Mailbag and FPL Tendon Reconstruction

Chuck and Chris discuss several listener submitted questions and comments on the CMC joint as well as a case of TFCC pathology.  Our focus is FPL rupture and reconstruction- we discuss interpositional tendon graft and FDS transfer.

Flexor Pollicis Longus Reconstruction After Rupture Following Distal Radius Fixation With Volar Locking Plate: A Technique Guide.
Welbeck A, Goldfarb CA, Calfee RP, Dy CJ.
Tech Hand Up Extrem Surg. 2024 Sep 1;28(3):124-128.  PMID: 38516925

Our surgical follow- up article will be published in JHS Go but is not yet available.

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As always, thanks to @iampetermartin for the amazing introduction and concluding music.

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Transcript

Meeting summary for Pod (02/01/2025)

Quick recap
Charles and Christopher shared their personal experiences and discussed various medical procedures, including recent surgeries, ice-related injuries, and hand injuries. They also discussed patient cases, surgical techniques, and the importance of maintaining broad exposure to different procedures. The conversation also touched on the risks associated with ulnar shortening, the management of FPL ruptures including preferred techniques for tendon grafting and reconstruction.

Next steps
• Consider having Warren Hammert as a guest to discuss metaphyseal shortening techniques.
• Christopher to share fellowship interview experiences in an upcoming episode.


Summary
Casual Conversation on Injuries and Treatments
Charles and Christopher had a casual conversation about their recent experiences. Charles shared his recent local anesthetic surgery and the subsequent black eye, while Christopher shared his experiences with ice-related injuries and hockey travel.  They also discussed the effectiveness of different treatments for hand injuries, with Charles mentioning a tip from a viewer on YouTube about ice and the CMC. 

Snow Shoveling and Surgical Procedures
Christopher and Charles discussed their experiences with snow shoveling and the challenges of maintaining a pristine driveway. They also discussed their views on the TightRope and LRTI procedures, with Charles expressing his belief that LRTI is the gold standard. They agreed on the importance of maintaining a broad exposure to different surgical procedures, despite the randomness of practice- for education and patient care. They also mentioned a listener's email and the sponsorship of the Upper Hand by PracticeLink.com, a widely used physician job search and career advancement resource. 

Wrist Pain and TFC Tear Discussion
Charles and Christopher discussed a patient case involving a young man in his forties with wrist pain, positive ulnar variance, and a complex TFC tear with likely foveal involvement. They agreed on the importance of addressing the TFC tear, possibly through a foveal repair, and performing an ulnar shortening osteotomy. They also debated the sequence of operations, with both typically performing the scope first.  Both would be repair the TFCC and shorten the ulna, formally with a plate.  They concluded by suggesting a future guest, Warren Hammert, to discuss metaphyseal shortening techniques. 

Risks, Expansion, and Personal Experiences
Charles and Christopher discussed the risks associated with shortening and the importance of not doing things in stages. They also reminisced about the past, mentioning VCRs, cassette tapes, and laser discs. Christopher mentioned that Checkpoint Surgical is expanding their biomaterial portfolio with the launch of ACM Shield, a dehydrated placental membrane allograft for use as a protective barrier in surgical applications. Charles and Christopher also shared personal experiences, with Charles mentioning his training days and Christopher recounting a recent trip to Wisconsin with his son for a youth hockey tournament. 

FPL Ruptures Post-Distal Radius Fixation
Christopher and Charles discussed the issue of FPL ruptures following distal radius fixation. They agreed that while it's possible to predict ruptures, it's not always clear. They also discussed the importance of keeping a close eye on patients post-surgery and the potential for complications down the line. They discussed different surgical techniques, including the use of interposed autografts and tendon transfers. They also discussed the management of the pronator quadratus (PQ) during surgery, with Charles expressing skepticism about the effectiveness of reapproximating the PQ. Christopher suggested the use of the brachioradialis to repair the PQ. They concluded by discussing the importance of contributing to the literature on this issue, with Christopher noting that their technique article had been helpful to others. 

Tendon Grafting and Reconstruction Techniques
Charles and Christopher discussed their preferred techniques for tendon grafting and reconstruction. Both agreed on the preference for interposition tendon grafts, with Charles mentioning his experience with pediatric patients in regard to using an FDS transfer. They also discussed the challenges of tendon harvesting and tensioning, with Charles explaining his method of using the transverse carpal ligament as a pulley. Christopher shared his experience and the importance of maintaining appropriate glide. They also discussed the potential for re-rupture and the option of an IP fusion. The conversation ended with a light-hearted discussion about their respective Super Bowl picks.