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'm pretty fair. How are you today?
I'm doing well. You know, I'm excited. You've given me a nice holiday treat. I'm going to tell everybody, we're doing an episode about nerve. So I'm very, very excited. Thank you, Dr. Goldfarb for my holiday gift.
Yes, I will. I will stumble through this episode, but it is it is in response to an overwhelming demand. So I have to respect the listeners.
You know, to quote a highbrow comedian named Will Ferrell, it gets the people going, give them what they want.
It must. I hope it does. I think it's pretty funny. That we're recording early on Saturday morning, the day before this podcast releases. I'm hiding out in my basement to not awaken my family. And you just got off the bike and you're in a dark room.
I'm also hiding from my family. And to help, to help you out I actually plugged into my to my Ethernet box just to make the connection that much better.
Thank you. That is huge. Thank you.
Well I'm realizing that it's, you know, I was really upset with my internet provider. And then I realized it's actually just the very thick plaster walls and our 100 year old house. Really throttles your wireless connection.
You and I both have that issue. One of the beauties of St. Louis, lots of great old homes. But the challenge is those thick plaster walls.
Yeah, it only it only took me eight months into the pandemic to figure that out.
Well done, well done. Alright, so two announcements. The first is a request. I'm not sure how many of our listeners actually subscribe to our podcast versus download it intermittently. It seems like subscriptions are a big deal. And so we would love it. If you guys would consider actually subscribing to the podcast.
That would be great. And if you could do that, that would basically be Dr. Goldfarb's holiday gift. So if you could get Chuck a gift by subscribing, that will help all of us out. It'd be like a return for this nice little gem of a nerve episode.
Please, that would be awesome. And then the other thing is we're gonna take a holiday break.
Yes, I don't think I've ever heard Chuck announce that he was taking time off publicly. We're gonna take two weeks off, to spend some additional time with our families, reflect and come back super strong in 2021. And that episode will be coming out on January 10. So we look forward to spending some time with our, with our families this holiday and at least a little more time. And we'll see you guys in 2021. But before we do that, we should
do the episode. So let's talk a little bit about what's been going on in your world. With everything COVID wise.
Um, yeah, we've been struggling through I guess it's probably the best way to say it getting cases done here and there and everywhere. It's made for a poor quality of life. It's made for struggles of my team, and frustration with my family. But I feel this, as we all do I'm sure, this strong sense of obligation to help our patients, which sounds kind of corny, but it's real. And sometimes we're helping them because they have a year end deductible that they want to meet. And sometimes, obviously,
it's more pressing concerns. But it's been a tough, it's been a tough four to six weeks for me. What about you?
Well, I mean, the fact that I'm operating at four different facilities in the span of one week, tells you that we are scrambling. But you know, I guess from the pandemic, and from necessity, breeds ingenuity. And so we've tried to come up with solutions. And, you know, we've talked about this on the on the wide awake episode with Sam, but we've actually found a way at least temporarily, to move some of these WALANT surgeries into the office. And it's been an
incredibly fun process. I won't say experiment, because a lot of thought and work went into it. We even did a dress rehearsal, and I convinced you to come do that.
I was so I don't know what the right word is. I was like, seriously, you want to do a dress rehearsal? I got a list of 18 things to do. But you know what? As with many things, you were absolutely right. It was worth the time. And we had a whole team of people there talking through each step in the process. And it just made sense so thank you.
Yeah, so it's it's been a lot of fun. I mean, I don't know if I'm right about many things. But this one I felt very strongly about it mainly because Jennifer Wolff when she gave a presentation to our traveling, hand club, shout out hashtag hand club. She talked about the importance of doing that kind of rehearsal, and we've now successfully done those cases on two separate days and a total of six cases of different variety. And it's gone
really, really well. Patients are in and out within an hour. They've loved it, the staff has
loved it. And honestly, a lot of credit goes to staff that have put in the time to make it work on the back end in terms of authorization, billing, etc. and helping us with getting things like supplies, and then our fellow I will shout her out specifically, Jocelyn Compton has done an amazing job, because essentially, she's acting as a scrub tech, which I think has had some very nice hidden educational value for all of us, makes us appreciate our OR staff
even more. But then also, you know, we need to know our way around the trays need to know how to, to set things up and do the case, you know, independently.
I think it's super interesting as well. And I would add that one of the things that Chris and I are struggling with, that maybe our listeners could help us we've surveyed a few people across the country, is the idea of truly doing this in the office in the United
States is tough. It's not the technical part, because we can figure that out, which Chris just said we have, it's dealing with the payers, because despite the fact that doing in the office is the right thing for the patient, and saves significant money for the for the payer and for the system. And potentially for the patient who doesn't have a big facility
fee or something like that. It's tough, because there is no fluff built into the system to allow any type of assistance with the cost of doing this outside of the operating room.
Yeah, essentially, we would need to find a way to build in a facility fee that covers at least the base cost of the instruments, the packs, all that kind of stuff. And you know, that facility fee, I guarantee you is going to be substantially leaner than what a facility fee that you know, an ASC or an outpatient hospital department would charge. I mean honestly, I've started to ask patients about what their out of pocket is and what the their bill for the facility was. And
it's staggering. I mean, it's in multiple 1000s of dollars for one case I did recently was 10 minutes under local, and it was a $6,000 charge to the payer for facility and she had 1200 out of pocket, which, you know, it really shows you that I think this is the right thing to do. And we'll find a way to make it work, obviously, in the best interest of the patient.
Yeah it's a really interesting thing again, all of us, I think every single person listening recognizes that our system, our payer system has challenges. I think the deeper into the weeds you get often the more the more challenges you realize, but we're not here really to talk about that. We're here to say that, I think with Chris's leadership, you know, doing the WALANT or local only cases in the OR is a win, don't get me wrong, that is absolutely
a win. But taking them completely out of your environment brings its own set of challenges. And I'm happy to say that due to the pandemic, at least for the foreseeable future, we're going to keep doing these in the clinic.
And and the other take home is that our listeners from outside the United States will probably continue to think that our health care system is absolutely bonkers. And they're right.
Hopefully they just hit the fast forward button they didn't shut off the podcasts because of this.
With all the American exceptionalism so why don't we launch into we've had some really good feedback and some reviews recently.
Yes, yes, we absolutely have. I liked this one. But I thoroughly enjoyed the radial sided wrist pain part one and two episodes. There was such great information and differential diagnosis rationale, but it was such an enjoyable listen, I even caught myself laughing. Probably at us, Chris but but I shouldn't editorialize. I cau- I even caught myself laughing especially when discussing the intersection syndrome. I am an OT beginning to study for and
then it kind of tapers off. But thank you for that kind review.
Probably about the the footsteps on freshly fallen sn w. But that was from
Thank you. It is interesting. We were debating whether to do that podcast and I think it worked out well. I think we're gonna have to try to think of some different angles like that. And I'm glad it was enjoyable at least
It was one that you you wanted to do. And I said, I don't know about that. And you've also wanted to do some similar episodes on elbow pain. So that's coming in 2021 because you were right about that one for sure.
It's a trade we're gonna do more nerve. We're also gonna do some elbow. Do you want to share the next one, which I also loved?
This is a really cool follow up. And we appreciate getting it from Sina Babazaday in Melbourne. Remember we talked about the six week orthopedic
unit. And Sina actually informed us that when they're visiting the UK A few years ago, one of the older surgeons commented in that in the 19th century, orthopedic surgeons would travel around the country to consult, they would travel intermittently to a number of rural locations, the average time it would take them to visit the same rural destination again was six weeks. So hence most things were treated in six week blocks and according to him, this is where the six week orthopedic time
unit came from. So we're appreciating maybe it is an old wives tale, but I do like having a reason to, to do things. So I'll count this as one.
I think that's awesome. And I think it's hilarious. And I'm a fan of everything historical. So it's really super interesting. I'm grateful that we're not traveling around too much. We're doing it virtually now with telehealth but not physically. So that's good news.
One more quick thing. I know that one of our listeners and friends Rob gray in Chicago, you were catching up on podcast episodes recently. So Chuck why don't you read this, this little anecdote from from Rob.
Yeah, I think this made Rob laugh. And it definitely made Chris and I laugh, it says, and Rob gave us permission to share this. It says I'm in the lounge at my surgery center the other week, and a rep comes in and asked if I'm Dr. Gray, she heard a Dr. Gray from Chicago mentioned on your podcast, and was more than a little impressed. I have now reached peak hand surgery fame. Bravo, bravo.
So shout out to the rep from the, in Chicago who called him Rob Gray for the podcast. That is awesome. So thank you for listening, both of you.
That is all right. Before we jump into our episode, I do want to say this partnership with QX md is interesting. And Chris, and I weren't sure you know about the product and weren't sure if kind of this relationship made sense. It actually has the data is pretty interesting. They've been sharing data with us. So I continue to use the app to access articles online. And so our relationship with qx MD has been really good. And I I recommend checking out their
product. And again, we're not paid for saying that I just think it's a it's a relationship that has been mutually beneficial.
Shout out qx MD and then if anybody else wants to actually pay us, please, please reach out.
We're desperately seeking our first actual sponsor.
If we get a sponsor, I guarantee you more mugs will be flowing out.
That's true.
Find us a sponsor. So Chuck, one of the things that came about in the listener survey was a request for A. more nerve and B. more technical episodes. So let's get into just the details of nerve repair.
Yeah I think, I'm sorry to interrupt, I was gonna say I think this is helpful, because Chris, and I likely think about some of this differently. We're obviously both fellowship trained hand surgeons. Chris is dedicating much of his career. I don't want to overstate it, but nerve is a passion of his. And for me nerve is part of what I do. And I have other passions, like kids and sports, and I certainly take
care of routine hand surgery. I don't do plexus, but we have a very different mindset when it comes to nerve. And so I'm never going to suggest that I'm right. And Chris is wrong. But I think when the literature is gray, we may differ on how we approach things. So hopefully, that'll be helpful for the listeners.
Yeah, and actually, one thing I kind of forgot was that before I started my practice, there wasn't a lot of nerve going on in, you know, our division, because it had just not been a focus of anybody on the orthopedic side. And I was reminded of that when I got an email from a former washu fellow who actually was a fellow the year before me, shout out June. And she had asked for advice on the case. And I gave her some advice. And I just kind of casually said, or you can just
do a nerve transfer. And then in her response, she had mentioned that, you know, that just wasn't part of her training. And I'd forgotten that before. You know, the last five years, we just didn't do a lot of nerve transfers. So I'm happy to say that I think that it complements the fellowship, it doesn't overrun it. But it is a big
part. And I think a lot of people, you know, when they come out into the job market practices want to hire somebody, who know how, who knows nerve and knows how to do nerve transfers. And to have that in your back pocket is really helpful, even if it's not a big part of your practice.
Yeah, that's well said, I am going to diverge a little bit for one quick story. So I also do a podcast for the AOA with Alexander Aleem. And there's a we had a special guest on this podcast will drop in a couple weeks. Again, by the AOA, we do different things for that one, it's very different than this. But for this one, we had a guest, Megan Conti Mica who Chris has a very close relationship with his side job. I mean, this is both of our
primary focus. This podcast is the one but Chris does a wonderful podcast with the hand society and with Megan, and she was on as a younger surgeon, I think she's been in practice five or six years, and talking about the challenges of starting a practice. And the reason I it, I think it was really great. It was really fun and understand why Chris and Megan have such a good rapport. She's an easy interview. But the reason I brought up, I'm bringing it up now is that I do respect what
Chris has done. And so for those of you who are residents, or maybe even students or fellows going into practice, you know, there's different ways to think about how one starts his or her practice, you can go in and be a hand surgeon abroad, hand surgeon, your bread and butter hand surgeon and do what comes your way. And that's fine. And to some extent, no matter who you are, where you practice, you have to do some of that. But
then you can find a passion. And I think when Chris came here, I don't know that Marty Boyer and I were super optimistic that he could carve out a robust nerve practice. And I think he has, he has done that. And it is growing, you know, week by week and month by month. But there were challenges in our system for Chris to be able to do that. But yet, he stuck to his guns, he understood that it would take time. And it's been really fun to watch. And he's done it and succeeded in many different
ways. And maybe that's a whole separate episode, because I think it's awesome what you've done. Anyways, I'll stop there.
Is that the second part of my Christmas gift? Thank you, Chuck. That was really nice of you to say. So let's talk about a case. So you've got a 32 year old laborer, who had a crush injury at work. And there is a median nerve deficit. And it's a high median nerve deficit. So you have a loss of AIN function, and you obviously have a loss of thenar function, and you've got a median nerve deficit, it's a crush injury. How do you think about when you
intervene on that patient? Like how, you know, very briefly, how do you think about when the nerve injury has declared kind of its prognosis?
Well, I'd like to say thank you for tossing me a softball to get this nerve discussion started. The first thing I would do is find Chris's number and send the patient over. No, I think, you know, first, obviously, I would try to understand exactly where the crush injury occurred. So for the purposes of this discussion, I hope it's okay, I would assume
it's proximal forearm. So you know, if there is even a lot of times in these real crush injuries, industrial crush injuries, there will be a soft tissue component, in addition to the nerve. And depending on what that looks like, I may give that time to heal. But if in, if it is the case, like it might be often I would have the patient. If it's been at least three or four weeks, I would send the patient for a nerve study, after a thorough exam, and I'm one of these hand surgeons, and not all
of us are like, I like detail. I like minutiae, I like numbers. And so I get as much of that done as I can in the office, and have a real discussion with the patient about expectations, crush injuries can be difficult, depending on the ultimate grading, but I send the patient for a nerve study at that first visit, ideally, and you?
Yah, I like, like many hand surgeons, I will say, I like data. And I think a lot of us have this attention to detail complex. And it's probably the exception, the hand surgeon that doesn't, I will get a six week study if I can, unless it's a self pay kind of situation, which, you know, unfortunately, it comes up a reasonable amount. Because I want to be able to compare something, have another data point to triangulate with
the examination. And then I will typically get a three month exam, you know, there are a couple of things that might change and accelerate that treatment algorithm if you know, somebody has explored the nerve, and it's told me that it is, you know, not intact, that just speeds things up and makes my life a lot easier. But in this particular situation, say it's a crush injury with a reasonable soft tissue envelope, and nobody
has intervened. I will wait, get a six week study and usually get a three month study, of course doing an exam the whole time.
A couple questions. Tell me whether this is dogma, or this is fact. But you said a six week study, not a three week study. So there is dogma, I think it's dogma that says three weeks is a good time to get a study. And I think there are some some real reasons for that. But tell us why you said six weeks.
Um, because I don't think a three week study is going to help you that much. Because I'm not I can, I am fairly confident and many of our listeners can do the same thing, make the diagnosis purely on clinical exam. So I'm not looking to make a diagnosis of a nerve injury. I'm trying to prognosticate. And a three week study gives me nothing in terms of prognosis, a six week study will. And it's really the three month study that I think will
tell the story. You know, again, we're not talking about Plexus. Plexus is a different kind of deal in terms of avulsion injuries, that kind of thing, but a branch type peripheral nerve injury. The six week study is helpful not required the three month studie is where I think the biggest difference is made. And most people will say if you have some kind of motor units present on the EMG part by the three month study that you should have a reasonable
outcome. It's really hard to find the literature that supports that. I'm actually writing a review article right now and I'm getting a lot of pushback on you know, the fact that this is dogma, the three month motor unit. And if anybody has an actual citation, it would be really helpful because right now I'm digging in textbooks trying to find it.
I love it. So a couple other just, not technical, but practical questions. Number one, I assume you tried to have the same person perform the nerve study at six weeks and three months, is that correct?
Yes, I try to. And then, you know, usually by the three month mark, I'll also be including some potential donors for nerve transfers. And so if I'm thinking about that in my algorithm, and I have I write on there, specifically potential donor, because even though the person that's doing my studies, is pretty good, and knows what I'm thinking about, you just don't want somebody to not check something because it doesn't help them make the diagnosis.
Again, we wait, the people that are, you know, most hand surgeons are advanced users of the nerve study, they're not looking to make a diagnosis, they're looking to prognosticate and help figure out what to do for the patient.
Okay, and then tell us between the six week, and we don't want to get too much on nerve studies, we would probably do an episode on nerve studies. But between the six weeks and three months, what do you see at three months, that screams Wait, things are going to be okay, versus what do you see at three months, that says, Okay, it's time to operate.
So the complete absence of a motor unit on the EMG for the the muscle that you're trying to, to assess. If there's nothing by three months, I think most of us would say you could probably intervene at that point. There's some controversy there with gunshot wounds, that kind of thing with the classic literature from Omer saying to wait a lot longer. I'm questioning some of that now. And I think a lot of people are
too. But you know, if if you see one to two motor units at three months, you know, maybe wait a little longer, the single motor unit, I think is not helpful at all. But if you see two to three, that kind of thing. And also it's remember, remember, the EMG is a qualitative assessment of the muscle most of the time, so you have to talk to the person doing the study. And usually they have a pretty good sense of what's going to get better, what's not going to get better, at least from their end.
How do you think about it?
Nothing more sophisticated than that, that's for darn sure. I am looking for the same things you just mentioned. And I'm looking for just improvement in general. And, you know, a traumatic injury is certainly different from you know, goes without saying that a traumatic injury is different from a different type of pathology, but I'm looking for the motor units. That's what I focus on, for sure.
So say you're at three months, and you've decided to intervene. And you're exploring the nerve. This is, again, where a lot of dogma and imperfection comes in. How do you assess that nerve? Once you're exposing it? How do you decide? Is it good? Is it not good?
What what I'm hoping for. And again, I think this goes without saying is a visual, visual cues on kind of where the pathology exactly is. and use those visual cues to help me intervene. I think, for many years that has been, at least in my practice, the way I've handled it, although we do have actual tools in the O R, which can be helpful. So what what do you think about as far as using tools in additional to visual inspection?
I mean, it's crazy how we're in 2020, we've been doing microsurgery for 40 or 50 years now. And it's still the look and the feel of the nerve. And, you know, we try to do things like I've used interoperative nerve studies, nerve to nerve action potentials, that kind of thing. When it works, it's really helpful, but it doesn't always work. And there's a highly variable technical component to it, where some places like Mayo and LSU have made it work really well. It just doesn't work
reliably for me. I'll still use it. I'd also use a handheld nerve stimulator. You know, there are obviously considerations in the extremity. We like to use a tourniquet and you know, you have a limitation before you get tourniquet related ischemia and your nerve stimulator is not particularly helpful. So when I'm planning out my case, and I'm orchestrating it in my head, I like to plan out the steps where I have to use a nerve stimulator, if I'm going to. And that happens pretty quickly.
Early on in the case, we think it's probably 30 minutes, maybe 45 minutes before that ischemia kicks in. But again, its look and feel of the nerve, and then eventually you got to cut into it.
So do you have a preferred nerve stimulator? And I know you don't have relationships with any of these companies? Or do you think it matters?
I think it does matter. I do like the checkpoint product. And I don't have a relationship yet. But we are actually going to do some funded research for checkpoint specifically on the question of tourniquet related ischemia. So that disclosure is actually I think it's going to be David's, but I will be a co investigator on that but but, you know, I've tried the other stimulators and have not found them to be as helpful and I've heard others say the same thing.
That's awesome. And I don't again, have near the volume that you do in this in this realm, but I've used the same and been happy with it, but also, again, being a less experienced nerve person. I probably have experienced even more frustration around, you know, this thing isn't working. What the heck's going on, you know, that kind of thing, which probably is user. At least to some degree, but but that's reality.
You know, one thing that I've realized is that when the trainees come in, they often pretend like they know how to use nerve stimulator and how it works. And they usually don't know completely. So I tried to make a point, especially with the residents to show them to make sure they know how you know what light's supposed to be blinking, when you know, it's stimulating and the different components of it and how to troubleshoot it, that kind of
thing. Because, again, like that's that stuff that like nobody ever teaches you unless you sit down and read the manual, which not everybody will,
yeah, it's super easy to get a trainee to read the manual for an ulnar shortening osteotomy it is less easy to get the this kind of manual read.
Well, they're usually reading different things when they're prepping for a nerve case with me, I'll tell you that.
Yes, agreed. All right. So let's just say we find the area that's and what are you looking for feel? Is it woodiness? Whatever that means? Is it lack of just the softness? And the Yeah, what are the words you use or the what kind of visual?
Yeah, I mean, it's all it's all of that. So you know, obviously, you're exposing healthy nerve as well. So that gives you a good sense. And when you can feel that transition point. And again, because it's such a subjective thing, I make sure the trainee feels it too. And you will typically feel that the transition point and, and honestly, that's when you just start cutting, because there are some cases in which you can do a very elegant, internal neurolysis and fascicular
dissection. But those cases are few and far in between. But sometimes I'll do that, you know, particularly if I know it's a neuroma incontinuity. And I maybe can just leave some of those fascicles intact. But once you start doing your unblock resection, I think you'll have a better sense. And I think you have to cut into the nerve to really know, some of one of our partners David Brogan is doing a lot of work on interoperative
nerve assessments. But you know, those assessments are, you know, going to be off probably another 5-10 years.
Objective assessments
Objective assessments using some really interesting imaging techniques, and, you know, really cool stuff that he'll probably start to publish in a couple years.
Yeah, I agree. It's really, really interesting information. So all right. So you know, to me, someone says cut the nerve. So I ask for my big mayo scissors. Is that the right approach?
It depends, are you going to cut it again? So you know, one of our partners, Marty likes to discuss how scissors are designed to crush tissue. That's how scissors work, right? So you know, yeah, I'll cut a nerve with scissors, but then I'll re cut the nerve with a blade. So I personally, you know, sometimes it is a matter of expediency to cut with scissors. It kind of depends on the situation, I won't say that it's wrong, but it's not ideal.
And I prefer the old school tongue depressor, you know, obviously wet the tongue depressor. So the nerve tissue doesn't stick on it. And I like a 10 blade to cut it back with a single, single smooth motion like Dr. Gelberman taught me.
So this is, I love everything you said, and the details absolutely matter. So are you, is it a rocking motion on the nerve? Is it a single, downward directed pressure? How do you cut the nerve with that template.
So you know, I like to do it where if I already have it cut, and I'm re cutting it to just kind of get a final pre repair, cut, I will have somebody pull traction on it with a gentle traction, of course, with a tooth forcep to provide steady counter, you have the tongue depressor underneath it. And then you take the tip of the 10 blade and like you're saying you rock it back. So you start to tip on the far end of the nerve. And then you rock the
belly of the blade back. So this matters, you're not cutting with the tip, you're using the belly, the wide belly of a 10 blade or a 15 depending on the size of the nerve. And it's one smooth motion, it's really important that that person is holding good steady counter, you've got firm support underneath the tongue depressor so that it's a single
smooth cut. And once you start cutting it multiple times and rocking back and forth and cutting down you know, it's it becomes really challenging to get a clean atraumatic cut on the nerve.
I love that and your first cut on the nerve. Are you looking for that to be the last cut on the nerve? Or do you generally accept that your first cut won't be your last, meaning you'll have to cut back further and tell me what you're looking for to to make that decision that I'm in a good spot.
Um, you know, I try to plan it so that my first cut is not my last. When you're bread loafing you know, and when you're working in a neuroma and you're trying to figure out, you know, where the healthy nerve
is. Remember, you can always cut more, and the more you cut initially it's going to be harder and harder to you're gonna have a longer gap, you know, so you're looking for that fascicular extrusion, you're looking for that healthy pattern, look and feel, you know, you should see the fascicles coming out and looking, you know, trying to emerge. And the tissue on the exterior, the, you know, the mesoneurium or external epineurium, whatever you want to call it, that should just look
good. But you really do want to see those extruding fascicles coming from the inside of the nerve.
Yeah, and I would say, again, based on been doing this a while, my guess is that we go wrong as nerve surgeons, when we may have bulging fascicles. And I do think that's a good expression. I don't know if you agree or not on one end, and then we may accept a little less on the other end of the nerve. And whether that's because of expediency and the sense that, oh, it'll be fine, and you put a couple stitches in. But I think more and more, especially with good options to bridge the gap.
People understand that there's no substitute for having really healthy nerve tissue on either end.
I agree with that. 100%. You know, and then oftentimes, you're left with a gap. But say, this is a setting in which you don't have a gap. You've mobilized the nerve ends, you've gotten a couple of centimeters from your neurolysis, your decompressions, whatever you do, how do you like to repair, say, a median nerve in the forearm?
Yeah, so for a median nerve in the forearm, I'll use an 8-0, nylon epineurial suture. And I'm trying to think I would probably use four sutures would be my guess. And I would not use glue, and I would be done. And I'm wincing a little bit, because Chris is now going to tell you how a nerve surgeon would deal with that same nerve?
Well, no, I think 8-0 is what a lot of people would do. And I think 8-0 is a very reasonable option. I mean, you know, the dogma on this was, you know, if it comes together with 8-0 nylon, there's not too much tension. And then if you look at kind of what you're, you don't want too much tension on the nerve. Because if you have, you know, more than 8% of strain, you know, you're going to have ischemia. And then if you have ischemia, that's going to lead to scar, and your nerve repair
is not going to heal ideally. So you want some kind of suture that is going to not give you more than 8%. And you know, there is some interesting work, I think Jeff Greenberg did it, where they checked, you know, 8-0 nylon, 9-0 nylon, etc. And 9-0 meets all the criteria that you need. So I after reading that paper, I switched to using 9-0 as my default. And I agree with you using kind of three or four sutures, it kind of depends on how it lines up, I will use a
microscope. Unless you know, for example, if I'm in the tight corner of the neck for a plexus, and the scope is just really hard to get in reliably, I may do it under greater magnification loops, like three fives for a nerve graph, but if I'm out in the extremity and a scope is totally reasonable and helpful and accessible, I will use a scope.
So let's be clear on that. So great, great info,
Oh, and Chuck microscope, not arthroscope. Microscope.
Oh, microscope, I was wondering, well it's going to get very soupy in there very quickly.
The cool kind of scope.
I don't know much about the micro scope. So let's be clear, because this will be a source of controversy. I would not use a scope there. And sometimes people don't use scopes for digital nerves. Is that horrible, horrible care we're providing when we don't use a scope for a digital nerve?
No, I don't think so. I think that, you know, if you feel confident you can do the repair under the magnification that you have. Great. You know, I mean, you know, there are a lot of surgeons, either plastic neurosurgeons, or orthopedic surgeons that repair nerves without a microscope. And we're learning that because we're participating in a multicenter study on PEG fusion. And they have to specifically say do it under a microscope, and many of the surgeons in the study
weren't doing that before. So I think that doing it without a microscope is fine. It's just whatever you're comfortable with, you know, there is some literature to support using a microscope in terms of look, you know, they looked at, you know, repairs done in a cadaver lab and checked quality by multiple assessors, and said that, you know, a microscope-assisted repair was technically higher graded than a loop repair.
Listen, you know, one of the places I work does not have a microscope and granted, I don't do nerve work there very often, if ever, but when I'm on trauma call for hand, and we have, you know, a significant injury to the hand. I'm doing nerve repairs on and I always do it under the microscope, there is no difference. I mean, I'm sorry, there is no question that there is a huge difference in visualization and your ability to assure as anatomical a repair as possible. So, microscopes are
amazing. And I will use them every opportunity I get, but flipping that around with high powered loops, I think you can do a very good job with it being more important that you have the nerve ends correct. And less important that your rotation could be off, you know, five degrees or something like that, in my opinion.
Yeah, I think that look, you know, when you're really assessing the nerve repair, when you're done, I think that's where the scope is really helpful to make sure you don't have any extruding fascicles coming out of your nerve repair, and that your epineurium is nicely tucked. But you know, it sometimes, like in those trauma cases, if you're doing a spaghetti wrist or a replant or something like that you need to move and, you know, expediency is important there.
In terms of glue, you mentioned that you don't like glue, what's the deal there?
I don't like glue, because I just don't use glue. And I think this is something that you can help me with today and maybe help some of our listeners because I think it gets to what you just said, extrusion and and comfort level with your repair. Tell me why I should be using glue.
I don't know if you need to use glue. I mean, if you're comfortable with your repair, you've gotten it lined up and it feels good. You know, I think that's fine. I don't think it takes anything away though. What I don't think glue does is replace suture. And there are some surgeons out there particularly in the, I think the pedes Plexus world that will only glue and maybe
you can get away with it. But you know, if you're going to spend that much time and effort doing something for, that's my personal bias, if you're gonna spend that much time and effort doing something for a patient. This is a high stakes surgery, you're going to do everything you can to make that repair as technically excellent as you can. I like lining it up with the suture. I don't like relying
on glue. But if the glue doesn't do any harm, I mean that it essentially acts as an adhesive cylinder that's there for about three weeks. You cannot rely on it to to take tension off of your repair, or anything like that. So an over reliance on glue, I think is is an error.
All right, talk me through the glue. So you're in the OR you've repaired your median nerve in the forearm and you used four 9-0 nylons. You brought the microscope in to assist with your repair and to judge your repair. After you were done. You're thrilled there's, actually you're not there's one bulging fascicle that's extruding from the nerve repair. First, what do you do with that? How do you deal with that fascicle and second, talk me through the real, you know, details on applying the glue.
So I think you know we're, in this case we're doing an epineural repair. You know, there are if you get really distal, in particular for the ulnar nerve, some people would make an argument to do group fascicular repairs. But in the setting where you have one little extruding fascicle I probably would take out a suture as painful as it is, and try to tuck that fascicle in or even just trim it back and then put a suture in the epineurium over the area where that fascicle was
extruding. I think that yeah, so trim it back with with scissors. You know, usually it's going to be a micro scissor, a straight serrated micro scissor to help with that cut, not ideal that you're cutting with a scissor. But I think in that situation, you're not taking down the whole thing and getting a blade in there. I've seen some people use a beaver blade in that setting. And if you can maneuver that in
there, go ahead. I like the beaver blade for assisting with the neurolysis part of the case. But usually will not do much more with with the Beaver. And then in terms of the glue. So one thing is that you know, just from a expediency perspective, when I asked them to prep the scope, I asked them to get the glue out, because the glue needs
time to thaw. And there's nothing worse than finishing a repair and wanting to put the glue on and then them saying well, it has to we have to get it out of the freezer, it has to thaw and you have to wait 5-10 minutes that is awful. So basically, the OR staff I work with knows that when they prep the scope they get, when they're prepping the microscope, they
get the glue out. And it's you know, I don't do the separate syringes drip drip technique that some people describe, I usually just use what's in the syringe, you know that dual
chamber that they have. And I, you have to make sure that it's ready, that it's thawed enough and that it the if you're using it multiple times throughout the case, you just want to check the syringe to make sure that it that it's coming out because sometimes it will get clogged and again nothing worse than going to put on your glue and the damn thing is clogged and you have to get another another
syringe tip. So just checking that off the field and making sure and then I don't put an excessive amount of glue I make a joke with the fellows whether they should put a hand surgery amount of glue or neurosurgery amount of glue because I've seen some neurosurgeons just glob the whole thing down and nothing against the neurosurgeons because it honestly doesn't matter. But I usually will try to do that nice little burrito technique in which you put the glue on with the nerve on a
background. put the glue on make sure it goes all the way around and then cinch the, cinch the blue background over I guess like a taco more than a burrito to help seal it in.
And then remove the blue background.
Of course because otherwise the nurses will get on you about that. Yeah background.
That's that's very helpful and not to put you on the spot. Are there different glue manufacturers? And do you know how much glue costs?
So the only glue manufacturer that I'm aware of for this particular setting is TISSEEL and I'm not sure exactly what the company that manufactures it is. But you know, it should be really clearly noted for technical reasons that this is an off label use of TISSEEL for nerve repair. So while it's widely accepted, it is off label. And I want to say it's a couple of hundred dollars. But we should
actually check on that. Because you know, in a cost conscious setting, like we even described earlier in the episode, that doesn't matter. I do think it's worth it, though.
Okay, that's helpful. I'm learning as I thought I might. Alright, we have a few more minutes to talk. So let's say you sticking with the median nerve case, which I think is a good one, for a lot of reasons. You've done your cutbacks, you have bulging fascicles. And, you know, Chuck here is operating. And I think that if I use a 2-0, nylon, I can re approximate these ends. But in the back of my head, I'm hearing Chris talking, he saying 8%, what did you say strain or
8% tension? And I'm thinking, I think this might be more than 8%. So I'm like, Alright, in all seriousness, we can't repair this primarily, what are my options? And so how do you think about that, Chris? Is it a no brainer that you use x, y, or z? How do you think about how to bridge that gap in a 55 year old laborer with a crush injury that now has beautiful, bulging fascicles on each end?
You know, I don't think it's a no brainer. I think there's emerging literature to support the use of an allograft. But if this is my median nerve, I'm not using an allograft I'm using a sural, cabled sural autograft. And I think that's a topic of debate. I think the good thing, the one good, one of the many good things that, you know, the emergence of nerve allograft has done is really allow us to say, alright, like, we really need to avoid tension
on repairs. But I just don't think that the evidence is there yet to support mixed or motor nerves being done with an allograft. You know, I think that the literature is going to evolve, and maybe in about three or four years, we'll have some more support. I always like to be careful about looking at the literature, who's written it, the support they've received that kind of thing, because I
think that is important. But I do think that it's good that the industry has moved into supporting research and really tried to elevate the level of evidence because honestly, the level of evidence for all this stuff is quite weak. One thing, you know, we can have a whole kind of technical part of how to do a nerve graft. You know, one thing that we didn't mention earlier was whether to use a nerve cutting device when you're
cutting the nerve. And I've found that, you know, I've tried it, and I've found it to be a little bit finicky with that blade that you use for the nerve cutting device. But those nerve cutting device templates, those things that you slide the nerve, around the nerve, those are great for for shaping your nerve graphs, and deciding how many cables that kind of thing. So we can talk about sural nerve harvest in a part two and cable graft formation, all that kind
of stuff. I will slide one mention in here for this particular case, in a high median nerve injury. I really like the nerve transfer that Bertelli has described, using a branch of the ulnar nerve going to the ADM as a nerve transfer to the APB or to the recurrent motor branch of the of the median nerve. That takes a lot of pressure off of us as hand surgeons, because if you've got a distal nerve transfer that can get to those thenar muscles in
time. Whatever you do up in the forum is gravy in terms of getting median nerve, extrinsic function and sensation back.
Alright, it pains me to say this, but clearly we need a part two to this episode. And let's just off the top of our heads talk about what we'll cover there just to tease the audience while they're enjoying their holiday break. So we are going to talk about some technical with a sural nerve graft. We can talk about the allograft options, what they're good for what they're not good for what the literature says we can, I'd like to talk some technical and decision making
with a digital nerve. How do you think about that? What else would we throw in that park?
I think for for the purpose of discussion, we should talk about conduits, and that kind of thing. Although I tech, I personally don't use them. I think that that is something that is often used and we should talk about nerve wraps because again, something that is often used that I don't like
Actually, I was gonna ask you about both of those, but I think we'll we'll leave it at that and we'll circle back in a couple weeks.
I will say the number of times that people have sent me cases saying I did this repair that and that and then I wrapped the nerve and I was like ah. Again, I'm probably in the minority in this opinion in terms of avoiding nerve wraps. But you're listening to our podcast, you're gonna get my opinion.
Yeah, well, listen, there's no doubt your expertise is is worth something. I don't know if it's worth everything, but it's worth something
I don't know. I don't know if I'd go so far as expertise. We'll call it opinion.
All right, awesome. This was actually surprisingly funny even though we're talking about nerve. So
Surprisingly, I mean, come on. Go Go, you're gonna go enjoy your world. Now you're gonna go do a congenital journal club with our fellows. And that's a fantastic program. And anybody looking at our fellowship, we do have one of those sessions is up on YouTube to check out and Chuck and Lily do a fantastic job with that journal club. So I still have PTSD from it, but I know it's a good educational opportunity.
You do not have PTSD. It is low key. But today we're talking about polydactyly. Radial, ulnar, central, ulnar dimelia. Yeah, I mean, come on. This is good stuff.
Oh my god, the look on your face. Go do that.
I just brightened up didn't I.
You did, everybody have a wonderful holiday season. We'll see you in the new year.
Hey, Chris, that was fun. Let's do it again real soon.
Sounds good. Well, be sure to check us out on Twitter @handpodcast. Hey, Chuck, what's your Twitter handle?
Mine is @congenitalhand. What about you?
Mine is @ChrisDyMD spelled d y. And if you'd like to email us, you can reach us at handpodcast@gmail.com.
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