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 pretty well, Happy New Year.
Happy New Year to you, too. And this is the first time we've taken a couple of weeks off from the podcast. How does that feel?
It was weird. I was looking forward to it, to be honest. But I've been kind of you know, looking forward to a break in general. But I kind of missed it.
Yeah, me too. And the amount of feedback we've gotten even on things like fellowship applications have been amazing. So we really do appreciate everybody giving us the feedback on the podcast. And it clearly, I think has found, found an audience. And we're hoping that the audience continues to grow. But we certainly appreciate everybody out there who's been tuning in.
Yeah, Chris, and I are continuing to strategize how to, I don't know it's not, it's a little awkward, because we're not trying to push ourselves on anyone. But we just want to make people aware and give people a chance to see if they enjoy the conversation. And, and like we've said so many times before, the enjoyment we get out of this is, is not just Chris and I going back and forth, but what we hear on Twitter, hear by email or the interaction we get from each of
you. So we really do value that and in whichever form you would provide it, it really makes this all worthwhile.
Well, we want to point everybody towards our listener survey. And that's, that's up on our website. And you can find us at theupperhandpodcast.wustl.edu. And the survey is posted there, we've had 67 responses, and thanks to everybody who has filled it out, it is your way to win an upper hand coffee mug, which we'll be doing a drawing for in the coming weeks.
Yeah, absolutely. Can I share a little bit from one of the survey responses?
I think that'd be great.
This one said have been listening since the podcast aired the thoughtfulness behind the discussion in the dialogue, which I assume is representative of the culture of the orthopedic hand program at Wash U has piqued my interest even more in the fellowship program there. And I think this has been I don't want to say easy, but I think this has been relatively straightforward for Chris and I because this is kind of our culture here.
Yeah, it is kind of what we do, except you don't have to go home and edit all the conference at the end of the day. But I appreciate the technical expertise that you bring to the table here among all of your other technical expertise.
Yeah, but it is, but it does hit the it does hit a point. And that is what we're proud of, which is the collaboration and the you know, respectfulness of each other's views, even though Chris and I seem as though we agree all the time. We really don't. And there's subtleties to our disagreements. But hopefully more of that will come out in the new year, as we kind of try to get into some of the things that have been requested, such
as surgical techniques. And Chris and I certainly vary a bit on some of these.
Yeah, so the 67 people who have been kind enough to fill out the survey 50, have asked for more info on surgical techniques. So we will try to get into the nuts and bolts of why we do it. And the reasons why I mean, I, I tend to be the kind of surgeon I think that has a reason pretty much for every kind of decision I make in the operating room, whether it's starting with the way things are set up in the room, or the implants I use or why each screw
goes in a certain order. So and I know you are very similar in that in that manner.
Yeah, I think that's exactly right. And one of the things I'll share in our anatomy session yesterday, I thought this was just really interesting. We were talking about the CMC joint and the relationship of the radial artery, you know, passing beneath the first compartment wrapping around heading from volar to dorsal. And I just have been very interested and we discussed, I share that, in general, it is not my style, to find every theoretically at risk structure during a procedure.
And I think the CMC joint and the radial artery are a perfect example because historically, I did not specifically find that structure. I have evolved. And now maybe it's because I work with trainees or for whatever reason, I a couple of spreads. It's not a big deal. A couple of spreads of the scissors, I find the radial artery I feel more comfortable knowing where it is. It hasn't changed my general philosophy. Do you find the radial artery for every CMC procedure you do, Chris?
Well, I do and I guess if we were looking for areas where we disagree, this would not be one but I think that's the legacy of how Dr. Gelberman taught me. And he is of the mindset of finding every structure. Now there are times where I think it is important to find it for you know, for the reason of you know, if something goes haywire. I need to know where it is in the field, I know
where it is right away. I think one example of where I personally will go look at a structure that maybe not everybody else does is when I'm doing a sub muscular ulnar nerve transposition, I will look over the top of the flexor pronator mass and see the median nerve as I'm dividing the flexor pronator mass, which I know not everybody does. But I want to know where that nerve is so I can protect it and move it away, especially if we're using pottery for that
portion of the procedure. It just makes me feel better.
Yeah, it's interesting. I had a recent case, that actually those are the pictures that I shared with you, Chris, where I do not routinely find the median nerve, despite having been taught that the goal of a sub muscular transposition is to put the ulnar nerve adjacent to the median nerve, but I did not routinely find the median nerve.
And in this particular case, as I carefully cut all the muscle of the flexor pronator mass, which absolutely kills me every time I do it, all of a sudden, the median nerve was right there very ulnar sided, and actually compressed a bit. But it was remarkable how ulnar it was, and I laid the, I laid the ulnar nerve down directly, I could have put it on top of the median nerve, which was fascinating. And I think it gets to your point, you know, should I be doing that? For every case? I'm
not sure. But certainly a high level of awareness is critical.
Yeah, and there are times where, you know, based on the preoperative clinical exam, I will find patients that have median nerve compression in the forearm. And at the same time, as I'm doing a sub muscular ulnar nerve transposition, I'll go and do a formal decompression, but usually, it's just because I want to know
where it is. And I think that I'm also still and I shared this in the prior episode last year, still trying to figure out my own sweet spot for how much, when I need to do a decompression of the median nerve in the forearm. Because I think it is a procedure in some practices that is over utilized and in under, other practices might be underutilized.
Yeah, I think we could probably devote an episode to that, honestly, because I think there's a wide range of feelings about it. And certainly the strength of feelings varies amongst different surgeons, that might be a good one to hit on.
But that would mean we have to do more nerve. And I know that's gonna bother you a lot. So we'll have to figure out some other sporty type topics to do before we go back into nerves.
To rejuvenate me. Yes, thank you. Thank you. Alright, well, since we're talking about nerves, should we jump into it?
Yeah, nerve Episode One was, I think really well received. I'll give a shout out to a colleague in Orlando, I think he's in Orlando Karan Desai. And he wrote me a nice message on Twitter saying how much he appreciated us diving into the basics. Because that's not the stuff that's always out there in terms of what you see at a meeting or what's in a textbook. And I think you know, some of the little practical details, I think, are helpful.
So hopefully, you know, this part two will be helpful for those that are listening, no matter whether you're a trainee, a seasoned surgeon or a hand therapist.
Yeah, it is interesting, when you get to a certain point in one's career, you make assumptions about what you know. And as you and I have talked about before, and could revisit again, the dogma of what we do and why we do it. And sometimes you miss points, or I'll speak for myself, sometimes I miss points or critical issues and conversations like this. While everyone will certainly not agree with everything we say, I think it will raise some issues which bear further discussion.
I think there's actually a pretty good case that would help facilitate this part two in the discussion, that I had recently, I had a patient with a radial nerve injury, in, you know, at the same time, a bad humerus fracture. And it was from a motor vehicle accident. So you would have thought that this was a kind of a stretch injury to the nerve. Our trainee astutely pointed out that there was a radial nerve palsy before
surgery. And during surgery, our fantastic trauma colleague went ahead and exposed the radial nerve to look at it, because they were plating the, plating the humerus. And that was incredibly helpful information because he told me the radial nerve was in complete discontinuity at the level of the kind of just distal to the so called spiral group. And that allows us a lot of, you know, to accelerate the decision making
process. You don't have to sit around waiting, wondering whether their nerve was intact or not. But long story short, we get to the OR, and we expose the nerve. And the nerve is obviously in complete discontinuity, but then we've got two ends of the nerve and I'm trying to figure out how much to cut back. And we talked in the last episode about the challenges of assessing an injured nerve and how much to cut back. And obviously, you can
always cut more. So we started bread loafing and I was surprised how good the fascicles look despite kind of a woody appearance on part of it. And that kind of leads us to a gap in our knowledge as surgeons is, you know, how do we assess injured nerves? And how do you you know, when you're looking at cut nerve ends, and trying to figure out you know, I'm trying not to put too long of a graft, but I need to be in good nerve, how do you go through that
process of cutting back? And that kind of thing?
The temporal component is certainly super important. And so I don't it sounds as though you went to the OR, immediately with this case, or certainly within a very short time.
Within a few weeks.
Yeah. And that's, that's really interesting, because I don't know that well, I do know that it will not have fully declared itself by that time. And so you have more experience with assessing nerve viability, we'd love to have more information than simple appearance and feel, I do use bulging fascicles as my
primary indicator. And I, you know, cut from distal to proximal, I think in the setting of a radial nerve, it's probably a little less important to work for every millimeter, because you're already going to be talking about a longer recovery period, and you're talking about a bigger gap, presumably, so probably a little less important. But it's visual for me primarily.
So how would you if you were to look at this gap, and you've got, you know, you've got your extruding fascicles on both ends, and say, you've got a reasonable length gap, three or four centimeters? Tell me how you were trained, and how you very occasionally very rarely will go harvest the sural nerve.
Yeah, I'm grateful that you're my partner. Because I don't have to do that all that much anymore. Sural nerve harvest is not my favorite
thing to do. You know, it's interesting, because with a radial nerve, I would assume you would have put the patient in a lateral position which would ease both your exposure and your harvest, or you could certainly argue for a prone position as well, with the arm over an arm board, either way, I think would give me good access, and you wouldn't be struggling for the
sural nerve harvest. While I do believe that transverse incisions for sural nerve harvests are acute, I have typically not proceeded in that direction, I typically make a longitudinal incision, find the nerve distally, isolate it. And then depending obviously, on what I need, you know, take the nerve. I know you do a tran-, you do the acute transverse incisions, as I recall.
It depends on who's doing it. So one of those things is you know, so for this particular case, unfortunately, we had the patient supine, because there was a possibility, depending on the gap of just straight out doing a nerve transfer. So I wanted the ability to use a hand table, so I had them supine, but actually have their arm up in like a McConnell arm holder, like a
shoulder scope kind of thing. So I could bring the arm over the chest and work laterally and posteriorly for the approach to the nerve, which obviously makes it harder to harvest sural nerve. I still remember in my first year of practice, our partner Marty Boyer coming and helping me with a Plexus case and volunteering to go harvest the sural nerve while the
patient was supine. And you know, the number of times that I heard about the crick in the neck for the following weeks, you know, I, I'd be rich if I got a dime for all of them. But it is hard because somebody is usually you know, I usually send a trainee to do it. Because it's it's actually really good practice to dissect around the nerve from a technical perspective. But you want somebody there that can help hold the leg for them if you're
in the supine position. I usually go with one longitudinal incision to start between the Achilles and the lateral malleolus, probably about three or four centimeters just to get your bearings. And then if it's me, I don't mind doing the transverse incisions going up proximally because I'm more obviously a little more experienced with it. But if it's a trainee, I tell him your one job is to find this nerve and do it well, because that nerve is gold. I don't want you getting
acute. I don't want any, you know, shortcuts on this, because we're here for one reason. It's pretty high stakes surgery.
Yeah, and it's great. I mean, it is a good with the right training, it's a good, you know, good way to give them autonomy and expect, you know, an excellent harvest. Go back, we're gonna have a whole chat about nerve transfers, we hope in the near future. But go back to what you said. You said you placed them supine, because there's a possibility of a nerve transfer, depending on the gap.
Explain what you mean. Does a small gap in this situation lead to a nerve transfer, a big gap leads you- explain what you mean.
Yeah. So for me, it was you know, if I was able to get, you know, we knew the nerve was- in this particular case, we knew there was discontinuity of nerve, but we'd have to trim back. And if we got to a gap that was I felt reasonable, somewhere less than five, maybe six or seven centimeters for a cable graft. If we were able to do that, then I would say, all right, well, let's see what we can get because we were so early on, we're only a few weeks from
the injury. And then if we get a response, we can track it a Tine s, we see some early wrist extension, that kind of thing. Great. We don't need to do anything else. I expect the PIN to recover, etc. But if I if I didn't see a good response after a reasonable length nerve graph, we could have you know, said, we still are early on the anterior forearm is still virgin anatomy, we can go to a nerve transfer within a few months, even within six months or something and still have a reasonable chance.
Now, if that gap was excessively long, I probably would have just jumped to the nerve transfers right then and there. And in this case, the gap wasn't excessively long. So it was a, it was it was kind of an interesting case, because I had a nice branch to the lower lateral head of the triceps that I transferred into the radial nerve as well. And that's a whole different. I don't know, if the radial nerve decision making algorithm deserves its own episode, it probably does.
Because there's a lot of controversy there.
Yeah, absolutely, we're gonna, I'm gonna stay away from saying tendon transfers rule the world. Alright, so let's say you've harvested-
It's ok, as long as long as you don't need to take because you can't extend your fingers independently. So that's fine, you know, lower your expectations.
Alright, I'm gonna ignore that and move on. So we have our sural nerve graft? How do you make the determination of how many cables you use? Is there a is it simply based on overlap on the proximal end of the radial nerve? Do you try to put as many cables as you can, based on the amount of nerve you have? Certainly you don't want to skimp, just talk through how you think about that.
Yeah, I think some of that obviously, depends on the diameter of the nerve you're working with. And I posted a case to Twitter, some pictures recently that showed me using the nerve cutting or neuro tone set from a company called ASSI, I have no conflicts of interest, I think they're the only ones that make it. And it essentially it, it sizes the nerve and then you can, it has a slit where you can put a scalpel in and cut through that. Now I don't love the scalpel on the blade that
comes with it. So I actually end up using that to help hold the nerve and then I will still cut over a tongue depressor. But while you're doing that, that helps you size, the diameter of the nerve. And that can help you figure out how many cables to use. And then there's a nice technique, I think it was described in a paper out of University of North Carolina, using those to help shape your sural graphs when you cable
them. So not only can it help you figure out how many cables you need, but then also helps you shape the graft so that it's easier to handle once it's back on the field.
Okay, and describe your suturing technique, when you do perform a cable graft. How many sutures you let's say you have three cables, which might be more than you would need. Let's say you have three cables for this radial nerve, you have plenty of length, tell me what you do next.
So probably a first good technical pearl that I was taught is that you know, when you're measuring your gap, the last thing you want to do is go size your your cable graft and then be short. So we measure your gap, add 20% and then you know use that 20% to make your cables. I like to use you know, put them in those neuro tone
holding devices. And then put a little fibrin glue or TISSEEL again, like we said last time it's an off label use for nerve but that helps then the nerve graft to handle a little bit easier and actually forms a nice little sealed epineurium type thing that you can use for handling and putting your
sutures in. After you've sealed both ends with some of the glue, you obviously have to cut it back again so that you're not you know, you so that you're coapting fascicles to fascicles and so you have the fresh end. And then I usually use a 9-0 nylon, and for the reasons that we stated in the last episode.
And I will use probably about four to five, three to four depending on you know the size of the nerve but spaced apart and used and applied in a manner so that nothing extrudes and that's where the microscope comes in handy. But honestly, there are cases where the scope is a little bit difficult to get in at the angle that you need. So I'll do the repair the grafting potentially under like three, five loops, and then look at it on the scope just to make sure I like everything that I'm seeing.
So you're putting at least one suture, one 9-0 suture for each cable? Right? I mean, I guess-
Yeah, I mean, the whole thing, the whole thing, basically, once you've glued it all together, and then cut it back to extruding fascicles on your graft. It handles like, you know, a single peripheral nerve. So then I usually spaced the sutures about 60 to 80 degrees apart.
Okay, and then you suture and do you add more TISSEEL over each end?
Yeah, I will. I know there are some places where you rely completely on the glue. I don't love that idea. But I will I will apply additional glue on top only after you've taken the picture so.
And what, and what's your ideal tension, so you have the ability to put this in sloppy somewhat tense obviously don't want it too tense so talk through that process.
So I will I, I tried to position the extremity in the manner in which I think the nerve will be under maximum tension potentially. So for this particular case, I extended the elbow. So that was potentially all the way out. So I had it in the arm holder extended it out, so that was at max tension. And then at this level the wrist doesn't really matter and the shoulder doesn't really matter because we were basically at the
distal third of the humerus. And then it's hard to say the just the right amount but you if you think it's too much, it's probably too much. The there's the you know, the 8-0 nylon dogma, you know, if it can hold with 8-0 nylon, it's probably Okay, that was examined in a good paper from Jeff Greenberg's group that looked at you know, 8-0 nylon versus 9-0 nylon and 9-0 nylon has more favorable characteristics in terms of you know, the amount of tension and
strain it can handle. So I usually use the 9-0 nylon as my quote, test. If it comes together easily with a 9-0 nylon. I'm good to go.
Perfect. Perfect. Okay. I'm ready to pivot to a different nerve topic.
You're so excited right now.
Any any final cable graft?
I think I think that's probably it. I mean, I think the the natural decision right now in 2021, is what's the role of an allograft? Because that is something where you would save a lot of time. And you know, potential donor site morbidity, and that's an acellular processed nerve allograft in the states that's manufactured, not manufactured, but processed, I guess, by a company called Axogen. And I don't know how widely available it is overseas.
But I mean, what's your thought on using an acellular processed nerve allograft in 2021, Chuck?
Well, as a, I guess, I would say, in the realm of nerves, I would consider myself a bread and butter hand surgeon. And so I certainly treat nerve injuries, I perform nerve repairs. When things get too complex, I rely on my partners who have a passion and more expertise on this. I was raised, I was raised really, without nerve conduits, or allografts. But I guess early in my career, nerve conduits were coming of age, and were very popular. And I have to say, my personal experience with
conduits was not great. And I didn't get the recovery that I hoped for. But really, that's all that's all we had to choose from. And so now, I think allografts do make a lot of sense, they do feel good to work with. And I think the results have been satisfying for me. My most common use of allograft is a digital nerve. A digital nerve that I can't primarily repair. And I've been very happy with the outcomes of those, I haven't really used allografts for other
more complicated reasons. And like much of what we all do for me, I if I'm questioning the role of an allograft versus a sural nerve cable graft, for example, the case we just discussed, I go back to what what I want done with me, and for me, the data, especially on mixed nerves, and especially on bigger nerves is just not compelling enough for allograft. So I would use a cable graft. So that's-
Ok, I agree with that.
Yeah. So share me, share your thoughts don't don't let me put words in your mouth.
I mean, I think the for the digital nerves in particular, I think allograft has supplanted any sort of role for conduits. And I think literature published by multiple groups, including those that are not beholden to, to industry demonstrates that. So I think the role for a conduit or connector in 2021 is much less. I know, there are a lot of folks who would like to use connectors and conduits to take pressure or take, remove some of the tension
from the repair site itself. I personally do not buy that argument, because I think that the introduction of the connector or the wrap actually increases the amount of scar formation that is present. So and that's, again, a very nerdy discussion that we can have, but
I don't buy it. I will say, you know, I should say, obviously, for disclosure of conflicts of interest, I don't have any consulting agreements with Axogen, I have done some occasional ad hoc consulting for them in a think tank capacity and that the compensation went directly to the American Foundation for Surgery of the Hand. So that just want to put that out there. But I don't think that the literature in 2021 supports the use of processed nerve allografts for a
mixed or a motor nerve. At least in my practice, I think that there are some emerging stuff out there. But I'm still a bit skeptical.
Is there any role for conduits in your practice today?
Now, I don't like I don't use it. I mean, you know, if I have a gap, I'm either going to do an autograft or if it's a digital nerve an allograft. And I don't I don't see how it really takes tension off of the repair. I mean, I understand the theoretical arguments. But I think that the potential introduction of scar and an inflammatory reaction from that collagen substances is it's real. I mean, we've seen that in our partner, David
Brogan's work in the lab. And anecdotally, you talk to many surgeons who have a lot of gray hair and less hair. That's what that's what they believe to.
All right, tell me how you and that, you know, cost is an issue, I constantly go back to. Tell me how you reconcile cost with a digital nerve allograft repair versus harvesting another alternative, whether it be the post interosseous nerve, or the medial antebrachial cutaneous nerve. How do you how do you reconcile that?
Yeah, I mean, I think that it depends on obviously, you can, you can make an argument based on economic calculations about the amount of time in the operating room that it takes for, you know, to harvest any sort of nerve graft, and then you can- autograft. And then you could add in the potential donor site morbidity argument, which I think that the more you ask people, maybe it is
a real concern. But but I personally have not had many people complain about donor site morbidity, at least from my most harvested site, which is the sural nerve, I do have a very honest conversation with them about it ahead of time, perhaps spend a little more time on it, because I'm concerned about that. But I don't think that the cost from a nerve, processed nerve allograft exceeds, I think it's worth it. In some cases, I should say it that way. But how
much do you think it is? I think it's an interesting discussion, because we as surgeons often don't know how much these things cost.
Well, you're right. I do not know how much these things cost. I want to say it's in the $2,000 range for a typical graft. I don't know what that means, necessarily. I certainly own the cost of things I use frequently. I just don't use our graph frequently enough.
Yeah, I mean how do you think about it? Because you do a lot of, you ran our Orthopedic Center. And you're, you're the executive vice chair of our department. So costs, on our side is a consideration. I mean, what if I came to you as a new surgeon saying, I only use conduits, I only use allografts? You know, this is my expectation, is that going to be a problem?
I think, you know, it is a tough balance, right? We want to be, especially in academics, that's not meant to put us on a different planet than anyone else. But especially in academics, we have to be willing to do different things to advance a field. And we need to be responsive to the literature. And we'll be, we need to be responsive to surgeons who have the right balance, but have a strong case to be made for a particular
preference. I think as, it's fortunate that I feel like most of us here are focused enough on cost and do our best to reduce costs so that when a surgeon comes and says, This is what I want to use, and this is why I think it matters, we tend to listen, you know, being in a surgery center environment is very different. It just is more difficult to spend dramatically different amounts of money for different implants, or things like allografts, I think.
So along those lines, if you're using an autograft Chuck, what are your go tos for, you know, do you like to use medial antebrachial cutaneous, because it's in the field? Do you like to use PIN, AIN, you kind of mentioned that earlier?
You know, I was swayed a little bit by I think Jim Higgins wrote the article years ago about the size and the fascicle density of the post interosseous nerve for digital nerves. And I have to say, I have used it and I'll probably will use it again, I think the danger of using the post interosseous nerve is that it's not appropriate in my experience for proximal digital
nerves. So at the palmar digital crease, for example, the proximal aspect of the proximal phalanx, but possibly from the PRP joint distally it can be perfect. So I don't certainly don't want to cable, the PIN. So I think in my experience it's not been robust enough to use proximally. What about yourself?
I agree with that. I mean, I think that anybody who's listening as a trainee, or anybody who's interested I love that paper that Higgins wrote I think it was 2012 JHS, but it's great because it tells you how many fascicles are in each of the donors. Size matches it to the digital nerve based on the location, excellent. It's a great paper in terms of using tables and illustrations to drive a point home. So check
that paper out if you haven't. I have been underwhelmed by the AIN and PIN when I have tried to use them as donor nerves. I don't love them. They tend to shrivel up they're smaller than when you harvest, they get shorter than when you harvest them. I don't love medial antebrachial and medial brachial just because I have that you know concern ingrained in my head about painful neuroma formation. But it is convenient
because it's in the field. And if you have the right amount of length that you need, it works pretty well. I go to is still sural for most things.
For most things. That was my next question. Yes, if you're not going to use an autograft, you'll go to sural. Let's conclude with one brief discussion on digital nerve repair. Talk me through briefly. Let's say you have a sharp laceration, you're in the hospital, the patient comes in and you take them to the OR right away, maybe not the most
common scenario we have. But I'm setting you up for the ability to perform a primary repair, just talk me through how you would think through a mid proximal phalanx digital nerve laceration with an associated artery injury, but the other digital artery is intact. How do you think about that?
Well, I mean, if the other digital artery is intact and the finger as well perfused, I tend not to go after the artery, except I will confess that I have, I used maximum MFE, maximum fellow experience, as a rationale for doing the other artery because I mean, it is, it's great micro, you're already got the scope out, you can you know it. The theory is, in theory, in theory, it's good for things like minimizing cold
intolerance. But it's really good for our fellows and our residents to get additional experience with arteries, especially when it's not high stakes, and you're going to redo it, redo it, redo it, you know, but I typically will follow similar techniques to what I described earlier, I still use 9-0 nylon, I will mobilize the nerve ends as much as I can, without creating too much trauma to the surrounding tissues. And, and if there, if I can repair it primarily with the finger and
extension, I will do that. If I cannot repair it primarily with the finger and extension, I do not want my digital nerve being the reason this patient gets stiff. So I will use an allograft usually in this setting. I try to make sure that whoever is consenting the patient, or if it's if it's not me, has talked to the patient explicitly about the possibility of a nerve allograft. What about
you? How do you, I mean, this is one of the more common nerve repairs that you would do in terms of being on call and that kind of thing?
I'd, not much to add, I think I've learned my lesson over the years to avoid tension at all cost. I don't want to say that I've skimped and, and repaired nerves that I haven't because I've tried not
to do that. But when you're in the OR, and it's the middle of the night, or even the middle of the day, and you've mobilized the nerve ends you have good looking fascicles on both proximal and distal stumps, you know you can, it can be it can be tempting to put the nerve together under a, quote, little bit of tension. And that's that's always it's always hard to decide because you're weighing that versus putting in some type of interposition and then requiring the nerve to pass
two suture repair points. And so it gets tricky. And I think you're right, I think that it has to be with the finger full extended, if fully extended with 9 or 10-0, nylon, you can't have undue tension. And what does that mean? I don't know, I don't know how to quantify it, but you just can't do it.
What, so what are your thoughts about scope versus loops? For this particular study, because I know that there are some places where you don't have a microscope available and you're, you're in a surgery center or whatever and you know, your you have your loops, you have the suture, but.
I made a decision early on to use 3.5 loops rather than 2.5 loops. And I think in the outpatient environment, I think it is perfectly appropriate to use loop only repair for digital nerves. However, there is no question in my mind that given a choice between loop repair or microscope repair, the visualization and I do believe the quality of repair is better with a microscope.
I will say you know your, these cases are challenging in fingers because unlike the scenario you just gave me it usually is not just a digital nerve and an artery, there usually is much more going on. And I think that it's important for us, as hand surgeons to remember that you got to think about the rest of
the finger. And yes, selfishly, if I want to, you know, put this patient, immobilize this patient in the dorsal blocking splint for six weeks for my primary nerve repair to heal, it can be great from a nerve repair, but it's going to be awful for the rest of the finger. And that's where i think that you know, where we rely on our therapy colleagues to to get people moving quickly. We need to give
them the tools to do that. And if I can do that with you know, a graft, especially with the support of the literature that's out there. I think that that's the right thing to do.
Yeah, I think that makes all the sense in the world. Alright, so I think we should conclude part two of nerve I can't talk nerve anymore. I'm all nerved out. But I do look forward to coming back and again, hopefully having a little bit of a discussion about nerve transfers and you can educate me. What should, any other Final Thoughts?
No, I think that part three nerves is going to be great. We have a couple of great topics we want to cover this month. We're really excited. We have our fellowship interviews for our fellowship coming up next month, so we'll talk a little bit about the process in an upcoming episode. I think both on the applicant side, it's different. It's also pretty different on our side in terms of how we, how we demonstrate what we do here, and also how
we, how we interview people. So it'd be great to get comments from anybody that's listening in terms of suggestions for how to do the process. Anybody that's gone through it with residency interviews recently or other fellowships. We'd love to learn because we're all in a brave new world now so.
Absolutely. All right. Take care of yourself. Be safe, and we'll talk soon.
All right, take care. Bye.
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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