0:10

Welcome to The

0:10

Upper Hand where Chuck and Chris

0:13

talk hand surgery.

0:14

We are two hand surgeons at Washington University in St. Louis here to

0:16

talk about all aspects of hand

0:19

surgery from technical to personal.

0:22

Thank you for

0:22

subscribing. Wherever you get

0:24

your podcasts.

0:25

And be sure to leave a

0:25

review that helps us get the

0:27

word out.

0:28

Oh, hey, Chris.

0:29

Hey, Chuck, how are you?

0:30

It's been a

0:30

pretty good day. How you been?

0:33

Doing well. I'm

0:33

excited about the new segment

0:36

we've got planned. I love the

0:36

fact that you have no idea

0:38

what's coming your way.

0:39

I'm a little

0:39

frightened. You scare me a

0:41

little bit with I'm giving up

0:41

control here. I don't know if

0:44

I'm comfortable with that.

0:45

Yeah, I know. And this

0:45

is why it's even better. Before

0:48

we before we jump in, do you

0:48

have any interesting reader or

0:51

excuse me listener feedback to

0:51

share with us?

0:54

I do see, you

0:54

know, I was at a fellowship

0:56

reunion a few weeks back, and it

0:56

was fantastic. And I was asked

0:59

to speak on social media. So I

0:59

shared some thoughts on Twitter

1:03

and Instagram. And I shared some

1:03

thoughts on the podcast. And it

1:07

was interesting that some people

1:07

had heard of the podcast some

1:09

people hadn't. A few of the

1:09

people who had not heard the

1:12

podcast since have logged on and

1:12

listened in. So this is from one

1:16

of my former co fellows. This is

1:16

from Mike Dedonna, who was a

1:21

year behind me. And he gave me

1:21

permission to share his review.

1:26

Chuck, it was so great to see

1:26

you in Jackson Hole I've just

1:29

completed a deep dive binge

1:29

listen to the podcast. And

1:32

here's the feedback I promised.

1:32

The podcast is in all caps.

1:37

Absolutely outstanding. You and

1:37

Chris are fantastic. I love

1:41

this. The two of you are

1:41

unbelievably engaging,

1:44

entertaining, authentic, honest,

1:44

funny, and of course, extremely

1:47

knowledgeable. I love the

1:47

breadth of topics as well as the

1:50

depth and clarity you provide on

1:50

everything from patient

1:53

presentation and indications to

1:53

surgical techniques with great

1:55

detail and specifics down to the

1:55

number of sutures you use to

1:59

close the carpal tunnel and love

1:59

the kiefhaber box, which is what

2:04

we call the retractor placement

2:04

for the carpal tunnel, as well

2:08

as discussion of complications

2:08

therapy and everything in

2:10

between. I've gotten my whole

2:10

team to listen, with one caveat.

2:14

They can't move to St. Louis, to

2:14

join you guys. You're that good.

2:17

Congrats to you. And Chris,

2:17

thank you very much. And so Wow,

2:21

Mike, that is really, really

2:21

nice. We appreciate the kind

2:24

words.

2:25

That's, that's awesome. And you have now managed to mention that you did

2:27

the Stern fellowship at least

2:31

four times in the last four

2:31

episodes. That is fantastic,

2:35

great fellowship. We're very

2:35

thankful to Dr. Stern for

2:38

training. An incredible number

2:38

of amazing hand surgeons. Well

2:42

included.

2:44

It's interesting it I'm trying to feel young by harking, you know,

2:45

back to those days, but it is

2:49

amazing. You know, when you

2:49

think about your legacy, what

2:53

does that look like? Is it the

2:53

patients you treated? Is it the

2:56

articles you wrote? Or is it the

2:56

people you touched and educated?

3:01

And I think the older I get, the

3:01

more realize I realize how

3:05

impactful that process is.

3:05

Looking in that room with all of

3:10

those former fellows, it was

3:10

really meaningful.

3:13

Well, that's, that's great. And you know, perhaps we should get Dr. Stern on at some

3:15

point just to talk about that

3:18

topic.

3:19

I would love

3:19

that. And he would love that I

3:22

feel confident you would know

3:22

better than I given your close

3:25

podcasting relationship with him.

3:27

Yeah, he's he's part

3:27

of the side gig, the side gig's

3:30

actually resuming again in

3:30

October. So First Hand is coming

3:33

back in October. We hope it's

3:33

been long enough that you've

3:35

missed us. And we're excited

3:35

about that.

3:38

You've been

3:38

renewed congratulations.

3:40

It was it was a

3:40

competitive process. So So here

3:45

is our new segment. It's called

3:45

we'll have hand surgery. So it

3:48

speaking of engaging our

3:48

listener community the topics

3:51

for this we'll have hand surgery

3:51

have been submitted by the

3:54

current medical student on my

3:54

rotation Ruba Socrab, who's

3:57

going to be doing her away

3:57

rotation at the University of

4:00

Michigan shortly so anybody up

4:00

in Ann Arbor look out for her.

4:02

She's fantastic. Noel Palumbo

4:02

current pgy three resident in

4:08

orthopedics here at Wash U and

4:08

Lauren Wessel current outgoing

4:14

hand fellow here at Wash U so

4:14

Chuck, six topics on the wheel

4:18

of hand surgery, very high tech,

4:18

six posts in a circle. Okay, so

4:22

what I'm going to do is I'm

4:22

going to spin a pin and whatever

4:25

side whatever topic we fall on,

4:25

we're going to talk about for 15

4:28

minutes.

4:29

Perfect. I

4:29

love that. While you're about to

4:31

do that, I do want to say that I

4:31

looked at our reviews online and

4:35

we don't we don't this is

4:35

totally totally side gab I'm not

4:38

just demeaning your wheel of

4:38

hand surgery, but I do. I do

4:43

want to say that I was reviewing

4:43

the the questionnaire we asked

4:49

listeners to fill out if you

4:49

haven't done that, please do it.

4:52

And they they were very clear

4:52

that they liked the nerve talk.

4:55

They want more sports, they want

4:55

more technical, so we're going

4:58

to do that but I also wanted

4:58

emphasise that the mugs are

5:01

coveted and there are people

5:01

that really want our mugs. So

5:04

we're going to send a mug to

5:04

people who send in questions

5:08

that we answer on air. And I'm

5:08

going to send Mike a mug for his

5:11

generous review. So sorry,

5:11

Chris, I had to get that out.

5:15

You know, I'm old. I forget

5:15

things. I have to say it when it

5:17

comes to mind.

5:18

And I did want to say,

5:18

Shohbit you're not getting a mug

5:21

until your papers published.

5:21

There's that current fellow

5:26

class is dying to get mugs. And

5:26

you know, Jeff Stepan you're

5:29

finally getting your mug and we

5:29

can't wait to have you back. So

5:32

um, and oh, Micah Sinclair, we

5:32

should get you a mug too.

5:37

Anyway, so on the wheel of hand

5:37

surgery.

5:39

Chris is being generous today.

5:41

Micah listens every

5:41

week, and we co chair the

5:44

Government Affairs Committee for

5:44

the for the hand society. She

5:47

does great work. So I think

5:47

she's earned what she has to

5:50

work with me on a committee. So

5:52

Amen. Thank you Micah.

5:54

The inclusion criteria

5:54

are expanding. So let's see here

5:58

favorite instruments

5:58

slash preference cards,

6:02

preparing for new or unfamiliar

6:02

cases. Didn't see that coming.

6:07

And I'll elaborate more as that

6:07

comes up. SLAC wrist. Never have

6:11

I ever, and networking. So I'm

6:11

going to spin this and I just

6:17

want to know before I spin it,

6:17

which topic Do you least want?

6:23

I think

6:23

they're all fine. I'm willing to

6:25

tackle any of them.

6:26

Alright, here we go.

6:26

Spinning. SLAC wrist, of course,

6:32

the only clinical topic, but we

6:32

can get into some technical

6:35

stuff. So on this wheel of hand

6:35

surgery, slack wrist is being

6:39

removed, and shall be replaced

6:39

by a new topic. It will be

6:43

sports, I promise for next time.

6:46

Perfect. Well,

6:46

this is great. Because those of

6:48

you who can't really envision

6:48

what this beautiful wheel looks

6:51

like, just join us on YouTube,

6:51

you can actually see it on our

6:55

zoom podcast.

6:56

We've been slacking on

6:56

the social meaning I have been

6:59

slacking on the social, I will

6:59

post a picture of this amazing

7:03

we'll have posted. But so this

7:03

is what happens when you don't

7:07

get your sports surgery on and,

7:07

you end up with a slack wrist.

7:10

So, Chuck, so let's talk about

7:10

SLAC wrist. So how often does

7:16

this actually come up? And

7:16

what's the classic story? For a

7:20

presentation of a patient with a SLAC wrist?

7:23

I guess I

7:23

would, I would say it's a bi

7:25

modal age distribution. And I

7:25

use that term just because I

7:28

wanted to work that into a

7:28

sentence. There's there's the

7:32

youngest-

7:33

There's the Chris

7:33

injury and the Chuck injury.

7:39

Fair enough,

7:39

although I might spread us apart

7:41

a little further.

7:42

I will probably Yeah. Okay.

7:44

So maybe

7:44

there's someone my age who fell

7:47

a year and a half ago, had some

7:47

wrist pain and went away. And

7:50

now that wrist pain has come

7:50

back with a vengeance. And then

7:52

there's the patient who's 65 or

7:52

70, who comes in with wrist

7:58

pain. And to me, it's super

7:58

interesting, because you don't

8:02

need an X ray on that 65 year

8:02

old. You can look at that wrist

8:07

and know what the diagnosis is.

8:07

But I think for me, there really

8:10

are two populations.

8:12

So I think I know what

8:12

you're talking about in terms of

8:14

what that wrist looks like. And

8:14

it's always that wrist that's

8:17

just like a little swollen in

8:17

the right spot. And it hurts,

8:20

obviously, I mean, looking just

8:20

looking at it, you can tell but

8:23

you know where it's gonna hurt.

8:23

You know, how do you do you ask

8:27

them if they had any trauma in

8:27

the past? Do you? Do you buy the

8:30

story? Do you? I mean, do you

8:30

believe them? Because most

8:32

people don't know?

8:34

Yeah. So again, just just to make sure we are crystal clear. We don't want

8:36

to be obtuse, but dorsal radial

8:40

swelling at the radioscaphoid

8:40

joint and point tenderness there

8:44

is the tip off. But again, you

8:44

can see it just by looking at

8:47

the wrist. I always ask, I don't

8:47

know if it matters, I guess it's

8:53

just part of the discussion. But

8:53

I always ask, do you?

8:57

I do just to see what

8:57

happens. I don't believe them. I

9:01

actually, you know, this patient

9:01

came in to see me recently one

9:05

of my recent clinics. And you

9:05

know, I immediately knew what

9:09

was going on and was very

9:09

curious to see what the X ray

9:11

was going to look like. And lo

9:11

and behold, it was a, you know,

9:15

already a SLAC wrist. So for the

9:15

listeners who are earlier on in

9:19

training, let's talk through the

9:19

progression of a SLAC wrist. So

9:24

you have an injury to the SL

9:24

ligament which leads to some

9:26

element of instability. And

9:26

eventually because that link

9:30

between the scaphoid and lunate

9:30

is no longer intact. The

9:33

scaphoid will flex. So what

9:33

happens there, Chuck in terms of

9:38

you know, the contact pressure

9:38

is yada yada yada?

9:41

Yeah, I think

9:41

we could go deep we could go

9:43

deep dive into the biomechanics

9:43

of how the carpus works, but I

9:49

think you said it really well.

9:49

Without that scapholunate

9:51

ligament the scaphoid is going

9:51

to flex. When the scahpoid

9:55

flexes the pressure between

9:55

initially this styloid of the

10:01

distal radius and the scaphoid

10:01

waist, and subsequently, the

10:05

proximal, more proximal distal

10:05

radius and the more proximal

10:08

scaphoid, the contact forces

10:08

increase. And because that's not

10:12

the regular load bearing

10:12

pattern, and you get arthritis

10:16

there.

10:17

So maybe just for

10:17

completeness sake, when we

10:20

replace this on the wheel, we'll

10:20

put scapholunate ligament

10:23

treatment and go a little more

10:23

into that. But let's say that

10:25

ship has sailed. It's an

10:25

irreparable ligament and you've

10:28

already developed arthritic

10:28

changes. How do you what do you

10:32

tell that patient? You know, I

10:32

tend to kind of give them you

10:34

know, hey, this process has

10:34

already started. We can't cure

10:37

it, we can treat it but we can't

10:37

cure it. I typically will start

10:41

them with a brace and a steroid

10:41

shot and a steroid shot if their

10:44

pain is real bad at that point.

10:44

Do you offer anything different

10:47

than that right away?

10:48

No, I think

10:48

that's exactly right. Because

10:51

you can make a patient

10:51

dramatically better I, I will

10:54

say, I'm not one to give steroid

10:54

injection after steroid

10:58

injection after steroid

10:58

injection, because I do believe

11:01

there are negative consequences

11:01

when you are potentially

11:04

salvaging some of the

11:04

articulations of the wrist. And

11:07

so I think a single injection

11:07

with the offer of a split works

11:10

great, and give the patient a

11:10

chance to see if they like it if

11:13

they can work with the splint,

11:13

and it solves their problem,

11:16

either temporarily, or more long

11:16

term. And if they fail that,

11:21

then we have options. We have

11:21

good surgical options.

11:24

So but what do you you

11:24

know, if you're putting in

11:27

steroids, and you say you're

11:27

doing some surgery down the line

11:31

that preserves some elements of

11:31

wrist motion? What are you

11:35

trying to save? Really? Because

11:35

I mean, if you're assuming your

11:38

steroids in the right place,

11:38

you're not really affecting the

11:40

mid carpal joint. You know, so

11:40

are you saying it's, it's the

11:44

impact on the radius cartilage

11:44

itself?

11:47

Yeah, I think they're, I mean, again, I don't know the science like some

11:49

listeners probably do. And some

11:52

scientists probably do. But I

11:52

think it's pretty clear that

11:55

repetitive steroid injections

11:55

have a negative impact on the

11:59

cartilage. And so the

11:59

radiolunate joint, if you're

12:01

going to consider, you know,

12:01

scaphoid excision and four bone

12:04

fusion, or we know that this

12:04

gave when the ligaments intact

12:07

and so the the steroids will

12:07

migrate to the mid carpal joint

12:10

as well.

12:11

So what's what's your

12:11

current thought process on

12:15

procedures other than a four

12:15

corner or? Or PRC? Do you see

12:20

any role for like radial

12:20

styloidectomy at all? Like, how

12:23

does that or even arthroscopy

12:23

some might argue?

12:26

Yeah, I mean,

12:26

I guess it depends a little bit

12:28

on the severity of the

12:28

arthrosis. I mean, if you catch

12:30

something really early, a scope

12:30

in my mind has a role for

12:34

confirming the diagnosis maybe.

12:34

And I don't really believe in

12:38

the whole cleanup procedure in

12:38

this situation, although some

12:40

might advocate for that as

12:40

buying time. I don't do a lot of

12:45

radial styloidectomies, you

12:45

know, those can be done

12:47

arthroscopically or open. I

12:47

think they're pretty

12:50

straightforward. There was a ton

12:50

of research done in years past,

12:53

especially after government

12:53

quantifying what type of

12:57

osteotomy made sense what angle

12:57

the osteotomy was to protect the

13:01

ligaments? I just don't do many

13:01

in 2021. Do you?

13:05

I don't thank you for

13:05

triggering me. Just the insert

13:12

the origin of the radius gave a

13:12

cavity ligament so okay. Well, I

13:17

guess in the short time that we

13:17

have left in terms of the

13:20

technical aspects, you know, how

13:20

do you decide between whether

13:24

you're going to offer a PRC or

13:24

four corner fusion?

13:27

Thank I do it. Well, first of all, the literature has become more

13:28

clear, right? the PRC is better,

13:32

it's less revised, it's less

13:32

expensive, patients are equally

13:36

happy. And most of us like the

13:36

PRC, I probably do more four

13:42

bone fusions than I do PRCs.

13:42

Having Having said that, of

13:46

course, you know, everyone's

13:46

like, what the heck is he

13:49

talking about? I think they're

13:49

both good options. I really do.

13:53

So an interesting

13:53

thing, I saw a patient as a

13:56

second opinion very recently,

13:56

who had a very straightforward

14:00

issue, and was recommended to

14:00

have a PRC by somebody else, and

14:05

came in and was like, That just

14:05

sounds ridiculous. So how do you

14:09

explain this procedure to the

14:09

patient of we're going to treat

14:12

your arthritis by removing an

14:12

entire row of bones. I mean,

14:15

clearly, we have to have that

14:15

conversation for thumb CMC

14:18

surgery, but just seems weird.

14:21

It's a hard

14:21

sell. So my hearing my

14:23

conversation goes like this. If

14:23

I'm selling a PRC, so you have

14:28

this significant arthritis, we

14:28

have to get rid of this

14:31

arthritic bone. And thankfully,

14:31

we can use other bones to

14:37

support your wrist. There's an

14:37

operation that's been around for

14:41

100 years, anything that's been

14:41

around this long has got to

14:45

work. And, and I draw a little

14:45

picture, a terrible picture, we

14:50

laugh at my art, and then I

14:50

explain what we're going to do

14:53

and I explained that I trust

14:53

this procedure and usually that

14:56

that convinces them. Are you

14:56

sold?

14:59

I love it. I'm

14:59

learning here. This is great. So

15:02

then how do you how do you sell

15:02

the four corner fusion?

15:05

I do tend to

15:05

use this stereotype if that's

15:08

the right word for four bone

15:08

fusions in that I think it does

15:12

maintain carporal height, I do

15:12

believe it probably has some

15:16

advantages from a strength

15:16

perspective, and it maintains

15:20

more normal anatomy. And so for

15:20

the patients that either a are

15:24

freaked out by the PRC, or B, or

15:24

a little younger and higher

15:28

demand, I think the four bone

15:28

fusion makes sense. And I do

15:33

still perform a four bone

15:33

fusion, you know, the concept of

15:35

just fusing the the capitolunate

15:35

joint has become a little more

15:40

in vogue lately. But I like the

15:40

four bone fusion and I still do

15:43

it.

15:44

So are you also taking

15:44

down, you know, the side to side

15:46

articulations? Are you just

15:46

doing like a two bicolumnar kind

15:49

of fusion?

15:50

Yeah, I like- That's a great question. I like that, I tend to really address

15:52

the two mid carpal joints, so

15:57

the capitolunate joint I

15:57

decorticate. And I fuse that

16:00

one. And I also fuse the joint

16:00

between the hamate and the

16:04

triquetrum. In a perfect world,

16:04

I have two screws, one going

16:09

from the lunate into the

16:09

capitate and a second going from

16:12

the triquetrum into the hamate

16:12

into the capitate. And I really

16:17

liked that. And I've been very

16:17

pleased with the results that I

16:19

get from that.

16:21

So we were on our

16:21

travel club meeting via zoom

16:24

recently of the the younger

16:24

generation of hand surgeons. And

16:28

we were discussing this very

16:28

topic and you know, I felt like

16:31

an outlier. Because there are

16:31

some of my colleagues are using

16:33

plates more and feeling more

16:33

confident in moving them earlier

16:38

on with the plates. And you

16:38

know, saying that, you know,

16:40

there are some reports of

16:40

construct failure with the type

16:43

of construct that you just

16:43

described that I use regularly

16:46

with early motion. So, you know,

16:46

if you could do four corner or

16:51

four bone bicolumnar kind of

16:51

fusion and move them early,

16:55

would they you think that would

16:55

make a difference in terms of

16:57

the evolving literature between

16:57

PRC and four bone fusion?

17:02

I fundamentally I don't believe that it's going to increase

17:04

motion dramatically in the long

17:06

term, it might make life a

17:06

little easier in the short term.

17:10

I guess the question is, would

17:10

you trust your plate and screws

17:15

in the lousy lunate bone? That's

17:15

that's ultimately to me the

17:18

riskiest issue, the lunate bone

17:18

is not healthy, it's small. And

17:22

we're trying to make sure it

17:22

fuses because that is the key to

17:25

the whole operation. So I

17:25

respect that people are doing

17:28

this, I don't feel a strong need

17:28

to investigate it, I guess, is

17:32

my response.

17:33

And then the other. The other thing, I think that it's challenging about these

17:35

sometimes if if it was getting

17:38

the lunate correction, and

17:38

getting the lunate correction,

17:41

but then also being able to get

17:41

your screw in the right position

17:44

in the lunate because

17:44

essentially, you've you've taken

17:47

down the mid carpal joint, your

17:47

capitolunate joint's taken down,

17:50

you're having to flex down,

17:50

essentially the wrist to get

17:53

that lunate in neutral posture.

17:53

But then also get your screw

17:58

kind of in the center of the

17:58

lunate, you know, volar to

18:01

dorsal. Do you have any tricks

18:01

for that because you know,

18:03

whatever, you know, I tried to

18:03

do that it's it's a little more

18:05

challenging just because you end

18:05

up flexing your wrist, but then

18:08

it made carpal joint opens up

18:08

and I try to keep it close. But

18:11

it's challenging sometimes.

18:13

Totally agree.

18:13

And it can be really

18:15

challenging. I would say a

18:15

couple of things, just to make

18:19

sure we're following up on the

18:19

biomechanics, without that

18:21

scaphoid to tether the lunate,

18:21

the lunate tends to go into DC.

18:26

So it dorsal flexes. And so our

18:26

goal with the surgery to create

18:31

the greatest arc of motion is to

18:31

get the new lunate neutral at

18:36

the fusion site with the

18:36

capitate. And so what I do is I

18:39

decorticate everything, I flex

18:39

the wrist, and sometimes I have

18:43

to release that volar lip of the

18:43

lunate, but I flex the wrist and

18:48

to get the capitate and the

18:48

lunate lined up, I place a six

18:51

two K wire securing the capitate

18:51

to the lunate and then I can put

18:56

the wrist wherever I want to put

18:56

my screw and I've been really

18:59

happy with that technique and

18:59

always start there and then go

19:02

to the other joint for fusion

19:02

later. So I like that I think

19:06

it's probably easier putting a

19:06

dorsal plate on in some respects

19:09

for that very reason. But I

19:09

hadn't been a huge impediment

19:13

for me with that technique.

19:15

And for your ulnar

19:15

sided screw separate incision

19:19

work through the same incision.

19:19

If you're in a separate

19:21

incision, how do you avoid, you

19:21

know, the dorsal cutaneous

19:25

branch of the ulnar nerve as as

19:25

as it's coming from volar to

19:27

dorsal?

19:28

Yeah, I'd be interested to hear what you do. I do make a separate incision

19:30

just distal to the ulnar

19:32

styloid I find the nerve or

19:32

nerve branches and free them and

19:37

then go right for that

19:37

triquetrum to place the K wire

19:40

and then the screw. What about

19:40

you?

19:43

I do the same. And

19:43

it's funny because I did that.

19:46

And that's how I remember

19:46

learning it from from Ryan

19:49

Calfee when I was this fellow.

19:49

And then I was teaching a fellow

19:52

to do I was like, Oh, this is

19:52

how Dr. Calfee does it too. And

19:55

they're like, Oh, no. Dr. Calfee

19:55

just does it through the dorsal

19:57

incision and I went for and I'm

19:57

like, What the hell And he's

20:00

like, oh, yeah I changed.

20:02

You can't just change.

20:04

I guess, you know, and he's like, it just made more sense to me. So that's good.

20:07

So let's say

20:07

you have do it. Well, I just put

20:12

it out. There's a question in a

20:12

classic SLAC wrist. Do you ever

20:16

consider a complete wrist

20:16

fusion? And do you ever consider

20:21

wrist arthroplasty?

20:24

I think I have a

20:24

higher threshold to consider

20:26

wrist arthroplasty. Just because

20:26

I am not as well versed in if I

20:29

have anybody that's interested

20:29

in it, you know, I have a

20:32

general sense of appropriate

20:32

indications and, you know,

20:34

expected outcomes I'll send them

20:34

to Marty. Since Marty Boyer, our

20:38

partner does that for our group.

20:38

Although I admittedly want to

20:41

learn more about it and then you

20:41

know, total wrist arthrodesis

20:45

I've done one for a SLAC wrist

20:45

because it the wrist honestly

20:49

looked really beat up on the X

20:49

rays and I had some concerns

20:52

about the lunate the radiolunate

20:52

joint. So I ended up offering

20:58

him a one and done surgery and

20:58

we did a wrist arthrodesis and

21:01

very happy.

21:03

I agree and

21:03

disagree. I agree that there are

21:07

certain patients that I think a

21:07

wrist arthroplasty makes sense

21:10

for. But for those patients, I

21:10

have no interest in learning how

21:14

to do a wrist arthroplasty and

21:14

I'm happy to send them to Dr.

21:17

Boyer. But it is an older lower

21:17

demand population. There is

21:21

another group that has very high

21:21

demand and very bad arthritis

21:27

and a formal wrist fusion a

21:27

complete wrist fusion makes

21:30

sense. And so I do think those

21:30

two operations come into play

21:33

although the vast majority of by

21:33

SLAC wrist patients are treated

21:36

successfully with either a PRC

21:36

or a four bone fusion.

21:40

Fantastic. Thanks for

21:40

playing Wheel of hand surgery. I

21:43

will replace SLAC wrist with

21:43

some other sportsy kind of topic

21:46

and we'll go from there.

21:48

Alright, so

21:48

listeners if you like the wheel,

21:50

let us know if you think it's

21:50

silly. Let us know. Have a good

21:53

one.

21:53

All right. You better like it.

21:57

Hey, Chris, that was fun. Let's do it again real soon.

22:00

Sounds good. Well, be

22:00

sure to check us out on Twitter

22:03

@Handpodcast. Hey, Chuck, what's your Twitter handle?

22:05

Mine is

22:05

@congenitalhand. What about you?

22:08

Mine is @ChrisDyMD

22:08

spelled d y. And if you'd like

22:11

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22:11

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22:16

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22:16

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22:18

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22:19

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22:22

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22:22

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22:24

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22:24

upper hand. Come back next time.