Welcome back, everyone. Our first speaker will be Dr. Avi Gilati, talking about hand tendon injuries. All right. Good, I guess, afternoon for almost everybody. Well, I guess, no, most people it's not afternoon yet. Thanks for having me. Trying to cover a whole lot on hand tendon injuries in what is, of course, a short amount of time. In 20 minutes, I'm gonna try to cover acute flexor tendon and acute extensor tendon injuries, focusing on the hand level and distal, and really try to go over anatomy, some biomechanics, try to pull in some more recent up-to-date literature where it is appropriate, and then mostly review treatments, and then, of course, that will be followed by an excellent therapy discussion where a lot of the bulk of outcomes with regards to tendon injuries really comes from. So we'll start with flexor tendons, reviewing the zones so that we are all talking about the same thing. Zone one is essentially distal to the FDS insertion, and then zone two are no man's land, which is probably a term we should stop using for any number of reasons. And then you see there three, four, and five, and then the thumb with its own subzones. Pulley system, obviously, always important to talk about. The pulley systems are used to decrease the moment arm length, essentially deliver force more efficiently down the finger. So bow stringing is often a concern people worry about with regards to releasing pulleys, and it's always a discussion when it comes to tendon management. The first thing you're thinking about is, how do I do this with the pulleys intact or with releasing as little of the pulley system as I can get away with? Biomechanically, the old dogma, or the historical dogma, is that the A2 and A4 pulleys of the fingers are the most important. And I think that in a lot of ways, we still generally believe that, but I think that the fear of manipulating them, releasing them, having them open, has shifted and changed substantially in recent years. Initially, the data that supported these theories came a lot of, a lot of it was from animal models. And as you see here, the right side column there is the millimeters of failure to touch the palm. And you see clearly where those numbers jumped or where you had these specimen trials where they either had A4 or A2 or both sectioned, where it seemed that releasing the other pulleys didn't necessarily result in the failure to reach palm touchdown. So that was one of the major drivers of concern about A2 and A4 pulleys. But more recently, Jin Bo-Tang and a series of other investigators have pushed this issue that you really can start to release A4 and maybe even some of A2, and that it has more to do with the continuity of pulley or sheath being opened than the actual pulleys themselves. This more recently was looked in a cadaver model, actually in our lab here at the Hand Center, where we essentially identify that you really can sacrifice A4 or A2 without impacting excursion substantially, as long as you keep it to about two centimeters of total length released. And it was more the length of release that was so impactful than anything else. Certainly these are in cadaver models and not clinical models, but the clinical data that Dr. Tang and certain others have been publishing do support a little bit more liberal approach to the pulleys than perhaps was previously considered. This then brings us to timing of repair. So generally speaking, primary repair of all tendons is preferred. I don't think that secondary and reconstruction options are ever really in the discussion in comparison to a primary repair if it can be done. Generally supported in the literature, you want to get your repair done within about seven days. I know that's not always clinically or logistically feasible, but the outcomes data that are available do support that. And generally speaking, when you do a primary repair, you have less stiffness, shorter disability rehabilitation. And certainly if you need a tenolysis, the results are better if the repair was a primary repair. So for all those reasons, that's why we think of primary repair being so superior at this time. This brings us to suture techniques. The ideal for a suture technique is that it is relatively easy and comfortable for you to do. There's some really strong literature recently that showed that actually wasn't so much the technique itself, but how comfortable the surgeon was in performing it that dictated the quality of the outcome. And I think that that's always important to remember as you hear or read about so many different techniques and different options, it's really about doing what you're best at because the quality of the repair is so important above almost all else. You want to make sure that you're resisting gapping, two millimeters or less of a gap, ideally not really any gap at all. And you want to have it be strong enough that it can hold up for early motion. And that is at least a four-strand repair. And I'm going to get into the biomechanics of that shortly. Certainly you want to keep the external surface smooth and limit bulk and be as atraumatic as possible. For core sutures, the strength is proportional to the number of strands you use. So the more strands or grasps, the strength and gap will improve. So locking loops are often considered and used and they can increase strength, but they also can risk collapse and cause gapping. So you need to find a balance there. And a lot of people have actually gone away from locking loops depending on the technique you use. But again, it comes down to being most comfortable with your technique and getting a consistent repair. Some of the more important things to consider is that you want your suture to be seven to 10 millimeters from the repair margin. There's some data to support that that I'll go over shortly. And that you want to keep that gap, as I mentioned, under two millimeters. More caliber and strands generally will provide you more strength, which I think is relatively logical, but it can create resistance and work reflection increases, which may ultimately set back your repair, especially if the repair is bulkier and you get all six strands done or you don't get as much closure down at the gap. So again, as I mentioned, there are so many different techniques and you'll see these published and discussed and shown, but really it's about doing what you're most comfortable with. This then brings us to the epitendinous suture. So epitendinous suture has been routinely shown in a series of different studies to increase the strength of a core repair up to 40%. And generally is a 6L proline or nylon used. And again, here there are different techniques, but the concept is reducing repair site bulk, preventing gapping and improving the gliding, reducing that work or resistance. And I think that most of us, when possible, do try to use epitendinous sutures for these repairs, especially in the zone two repairs that are so notoriously difficult. So where does all this come from? Again, a lot of these data have been around for quite some time, some of it from animal models and some of it in cadaver testing, but effectively the seven to 10 millimeter range comes from the ultimate load to failure, which is this column on the left, and then the movements that create that amount of force. So the seven to 10 millimeter gapping, for example, is when you'll see repairs that can hold up to the 70, 80, 90 newtons. And generally speaking, it's much harder to get that strength with being closer to the repair margin. Similarly, and perhaps most notably is this four versus six repair that I have circled in the red in the middle. The four-strand gets you just about to the force created with a strong composite grip, and then six-strand repair often gets you much greater strength and resistance to sort of maximum load. And then you'll see here on the far right how epitendinous improves the load to failure from a four-strand core Kessler, and then you add the epitendinous there, or a four-core locking cruciate and add it to epitendinous. And that's why a lot of people have moved to using those epitendinous sutures. What does this all mean in the three minutes that we have to discuss it today? The pulley debate is moving. You probably can open A4 and maybe even A2 as long as you don't also have A3 and A5 open around A4, or maybe A1 plus A2 is where you can get to some trouble. That is certainly a moving target, but important to consider because again, the quality of the repair is likely more important than which pulley is. Aiming for four-strands, six-strands will give you probably better strength at four weeks, especially. But again, four-strands tends to give you enough strength to start an early motion protocol, and that's especially true if you use an epitendinous stitch. Try to keep it from around 0.7 millimeters to one centimeter from the cut end, then less than two millimeter gapping. The epitendinous debate, again, I think most people have moved to use it. It's unclear that it changes the debate around the four versus six strand, but it may add enough strength to a four-strand to allow grasp at six weeks, which is really the most important. And I know that we will talk about that more in the therapy discussion coming up shortly. Focusing a little bit on specific areas, the zone one lacerations, relatively distal, they can be primarily repaired if the stump is adequate, although that's not often the case. Otherwise, you're looking to use a pullout button or many surgeons, myself included, will now often try to use bone anchors instead of the pull-through, but I think both can provide excellent, strong repairs. We look to measure outcomes. The total active motion is the outcome that we get to measure. The good result, which I really like to highlight here, is that 180 to 220 degrees is what you're looking at for a good result. And already there, knowing that normal is 260 to 280, should put into framework what we think is a good result from these injuries. So even when repairs are excellent and you're getting into excellent therapy, our outcomes are never, quote, normal. And I think that's important to establish very early. Complications from tendon repairs include things like tendon rupture, inadequate tendon excursion, adhesions, lag, finger stiffness, and then the far more uncommon, but certainly treacherous when they occur, lumbrical plus or quadriga, things that we don't really have a lot of time to go into today, but need to be on your radar after these repairs. And then certainly it's important to know that about 10% of people slightly above that will require reoperation. And I think in some practices, a lot more machinery-related or industry-related injuries, that number's probably a bit higher. So tendon healing is important to understand. Ruptures are most common in that first week, which is when therapy starts, but it's also when the tendon is itself the weakest. And then again, at four to six weeks, which is really when active motion, especially for those who did place and hold or some of the more restricted protocols will get moving. Ruptures generally should approach with exploration and repair when the situation is appropriate. And as you see here, the majority of strength returns four to six weeks after the repair with the percentages tracking there as listed there. And maximum strength is generally not until six months after repair. Again, here, this brings us sort of together the time in weeks, the force, and the strength of repair. I think this is one of those plots that I've gone back to and looked at over and over and over again to just sort of remind myself where the different strand repairs get you from a strength perspective and where the tendon itself is in its strength curve. And as you see here, it gets weaker before it gets stronger. And I think that that's always really important to remember, even for those of us doing the wide awake techniques and seeing these repairs in real time, there is a weakening that happens before it gets strong. This also then opens the discussion about partial injuries. So the traditional teaching is that 50% or so require repair, but there has been some recently published literature of the past decade or two that up to 90%, if there's no resistance in gliding, which I think is a relatively rare bird, but if you have 90%, that doesn't have a lot of resistance, you may not even need to repair that. The key is the resistance issue and confirming that it's not stagnant or resistant, whether you do that under a Wow Ant and Explore or whether you're doing it under ultrasound. And that is an evolving area as well, using ultrasound for these evaluations. So that brings us to, rapidly to extensor tendons. So extensor tendon zones are different than flexor tendon zones, which is annoying just to remember. Again, to review them here, and we'll go through them a little bit more with different techniques and zone specific repair issues. But generally speaking over the dorsal hand, things to remember. So the proprius tendons are usually owner to the commonest tendons, meaning the EIP and EDC, assuming the EIP and EDM are owner to the EDC. Half of people don't even have a tendon to the small finger in the EDC. And there may be a separate muscle belly for the index finger EDC. Some anatomy things to remember as you talk about these repairs. And then the junctura always are important to consider. They generally can mask a proximal injury and it's important to understand that the junctura can link the EDC tendons and create a little bit of confusion on initial exam. Dorsal finger anatomy, I think, is one of those things that, again, I often bring up and review time and time again as I approach cases or injuries, because it can get quite complicated between the terminal tendon, the triangular ligaments, the central slip versus the lateral bands and lateral components. And I think, again, this is important to review not in a 20 minute blitz talk, but to sit down and really understand as you approach these injuries. And this is the lateral view of the dorsal finger, trying to get a better view of the oblique and transverse retinacular ligaments and how they interact. And then certainly the lumbrical, which is such an important component of the lateral anatomy as well. So going back to the zones of injury, that zone one injury is really that terminal tendon. So kind of going back here, you see the terminal tendon there from the top down view. That's your zone one injury. Zone two is more of the triangular ligament, whereas zone three, you're hitting your central slip. Zone four is the proximal phalanx and then five MCP. So I actually find extensors are much easier to think about the anatomy than to think about the numbers, but I think whatever system works for you is important because keeping this all organized is how you approach the different injuries. Techniques are far less complicated or have not been made complicated yet compared to flexor tendons. But generally speaking, the more distal, the tendon is really quite flat. And so when you're repairing extensor tendon over the finger, you're often just using figure of eight or mattress sutures because that's all that'll hold. Thicker caliber is in zone five and proximal, and you can use some core suture methods depending on your preference. The mallet finger is the sort of most common zone one known issue. Generally speaking, these can be closed with splint. A type one mallet finger, as you see on this right side, is really just soft tissue or sort of subluxating. Type two is the full rupture. And type three has your open components. So type two and one are pretty easily repaired with a splint, and you have to repair a laceration if it exists. If there's soft tissue deficit is when you get to a little bit of consideration about what you need to do to reconstruct, but that's more to do with the soft tissue problem than the tendon problem. Because usually that scar is essentially the same thing as having tendon there, which is why so many of us have moved to either splinting alone or a single longitudinal pin plus the soft tissue coverage for those injuries, because really you just need it to scar down and avoid that massive lag. The C-more fracture is its own unique entity. And so that is one that you need to be on the lookout for with regards to the germinal matrix and interposed matrix. And that maybe needs to be treated open. But even the fracture components, as you see in type 4B, 4C, a lot of those can be treated closed, especially in older patients, even if the anatomy does not look like you're getting excellent bony opposition. The mallet fracture with subluxation. The big debate around here is splint or surgery. The outcomes are pretty similar, meaning you probably do not need to operate on almost all of these. I know that there are some providers that still do, and certainly in younger patients or athletes, you sort of maybe shift your consideration to get a more robust repair, but across the available literature, the outcomes are really quite similar. This then moves us to zone 2. Generally zone 2 injuries are open injuries. You know, of course with mallet, you can have a lot of closed mallet, but generally zone 2, and then proximally you're talking about open injuries, although there's some exceptions to that. Often this is a flat tendon where you get that open repair with sort of the mattress sutures. I personally have moved to using microsuture or something absorbable, because oftentimes you'll get some wound delayed healing and things, and the risk of exposing a permanent suture doesn't seem worth it to me, and I think that they can heal with absorbable suture, although I don't know that there's excellent literature to support one way or the other. Again here, if you have less than 50% injury, you probably don't need to repair. You only really need one lateral band, although again, you're going to want to sort of test how the finger is functioning, and generally the original teaching was about immobilizing for up to six weeks, but that can be really difficult, and especially depending on where the injury is, you worry about PIP stiffness there, but certainly Hannah will talk about that a lot more than what we're going to talk about here. Zone 3 in the central slip disruption is where it gets far more complicated. The acute boutonniere, but it also can present quite late in that sort of damned finger, funny position, and then they come in with what could have been even just a closed injury. Elson's test is often described, although I quite frankly find that a difficult test to execute, but it's an attempt at understanding how the lateral bands are functioning, and then whether there's a fracture there or not may change the calculus on management. If there's a fracture fragment attached to the central slip, there are some people who approach those with more regularly and open fixation, and there's a series of literature to show that you can get pretty good outcomes with that versus just closed treatment. The closed treatment, generally you're looking at a PIP extension splint, but you really want to allow DIP motion as reflected in this diagram here, and you want to maintain that for around six weeks. The delayed presentation, you can try as late as six to 12 weeks if there's no contracture, but how well that works is definitely situational. The open injury repair, there are a lot of techniques for that. Some people protect with a PIP pin. If you're really worried about management afterwards, but it doesn't necessarily need to happen as long as you can get it immobilized to extension, and again here, the DIP motion and MCP motion are important in recovery, and again, we'll hear more about the therapy components in the next talk. Residual extension lag is common after rehab. That's true for MALS. That's true for central slips. I think that's really important to know and to talk about with patients. Residual extension lag is very common. Again, here, this debate about the fracture component of the zone three injury. There are a lot of debates on fragment size, amount of displacement and lag. Very heterogeneous with mixed outcomes, and so I wish I could tell you more, but honestly, I don't think we have a good answer as to whether you do open or just closed reduction and management there, but with a large fragment like that, I think a lot of providers are motivated for open repair, and I think that you can get quite good outcomes doing that. Zone four, again, here, you're over the proximal finger approaching the MCP. Rarely, this is a complete injury. Usually, these are pretty easy to manage without too much difficulty. Zone five, be aware of the fight bites. Always have that on your radar. It's a broad tendon. Again, here, complete disruption is somewhat unusual, but when it happens, it's usually a flat type repair, and the rehab after these injuries, generally, you're trying to keep the MCP in extension and allow PIP and VIP motion, so a lot of providers have moved to sort of relative motion splints for that and for the sagittal band injury, which again, here, you see the three types of sagittal band injuries. Those are often closed, but they can be open injuries, and that sagittal band injury, whether it's a tendon injury at this level or a sagittal band injury at this level, you are really looking at a repair that then involves MCP staying straight without causing PIP and VIP stiffness. So here's what that splint looks like, and again, I think this is a nice tie-in to the upcoming therapy talk. And then zone six, again, have junctura on the mind. It may sort of make the exam a little bit harder to interpret and understand where you are relative to junctura as you are managing these injuries. Thanks very much. Thank you, Avi, for that whirlwind tour. I think covering all of flexors and extensors in 20 minutes is always challenging, and we've given Hannah Gift a challenge also, 15 minutes for all of rehabilitation after tendon repair. Thank you very much. I am Hannah. I'm coming to you from St. Louis, Missouri, and I'm honored to be part of this group and to be here with some of my favorite ASHT colleagues. So thank you so much for having me. And like they said, I have a big task talking about tendon rehabilitation in such a short amount of time, and I don't get paid to do anything. So no relevant conflicts there. I know in most of these cases, they come acute and they're handled immediately, but if it's a patient who shows up in your office or someone that you have a little bit of time before you're scheduling that surgery, I want you to consider what the impact of a preoperative therapy visit could do with the goal of having that 45 minutes to an hour of the therapist explaining what is pain? Why is it protective? Why is it guiding our rehab? We can talk about what swelling looks like and how we need to manage that, and we can really hit home the idea of moving it, but not using it. We can also establish those expectations where your hand will be functional, it will work, but it might not look exactly as it did before, and that way there's no frustration at the end of all of this. We can also talk about what clothing works best after surgery. How do we get dressed? How do we change diapers? Those one-handed techniques can really be valuable with their quality of the next six weeks of having that orthosis on. And then we can look at those passive deficits and address them right away, because if we can get supple joints before going into surgery, we're going to have a much better outcome coming after. Now, many of you work in a situation where the therapist has access to your progress notes and your operative notes, but I work more in a community base where I don't have that information available to me. So often my order says flexor tendon repair and then the preferred protocol, or even flexor tendon repair appropriate protocol. But there are changes I might make based on where the injury is, what structures were repaired or what structures were not repaired, and then at what strength, if there's any concerns about your confidence of the repair, things like that. And then with the other injuries associated, that might change my rehab approach as well. So having that information before we start the rehab process will really maximize the outcomes at the end. So we're going to start on the flexor tendon side. We use the term early active motion, but it's kind of a confusing term because the reality is a lot of our different protocols have some kind of early active component, but often in the extension direction. So if we use the term true active flexion, that's the most appropriate way to describe the patient truly actively flexing those fingers. And that's a very common way to progress this program. But there is a role for some of those early passive flexion approaches or the place and hold approaches. So ultimately the surgeon, the therapist, and all of the patient factors combined make that patient centered approach as we move forward. And what we're trying to do in therapy based on all of those factors is to create the most amount of tendon excursion with the least amount of force. And so regardless of what protocol we're using, we still have to use our clinical reasoning as we approach these patients. So we have this pyramid of progressive forces. And what this tells us is at the bottom, the exercises that put the least amount of force on that tendon. And what we do is we gradually walk up that pyramid, walk up that progression. And how we know when to do that is based on assessing that patient very frequently. So what we want to do is look at their passive and their active range of motion from session to session. When we're looking at that and there is no discrepancy between their active and passive flexion, I'm thinking there are not a whole lot of adhesions there. I really need to protect that patient. I need to make sure we're staying pretty low on that pyramid to make sure I don't make that tendon vulnerable. If I'm looking at my measurements and there is a greater than a 10% resolution of that lag between the active and passive motion, that means the tendon's responding to my program. The tendon's happy with what we're doing. So we're not going to push it. We're going to stay right there because it's working. It's responding well. But if I'm looking at my measurements and looking at less than 10% resolution of that lag, that tendon's not responding to what we're doing in therapy. So I need to add more stress to that tendon. And so these frequent measurements are how we guide our clinical reasoning moving forward. The initial visit in my dream world would be about day three to five. We give them a couple days to let them calm down, let the swelling calm down. We don't want to wait too long because like you said, the tendon does start to weaken around week one to two. So if they're sent to me day 10 to day 14, I might not feel as confident starting that true active flexion as I do day three to five. Now, each of the progressions involves some type of dorsal block and shown there is an example of the risk being in kind of a neutral position. Now, previously we had the risk more in a flex position, but if the physician's preference is to perform exercise within the orthosis, we're looking at an active and passive insufficiency issue with that true active flexion where the digital flexors are actively insufficient, but we have a lot of resistance from the extensors on the passive side. So if we have it in neutral, we're maximizing that synergistic motion, which puts the least amount of stress on that tendon, which is allowing some wrist extension with our finger flexion. The MP joints being in a, in a mid range position, if we go all the way to 90, we can get some resistance on the extensor side, but we also, we just don't have a whole lot of room for that true active flexion, but we also could potentially get some scarring between the lumbar coals and the flexor tendons that create that paradoxical extension that we really don't want to happen. So that mid range is, is really an ideal position for that, that orthosis. And then our initial steps are just to address that work of flexion, decrease the swelling, decrease the joint stiffness, and make sure there's nothing else making it harder for that tendon to work than it already is. So just like with exercising in general, we need that patient to understand that passive warmup is really important. We always warm up before we do our exercises and we can do that through a passive range of motion or those modified Durant exercises. And I also want to early initiate that reverse blocking where we hold the MP in a flex position and perform PIP extension prevents those flexion contractions of the PIP joint. And if we're starting a true active flexion approach, we'll start with an active half fist, but we want to initiate motion at that DIP joint. My model here didn't do the best example. She kind of started at her MP joint. So I did not appropriately educate her before filming this video, but my patient would definitely know we want to start that flexion at the DIP joint because that's how true motion is started. And we're going to do that half fist initially. And then week four to five, we might start actually coming into that full fist as we evaluate. And as we progress this patient, eventually we might hit the joint blocking phase, but traditionally without a tendon repair, how we tend to have them perform joint blocking is by holding that volar aspect of the proximal phalanx. But we're going to put a lot of stress on that flexor tendon by holding it that way. So we're going to encourage our patients to hold the lateral side of the bone to make sure we're not putting any added pressure on that tendon. And then as we move forward, we want to make that hand feel like a hand again. So doing functional activity, working on that composite flexion, that in-hand manipulation can be really, really impactful. And then when we hit that 12 week mark, we want to start really maybe adding some strength to that program. There's different ways to do that, but some of my favorites here, crumpling up a magazine page really helps get those fingers to get into that fist, but also can add a little bit of a resistance function. And then also wringing out a wash rag can be another functional activity that can improve their strength. Injury immobilization can create a really rapid change of the motor and sensory representation on the brain. It can shrink or smudge that area of the brain. So that's something that we need to consider in how we can combat that. And one way is visualization, which is just having them actively visualize themselves creating that flexion and extension arc of motion. And then another way is using that mirror visual feedback where we have the affected hand behind the mirror and the unaffected out front. And we're having the brain actually see that hand come into that full fist. And so we're getting the brain seeing composite flexion in that full fist without actually stressing the tendon. And one other thing you might hear about therapists utilizing is some kind of iPhone game where the brain sees the task and tells the finger what to respond and how to manage that. And so it works on that brain hand connection when we get to that point. All through the whole process of rehab, we're really emphasizing that flexion starts at the DIP joint, but the reality is motion moves to the path of least resistance. And so when we have stiffness, when we have scar adhesions, a lot of times we start bending with the MP joints instead of the DIP joints. And one of the ways that we can improve that is using that relative motion orthosis by holding the affected MP joint in extension. And then more force goes through the PIP and the DIP to normalize that movement pattern. Another fun way we use relative motion orthosis for FTP repairs is maximizing that quadrigia effect of FTP. And we can use this alongside our dorsal block orthosis or even in a wrist immobilization orthosis. And it allows for a lot more motion, but that quadrigia effect prevents too much motion on that tendon. It can allow them to move that hand and use it a little bit earlier and then prevents the stiffness of the other digits that weren't really involved, but still have to be in that dorsal block. We're going to swap over to the extensor tendon side. And the reality is depending on the injury, we treat them all differently. So I only have so much time to discuss that. But like you said, for zone one, we're going to immobilize that tendon and we want the DIP in an extension, but we want the PIP moving frequently and that can help decrease the swelling and decrease that stiffness. And shown here is an example of an orthosis we might use when they have laxity in their PIP joints, or maybe the swan neck has already started to develop. Some people always include the PIP joint just to be safe, but some people only do so when they see the other joints being hyper mobile, but it is beneficial to have that in the back of your mind. And then we talked about the immobilization of the PIP joint for those zone threes and really focusing on that DIP flexion to pull those lateral bands back on the dorsal aspect of the joint. And then if we have that chronic extensor leg that we talked about, those relative motion orthosis with the affected digit in flexion can really help get more PIP extension force through that finger as we're moving. And then zone four to seven using a relative motion orthosis within a width of volar wrist orthosis can be really valuable. And there's a lot of different approaches to extensor tendon rehabilitation. I'm just sharing a couple on here, but there are a couple of similarities between all of extensor tendon rehab. A mentor explained extensor tendons to me that they're kind of like a rubber band, like you would put around your newspaper or even a hair tie for the females that are the men that have hair ties that once they're overstretched, you can't get them back small again. So we really have to focus on the isolated joint motion over composite flexion and making sure that we never sacrifice extension to gain flexion. And that's, what's hard for the patient to understand is because they know bending, bending is functional, but the reality is we have to maintain that extension and we are measuring them with each orthosis change, with each new exercise, with each new home program, we're frequently measuring that extensor lag and making sure that we address it immediately so that it doesn't become worse as we go forward. The last point I wanted to make is just the consideration of equity. And I live in a big area, but there are surrounding areas, especially hour, two hours away that still come to St. Louis for care, but then go back to their community where they might not have a CHT involved. And the indirect costs of having time off work and driving hours to therapy, things like that can be pretty significant. And as we've gotten better with our tele-rehab, there are situations where these patients can be evaluated and treated occasionally over the virtual platforms. Because we can look at the range of motion, their movement pattern, we can look at the wound healing, we can continue to educate about pain. So it is something to think about is as we move forward with tele-rehab is some of these patients could really benefit from having a CHT, but yet not having to travel hours away to get to that care. So I really appreciate everybody's time and I will move to the next person. Thank you so much, Hannah. That was great. There was one question in the chat for you, which maybe you can answer quickly while the next group is getting ready. How can you tell the discrepancy between active versus passive range of motion is due to adhesions versus gapping or elongation in the repaired tendon? So it is hard. That's a really good point. And that's why we measure each visit, because if it's kind of a sudden change versus a gradual change, I would be thinking more adhesions, but I also be thinking the timeline. So if it's happening at week one or two before the scar tissue is really forming, I'd be thinking more of the gapping side. If it's later on and it's more of a gradual thing, I'd be thinking more adhesions, but it's definitely a difficult thing to sort out on our end. Great. Thanks so much. We have a great panel next, case-based discussions of hand fracture fixation and rehabilitation by Drs. Weichao, Dr. Desai, and Kristen Valdez. Great. Thank you, Dr. Fox. I think I'm getting started. This is Ellen Weichao. I'll leave my video off because I don't have great internet, but I wanted to present two metacarpal fracture fixation cases. I'm a faculty instructor for oxygen. That's my only disclosure. First case here, this is interesting for me. I just did not use this type of technology when I was in training. So here I have a gentleman with a single metacarpal isolated fracture. It unfortunately was an open fracture through the index metacarpal. You see the shortening, the displacement. And so based on his past medical history, he's a pretty active guy, dominant hand. I'd like to proceed with next slide. Thank you, sir. Thank you. Went ahead and did an operative fixation with this internal intramedullary screw. And I found the benefit of the screw placement is actually quite straightforward. And a single K wire comes with the equipment, get the reduction. I had the sort of open fracture along the fracture line. So I was able to manipulate the fracture into reduction well. And I began therapy with him on post-op day five and only just the Velcro wrist split. Next slide, please. And so you can see the progression. Can you advance the slide for me, please? Thank you. So here he is on post-op day five. So again, incision on the metacarpal head where the screw was inserted, and then the one over the fracture itself. And as he progresses through healing, you can see the bony callus at the fracture site. And again, I can get the reduction without the fixing the rotation. Next slide. And get pretty good range of motion, maintain his range of motion with minimal stiffness on an older gentleman diabetic, which is always a concern. Here's my second case of the same type of fixation, 32-year-old. And I have, unfortunately, a gentleman that punched the wall. So not the best patient. And sometimes with these patients, I have a conversation with them, and I'm also concerned about placing internal hardware in case there's a high rate of recidivism with this type of injury. But with this gentleman, he said it was an isolated incident, never did it before, never did it again. So I went ahead again to try to get him back to his dominant hand working again, went with the same approach. Next slide, please. So I was able to make a small incision on the dorsum of the fracture site to help with the reduction because he did present a little late. But again, very straightforward access into the intramedullary canal of the metacarpal, place this intramedullary screw, which is not a compressive screw, so it helps avoid sort of over compression if there is a comminution. But luckily here, this is pretty transverse. Next slide. So post-op day seven, seeing him for the first time, I get him range of motion, started with therapy right away. And here is further post-op, again, with the bony callus of the fracture site. Next slide. And I always try to show, see as the progression healing. And then last slide should be my clinical slide of him with very reasonable range of motion. And again, I transitioned right away, next slide, to the, right there, thank you, to the removable Velcro splint right away so that you can get them moving and less restricted in a cast and so forth. Thank you very much. Oh, and those are, those are great cases. And I'm definitely a big fan of using those intramedullary screws as well. In your second case, you showed something that I often run into, which is, you know, the early x-rays show a little bit more lucency around the fracture site. And I think, you know, you just sort of have to stick with those patients a little bit and tell them that it is going to heal, because that ismal fit, that screw, and that ismal fit is so tight that I think you do get a little bit of erosive changes at the fracture site. And then eventually it fills in. But when I first started doing this technique, I noticed that all the time, and I was worried that we were causing more problems than solving, but these are great. Absolutely. Yeah. Yeah. I find that I really, when I place the screw, once I, before I let the screw cross the fracture site, I really put a lot of pressure in trying to reduce it clinically as I advance the screw, because as you are engaging that bone, you can actually cause a little distraction. And so I really have one person kind of holding the reduction strongly, actually, traction as I advance the screw. So I find that that helps a little bit, but you're right, that little bit of a gap can be a little nerve wracking. And, but luckily I've been able to coach my patients through it. Yeah. Yeah. Yeah. Thank you. All right. So we'll, we'll continue on with a couple more cases here. Thank you all for attending. And, and the past few talks have been fantastic so far. So hopefully we'll keep, keep the discussion going here. All right. Let's see. This slide's not advancing. Oh, here we go. All right. So my first case is a 34 year old male. He's an IT consultant who had a cricket injury to his left ring finger. And if anybody has taken care of any cricket players you may have actually seen this injury. It's fairly common for the fielders. And I've had to actually learn a little bit of cricket because I've seen this injury several times now. But he presented to a walking clinic locally with what you see here. So he's got a mallet fracture and within the same finger he has this PIP fracture subluxation near dislocation. Helen, I think looking at this, what are your thoughts on acute management of these? You have any pearls on how you would manage something like this? Yeah, no, these are tricky. I, when I see these I always try to counsel the patient that there is one of those, you know, terrible injuries to ever get. And so early action is better. It kind of, I will, you know, plan for sort of KY fixation if possible and then do those dynamic motion splints oftentimes because I find that just sort of offloading the joint is something I want to do and just try to, without, you know, having to cast them and just keep it moving. But yeah, these are very challenging. I kind of lay a lot of grape with these patients when I see them. Absolutely. Well, this patient, unfortunately, they, it took them a little while to end up in our office. So he eventually came in at about six weeks. And so these are the images that we have at six weeks. And you can see that distally his mallet fracture appears to be doing just fine. But there's really no improvement in his PIP level injury. So you can see that there's, you know, even on the previous films, there's quite a bit of comminution of that bowler rim and dorsally, it appears that the cortex is intact. And as we fast forward to six weeks, that comminution is very evident there now. And I think this is starting to behave as very much a problematic injury. And we've got that classic V sign that is signifying the dorsal subluxation of the PIP joint. So at this stage, Helen, what are your thoughts? Now he's six weeks out. Any ideas? Yeah, this is definitely more challenging. I think it's going to be definitely something that needs to be open. And I'm talking about maybe having to do something like a hemi-hemi to replace that volar comminution just to get that the joint back into alignment. Yep, I agree. I agree. So I basically counseled this patient that the mallet was doing really well, we would leave that alone. But, you know, here's a situation where we have a very, you know, it was a challenging injury to start off with. And now I'm really worried about this patient. And I agree that the hemi-hemi has sort of been a very useful tool in addressing these, especially with the delayed presentation, because that bone, if you've ever treated this injury, that bone, even in the acute setting, is very comminuted, very fragile. And as you start trying to reduce it, it becomes even more challenging to manipulate and reduce. But fortunately, there's a relatively new technique, the seatbelt technique, that I think has worked well in these injuries for me. The prerequisite for this treatment is that the dorsal cortex needs to be intact. If the dorsal cortex is involved, then I tend to agree that some sort of dynamic external fixator or something that's going to apply some longitudinal traction, but provide for some gentle early range of motion would be ideal. But this is a case where we opted to utilize the shotgun approach to the PIP, removed or moved the tendons out of the way. And we were able to actually piece together and sort of tamp up that volar rim and just sort of get a general reduction of that articular surface. But you can see here, what's so impressive is just how comminuted that articular surface is. And this is just a simple 1-3 plate and three screws. And when you do it through the shotgun approach, you're able to visualize where those screws are exiting the dorsal cortex. And what this does is it forms a nice cage to support that articular surface. And when we look at the post-op films, these are pretty recent post-op films, or soon after the surgery post-op films, you can see that there is a little bit of, you know, changes dorsally. There's definitely a lot of comminution. And when you're, again, trying to piece these together, it's very difficult to prevent that comminution from getting worse. But you can see that we've been able to reduce the joint by basically using this plate as a new volar buttress. We're able to reduce that joint. And with the flexor tendons intact, they're able to sort of hold that PIP inflection. And that really provides the reduction moment to hold this reduced. So this is somebody who we start on a fairly early range of motion program. So, you know, Chris, I'll toss this up to you. I mean, what are your thoughts on injuries at the level of the PIP? I know we want to get these moving, but when they present to you, you know, how do you work them up and sort of manage their expectations and coach them through range of motion? Yeah, absolutely. And I love to start early motion as long as we're not worried about either the volar plate or the central slip. And try to begin active range of motion rather than passive range of motion and let pain be their guide. Because the PIP joint, if left immobilized for any extent of time, will certainly become a very stiff joint that is really hard to manage after the fact. Yeah. Yeah, so what we've done for these injuries now, we'll immobilize them for three to five days, get them into our therapist's office, and then start some gentle range of motion with a finger gutter splint that they can wear when they're being active doing things. And I think, you know, these patients do quite well. They're able to, as long as you can get the joint moving early, they can sort of defeat that sort of mantra of the PIP joint being a very problematic joint. And this has been a very powerful technique in treating these injuries where, you know, I think the Hemihemate has sort of been the treatment of choice in the past. This is offering another alternative. All right, so we've got a couple more minutes. I'll just, I'll hit on one more case here. This is a 19-year-old male. He's a D1 scholarship football player. In practice, one day, he hit his hand on the helmet of one of his teammates. And he's got this middle phalanx fracture that I think really does have the appearance of almost a pilon longitudinal type injury. And the reason why I wanted to put this case in here was because it, you know, sort of lends a little bit of credence to something simple, sometimes the simple treatment options can be very useful for us. So this patient, we took him back to the operating room, and we were able to pull him out to length and apply a little bit of compression across that dorsal segment. And it was actually impressive how nicely he reduced. So this is somebody that I think something simple like P to A lag screws can provide a really nice treatment option that helps reduce that articular fracture, but also treat what kind of was behaving like less so a pilon injury and more so just a, almost like a central slip, large avulsion type injury. But the three lag screws were able to stabilize him. And then from, you know, considering the post-op protocol, you know, this is a fracture with a central slip equivalent injury. And I think it's important to recognize, you know, this is somebody we want to immobilize for a little while, or should we get him moving. The central slip attachment was fine. It was really just that fracture. And he's a young, healthy guy. So you know his bone quality is going to be really good with three lag screws. So this is definitely one that we would encourage early motion. But similar to the other case, any patient that has intraarticular pathology within the PIP, we're going to worry about stiffness. It's sort of the problem with injuries across the PIP, as we all know. And then the consideration is return to play. You know, he's a D1 scholarship athlete. This is excellent fixation. It's very strong. Fortunately, he's not a skilled player. So I was able to let him play in a club cast that we would just remove after every game. I don't know if, Chris, you have any other advice on rehabbing these types of injuries? No, again, just early active motion as long as, like you said, that the central slip was intact. So it's nice to get them moving right away. And as far as return to sports, you know, as long as they're wearing something, each club, so to speak, has its own restrictions on what they can wear. And we just have to find out from either the athletic trainer or the coach what type of device that is safe to return to play in. One quick question from the chat before we end this session for Dr. Desai. What's your experience with ligamentotaxis for case one in an acute setting? So, you know, I think, I'm just going to pull up those films here again. You know, I think that ligamentotaxis could reduce that fracture. I've tried things like extension block pinning on these in the past. And I'm just never really happy with how that volar rim is reduced. And I think you really do need to have that volar buttress to allow for true inherent joint stability. And so whenever I've used just ligamentotaxis primarily for these volar lip fracture fragments, I just don't think it's providing enough correction of that. But, you know, sometimes you can get lucky. If you pull traction and it reduces beautifully or perfectly, you can either do a dynamic X fix or do an extension block pin or something that will just prevent that from displacing. So I would say that my experience with it is something I've tried in the past but have gravitated more and more to just opening these up and fixing them. Great. Thank you. So we're going to move on now into small joint arthroplasty by Dr. Kaplan. Awesome. All right. Thank you very much. Pleasure taking part in the meeting this morning. Thanks for the invitation. So my charge here is talking about small joint arthroplasty. Trying to get my slide control working. There we go. So no conflicts to disclose. So arthroplasty in the small joints, you know, obviously this is something that's been around for quite a while. Although we don't have really the innovation, we don't really have kind of gotten to a point of arthroplasty in the hand, in the small joints, that really has shown the test of time. So it really does remain a controversial topic, particularly when we start talking, when we look at the PIP joint. You know, so just a quick overview today. We're going to talk about some indications, the relevant anatomy, options of implants to utilize, a little bit on the techniques and these outcomes. So in general, with every arthritic joint, we're really having kind of an arthritis talk with a patient. You know, we want to kind of find out where they are, how bad their pain is, how bad is it truly interfering with their quality of life, their function, their ability to do what they want to do, and what are their expectations going to be after the surgery? You know, are they looking just for pain relief? Are they looking to try and improve their function? What are they going to be doing? And these all come into play as far as appropriate patient selection, particularly when we're looking at implants, that they don't have the longevity as PIP or knee replacements do. Etiologies typically are going to be either an inflammatory etiology, an osteoarthritic etiology, or even in certain circumstances, we can utilize these implants for post-traumatic settings. The benefits, as we all know, of an arthroplasty is not only do we get great pain relief, but we can maintain some degree of mobility, and that is particularly important depending on the joint we're talking about. The cons are going to be the durability. You know, these patients are going to have to go through some rehabilitation following an arthroplasty procedure in order to optimize their recovery. And these joints aren't particularly durable, again, compared to some of the other implants that we have out there. And there may be some residual deformity associated with an arthroplasty option. For the MCP joint in particular, fusion is a more debilitating option. You know, the MP joint is very important in helping position our fingers in space, getting our fingers around objects or close together to hold things. It really provides an important amount of function to maintain mobility at the MP joint level. Also at the MP joint, they're more of a supporting structure. So joints from index to small are stacked right against each other, and you have intermetacarpal ligaments and things that are helping provide some extra stability. For the PIP joint, stability trumps motion most of the time. For most patients, you know, again, the MP joint has positioned the finger in space, and the PIP joint is helping to stabilize the finger against the object to allow us to manipulate them. There's increased lateral and torsional stresses across the PIP joint, which put more strain on these implants and promote loosening and decreased longevity. And the amount of deformity or laxity present in a PIP joint really will predicate whether or not an arthroplasty option is even feasible. You know, we consider arthroplasty, again, patient selection. We want to make sure the patient's expectations are in line with what the potential outcomes of an arthroplasty would be. They really have to have a healthy, soft tissue envelope. The flexure and extensor tendon system needs to work. Patients with rheumatoid who have attritional ruptures of their extensors and can't extend their MP joints aren't really going to benefit a lot from an arthroplasty until you can regain that extensor function. Emotion has to be a priority. You really need a patient who can be compliant and is going to hopefully be careful with that implant long-term. And you want their inflammatory disease to be stable. I mean, fortunately, I think around the country, we're not seeing as many patients with advanced rheumatoid destruction due to the presence and use of DMARDs, but I'm always surprised once or twice a year someone comes in with advanced disease and they just have not sought treatment yet. When we talk about our implant options, I'm really either talking about a surface replacement option or a silicon option. For surface replacements, these are going to be best in joints with minimal or correctable deformity, joints with intact collateral ligaments, or in those traumatic situations where we're considering a hemiorthroplasty, these surface replacements are perfect. Silicon replacements are going to be best utilized in patients with significant deformity. So in the MP joint, when you already have volar and ulnar subluxation of the joint, you know, particularly in patients where you can't passively correct it, you're going to want to move towards a silicon option. The surface replacements are not going to work well. And same thing with a PIP joint. If you have either rheumatoid or an osteoarthritic patient with more deformity and more erosive changes and instability, a silicon option is going to be your better bet. The anatomy of the MP joint, and this kind of gets into the designs, particularly with the surface replacements, is more of a chondroid joint. You know, the metacarpal head is eccentric. You know, so as the fingers are in extension, they allow you to move the fingers into abduction and adduction to help position those fingers in space. And as you go into flexion, those joints become more stable with the bicondylar volar part of the metacarpal head and help lock those joints in place for more precision use and force. So again, for the MP joint, we have surface replacement options, either pyrocarbon or a metal-on-poly option, and we have silicon options. And these come in various designs as well, from a straight implant to a pre-flexed implant. Grommets are not utilized as often as they are in the past. That was an attempt to kind of solve loosening. But with the newer materials, I think we have kind of moved away from the grommet options. Who are the typical patients for these? So the typical replacement for the surface replacement is going to be that osteoarthritic patient with a more mild deformity. I mean, they can have a little bit of subluxation, but typically these patients have intact collateral ligaments. They have a worn-out joint. And in those, I think the surface replacements are a great option. For the patients with advanced rheumatoid or other inflammatory arthropathies, where they have this volar ulnar drift, they have fixed flexion deformities, you're going to be much better off with a silicon option. As far as approaches, again, with the rheumatoid patient, oftentimes you'll have concomitant pathology at the wrist. So these patients will have kind of volar ulnar subluxation of the carpus and a typical zigzag deformity. And if you try to address the MP joints without first correcting the wrist, you're going to still have abnormal forces against that MP joint, which is going to cause recurrent deformity. So in many of these patients, the wrist should be treated first. As you approach them, kind of two popular options, this patient's hand on the right, I mean, she has two longitudinal incisions and she actually had already had surgery on those fingers. So you can get to all four fingers either through a vertical incision, between the second and third metacarpal and a second incision between the fourth and fifth, or you can do a transverse incision. I think it's really dealer's choice. The argument against the transverse incision is that you're more likely potentially to disrupt venous outflow from the hand. But I think if you're careful, the venous structures are in that intermetacarpal gutters and you can protect those easily. And you get, if you're going to do all four fingers, I would typically do a transverse incision. You get great exposure and you can kind of work on all four fingers. If you're just doing one or two, I think the vertical incision works pretty well. As far as the treatment of the extensor mechanism, that really depends on the amount of the deformity and whether they already have subluxation of their extensors. So if the extensor is subluxated into that ulnar gutter, you're going to want to release the ulnar sagittal band to help you re-centralize the tendon on the way out. If there's no significant extensor subluxation, typically a tendon split will work well and give you great exposure. As far as collateral ligaments, it kind of, again, will depend. If you're doing a surface replacement, you want to protect those ligaments. They're going to be very important for your overall function and longevity. Whereas with the silicones, a lot of the time, you already have significant disruption in that. And so you want to move ahead. Intrinsic tightness testing is also important to be done because you can release those intrinsics along the way. This kind of gets into a little bit of soft tissue rebalancing, which is important on the MP joint particularly. You know, if you have a rheumatoid patient with deformity, you're going to need to release the ulnar intrinsics and potentially rebalance on the way out. Cross-intrinsic transfers can be helpful in order to help counteract those deficiencies as well. So what are the outcomes? For rheumatoid, Trail et al. in 2004 looked at 381 patients with average 17-year follow-up and found survivorship of 63%, an interest in implant failure of 66%, which kind of tells you that a lot of these silicone implants will fail, but patients are still overall doing well with them. Similar results by Goldfarb and Stern in 2003, 36 patients with 208 implants had average follow-up of 14 years. They found survivorship of 93% with failure of 63%. I think this is the important take-home as far as what to tell patients. You know, if you look at the arc of motion, the preoperative motion was an arc of 30 degrees, postoperatively 36, which was a non-significant change. But what they found is that the position of that arc went into a more extension posture. So patients can get more function because their fingers are positioned better in space. But their overall mobility may not improve. So kind of a quick example of a typical rheumatoid patient, you know, same thing we talked about earlier, kind of address the risk first, stabilize that, got it straight, and then put in the replacements. For silicone for osteoarthritis, in 2018, Morrill and Weiss looked at 35 patients with 40 implants, finding survival rate of 97% with a failure rate of 13%. Neural et al. in 2013, also a smaller group, 30 patients, 38 implants, that follow-up of four and a half years, found survival rate of 89% with a failure rate of 11%. And if you look at the arc of motion of these two groups, also about a 70-degree arc. So in the osteoarthritic patient, again, ligaments are intact. You have higher survival rates, lower implant failure rates, although these were definitely a shorter follow-up. As far as surface replacement, pyrocarbon and metal poly. Pyrocarbon, 2015, Dixon looked at 35 index, 16 middle fingers with a five-year follow-up, finding survival rate of 88% at 10 years and 11% revision rate. Metal poly, there hasn't been anything very long-term on these. Found an abstract at FESH from a couple of years ago. They found, again, no significant change in arc of motion, 42% pre to 46% post. Had eight implants had revision. Quick illustrative case, just gonna show, there's a recent osteoarthritic with surface replacement. He's four months out right now, so he still has a fair amount of swelling around his second NP joint, but already great pain relief, good function. And I found this fairly typical. These patients, at least in my hand, seem to maintain some degree of an extension leg. I think there's always a consideration between overstuffing the joint or making it too loose. You have to be a little careful there. So PIP, a little bit different anatomy. Obviously it's a bicondylar hinge, really one plane of motion that you have to worry about. And it provides about 40% of overall finger motion. So these implants are a little bit more, the PIP joint itself is very constrained. You don't get a ton of constraint with the implant, which is why the clavicles are still important. But again, we have surface replacement options and silicone options. Approach for the PIP joint, numerous different approaches have been discussed. You can either do a dorsal approach going through the extension mechanism. This is probably the easiest, but you have the highest risk of problems with the extension mechanism afterwards. Bowler approach, which is my preferred approach. And it's similar to the shotgun approach that you saw in the talk previously. No need to protect the extension afterwards. So I think these patients can get them moving a little bit quicker, but there is a risk of swan neck deformity, which is why it's important to address and repair the bowler plate. And then lateral approaches can be, have been discussed as well. The advantage there is that you don't really have to protect the extension. You're not mucking around with the flexor system, but you do have to protect your collateral. Outcomes, silicone replacements. So lower numbers. And one thing just to keep in mind is some of these PIP arthroplasties, especially the surface replacements are still under a humanitarian exemption with the FDA. So oftentimes you need to have an IRB at your institution even to put these implants in. But PIP joints can do pretty well. These silicone implants and the 69 joints maintain mobility from 44 to 46% postoperatively. Nine, excuse me, five failures and only two revisions, two fusions. In 2019, 45 joints in 25 patients. Average followup, again, pretty intermediate, three and a half years. Survival rate was 80%. Range of motion maintained about 59 degrees. Implant fracture rate of 12. Surface replacement, again, lower numbers in general, 39 joints in 21 patients had a survival rate at nine years at 74%, maintaining mobility of around, you know, 55 degrees. And Pritchett and Rizzo in 2011, I thought this was interesting, and they had a big number of 294 implants, 203 were pyrocarbon and 91 metal poly. They had to do reoperation in 76 fingers, and they found the, so that's a 26% revision rate. And the main reason for a revision was extensor dysfunction in 51 of these patients. And almost all of those had a dorsal approach with 46 going through an extensor splitting approach, 13 through a central slip reflecting, and 10 with a chamois. Only six were lateral approaches, and one was a volar approach. But they didn't all do so great. You know, nine required fusion, couple had multiple operations, and two ended up actually, excuse me, six actually ended up being amputated. It's a busy slide, but kind of quick example of kind of older patient with OA, minimal deformity, a silicone replacement can work great. And even in RA, if there's more deformity, again, deal with silicone. As far as pyrocarbon versus silicone, again, not a lot of information out there. Chan looked at a meta-analysis of 35 studies and found no significant difference in range of motion, pinch, or grip strength, whether you went with pyrocarbon or silicone. But revision and salvage procedures are higher after pyrocarbon technique. And lastly, the other debate is kind of in the index finger PIP joint, what do you do? So Vitali in 2015 looked at 79 joints, 65 had an arthroplasty, 14 had an arthrodesis, had a fairly good follow-up of the arthroplasty patients. They didn't look at the arthrodesis after eight months because they figured once they had healed, they had healed. But there was a 60% re-operation rate in the arthroplasty group, only 21% in the arthrodesis group. But they found no difference overall in pinch strength, pain, satisfaction, other than key pinch was the only difference. So I think even in the index finger, if you counsel your patients well, again, right expectations, try not to use lateral stress against your index finger in space, you can get away with an arthroplasty in the right patient. And thank you very much and apologize for going over a little bit. Next, we're going to have Nancy Naughton talk about rehab after arthroplasty. Thank you so much for having me. I'm honored to be a part of this faculty. I have nothing to disclose, so we're going to get started. Doctor did a great job already discussing the indications, so I'm going to skip to the evidence, which is sparse for rehab after an arthroplasty for the PIP joint. But I did include this study, this recent systematic review, even though it's a surgical study, they did look at the outcomes in relation to OT. And basically what they found were there were no differences in duration of mobilization in time to the beginning of OT or the number of OT sessions between the two groups, and none of these correlated with post-op range of motion. So I feel like the take-home message for us is our patients, whether they're a dorsal, ovarial, or approach, we can expect pretty good and similar outcomes. This slide regarding the literature I put up because I just would like to show you what the wide variability is in post-op rehab. So we, you can see that some, one study immobilized them for five days while others had an immobilization period of two weeks. Splinting was different, and start of motion was also different. The outcomes of these studies were very similar. So again, I think for us it's important to know as the therapist that since there is no one best approach, we have some wiggle room. So we can base some of our decisions on the patient and their soft tissue healing, your own clinical expertise, and of course, you know, surgeon training and surgeon preference as well. This is what's important for us. What are the therapy considerations? Which implant was used? What was the surgical approach? So then we're going to know what structures do we need to protect and respect, and which ones can we start to move? This is a nice slide, it's busy, but I feel like it's good for you to have in your toolbox because Sherry Felcher did a really nice study in 2010. So it really outlines well the, so you'll see the approach that was used surgically, then what tissues are going to be involved, repaired or released, and then we'll know which intact structures remain. So how and when do we start motion and what would be the best orthosis? And I will discuss this a little bit more detail soon. So for all orthoptasties, MCP or PIP, these are very important considerations. We really need to avoid lateral stress, so we can think about that when we are either body taping them or if we're using a dynamic extension splint. We really want to control edema right out of the gate, so we can minimize any kind of scarring or adhesion formation. And really it's important to limit torsional forces. So an example would be instead of spiral wrapping your your co-band, consider crimping it as opposed to creating any excess force. And then always be on the lookout for that dreaded extensor lag with the dorsal approach. I compare that to the dreaded PIP flexion contracture for tendon repairs. Dr. did a great job going in through this about silicone implants, but I think what we need to educate our patients on is they're not going to get full range of motion, they should get functional range of motion. And at four weeks you're hoping to have them around the 45 degree mark. One systematic review found an arc of motion of only 44 degrees, and I believe we can do better than that. So here's a side-by-side comparison that I thought would be helpful. So with the volar approach, the extensor mechanism and the flexor tendon integrity is maintained, but they're going to be releasing the A3 pulley, the volar plate, and perhaps some partial collateral ligament. This might allow us some early post-op range of motion, so we can disallow some tendon adhesion formation and joint contracture. Probably the best orthosis to consider for these patients are going to be a dorsal blocking splint, so it will allow you to actively flex the PIP joint, but will disallow full PIP extension, and that's while we protect all the structures on the volar surface, most especially the volar plate. Differently, the dorsal approach is going to involve the central slip, so we're going to have to protect that extensor mechanism, and due to that central tendon disruption, we may need to consider splinting these patients just a little bit longer, and the obvious complication is going to be the extensor lag, where the obvious complication for the volar approach would be a swan neck hyperextension at the PIP. So, surface replacement arthroplasties have several manufacturers, and I put this slide up primarily so you can see that some of the manufacturers have their own protocols, and I included their websites. I don't use any of them specifically, but sometimes you can look at them and see what their expectations are, and you may be able to use a hybrid of them. There are published protocols, however. We're going to go over these. So, this first one we're going to look at, the controlled motion program, is for both silicone or surface replacement, which is nice. It's a five-phase program, so in the early phase, we're going to want to immobilize those MCP joints in like 20 to 30 degrees of flexion, so we don't get tight collateral ligaments, but the PIP joint needs to be in full extension. We're going to address everything we would always address postoperatively, which would be edema and range of motion of the non-embalmed digits. By the second week, you can move them to a clamshell orthosis with the PIP joint in zero, but allow MP and DIP motion. You're going to wear it pretty much all the time and continue to work on edema and scar and desensitize anything that's hypersensitive. By the third week, if there's no extensor lag, you can advance them to a figure of eight and a buddy strap. Occasionally, and I do do this, you may want to consider a silicone spacer to prevent any deviation at the PIP joint when you are doing the strapping, and I have a picture of that coming up shortly. Then you can just gently progress their flexion as long as they're maintaining full extension. You're going to continue with your knight orthosis or the cylindrical PIP joint splint, and by the third week, you're hoping to have them somewhere around 45 degrees. The figure of eight splint is helpful for swan neck deformity, but if you start to notice a DIP lag, then I'm going to show you what is recommended. He calls it the ranger splint. You can see what this is doing. It's going to block full PIP extension but allow PIP flexion, and then that DIP joint is going to be stabilized in a neutral position, and this will just help with returning some of the stability of the soft tissue. Here is the, if you look at D, that's the silicone spacer in between the fingers when you're body strapping, so you can see both fingers are in a nice neutral position and there's no lateral force there. And then you're basically just going to progress them in the next two phases with range of motion and working on their swelling. You can start light resistance with their figure of eight orthosis on, and you're going to keep them in their knight orthosis at this point, and hopefully around the six-week mark will be around 60 degrees. So next phase, you can start to wean them from their figure of eight if they have good lateral stability and there's no hyperextension noted. Oftentimes there will be a bit of a lag that they consider acceptable, 10 to 20 degrees. Keep that daytime orthosis handy for heavy-duty stuff, and then you can wean them out of their knight orthosis. So Sherry Folcher developed this rehab program for PIP pyrocarbon arthroplasty in response to some of the shortcomings and pitfalls that conform with the manufacturer protocols. So again, similarly as the other protocol, the full-time splint is going to be a roller-based hand splint that has the MP joints and some flexion, but full PIP and DIP extension. What I like about her suggestion, and I do use this, is she recommends two exercise orthosis splints because we are going to start allowing movement of the PIP and DIP joints. So this is from her article. You can see her resting splint on the left, and then the template splint, which I feel like sets our patients up for success. So when we start saying we can start moving the PIP joint 30 degrees and the DIP joint 20 degrees, what does that mean to the patient? So if we make the template splint that allows that amount of motion, then we're going to be sure that they're performing sufficiently, but they're not overdoing it, but they are doing it appropriately. If the lateral bands were not involved, it's nice to have the PIP joint extension splint to start to move that DIP joint. And just with the other protocol, you're just going to gradually increase how much motion you allow. Week two, week three, you're just bumping them up by 10 degrees each week. If active DIP flexion is less than 30 degrees, you can start some gentle active assistive to get them to about 40 degrees. Again, be mindful of the extensor lag. We don't want to sacrifice for that. And then you're just going to continue to modify their splint to allow for more motion. They can start to do a little bit of light functional activities without their orthosis on. And then by the fourth week, you can, if they are having a tight PIP joint, you can consider intermittently using a PIP flexion splint at this point, but you definitely want to continue with the static extension orthosis. And week five, move them to somebody taping if they are needing some help with regaining full flexion. But again, never sacrifice flexion for an increased extensor lag. And then you're just going to continue to advance them and wean them from their orthosis as you move through week six and eight. Continually educate your patients on joint protection and avoiding the importance of avoiding any rotational or lateral forces, especially specific to the index finger. As we know that, you know, with that lateral prehension, it's easy to load that fingernail in the wrong direction. Here are a picture of the various orthoses that have been mentioned. So there's that pulley ring splint, which is often found best for the roller approach, which will disallow too much PIP extension. And the dynamic splints, just one small thing I was going to mention is for the surface replacement. Just remember the line of pull is going to be very important for those surface replacement arthroplasty because they are two component pieces. Moving to the MCP, similar implant types. We often see it with severe RA, but not only with RA. Again, I feel like a broken record, not great evidence for the therapy component of the arthroplasty. So the literature often describes two primary programs for the silicone implants and it's one is the short arc motion with the static orthosis and the other is a dynamic extension orthosis program. So these are pictures of the static hand-based orthosis that blocks the MPs in extension, but allows PIP and DIP motion. And the short arc motion program that goes along with that is again, as with the others, it's just a gradual progression in motion. So weeks one and two, you're going to allow MP joints to move to about 30 degrees. And again, a template orthosis you may find helpful. And then from here, just each week, advance them if there's no extensor lag by about 10 degrees. And by the sixth week, have them doing light activities, light prehension activities, and use it for light ADLs. Make sure the extensor tendons are gliding well though. And as you saw the picture of the two, the orthoses, the one is for the daytime. Nighttime one is recommended as a forearm-based resting hand orthosis, which will have the wrist in slight extension, the MPs in extension, and the IPs in a resting position. However, if you're having issues with getting orthoses covered, or patient compliance, or maybe cognitive issues, similar results have been found with a resting hand orthosis with the MP joints inflection and the IP joints in 10 to 20 degrees inflection. And then the dynamic extension orthosis program, basically you're making that dynamic extension, the dorsal outrigger splint, with a little bit of a radial pull. You're going to work on all the same things that you would work on either protocol swelling, range of motion within the orthosis. Oftentimes I think dynamic splints are very clumsy, so sleeping with them is very difficult. So you may want to consider placing them in a static night orthosis. If by the third week, and the implant is clinically stable, you start your short arc motion with paying attention to the alignment, you can exercise them out of the orthosis. And if they're primarily tight for MCP flexion, consider a dynamic flexion orthosis to kind of help with this in conjunction with their extension orthosis. Of course, if extension is limited, you want to really focus on EDC glides, and may have to increase their time in the extension orthosis. Hydrocarbon, basically with this, I think the most important thing to know is we probably need to delay the start of movement with patients with RA. That's just due to the nature of their soft tissue not being as vibrant as those with traumatic OA or regular OA. And with OA and pyrocarbon, you can start them early for movement, move them their MPEs to about 60 degrees for the first four weeks, and then you could advance from there. Try to encourage more tip-to-tip prehension as opposed to lateral prehension. And by the six weeks, you can wean them from the orthosis and really upgrade all their activities. There are those special considerations, as I mentioned, for the index finger. So despite our best efforts, it still may have a tendency for pronation. But one way that you can adjust for this throughout the whole rehab process is by managing their orthosis appropriately to disallow it to go into that pronated position. So our take-home message is, you know, every patient is different. So base a lot of your decisions on the unique goals and life demands of your patient and their social roles. It's such a dynamic process. Sometimes I feel like I change their program every time I see them. Patient satisfaction is key, and it may not be associated with increased range of motion or grip strength. And here is my one guy that had a PIP that was so painful, and all we wanted to do was return to his little percussion band, and here he is a few weeks later. So that was my success story there. Thank you very much for your attention. Thank you, Nancy. We're now going to be joined by Dr. Baltzer and Dr. Mercer, with Nancy talking about a case-based discussion for some CMC surgery or therapy or both. Thank you. Hi, everybody. So we have a trio, Heather Baltzer from Canada, Nancy, whom we've met from Pennsylvania, and I'm Deanna Mercer from Albuquerque, New Mexico. These are my disclosures. So the first case is this very interesting individual. His name is Mungo Jerry. He is in a band. That's what he does for a living. He's a guitarist. He plays at all of the coffee shops and bars around town, and he came to me in 2010 to talk about his thumb pain. And so, next slide. We talked a lot about non-operative treatment options, and Nancy, if you want to take it from here. Sure. So I'm going to address symptomatic thumb CMC OA in the early stages from the perspective of a hand therapist, and as we all know, our role is critical here because the patient's X-rays may look pretty good, but they have debilitating pain, and they're not able to engage in a lot of their everyday activities that are important to them. So when I first see these patients, the first thing I like to do is I have them complete a patient-rated outcome measure. There's a plethora of them out there, and they're all really good and very reliable. I tend to favor the Thumb Disability Index because it is a reliable, reproducible, but it's very specific to this diagnosis precisely. So I feel like this is helpful. This helps identify where the patient is, aside from X-rays, aside from range of motion measurements or strength. So to me, I garnish a lot of my information from that. And from here, we move on to treatment, and I thought I would just discuss this CMC Joint Dynamic Stability Program, which was originally described long ago, 2000, by the late Jan Albrecht, but has since has been researched, and a recent retrospective study found a clinically statistically significant decrease in pain and disability with this program. So I thought I would just go over this. It's a staged approach, and it's based on neuromuscular re-education by relearning patterns. We talk about the stable C, which is that top left-hand picture, and there's some manual technique to this. So the next slide is an adductor pollicis release, and that is to increase the muscle extensibility. You could do it for like 30 seconds, several times per day. And the next slide, I don't know why the slide's advanced, but there was a picture up there of self-gentle mobilization, and that's done to centralize the metacarpal on the trapezium. And you'll do this for one to three minutes, maybe twice a day. And then, there we are. And then we'll move down to the bottom slides. The bottom left is adductor pollicis brevis strengthening, and that's to open up the web space. And the opponent's pollicis is also targeted, and that's to help restore pronation, which is often lost with adductor tightness. And then you can see first dorsal interossei strengthening, and that is to help keep the metacarpal out of that radially subluxed posture. And if your patient has an unstable CMC joint, you can offer some manual assistance to the metacarpal while in that C position. So while they're co-contracting the opponent's pollicis, the extensor, and flexor pollicis brevis, you may also be able to accomplish this with, you know, something like a tennis ball. And then the next slide, yes, so orthoses are very important for these people and there's a wide variety, custom, prefab, and a wide range of materials. So for the most part, the orthoses are going to position the thumb in palmar abduction, slight flexion with some medial rotation of the metacarpal, and that's to promote a natural stability at the base of the thumb by increasing the joint congruity. So how we accomplish that, we would like to include the patient in this decision. You know, studies have shown that orthoses do help with pain, but they don't identify which is the best orthoses. So the evidence-based approach will be best here, and that will be the therapist and their experience, patient preference, and their life demands. So for example, if we have a painful CMC joint patient and they present with a lot of hyperextension at the thumb MP joint, you would definitely want to encourage including that MP joint in some slight flexion. However, if they have a painful CMC joint and their MP joint is stable, you can consider just immobilizing, like the splint in the top right-hand corner, the CMC joint, if that's going to control their pain and allow them, you know, the function that they're looking for. So I think I like to say my favorite orthosis is the one that the patient is going to wear, because I really do believe that. I mean, we can make the coolest orthosis in town, but if they, if it's not comfortable or they don't like it, they're not going to wear it. So I think including the patient and knowing their preference is critical. Basically, these, treating these patients is really a multimodal approach with lots of interventions, including orthoses and exercises and patient education. I had a slide of patient education on there, and I think it's important that we just know how the patient learns best, and that's how we need to instruct them. So whether it's through pictures or videotaping them doing the tasks, I have become very fond of having the patient do it in the clinic, and I will videotape them and give them verbal feedback, and then they can take that home with them and have it. So I think treating these patients is a comprehensive approach is key in understanding their life demands and what their goals are, and we can help create a program that's going to maximize their function and decrease their pain. So, and that's it. Thank you, Nancy. That's very instructive. Thank you so much. So this, so the previous x-ray I showed was 2010, and we did all these things that Nancy said to sort of try to, you know, nurse them along and keep them going, and he then came back in 2013, and the right side was worse than the left, and he wanted the right side done first. So on that side, I actually did a partial trapeziectomy with partial base of the first metacarpal resection, which I don't typically remove the entire trapezium. I like to preserve all of the ligaments, and I do a really nice ligamentous repair at the end of this resection, and he actually did very well. So this is him, you know, a little, a little ways out, couple years, he's doing okay, but now he has problems with the left thumb, and what he told me was that if I did the procedure that I did on the right to the left side, that even though his pain was gone, he wouldn't have the strength to actually play his guitar. And so we chose to proceed with a, so we, again, nursed him along, and we braced him, and we did injections, and until he said, well, you know, I can't play my guitar anymore, it's too painful. And so we actually, on the left side, did an implant arthroplasty, and from this, he actually did extremely well. He had really excellent range of motion. He actually had better range of motion on the implant side than on the partial resection side. As we all know, no matter what you do, the thumb does subside a little bit when you remove that pillar of bone. You really can't withstand the, the axial compression load that the thumb experiences with daily use, and so he actually did quite well. He came back to see me at two and a half years out, actually, for his little finger that he had smashed in a door, and so I was able to get these pictures of him, of his left and right hand, and he was playing his guitar, and he was quite happy with the outcome. So both procedures actually worked very well for him, but on the right side, he was a little weaker than the left, and he was able to do all the things that he wanted to do. So he's still playing around town, super nice guy. Now, Dr. Baltzer. Good afternoon, everyone. My name is Heather Baltzer, and I'm from the University of Toronto. Thanks very much for including me in this panel. So I'll talk about patient use on the other side of their trapeziectomy. So this is a 63-year-old female who presented to my clinic, and she had a trapeziectomy and an LRTI three years ago at another institution, and she was coming back with pain at the base of her thumb, and she thought, you know, after her original surgery, when she got over her original pain, things had gotten better, but then progressively over the last year and a half, she's starting to have more pain at the base of the thumb. So I think this is an important topic to talk about because you really need to try and assess out where the source of the pain is. You can see that her grip strength was pretty diminished on that side compared to her contralateral side, as was her pinch, and she wasn't really able to use that hand. So you want to think about the sources of pain in these patients. So you want to consider, is this a situation where she's having subsidence of her metacarpal onto her scapoid, and that's what's causing the pain? Her metacarpal didn't look that subsided, and it wasn't that lax. Always difficult to tell for sure without fluoro, but just in that situation, it didn't seem like a source of pain. Is it coming from her MCP joint? Wasn't an issue. It had also been used by the previous surgeon. And then looking at her ST joint, you can see that she has some arthrosis between the scapoid and the trapezoid, and that seemed to be the source of her pain, but these are also another patient population that I really like to try to optimize before thinking about going back and doing any revision surgery with therapy. So it might be great to get any thoughts from Nancy on how she approaches these patients that have had a failed or a poor outcome after a trapeziectomy and an LRTI. Yeah, so I mean a lot of times we base what we do with these patients on their pain level and how they're doing, you know, functionally. So oftentimes splinting is one of our go-tos, so we'll try various splints on them to see if we can kind of help stabilize them and if that helps their pain at all. And then we're constantly trying to re-educate these patients on joint protection and adaptive equipment. So I think a lot depends on what their pain level is like and how much instability, if any, they have. But oftentimes we'll try to find an orthosis that may fit them well, allow them function, and help with their pain. That's probably, and then education. Yeah, thanks. And I often will add in continued steroid injections as well to augment that and see if that's sufficient to get them through their pain so they don't need another operation. In this case it wasn't sufficient, so can we, I don't know if I have the, oh I do have the ability to advance the slides, great. So there's her STOA. There we go. And so what we ended up doing for her was to go back and do a revision. So we open everything, debride the interval where she had the LRTI, and take out the distal part, or sorry, the proximal part of her trapezoid, just to create a space and decompress that arthritic joint. I interposed some of the residuum from her previous interpositional arthroplasty into that interval, and then closed things back up, mobilized her for about four weeks afterwards, and then reinstituted her therapy program. So at six months post-op, she had a pretty reasonable outcome with not complete resolution of her pain. She had 50% resolution of her pain, but improvement in her grip strength and her pinch, and she was using her hand more commonly. I think something that's really important to stress in these patients is that if they don't have a perfect outcome after an LRTI, the likelihood that they're ever going to be pain-free, and this is something about setting expectations obviously before you even do your original arthroplasty, whatever your choice is for these patients, but setting the expectation that their pain may not be completely gone afterwards. And so in these patients particularly, when they've had a failed LRTI, or they have pain for some reason afterwards, the chance that they'll have a pain-free existence after is pretty unlikely. But I would consider a 50% resolution of pain from this is a good outcome in this situation. But I'd love to hear, Deanna, your thoughts on these patients, because they can be quite challenging. Yes, I agree completely, and you know, we call these in clinic, our endearing term is the CMC cripple, because it's so hard to manage their persistent pain after whatever procedure they had. And the abutment of the base of the metacarpal, sometimes on the trapezoid, and you know, the the STT arthritis that is present, I think that the resection is a really good option and a good approach here. And letting them know that probably they're not going to have zero pain, but they're going to have a thumb that is functional and tolerable in use. So it's hard to get a slam dunk on this, in this situation, this problem. So next case is that of a relatively young woman, she's in her early 50s, and she had a very unstable CMC joint. She actively, I could totally dislocate her metacarpal, and here is me reducing it, and then if you just give it a little load, it would just totally dislocate. So she was, this was not a functional hand for her. And we did, we talked about options here. So Dr. Baltzer, what are your thoughts here on what you might do? So she's, you know, she's got some mild arthritis, but frank instability of the thumb CMC joint. Other right, the contralateral hand is normal, she does not have any inflammatory arthritis. So I think, you know, starting with something like splinting could be an option. She's quite young now, so it's probably not really a viable long-term solution, but it depends on her thoughts on going into surgery. Depending on the degree of arthrosis in the joint, you could consider doing some kind of stabilizing procedure, whether it's a mid-low procedure to help with the joint doing some kind of stabilizing procedure, whether it's a mid-low procedure to try and reconstruct that whole or weak ligament. Sometimes what I do is just take a slip of the APL and transect it proximally, and then bring it up and weave it around the CRL on itself, and then placate that capsule really tightly, just to try and sock everything in, mobilize them for four to six weeks and see if that stabilizes. So that's another potential option, or even adding in a tight rope. Just, it all depends on how her joint is. If her joint is totally destroyed, then I think you would be thinking about doing something else where you're maybe taking out that painful joint surface and doing an arthroplasty. Right, and I think an extension osteotomy here is also an option. So we talked about all these things, and we also talked about potentially utilizing the implant arthroplasty, which is what we ended up doing here. So the joint itself was not actually very worn. She had very mild arthritis, but her soft tissues were very lax, and so we stabilized the joint with the implant, and we then did a lot of soft tissue work to really stabilize that joint. And she, here is a, so you know, just getting the joint congruent and stable is very important as an intraoperative technique. So technically, you have to make sure that you get that right, and so this is her just a couple weeks out, and she actually was not wearing her splint, which you know was not ideal, but she was using her hand normally. So we put her back in the splint, and we, you know, we sent her back to Nancy and said please wear your splint, let the soft tissues heal. And then this is her at about six and a half months out from surgery. The thumb was stable, and she had a much more functional hand. And then this is our last case. Are we okay to go ahead with this? I thought that we were ending it too. Yes, go ahead and go through this last case. Thank you. Okay, great. So this is a patient presenting, actually referred from a colleague, 53-year-old female who had progressively painful OA, and she was not responding to non-surgical intervention. She sort of maxed out on the therapy options. She had been educated about the potential for arthroplasty at the joint, but was really not keen to go ahead with anything in terms of a secondary trapezium, and was interested in other options. And I've had a number of patients like this in my practice, and so this has kind of made me extend the menu of options that I will offer to these patients. So someone like this that has has definitely OA, but it's not severe in terms of the joint destruction or the deformity of the joint, I'll offer them a debridement of the joint arthroscopically, and I don't know if I can advance that. Yeah. In order just to clean up the joint and the synovitis within the joint, and then augment that with adipose transfer into the joint to create sort of like an interpositional arthroplasty, I used to just do the fat grafting, and now I'm doing the arthroscopy initially just to clean the joint up. I also like to use thermal application of the joints of the bolar feet ligament just to give it a little bit of stability. And these are just the standard portals that you do on either side of the abductor pollicis lumbus or the first dorsal compartment tendons. And then here is the fat which is harvested from the abdomen and then injected directly into the joint. And what you can see in the images here is her pre-op fluoro and then her post-op fluoro where there's the expansion of the joint. And so it's really variable in these patients. Some of them do really well. I'm finding that about 50% of patients go on to have pain resolution at a year, which is great, and they have very little downtime and pretty good functional outcomes. However, there is a group of patients that don't do well after this, and then we start to talk about more conventional treatment of their CMC joint issues. So we'll go on to the last slide. Thanks everyone for including us in this panel. Thank you. That was a great session on hand there. I really went through a lot of very interesting topics and a lot of depth and with a lot of excellent content from all of our faculty. So now we're going to open it up for a few minutes of questions and just of interest in staying on time, we'll probably allot about five minutes for questions here. But there's one from the participants here. So if for one of your cases, I believe Dr. Mercer, the joint surface was reasonable, why not just try soft tissue stabilizing procedure first? Yeah, so that's a great question. And it was a discussion that we had and it was one of the possible outcomes from the initial sort of exposure. There was some joint wear and she had very patchless tissue, so she didn't have great tissue. And so the decision was made after I identified all these things to proceed with the implant arthroplasty. I think that for her, I was less leaning towards ligamentous reconstruction and more leaning towards actually an osteotomy. You know, I thought that if we sort of redirected the base of the metacarpal and then reefed up the soft tissue, so sort of a combination of osteotomy with ligamentous reefing, that maybe we could get her stability. But in the end, she did have some wear and some osteophytes. And so we pulled the trigger and did the arthroplasty from what she did very well. She was very happy. Thank you. If anyone else has any questions, please type them into the chat or the Q&A. I had one actually for the folks in the panel talking about hand fracture fixation and mainly for the therapists to get their input. For interarticular P2 base fractures or PIP fracture dislocations, what do the therapists feel are the best kind of fixation constructs for how patients mobilize postoperatively? And what is your feeling based on what you see caring for these patients? Chris, I think you're still muted. I don't think I've ever been asked that question before. You know, we usually just kind of get what we get. But I will say that, you know, I have seen very good results with just with the plating and with the small plates that are now available. And just it's interesting over the years in my age is that, you know, we that really the plating that are so microscopic nowadays have really improved the outcomes that I see with patients compared to actually immobilizing them years ago or even using the big distraction or thought that was around for some time. So things have really advanced quite a bit. Great, thank you. We have some more questions from participants here. So for the panelists for the CMC, when do you consider osteotomy of thumb metacarpal versus CMC arthritis? And I answered it in the chat. It's typically mild arthritis in a young patient with dorsal radial subluxation. These patients do well with an osteotomy, with a metacarpal extension osteotomy. It basically redirects the forces of the base of the metacarpal and the trapezium. Deanna, can I ask you a follow-up question to that, if that's all right? This is something I usually do. So I'm just interested to know, like, does that buy you time or like how, how, what are the long-term effects of something like that? Yeah, so that's a great question. It does buy you time. I think that it's a more functional thumb. Again, I'm not super huge. I know that a lot of people resect the trapezium. I'm not huge on trapezial resection. What I see is in those patients long-term is that they have a weak thumb and they have hyperextension of the MP joint. Just last week I fused two MP joints from trapeziums resected in the community. And so I think that the, you know, I am sort of a proponent of try to keep your parts if you can and try to maintain the anatomy. And so I think that yes, you're right Heather, that you do buy time, but sometimes these people have their osteotomy and they don't have to have additional procedures. Great. There's one more question here from the participants. Dr. Baltzer, what volume of fat do you inject for your CMC injections? And I actually have a follow-up question to that. How, how long do you see that joint distraction main, maintain postoperatively? Yeah, thanks Brandon. Usually one to two cc's of fat gets injected depending on the size of the joint. And then it's really interesting. We started X-raying these patients expecting to see that distraction. And then as much as early as a month out from surgery, there's the joint looks exactly the same as it did pre-op, but that doesn't have any relationship to their outcome. So it's not a spacer effect at all. It's something else that's causing a pain reduction in these patients. Very interesting. Yeah. All right. So we're actually going to wrap up with that session here. We're going to take a couple minutes to transition into our breakout sessions.

small joint arthroplasty

severe pain

functional limitations

arthritis

hand

fingers

implant types

controversial topic

patient evaluation

post-surgery expectations

hand surgery

therapy

arthroplasty

thumb CMC OA