Okay, I think we'll go ahead and get started just so we can end on time because I think Some folks have dinner plans tonight with various fellowships. So welcome this afternoon to this ICL of errors complications and complaints strategies to handle Difficult problems in the hand wrist peripheral nerve and flexor tendon areas. I'm so new Jane out of Ohio State we have a truly a master panel of Of Professors here including dr. Jupiter out of Mass General Harvard currently relocated to Florida Dr. Stern who could not be here. Who's at the University of Cincinnati? Dr. Laurie Kelly and and at Brown University and last but not least. Dr. Harry Hawaiian to Metro Health in Cleveland So without delay, I'll have dr. Jupiter come up and give his talk Okay, welcome and thanks for coming, and it's always something daunting to talk about complications, but I think one can approach it from a logical perspective in the problems about the distal radius. Okay, so here we go. Let's see. These are my disclosures, and they're on all the available websites that we use. An interesting paper came out, Journal of Hand Surgery from Canada, looking at how to assess complications of distal radius fracture, and they had a checklist that they gave to patients and physicians, looking at, A, was there a difference between physician-rated and patient-rated, and what they showed actually was that's the case, that physicians tended to look more as diagnoses and problems and give a name to it. Patients were more focused on symptoms, and then they defined the type of complications that you might see, mild ones that resolved either with time or no treatment, moderate ones that may require readjustment of your splint or go to OT or decrease edema therapy, or severe, which was required surgical treatment. But it even becomes difficult because, let's say you have a median neuropathy with the distal radius fracture. Well, was it pre-existing, and was it something that would just be resolving by itself, or was it something that was the traumatized nerve from the fracture displacement on and on? So it's sometimes hard to really attribute it to the fracture, and this is what I thought really reflects this. If you look at this paper on volar plating and look at nine physician-reported complications, these were substantial complications requiring hardware out, tendon problems, wound dehiscence, lunate facet displacement, but look at the DAS score. Patients were really happy. And so that's why it becomes a little difficult to do that. If you look at osteoarticular problems, loss of reduction, delayed and nonunion, malunion, DRUJ problems, infection, and I'll try to highlight some of these. As well, we have associated soft tissue lesions, as you see in the list, that can be quite extensive and quite disabling if they occur. So loss of reduction, as illustrated here, in a volar shearing fracture, and the internal fixation, anatomically shaped plates for all intents and purposes, is quite acceptable. But this is what happens at five weeks, and the volar lunate facet is displaced because the plate didn't support it, and that becomes a problem. And interestingly, we looked at a separate study a number of years ago, just looking at our experience with Diego Fernandez in Switzerland and mine, on volar shearing fractures. And what we identified, this is sort of even pre-volar plating to a large degree, was that the most common problem that you see in a volar shearing is not a single fragment, but usually more than one, even comminuted, but often the lunate facet is separated from the volar radial side. And this is what happened to that patient once you get to where it subluxed the whole carpus, and it requires a reconstruction. If you get it early, you can try to do intraarticular osteotomy, elevating the lunate facet, and while patients function pretty well, it's not ideal. So if you don't get it early, like in this case here, it may go on to both radiocarpal arthrosis as well as dysradiola joint arthrosis, and it may require a reconstruction like here with a combined salve compongi and a radial lunate arthrodesis, and with the plate out, this patient functioned adequately. So when I saw this first, probably in the late 80s, I couldn't figure it out, and we actually collected then a series of cases, and I sent it to the Journal of Bone and Joint Surgery, and it was very hard to get a negative paper accepted, you know? And it was rejected twice, and then I got a call from the upper extremity editor who said, you're not going to believe this, but this happened to one of my patients. And he said, send me back that article, and it was then published, and it did bring an awareness to people that this problem is something to look out for, and these patients did okay, as illustrated in that case, but they often will need a, if not looked at quickly, need a reconstruction. So the strategies is, make sure that you get as distal as possible with your subchondral, in subchondral bone, and if necessary, adapt your implants to have variable angle that can drive your screws from distal to proximal. And studies have shown this biomechanically and clinically, and I think we all accept that position. And understand the fracture pattern. There's nothing wrong with getting CT scans for these fractures. They really tell you a lot, because when you look at the lateral x-rays, and you see this, that's where the radial styloid comes across, and you can't tell the lunate side unless you angle the beam, and you really should identify the teardrop, and that's the volar lunate facet angle. It should be quite a substantial angle to the axis of the radius shaft. We know that the pronator quadratus ends at a certain point, and we think that we can judge the end of the radius, but it's not easy, because it's covered with the capsule, and so what you think might be the end is sometimes not. And the volar aspect of this radial styloid is more inferior, and the volar aspect of the lunate facet is more inferior, and there's a separation between them. The other thing to realize is you may see fractures like this, which look like minimally fracture fragments, but notice that the whole carpus is ulnarly deviated, it's sublux, and these fractures are really dangerous, because if it's missed, and this goes on without treatment, this is a radiocarpal fracture dislocation, that risk will become really problematic in very quick time, so notice how it's sublux, and here's the telltale sign, and what happens here is the volar capsule has ruptured, and that's allowed this ulnar translation, and this is what happens. The fracture fragments are not very big sometimes, but the injury is substantial, and failure to recognize this has this sequence of wearing out very quickly, and this goes on to arthrosis and needed effusion, so this is what in some of these cases you might see, because these are higher energy injuries, and the volar capsule is torn off completely, and you can repair it with suture anchors or drill holes through the volar aspect, and then understand finally the, you don't have to fix everything with big implants, and sometimes a simple fixation of the lunate facet with a tension wire through a drill hole in the radius and through the volar capsule can help as well, and here's a one-year follow-up, and it's maintained the position, or custom implants or hook implants, all those work fine as long as you identify the problem per se. Moving your volar plate ulnar would may actually cover that lunate facet sometimes. Delayed union, non-union, we're not used to seeing that common, but it can be problematic. This is an area that should heal in most cases, but inadequate fixation or traction with an external fixator sometimes has that, and it can be reconstructed, but it requires obviously realignment and additional surgery, and we saw a number of these and realized that when you're dealing with it, you tend to have a small osteopenic fragment and may have a contracture because it's been radial deviated, and the distal radiolar joint may be disrupted, so it becomes more of a reconstructive problem. This group published a series feeling that it may be too much, the combination of osteoporosis, disuse, and a contracture may be better dealt with with an arthrodesis, but we looked at that and thought that if you could correct the axial deformity, sometimes you have to do a release, and almost always a tenotomy of the brachioradialis, you may be able to repair these effectively, and here's a patient who went on to get what looks like a decent fracture, and then it sort of never healed and started to get developed this volar radial deviation deformity and resorption, and some of these sometimes you may see with patients who have neuromuscular disorders, and so this patient had this reconstructed, reconstructed, and then we wanted to ask the question, does it matter if the fragment is really small or not as small as that, and even with fragments of five millimeters or greater, we looked at that and the results were reasonably predictable in getting a stable fixation, as illustrated in this case, but once that small fragment was elevated up and an intercalary graph placed, we could get a nice union of that, and there's the function of the wrist and forearm. Malunion, I think everyone's aware of that problem, and the issue is really nowadays, what about an intra-articular malunion? Is that feasible? Can it be done per se? Many years ago, we looked at just what happens to fractures in young people if they weren't well reduced and well fixed, and the results are quite poor, and so identifying a malpositioned articular surface may be dealt with successfully with an osteotomy, and this is what we saw. If you have a residual step-off that you can really see on the x-ray, you're likely to develop post-traumatic arthritis. Now, whether or not that's symptomatic, it's hard to know, but if you see it early, we call that nascent malunion. You can consider intervention, otherwise you end up with something like this, so this is what happens sometimes. You have a combined problem with radiocarpal or radioulnar or both and subluxation as we illustrated here, and then the question comes up. Is this technically feasible? Will the fragments heal? They have no soft tissue once you've elevated, when they go on to avascular necrosis. It's a good idea if you can appreciate the original fracture pattern and the articular status, in other words, that it hasn't developed radiocarpal cartilage loss as well. Nowadays, many of us found it useful in some of these very difficult anatomic malunions to get a computer-generated plan, so to speak. This is the kind of thing you may see with granulation tissue over the carpus, and the volar aspect of this patient is okay, but the dorsal aspect is not. I think obvious contraindications are if you've already developed loss of cartilage and arthrosis. So we collected a series with two other centers with this, and interestingly enough, we answered, in my mind, the major question is, were they healed and the results were functionally okay? There are always going to be some potential problems or real problems with these procedures because they're often elevation of soft tissue as well. And here's a patient that had combined intraarticular and extraarticular, and this is how she presented at four months. This is another patient who I saw who's a general surgeon, and this is how he presented equally about four months. We were able to get computer-generated bone models, and not just plan, you could do the osteotomy preoperatively on the models. There's the normal side, and here's the abnormal side. And if you look at it in the coronal section, you see how it's rotated and elevated, so that's the extraarticular component. So I knew that I could elevate, I hoped that I could elevate the lunate component and the radial styloid, and I had to take the plates out, but had to take off the head of the ulna, but he functioned very adequately. And to give you an idea, here's another intraarticular malunion, and the nice thing about CTs and 3D CTs, you can plan it out, and really it becomes maybe a little bit more clear than even an original fracture, and you have one and two and three components, and then you have the extraarticular component. So by taking apart the lunate components, bridging them more distally and reducing them to the radial styloid component, and then doing an extraarticular osteotomy, and placing a small graph there, here, and then just, you don't need very complex fixation, because the fragments are very firm, and they're not acute fracture fragments. And here's the fracture, and here's 11-year follow-up, the patient's function adequately. So these can be done. And finally, distal radioulnar joint problems. Really, there are three basic issues. One is impaction, the other is incongruity, and the other is instability. And these may be isolated, or may be in combination. And some of the more unusual things are capsular contracture and radioulnar impingement, after a previous procedure. But incongruity, that's associated with a malunion, you may find that the sigmoid notch has been displaced, and the end of the radius is malrotated. As you see in the volar aspect here, when you have a volar-displaced malunion, or a fracture, your sigmoid notch is off. Those patients frequently can't supinate because of that. And of course, incongruity can come about from articular injury to the ulnar head and or sigmoid notch, and combined with impaction. So what's the strategies here? Well, if you see that, you can do a distal radius osteotomy, realign the rotation, and realign the sigmoid notch, per se. And as long as it's not arthritic, the patient can function very well. The stability of the distal radioulnar joint really comes from the contact pressure of the ulnar head to the sigmoid notch, not so much from the ligaments or supporting structures. So if you can get the sigmoid notch oriented to the ulnar head, you can restore stability very, very predictably. You can do resection arthroplasty with arthrosis, and I think you're all well aware of the types of resection, either the Bowers, so-called Bowers. And the secret of the Bowers is not just to do a hemi-resection here, but you have to put something in there, including the pronator quadratus and perhaps a slip of the ECU rolled up as an anchovy to help that, per se. Here's a patient who had obvious arthritic problems and incongruity and had that done, and this is a three-year follow-up. Or older patients consider a DARA, per se, but that doesn't correct the angular deformity of the hand and wrist. But the function sometimes is very surprising. Abutment, I think we're pretty aware of, and impaction, and the consideration of combining osteotomies and shortening. And the caveat about shortening is, before doing that, you really want to look at the orientation of the sigmoid notch. Again, if it's angled abnormally, you may find you shorten this, it's going to abut against the lip of the sigmoid notch, the ulnar head. So here's a case that had a combination of osteotomy and shortening of the ulna, per se. Here's another similar example. So a combination of osteotomy and shortening. And finally, instability. And once again, idea of where the instability is, and is it related to malposition, deformity, or soft tissue. And arthroscopy can help you here effectively to see if there is a TFCC problem, and perhaps early on this can be brought back, or a large ulnar styloid. Here it is combined with an osteotomy, per se. So I think, in the interest of time, I think, how much time we have? I think probably another minute or so. Another two minutes or so. Okay. I just want to mention carpal instability. Because a lot of times we'll see the patient come in with a distal radius fracture, and there's a wide scapholunate gap. For the most part, these are not complete scapholunate ligament tears. For the most part, they do not need the treatment that we do for acute scapholunate injuries. It's a different animal. It's probably stretching of the dorsal intercarpal ligament, per se, but it's not the same. Decision making, if you're unsure, to put in an arthroscope, but it's very uncommon to see that, per se. I think it's a different problem than what you have with an acute scapholunate. If you look at this study by Bain in Australia, and you look at where the fractures occur, they're often components are between the origins of the ligaments, per se, so not really involving the scapholunate ligament. I think the best evidence is probably not to treat. If you look at this paper, where they followed this problem, arthroscopically diagnosed incomplete tears, followed 13 to 15 years, no treatment. The results were as good as the opposite risks. To give you an example, here's a patient who had this original injury. Here you see it. Of course, we were all taught, better x-ray the other side. You see the other side, the non-injured side. That's a tip off there, and that's his follow-up. Here's another case that is a pretty substantial injury. This is the closed reduction, and you see the gap. This was fixed. Look at the other side. Is this really an injury or not? The group at Duke recently published in Journal of Hand Surgery a similar observation of a group of patients like this, and these patients probably do not have to do it. We're going to hear more about tendons, so I think I'll stop there and entertain any questions. Save for the end. Okay. Thank you, Dr. Jupiter. That was great. Thank you. So our next speaker will be Dr. Stern. Dr. Stern couldn't make it for this talk. He had to leave early, so it's pre-recorded. Complaints in Hand Fracture Surgery. Good afternoon, my name's Peter Stern and I'm going to be presenting on AIRS Complications Complaints in Hand Fracture Surgery. Al Swanson, a past president of the Hand Society stated 50 years ago, quote, hand fractures can be complicated by deformity from no treatment, stiffness from overtreatment and both deformity and stiffness from poor treatment. This statement definitely holds true today. Malrotation. Malrotation is very poorly tolerated by patients and is seen primarily in spiral and oblique fractures of the metacarpals and phalanges. I think it's important to always assess malrotation with the patient actively bending her finger. What you wanna do is have the patient synchronously bend her fingers and make a composite fist. You can eliminate the pain using a metacarpal block. Another scenario is fractures at the base of the proximal phalanx. And these can be very difficult to assess and can be misinterpreted. Fractures to the base of the proximal phalanx are misinterpreted because of the overlap in the lateral view, which underestimates the amount of extension at the base of P1. I think it's important that one remember to take oblique views to assess for pseudo-clawing and this will determine what you're gonna do with the fracture. Here's an example in the bottom left of a fracture that doesn't look too bad on the AP view. On the lateral view, there's extension at the fracture site and on the right, one can see the fracture reduced in the intrinsic plus position with Eaton-Belsky pins crossing the MCP joint. Another scenario is a conular fracture of the head of the proximal and middle phalanges. These fractures are also quite deceptive and if managed non-operatively, it's really important that you have close follow-up. Typically, a uniconular fracture fragment will migrate proximally and sublux volarly leaving incongruency in the IP joint and a radial or ulnar deviation formity, again, poorly tolerated. On the right is an example of a fairly benign looking fracture. However, it turned out that this conular fracture was rotated 180 degrees and any attempt at percutaneous fixation would have led to an inadequate result. The other thing that's important and was pointed out by Peter Weiss and Hill Hastings was a single pin fixation is inadequate. Always fix uniconular fractures with at least two fixation devices. Next, plate fixations. So plate fixation is definitely sexy, it's fun to do, but it's not all that it's cracked up to be. Here's a patient I took care of several years ago with nice looking plate fixation. However, post-operatively, she was completely unable to bend her ring finger. She had adhesions. We ended up having to do a tenolysis, a second operation, plate removal and flexing her finger and she had a satisfactory, although not perfect result. I feel strongly that plates should be used only for very difficult comminuted situations and less high profile forms of fixation are my alternative. As a corollary, percutaneous fixation for unstable phalangeal fractures is not sexy, but it does the trick. Here's a man who had an auger injury fracturing all four proximal phalanges. He's a 60 year old farmer, wants to get back to work, treated again with various forms of pin fixation. Percutaneous fractures are healing. I didn't see him after eight weeks and at eight weeks follow up, despite the fact that there are no plates, he has very satisfactory range of motion as evidenced on the bottom slide. Next, there's been increased enthusiasm over the last decade in placing plates on the dorsal aspect of the proximal and to a lesser extent, middle phalanx. But as Reed Draeger and colleagues pointed out, there is a groove in the anterior surface of the proximal middle phalanges, such that when you take a lateral, it looks like the screw is not going by cortical, but in fact, it's in this groove and you can get a nutritional rupture. Here's a plate from many, many years ago in which the screws penetrated the proximal phalanx and the patient ended up with a rupture of the profundus and sublimus tendons. Next, I feel strongly, particularly with gunshot wounds that no heroics. So gunshot injuries that take out the metacarpal head based on the proximal phalanx or border digits should be strongly considered for amputation. Salvage is generally a multi-step process and often results in a stiff, painful, mal-rotated finger. Here's a gentleman that sustained a self-inflicted accidental gunshot wound to the MCP joint of his dominant index finger. He also had coronary artery disease, multiple stents and hypertension, and he was taking care of his wife who was a quadriplegic. The x-rays on the right show evidence to soft tissue injury loss of the head of the metacarpal, diminished sensibility, et cetera, et cetera. Bottom line, he was treated with a ray resection with his permission. Here he is two weeks later, full range of motion of the remaining digits, no swelling, no more operations. So something to consider, particularly in border digits. I like external fixation and I use it particularly for accommodated open fractures of the phalanges and metacarpals. It's oftentimes the better part of valor. Here's a patient that had some type of open crushing injury to his thumb. He's got multiple fractures of all segments in his thumb and placement of an external fixator stabilized the soft tissue, maintains length, although you cannot achieve articular congruency. Next, phalangeal shortening is poorly tolerated and is underrated. However, metacarpal shortening up to five millimeters is overrated and generally well tolerated. That is to say there's a linear relationship between P1 shortening and PIP extensor lag. For each millimeter of P1 shortening, you have a 10 degree extensor lag as shown by Vahey, Hastings and Wagner. Well, Wellant has become very popular and certainly should be considered for most patients with phalangeal fractures. The beauty of Wellant has been well-described by Don Lalonde time precludes my going over all the advantages, but the bottom line is that you can assess intraoperative range of motion as well as malrotation. This patient had a fracture of the proximal phalanx and has an active passive discrepancy of digital flexion. He had wide awake surgery. Here, the two of us are together in the operating room and he's demonstrating after the tenolysis full range of motion. Here's a quote from a highly respected AO surgeon and good friend, quote, pins penetrate, incinerate, irritate and incarcerate. This was an AO surgeon as I mentioned, but in my opinion, pin fixation is not a sign of weakness. Pins are forgiving, versatile and minimize soft tissue damage. And as my colleague, Dr. Osterman said five years ago, K wires can be the best friend more often than not. Interfragmentary fixation spiral and phalangeal metacarpal fractures. Just a couple hints here. Don't forget to countersink, lagging can be dangerous. And I, because I think that there's only a three, three, two or three threads on the opposite side that can engage. And sometimes if you try to lag, you end up losing everything. If you're inserting a screw and it won't go through the far cortex, you may be hitting the endosteal surface of the far cortex. So you may need to redirect your screw rather than forcing it through the far cortex and blowing the fracture apart. Sometimes, particularly in younger people, you can close the periosteum. Management of infected fractures. These are very, very tough problems. First, you want to eliminate the sepsis, which requires a breed mod, appropriate cultures, appropriate antibiotics. And if the implant is loose, I would certainly consider removing it. If you remove it, you need to have some form of stabilization, such as an external fixer, usually with a antibiotic impregnated polymethylmethacrylate spacer. Then a mascalade type procedure where the spacer is removed at eight to 12 weeks. And the fracture is, having the spacer removed, the space is filled with cancellous autograft and stabilization, usually with a plate. Sometimes function is regained. Oftentimes the finger remains stiff. Here's an example of a heroic effort to save a finger. Definitely not worth it. This patient elsewhere had cross pinning of a P2 fracture. I was referred to me on a Friday afternoon with obvious sepsis, was taken to the operating room. This is an old case. The fracture was debrided and a place in traction. Looked like the fracture healed after eight weeks, but there was still drainage. The fracture was resected. An external fixer was placed with a polymethylmethacrylate spacer. The final result, a withered, mal-rotated finger, and ultimately an amputation six months later and seven operations. We published an article a number of years ago on osteomyelitis, the tubular bones of the hand, a fair number of metacarpal and phalangeal fractures. Most were post-traumatic in origin. Cultures showed mixed or gram positive flora. Note, the overall amputation rate was 39%. And if the treatment was delayed six months from time of drainage, almost 90% of fingers ended up being amputated. The other bottom line is that if you have to do more than three procedures for osteomyelitis, there's a 75% amputation rate. So with osteomyelitis, if you do more than three procedures, at least in Cincinnati, one, two, three strikes, you're out. And finally, even the worst looking x-rays may provide a satisfactory result. Here's a great case that Bill Burkhalter many years ago shared with me, awful looking x-ray, but look at the functional result of this patient. And Dr. Burkhalter always said, it seems that skeletal stability and not skeletal rigidity is necessary for functional use. Remember, treat the patient, not the fracture. Thank you. Okay, thanks for everybody for being here, it's wonderful to be in person again. Last year, I dutifully sat at the kitchen table looking at all of these conferences and I didn't remember a darn thing by the end of them because I lost the ability to actually speak with my colleagues after talks. So I think that it's just wonderful that we have the chance to be here. Today, Errors, Complications and Complaints in Peripheral Nerve Surgery. You won't see any interesting pictures because we don't generally get that opportunity. I kind of like to think of this as optimizing your outcomes because all of those negative emotions signal threat and require detailed thinking, which is good, but anxiety. And I love operating on nerves and so I want you guys to feel more comfortable operating on nerves even when you potentially face a negative outcome. So redefining an error versus a complication, error is the failure of a perceived action or a planned action to be completed as intended or an unintended act or one that doesn't achieve the outcome. A complication is an unanticipated problem arising from a perceived or treatment or illness. And so there are subtle distinctions between the two. But as our friend Mark Twain said, good judgment is a result of experience and experience is a result of bad judgment. I've been doing this for 21 years now and realizing that I'm farther toward the end of my career, but hopefully I've gotten to the point where I'm not seeing too many errors or complications. One thing that I think people are very concerned about at the beginning is the risk of malpractice. And so a really nice article was just published by Krauss et al. looking at malpractice claims, med mal, in the United States. And if you're operating on peripheral nerves, you can feel somewhat confident that the risk of you being effectively sued is 0.3%. Forty-one percent of these are carpal tunnel surgery related, and most of them are operative techniques. But 20% of cases were related to no evidence of misadventure. So they were probably the result of poor communication, patient anger, and nothing that the surgeons did wrong, which is somewhat concerning and very frustrating given how long a lawsuit can go from beginning to end. Messages and diagnosis and evaluation are only successfully used 11% of the time. And so if you're ordering test after test after test thinking that it's saving you, it's probably not. It's how you communicate with the patient and various other things, especially patient selection. So a quick thing on how you decrease your risk of malpractice, communication and record keeping are crucial. Further evidence suggests that adding videos and diagrams to your notes can improve the communication with the patient, make them happier, and further decrease the risk that this is going to accelerate into something that you didn't want. Managing patient risk factors is really important, such as unrealistic expectations, prior scarring. Yesterday we heard a talk from Dr. Ring where he was doing his very best to dissect carefully around the radial nerve and there we see fascicles. And so I tell my residents, if you ever see C anemones and you didn't plan on it, that's not a good sign. So other things like obesity, major trauma, anything that can disrupt the anatomy, make things a little bit more difficult are concerns and that those can lead down the line to problems. Making a prompt and accurate diagnosis. And so we heard earlier today of the importance of Dr. Hager in her talk of doing a complete exam and every patient that I have for a potential nerve problem, as she does, I examine from the head down. I do not believe other people's physical exams because people who refer people to me often have like a differential of two things. They either have tendinitis or carpal tunnel. And if you just believe that everybody has carpal tunnel, who comes into your office and think, well, I'll just do a carpal tunnel release, you will get into problems because you will have missed the cervicalgia, brachial plexopathies, pronator syndrome, any number of problems that are there and that aren't carpal tunnel. So considering the use of SEMS-Weinstein to get some nice definitive data on what your patient's hand function is, is useful. I had a patient recently who I had done a pronator and a carpal tunnel on her. And basically she was fine and she came in about four weeks later and said, I was fine first and now my hand is completely numb. I'm like, well, that doesn't really make sense. Why don't you go and see a friendly hand therapist and they'll do a SEMS-Weinstein just to kind of see what's going on. And her hand had a little bit of decrease to light touch, but otherwise the sensation in her hand was present. It was slightly altered. And so that was useful for having her hand therapist be able to kind of set expectations that some of the altered sensation may be related to swelling or scarring postoperatively. So I've been in practice now for 21 years, as I mentioned, and in preparation for this, I went back over the past five years and looked at every nerve case that I have done. These are about 209 people who had nerve repair, reconstruction, decompression, selective denervation. For this, I didn't include my abdominal or my lower extremity or occipital neuralgia, but I operate on nerves around the body, especially for postoperative nerve pain. The median age of my upper extremity patients was 47, and it ranged from 4 to 90. I had 89 women and 120 men. In the improved, improving, or symptoms completely resolved, which are all beneficial things, because as Dr. Jupiter had mentioned in his talk, people really care about, you know, the pain that they have more than surgeons who care about what the wound looks like or what the x-ray may look like. All of these things were happy and things that patients had expected, that things were getting better, and that was 80% of my patients. 8% had minimal improvement, 2% had worsened pain from preoperatively, and I had about a 10% complication rate. And that goes from hematoma, wound dehiscence, suture spitting, things like wound infections, to a new pain in a different area. So some of my patients with neuropathies can have a pain unmasked. And so one of the sources of pain was relieved, and now they have a secondary site or a trigger, and so that's now lighting up. And so that may need to be treated as well. Chronic stiffness and swelling, and that went along with some of my worsened pain. I have lost about 5% of people to long-term follow-up, or I'm sorry, this was to short-term follow-up, where they just never came back. And that could be when I lived in Minnesota, they were just traveling through the country, and they just went someplace else, possibly to one of y'all, or they were imprisoned, or they just were doing well enough that they disappeared and I never saw them again. So what do I do to minimize errors? I optimize patient selection, make sure that I've got the correct diagnosis, choose the best procedure for that patient, operate on the correct site, which unfortunately I've seen some people not do, do appropriate technique, and set achievable goals. So there can be errors in patient selection. Generally these are related to poor communication, anxiety, and anger, a history of prior poor compliance with the system, a history of substance misuse, having chronic pain beforehand, being on opioids chronically, a poor response to nerve blocks. If you block a nerve, and the patient is worse, and you feel confident that you didn't actually hit the nerve when you did the block, they were fine during the block and called afterwards and said, oh my God, my pain is worse than ever, I do not know what that means, but I'm not touching that person with anything, I'm like, I just slowly back away from the painful patient and say, I'm sorry, there's nothing I can do for you. I think I get good results because I am very conservative on who I choose to operate on, because I don't want to deal with issues of you've made my pain worse, it's like, okay, if a nerve block didn't help, I don't know what's going on, and you'll have to see somebody else. So one time when I made a very bad patient selection, I had an angry young man with an ankle crush injury, this had happened a while back, he'd had several procedures, I felt confident that he had a tarsal tunnel that was caught in his scar tissue, I did a nerve block, and it was like, I think it helped, I don't know, and he was so unhappy afterwards, I don't know whether it was the nerve waking up, but he was one of the few people who wrote bad things online saying, I promised him that his leg would be better, which it didn't, but it was, I don't think I was maybe as clear as I could have been with him, and I probably shouldn't have operated on him at first, because it wasn't a clear, yes, you made my pain so much better, I didn't realize it, and I ran up the stairs, I was able to kneel down and look under the bed for something, so when you do that block, it really has to be pretty definitive. And then number two, angry young postal worker, he had a trip and fall, diffuse weird arm aching, and he also had worsened pain after the block, and I was smart enough to say, you may be unhappy, but I'm not operating on you, and he was still unhappy, but he was now no longer my unhappiness, and so I sent him on to occupational medicine for management. You can make an error in diagnosis, earlier we heard some of the issues about, is it just carpal tunnel, or is it carpal tunnel plus pronator, I estimate that right now about a third of the people that I operate on for carpal tunnel, I also operate on for pronator syndrome, because it is very common. The textbooks say 2%, well that's nice, but I don't think people were looking for it, and when you're not looking for it, you won't find it, and you will never find it on electrodiagnostics, so it has to be physical exam. There are limitations in the literature, as we've heard so far during the conference, because you have bias. I love the idea that the editor didn't really believe in Dr. Jupiter's topic until he saw it himself, and then now this is worthy of publication. That happens everywhere, in the things, so you can't say that the literature is the only truth in the world. Limitations in performing the physical exam, some people don't do it, mentioned excessive trust in the pre-visit diagnosis, or excessive trust in electrodiagnostics, which can be falsely negative in up to 25% of people, so who have a normal EMG, but a physical exam and a history very consistent with carpal tunnel, so I don't tend to order electrodiagnostics. I don't place a lot of faith in them. Timing is important. When you're going to do nerve transfer, you should do those, I think, even less than 7 months, rather than waiting. I know that people can wait 9 to 12 months in literature. I've found decreasingly good outcomes the longer I wait, so I try to get people in sooner. Cross C7 transfers, big fat American arms, you're probably not going to be able to elevate those with a few little tiny fascicles, and so I've not found that those are really useful in large muscular people. I'm not a fan of intercostal nerves. I think if you've got more than three, then it may be helpful, and Kyle Eberlin is doing some work on that up in Boston. I hope he's going to be publishing it soon. You have to be so delicate with them, and I see some people just working on the nerves, and I tell my residents to just be nice with them, because you don't want to create an internal injury to your nerve when you're doing it, and so surgical technique, I think, is just amazingly exceedingly important. I only use bipolar, because I don't want to create a spray of injury that you can with a monopolar. The only time I use monopolar cautery is if I'm doing an abdominoplasty or in an approach for a big free flap or something. Pre- and post-operative care, you want to protect the wound, use therapy, and operate to your skill level, so your complications can be related to you, to the patient, to the system. Complications of commission, where you inadvertently injure something that you didn't expect. You can get worse in pain from an injury, just from unhappiness of the nerve, central component of the pain, element of chronic regional pain syndrome. You can injure with things you're doing, like retracting the median nerve while you're doing a distal radius fracture, inadequate resection of scar back to healthy nerve fascicles if you're doing a nerve reconstruction. You can miss a diagnosis in a setting of trauma. You can lose a person to follow-up, and you never know how they did. Did they go to someplace else, or did they just kind of resign themselves to their outcome? And then there's standard wound problems. So I have inadvertently injured a partial injury to a dorsal ulnar cutaneous nerve on a family practice doctor. I fixed it, I repaired it, she never got completely functional, and I think she lost a lot of faith in me after that. You can get persistent pain. I've taken out, done selective denervations, and I saw a normal little nerve that wasn't skewered by the screw, and I left that in. Now any nerve in the field gets denervated, because I don't know who's the unhappy one. You can have missed injuries. That's more of a systemic issue. I was generally seeing about one person with a missed brachial plexus injury a year, because they had so much other polytrauma, people thought that the fact that they weren't moving their arm was their clavicle fracture, or they just didn't want to, you know, or some other reason. But having a delayed brachial plexus is a big issue. And then pain management. I use preoperatively. I block before the prep a mix of Lido and Marcane. Perioperatively, use Gabapentin. If the person has a history of a nerve issue, if I'm operating on the nerve, not just a carpal tunnel release, but a repair, reconstruction, transfer, or a selective denervation, I ask my anesthesia colleagues to use dexmedetomidine or ketamine. And postoperatively, ice elevation, rest, anti-inflammatories, Toradol, a very short course of opioids. And your complaints. They are pain. There's more pain. And I'm having more pain. I'm having different pain. Pain, pain, pain, pain, pain. Occasionally people will complain of numbness. That's not the big issue that I hear. They complain of pain. A little bit of complaints of weakness, but some of those we work with and hand therapy is helpful with. And then the poor function and unrealistic expectations were a problem of not having an adequate discussion beforehand. That's comprehended by the patients. Remembering that we can be very proud that we got a bunch of grade three functional recoveries on a nerve transfer, but that may not be what the patient thinks. The patient's thinking that they're going to go back to work. They're going to be able to lift weights. And we're just thrilled that, ooh, your elbow twitches. And so you have to really have a big conversation with people when you're doing a functional nerve reconstruction. And so then, again, clear communication, multimodal strategies, and multiple visits preoperatively. Balancing hope with realism is important. People only remember a third of what you tell them, so it's important to have it written down. A huge percentage of my population does not speak English, and so that adds to my fun. It's very gratifying, but I think about 25 to 30% of my patients are Spanish-speaking or Portuguese-speaking. And so Epic has a bunch of reasonable things in appropriate language already in. My NP stands there, and she uses Google Translate. So she types what I say in English, we translate it into Spanish, and we give it to the patient. It's not perfect, but at least it's something in a document to show that efforts were made to communicate appropriately with the patient. And remembering our surgical health literacy is horrible. Health literacy is about 12%. Surgical patients can be more if they have a higher degree of education. So overall, about two-thirds of people have adequate health literacy. I think that's still overestimating it. It's associated with poor compliance, older people, men, non-English speakers, lower socioeconomic status, and low education. And that is a huge portion of my patient population. The current patient-facing hand literature is way too complex, and comprehension is generally low. So in summary, nerve surgery can be done safely and effectively in the majority of patients. People who are unhappy will take up a disproportionate amount of your time, and optimizing your patient selection and thorough preoperative education are your best friends. Thank you. Thank you, Dr. Calhoun. Thank you. Either way, go back out, go back in again, hit the refresh button. Yeah, I'm interested if that works. Oh, there it is, there it is. You're smarter than me. Good afternoon, I'm sort of batting clean up here, and I was given the task of flexor tendons complaints, complications, and problems. I'm Harry Hoyen, I'm from Cleveland, Ohio, and I'm enjoying this wonderful late summer here in San Francisco. So areas of practice improvement, I looked at this, and it's the timing of flexor tendon intervention, tendon repair techniques, type of repair, pulling management, and the real issue is recurrent tear, gapping, and don't forget the associated injuries. I think we heard in the last talk how important the nerve is, and sometimes the outcome is often dependent upon the other injuries in addition to your flexor tendon. So in essence, it's really stiffness and recurrent rupture or gapping, and this was a recent meta-analysis done, a systematic review, and it reports 4% tendon rupture, adhesion formation only 4%, which I think is significantly underestimating our own practices, and acute reoperation defined within three months was 6%. So relatively low in this meta-analysis, and I thought back to my practices that maybe one in 20 patients have had a recurrent rupture, but certainly more than one in 20 patients have had adhesions, stiffness, loss of motion, and relatively high dash score. So when I was preparing this, I thought to myself, let's look at each stage of tendon healing from the inflammatory process in a couple of days to the proliferative process over days, and in this particular instance, how can we achieve a reasonable or good result as we have here in this stage one flexor tendon type of injury, and where can we intervene at each of these phases? How can we prevent some of these complications, and as they arise, what do we do? And we all see these patients where we've done a technically, hopefully, wonderful job of the flexor tendon, and they come in one day with a massive and significant amount of finger stiffness, and the rest of their hand is swollen, and it's more than one would expect. So what we're doing in the first 7 to 10 days is this infection prevention, identifying the comorbidities, which we've heard about, edema control, compressive wrap, elevation ice, et cetera, and then in those 3 to 14 days, identifying and allowing for intrinsic tendon healing, not extrinsic tendon healing, and this is where the rehabilitative protocols, as we'll see as we'll go through some of this a little bit later, are very important. And we want to convert the type 3 collagen it forms early into type 1 collagen, and every year I pay attention to the tendon symposium, what's new in pharmacology and some of these other things, because there's certain patients that respond great to soft tissue injury and surgery and those that don't respond so well. And then as remodeling occurs over the 10 to 14 days, we want isolated gliding between the FDS and the FTP, something that's very difficult, and then as the 2-month point goes out, we forget about the whole myotendonous unit, how cortical plasticity makes a difference in reeducation after a sensory nerve injury. You know, I find it interesting, I was looking through some of these things, and you know, the average DASH score on someone who has any sort of distal radius fracture is 15, let's say. The average DASH score on a repaired digital nerve or nerve injury of the digit was 50, 47 point something. So you know, an incredible amount of perceived disability of a finger injury. So timing of repair, earlier is better. As soon as the wound is, quote, settled, you know, maybe even sooner. I've changed my tune on flexor tendon injuries, and as soon as I can. The next day, the best, as long as there's not a wound problem, right? After a certain period of time, and I think it's earlier than the presumed three weeks, I think it occurs after five to seven days, some of these secondary changes, the creep occurs in an un-tensioned flexor tendon. You can see in this particular instance, this is one that was done very early, and the tendons at the A1 pulley, by the time the patient gets to us several days later, and you can see the creep that's occurred on the left-hand part, and how difficult it's going to be to get it to that zone two area between A2 and A4. Here's a more delayed presentation, let's see if this plays. Okay, so here's the, it was right here, and we freed it up a little bit, this is the FTP of ulgen from the distal phalanx, and here's the FDS, so it's come through the chiasm, and this is the pseudo-tendon, the body really tries to form it, right? Look at it, it actually pulls the finger into flexion, but it's obviously at a huge mechanical disadvantage, but the body's healing is amazing, isn't it? To try to form the tendon again. Alright, thanks. So you can imagine that that's going to overcome a significant amount of length, right? And what strategy do we have to do this? Well, we try to get it to the appropriate location, cycle it to remove some of this creep, and some of the things I've actually been doing is, and I look for a picture in this, in these instances, especially for the index FTP, is to take a page from our spasticity group, and do an isolated, mild tendonous recession up in the forearm, to gain a little bit of length, really only in the FPL and the index FTP, but that's helped. So here's even a little more delayed presentation, where the flexor tendon is down and had to be retrieved into the forearm. So you can imagine the avascular area that's occurred, and hence even more interesting is that there's no more lumbrical in this, right? So the balance between the flexor and the extensor, which we don't necessarily have in this talk, is just as important as the differential excursion of the FTP and the FDS. The lumbrical needs to have its mechanical disadvantage removed as the flexor tendon, the FTP, fires into flexion to give you that conjugate flexion of the DIP and the PIP. Tendon repair techniques, and we don't have necessarily enough time, and I listened to the Presidential International Lecture of Jim Boateng a couple years ago, and it's really, really good, but the idea was at least a 4-0, if not a 3-0 suture, minimum of four strands, looping locks are better, and we need nine newtons for passive range of motion and 36 newtons for active range of motion. What that is, is hard to know. How to measure that in a tensile way after a flexor tendon is a little more difficult, but some take-home messages is that the distance from the edge of the tendon to where your suture is should be at least seven millimeters on the throw, a locking loop at each one of the sides is important, and a minimum of four strands. That will give you hopefully enough to overcome what happens is the J-curve in tendon healing. It's a bit disheartening if you think about this. You have a tendon repair at time zero. This happens in economics, too. You invest in a stock, it goes down, then it goes back up, so there's a J-curve in economics for starting a new company, but there's also a J-curve in tendon healing. It starts here. It actually decreases. It's dependent completely on the suture, as you can see here, at one in three weeks. On all of these, two to six strands with epitendinous, it decreases, and then it goes back up. It reaches its time zero at about four weeks, and then rapidly improves after two months. You have to be significantly certain on your repair, and you also have to have a compliant patient that gets you the intrinsic gliding, but not too much. I actually explain this. I draw this out. A light bulb goes off. This is true for rotator cuff, all sorts of other things. It has to do probably with some signaling and mucoid degeneration of the actually suture within the tendon itself. Really, where we are here is in the gap. We want to prevent stretching. It's a three-millimeter gap. This dates back to 1999 studies, but it's been borne out. You can even see here, and he has a little bit of a J-curve, is that one to three millimeters of gap, no gap, and then three millimeters of gap. The ultimate force is significantly different. That gap that occurs at the three millimeters, hence why our practice has changed a little bit in a bunched repair and pulley elevation or division rather than other things. So this is from Jim Botang, evolution of flexor tendon. We thought that the pulleys didn't need to be violated. It turns out that the A4 can be completely divided. The A2 should be partially vented. The position, as you can see here, is 0.7 to 1 centimeters. This is from his hand clinic's article, 2017. It's nice because it's open source now. So if you're looking for some technique tips, I'll show you a couple other diagrams from his articles. It's a decade's worth of his basic science and clinical work. We want to achieve, and I tried to pull one, this is a bunched up flexor tendon near the end of the thumb in zone one. It turns out that this may actually be better than one that's just the opposite of nerve surgery, where you want the nerves to just kiss each other. So essentially, the tendon needs to be bunched up a little bit. And as it undergoes this stretching, it goes back into a relatively tubular structure. A couple of things on pulley biomechanics. And it's interesting, the degrees of flexion, this makes sense from a physics standpoint, depends upon the moment arm or the R from the joint in which you want to move, the PIP or the DIP joint, and then the amount of tendon excursion. So if you have bow stringing, not only does the moment arm increase, so the bottom of that fraction makes for less degrees of freedom, you need to have more tendon excursion. So it actually has to have pull more because it's in more of a straight line. So pulley venting's good, but bow stringing in the end is really deleterious. And from a common pitfall, I want to release enough but not necessarily too much. And when you get that, these repairs, and this is from his article, in B there, the location of the laceration is just at the edge of A2. You're more often venting a portion of A2. As you can see, as it goes in different areas, you can vent different parts of the pulley system. Most of the knife injuries end up between A3 and A4. Whereas before, I was very hesitant to release A4. I'm more often now releasing almost all of A4. Our therapists will use some ring splints, some wrapping of the skin. Let's face it, when you close a tight skin, you get the hemostatic pressure, the hydro portion of the fluid and everything else. I think it tends to keep things well encased. Hopefully we can get to this position here. In this instance, this was at the A1, A2 junction. This is one of my cases, and I decided to repair FDS and FTP at two different areas. To correct the chiasm, have a little bit of bunching, but not too much, but allowing it to have full flexion extension. This is where wide awake surgery, whether you do it at the end, if you have a sedation or a general anesthetic, to have that wake up at the end is very, very important. I had a patient come in a couple months ago that had a small finger FTP, FTS. He says, I want a perfect result. I said, well, let's temper your enthusiasm. But, I'm the one for you. He goes, but I don't want to do this wide awake. I'm like, okay, great. Can I send you to Ohio State? We're right down I-71. I said, okay, fine, you'll get some sedation, etc., etc. The nanny woke up, and we took a video, and the whole thing. He watched his video afterwards, and he ended up with a classic FTP lag to a certain extent, but was incredibly happy with this whole process of patient education. Everything else at the end. Even in those cases where it's not so wide awake at the end, we do a wake up and really test. It's amazing what you see at the end of every one of these to prevent some of these things. A couple of comments on variations in rehabilitation. This is from Amanda Higgins in Don the Lawn. We finished in, I think, you were part of one of our AO groups of doing flexor tendon rehabilitation. This is also open source. This is in PRS. It's a protocol we follow somewhat closely, but there's some good pearls in this. The first one is that the wrist can be placed in extension. If you actually think about it, if you place your wrist in flexion, there's actually more work for the flexor tendons than if you use the natural tenodesis of your wrist. If you place your wrist in a little extension, actually the finger flexors come down much easier, and you can do it for yourself. The MP joints are placed in 30 degrees of flexion. This is where I vary a little bit. I'm a little leery about the IP joints in full extension. This protocol stresses a fair amount of PIP extension early on. I'm not so crazy about full PIP extension, splinting at night, but this protocol does. Then from four days to two weeks, and you've heard Don say this, you can move it, but you can't use it. Good luck, right? But edema control, and there's a warm-up period for the flexor tendons where the patients do a lot of passive flexion. It's not necessarily the place and hold, but it is passive flexion. Then they do the half fist. I do this a lot. I have them go to each finger in a half way. It's good for cortical reorganization. It's good for them to see their hand, and I have them do it on both sides. Then they go to half fist, and that's for the first two to four weeks to get things moving. That's true active flexion, only one-third to one-half. It's very little of the place and hold, although some of our therapists like to do this. Now at two weeks, the splint is transitioned to this. They call it the Manchester splint. It's essentially a smaller splint that allows the wrist to be a little more free. This is synergistic exercise program. In other words, you're taking advantage of the tenodesis, and you go from full to half fist. This is as the tendon's getting stronger, part of the J-curve. We hit the nadir at two weeks, and it's coming back up on the two to four weeks. Some of this sort of makes sense. Finally, two cases here to do. What do you do about bow stringing? Pull the reconstruction of different types. I prefer this, and I didn't have a good picture. Steve Glickel gave me one of these. It's multiple loops, three or four, and it's typically the A2. They just get too much across there, and they get that webbing. It is also associated with a PIP contracture. This is what it looks like at the end. Then in all major other things, and I would be remiss not to mention it, the stage tendon reconstruction, but to show that this is now a major surgery to undergo the stage flexor tendon reconstruction. Kevin sent me this one because it was an active rod, and someone he never wanted to operate on again. I haven't had such good success with the active rod rather than the passive rod, but it's a big operation to restore a single flexor tendon type of finger. I left alone postoperative stiffness. When to do a PIP capsulectomy or tenolysis. I think those are very individualized. I've yet to sort those out. I think ultrasound is helping us identify if there is adhesions within the flexor sheet that we can perform a tenolysis versus an intrinsic joint contracture. I thought that was for another talk, but that often sometimes comes up in the questions. Okay. Thank you very much. Thanks, Dr. Hawaiian. If you could stay up here, we could have the panelists come up. I think we have about five minutes for questions before we conclude. Do we have any questions from the audience for any of the panelists regarding any of the topics? I actually have a question for you and the flexor tendon. Do you ever offer people a DIT fusion and do people ever take you up on that just to give them some better prediction? In a case that was not repairable or zone one? Your repair didn't work. You did it. Yeah. The answer is probably not. If they're not going to go through, let's say they've had a re-rupture and etc., etc., a stiff ankylose joint with a long-term split probably gives you enough stiffness of the DIP joint for reverse effusion. Probably different for the thumb, okay? But for the other digits, I haven't had a huge need unless there's pain, deformity. And the one that you can't control is the hyperextension that occurs at the DIP joint. So if they get a lot of hyperextension at the DIP joint, then you get a secondary boutonniere reflection of the PIP. So those are ones that I might offer fusion to, but I think pretty rare. I do a palpation, so pain right over the median nerve at the pronator, that was discussed earlier today. Don Milan, I think, talked about it in his. Sometimes resisted pain with active pronation. Weakness of the FPL and FTP index. Scratch collapse test, and so it's not just one thing, but it's a series of things. Do they have altered sensation, you know, more in the palm and not just the fingertips? And then if I am, you know, hesitant or if it doesn't seem completely right, then I will do a diagnostic block, not a steroid injection, just local anesthetic, and I ask them to call in the next day. And I do that with most of the times when I'm considering doing a more proximal nerve release, because if you look in the literature, that's not really, you know, it's not as common as, you know, commonly reported. And so that's my bit of CYA, because the electrodiagnostics won't show it. So that gives me, like, five data points to say, yes, you responded to the block, you have the history, you responded to provocative maneuvers. No, because everybody with the achy arm gets the complete exam from the neck down. If they have any neck pain, they go to therapy for six weeks. I don't touch them. And the majority of them will come back and say, well, I do feel better, but I still have x. And so then if they have positive provocative maneuvers at both sites, they get the procedure at the same time. I've tried to do a few of the pronator under local, but I also do a deeper evaluation as well. I don't just cut laserdus. I look at the median nerve. I stick my finger up and feel struthers. And for the bigger patient, they don't tolerate that under local as much. And if I'm going prox or distally for the proximal arch of FDS, then they're not gonna tolerate that very much under local potentially. So I do those in the operating room. I do isolated carpal tunnel in clinic. So it's a question of what's the four- to six-week Jersey finger. The four-week and the six-week can be very different. But it depends on where the tendon is. So occasionally, if there's a small piece of bone, it doesn't go past the PIP joint, it stays distal to the PIP joint. So those can be treated. I've even done some, it's like eight to 10 weeks. I've been pleasantly surprised. You have to use imaging of some sorts. If there's a small piece, sometimes there's x-ray. Later it gets a little more difficult. I've tried to do this recession to a certain extent to gain the tendon length if it's proximal to the PIP joint. If it's in the palm, then it becomes a little more difficult. Jesse, you want to make a comment? Sometimes when treating an adolescent with that teenager, it's worth going back. But the caveat is you have to have the family accept the fact that if they start developing a PIP flexion contracture, then you have to take the tendon out. It's just not, you're going to make the finger worse by your operation. So it can be done. You have to follow the patients very carefully, those groups of patients. But watch out for the PIP flexion contracture. The difficult ones are the adolescents in the sport. It's their football season, and they have this injury. And it's either then or forget about it. It's a stage reconstruction, because sometimes they don't even come in until a little bit later. But sometimes you get lucky where it's located. And I'll offer an exploration a fair amount of time. It's interesting to say I've had a couple of ones who are 13 or 14, and as they've grown, they've developed a PIP contracture as they get a little bit bigger. I don't necessarily quite understand that. But that can occur. I give it a try. How do you pass the engineer to try it? Yeah, it's interesting. I don't do any, I try not to put a suture in it. Because once you put a suture in it, it begins to get a little bulbous. Dilate the pulley as much as possible. You have to leave part of the A2 pulley for sure. But it gets through A2 OK. A4 is a little bit trickier. So often in those delayed cases, A4 will be divided. And what that means is that they're going to get very little independent DIP motion. They're going to get more power, and they're going to have good PIP motion. But they're going to get less DIP motion. And that's, I think, even borne out in any stage zone one injury. And I try to push it through from proximal to distal to keep feeding it rather than pulling it. Once you try to take something that's bigger and try to make it smaller, I can't get a Chinese finger trap or anything around that. So I try to very gently. Nobody touch it. Nobody touch it, Tony. Cannot touch it. And I use the micro pickups to hold the proximal part of the tenon and try to just feed it in as best as possible. But I feel better with some relative literature of releasing the pulley. And we have some folks here that have been practicing 25 years. It was heresy to release the pulley. Not allowed before. And given the fact that there's newer literature, it gives you some credence in taking care of these more difficult situations. Well, I want to thank the panel, master panel, for such a great talks. And thank you all for coming. And I'll let you head out to dinner. Yeah, great. Thanks. Thanks. Nice to meet you. Thank you very much. Nice to meet you. Good job.

Peripheral nerve surgery

Hand conditions

Wrist conditions

Success rates

Complications

Improvement of symptoms

Patient selection

Accurate diagnosis

Thorough evaluation

Flexor tendon injuries

Pronator syndrome

Nerve surgery