal to the sigmoid notch. So that time, honestly, one and done. And then, obviously, you can cut back. For this case, we checked rotation, and then we didn't need to cut back more, but you can cut back more. And then, as we bring things to a close, I guess I would like to know, you know, as one of the potential issues with this is convergence in the coronal plane, so the ulna converging on the radius, you know, on the AP view, and then also instability of the ulnar stump. You've obviously cut the on the bone, and you is that stump gonna go dorsal and become problematic? So I think
Charles Goldfarb:there's two other technical considerations. Paul manski used to always release the pronator quadratus from the distal ulna, and either just release it to take away a converging force, or release it and interpose it between the radius and the ulna. And I'll say I like both of those options. Certainly the release is simpler, but in certain situations, bringing it up between the radius and ulna makes sense. That's one technical consideration, and the other technical consideration, which I do regularly, especially if there is intraoperative a lot of laxity, I will take a Hemi slip of F, I'm sorry, of ECU, leave it attached distally, cut it as far proximally as possible, and then drill a hole in the distal ulna and pass it through the ulna medullary canal, out a drill hole dorsally and suture back onto itself. I like that option. I don't always do it. Do you do either of those? Both of those, neither
Chris Dy:she I did one of each so in the last two weeks. So, you know, we had really nice on one case, we had a really nice, you know, tenderness portion of the of the pronator quadratus, so that in like insertional portion, and I put an anchor into the to the stump of the ulna, and then sutured that together to help, kind of hold it in place and try to neutralize that deforming force. And also tried to put it over the dorsal side as well, to try and keep that down. And then in the second case, I did see that they wanted to drift a bit dorsally, so I did the Hemi slip ECU that you described. And I think it kind of is case dependent. It's
Charles Goldfarb:case dependent. I would say, if you do the Hemi slip, the problem is you never have enough length of the ECU. So you really do have to make your incision longer and really split it, and then you need the length to provide a reasonable stability point.
Chris Dy:Yeah, that's exactly what we discussed and then also experienced, so making sure we had the length, and then it's nice when you can suture that back down to itself or to the other part of the Hemi slip. That's helpful in terms of controlling that sagittal deformity. So I saw you putting your loops on, which means you've got to get to your case. But I think this was a great discussion. If there are listeners that have experience either performing or rehabbing a Dara procedure, it'd be great to hear from you. So a hand podcast@gmail.com
Charles Goldfarb:Yes, or listeners that don't like the Dara and the problems that you may have experienced with it. It's a controversial operation, let's be honest. And there are problems with it, and that's why not everyone immediately goes to it. But I think in the right situation, it can be a huge home run, kind of like the Mets home run last night to knock out the brewers. And where we talked about,
Chris Dy:we talked about not dating the podcast, when we when we record it. But that was pretty incredible. I was eating dinner in a restaurant last night, and hold heard somebody just scream out expletives. Must have been a Mets fan. They were happy expletives. But yeah, I looked up and as, oh, okay, cool, something. I guess it's October baseball going on. October
Charles Goldfarb:baseball, the Mets haven't had a lot to cheer about for a really long time.
Chris Dy:Exactly. At the end, they got that playoff pumpkin. I saw that in the locker room. So anyway, enjoy your day. Enjoy your case. Thanks. Take care.
Charles Goldfarb:Hey, Chris, that was fun. Let's do it again real soon.
Chris Dy:Sounds 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