December 22, 2024 • 34 mins
Chuck and Chris celebrate the last episode of 2024 with a 'Future of Hand Surgery' episode. We prognosticate who will be performing carpal tunnel releases, how we will treat the CMC joint, what wrist arthroscopy will include, how we will repair nerves and tendons, and so much more. Join us and share your thoughts by email!
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Charles Goldfarb (00:00):
Chuck, welcome to the upper hand podcast, where
(00:07):
Chuck and Chris talk handsurgery.
Chris Dy (00:09):
We are two hand surgeons at Washington
University in St Louis, here totalk about all things hand
surgery related from technicalto personal.
Charles Goldfarb (00:17):
Please subscribe wherever you get your
podcasts, and thank
Chris Dy (00:20):
you in advance for leaving a review and rating that
helps us get the word out. Youcan email us at hand
podcast@gmail.com so let's getto the episode.
Charles Goldfarb (00:30):
Oh, hey Chris, Hey Chuck. How are you? I'm
fantastic. It's that time ofyear
Chris Dy (00:36):
That's great, you know. So every time in
conference, I want to say, HeyChuck, and I can't, because
everybody mocks me when, uh, youknow, there. So the thing is,
now that the fellows either wantto make the podcast or they
don't want to make it on thepodcast. So as everybody knows,
first fellow of the year withme, Dan Hong was all about being
on the podcast, and subtly, notso subtly, requested that I drop
(00:59):
his name on the podcast, becausehe's going to getting all these
text messages from his friends.
Second fellow year, somethinghappened. And he's like, you're
going to talk about this on thepodcast, aren't you? And he
started saying, hey, Chuck,guess what happened? I said I
would never do that. I had suchan enjoyable time with the
second fellow Nick colada. Hewas so fun to have on rotation
(01:19):
because he nerds out about thesame stuff I drew out about. But
we'll see how the third fellowgoes, Eric. He's on rotation
with me now. Loving Eric Jiang,so, yeah, best time of the year
for her. For surgeons, you know,proceduralists, I will say in
general,
Charles Goldfarb (01:36):
it is really funny when you talk about
conference, because we weredoing our research conference on
Monday, and it's just going downthis freaking nerve pathway. And
I felt like I was on the pod,and I just, I felt like I needed
to be careful not to interactwith you like I would on the pod
to say, enough of the freakingnerve stuff. But hey, it is what
it is.
Chris Dy (01:55):
It was the research meeting that I lead you know,
which I guess, for those thataren't familiar with it, but if
our division, we do a monthlyresearch meeting, and a couple
years ago, we made a change sothat there was a rotating
moderator for the meeting thatwould be a different faculty
member to talk, you know, justin general, about what's going
on in Division, ask the fellowsfor updates on their projects
(02:15):
that they're working on, andthen talk about their own
research program, which I thinkhas been really fun, because all
of us do a ton of research. Butjust, you know, we have our
little spaces and niches. Just,you know, like I do the nerve
stuff, the clinical research,David does basic science, nerve
you and Lindley do a ton ofstuff with, could you do a lot
of stuff with the adolescentsand sports? So, you know, it's
nice to be able to catch up onthat. But yes, I also almost
(02:39):
slipped into podcast modebecause we were on Zoom, we were
talking about her,
Charles Goldfarb (02:44):
yeah, it's really hard to keep up with one
another. I mean, we have eighthand surgeons. We're all super
busy. We're all doing differentthings. Obviously we have
overlap. The other thing, Imean, I do love just getting
together in person or even onZoom. It's a nice it's a, you
know, it's a substitute, butit's fun to hear what you are
doing, because I get a sense,but talking details is really
helpful. So I do like theresearch meeting for that
(03:05):
reason, for sure, absolutely.
Chris Dy (03:08):
So yeah, it's a busy time of the year. Everybody's
met their deductibles, and I'vebeen hearing about it for many
months now. I'm glad that oureighth hand surgeon has joined.
Jason Strauss joined us from theUniversity of Chicago, and
that's I've certainly heardless. I've been waiting four
months to get in. Honestly, ithasn't come up, but that's been
replaced by so I met mydeductible, and I was on the
(03:32):
unfortunate end of the schedulethis holiday season because I
had the surgical center where Iwork is closed on Christmas Eve,
obviously closed on ChristmasDay, but Christmas Eve is my or
day. Christmas Eve is also orNew Year's Eve is also my or
day. Surgery Center where I workat is closer too, so I've
scrambling to find extra time,which I successfully have, but
(03:55):
my schedule will Off, off kilterfor in the next couple of weeks.
Charles Goldfarb (03:59):
It's hard, but yesterday, I had just, I mean,
when you have a it's almost likeyou don't want to get injured on
July 1 with a new round ofresidents and fellows, or
residents at least, you don'twant to get injured right about
now, because the schedule isbooked solid, like I have
squeezed and pushed, and there'salmost no leeway. So if you have
(04:19):
a trauma now, either it getstaken care of immediately, but
kind of walking the office andexpecting to get a fracture
taken care of is just almostimpossible. It's honestly
frustrating.
Chris Dy (04:31):
It makes it very, very challenging. I mean, it's been,
you know, it's been busy withthe nerve stuff too. I was we
did four Plexus cases in fivedays, big cases, one, super big
one and three kind of mediumsized ones, you know. So it was,
it's been a busy time, and I'llbe looking forward to some
quieter times in January. Butit's, you know, nerve, nerve,
(04:55):
nerve, a lot of other stuff.
Nerve, NF, nerve, which I love,but it's a. I'm sure this
current phase is sustainable themonth of December. Case, no,
Charles Goldfarb (05:05):
I think we all feel that way. I understand one
of those cases you did, maybestarted at 730 to finish around
10 or 10 (05:11):
30pm and for me, a three hour case is is more than
I ever want to do. But, youknow, I it, I admire those who
have more endurance than me.
Chris Dy (05:25):
To be fair, it was a Wednesday, so it was an 830
start, and then by the time youactually start the case after
setting up a plexus, you know,you're solid 45 minutes into the
room. But for us, you know,obviously you don't want to have
to do those cases, but they arereally engaging and exciting
cases to do. And I think DavidBergen and I have come up with a
pretty good system, and we did alot of work in that time, and
(05:46):
patients doing well so far. Sovery excited to continue the
nerve adventures in 2025 we dohave a fun episode that we're
going to do today about thefuture of hand surgery. I think
you came up with this idea whileyou were sitting in business
school class. Is that it?
Charles Goldfarb (06:05):
I try to focus, but hey, sometimes the
mind drips. I don't know when Icame up with the idea, and I
don't I, you know, hopefullythat, you know, we come up with
enough interesting topics, but Ihope our listeners will also
pepper us with differentconcepts for what the future of
hand surgery will look like. So
Chris Dy (06:19):
when you emailed this to me, I immediately thought of
the the Conan O'Brien skit, andthis is totally gonna date me.
But when Conan was on NBC, andhe was following Jay Leno, so he
was in, like, the in the easterntime zone, that's like the, I
guess, they 1230 slot. Yeah, Iloved watching Conan back in the
day, and it was, I guess, in thelate 90s, and they would have
(06:43):
this segment with he and AndyRichter would would have called
in the year 2000 where theywould just make these off the
ball predictions, many of themhilarious, about what was going
to happen in the year 2000 andthen then we add the whole y 2k
thing and everything. I feellike the future of hand surgery
could be a little bit like that.
So we'll see. We'll see what youcome up with.
Charles Goldfarb (07:02):
Well, we'll let the listeners be the judge
of how poorly or how well we maydo. Yeah, I think there's some
interesting, interesting things.
Chris Dy (07:11):
So first off, want to thank our sponsors over at
practice. Link, the apprehendedsponsor at practice. Link.com,
the most widely used physicianjob search and career
advancement resource.
Charles Goldfarb (07:20):
But coming a physician is hard. Finding the
right job does not have to bejoined. Practice link, for free
today at www dot practicelink.com, backslash the upper
hand, and we are grateful topractice link. They have been
with us, I don't know, coupleyears now, three years, maybe.
So thank you very much to them.
Yes,
Chris Dy (07:38):
and they're always great resource for our local
residents and fellows, and youreally do take care of them in
terms of providing access tosporting events. So we were the
beneficiary of that for a bluesgame recently. So thank you
practice, Lee. So these are yourhot takes that you came up with
for the future of hand surgeryin 2025 and beyond. So the first
(08:00):
one, I think is reallyinteresting. And I know I've
talked about this before, carpaltunnel release will be performed
by others, such as physiatristsand neurologists.
Charles Goldfarb (08:12):
Go and I might even and people are gonna, are
gonna wince when I say this. Itmight be podiatrist. It's
interesting. I learned a lotabout podiatry. Podiatry is
licensed to do hand surgery insome states, which makes no
sense to me. But I think thepoint is, have we gotten to a
stage where the technologyallows a simplistic approach to
(08:33):
treating carpal tunnel syndrome?
And you know, some of thisprediction is tongue in cheek,
because I don't know that. Itruly believe that, but I do
think it's not going to be 100%of hand surgeons indefinitely.
It's not right now. Well, it'snot right now. What percent it's
got to be, I don't know.
Chris Dy (08:51):
But I mean, I think the you know, as listeners may
know, at least in the US, thereis a new ultrasound guided
carpal tunnel release device andan ultrasound guided trigger
finger release device. And whilethey are currently training hand
surgeons only, I I am fullyaware that their plans are to
train non hand surgeons to dothis surgery too, and that could
(09:12):
be neurologists pm and arethey've approached people in our
pm and our division about doingthe surgery, and I think they
were internal discussions, fromwhat I understand, and the
carpal tunnel release remainsfirmly in the domain of the hand
surgeon, but you know, and alsoorthopedic surgeons and plastic
surgeons and general surgeons, Imean people who have trained to
do the actual surgery. But,yeah, no, that's coming. It
(09:35):
scares me. I think one of theour our partner, David Bergen,
talks about how he's morestressed about a carpal tunnel
release than a crazy Plexuscase, because the expectations
are completely different. Imean, you have to be perfect on
every carpal tunnel. I mean, youshould be. I think, whereas a
crazy Plexus is like there areonly a handful of people, you
(09:57):
know, not a handful, but there'sonly a certain number of people
in the. And theninternationally, of course, that
are, you know, really doingPlexus surgery. So there's a lot
of variability in the casepresentation, a lot of
variability in treatment andexpectation. So the bar is very
different. So
Charles Goldfarb (10:11):
should hand surgeons be teaching non hand
surgeons? And again, we're nottrying to exclude orthopedic
surgeons and plastic surgeonswho are trained, but should hand
surgeons be treating non handsurgeries. To do these surgeries
like carpal tunnel
Chris Dy (10:23):
release, I think it depends on, you know. I think,
you know, there are some people,you know, who feel very strongly
that if you can't handle anddeal with the complications that
a procedure generates, youshould not be doing said
procedure, you know. But also,there are probably access issues
in terms of getting in. And Ithink some of the marketing
around at least this currentultrasound guided device is that
(10:45):
there are a lot of people don'twant to have quote surgery, and
you're seeing a hand surgeon,you know, even though a lot of
what we do is non operative,people still have that
mentality. When you're seeingthe surgeon, they're going to
want to do surgery. If you canmake a carpal tunnel release a
quote procedure that's done inthe office by a non surgeon.
Maybe it's a little lessintimidating, and, you know,
makes people more interested inhaving it done.
Charles Goldfarb (11:07):
Yeah. I mean, this is the hallmark procedure
for hand surgeons, no doubtabout it. And it's not
glamorous, but there are, Iguess I would say there are
challenges, both diagnosis,counseling and technical. And
the vast majority of time,things go just fine. But, you
know, I don't know the numbersyou quote for a successful
outcome in carpal tunnelrelease, but it's not 95% you
(11:32):
know, it's just not. So it's aninteresting concept, yeah,
Chris Dy (11:36):
and I agree, and you know, I will say, to be fair,
there I've seen some incrediblyskilled, you know, PM, and our
docs and neurologists use theultrasound to do some really
skilled procedures, like verychallenging procedures. I mean,
when I was up at, when I was upat Mayo for as part of the
government travels, governmentscholarship travels, I watched,
(11:57):
you know, them, do someultrasound guided thread carpal
tunnel releases, which is reallycool to do. You know, Alex Shin
was doing that with with thephysiatrist together, and did a
lot of them, and they lookedgreat. I think it's probably a
combination approach, orcollaboration approach, that
would be best. But just thephysical amount of time that you
(12:17):
need for two people to two busydoctors to do something together
is is hard for something asrelatively routine as a carpal
tunnel release?
Charles Goldfarb (12:26):
Yeah, I have nothing to add. So, so, yeah,
maybe, maybe, I don't know. In2030 will it be 25% of cases are
done by non answers. I don'tknow. Yeah,
Chris Dy (12:36):
I don't know. And I don't know if there's a, I guess
there's an admin data studywaiting to happen in the future.
So we'll see.
Charles Goldfarb (12:42):
We will see, all right. Number two, the thumb
CMC joint, will be treated withimplant arthroplasty
Chris Dy (12:50):
alone. You mean in the United States, because it's
already being done other placesin
Charles Goldfarb (12:54):
the United States, by 2030, CMC will be an
implant arthroplasty procedure,and we won't be doing fcr, we
won't be doing suture suspensionplastic, we won't do an implant.
I like the suture implants. Whatdo you think? No,
Chris Dy (13:15):
I do not think that's gonna happen,
Charles Goldfarb (13:17):
and why and why not. I
Chris Dy (13:19):
think that the it's going to take a lot to change
surgeons minds about what to doin the US. And I think the track
record of multiple unsuccessfullaunches of implant arthroplasty
for thumb, CMC in the US markethas honestly, I think it's
probably, you know, killed theprocedure, potentially for
(13:40):
future generations. I wasintrigued. We had a visitor come
from South Africa last year, andhe was talking about his thumb
CMC experience and implantarthroplasty. And I was
intrigued. And then I haveenough happy thumb CMC patients
who are treated with trapeziumand suspension of some sort,
where I'm not going to change.
So we're to require a fair bitof evidence, and those studies
(14:01):
are expensive and are probablynot going to be done. I
Charles Goldfarb (14:08):
think that's well said. You know, it's so
interesting and sometimesfrustrating, and I will leave
the person nameless, but, and Idon't, I don't think you do it
this way, but as an example ofkind of the challenge of having
surgeons change. In conference,we were talking, I think, in
research conference, we weretalking about, or else clinical
(14:28):
conference, we were talkingabout how we approach the CMC
joint, straight dorsal orWagner. You might call it the
Wagner approach,
Chris Dy (14:36):
and not as fancy as you with the Wagner
Charles Goldfarb (14:39):
and one of my partners, who I have immense
respect for, only uses theWagner, and I just don't
understand it. It doesn'tprovide better access. You do
have more nerve, you know, nerveirritation afterwards. Why in
the world will we do that? It'sjust that's how that person was
trained. And deviating from thatcourse, you. It's just hard,
(15:00):
right?
Chris Dy (15:01):
It's very hard to change people's minds when they
have success with something,right? Like, why would they
change? Like, you know, that'swhat works. What works in your
hands, right? You know, weactually have two partners that
use the Wagner routinely. So,no, no, you know, I'll let we're
not going to call them outbecause, you know, but actually,
(15:22):
I think if you're doing the, ifyou're doing the genie Delson,
your technique, you know, it'sactually easier from a Wagner,
it's quite challenging, I think,to do from a dorsal approach.
But our partners are using thattechnique as of right now. But
you know, just saying, there aretechnical reasons to use a
Wagner, you know, if that's yourpreferred suspension, what's you
(15:44):
know, you're much older thanmuch, much older than me, much
and trained in, you know, backwhen I think, you know, people
were being admitted beforecarpal tunnel releases and sent
home after three days in theICU. So what was the feeling
about implant arthroplasty, backwhen some of those implants were
being introduced in the 90s inthe
Charles Goldfarb (16:04):
States, I was taught with the classic Burton
and Pellegrini fcr, and therewas a widespread skepticism with
the introduction of any implantarthroplasty. And so, you know,
at in since where I did myresidency, here at Wash U in
Cincinnati, with Peter Stern,Tom kefir and others, and then
(16:26):
back at WashU. I don't thinkanyone's I've never seen an
implant arthroplasty performed.
Chris Dy (16:32):
Do you feel like there is a chance for it to be adopted
in the United States? Thatwouldn't take Yeah?
Charles Goldfarb (16:41):
It would take an amazingly convincing study,
and it would also take anarticulate proponent of the
procedure sharing his or herresults repetitively at national
meetings. I mean, it's just itwould be a slog to change the
perspective of so many people. Ithink it could happen. I mean,
(17:01):
given the success of hips andknees, and I mean, you would
think that there's a, at leastamongst orthopedic surgeons,
there is an underlyingacceptance that implants are
great, but it's just not forhand surgeons. Do you think that
there's
Chris Dy (17:19):
a market to develop said device, and, you know, and
obviously, it's been developedin other countries, and there
have been reports of excellentresults in, you know,
internationally, I
Charles Goldfarb (17:31):
like to your point earlier, I just don't
think in the United States,we're ready for it. I think
that's the hope that colleaguesoverseas will share compelling
results that aren't like a skoshbetter than our results. However
we're doing it, they have to benotably better. You know,
decrease early failure rate,decrease late failure rate, and
(17:52):
really happy patients. Becausethe reality is, I think we all
know there is one truth, andthis one truth that will prevent
me from ever doing a prospectiverandomized trial again, if the
results are always about thesame, whatever you do, yeah, I
mean, it's
Chris Dy (18:04):
really, I won't say that, you know, a thumb CMC
surgery is as reproducible as acarpal tunnel release. But, I
mean, I think that's the issuethat, you know, studies have
when they're trying to show thatthey're not significantly
different, you know, compared toan existing gold standard, gold
(18:25):
being a relative term, right?
And then, you know, you actuallyhave to show that you're better,
which, in some ways can beharder. So I just don't think
the evidence is going to come,and I think it does have to come
from somebody who is respected,articulate, and not crossing
into the line of evangelistic,which I think a lot of people
who when they feel reallypassionate on something that
(18:45):
they've innovated, it does comeacross as evangelistic at times,
which you know right or wrong,but you're just so into it and
in the weeds and invested, yeah,
Charles Goldfarb (18:54):
well said. I mean, what was the last great
shift in surgeon, hand surgeonbehavior. Was it the volar plate
with George or Bay? I think
Chris Dy (19:05):
the volar plate is probably the one that we would
recognize, you know, I thinkthat, I think we're having Sanj
back on pretty soon, and youguys will talk a little bit
about, you know, maybe a shiftin, you know, arthroscopic
treatments before the volarplate, you know, microsurgery,
Charles Goldfarb (19:19):
yeah, yeah.
And the other, the other distalradius innovation that I think
has been rapidly and widelyaccepted is the spanning plate.
Those are both, you know, we'rebig changes, but yeah, let me,
let me back up. And just maybeas a future of hand surgery
number three will be wristarthroscopy will continue to
(19:39):
evolve, maybe some fits andstarts, but open scape, Fauci
lunate ligament repair will behistorical. And I think the
future of hand surgery includesall arthroscopic treatment, just
like the evolution of rotatorcuff repair.
Chris Dy (19:59):
I think that's.
Probably right. I mean, youknow, and I also think to
piggyback on your three, I'llmake it a three A. I think in 10
years, you're going to havearthroscopy fellowships for
hand, wrist and elbow.
Charles Goldfarb (20:13):
Yeah, interesting. Just like people
have, like,
Chris Dy (20:15):
you know, your extra three months, you do for six
months for peds, and some peopledo it for micro, I think they're
going to be arthroscopyfellowships, mini fellowships.
Charles Goldfarb (20:25):
That implies programs where there's an
abundance of volume that wouldallow that. I've always
struggled with that because I,I, you know, I do a lot of
elbow, which I don't think isdone a lot, and we have a
visitor.
Chris Dy (20:45):
We do have visitor.
Did you want to introduceyourself? Okay, go ahead. My
name is Evelina, and I'm sixyears old.
Charles Goldfarb (20:55):
Thanks for joining us, for talking about
your future in hand surgery.
Chris Dy (21:00):
I can't hear you because I have headphones. Okay,
Can daddy finish the podcast?
Yeah? Okay, daddy, thank you.
Charles Goldfarb (21:09):
Yeah. So, so I do a lot of elbow work, and yet
the challenge is having enoughto welcome visitors, or, you
know, enough localized but Ithink you're right. An upper
extremity arthroscopy fellowshipmakes a lot of sense. I think
you're
Chris Dy (21:25):
going to be doing more and more through the scope, and
people are going to want to cometo learn, and I think I'm going
to be doing less and lessthrough the scope. I mean,
that's honestly as and I'minterested. Just personally, I
want to remain broad as a handsurgeon, but I also recognize
there's too many fields to keepup with, like, you know, to be
honest with, even in our narrowlane of hand surgery, there's
various things that I'm just notgoing to be up on as much. And,
(21:48):
you know, I think that I'llprobably have to select at some
point.
Charles Goldfarb (21:51):
It's so true, and you're wise not to narrow
too soon. We've talked aboutthat. I firmly believe, stay
broad as long as you can. But atour institution, oh, it would be
okay if you decided to just donerve but you drive 100 miles,
or even 50 miles, or 30 milesoutside of the academic
institution, and you can't bethat narrow. So it does get
harder and harder to stay up todate. So is there going to be
(22:12):
increased specialization? And Ithink that may be the future of
hand surgery that you'realluding to. I don't think it's
three a I think it's four. Ithink that that we will continue
to narrow what hand surgerylooks like. Yeah,
Chris Dy (22:22):
and I but, you know, I think it is, is important to
have that broad base, not onlyfor just, you know, in access
for patients, but my own sanity.
I mean, I can't do only nerve,because doing only nerve means a
lot of pain, and then you need,I need the winds. I need the
carpal tunnels, the triggerfingers, the basal joints, you
know, the dystopia stretchers. Ineed balance in that regard to
(22:45):
to give me the energy to keepgoing on some of the nerve,
because the nerve can reallydrain you.
Charles Goldfarb (22:51):
It's so true.
Well, not just nerve. So I'vesaid to my nurse, she doesn't
listen to me, but I've said tomy nurse, you know, my sweet
spot for wrist arthroscopy istwo in a single day. I'm happy
to do three when I have four istoo much. There's too many
scopes total.
Chris Dy (23:06):
I've actually so I'm now working with a new with an
athletic trainer as my primarysupport person for my team, and
she's wonderful. But, you know,she booked me, I think, four
older nerve transpositions in aday. And I'm like, I love that
surgery. I know I do a lot ofthem, but that's just a lot. And
then I told her, I have a limiton the number of, well, not
cases I'll do in a day. And Ithink because of the way that
(23:31):
the scheduling happened, I thinkI have six, well, on cases the
day after Christmas, which isjust going to be a lot. It's
just it's really taxing on my,on my ability to entertain at
the same time as doing surgery,it's a lot
Charles Goldfarb (23:44):
and, and, yeah, three or four valance are
plenty for me, and I would saythe same about owners. My
goodness, after three in oneday, it's, it's, that's, that's
Chris Dy (23:55):
too many. So one more prediction, maybe carpal tunnel
releases and trigger fingerreleases will not be done in the
operating room in 2035
Charles Goldfarb (24:04):
100% agree.
100 Wait, we got one more afterthat. 100% agree that we will
not be doing the little cases inthe OR. And honestly, I don't
think it's gonna take 10 yearsto get
Chris Dy (24:15):
there. Um, okay, well, why don't we before we jump into
the next
Charles Goldfarb (24:19):
Wait, wait, wait, wait, I want to do the
next hot take. Oh, you're goingto do you're going to thank
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Chris Dy (24:27):
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Charles Goldfarb (24:53):
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confirmation of nerve functionand procedures with risk of
iatrogenic nerve injury. Tolearn more, visit
www.checkpointsurgical.comcheckpoint surgical driving
innovation and hand surgery. Canyou please translate? Well, I
(25:16):
just heard,
Chris Dy (25:17):
do you know how you own so Guardian is the unipolar
stimulator. So that's the blueone. That's what I call the blue
one. The purple one, which is abipolar stimulator, which is the
Gemini, so the Guardians, theblue one the monopolar so you
put this little doohickey on it,attaches to it, and then,
instead of applying thestimulator directly to the
(25:38):
nerve, you can then hook a leadon. It's like a little plastic U
shape that can hook around thenerve a dramatically. There are
some holes if you want to put acouple of stitches in it to keep
it there, but then you canstimulate the nerve consistently
without having to take thedevice on and off, touch it on
and off, etcetera. So I thinkthere are other applications
that checkpoint is thinkingabout down the line for said
(25:59):
lead, but I should not say morethan that, but yeah, it's a nice
way to keep the lead in the sameplace, if that's your if that's
your goal, to stimulate thenerve in a consistent place, if
that's
Charles Goldfarb (26:09):
your goal, gotcha, that's over my head. But
sounds, sounds interesting. Sowhat's nerve repair gonna look
like in seven years? I
Chris Dy (26:20):
think it's an interesting question, because
of, you know, the for many yearswhen you've been trying to look
at nerve conduits, things to getaway from sutures, perhaps a
suture less nerve repair, thequestion is always, does it
generate more scar debris, etc,than you know that it's worth
(26:41):
but sutures also generate scar.
And sutures introduce the, youknow, human variability and
technique. Newer devices havebeen introduced, you know, using
small hooks that kind of go intothe epineurium and can keep a
nerve together. I'm not surethat nerve repair is going to go
in that direction. I think manywill, many will use said device,
(27:03):
or a conduit or something to goto a suture less repair. I still
think we need to train ourfellows and residents about how
to use micro sutures to putnerves together. I think there's
a training aspect to it. I'dlike to see if we can get away
from a number of st like thevast number of stitches, so
maybe go to just a single or twostitches and use something else
(27:25):
to keep the CO optationtogether. My prediction is that
these devices will then be usedas drug delivery devices, and I
think that's probably wherethings
Charles Goldfarb (27:38):
are going to go. It makes a lot of sense.
We've watched our previous chairand senior partner dedicate our
career towards the manual suturerepair of flexor tendons. And as
he sort of finished his 40 yearswith NIHR one funding, he was
into the drug delivery game fortendon healing. It just makes
(28:00):
sense for tendons, for nerves,or whatever.
Chris Dy (28:05):
I think, I think, you know, hopefully that's something
that the appropriate cocktailwill be figured out, and that,
you know that's probably notgoing to be ready for prime
time, I think, for, you know, asolid one or two decades. But I
think this is laying thegroundwork for that.
Charles Goldfarb (28:20):
So for doing long term predictions, are you
ready to go off the nerve?
Because I don't. I know it's,it's tough to stop talking
about, do you have anything elseyou possibly there's no more
nerve talk this episode. So Iwant people
Chris Dy (28:31):
to email saying how much more nerve they want, or if
they want, you know, I want tosay, email us and say what you
want, right? Like, you know, wehave a, we have a great grab bag
episode that's going to come outin next month. At some point,
we've had some great emails, sowe appreciate all the emails,
including some fun facts aboutthe origin of Halloween. So we
had a correction the that'll bea great episode. But if you want
(28:57):
more nerve, please email us handpodcast@gmail.com more and more
of anything. I'm sure you wantmore sports. Whenever I see
people in person, people inperson, they always talk about
how they want more sports andarthroscopy stuff. So I admit
I'll have to. I do enjoylearning during those episodes.
So thank you for that,absolutely.
Charles Goldfarb (29:13):
So I'll talk a little bit what I think the
future of congenital handsurgery is.
Chris Dy (29:20):
And you didn't tell me you're going congenital On this
episode, there's
Charles Goldfarb (29:24):
been a clamoring the listeners, for the
three of you that like
Chris Dy (29:27):
congenital, please, please keep listening if you're
if you're not in the congenitaljust, you know, you can keep
listening to it.
Charles Goldfarb (29:33):
This is going to be short and obtuse. Gene
therapy will be there one day.
You know, right now, genetherapy is super expensive.
We're using it for, you know,obviously for cancer. There's
been some work done with sicklecell, and, you know, it's going
to be arthritis, etc, etc. Somaybe CMC arthritis doesn't
exist anymore with gene therapy,but, but I think Gene therapy
(29:54):
will, will, will change the waywe think about congenital
conditions and. Smart enough toknow exactly what that means,
but I don't think we'll betreating the same volume and in
15 years that we are today.
That's
Chris Dy (30:07):
exciting, but the problems that we're producing so
many congenital hand surgeons.
Everybody wants to docongenital. I just read every
fellowship application that wereceived. I mean the number of
people that want to do pizza andcongenital like Good God, do we
need another congenital handsurgery?
Charles Goldfarb (30:24):
News flash, we probably don't, but maybe I need
to retire so, so there's space,there's room. Um, so
Chris Dy (30:31):
quick, quick question.
Do you think Gene therapy forarthritis will be ready before
an accepted thumb CMC implant inthe United States. I think
Charles Goldfarb (30:42):
it might be. I think it might be. And the work
that our colleague and ourpartner, Fauci like doing in
regards to osteoarthritis andtreatment is unbelievable for
those of you, and I can't speakeloquently about it, but the
work being done in the lab forour osteoarthritis and treatment
for it is unbelievable. We'renot that far away. To Chris's
(31:05):
point, yes, I'm voting for genetherapy, but I think
Chris Dy (31:08):
Gene therapy will get there before a thumb CMC implant
is widely adopted in the UnitedStates. Now, patients, I have to
answer that question a lot. Imean, like my whole spiel about
arthritis is that we have nocure for it, but they're working
on it in WashU. I mean, Faucireceived the largest grant in
Washington history. It's anincredible amount of money. So
yeah, see, they're working veryhard on on fixing that. One
(31:29):
other question before we close,do you ever think that there
will be in utero surgery forcongenital hand issues?
Charles Goldfarb (31:36):
So there currently is, theoretically, the
problem today is the risk oflike, if you have a constriction
band around the forearm or upperarm, that's severe. I think our
general surgery colleagues wouldpotentially treat that in utero.
But most of the other stuff isthe risk benefit ratio is off. I
(32:00):
don't know how that changes. I'mjust not that knowledgeable.
But, yeah, I think that'llincrease as well I do. Okay,
yeah, good. One important one,how many hand surgery podcasts
will there be in 2030
Chris Dy (32:16):
so I, interestingly enough, I did look a lot last
week. I was, I can't rememberwhat prompted me to do it. There
are a couple other hand surgerypodcasts that have a limited run
of episodes. I can't say thatanybody has, you know, five
years in a game like others, butit's crazy. We're going up on
our five year anniversary nextmonth. Who would I feel like it?
(32:37):
I feel like you owe me a gift.
Charles Goldfarb (32:40):
This is your gift.
Chris Dy (32:43):
But, yeah, no, I don't, I don't know. Maybe I
don't know if there'll be onehand surgery podcast in five
years. We'll see You're awful,you're awful busy,
Charles Goldfarb (32:53):
so
Chris Dy (32:55):
funny. I don't know.
And, you know, I think that whoknows what the next educational
kind of venue is going to be. Imean, I think that fortunately,
we were, I wouldn't say, aheadof the curve. We were timed
appropriately, I think withthat, with the upper hand, but
who knows where it's going togo. Yeah,
Charles Goldfarb (33:11):
for those of you listen, we're grateful for
our listeners. This is a laborof love. We do enjoy it, for
sure. What's been fascinatingfor me, and that goes to the
listeners who are still tuned inand haven't dropped off yet. You
know, most of you listen in theaudio only format, but our
YouTube viewership, why peoplewant to see Chris and me sit
here and talk? I do not know.
But our YouTube viewership isgoing through the roof. I mean,
(33:33):
I think we had six or 700recently. It's really
remarkable. I
Chris Dy (33:38):
think it's just easier to pull stuff up on your on your
computer or your phone onYouTube, maybe just like, let it
roll. That might be it. Or theyjust, I mean, they love seeing
your dome. It's great.
Charles Goldfarb (33:49):
I got a kind of shortcut. What happens
Chris Dy (33:54):
looking good? Well, I wish you the best holiday season
and a great end to your 2024,Chuck. It is always fun to do
this together, and I lookforward to another another year
of it, hopefully every dude,happy holidays. Happy holidays.
Take care.
Charles Goldfarb (34:13):
Hey, Chris, that was fun. Let's do it again
real soon. Sounds
Chris Dy (34:16):
good. Well, be sure to email us with topic suggestions
and feedback. You can reach usat hand, podcast@gmail.com
Charles Goldfarb (34:23):
and remember, please subscribe wherever you
get your podcast,
Chris Dy (34:26):
and be sure to leave a review that helps us get the
word out. Special,
Charles Goldfarb (34:31):
thanks to Peter Martin for the amazing
music.
Chris Dy (34:34):
And remember, keep the upper hand come back next time
you
Chuck, welcome to the upper hand podcast, where
(00:07):
Chuck and Chris talk handsurgery.
Chris Dy (00:09):
We are two hand surgeons at Washington
University in St Louis, here totalk about all things hand
surgery related from technicalto personal.
Charles Goldfarb (00:17):
Please subscribe wherever you get your
podcasts, and thank
Chris Dy (00:20):
you in advance for leaving a review and rating that
helps us get the word out. Youcan email us at hand
podcast@gmail.com so let's getto the episode.
Charles Goldfarb (00:30):
Oh, hey Chris, Hey Chuck. How are you? I'm
fantastic. It's that time ofyear
Chris Dy (00:36):
That's great, you know. So every time in
conference, I want to say, HeyChuck, and I can't, because
everybody mocks me when, uh, youknow, there. So the thing is,
now that the fellows either wantto make the podcast or they
don't want to make it on thepodcast. So as everybody knows,
first fellow of the year withme, Dan Hong was all about being
on the podcast, and subtly, notso subtly, requested that I drop
(00:59):
his name on the podcast, becausehe's going to getting all these
text messages from his friends.
Second fellow year, somethinghappened. And he's like, you're
going to talk about this on thepodcast, aren't you? And he
started saying, hey, Chuck,guess what happened? I said I
would never do that. I had suchan enjoyable time with the
second fellow Nick colada. Hewas so fun to have on rotation
(01:19):
because he nerds out about thesame stuff I drew out about. But
we'll see how the third fellowgoes, Eric. He's on rotation
with me now. Loving Eric Jiang,so, yeah, best time of the year
for her. For surgeons, you know,proceduralists, I will say in
general,
Charles Goldfarb (01:36):
it is really funny when you talk about
conference, because we weredoing our research conference on
Monday, and it's just going downthis freaking nerve pathway. And
I felt like I was on the pod,and I just, I felt like I needed
to be careful not to interactwith you like I would on the pod
to say, enough of the freakingnerve stuff. But hey, it is what
it is.
Chris Dy (01:55):
It was the research meeting that I lead you know,
which I guess, for those thataren't familiar with it, but if
our division, we do a monthlyresearch meeting, and a couple
years ago, we made a change sothat there was a rotating
moderator for the meeting thatwould be a different faculty
member to talk, you know, justin general, about what's going
on in Division, ask the fellowsfor updates on their projects
(02:15):
that they're working on, andthen talk about their own
research program, which I thinkhas been really fun, because all
of us do a ton of research. Butjust, you know, we have our
little spaces and niches. Just,you know, like I do the nerve
stuff, the clinical research,David does basic science, nerve
you and Lindley do a ton ofstuff with, could you do a lot
of stuff with the adolescentsand sports? So, you know, it's
nice to be able to catch up onthat. But yes, I also almost
(02:39):
slipped into podcast modebecause we were on Zoom, we were
talking about her,
Charles Goldfarb (02:44):
yeah, it's really hard to keep up with one
another. I mean, we have eighthand surgeons. We're all super
busy. We're all doing differentthings. Obviously we have
overlap. The other thing, Imean, I do love just getting
together in person or even onZoom. It's a nice it's a, you
know, it's a substitute, butit's fun to hear what you are
doing, because I get a sense,but talking details is really
helpful. So I do like theresearch meeting for that
(03:05):
reason, for sure, absolutely.
Chris Dy (03:08):
So yeah, it's a busy time of the year. Everybody's
met their deductibles, and I'vebeen hearing about it for many
months now. I'm glad that oureighth hand surgeon has joined.
Jason Strauss joined us from theUniversity of Chicago, and
that's I've certainly heardless. I've been waiting four
months to get in. Honestly, ithasn't come up, but that's been
replaced by so I met mydeductible, and I was on the
(03:32):
unfortunate end of the schedulethis holiday season because I
had the surgical center where Iwork is closed on Christmas Eve,
obviously closed on ChristmasDay, but Christmas Eve is my or
day. Christmas Eve is also orNew Year's Eve is also my or
day. Surgery Center where I workat is closer too, so I've
scrambling to find extra time,which I successfully have, but
(03:55):
my schedule will Off, off kilterfor in the next couple of weeks.
Charles Goldfarb (03:59):
It's hard, but yesterday, I had just, I mean,
when you have a it's almost likeyou don't want to get injured on
July 1 with a new round ofresidents and fellows, or
residents at least, you don'twant to get injured right about
now, because the schedule isbooked solid, like I have
squeezed and pushed, and there'salmost no leeway. So if you have
(04:19):
a trauma now, either it getstaken care of immediately, but
kind of walking the office andexpecting to get a fracture
taken care of is just almostimpossible. It's honestly
frustrating.
Chris Dy (04:31):
It makes it very, very challenging. I mean, it's been,
you know, it's been busy withthe nerve stuff too. I was we
did four Plexus cases in fivedays, big cases, one, super big
one and three kind of mediumsized ones, you know. So it was,
it's been a busy time, and I'llbe looking forward to some
quieter times in January. Butit's, you know, nerve, nerve,
(04:55):
nerve, a lot of other stuff.
Nerve, NF, nerve, which I love,but it's a. I'm sure this
current phase is sustainable themonth of December. Case, no,
Charles Goldfarb (05:05):
I think we all feel that way. I understand one
of those cases you did, maybestarted at 730 to finish around
10 or 10 (05:11):
30pm and for me, a three hour case is is more than
I ever want to do. But, youknow, I it, I admire those who
have more endurance than me.
Chris Dy (05:25):
To be fair, it was a Wednesday, so it was an 830
start, and then by the time youactually start the case after
setting up a plexus, you know,you're solid 45 minutes into the
room. But for us, you know,obviously you don't want to have
to do those cases, but they arereally engaging and exciting
cases to do. And I think DavidBergen and I have come up with a
pretty good system, and we did alot of work in that time, and
(05:46):
patients doing well so far. Sovery excited to continue the
nerve adventures in 2025 we dohave a fun episode that we're
going to do today about thefuture of hand surgery. I think
you came up with this idea whileyou were sitting in business
school class. Is that it?
Charles Goldfarb (06:05):
I try to focus, but hey, sometimes the
mind drips. I don't know when Icame up with the idea, and I
don't I, you know, hopefullythat, you know, we come up with
enough interesting topics, but Ihope our listeners will also
pepper us with differentconcepts for what the future of
hand surgery will look like. So
Chris Dy (06:19):
when you emailed this to me, I immediately thought of
the the Conan O'Brien skit, andthis is totally gonna date me.
But when Conan was on NBC, andhe was following Jay Leno, so he
was in, like, the in the easterntime zone, that's like the, I
guess, they 1230 slot. Yeah, Iloved watching Conan back in the
day, and it was, I guess, in thelate 90s, and they would have
(06:43):
this segment with he and AndyRichter would would have called
in the year 2000 where theywould just make these off the
ball predictions, many of themhilarious, about what was going
to happen in the year 2000 andthen then we add the whole y 2k
thing and everything. I feellike the future of hand surgery
could be a little bit like that.
So we'll see. We'll see what youcome up with.
Charles Goldfarb (07:02):
Well, we'll let the listeners be the judge
of how poorly or how well we maydo. Yeah, I think there's some
interesting, interesting things.
Chris Dy (07:11):
So first off, want to thank our sponsors over at
practice. Link, the apprehendedsponsor at practice. Link.com,
the most widely used physicianjob search and career
advancement resource.
Charles Goldfarb (07:20):
But coming a physician is hard. Finding the
right job does not have to bejoined. Practice link, for free
today at www dot practicelink.com, backslash the upper
hand, and we are grateful topractice link. They have been
with us, I don't know, coupleyears now, three years, maybe.
So thank you very much to them.
Yes,
Chris Dy (07:38):
and they're always great resource for our local
residents and fellows, and youreally do take care of them in
terms of providing access tosporting events. So we were the
beneficiary of that for a bluesgame recently. So thank you
practice, Lee. So these are yourhot takes that you came up with
for the future of hand surgeryin 2025 and beyond. So the first
(08:00):
one, I think is reallyinteresting. And I know I've
talked about this before, carpaltunnel release will be performed
by others, such as physiatristsand neurologists.
Charles Goldfarb (08:12):
Go and I might even and people are gonna, are
gonna wince when I say this. Itmight be podiatrist. It's
interesting. I learned a lotabout podiatry. Podiatry is
licensed to do hand surgery insome states, which makes no
sense to me. But I think thepoint is, have we gotten to a
stage where the technologyallows a simplistic approach to
(08:33):
treating carpal tunnel syndrome?
And you know, some of thisprediction is tongue in cheek,
because I don't know that. Itruly believe that, but I do
think it's not going to be 100%of hand surgeons indefinitely.
It's not right now. Well, it'snot right now. What percent it's
got to be, I don't know.
Chris Dy (08:51):
But I mean, I think the you know, as listeners may
know, at least in the US, thereis a new ultrasound guided
carpal tunnel release device andan ultrasound guided trigger
finger release device. And whilethey are currently training hand
surgeons only, I I am fullyaware that their plans are to
train non hand surgeons to dothis surgery too, and that could
(09:12):
be neurologists pm and arethey've approached people in our
pm and our division about doingthe surgery, and I think they
were internal discussions, fromwhat I understand, and the
carpal tunnel release remainsfirmly in the domain of the hand
surgeon, but you know, and alsoorthopedic surgeons and plastic
surgeons and general surgeons, Imean people who have trained to
do the actual surgery. But,yeah, no, that's coming. It
(09:35):
scares me. I think one of theour our partner, David Bergen,
talks about how he's morestressed about a carpal tunnel
release than a crazy Plexuscase, because the expectations
are completely different. Imean, you have to be perfect on
every carpal tunnel. I mean, youshould be. I think, whereas a
crazy Plexus is like there areonly a handful of people, you
(09:57):
know, not a handful, but there'sonly a certain number of people
in the. And theninternationally, of course, that
are, you know, really doingPlexus surgery. So there's a lot
of variability in the casepresentation, a lot of
variability in treatment andexpectation. So the bar is very
different. So
Charles Goldfarb (10:11):
should hand surgeons be teaching non hand
surgeons? And again, we're nottrying to exclude orthopedic
surgeons and plastic surgeonswho are trained, but should hand
surgeons be treating non handsurgeries. To do these surgeries
like carpal tunnel
Chris Dy (10:23):
release, I think it depends on, you know. I think,
you know, there are some people,you know, who feel very strongly
that if you can't handle anddeal with the complications that
a procedure generates, youshould not be doing said
procedure, you know. But also,there are probably access issues
in terms of getting in. And Ithink some of the marketing
around at least this currentultrasound guided device is that
(10:45):
there are a lot of people don'twant to have quote surgery, and
you're seeing a hand surgeon,you know, even though a lot of
what we do is non operative,people still have that
mentality. When you're seeingthe surgeon, they're going to
want to do surgery. If you canmake a carpal tunnel release a
quote procedure that's done inthe office by a non surgeon.
Maybe it's a little lessintimidating, and, you know,
makes people more interested inhaving it done.
Charles Goldfarb (11:07):
Yeah. I mean, this is the hallmark procedure
for hand surgeons, no doubtabout it. And it's not
glamorous, but there are, Iguess I would say there are
challenges, both diagnosis,counseling and technical. And
the vast majority of time,things go just fine. But, you
know, I don't know the numbersyou quote for a successful
outcome in carpal tunnelrelease, but it's not 95% you
(11:32):
know, it's just not. So it's aninteresting concept, yeah,
Chris Dy (11:36):
and I agree, and you know, I will say, to be fair,
there I've seen some incrediblyskilled, you know, PM, and our
docs and neurologists use theultrasound to do some really
skilled procedures, like verychallenging procedures. I mean,
when I was up at, when I was upat Mayo for as part of the
government travels, governmentscholarship travels, I watched,
(11:57):
you know, them, do someultrasound guided thread carpal
tunnel releases, which is reallycool to do. You know, Alex Shin
was doing that with with thephysiatrist together, and did a
lot of them, and they lookedgreat. I think it's probably a
combination approach, orcollaboration approach, that
would be best. But just thephysical amount of time that you
(12:17):
need for two people to two busydoctors to do something together
is is hard for something asrelatively routine as a carpal
tunnel release?
Charles Goldfarb (12:26):
Yeah, I have nothing to add. So, so, yeah,
maybe, maybe, I don't know. In2030 will it be 25% of cases are
done by non answers. I don'tknow. Yeah,
Chris Dy (12:36):
I don't know. And I don't know if there's a, I guess
there's an admin data studywaiting to happen in the future.
So we'll see.
Charles Goldfarb (12:42):
We will see, all right. Number two, the thumb
CMC joint, will be treated withimplant arthroplasty
Chris Dy (12:50):
alone. You mean in the United States, because it's
already being done other placesin
Charles Goldfarb (12:54):
the United States, by 2030, CMC will be an
implant arthroplasty procedure,and we won't be doing fcr, we
won't be doing suture suspensionplastic, we won't do an implant.
I like the suture implants. Whatdo you think? No,
Chris Dy (13:15):
I do not think that's gonna happen,
Charles Goldfarb (13:17):
and why and why not. I
Chris Dy (13:19):
think that the it's going to take a lot to change
surgeons minds about what to doin the US. And I think the track
record of multiple unsuccessfullaunches of implant arthroplasty
for thumb, CMC in the US markethas honestly, I think it's
probably, you know, killed theprocedure, potentially for
(13:40):
future generations. I wasintrigued. We had a visitor come
from South Africa last year, andhe was talking about his thumb
CMC experience and implantarthroplasty. And I was
intrigued. And then I haveenough happy thumb CMC patients
who are treated with trapeziumand suspension of some sort,
where I'm not going to change.
So we're to require a fair bitof evidence, and those studies
(14:01):
are expensive and are probablynot going to be done. I
Charles Goldfarb (14:08):
think that's well said. You know, it's so
interesting and sometimesfrustrating, and I will leave
the person nameless, but, and Idon't, I don't think you do it
this way, but as an example ofkind of the challenge of having
surgeons change. In conference,we were talking, I think, in
research conference, we weretalking about, or else clinical
(14:28):
conference, we were talkingabout how we approach the CMC
joint, straight dorsal orWagner. You might call it the
Wagner approach,
Chris Dy (14:36):
and not as fancy as you with the Wagner
Charles Goldfarb (14:39):
and one of my partners, who I have immense
respect for, only uses theWagner, and I just don't
understand it. It doesn'tprovide better access. You do
have more nerve, you know, nerveirritation afterwards. Why in
the world will we do that? It'sjust that's how that person was
trained. And deviating from thatcourse, you. It's just hard,
(15:00):
right?
Chris Dy (15:01):
It's very hard to change people's minds when they
have success with something,right? Like, why would they
change? Like, you know, that'swhat works. What works in your
hands, right? You know, weactually have two partners that
use the Wagner routinely. So,no, no, you know, I'll let we're
not going to call them outbecause, you know, but actually,
(15:22):
I think if you're doing the, ifyou're doing the genie Delson,
your technique, you know, it'sactually easier from a Wagner,
it's quite challenging, I think,to do from a dorsal approach.
But our partners are using thattechnique as of right now. But
you know, just saying, there aretechnical reasons to use a
Wagner, you know, if that's yourpreferred suspension, what's you
(15:44):
know, you're much older thanmuch, much older than me, much
and trained in, you know, backwhen I think, you know, people
were being admitted beforecarpal tunnel releases and sent
home after three days in theICU. So what was the feeling
about implant arthroplasty, backwhen some of those implants were
being introduced in the 90s inthe
Charles Goldfarb (16:04):
States, I was taught with the classic Burton
and Pellegrini fcr, and therewas a widespread skepticism with
the introduction of any implantarthroplasty. And so, you know,
at in since where I did myresidency, here at Wash U in
Cincinnati, with Peter Stern,Tom kefir and others, and then
(16:26):
back at WashU. I don't thinkanyone's I've never seen an
implant arthroplasty performed.
Chris Dy (16:32):
Do you feel like there is a chance for it to be adopted
in the United States? Thatwouldn't take Yeah?
Charles Goldfarb (16:41):
It would take an amazingly convincing study,
and it would also take anarticulate proponent of the
procedure sharing his or herresults repetitively at national
meetings. I mean, it's just itwould be a slog to change the
perspective of so many people. Ithink it could happen. I mean,
(17:01):
given the success of hips andknees, and I mean, you would
think that there's a, at leastamongst orthopedic surgeons,
there is an underlyingacceptance that implants are
great, but it's just not forhand surgeons. Do you think that
there's
Chris Dy (17:19):
a market to develop said device, and, you know, and
obviously, it's been developedin other countries, and there
have been reports of excellentresults in, you know,
internationally, I
Charles Goldfarb (17:31):
like to your point earlier, I just don't
think in the United States,we're ready for it. I think
that's the hope that colleaguesoverseas will share compelling
results that aren't like a skoshbetter than our results. However
we're doing it, they have to benotably better. You know,
decrease early failure rate,decrease late failure rate, and
(17:52):
really happy patients. Becausethe reality is, I think we all
know there is one truth, andthis one truth that will prevent
me from ever doing a prospectiverandomized trial again, if the
results are always about thesame, whatever you do, yeah, I
mean, it's
Chris Dy (18:04):
really, I won't say that, you know, a thumb CMC
surgery is as reproducible as acarpal tunnel release. But, I
mean, I think that's the issuethat, you know, studies have
when they're trying to show thatthey're not significantly
different, you know, compared toan existing gold standard, gold
(18:25):
being a relative term, right?
And then, you know, you actuallyhave to show that you're better,
which, in some ways can beharder. So I just don't think
the evidence is going to come,and I think it does have to come
from somebody who is respected,articulate, and not crossing
into the line of evangelistic,which I think a lot of people
who when they feel reallypassionate on something that
(18:45):
they've innovated, it does comeacross as evangelistic at times,
which you know right or wrong,but you're just so into it and
in the weeds and invested, yeah,
Charles Goldfarb (18:54):
well said. I mean, what was the last great
shift in surgeon, hand surgeonbehavior. Was it the volar plate
with George or Bay? I think
Chris Dy (19:05):
the volar plate is probably the one that we would
recognize, you know, I thinkthat, I think we're having Sanj
back on pretty soon, and youguys will talk a little bit
about, you know, maybe a shiftin, you know, arthroscopic
treatments before the volarplate, you know, microsurgery,
Charles Goldfarb (19:19):
yeah, yeah.
And the other, the other distalradius innovation that I think
has been rapidly and widelyaccepted is the spanning plate.
Those are both, you know, we'rebig changes, but yeah, let me,
let me back up. And just maybeas a future of hand surgery
number three will be wristarthroscopy will continue to
(19:39):
evolve, maybe some fits andstarts, but open scape, Fauci
lunate ligament repair will behistorical. And I think the
future of hand surgery includesall arthroscopic treatment, just
like the evolution of rotatorcuff repair.
Chris Dy (19:59):
I think that's.
Probably right. I mean, youknow, and I also think to
piggyback on your three, I'llmake it a three A. I think in 10
years, you're going to havearthroscopy fellowships for
hand, wrist and elbow.
Charles Goldfarb (20:13):
Yeah, interesting. Just like people
have, like,
Chris Dy (20:15):
you know, your extra three months, you do for six
months for peds, and some peopledo it for micro, I think they're
going to be arthroscopyfellowships, mini fellowships.
Charles Goldfarb (20:25):
That implies programs where there's an
abundance of volume that wouldallow that. I've always
struggled with that because I,I, you know, I do a lot of
elbow, which I don't think isdone a lot, and we have a
visitor.
Chris Dy (20:45):
We do have visitor.
Did you want to introduceyourself? Okay, go ahead. My
name is Evelina, and I'm sixyears old.
Charles Goldfarb (20:55):
Thanks for joining us, for talking about
your future in hand surgery.
Chris Dy (21:00):
I can't hear you because I have headphones. Okay,
Can daddy finish the podcast?
Yeah? Okay, daddy, thank you.
Charles Goldfarb (21:09):
Yeah. So, so I do a lot of elbow work, and yet
the challenge is having enoughto welcome visitors, or, you
know, enough localized but Ithink you're right. An upper
extremity arthroscopy fellowshipmakes a lot of sense. I think
you're
Chris Dy (21:25):
going to be doing more and more through the scope, and
people are going to want to cometo learn, and I think I'm going
to be doing less and lessthrough the scope. I mean,
that's honestly as and I'minterested. Just personally, I
want to remain broad as a handsurgeon, but I also recognize
there's too many fields to keepup with, like, you know, to be
honest with, even in our narrowlane of hand surgery, there's
various things that I'm just notgoing to be up on as much. And,
(21:48):
you know, I think that I'llprobably have to select at some
point.
Charles Goldfarb (21:51):
It's so true, and you're wise not to narrow
too soon. We've talked aboutthat. I firmly believe, stay
broad as long as you can. But atour institution, oh, it would be
okay if you decided to just donerve but you drive 100 miles,
or even 50 miles, or 30 milesoutside of the academic
institution, and you can't bethat narrow. So it does get
harder and harder to stay up todate. So is there going to be
(22:12):
increased specialization? And Ithink that may be the future of
hand surgery that you'realluding to. I don't think it's
three a I think it's four. Ithink that that we will continue
to narrow what hand surgerylooks like. Yeah,
Chris Dy (22:22):
and I but, you know, I think it is, is important to
have that broad base, not onlyfor just, you know, in access
for patients, but my own sanity.
I mean, I can't do only nerve,because doing only nerve means a
lot of pain, and then you need,I need the winds. I need the
carpal tunnels, the triggerfingers, the basal joints, you
know, the dystopia stretchers. Ineed balance in that regard to
(22:45):
to give me the energy to keepgoing on some of the nerve,
because the nerve can reallydrain you.
Charles Goldfarb (22:51):
It's so true.
Well, not just nerve. So I'vesaid to my nurse, she doesn't
listen to me, but I've said tomy nurse, you know, my sweet
spot for wrist arthroscopy istwo in a single day. I'm happy
to do three when I have four istoo much. There's too many
scopes total.
Chris Dy (23:06):
I've actually so I'm now working with a new with an
athletic trainer as my primarysupport person for my team, and
she's wonderful. But, you know,she booked me, I think, four
older nerve transpositions in aday. And I'm like, I love that
surgery. I know I do a lot ofthem, but that's just a lot. And
then I told her, I have a limiton the number of, well, not
cases I'll do in a day. And Ithink because of the way that
(23:31):
the scheduling happened, I thinkI have six, well, on cases the
day after Christmas, which isjust going to be a lot. It's
just it's really taxing on my,on my ability to entertain at
the same time as doing surgery,it's a lot
Charles Goldfarb (23:44):
and, and, yeah, three or four valance are
plenty for me, and I would saythe same about owners. My
goodness, after three in oneday, it's, it's, that's, that's
Chris Dy (23:55):
too many. So one more prediction, maybe carpal tunnel
releases and trigger fingerreleases will not be done in the
operating room in 2035
Charles Goldfarb (24:04):
100% agree.
100 Wait, we got one more afterthat. 100% agree that we will
not be doing the little cases inthe OR. And honestly, I don't
think it's gonna take 10 yearsto get
Chris Dy (24:15):
there. Um, okay, well, why don't we before we jump into
the next
Charles Goldfarb (24:19):
Wait, wait, wait, wait, I want to do the
next hot take. Oh, you're goingto do you're going to thank
another sponsor. I'm going tothank our sponsor.
Chris Dy (24:27):
Stop that can't stop that, and it's relevant to the
next top take. So the upper handis sponsored by checkpoint
surgical provider, innovativesolutions for peripheral nerve
surgery. Did you know thatcheckpoint offers an accessory
to the Guardian nervestimulator, the intraoperative
lead accessory, which connectseasily to Guardian with a simple
push on motion, enables handsfree stimulation delivery to a
(24:50):
consistent assessment site. This
Charles Goldfarb (24:53):
makes it easier to repeatedly assess
motor nerve excitabilitythroughout a procedure such as
in a neural. Or decompression,and also enables repeated
confirmation of nerve functionand procedures with risk of
iatrogenic nerve injury. Tolearn more, visit
www.checkpointsurgical.comcheckpoint surgical driving
innovation and hand surgery. Canyou please translate? Well, I
(25:16):
just heard,
Chris Dy (25:17):
do you know how you own so Guardian is the unipolar
stimulator. So that's the blueone. That's what I call the blue
one. The purple one, which is abipolar stimulator, which is the
Gemini, so the Guardians, theblue one the monopolar so you
put this little doohickey on it,attaches to it, and then,
instead of applying thestimulator directly to the
(25:38):
nerve, you can then hook a leadon. It's like a little plastic U
shape that can hook around thenerve a dramatically. There are
some holes if you want to put acouple of stitches in it to keep
it there, but then you canstimulate the nerve consistently
without having to take thedevice on and off, touch it on
and off, etcetera. So I thinkthere are other applications
that checkpoint is thinkingabout down the line for said
(25:59):
lead, but I should not say morethan that, but yeah, it's a nice
way to keep the lead in the sameplace, if that's your if that's
your goal, to stimulate thenerve in a consistent place, if
that's
Charles Goldfarb (26:09):
your goal, gotcha, that's over my head. But
sounds, sounds interesting. Sowhat's nerve repair gonna look
like in seven years? I
Chris Dy (26:20):
think it's an interesting question, because
of, you know, the for many yearswhen you've been trying to look
at nerve conduits, things to getaway from sutures, perhaps a
suture less nerve repair, thequestion is always, does it
generate more scar debris, etc,than you know that it's worth
(26:41):
but sutures also generate scar.
And sutures introduce the, youknow, human variability and
technique. Newer devices havebeen introduced, you know, using
small hooks that kind of go intothe epineurium and can keep a
nerve together. I'm not surethat nerve repair is going to go
in that direction. I think manywill, many will use said device,
(27:03):
or a conduit or something to goto a suture less repair. I still
think we need to train ourfellows and residents about how
to use micro sutures to putnerves together. I think there's
a training aspect to it. I'dlike to see if we can get away
from a number of st like thevast number of stitches, so
maybe go to just a single or twostitches and use something else
(27:25):
to keep the CO optationtogether. My prediction is that
these devices will then be usedas drug delivery devices, and I
think that's probably wherethings
Charles Goldfarb (27:38):
are going to go. It makes a lot of sense.
We've watched our previous chairand senior partner dedicate our
career towards the manual suturerepair of flexor tendons. And as
he sort of finished his 40 yearswith NIHR one funding, he was
into the drug delivery game fortendon healing. It just makes
(28:00):
sense for tendons, for nerves,or whatever.
Chris Dy (28:05):
I think, I think, you know, hopefully that's something
that the appropriate cocktailwill be figured out, and that,
you know that's probably notgoing to be ready for prime
time, I think, for, you know, asolid one or two decades. But I
think this is laying thegroundwork for that.
Charles Goldfarb (28:20):
So for doing long term predictions, are you
ready to go off the nerve?
Because I don't. I know it's,it's tough to stop talking
about, do you have anything elseyou possibly there's no more
nerve talk this episode. So Iwant people
Chris Dy (28:31):
to email saying how much more nerve they want, or if
they want, you know, I want tosay, email us and say what you
want, right? Like, you know, wehave a, we have a great grab bag
episode that's going to come outin next month. At some point,
we've had some great emails, sowe appreciate all the emails,
including some fun facts aboutthe origin of Halloween. So we
had a correction the that'll bea great episode. But if you want
(28:57):
more nerve, please email us handpodcast@gmail.com more and more
of anything. I'm sure you wantmore sports. Whenever I see
people in person, people inperson, they always talk about
how they want more sports andarthroscopy stuff. So I admit
I'll have to. I do enjoylearning during those episodes.
So thank you for that,absolutely.
Charles Goldfarb (29:13):
So I'll talk a little bit what I think the
future of congenital handsurgery is.
Chris Dy (29:20):
And you didn't tell me you're going congenital On this
episode, there's
Charles Goldfarb (29:24):
been a clamoring the listeners, for the
three of you that like
Chris Dy (29:27):
congenital, please, please keep listening if you're
if you're not in the congenitaljust, you know, you can keep
listening to it.
Charles Goldfarb (29:33):
This is going to be short and obtuse. Gene
therapy will be there one day.
You know, right now, genetherapy is super expensive.
We're using it for, you know,obviously for cancer. There's
been some work done with sicklecell, and, you know, it's going
to be arthritis, etc, etc. Somaybe CMC arthritis doesn't
exist anymore with gene therapy,but, but I think Gene therapy
(29:54):
will, will, will change the waywe think about congenital
conditions and. Smart enough toknow exactly what that means,
but I don't think we'll betreating the same volume and in
15 years that we are today.
That's
Chris Dy (30:07):
exciting, but the problems that we're producing so
many congenital hand surgeons.
Everybody wants to docongenital. I just read every
fellowship application that wereceived. I mean the number of
people that want to do pizza andcongenital like Good God, do we
need another congenital handsurgery?
Charles Goldfarb (30:24):
News flash, we probably don't, but maybe I need
to retire so, so there's space,there's room. Um, so
Chris Dy (30:31):
quick, quick question.
Do you think Gene therapy forarthritis will be ready before
an accepted thumb CMC implant inthe United States. I think
Charles Goldfarb (30:42):
it might be. I think it might be. And the work
that our colleague and ourpartner, Fauci like doing in
regards to osteoarthritis andtreatment is unbelievable for
those of you, and I can't speakeloquently about it, but the
work being done in the lab forour osteoarthritis and treatment
for it is unbelievable. We'renot that far away. To Chris's
(31:05):
point, yes, I'm voting for genetherapy, but I think
Chris Dy (31:08):
Gene therapy will get there before a thumb CMC implant
is widely adopted in the UnitedStates. Now, patients, I have to
answer that question a lot. Imean, like my whole spiel about
arthritis is that we have nocure for it, but they're working
on it in WashU. I mean, Faucireceived the largest grant in
Washington history. It's anincredible amount of money. So
yeah, see, they're working veryhard on on fixing that. One
(31:29):
other question before we close,do you ever think that there
will be in utero surgery forcongenital hand issues?
Charles Goldfarb (31:36):
So there currently is, theoretically, the
problem today is the risk oflike, if you have a constriction
band around the forearm or upperarm, that's severe. I think our
general surgery colleagues wouldpotentially treat that in utero.
But most of the other stuff isthe risk benefit ratio is off. I
(32:00):
don't know how that changes. I'mjust not that knowledgeable.
But, yeah, I think that'llincrease as well I do. Okay,
yeah, good. One important one,how many hand surgery podcasts
will there be in 2030
Chris Dy (32:16):
so I, interestingly enough, I did look a lot last
week. I was, I can't rememberwhat prompted me to do it. There
are a couple other hand surgerypodcasts that have a limited run
of episodes. I can't say thatanybody has, you know, five
years in a game like others, butit's crazy. We're going up on
our five year anniversary nextmonth. Who would I feel like it?
(32:37):
I feel like you owe me a gift.
Charles Goldfarb (32:40):
This is your gift.
Chris Dy (32:43):
But, yeah, no, I don't, I don't know. Maybe I
don't know if there'll be onehand surgery podcast in five
years. We'll see You're awful,you're awful busy,
Charles Goldfarb (32:53):
so
Chris Dy (32:55):
funny. I don't know.
And, you know, I think that whoknows what the next educational
kind of venue is going to be. Imean, I think that fortunately,
we were, I wouldn't say, aheadof the curve. We were timed
appropriately, I think withthat, with the upper hand, but
who knows where it's going togo. Yeah,
Charles Goldfarb (33:11):
for those of you listen, we're grateful for
our listeners. This is a laborof love. We do enjoy it, for
sure. What's been fascinatingfor me, and that goes to the
listeners who are still tuned inand haven't dropped off yet. You
know, most of you listen in theaudio only format, but our
YouTube viewership, why peoplewant to see Chris and me sit
here and talk? I do not know.
But our YouTube viewership isgoing through the roof. I mean,
(33:33):
I think we had six or 700recently. It's really
remarkable. I
Chris Dy (33:38):
think it's just easier to pull stuff up on your on your
computer or your phone onYouTube, maybe just like, let it
roll. That might be it. Or theyjust, I mean, they love seeing
your dome. It's great.
Charles Goldfarb (33:49):
I got a kind of shortcut. What happens
Chris Dy (33:54):
looking good? Well, I wish you the best holiday season
and a great end to your 2024,Chuck. It is always fun to do
this together, and I lookforward to another another year
of it, hopefully every dude,happy holidays. Happy holidays.
Take care.
Charles Goldfarb (34:13):
Hey, Chris, that was fun. Let's do it again
real soon. Sounds
Chris Dy (34:16):
good. Well, be sure to email us with topic suggestions
and feedback. You can reach usat hand, podcast@gmail.com
Charles Goldfarb (34:23):
and remember, please subscribe wherever you
get your podcast,
Chris Dy (34:26):
and be sure to leave a review that helps us get the
word out. Special,
Charles Goldfarb (34:31):
thanks to Peter Martin for the amazing
music.
Chris Dy (34:34):
And remember, keep the upper hand come back next time
you
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