Welcome to the upper hand, where Chuck and Chris talk hand surgery.
We are two hand surgeons at Washington University in St. Louis here to talk about all aspects of hand surgery from technical to personal.
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Oh, hey, Chris.
Hey, Chuck, how are you?
I am well on this fine morning. How are you?
I'm good. I'm trying to figure out what the weather's supposed to be like in St. Louis this time of the year, you've been here longer than I have.
It is unbelievable because, you know, for late September, early October, it was freezing in this Alabama boys opinion. And now it's you know, and by freezing I mean, in the 30s. And now it's gonna be 80 today, I think again.
Yeah, I'm hoping to get a few more days on the grill this weekend. I think that'll be nice. That's all I'm concerned about.
So here's a practical thing that my wife and I've been talking about. We have teenagers, and they do get together with their friends, we insist to be outside, we insist to be socially distance. And about three months ago, my wife said, you know, if we're going to continue this, we need to order some outdoor heaters, or firepit. And we did both. And now you cannot find those items. They're unavailable. It's fascinating,
Wise.
Yeah, I look, I know where the brains are in the family.
Nice. That's a sign of a good leader.
Who knows who the leader is?
So any, any fun cases recently?
You know, I did. I had a great case. Um, you know, I really enjoy elbow arthroscopy, and just the elbow in general. And I've always wondered why that is well I like sports and I like scoping. That's part of it. I think the other part of it is it feels a little unconquered. To me many areas in hand surgery. You know, you kind of there's been a ton of research and you know, what will happen if I do A, B and C but the elbow I think we are still learning we are still figuring things out. So I had a
10 year old with an OCD. And that's a you know, that's young. Certainly we see that. And the interesting thing about her OCD, it was one it was large, and two it was repairable, which in my experience, people talk a lot about repairing them.
microfracture drilling, and then OATs and all of those have a role, I will be honest and say that it is super rare that I have found patients that can be repaired that is put the cartilage, they avulsed or they you know, the cartilage is free floating back into the deficit, and that requires reasonable bone on the cartilage. That case was fun. It was a little challenging, and I think it offers a chance of the best possible outcome. Now we'll see if it heals,
I think elbow it remains one of the black, a couple of black boxes in hand and upper extremity surgery. I've always admired how you dove into the black boxes, the ulnar sided wrist pain, the elbow pain, I think it's fantastic for for you to look for challenges, and especially as your partner to be able to send you patients with these types of conditions. So kudos.
Well, I appreciate it. And thank you for saying that fun, fun for me, hopefully good outcome for the patient and more to come.
Yeah, and if anybody is listening and is thinking about our fellowship or our residency, that elbow arthroscopy experience with with Chuck is fantastic, and is one that is a little bit hard to come by on the fellowship trail. So if you're checking us out, make sure to keep that in mind. I know things are a little different this year in the virtual application season. Now, Chuck, do you mind if I share an email that we received recently?
I would love if you shared an email we received.
Well, so thank you to Bob Vandemark, a fantastic practicing hand surgeon out in South Dakota, who has been listening to us and he says that we hit a home run with the three Part Dupuytren's podcast, adding Charlie Eaton was a treat for sure. The podcast was one of the better presentations I've ever heard about Dupuytren's. Your podcast is a great addition to my drive to work. It is only a 10 minute commute here in South Dakota. Wow. But it is time well spent. So thank you to Bob for
that wonderful feedback. We certainly appreciate it.
That is super kind and certainly, you know we appreciate it. As we've said many times the comments and the reviews are what drive us. I had two patients last week two Dupuytren's patients who had listened to all three podcasts. And that is not our, our I don't want to say intended because we love it. But that is not the audience we thought we would attract and so we're still figuring it out who's listening.
Yeah, I think there are a lot of different audience segments that have tuned in and we've been pleasantly surprised You know, at some point maybe we'll have a patient on the podcast if that segment continues to grow. I've had a couple come in, say that they've heard about the podcast and listened to the ones on carpal tunnel, etc. So, so one more, one more segment that we'd like to introduce here. Thank you to all of our listeners, wonderful community of surgeons, therapists, trainees, patients.
We read a review a couple of weeks ago from Anna ML Sloan, in which she talked about how much she loved the podcast. Thank you. And she also asked us a question and maybe we could start a bit of a grab bag. So if you have any additional questions outside of this one, feel free to leave it in a review or email us at handpodcast@gmail.com or tweet at @handpodcast and we'd be happy to answer it on the on the air here. So Chuck, Anna's question was do you use the Burton Pellegrini method for CMC
arthroplasty? And what are your thoughts on comparing that method to other types of CMC- CMC arthroplasty surgery.
Yeah, we may have even touched on that a little bit. I think it's a great question. And it's interesting. I have a little bit of an unusual case coming up where I'm considering an interposition tendon graft for an FPL rupture. And I was searching through Hand-E on the hand society website, and I found a video which I did not have time to watch, which was discussing. Is there a role for the Burton Pellegrini LRTI anymore, that
was one video. And the other video is the gold standard, the Burton and Pellegrini LRTI and they're both within the last two years. So I think the reader's comment slash question is a good one. And, you know, as as Chris knows, and I think we've mentioned we are in the midst of a prospective randomized study, for better or worse, looking at two what I would say are increasingly, you know,
prevalent treatment options. So we are doing the classic Burton and Pellegrini, trapezium excision and FCR interposition arthroplasty as one option and one limb of our randomized study and the other limb is the suture tape, suspension plasty with again, trapezium excision. And so when I describe this, these options to patients, and some will disagree, and I hope those who disagree and maybe Chris is one of them, but some will disagree. I say to patients, the gold standard is the Burton and
Pellegrini arthroplasty. And I really do believe that it's the gold standard, because we know what happens over 15 to 20 years, we know it's not perfect. We know there's a long initial recovery, but we know it's a really good operation and it has stood the test of time. And now on the other hand, we have these newer options, one of which is the suture tape suspension plasty which is really good. And it's a fast recovery, but we don't know what happens down the
road. We have lots of clues and suggestions, that it's a good option. So in my hands, the Burton and Pellegrini, which is the way I do it, is a really good option is how do you see it?
You know, I see them both as good options. I think the clincher is honestly the surgeon comfort with initiating motion and subsequent strengthening. And I feel like we've done it, at least in our group. We've done it for so long, in the same way with the Burton Pellegrini. And admittedly, were a little more conservative with the rehab protocols after Burton Pellegrini, because like you said, you know what you're going
to get, it is reliable. You know the outcome you're going to get with that surgery and with that rehab protocol, whereas with the technology that we've seen with the suture tape, and the interoperative inspection, we tend to feel a little bit better about how stout that is. And I think we allow ourselves a little more leeway, and
accelerate the rehab sooner. And I think that's going to be a key and I know that Nick Casmers and his group over in Utah, one of our former trainees have looked at the impact of the different therapy protocols after thumb, CMC arthroplasty of all types and it is all over the map. So
that's a huge variable. And I think that's one thing that maybe we could even dive into on a future episode is specifically looking at the rehab after a thumb, CMC arthroplasty so looking beyond the surgery choice, but even beyond these two options, a Burton Pellegrini and a suture tape augmentation, you even have the Welbe which a lot of surgeons have used with great results, and then even more simplistically, the, the FCR suspension, just this heavy suture that Jean Delsonur has
described and she's had great results and Peter Weiss has shown great results with that. So there are a lot of ways to do it. I think the key is A) getting the trapezium out, and then B) finding a way where you can suspend things with confidence and then initiate the rehab protocol of choice.
Yeah, good stuff. I do think we should write that down. We need to do an extensive podcast on both non operative care of the CMC arthroplasty patient because there's actually good literature with an incredible, highly successful rate of avoiding
surgery. And then we obviously have the post surgical care and I'll say one of the things I had another patient come in with bilateral CMC pain, wanted surgery and asked if she could have bilateral surgery, which I used to think was crazy, actually, I still think it's crazy. But I've had two patients who've asked for it and I've done it with the suture tape, and they have loved it. I would never do that with a Burton Pellegrini. It's just too tough
and the recovery's too long. So it's a crazy thing in my mind, but it's just another way that patients help us forward with our forward thinking.
I'm gonna add one more thing. I think that's an interesting pearl that I learned from a recent fellow research project. So Jeff Stepan last year is one of last year's fellows in our hand fellowship, who is now in practice at the University of Chicago. His fellow research project was a qualitative study in which we asked patients who had a CMC arthroplasty, what their experience was like, and specifically what they wished they knew, heading into surgery or what they wished they were
told. And the biggest thing that came about was the duration of recovery. We tend to undersell how long it takes to get over the surgery. And patients wished that we told them how long they really would take to get over it in terms of until their thumb felt better. And in preliminary analysis, it looks like it's probably six to nine months until they are feeling much better. And we probably tell them a little bit shorter.
Another interesting point was that the therapists have actually course corrected for us so that when they start to talk to the patient, say, Oh, no, no, no doctor, so and so it didn't really mean that, they meant that it would take you this long instead. So that's something that I think we need to keep in
mind. And I've tried to incorporate into my discussions with patients recently makes them a little less enthusiastic about surgery, to be honest with you, but at least I'm getting in front of some expectations early on.
Well, and that's interesting, because we're going to get to the concept of patient satisfaction here in a couple minutes. When we get to the meat of our discussion, before we jumped into a highlights or takeaways that Chris and I had from the hands society annual meeting, I do want to reiterate that our we have a partnership with QxMD, I continue to use their Read app, which helps me identify and as Chris nicely labeled it as an
aggregator. It helps me identify articles, I'm pretty good about keeping up with the literature. But using search terms that you know, I get a regular email with terms, anything from elbow arthroscopy to OCD, to thumb polydactyly. And it just helps me keep on top of things. There's different ways to do it, I found this one would be pretty helpful.
And it's easy to set up too. So quick download from the whatever app store that you use. And then you just enter some information and you're off and running.
Absolutely. All right, let's pivot. So we recently completed as you know, we're, you know, a few days after the 2020 Hand Society annual meeting, which was virtual. Some of it was pre recorded, some of it was live. I'll give you my biggest takeaway. It's, it's they pulled it off is my biggest takeaway. And it was far more than a zoom meeting, for the timeframe and for the effort, I think they did
a wonderful job. And the bottom line is I learned stuff, and I had a good time, I would have had a better time had I been there. I thought it was great.
The format was really cool. So for some of the bigger keynote type sessions that would have been in the main theater, you know, at the- at an in person meeting, there was a really cool virtual platform that was polished had engineers and editors working on it production experts, certainly a lot of rehearsal time going into it. But to be honest with you I think that rehearsal time was in fact well spent, and so much effort from the hand society staff and from the program
chairs put into it. And you know really kudos to all the ASSH staff members and to Dawn LaPorte and Ryan Calfee.
For sure. Totally agree. Well said. So why don't we I do I think what we what you and I had discussed is that we would go over some of the award winning papers, just because I think that's interesting. And I they're just such an important part of our society. And yet they send a strong message about what matters. So I would like to go through some of those papers and we don't have the actual papers and I didn't see honestly all the presentations, but we had the abstracts and you and I had
a chance to review. But before we do that, why don't we talk about our biggest takeaways, whether that be tangible knowledge gained, or whatever. Share a couple with me from from your perspective and I know what it's going to be about it's gonna be nerve nerve nerve.
So I again, it is about nerve. I was supposed to be the 2019 to 2020 hand society Gelberman traveling fellow. That experience was cut short by the pandemic and I hope to resume it soon, but one of the trips I was supposed to take was to go visit professor Jaime Bertelli in Florianopolis, Brazil, somebody who is increasingly recognized as a preeminent, you know, leader and scholar in peripheral nerve Plexus and nerve
transfers. And he has a high volume of patients, he's got some innovative techniques, and then he presented some interesting concepts, which have kind of crept into some of the technique papers in the past, but to hear him present it in context is always helpful. So the thought of potentially transferring the anterior interosseous nerve at the mid forearm into the distal aspect of the posterior interosseous nerve to treat a radial nerve
palsy was interesting. And that's separate from a nerve transfer more proximally to restore wrist extension. So this is for that last part of, you know, finger extension EIP EDC, EPL, that kind of thing. And I thought that was interesting. anatomically, I find it very interesting. And I can't wait to get into the cadaver lab to take
a look at that. He also presented another interesting transfer, which I've seen him publish in the past to treat restore pinch by transferring one of the thenar branches over to the, to the adductor pollicis. And I think that's a terrifying operation but could provide some really great results for that last part of ulnar intrinsic function that we all struggle to get.
Yeah, good stuff. All right, I can go I don't know if you have more but I have a couple. The first thing I learned and I do really value the topic of leadership is I really like Raja Sabapathy's guest, I think his guests Nation Address and, you know, Raja was representing India, which was the guest nation. And he was a presidential invited speaker, and our institution, and especially Marty Boyer has a close relationship with Raja who's just a wonderful person,
and has a lot to share. And I thought, his lecture about the building of his practice, the building of his hospital, the development of his site, as an international resource for micro education was phenomenal. It was really a great talk. And I think the story that I loved best was the story about the helicopter. And, and I think that, you know, they've come such a long way.
And they, they, his hospital was able to develop, I think the first in India, and it was publicized as such, and there's a lot of press that they had a helicopter, which could bring patients from injury, you know, from other sites to the Ganga hospital for surgery, you know, huge fanfare, everything was going great. And then eight months later, they had to close down the service, because it was more than whether their hospital was ready to provide that
service. It was whether it was about the country being ready and other areas being ready. It's just an interesting leadership, and experiential note. So I thought that was fascinating. I thought the talk was fantastic.
It was a great talk. And and, you know, the thing I took away from that was, imagine if you could create a value structure for healthcare delivery from scratch, that's essentially what he's done. And I find it fascinating that he's able to deliver his hospital is able to deliver high volume,
high quality care. And it starts with the attending surgeon going and seeing the patient in the emergency room, they are the first person to assess the patient, so they know exactly what the plan is going to be from the very beginning. And that surgeon then determines how much the patient's going to pay, which I think is fantastic, it's transparent, they pay what they can, and they deliver the same quality of care to patients, regardless of what they end up
getting. So I mean, I visited the Ganga hospital as part of our fellowship. And, you know, thank you to you and Marty for supporting that. And anybody who's looking at the fellowship that typically is a component of the year, it's a fantastic place, and to see him distill it in such a manner was really was was great. And it's fortunately is going to be available available on demand for anybody that has registered for the meeting.
Yeah, and innovation. And we talk a lot about innovation. We all want to be innovators. You know, some of our brains are wired that way, some of our brains are not and
that's fine. But clearly Raja is an innovator and the concept of having an anesthesiologist also meet the patient super early and and provide an early block, which just makes the whole trauma process so different, is again, huge innovation, whether either of those things are doable in the United States that is the surgeon always seeing the patient is in the ER first and whether an early block is possible. Maybe not. But maybe it's something we aspire to.
Yeah, there is a program that it when I was a resident at New York, at the Cornell, New York Presbyterian system, they were trying to do an ER early spinal block for patients with hip fractures. It never took off for a number of reasons. But same concept. I mean, it makes sense. You know, once you get an exam on the patient, you know what the diagnosis is, you know, eventually where it's heading in
terms of management. Try to make the patient comfortable as those patients are really uncomfortable.
Yeah, I know we need to move on to our topic. But I will say this I was fortunate enough to be involved and help lead a pre course on arthroscopy, that was pre recorded. And it was great. It had some of the giants and wrist arthroscopy in the world. And it was co co moderated by P.C. Ho, and Paco del Pinal and, you know, they're both fantastic. They're both again, innovators, they're clear thinkers. And, you know, in a field like arthroscopy, you know, everything looks initially like
you've gone too far. Like, why do that arthroscopically when it's so easy to do in an open fashion. And so P.C. Ho, is doing his scapholunate reconstructions arthroscopically. First of all, it seems like a lion's task. I mean, it's a it's a massive undertaking, it does seem far more challenging than it would be open. His early results seem really good. He's optimistic. I will say my hesitation in the technique I currently use is that I am even with a ligament
sparing approach. I don't think it's truly ligament sparing in all aspects, I think we are potentially further destabilizing the carpus in an effort to reconstruct the scapholunate ligament. And so the concept of an all arthroscopic repair is appealing. But man right now, it feels like a massive mountain to climb. And I don't know whether it'll simplify. But I applaud folks like PC who are pushing the envelope and trying to bring our surgical discipline in the forward direction.
Along those lines, I saw a great presentation by Scott Wolfe on his current algorithm for scapholunate instability, and he's not pushing an arthroscopic approach. But you know, to the point that you make, he is working. He's now using a front and back volar dorsal approach to reconstruct those ligaments and that may have some issues. His results have been great as
of Michael Tonkin's. So perhaps that's the way I mean, that's a huge area in which we still are going to see a lot of change, I think in the next 15-20 years, hopefully for the better in hand surgery.
Absolutely. All right, let's jump into the award winning papers. And maybe let's I don't know if you have a preference, but why don't we sit Why don't we start with perhaps the hardest one for us to discuss, which is Du Bois award winner. And that represents the best resident-fellow paper. The title is ectoderm derived went and hedgehog signaling drive digit tip regeneration. The presenter was I hope I don't totally get his name wrong.
Janos Barrera. And it really interesting basic science paper. Thankfully, from congenital studies, I know a little bit about the signaling mechanisms. But this paper, I think it'll be great to see the actual paper, because the abstract probably doesn't do it justice, what were your takeaways and maybe briefly summarize their findings more than I just did, if you can?
Sure. So I mean, my takeaway was that this is something that I was going to turn to you to discuss because more in your world in mine, I agree with you on wanting to see the whole paper. Because, like you I'm not a basic scientist, I'm not a lab scientist. So I think it's helpful to see really effective illustrations of work. The biggest thing that comes to mind is what I'm working with, with our partner, David Brogan on on his lab work, and I just need to see the illustrations.
And I think the biggest contribution I have is helping him make those illustrations understandable to people like me who are unfamiliar with the basic science. Yeah, so as a non congenital surgeon, I think it's really difficult for me to take a whole lot away from this, to be honest with you.
Yeah. And so let's just keep it really simple. We talk about kids as being salamanders, and having the chance to regrow injured digit tips and how do they do
that? So great question. And certainly this paper doesn't suggest it has the answers but it looked at murine digit tip seven days after amputation and did a micro array analysis so genetic analysis, and it confirmed that went I don't know if it WNT 7A, which is the one I'm most familiar with from from limb formation, and hedgehog, and I assume it's sonic hedgehog. It looked at the importance of those two signaling mechanisms to help in digit tip regeneration. so
fascinating. I look forward to learning more, but you know, really good stuff. It's always interesting to me when we get these basic science papers that win the resident fellows award, because while a resident fellow was undoubtedly involved, this is the sign of a bigger lab with clearly a lot of power behind it.
Why don't we talk about the the paper that you had mentioned before about patient dissatisfaction, you know, so this is a poster entitled patient dissatisfaction after highly, quote successful hand procedures from Orrin Franco and William Slicker and this word, this won the the Bruner Award for Best clinical poster. So this, this was really interesting to me because they actually set up our prospective hand surgery database, which in
and of itself is a feat. And from a hearing registry, the registry and prospective study symposium that you chaired at the meeting, and Kevin Chung's presidential address, you know, registries and setting up a national database is going to be a big push for the hand society and the hand surgery community in general.
Yeah, so Orrin is a good example of a forward thinker, and he's passionate about technology. He did the stern fellowship, and I've gotten to know him a little bit through that process. And he has, I don't want to get it wrong. And I apologize if I do, but he has a business. And he helps practices of all varieties collect data. And the idea is that when a patient leaves, they get an email, and they answer
questions. One of those, you know, the, they use the DASH questionnaire, or the quick DASH questionnaire is their primary measure. But in this study, he used he used all the data aggregated, so it wasn't just his patient data, he used all the data aggregated by those participating in this process, basically, patient satisfaction based on the likelihood of repeating the surgery. And it's a really simplistic, and I applaud simplicity, way to
assess patient satisfaction. And so he looked at a range of diagnoses, and basically all the diagnoses collected, and a huge number of patients over 6000. And more than 10,000 responses, and they the takeaway for them was about 80% of respondents demonstrated satisfaction. And we can quibble with the techniques of coming to this
conclusion. But that's an important concept for us as surgeons, and our therapists, colleagues and all of us to remember that no matter how simple the surgery, you cannot get 100% satisfaction. And the numbers we quote for like total knee and total hip of 95% satisfaction are incredible. And maybe we can't get there in hand surgery, or maybe we can I don't know, it's so many questions are raised, but I think this is a valuable contribution.
I think the the overall finding that he has that as an aggregate, hand surgeries, all of them included. In this case, they studied open and endoscopy, carpal tunnel separately, trigger finger, wrist fracture, LRTI, de Quervain's and ganglions. 80% seems like a very reasonable number. You know, that is a question I asked patients in post op, if they would do it again. And kudos to Oren for actually, you know, recording it and bring it to us for research.
If you look at the the figure figure two that accompanies the paper, I feel like they're, you know, they're Yes, most definitely I would repeat the surgery, or even most likely, those tend to be a little more modest than at least what I think I see for some of my more reliable procedures, like an open carpal tunnel release or a trigger finger. I agree with what they've come up with here about the LRTI in terms of it being a more modest, modest
outcome. So I would love to read the the actual paper and to see how this flushes out in some sort of subgroup analyses. I think they're onto something. kudos for the big effort.
Absolutely. Absolutely. All right, an inch at a time. Let's keep rolling, let's do the clinical pearl award. This was for a poster, which looked at biomechanical comparison of three thumb, ulnar collateral ligament reconstruction methods by Steve Kohler as the presenter. And this I think, was a really again, for me as a sports lover. I think this was really interesting.
Yeah, so I mean, they looked at it was a biomechanical comparison. So that that in and of itself has value but also has its limitations and how directly it applies to patients who then subsequently heal and undergo immobilization versus early rehab. And they looked at motion at the MP joint after they use the suture anchor alone. suture tape with suture tape as augmentation to the anchor or a reconstruction using a palmeris
graft. And they found that the strongest the strongest reconstruction at maintaining MP joint congruity was the suture tape augmentation. Does that mirror your clinical experience?
Yes, so this is not surprising. But I'm a believer in don't take anything for granted. And this makes all the sense in the world and this proves what many people have found with lab based congruity testing. The suture tape works, it's rigid. It holds things where they should be. Obviously real life is different than lab and there's pros and cons and indications for each of these
techniques. So for example, if there was zero collagen or ligament able to be repaired, I would probably still use a Palmeris longus graft, I would use an autograph. You know, not an allograft as this paper references, but talking, you know, differently. But this is important information. And so I applaud them, and I think it adds to our body of knowledge.
So the struggle with these studies is that it's time zero biomechanics. And I think the clinical conundrum is the chronic tear. And do you use a suture tape alone? Or do you supplement that suture tape? Because you believe in it based on your experience in this study, with some kind of collagen, whether that's somebody Palmeris, a strip of one of their extensors? I don't know the answer to that. And there's no way that one of these biomechanical studies will ever be able to because again, these
are timezero studies. And I think that we believe in the suture tape. And if there is any sort of native collagen, I will use a suture tape and then rely on that and try to repair whatever native collagen is there. But it's really hard when you don't have anything and you're struggling whether to make large tunnels try to tension in a graft, and then back it up with suture tape or
Yeah, no easy answers, no easy answers. just do the suture tape? Alright, let's jump to the Emanual Kaplan award. So this is given by the New York society for surgery the hand and it is a paper or poster from the hand society about anatomical excellence in surgery of a hand and this paper. The senior author was Michael Hausman. And it was I'm not sure who the presenting author was. But the paper was on the effect of bowler tilt and plate position on FPL tendon pressure in the
distal radius. So again, a really timely and important concept. What did you think?
You know, I think that the takeaways were similar to a study that was published in journal of hand surgery A few years ago, looking at when the tendons are at risk for rupture after a volar plate. And you know, with increasing dorsal tilt and a non anatomic type, fracture union, it is increased risk because those tendons are now going to drape over the volar plate, or at least at risk for draping over the volar plate. More often, particularly
with the wrist and extension. So clinically how I've applied the findings from this paper, as well as the study I read a couple of years ago, was that when I look at patients and talk to them postoperatively about the risks to the flexor tendons, I do it with the wrist in extension, and I will have them grip down and check FPL separately, to feel for crepitis to feel for any inflammation
over those flexor tendons. So I thought it was an interesting study that certainly has clinical applicability, and is practical to anybody who's either doing the surgery or rehabbing patients afterwards.
Love your comments, love how you use this for, you know, clinical relevance. Again, this cadaver study is useful. It's important information, it confirms what we know, you know, we know going distal the watershed line carries a risk. And we know intuitively that a dorsally tilted distal radius is going to put increased pressure on the tendons, but showing the contributions in this cadaver model I think was helpful.
You know, for me, we haven't had a full distal radius episode yet. And we probably should, I really try not to use a volar, a standard volar locking plate when I have to go
distal to the watershed line. If I'm going distal to the watershed line, I'm usually using a different sort of implant and venturing into the fragment specific type strategies, which will you know, generate some eye rolls on x rays in terms of did you do too much, but it's also I'm trying to use thinner implants as I go distally because I don't ever want to come back.
Yeah, and I think that's right. And if you don't and I admit I don't always that I tell the patient we should probably take the hardware out. And I am not convinced my clinical exam for post operative crepitis or patient complaints is good enough to prevent problems down the road.
So what did you take home from our final paper? This was from a couple of folks that we're familiar with, Ben Gray former resident here washu, Nick Kazmer is another former resident here at Wash U. This was the Sumner Koch award awarded by the Chicago society for surgery of the hand and effective corticosteroid injections on the risk of post op surgical site infections in patients undergoing elective carpal tunnel.
Yeah, I like First of all, I admire what these guys have done. And you know, Nick is it I don't know who was the driver of this study, but Nick has done a great job. This used a national claims dat claims based database you know far more about that than I do. And it looked at patients with elective carpal tunnel over a 15 year period and tried to assess the Impact of corticosteroid injections and the risk of post operative infection. And basically, they, I mean, the numbers are kind of
astounding. So their summary was the risk of a post operative infection requiring surgery was significantly greater for carpal tunnel release patients that received a corticosteroid injection within one year. I talked about six weeks. This is startling.
But yeah, kudos to to Nick and Ben for putting this together. And Nick has been on an absolute tear in terms of writing really nice papers that I think affect affect practice. Seems like he's gotten the Calfee gene. But I find it interesting here, I think I'd like to see their other odds ratios associated with this with the risk of infection, because the co-morbidities played a big role in this. So I'm not sure if it's the injection itself,
versus the comorbidities. I know they adjusted for that in their regression model. But it would be good to see. Take home here is that you have an 11% higher risk of having a infection if you've had a steroid injection within one year of your open carpal tunnel release. I think this is one where you have to read the paper administrative data, it always has its challenges in terms of applying it directly to clinical practice. I'm all too familiar with that.
All right. So we've we've talked about a lot. We didn't hit some other awards, but we've hit the big five. And I think it's been fun. Again, kudos to everyone involved with the hand society for pulling off a great meeting. And I think it's been fun talking about it.
Absolutely. Congratulations to all the authors for their award winning papers. Thank you for adding to the meeting, and certainly adding to our knowledge and look forward to seeing these things in press eventually.
All right, Chris, I think we're both off in our different directions. Have a great day.
All right, you too. Take care. Bye, everybody.
Hey, Chris, that was fun. Let's do it again real soon.
Sounds good. Well, be sure to check us out on Twitter @hand podcast. Hey, Chuck, what's your Twitter handle?
Mine is @congenital hand.
What about you? Mine is @ChrisDyMD spelled d y. And if you'd like to email us, you can reach us at hand podcast@gmail.com.
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