The Upper Hand: Chuck & Chris Talk Hand Surgery
The Upper Hand: Chuck & Chris Talk Hand Surgery
The LRTI in 2025
Chuck and Chris discuss a listener submitted case and use the topic for a deep dive on thumb CMC/ basal joint arthritis and the gold standard of care, the LRTI. Hear Chuck and Chris' thoughts on the technical aspects of the operation and hear how they differ in their approaches.
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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,
Chris Dy:Hey Chuck, how are you?
Charles Goldfarb:I'm great. How are you?
Chris Dy:Great, its 2025 excited. New New Year. We're officially in and we've given all our predictions for the future of hand surgery, and we've dealt with Snowmageddon in St Louis.
Charles Goldfarb:Oh my god, we have dealt with Snowmageddon. We're getting more as we speak on January 10, you know, I was thinking about our future of hand surgery podcast, and the only thing we didn't discuss was artificial intelligence, and it really wasn't the purpose of that episode, but it's another interesting topic, which we could touch on today or another time.
Chris Dy:Yeah, we absolutely should. I know, we've gotten some great emails from listeners about AI, and I think that we should probably devote an episode to it, to maybe even have a guest again in terms of discussing that, what's going on in your world? Penny, I've got a meeting coming up. I'm very excited about by the time this episode drops, it'll be on the tail end of that meeting. But how about you?
Charles Goldfarb:Yeah well, I can't compete with a Hawaii meeting. There's no competing with that. No. Life is a quiet B School. Last four months, a lot of travel coming up, but all is well, had a great holiday with the family. Yeah? All good.
Chris Dy:Yeah its good. Somebody asked me recently about my travel coming up, and I had a hard time remembering it, which is good in terms of work related trips. I'm very happy right now that I don't have a lot coming up. We've got a big spring break trip coming up in a couple of months. But yes, it's a people always ask, you know, you say you're going to a meeting, and they say where, and they immediately judge you when you say Hawaii, but it's the American Society peripheral nerve and also, concomitantly, the American Association of hand surgery. Although I'm not really doing much for that meeting, aside from a jointly program at ICL with the aspn,
Charles Goldfarb:I'm definitely judging, but all right, a little bit of a tangent. And you know, my business school interest and all that stuff, there's a guy named Jesse Itzler who, I don't know, what he did to make a mint. He married a woman, I believe, named Sarah Blakely, who started the company Spanx and was one of the first self made female billionaires. But occasionally I see Jesse. And I met and hung out with Jesse a bit when I did the Duke basketball camp, and that's been many years, like we had
Chris Dy:tried, I forgot about that. That is, that is some grown person, uh, I've made it, and I want to relive my, uh, my childhood dreams,
Charles Goldfarb:yeah. And the key is, I think you have to be at least 35 to do it. I was maybe 36
Chris Dy:but I don't have enough money to do it until you're 35 or 36 if you do then
Charles Goldfarb:that's exactly right. Anyways, talking about the travel I have thought about, I think you may have something like this in your office. He is like, sort of marketing this year long, massive calendar where you visualize what you do, right there. Yeah, five times that side.
Chris Dy:I used to have a bigger one, but then somebody made me move offices. And, yeah, yeah,
Charles Goldfarb:it's just interesting, because I do I struggle and like, I think my stress level is directly proportional to my grasp of what I have going on. So occasionally I go take these deep dives into what, where I'm traveling, how I'm prepared. Do I need my tickets and all that stuff. And there's many techniques to decrease the stress, but just organization and visualization help. Yeah,
Chris Dy:no, I'm a big visual person, so whether it's doing a wall calendar for traveling, or whether it's when I have my New Year's resolutions like literally checking a calendar box, which we, which I did talk about with a fellow recently, Eric Jang, about his new year's resolutions, and I'm big visual person, so I think I don't know you probably are at the point as an executive now where you are probably counting the number of days you travel. I know a lot of people who are big in the executive space will say, I'm only traveling X number of days this year, and become much more selective about which opportunities they declined or accept based on how much travel they've already committed to. So, yeah, no, I need to see it. Whenever some trip comes up or an invite comes in automatically, the email is to my admin saying, please put this on Outlook. Please let the clinical team know, and please put it on the wall. Calendar. Has to happen. I need to see it in a certain way, in multiple that way, I still print out things too. So I mean, yeah, it's so
Charles Goldfarb:interesting because you're not the only one who prints things out. I am old and do not print stuff out, but Lindley wall is another example. She prints everything out or handwrites.
Chris Dy:I remember getting a manuscript back from a, I'll say, from Dr McKinnon, and I got him. I just heard back from her. We were working together on a paper. It was printed, it was in red pencil. And I was like, this is just like my childhood, like I used to send my papers to give my my older sister, who's an amazing writer, I would give her my papers to edit, and she made me a much better writer, but it would always come back in red pen, so a little bit of PTSD, but it may be better in the end, and actually helped rewrite a introduction for a medical student yesterday, and I wrote it out on the notepad and then just typed it up because it just the thoughts flow better for me when I have pen in hand. That's
Charles Goldfarb:so interesting. I think it's a this is a real to me. This is a super interesting topic because it's also about like, how do we absorb knowledge from a reading perspective, like, can you learn reading and highlighting on a PDF versus a printed document where you're marking it up? I actually have made myself transition to the PDF absorption model, and that's what I've done in school as well. But as I think I've mentioned before, again, I'm one of the older people in my class, and I'm one of the few people who uses an iPad and markup like that rather than looking at the printed version.
Chris Dy:So when you go to this really interesting point, when you go to a executive council meeting or whatever for the hand society, or everything else that you do, a lot of times, those agendas now are completely electronic, and they say we're not going to print them. Do you still print them? Or do you just go electronic? Oh,
Charles Goldfarb:I haven't printed anything like that in 10 years. Yeah. Do you still print
Chris Dy:occasionally, occasionally. Sometimes it's because I forget to attach the PDF to the outlook. It's all thing, but, but, yeah, no, and I've gotten grief from the amazing Hand Therapist I work with in clinic, Jamie find dice. She gives me grief, because every time I read an OP note, because I'm like, going to tell her something, I will highlight the text as I'm reading, and somewhere, it's like a pet peeve of hers or something, and I didn't realize I was doing it. So I'm big highlighter, you know, my I had to restrain myself when I was in medical school the number of different highlighted sections, because then the entire page was highlighted when I was reading. So
Charles Goldfarb:that's exactly right. I mean, there are some, and my kids obviously guided me. There are some amazing apps for the iPad, I'm sure, for every trying device, that really allow you to mark it up, like it's like it's a printed document. So it's been great. I really like it. I've adjusted, I've adapted. And the more you mark up, I think the more interactive you are, however you do it, the better
Chris Dy:see that dog's getting some new tricks. So we have some really interesting cases to discuss today. I've centered around thumb, CMC, I know I sort of surprised you with this topic, with this request, but I think it's been it's relevant. I had some really interesting questions to ask you about it, but first, before we dive into our clinical topic, we should probably acknowledge our wonderful sponsors and friends over at practice link,
Charles Goldfarb:absolutely, the upper hand is sponsored by practicelink.com the most widely used physician job search and career advancement resource.
Chris Dy:Becoming a physician is hard. Finding the right job doesn't have to be join practice link, for free today at www.practicelink.com/the upper hand. Now, one thing I want to ask the folks that are listening or watching, before we dive into the case, is, I grew up in Florida, and I'm trying to figure out how to deal with all the snow. And the question I have is, do you two questions just to throw out there? You don't have to answer tonight. I just want people to tell me what they think you think. Do you salt your driveway, sidewalk, etc, before the snow falls, or do you wait until after the snow falls, and then is there utility in doing like a mid if you have snowfall, and then you got to break for a couple of hours before the next wave? Should you shovel before the next wave of snow falls. So those are the things that I've been struggling with in the last week, trying to figure out those
Charles Goldfarb:are great questions. And I grew up in Alabama, so I'm not going to be the resource to help. This is an epic snowfall for St Louis, because for a couple of reasons. One is typical that 24 hours later, it's 50 degrees and the snow is gone, and we have stacks of snow, which we never do, and now we're getting more snow. I don't know the answer to those questions. I don't have a snowblower. We marginally shoveled, but the reality is, we're sort of just ignoring it and hoping it goes away before neighbors complain or anything. So it
Chris Dy:was so gratifying to shovel the driveway after, you know, I had a case on the, you know, the snow day that we have was on Monday. I had a case that went and then, fortunately, and then my I came out of the case and found that my clinic was canceled, so I just knocked out a bunch of stuff in the office. Had to buy a new snow shovel because I fractured my first one and learned that I needed exactly they were my second store. I was in luck, but I bought two just in case.
Charles Goldfarb:Yes, let's
Chris Dy:dive into our case. So this is one that was sent in by a listener, and for obvious reasons, I'm not going to disclose who, but we appreciate you sending in a case. So this is one in which there's a younger patient, like young by anybody's stretch of the imagination, who had a. Pcectomy and the suspension with a tightrope. I don't know if there's a way around discussing the actual name of the implant, but the pain and is still having pain, and this is, you know, a number of months later. The pain is not necessarily at the trapezium site, but is actually just where the button is on the second metacarpal. The question is, you know, do you in terms of, if you're going to do something surgically, would removing just the button destabilize the construct? And how would you go about that? I mean, I don't have a lot of experience with the tightrope, so I'd love to hear your thoughts. Chuck, yeah, so it's
Charles Goldfarb:an interesting question. I'll start by saying I like the concept of the mini tight rope for CMC. You can use it for CMC arthritis. You can use it for instability. Sometimes it can provide enough stability to kind of solve the problem. I never use it in a primary situation, but it is my go to of choice in a revision situation. The reason I don't use it in a primary situation is one it can be a little technically finicky to get the path directly correct between the base of the thumb metacarpal and the base of the second metacarpal, and that can be a little tricky, not that tricky, but can be a little tricky. And you want to not just hit the second metacarpal. You sort of want to hit the second metacarpal in a way that the button that will be on the ulnar side of the second metacarpal is not too dorsal,
Chris Dy:right? So it's got to be straight, ulnar and not dorsal, right?
Charles Goldfarb:And then you ideally even can bring some fascia over the top to prevent this problem. And so this is a problem. This is a recognized frustration with this technique. And the reality is, I am fully supportive. Knock on wood. I've not had to do this, but we, the person, should absolutely take out the button, because I think that conceptually, you're looking for scar tissue, like you are with an internal brace, and like you are with a trapezium with pinning. You're just looking for scar tissue. And usually that's sufficient.
Chris Dy:So it's, that's, I mean, so a lot of great pearls in there. And I don't have, you know, I think I saw one of these in residency, and then when I got here, nobody was doing it for fellowship, so I haven't really seen it. It's interesting that, and I'm aware of the literature that she described with this being an issue. I mean, you know, you describe that as your go to technique for a revision. Does it matter what was done the first time around? Because then, when I talk to patients about difference between a suture, tape, suspension, internal brace kind of thing versus an lrti, I tell them, you know, my backup is the other one. I don't really even put tight rope in the equation. I think I'm biased because of how it was trained. But when is this your go to like?
Charles Goldfarb:So the benefit of using this technique, that is the mini tight rope technique, in a revision situation, is simplicity. So usually when you're doing revision, no matter what the primary surgery was, you have a bunch of scar tissue which exist where the trapezium used to be. And most of the time you're doing it because there's been proximal migration or subsidence of the thumb Ray. And so the good thing is you can still distract the thumb Ray distally, so you can reestablish that space. It's not like it's scarred in proximally. It's just scarred in and so if you go in and you try to do an lrti Second, or you go in and you try to do a super suture tape suspension plastic second, you got to take out all that scar tissue. You got to think a lot about the radial artery. So the beauty of this technique is you distract the thumb, and you fire your mini tight rope across the thumb, metacarpal to the index metacarpal, and you're done. And I have been super happy with this technique in the revision setting.
Chris Dy:Okay, well, that's that's really good to know, and that's actually a really good segue to our next clinical question. And before we do that, I wanted to discuss our friends over at checkpoint. They've got on February 8, which is coming up pretty quickly, checkpoint is supporting the Ohio State University upper extremity, nerve and tendon surgical skills course for fellows and practicing surgeons. Of course, faculty includes doctors Amy Moore, Kyle eberlin And Holly power.
Charles Goldfarb:To learn more about this program and to register, please visit nerve master.com you can also find the link to register in the upper hand podcast episode description. That's a cue to me to put that in Doctor, I was going
Chris Dy:I was going to send you the email, please do thanks Mecca
Charles Goldfarb:Checkpoint, surgical driving innovation and nerve surgery. And I'm, in all seriousness, that's going to be a great course. Yeah, that's
Chris Dy:going to be a great course. I think that Dr Moore has done a wonderful job, you know, lining up the faculty. I think it's second year in a row they're doing it. And I think it's going to be really. Beneficial. So especially if you're a trainee interested in a nerve, you should go check out that course for
Charles Goldfarb:sure. Let me share in anticipation of our next topic around CMC, I had an interesting patient within the last month that came in. She traveled a bit of a distance, and she had had surgery on one of her thumbs. She didn't know exactly what was done. It was about 18 months ago, and she was really happy. And I asked her what was done. She didn't know, but she shared a whole bunch of X rays. So I reviewed the X rays. It didn't look like a mini tight rope. It did not look like a it definitely wasn't an fcr or an lrti. So I was thinking it must have been a suture tape suspension plastic, although it also could have been a trapezium excision with pinning. But I didn't I asked her about pins. Who
Chris Dy:does that anymore? Well, not in this country.
Charles Goldfarb:So I said, as she said, her doctor was almost apologetic, because there had been proximal migration of the thumb Ray, and it looked like there was bone on bone, based on the thumb metacarpal to the skateboard, and the X ray certainly looked that way. But she was totally pain free. She was happy she was pain free. But it's interesting, because I think she lost a little confidence in the other position, and so she was coming for another opinion. We talked about options and we talked about, basically, for me these days, there's two options. One is a standard lrti, which I told her specifically, in my mind, remains the gold standard. And the second option being the suture tape suspension plastic or tight rope. I'm sorry, not tight rope, suture tape suspension plastic original brace. It was a great conversation. But I think lrti still has a really important place in the treatment of thumb CMC arthritis. I
Chris Dy:think it does too. And, you know, I just, I talked about my bias, obviously, and how it was trained. I did a lot of LRT eyes and fellowship, a lot of lrtis. And I still, you know, will use it in certain situations. I mean, I guess I'd love to know your remaining indications for an lrti in 2025
Charles Goldfarb:and then we're going to talk a little about technical I hope as well.
Chris Dy:Oh, absolutely, absolutely that this is just the opening salvo. So
Charles Goldfarb:as you know, we shared our experience in a prospective randomized trial looking at different techniques for CMC, and the bottom line is, they're about the same. There seem to be that's just, that's
Chris Dy:just chuck flexing his level of evidence on everybody. Look at that so impressive. Last
Charles Goldfarb:time I ever, ever do that kind of study. The reality is, you know, I think the experience in the hands of the surgeon matters a lot, and there certainly is some relative pros and there are relative cons to each technique. I like the lrti. I don't do it that much anymore, because I really do like the suture tape suspension blasting because it's fast. Patients are under anesthesia last time they start therapy within a week, and at six weeks, they're out of a splint. The only catch is, I am very careful not to tell patients they're going to be 100% sooner, so I don't think it's a faster overall recovery. It's just a faster return to daily activities with the removal price. So I don't push lrti on anyone, but there are patients who come in, and I go over the relative pros and cons, and they choose lrti, but I would say it's probably five to one, sutur Tate versus lrti. What about you? When was,
Chris Dy:when was the last time you did an lrti outside of the RCT that you ran?
Charles Goldfarb:Oh, probably six months ago. Okay. How
Chris Dy:many LRT is you think our residents and some fellows have seen they don't see them anymore. So that's actually in the, you know, a little bit tongue in cheek, but that is one of my remaining indications, is MFE, which other program fellowship directors will know, but maximizing your fellow experience. And same thing for the residents. But I think it's an important procedure to learn how to do, because it does remain the gold standard, and I probably need to work a little more in indicating that in the right patient. You know, I think that one topic of discussion, I think one thing we talked about for the RCT that you ran was, could you still do the same rehab protocol you use for your suture tape suspensions with the lrti patients? And it was work out of Utah, showing that, you know, I think you can potentially do that,
Charles Goldfarb:yeah, or close enough. I mean, Utah looked at, I think, two weeks versus four weeks of casting, or was it four versus six? But they looked at a shorter cast immobilization period and demonstrated similar outcomes. So I think you probably can, but the key with the lrti is you have to have enough of a grasp of the tendon used to support the thumb metacarpal, and you do want a little scarring before you depend completely on your suture and completely on the tendon integrity to support the thumb. That's why I like to go a little more slowly. Yeah,
Chris Dy:no, I think that those are absolutely good points. I mean, I think that we oftentimes forget to ask why, or explain why. We slow down the protocol when we talk. Our trainees. So it's good for you to explain that, you know, I think this is an lrti. First off, my remaining indications for TI is that they've had one done on the other side, and they really like it. They don't want anything different, which was one of the reasons why I did one recently, and then I use it in a revision setting, or if you have the discussion about the potential options, and they offer something that's completely autologous.
Charles Goldfarb:Yeah, that's great. So let me, you know, I'm a history major. Let me, let me give a little history here. So Burton and Pellegrini from University of Rochester, first described the concept of the lrti, which stands for ligament replacement, tendon interposition, using either half or the entire fcr. I did some as a resident, but in fellowship in Cincinnati, we did a ton of these, and everyone sort of had the same protocol, which I think is really an amazing thing, where you're doing it the exact same way every time, and patients have really, really reliable, good results. And so it is a procedure we should, you know, every hand surgeon should know how to do, even though we may not choose to make it our first option.
Chris Dy:So I have fond and traumatic memories of LRT eyes and fellowship, because it is a very technique, like you said, like it's a very technically specific procedure. It's do this, do this, do this, do this, do this. Should be the same way every time. And I went back when I had a couple of recent lrtis, which I've had in the last few weeks. I hadn't done it in a long time. So I pulled up my Google Docs from my fellowship and read my fellowship notes, which were very specific and interestingly, very different based on which attending I had worked with, but the one, the one that I remember the most, and perhaps there was a little bit of Stockholm Syndrome, but I wanted to review my notes from review my notes from Dr government's rotation, and reviewed all of those, and I just remember how technical it was. So let's start with the technical aspects. So is in 2025 dorsal approach or Wagner approach? Yeah,
Charles Goldfarb:I am a big believer in the dorsal approach. I have nothing against the Wagner approach, or the Wagner approach. How you say it?
Chris Dy:The Birmingham boy calls it a Wagner approach.
Charles Goldfarb:The benefit of the dorsal approach, as I think we've talked about, is, I think the chances of irritating the either superficial branch of the radial nerve or the LA BC, is far less. And so there's less nerve complaints when you go straight dorsal. But the Wagner approach is elegant. It gives you a bigger approach. And there's certainly nothing wrong with it.
Chris Dy:Yeah, we talked about this in a recent episode, but I think that if you're trying to do the kind of Genie Delson, your suspension plastic that way, I think a Wagner is the way to go. It's very hard to do from a dorsal approach. But yeah, I also would dorsal. So the technical aspects of removing the trapezium, I think, are no different. Do you do anything differently in terms of other than telling your resident fellow to really protect the fcr as you're doing this,
Charles Goldfarb:protect the fcr, protect the radio artery. As I've said, I went through a phase where I didn't identify the radar. I identify the radial artery every time I use hominins, put a Homan in the scape o trapezial joint, and carefully lever it, because you can traumatize the radial artery. And then I elevate soft tissues dorsally, bolily, obviously expose the trapezio metacarpal joint. I have done it every which way. I typically now do not try to excise the trapezium in total. Rather, I subdivide it with an osteotome and then take it out. What's your current technique? Kind
Chris Dy:of depends on who I'm working with and how I'm feeling that day excising the trapezium. The principles are same. I do identify the radial artery. I like the Homans, but before doing the Homans, it's, for me, it's a sharp dissection with a scalpel. Or, you know, depending on what the trainee prefers. They can also use a the cautery to get the periosum in the capsule off so the dorsal part and the initial kind of, as you go to the mid axial line can be with the knife or the Bovie. And then that's making sure to find the radial artery. And then also dissect out the radial artery, because as you come on the different sides of it, you can also encounter some branches that you need to be mindful of, as you know. And then I'll use a the number nine freer, or as our partner Marty calls it, the Dingman, and use the sharp end to kind of get over the edge. And then the rule is, as you get vola, nothing sharp. And I'll use a McLaren after starting the dissection with the home and parking the home, and use the McLaren to get around the bottom. And once you're around, kind of the bottom, and I think that's, you know, the reason to use the McLaren is just to avoid any risk of the fcr. And that's when we decide whether we're going to excise on block or we're going to piecemeal. I very rarely take out an osteotome. I do like the challenge to our trainees to remove on block, and then eventually we just end up taking out piecemeal most of the time, although, I will say recent fellow, current fellow, Eric Jang, has done a great job getting a call. Out on block, and he told me that you take it out on block. So it's interesting that there perhaps has been some deviation that's
Charles Goldfarb:so interesting I'm going to share. I'm going to try something new for our YouTube watchers. I'm going to share my screen open really a random site to show what a maglari is, for those who don't know. And this site is just the first one metatarsal elevator, yep, right. It's a foot and ankle tool that's a little bit sharp on the tip, and it can be really helpful. So I was doing a CMC with Eric on recently, and he said he is working with you, and you love the maglamary. And he you know, I said, Well, we can use the magamerie, but we didn't use the McLaren. I explained why. And I think the mcglamery tool is very good in experienced hands. I think it is a tough thing to take a trainee through, in my opinion, which is one of the reasons I don't use it that often. It's fair, absolutely.
Chris Dy:And I think the other thing I'll say is I every time, never say never, never say, always, but always. I will put a pin in the I'll put a 62k wire in the trapezium and check on X ray, because you don't want to be that person takes out the wrong bone. And sometimes the anatomy can be challenging. If there's some, if there's, you know, dorsal migration of the base of the metacarpal, etc. You just want to be sure this, this surgery is a three shot on three shots on the floor, and that's the first shot is just making sure that we got that the right bone. And then also, I'll use that, if I'm doing a suture tape, I'll use that as a gage of the bone quality, just getting a sense of how good the bone is, potentially. And so whether, and this is just for workflow, whether to open the kit or not, if we're doing a suture tape, but, but yeah, so then trapezium is out,
Charles Goldfarb:yeah, so, well, first of all, I've never used the CRM. I just don't think it's, it's helpful for me. Obviously, I'm not being critical in any way, judgy, maybe, but not critical. No.
Chris Dy:CRM idea. I was down the hall when I got the when I heard the call in a different institution. So,
Charles Goldfarb:yeah, no, I believe it. I do think if you're not going to use a CRM, you need to be obviously, 100% confident of what you're doing, which some listeners are going to be like, wait a second, you took out some someone, not you, not I, took out the wrong bone, or took out the distal half of the scaphoid. Yeah, it can happen. So trapezium is out, and now for me, you know you identify the fcr, I would say 99% of the time you can get a good sense of the quality fcr. With severe arthritis, the fcr can be affected. So you always have to be ready to pivot, whether, again, not, not really necessary, then my next step is to harvest the fcr. So
Chris Dy:how do you now? Well, first off, how frequently and how many times has the fcr not been reasonable quality,
Charles Goldfarb:incredibly, rarely, once or twice in 20 years.
Chris Dy:Okay, perfect. So then, how are you going about initially, like, how? What do you tell patients? Earns a number of incisions, where the incisions are going to be, etc, for getting your fcr out
Charles Goldfarb:right. So longitudinal, dorsal incision, for the exposure for the joint and the trapezium, I make one additional incision, and that additional incision I use the width of my palm, which is about 10 centimeters. I start at the risk crease, and then at the kind of directly over the fcr proximal to my little finger. So roughly here I make a small transverse incision. I'll just keep going. I spread after the incision, I spread down identify the fcr that's usually at the level where the fcr tendon is visible as it originates from muscle
Chris Dy:attendance junction. Thank you. I
Charles Goldfarb:isolate it. I 100% confirm I have the fcr by working back into the hole that is the original incision. Once I'm positive I cut it there. What do you do?
Chris Dy:I do it differently. So a First off, yeah, I was love it when surgeons say things based on the width of their hand. There was a surgeon in residency who swore that the radial nerve was always the width of his hand above the lateral epicondyle. Like so repeatable, so accurate, sure, but I will make a a about a three centimeter longitudinal incision over the fcr just proximal to the risk crease, identify my fcr there, do your various checks to ensure it is indeed the fcr same as yours, but also including making sure none of the fingers are moving, because you don't want to be that person either. And then I'd make a, you know, I'd like to get it, you know, in terms of transecting it, I agree with transacting at the musculotend in this junction. I will make a couple of small transverse counter incisions, you know, to to free up the fcr tendon. And then the more proximal counter incision is where I divide the F. Our tendon in the recent case, I was really because I was like, I probably didn't need this second counter incision, but, and because I didn't need all the length, I just didn't ever want to run out of length on this one. And so, yeah, I repaint the penalty of cutting the cutting the tendon, so I will then make sure it's completely free through the incisions, and then divide it to approximate the musculotend in this junction, pull it into the main to the to the volar wrist incision, and then try to pull it through from the from the from the dorsal thumb incision, you know, just by freeing it up and then pulling on the fcr there, I remember Dr gelberman, at least in my notes. So there may be something lost in translation, he would make a separate he would try to at least have a separate subcutaneous tunnel in passing an instrument from the main dorsal incision into the volar incision. And I have not found that necessary in practice.
Charles Goldfarb:I will say that the benefit of the Wagner incision is when you curve volar along the wrist crease, you get a second access point to the fcr tendon. But I will strongly say that I don't think you need it for me. One small incision, 10 centimeters proximal to risk. Freeze the width of my hand.
Chris Dy:Everybody, go measure the width of your hand. I should. So actually did that in residency. I measured the width of my hand because I kept asking, like, how is my hand compared to Dr so and so, I'll say, Dr Hotchkiss. How does it compare to Dr HOTCH gets his aunt Well,
Charles Goldfarb:you know, it's funny, because I was talking about this the other day. Michelle Carlson, Michelle Gerwin, when she wrote the paper, talked about where the radial nerve came in, tearily, and it was 10 centimeters proximal to lateral epicondyle and I this week said, you know, in a kid, you can't count on 10 centimeters, but it's a valid, valid point. But for me in the or it works every
Chris Dy:time in my hands, yeah. So you
Charles Goldfarb:harvest the whole tendon, not a Hemi tendon, or half a tendon. I think if people who take half the tendon, absolutely have to have the counter incision. If you're taking the whole tendon, which is what I do, I don't think you need, you don't always need the counter incision.
Chris Dy:Why do you take the whole tenant on half of the tendon? Because tendon? Because I end up taking the whole tendon, and sometimes I end up using half
Charles Goldfarb:of the tendons. I take it and use it. I just think it's easier and faster. And I don't think patients complain ever about the lack of the fcr,
Chris Dy:right? Do you think it? Do you think taking less tendon would potentially lead to less soreness? Because I think that is one complaint that I've least heard historically reported about the fcr. It
Charles Goldfarb:could, absolutely could. Um, don't know, I just don't get complaints about it. And then maybe that's because I mobilized for four weeks in the cast. You know, they would ask, or they would ask,
Chris Dy:all right, so then, so we've got the fcr into the main incision, whether that's a Wagner or a dorsal approach, whatnot. So
Charles Goldfarb:I take a 2.5 millimeter drill bit and we have a little set. Where's it? 2.5 3.5 4.0 and 4.5 I usually we
Chris Dy:used to have a little set at my place, and now, since I didn't use it for so long, they sent it away, which was no painful point of contention, which I will bring up next time I do an fcr at that R, A, L, R, T. I at that place. Yeah.
Charles Goldfarb:So basically, you want to be in the plane of the thumbnail. You want to drill a couple of centimeters proximal to the base of the thumb. Metacarpal. I drill straight in in Dorset of volar. Once I get into the medullary canal. I pull back, drop my hand, and I try to exit at the vola articular surface of the metacarpal. And once you do your first drill bit, you quickly do a second and third drill bit, 4.0 is almost always sufficiently big enough to pass your tendon. So talk
Chris Dy:about the you talked about the McLaren and how it's hard to, you know, have somebody else do it through somebody else's hands. I find that to be really hard, the drop, the initial dorsal volar drop, and get, you know, so it's like we could do it, they can do it, but me trusting them to do it without having done that case a lot. So I make two separate drills. I do two separate passes, Dorset and roller, and then through the articular surface to, you know, just to open the measured layer canal. And do you often you go to a four? Oh, every time.
Charles Goldfarb:Yeah. I mean, if I'm using the whole tenant, I go to a four. Oh, and I guess if someone was really small, as in metacarpal width, I'd be a little careful. But no, I do. And I think the other technical Pearl is that drill hole cannot be directly adjacent to the base of the metacarpal, because you can break through that bone. So you have to go, that was my
Chris Dy:next question is, how do you ensure that your tunnel is big enough for when you're drilling and moving up in those drill sizes, and then also when you're passing a tendon? It may be a little tight,
Charles Goldfarb:yeah, I wish I could say exact measurement, but I think if you're two or three centimeters, probably
Chris Dy:the width of your the width of your pinky finger,
Charles Goldfarb:maybe that. Maybe that's it. I'll look next time. Yeah, I think you have to be careful, because otherwise, then you got a more challenging issue if you break through the bone. Which, which can happen. But knock on wood, I don't recall it happening.
Chris Dy:Right, right? Yeah. So you're using. The whole tendon. How do you pass the tendon through the tunnel and which direction do you pass it in? Right?
Charles Goldfarb:So to me, this is the buttsiest part of the procedure, because I want to be I want to not open things that we don't really need. So trying to save money and not waste too much time. So you know that your fcr tendon is attaching to the volar base of the second metacarpal. And the whole concept of the procedure is you come, you bring the tendon from deep exiting out the dorsal aspect of your thumb metacarpal. So now you've linked your thumb metacarpal to its deep second metacarpal insertion. And how you get it through. I usually have a whip stitch in the cut end of the fcr, long enough that I can sort of pull it through and hopefully wiggle it through without too much difficulty. I don't know of a simplistic approach. I'd love to hear a pearl from you, but that's the funciest part of the procedure. Yeah,
Chris Dy:I just opened the Houston suture passer because it's just easier. And I get it. I get what you're saying in terms of cost, but also time of the or so, the whip stitch, I think, is super helpful. And then I use the whip stitch and kind of tubularize the the end of the tendon. And I've probably, at that point already gotten run rid of the muscular, whatever muscular attachments are there, whip stitch it, and then pass the whip stitch through with the so I passed the Hewson suture passer. You could honestly just use, like a viral and loop it around, or whatever sutra that you have, and loop it around and put the loop through from dorsal exiting the articular surface, pass your other stitch. Use that passing stitch to bring the tendon from articular surface out dorsally. And then I use a smooth, non tooth forcep to help wiggle that through little irrigation, little prayer, make sure the tunnel is big enough.
Charles Goldfarb:Yeah. All true. All true. And then from there, you now have your tendon exiting dorsally. And while I'm distracting the thumb, I use a two oebon to either grab the tendon itself as deep as possible, or some bowler capsule you don't want to take too huge of a bite. And then I suture tendon to tendon as deep as possible I can do. And that can be a little tricky as well, but one or two sutures there anchor the thumb in a distracted position. Do you loop your tendon at all? I do not. I Well, I'm not sure if I know what you mean by loop. But first I just I suture, tended to tender, tended to capsule. And then I do my favorite suture of all, the dolphin stitch, the
Chris Dy:Haven stitch, the PTSD from the dolphin stitch. And fellowship with you. And Galbraith, oh, it's
Charles Goldfarb:great. So for those who aren't familiar with the dolphins, I hate
Unknown:it so much. It is awful. It's so unnecessary.
Charles Goldfarb:So the dolphin. So to do a dolphin stitch and appreciate its magnificence when you
Chris Dy:This is like, this is really like, hand surgeon, like, nerdiness, right here the dolphin stitch. It's
Charles Goldfarb:a way to accomplish an anchovy or a balling up with a tendon, and put it into the space where the trapezium used to be. And so basically you put, usually, in this case, I put two stitches in. So the first stitch is done, cut short, and that's 10 into tenon. And then I put another deep stitch in, 10 into tenon, and I leave the needle attached to the long end of the suture, and then, essentially, I hold the tendon up, and I kind of whip in and out, exactly like a dolphin. And then at the end, you have your suture, and you have your tendon, and you can just scrunch your tendon down into the wound, and you have a beautiful anchovy. And then you can close your capsule and get out of dodge.
Chris Dy:So I was going to ask you, do you use a suture anchor? In this case, it sounds like you don't, if you're minimizing cost.
Charles Goldfarb:Oh, my God, yes, I do not, because I clearly am more cost conscious than you, even though I'm not sure you use an anchor. I know our partners use anchors. I used
Chris Dy:an I mean, I use an anchor because that's how I was, at least the procedure I remember the most, whether it was embellished in my and burned in my brain, for so many reasons, I use an anchor and then I accomplish the what you're doing with the dolphin stitch, with one of the one of the sutures coming out of that anchor, and just cinch
Charles Goldfarb:it down. Wait, be clear, where are you putting your anchor?
Chris Dy:So the anchor is at the the trapezoid. Okay, so it's a the cheapest anchor in the set. It's an old anchor. I don't even realize. I'm surprised I still make it, to be honest with you, it's got a two Oh, at the bond or suture in there, and I use one of the needles to, I will physically roll the the tendon up with the tooth less forcep inside of it, and then have the have somebody pass the suture through a couple of times, and then remove the forceps. And then you just cinch it down with your finger, because you've got your other part of the suture. Coming out of the anchor as your post. Yeah,
Charles Goldfarb:that's great. So an expensive way
Chris Dy:to do an lrti, apparently, with a Houston suture passer and an anchor
Charles Goldfarb:and the CR so my procedure, the TAC, you
Chris Dy:don't take a CRM at the end. Nothing to confirm what that you did, what you're supposed to do, that you've got suspension without anybody holding the thumb. Nope,
Charles Goldfarb:I can see that and feel that and be confident in that. Oh, my God, if someone from Blue Cross Blue Shield is listening, there's the Goldfarb technique about $120 and there's the D technique coming in at 1500
Chris Dy:No, it is not. I will look, I will show you the receipts from our logs, at least what we what the hospital charges for the the cheapest sutra anchor in the set. Yeah. And then question for you, how often you check an X rays after this, like in the office?
Charles Goldfarb:Yeah, that's fair. I used to get one at six weeks and get one at one year, when I made everyone come back at one year. I don't get any X rays after if there's a concern about painful impingement, I will get a mini C arm or a standard x ray. But I don't routinely X ray, do you?
Chris Dy:I try not to for the same reasons, but it will obviously very low threshold to get one if there is a concern aside from the routine post operative discomfort, and if they do as expected in terms of normal trajectory of recovery, then no X rays. Yes,
Charles Goldfarb:it's funny. When I was a younger man, I was involved with the aaos, the Academy's CPG for CMC, so clinical practice guideline for the CMC joint, and we were discussing kind of what needed to be included in the clinical practice guideline. And discussion of X rays came up at the time, I was adamant about at least getting a couple X rays while I followed the patients over the years preoperatively, and it became clear that the more experienced people in the room barely got X rays pre op. You don't, you know, you know the diagnosis you're treating the diagnosis. I do get 1x ray pre op? I don't think it's necessary, but just the whole need for X rays to assess or confirm just seems less important to me over time.
Chris Dy:Yeah, so I'll get an x ray if it's coming to surgery. I'll say it's for pre operative planning. I will do it when they're on the way out the door, and I will do it in the formal X ray system so that if any insurer questions, it is there for them to see, and they don't have to dig into my CRMs or into my note to find it.
Charles Goldfarb:Yeah, that's fair. It's probably smart. It's probably smart. So again, lrti is a gold standard. I strongly feel it's it maintains this position there. It's a great operation. I think a lot of people still do it. Maybe, maybe a study down the road could be looking at some large databases to understand but no
Chris Dy:more studies on LRTs, please. I think that was from you. So yeah, we can we talked about 3030, minutes about lrtis, but we'd love to hear how listeners do it. Send us a note hand podcast@gmail.com or leave it in a review and let us know.
Charles Goldfarb:Have a great day. All right, you too. 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 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, and remember,
Chris Dy:keep the upper hand. Come back next time you.