The Upper Hand: Chuck & Chris Talk Hand Surgery
The Upper Hand: Chuck & Chris Talk Hand Surgery
The Future of Hand Surgery
Chuck and Chris celebrate the last episode of 2024 with a 'Future of Hand Surgery' episode. We prognosticate who will be performing carpal tunnel releases, how we will treat the CMC joint, what wrist arthroscopy will include, how we will repair nerves and tendons, and so much more. Join us and share your thoughts by email!
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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 hand podcast@gmail.com so let's get to the episode.
Charles Goldfarb:Oh, hey Chris, Hey Chuck. How are you? I'm fantastic. It's that time of year
Chris Dy:That's great, you know. So every time in conference, I want to say, Hey Chuck, and I can't, because everybody mocks me when, uh, you know, there. So the thing is, now that the fellows either want to make the podcast or they don't want to make it on the podcast. So as everybody knows, first fellow of the year with me, Dan Hong was all about being on the podcast, and subtly, not so subtly, requested that I drop his name on the podcast, because he's going to getting all these text messages from his friends. Second fellow year, something happened. And he's like, you're going to talk about this on the podcast, aren't you? And he started saying, hey, Chuck, guess what happened? I said I would never do that. I had such an enjoyable time with the second fellow Nick colada. He was so fun to have on rotation because he nerds out about the same stuff I drew out about. But we'll see how the third fellow goes, Eric. He's on rotation with me now. Loving Eric Jiang, so, yeah, best time of the year for her. For surgeons, you know, proceduralists, I will say in general,
Charles Goldfarb:it is really funny when you talk about conference, because we were doing our research conference on Monday, and it's just going down this freaking nerve pathway. And I felt like I was on the pod, and I just, I felt like I needed to be careful not to interact with you like I would on the pod to say, enough of the freaking nerve stuff. But hey, it is what it is.
Chris Dy:It was the research meeting that I lead you know, which I guess, for those that aren't familiar with it, but if our division, we do a monthly research meeting, and a couple years ago, we made a change so that there was a rotating moderator for the meeting that would be a different faculty member to talk, you know, just in general, about what's going on in Division, ask the fellows for updates on their projects that they're working on, and then talk about their own research program, which I think has been really fun, because all of us do a ton of research. But just, you know, we have our little spaces and niches. Just, you know, like I do the nerve stuff, the clinical research, David does basic science, nerve you and Lindley do a ton of stuff with, could you do a lot of stuff with the adolescents and sports? So, you know, it's nice to be able to catch up on that. But yes, I also almost slipped into podcast mode because we were on Zoom, we were talking about her,
Charles Goldfarb:yeah, it's really hard to keep up with one another. I mean, we have eight hand surgeons. We're all super busy. We're all doing different things. Obviously we have overlap. The other thing, I mean, I do love just getting together in person or even on Zoom. It's a nice it's a, you know, it's a substitute, but it's fun to hear what you are doing, because I get a sense, but talking details is really helpful. So I do like the research meeting for that reason, for sure, absolutely.
Chris Dy:So yeah, it's a busy time of the year. Everybody's met their deductibles, and I've been hearing about it for many months now. I'm glad that our eighth hand surgeon has joined. Jason Strauss joined us from the University of Chicago, and that's I've certainly heard less. I've been waiting four months to get in. Honestly, it hasn't come up, but that's been replaced by so I met my deductible, and I was on the unfortunate end of the schedule this holiday season because I had the surgical center where I work is closed on Christmas Eve, obviously closed on Christmas Day, but Christmas Eve is my or day. Christmas Eve is also or New Year's Eve is also my or day. Surgery Center where I work at is closer too, so I've scrambling to find extra time, which I successfully have, but my schedule will Off, off kilter for in the next couple of weeks.
Charles Goldfarb:It's hard, but yesterday, I had just, I mean, when you have a it's almost like you don't want to get injured on July 1 with a new round of residents and fellows, or residents at least, you don't want to get injured right about now, because the schedule is booked solid, like I have squeezed and pushed, and there's almost no leeway. So if you have a trauma now, either it gets taken care of immediately, but kind of walking the office and expecting to get a fracture taken care of is just almost impossible. It's honestly frustrating.
Chris Dy:It makes it very, very challenging. I mean, it's been, you know, it's been busy with the nerve stuff too. I was we did four Plexus cases in five days, big cases, one, super big one and three kind of medium sized ones, you know. So it was, it's been a busy time, and I'll be looking forward to some quieter times in January. But it's, you know, nerve, nerve, nerve, a lot of other stuff. Nerve, NF, nerve, which I love, but it's a. I'm sure this current phase is sustainable the month of December. Case, no,
Charles Goldfarb:I think we all feel that way. I understand one of those cases you did, maybe started at 730 to finish around
10 or 10:30pm and for me, a three hour case is is more than I ever want to do. But, you know, I it, I admire those who have more endurance than me.
Chris Dy:To be fair, it was a Wednesday, so it was an 830 start, and then by the time you actually start the case after setting up a plexus, you know, you're solid 45 minutes into the room. But for us, you know, obviously you don't want to have to do those cases, but they are really engaging and exciting cases to do. And I think David Bergen and I have come up with a pretty good system, and we did a lot of work in that time, and patients doing well so far. So very excited to continue the nerve adventures in 2025 we do have a fun episode that we're going to do today about the future of hand surgery. I think you came up with this idea while you were sitting in business school class. Is that it?
Charles Goldfarb:I try to focus, but hey, sometimes the mind drips. I don't know when I came up with the idea, and I don't I, you know, hopefully that, you know, we come up with enough interesting topics, but I hope our listeners will also pepper us with different concepts for what the future of hand surgery will look like. So
Chris Dy:when you emailed this to me, I immediately thought of the the Conan O'Brien skit, and this is totally gonna date me. But when Conan was on NBC, and he was following Jay Leno, so he was in, like, the in the eastern time zone, that's like the, I guess, they 1230 slot. Yeah, I loved watching Conan back in the day, and it was, I guess, in the late 90s, and they would have this segment with he and Andy Richter would would have called in the year 2000 where they would just make these off the ball predictions, many of them hilarious, about what was going to happen in the year 2000 and then then we add the whole y 2k thing and everything. I feel like the future of hand surgery could be a little bit like that. So we'll see. We'll see what you come up with.
Charles Goldfarb:Well, we'll let the listeners be the judge of how poorly or how well we may do. Yeah, I think there's some interesting, interesting things.
Chris Dy:So first off, want to thank our sponsors over at practice. Link, the apprehended sponsor at practice. Link.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. Practice link, for free today at www dot practice link.com, backslash the upper hand, and we are grateful to practice link. They have been with us, I don't know, couple years now, three years, maybe. So thank you very much to them. Yes,
Chris Dy:and they're always great resource for our local residents and fellows, and you really do take care of them in terms of providing access to sporting events. So we were the beneficiary of that for a blues game recently. So thank you practice, Lee. So these are your hot takes that you came up with for the future of hand surgery in 2025 and beyond. So the first one, I think is really interesting. And I know I've talked about this before, carpal tunnel release will be performed by others, such as physiatrists and neurologists.
Charles Goldfarb:Go and I might even and people are gonna, are gonna wince when I say this. It might be podiatrist. It's interesting. I learned a lot about podiatry. Podiatry is licensed to do hand surgery in some states, which makes no sense to me. But I think the point is, have we gotten to a stage where the technology allows a simplistic approach to treating carpal tunnel syndrome? And you know, some of this prediction is tongue in cheek, because I don't know that. I truly believe that, but I do think it's not going to be 100% of hand surgeons indefinitely. It's not right now. Well, it's not right now. What percent it's got to be, I don't know.
Chris Dy:But I mean, I think the you know, as listeners may know, at least in the US, there is a new ultrasound guided carpal tunnel release device and an ultrasound guided trigger finger release device. And while they are currently training hand surgeons only, I I am fully aware that their plans are to train non hand surgeons to do this surgery too, and that could be neurologists pm and are they've approached people in our pm and our division about doing the surgery, and I think they were internal discussions, from what I understand, and the carpal tunnel release remains firmly in the domain of the hand surgeon, but you know, and also orthopedic surgeons and plastic surgeons and general surgeons, I mean people who have trained to do the actual surgery. But, yeah, no, that's coming. It scares me. I think one of the our our partner, David Bergen, talks about how he's more stressed about a carpal tunnel release than a crazy Plexus case, because the expectations are completely different. I mean, you have to be perfect on every carpal tunnel. I mean, you should be. I think, whereas a crazy Plexus is like there are only a handful of people, you know, not a handful, but there's only a certain number of people in the. And then internationally, of course, that are, you know, really doing Plexus surgery. So there's a lot of variability in the case presentation, a lot of variability in treatment and expectation. So the bar is very different. So
Charles Goldfarb:should hand surgeons be teaching non hand surgeons? And again, we're not trying to exclude orthopedic surgeons and plastic surgeons who are trained, but should hand surgeons be treating non hand surgeries. To do these surgeries like carpal tunnel
Chris Dy:release, I think it depends on, you know. I think, you know, there are some people, you know, who feel very strongly that if you can't handle and deal with the complications that a procedure generates, you should not be doing said procedure, you know. But also, there are probably access issues in terms of getting in. And I think some of the marketing around at least this current ultrasound guided device is that there are a lot of people don't want to have quote surgery, and you're seeing a hand surgeon, you know, even though a lot of what we do is non operative, people still have that mentality. When you're seeing the surgeon, they're going to want to do surgery. If you can make a carpal tunnel release a quote procedure that's done in the office by a non surgeon. Maybe it's a little less intimidating, and, you know, makes people more interested in having it done.
Charles Goldfarb:Yeah. I mean, this is the hallmark procedure for hand surgeons, no doubt about it. And it's not glamorous, but there are, I guess I would say there are challenges, both diagnosis, counseling and technical. And the vast majority of time, things go just fine. But, you know, I don't know the numbers you quote for a successful outcome in carpal tunnel release, but it's not 95% you know, it's just not. So it's an interesting concept, yeah,
Chris Dy:and I agree, and you know, I will say, to be fair, there I've seen some incredibly skilled, you know, PM, and our docs and neurologists use the ultrasound to do some really skilled procedures, like very challenging procedures. I mean, when I was up at, when I was up at Mayo for as part of the government travels, government scholarship travels, I watched, you know, them, do some ultrasound guided thread carpal tunnel releases, which is really cool to do. You know, Alex Shin was doing that with with the physiatrist together, and did a lot of them, and they looked great. I think it's probably a combination approach, or collaboration approach, that would be best. But just the physical amount of time that you need for two people to two busy doctors to do something together is is hard for something as relatively routine as a carpal tunnel release?
Charles Goldfarb:Yeah, I have nothing to add. So, so, yeah, maybe, maybe, I don't know. In 2030 will it be 25% of cases are done by non answers. I don't know. Yeah,
Chris Dy:I don't know. And I don't know if there's a, I guess there's an admin data study waiting to happen in the future. So we'll see.
Charles Goldfarb:We will see, all right. Number two, the thumb CMC joint, will be treated with implant arthroplasty
Chris Dy:alone. You mean in the United States, because it's already being done other places in
Charles Goldfarb:the United States, by 2030, CMC will be an implant arthroplasty procedure, and we won't be doing fcr, we won't be doing suture suspension plastic, we won't do an implant. I like the suture implants. What do you think? No,
Chris Dy:I do not think that's gonna happen,
Charles Goldfarb:and why and why not. I
Chris Dy:think that the it's going to take a lot to change surgeons minds about what to do in the US. And I think the track record of multiple unsuccessful launches of implant arthroplasty for thumb, CMC in the US market has honestly, I think it's probably, you know, killed the procedure, potentially for future generations. I was intrigued. We had a visitor come from South Africa last year, and he was talking about his thumb CMC experience and implant arthroplasty. And I was intrigued. And then I have enough happy thumb CMC patients who are treated with trapezium and suspension of some sort, where I'm not going to change. So we're to require a fair bit of evidence, and those studies are expensive and are probably not going to be done. I
Charles Goldfarb:think that's well said. You know, it's so interesting and sometimes frustrating, and I will leave the person nameless, but, and I don't, I don't think you do it this way, but as an example of kind of the challenge of having surgeons change. In conference, we were talking, I think, in research conference, we were talking about, or else clinical conference, we were talking about how we approach the CMC joint, straight dorsal or Wagner. You might call it the Wagner approach,
Chris Dy:and not as fancy as you with the Wagner
Charles Goldfarb:and one of my partners, who I have immense respect for, only uses the Wagner, and I just don't understand it. It doesn't provide better access. You do have more nerve, you know, nerve irritation afterwards. Why in the world will we do that? It's just that's how that person was trained. And deviating from that course, you. It's just hard, right?
Chris Dy:It's very hard to change people's minds when they have success with something, right? Like, why would they change? Like, you know, that's what works. What works in your hands, right? You know, we actually have two partners that use the Wagner routinely. So, no, no, you know, I'll let we're not going to call them out because, you know, but actually, I think if you're doing the, if you're doing the genie Delson, your technique, you know, it's actually easier from a Wagner, it's quite challenging, I think, to do from a dorsal approach. But our partners are using that technique as of right now. But you know, just saying, there are technical reasons to use a Wagner, you know, if that's your preferred suspension, what's you know, you're much older than much, much older than me, much and trained in, you know, back when I think, you know, people were being admitted before carpal tunnel releases and sent home after three days in the ICU. So what was the feeling about implant arthroplasty, back when some of those implants were being introduced in the 90s in the
Charles Goldfarb:States, I was taught with the classic Burton and Pellegrini fcr, and there was a widespread skepticism with the introduction of any implant arthroplasty. And so, you know, at in since where I did my residency, here at Wash U in Cincinnati, with Peter Stern, Tom kefir and others, and then back at WashU. I don't think anyone's I've never seen an implant arthroplasty performed.
Chris Dy:Do you feel like there is a chance for it to be adopted in the United States? That wouldn't take Yeah?
Charles Goldfarb:It would take an amazingly convincing study, and it would also take an articulate proponent of the procedure sharing his or her results repetitively at national meetings. I mean, it's just it would be a slog to change the perspective of so many people. I think it could happen. I mean, given the success of hips and knees, and I mean, you would think that there's a, at least amongst orthopedic surgeons, there is an underlying acceptance that implants are great, but it's just not for hand surgeons. Do you think that there's
Chris Dy:a market to develop said device, and, you know, and obviously, it's been developed in other countries, and there have been reports of excellent results in, you know, internationally, I
Charles Goldfarb:like to your point earlier, I just don't think in the United States, we're ready for it. I think that's the hope that colleagues overseas will share compelling results that aren't like a skosh better than our results. However we're doing it, they have to be notably better. You know, decrease early failure rate, decrease late failure rate, and really happy patients. Because the reality is, I think we all know there is one truth, and this one truth that will prevent me from ever doing a prospective randomized trial again, if the results are always about the same, whatever you do, yeah, I mean, it's
Chris Dy:really, I won't say that, you know, a thumb CMC surgery is as reproducible as a carpal tunnel release. But, I mean, I think that's the issue that, you know, studies have when they're trying to show that they're not significantly different, you know, compared to an existing gold standard, gold being a relative term, right? And then, you know, you actually have to show that you're better, which, in some ways can be harder. So I just don't think the evidence is going to come, and I think it does have to come from somebody who is respected, articulate, and not crossing into the line of evangelistic, which I think a lot of people who when they feel really passionate on something that they've innovated, it does come across as evangelistic at times, which you know right or wrong, but you're just so into it and in the weeds and invested, yeah,
Charles Goldfarb:well said. I mean, what was the last great shift in surgeon, hand surgeon behavior. Was it the volar plate with George or Bay? I think
Chris Dy:the volar plate is probably the one that we would recognize, you know, I think that, I think we're having Sanj back on pretty soon, and you guys will talk a little bit about, you know, maybe a shift in, you know, arthroscopic treatments before the volar plate, you know, microsurgery,
Charles Goldfarb:yeah, yeah. And the other, the other distal radius innovation that I think has been rapidly and widely accepted is the spanning plate. Those are both, you know, we're big changes, but yeah, let me, let me back up. And just maybe as a future of hand surgery number three will be wrist arthroscopy will continue to evolve, maybe some fits and starts, but open scape, Fauci lunate ligament repair will be historical. And I think the future of hand surgery includes all arthroscopic treatment, just like the evolution of rotator cuff repair.
Chris Dy:I think that's. Probably right. I mean, you know, and I also think to piggyback on your three, I'll make it a three A. I think in 10 years, you're going to have arthroscopy fellowships for hand, wrist and elbow.
Charles Goldfarb:Yeah, interesting. Just like people have, like,
Chris Dy:you know, your extra three months, you do for six months for peds, and some people do it for micro, I think they're going to be arthroscopy fellowships, mini fellowships.
Charles Goldfarb:That implies programs where there's an abundance of volume that would allow that. I've always struggled with that because I, I, you know, I do a lot of elbow, which I don't think is done a lot, and we have a visitor.
Chris Dy:We do have visitor. Did you want to introduce yourself? Okay, go ahead. My name is Evelina, and I'm six years old.
Charles Goldfarb:Thanks for joining us, for talking about your future in hand surgery.
Chris Dy:I can't hear you because I have headphones. Okay, Can daddy finish the podcast? Yeah? Okay, daddy, thank you.
Charles Goldfarb:Yeah. So, so I do a lot of elbow work, and yet the challenge is having enough to welcome visitors, or, you know, enough localized but I think you're right. An upper extremity arthroscopy fellowship makes a lot of sense. I think you're
Chris Dy:going to be doing more and more through the scope, and people are going to want to come to learn, and I think I'm going to be doing less and less through the scope. I mean, that's honestly as and I'm interested. Just personally, I want to remain broad as a hand surgeon, but I also recognize there's too many fields to keep up with, like, you know, to be honest with, even in our narrow lane of hand surgery, there's various things that I'm just not going to be up on as much. And, you know, I think that I'll probably have to select at some point.
Charles Goldfarb:It's so true, and you're wise not to narrow too soon. We've talked about that. I firmly believe, stay broad as long as you can. But at our institution, oh, it would be okay if you decided to just do nerve but you drive 100 miles, or even 50 miles, or 30 miles outside of the academic institution, and you can't be that narrow. So it does get harder and harder to stay up to date. So is there going to be increased specialization? And I think that may be the future of hand surgery that you're alluding to. I don't think it's three a I think it's four. I think that that we will continue to narrow what hand surgery looks like. Yeah,
Chris Dy:and I but, you know, I think it is, is important to have that broad base, not only for just, you know, in access for patients, but my own sanity. I mean, I can't do only nerve, because doing only nerve means a lot of pain, and then you need, I need the winds. I need the carpal tunnels, the trigger fingers, the basal joints, you know, the dystopia stretchers. I need balance in that regard to to give me the energy to keep going on some of the nerve, because the nerve can really drain you.
Charles Goldfarb:It's so true. Well, not just nerve. So I've said to my nurse, she doesn't listen to me, but I've said to my nurse, you know, my sweet spot for wrist arthroscopy is two in a single day. I'm happy to do three when I have four is too much. There's too many scopes total.
Chris Dy:I've actually so I'm now working with a new with an athletic trainer as my primary support person for my team, and she's wonderful. But, you know, she booked me, I think, four older nerve transpositions in a day. And I'm like, I love that surgery. I know I do a lot of them, but that's just a lot. And then I told her, I have a limit on the number of, well, not cases I'll do in a day. And I think because of the way that the scheduling happened, I think I have six, well, on cases the day after Christmas, which is just going to be a lot. It's just it's really taxing on my, on my ability to entertain at the same time as doing surgery, it's a lot
Charles Goldfarb:and, and, yeah, three or four valance are plenty for me, and I would say the same about owners. My goodness, after three in one day, it's, it's, that's, that's
Chris Dy:too many. So one more prediction, maybe carpal tunnel releases and trigger finger releases will not be done in the operating room in 2035
Charles Goldfarb:100% agree. 100 Wait, we got one more after that. 100% agree that we will not be doing the little cases in the OR. And honestly, I don't think it's gonna take 10 years to get
Chris Dy:there. Um, okay, well, why don't we before we jump into the next
Charles Goldfarb:Wait, wait, wait, wait, I want to do the next hot take. Oh, you're going to do you're going to thank another sponsor. I'm going to thank our sponsor.
Chris Dy:Stop that can't stop that, and it's relevant to the next top take. So the upper hand is sponsored by checkpoint surgical provider, innovative solutions for peripheral nerve surgery. Did you know that checkpoint offers an accessory to the Guardian nerve stimulator, the intraoperative lead accessory, which connects easily to Guardian with a simple push on motion, enables hands free stimulation delivery to a consistent assessment site. This
Charles Goldfarb:makes it easier to repeatedly assess motor nerve excitability throughout a procedure such as in a neural. Or decompression, and also enables repeated confirmation of nerve function and procedures with risk of iatrogenic nerve injury. To learn more, visit www.checkpointsurgical.com checkpoint surgical driving innovation and hand surgery. Can you please translate? Well, I just heard,
Chris Dy:do you know how you own so Guardian is the unipolar stimulator. So that's the blue one. That's what I call the blue one. The purple one, which is a bipolar stimulator, which is the Gemini, so the Guardians, the blue one the monopolar so you put this little doohickey on it, attaches to it, and then, instead of applying the stimulator directly to the nerve, you can then hook a lead on. It's like a little plastic U shape that can hook around the nerve a dramatically. There are some holes if you want to put a couple of stitches in it to keep it there, but then you can stimulate the nerve consistently without having to take the device on and off, touch it on and off, etcetera. So I think there are other applications that checkpoint is thinking about down the line for said lead, but I should not say more than that, but yeah, it's a nice way to keep the lead in the same place, if that's your if that's your goal, to stimulate the nerve in a consistent place, if that's
Charles Goldfarb:your goal, gotcha, that's over my head. But sounds, sounds interesting. So what's nerve repair gonna look like in seven years? I
Chris Dy:think it's an interesting question, because of, you know, the for many years when you've been trying to look at nerve conduits, things to get away from sutures, perhaps a suture less nerve repair, the question is always, does it generate more scar debris, etc, than you know that it's worth but sutures also generate scar. And sutures introduce the, you know, human variability and technique. Newer devices have been introduced, you know, using small hooks that kind of go into the epineurium and can keep a nerve together. I'm not sure that nerve repair is going to go in that direction. I think many will, many will use said device, or a conduit or something to go to a suture less repair. I still think we need to train our fellows and residents about how to use micro sutures to put nerves together. I think there's a training aspect to it. I'd like to see if we can get away from a number of st like the vast number of stitches, so maybe go to just a single or two stitches and use something else to keep the CO optation together. My prediction is that these devices will then be used as drug delivery devices, and I think that's probably where things
Charles Goldfarb:are going to go. It makes a lot of sense. We've watched our previous chair and senior partner dedicate our career towards the manual suture repair of flexor tendons. And as he sort of finished his 40 years with NIHR one funding, he was into the drug delivery game for tendon healing. It just makes sense for tendons, for nerves, or whatever.
Chris Dy:I think, I think, you know, hopefully that's something that the appropriate cocktail will be figured out, and that, you know that's probably not going to be ready for prime time, I think, for, you know, a solid one or two decades. But I think this is laying the groundwork for that.
Charles Goldfarb:So for doing long term predictions, are you ready to go off the nerve? Because I don't. I know it's, it's tough to stop talking about, do you have anything else you possibly there's no more nerve talk this episode. So I want people
Chris Dy:to email saying how much more nerve they want, or if they want, you know, I want to say, email us and say what you want, right? Like, you know, we have a, we have a great grab bag episode that's going to come out in next month. At some point, we've had some great emails, so we appreciate all the emails, including some fun facts about the origin of Halloween. So we had a correction the that'll be a great episode. But if you want more nerve, please email us hand podcast@gmail.com more and more of anything. I'm sure you want more sports. Whenever I see people in person, people in person, they always talk about how they want more sports and arthroscopy stuff. So I admit I'll have to. I do enjoy learning during those episodes. So thank you for that, absolutely.
Charles Goldfarb:So I'll talk a little bit what I think the future of congenital hand surgery is.
Chris Dy:And you didn't tell me you're going congenital On this episode, there's
Charles Goldfarb:been a clamoring the listeners, for the three of you that like
Chris Dy:congenital, please, please keep listening if you're if you're not in the congenital just, you know, you can keep listening to it.
Charles Goldfarb:This is going to be short and obtuse. Gene therapy will be there one day. You know, right now, gene therapy is super expensive. We're using it for, you know, obviously for cancer. There's been some work done with sickle cell, and, you know, it's going to be arthritis, etc, etc. So maybe CMC arthritis doesn't exist anymore with gene therapy, but, but I think Gene therapy will, will, will change the way we think about congenital conditions and. Smart enough to know exactly what that means, but I don't think we'll be treating the same volume and in 15 years that we are today. That's
Chris Dy:exciting, but the problems that we're producing so many congenital hand surgeons. Everybody wants to do congenital. I just read every fellowship application that we received. I mean the number of people that want to do pizza and congenital like Good God, do we need another congenital hand surgery?
Charles Goldfarb:News flash, we probably don't, but maybe I need to retire so, so there's space, there's room. Um, so
Chris Dy:quick, quick question. Do you think Gene therapy for arthritis will be ready before an accepted thumb CMC implant in the United States. I think
Charles Goldfarb:it might be. I think it might be. And the work that our colleague and our partner, Fauci like doing in regards to osteoarthritis and treatment is unbelievable for those of you, and I can't speak eloquently about it, but the work being done in the lab for our osteoarthritis and treatment for it is unbelievable. We're not that far away. To Chris's point, yes, I'm voting for gene therapy, but I think
Chris Dy:Gene therapy will get there before a thumb CMC implant is widely adopted in the United States. Now, patients, I have to answer that question a lot. I mean, like my whole spiel about arthritis is that we have no cure for it, but they're working on it in WashU. I mean, Fauci received the largest grant in Washington history. It's an incredible amount of money. So yeah, see, they're working very hard on on fixing that. One other question before we close, do you ever think that there will be in utero surgery for congenital hand issues?
Charles Goldfarb:So there currently is, theoretically, the problem today is the risk of like, if you have a constriction band around the forearm or upper arm, that's severe. I think our general surgery colleagues would potentially treat that in utero. But most of the other stuff is the risk benefit ratio is off. I don't know how that changes. I'm just not that knowledgeable. But, yeah, I think that'll increase as well I do. Okay, yeah, good. One important one, how many hand surgery podcasts will there be in 2030
Chris Dy:so I, interestingly enough, I did look a lot last week. I was, I can't remember what prompted me to do it. There are a couple other hand surgery podcasts that have a limited run of episodes. I can't say that anybody has, you know, five years in a game like others, but it's crazy. We're going up on our five year anniversary next month. Who would I feel like it? I feel like you owe me a gift.
Charles Goldfarb:This is your gift.
Chris Dy:But, yeah, no, I don't, I don't know. Maybe I don't know if there'll be one hand surgery podcast in five years. We'll see You're awful, you're awful busy,
Charles Goldfarb:so
Chris Dy:funny. I don't know. And, you know, I think that who knows what the next educational kind of venue is going to be. I mean, I think that fortunately, we were, I wouldn't say, ahead of the curve. We were timed appropriately, I think with that, with the upper hand, but who knows where it's going to go. Yeah,
Charles Goldfarb:for those of you listen, we're grateful for our listeners. This is a labor of love. We do enjoy it, for sure. What's been fascinating for me, and that goes to the listeners who are still tuned in and haven't dropped off yet. You know, most of you listen in the audio only format, but our YouTube viewership, why people want to see Chris and me sit here and talk? I do not know. But our YouTube viewership is going through the roof. I mean, I think we had six or 700 recently. It's really remarkable. I
Chris Dy:think it's just easier to pull stuff up on your on your computer or your phone on YouTube, maybe just like, let it roll. That might be it. Or they just, I mean, they love seeing your dome. It's great.
Charles Goldfarb:I got a kind of shortcut. What happens
Chris Dy:looking good? Well, I wish you the best holiday season and a great end to your 2024, Chuck. It is always fun to do this together, and I look forward to another another year of it, hopefully every dude, happy holidays. Happy holidays. Take care.
Charles Goldfarb: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 hand, podcast@gmail.com
Charles Goldfarb:and remember, please subscribe wherever you get your podcast,
Chris Dy:and be sure to leave a review that helps us get the word out. Special,
Charles Goldfarb:thanks to Peter Martin for the amazing music.
Chris Dy:And remember, keep the upper hand come back next time you