We have a minute, I still have a minute. Good afternoon, thank you all for coming, lots of friends in the audience from several different countries, which is very exciting for you all to be here. And I'm going to do the introduction and use up a few more minutes while people arrive from other parts of the Heinz Auditorium, and that'll let my colleagues on the program have a chance to speak to an even wider audience. So under the conflicts of interest, I want to show you this book called Pain Solutions. The topic of our talk today is on joint denervation, and from edellin.com you can download this book free or any of the chapters are free. It's also available on Amazon.com, and it came out in 2013 as its third edition, and it has many other chapters related to things that hand surgeons do. Now in 2019, this book was published, Joint Denervation. It's now out in Chinese for those of you who can read Mandarin, and you can get it on Amazon.com or on Springer. And besides the joints that we're going to talk about today, this has lower extremity joints, so you can learn about denervating the knee, the ankle, and the foot, and even the hip. So I'd recommend this to you, even though that's a conflict of interest for me to say because there's very little available, actually, in any comprehensive way on the innervation of the human joints. And so this has collected all the joints into one place for you to read. Our faculty today includes Nick Rose who's here with his son Colin. Nick has been past president of the Southern California Hand Surgery Society and he did his hand fellowship with David Green. He'll be speaking about as you can see the lateral humeral epicondyle. Andreas Goretz will speak next. He's an associate professor now at Basel in Switzerland and besides working on joints he's an expert in tetraplegia and transfers for that type of hand deformity. And finally Sammy Tufaha will speak. He is about to become an associate professor of plastic surgery in our group at Johns Hopkins. He did his hand fellowship at the Mayo Clinic and he's going to be talking about the wrist and primarily the CMC joint. I heard there was a very good workshop this morning on how a young person with pain in their CMC joint should be approached with various degrees of tendon work, joint work including fusions and apparently denervation of the CMC joint one. So I'm very gratified about that. What is partial joint denervation? This implies that pain originates from an injured joint sensory nerve and I know that when you go through orthopedic surgery you think joint pain only comes from tendons, ligaments, cartilage, bone and joints usually not discussed. But today's all about pain which if you can perceive it it must come from a nerve and our task is to find those nerves. They must exist. We can identify them with loops and if that's true then they can be resected safely. Those are the surgical approaches we're going to talk about today. Partial joint denervation implies that pain can be stopped and we can preserve joint function. Now many of you will probably use joint denervation as a bailout for people in whom you've replaced joints and they still have some pain. But in time you may decide that you wish to do joint denervation as the first approach not the bailout approach because doing a joint denervation leaves open the fact that you can go back and do any other work on that joint afterwards that you would like if in fact the pain recurs. So the first joint denervation was really reported for the hip joint and once Charlie in the UK came out with a great approach to a hip joint replacement, denervating hip joints came out of favor. But it still could be done if necessary and there's a chapter on that in the book. Historically total joint denervation was done and this was primarily in Europe. Nicholas Rudinger about whom Andreas and I have written a historical paper actually was the first to identify the nerves in human joints. But he did it in a PhD thesis and it was hidden in the library in Munich and really not known. When I started Wilhelm had popularized this approach to total joint denervation in Germany but his papers were in German and therefore unknownst to those of us not reading German. And so Wilhelm began popularizing that to make a wrist painless you needed to remove all these different nerves and their branches and you had to have multiple incisions. And when I was finishing my hand fellowship Dieter Buck-Gramko published in the Journal of Hand Surgery this comprehensive paper on more than 300 patients who've had total wrist denervations in the German speaking population. They didn't get such great results and of interest to me was the failures were patients who had instability patterns in the wrist joint. So we never denervate an unstable joint. The joints have to be stable because pain is protective, right? So we need to have a stable joint. So that's a contraindication to a joint denervation. And if you carefully analyze Buck-Gramko's results, most of his patients in fact didn't have all the nerves removed and 20% of the patients had complete relief regardless of how many nerves he removed. And I began the concept of partial joint denervation when I was a resident still in plastic surgery at Johns Hopkins helping an orthopedic resident remove what I thought was a recurrent wrist ganglion and it turned out to be a nerve. And this sent me to the anatomy lab which is where we find what truth is for surgeons. And I found this mass was actually an aroma and that led us to understand the innervation through the radial side of the fourth extensor compartment of the posterior interosseous nerve. And in 1985 we just denervated the dorsal wrist. And when Susan McKinnon was our hand fellow in 81 and 82, we identified the anterior interosseous nerve and that was the beginning of partial joint denervation. Later you'll hear Sammy talk a little bit more about the wrist joint but I just wanted to introduce that as the concept of a partial joint denervation. I want to talk a little bit about shoulder denervation and I think as most of you know patients who have acromioplasty or rotator cuff repair, about 20% of them still have persistent shoulder pain. When Oscar Osmond was with us for about three years, the first research he did was work on the innervation of the human shoulder joint. And the most common pain in the shoulder that people have is anterior and Oscar found this to be due to a branch of the lateral pectoral nerve which crosses this bone and we can identify it in that location. So we won't talk about inferior shoulder pain which is quite rare and posterior shoulder pain. So I want you to look on the wall behind this man's left arm and see the switch for the temperature and if you press right down on the coracoid, that's where the pain will be and they'll say ouch. You can see his incision from previous open shoulder surgery. To do the nerve block, the patient lies down and the needle goes down and hits the coracoid. You know there are lots of major vessels and nerves on the deep side so you just hit the coracoid and that's it. Nerve blocks throughout these talks are critical. The positive predictive value of relief of pain with a nerve block is probably more than 90%. If a patient doesn't get better after the nerve block, there's another nerve involved and that will become very clear when we get down to the wrist. So you see the difference, there it is before and after the block and he's had everything orthopedic surgery could do for his shoulder. It's stable but he wouldn't lift his shoulder and after the block he could. There's the previous open incision. We make a little v-shaped incision, you retract the pectoralis, identify the small nerve, resect the nerve and let it lie under the pectoralis muscle. How many operations have you had on your rotator cuff? Three on the right shoulder. How long has your shoulder been bothering you? Five and a half years. These are where your incisions are. Are you able to lift your arm up over your head yet? No. How far can it go? Right there. How long has it been since your surgery? 24 hours. You had trouble lifting your hand over your head before surgery, didn't you? I sure did. I couldn't get it more than half way up. Okay, let's see how it works now. Okay, put it back down. Now lift it up straight in front of you too. Do you have any more of that shoulder pain you had before? None at all. Are you happy? I am tickled to death. It's been five and a half years. Thank you. I'm criticized sometimes for showing immediate post-operative results and so I'll show you at the end a long-term result. I don't get many shoulder pain patients and I have not updated patients since the year 2004 but at that time there were 12 patients. This is the mechanisms of their injury, interval from injury to the surgery time. You'll notice the improvement in the post-op range of motion and the follow-up time for these patients. The pain level drops and we get a good number of good to excellent results. I know this looks like a picture of some man standing with someone with a gun behind his head but again it shows you the ability to raise both shoulders. You injured your shoulder at work, is that right? Yes. That was maybe seven or eight years ago. Yes. Did you have operations on your rotator cuff? Yes. After the orthopedic surgery, could you lift your arm up? No. Did you still have pain? Yes. Where did your shoulder hurt? Show us with your hand. Right around there. It's about five or six years since I operated on your shoulder. About seven. I took out the painful nerve, right? Right. Let's see, can you lift your arm up over your head now? Yes. That's great. Put it back down. Let's see, lift it up again. Put it back down. Are you going to start work as a longshoreman? Yes. Are you happy? Yes. The final thing I'd like to show you is working our way distally. This isn't really elbow joint pain. It's pain from the medial humeral epicondyle and Nick will talk about the lateral humeral epicondyle. But similar to the story that you'll hear from Nick, people that have pain medially are thought to have either a Tommy John lesion or an older nerve compression problem. But in the absence of those, we have to figure out which nerve might innervate the medial humeral epicondyle and have tears when those muscles originating at that site have been injured from overuse and golf or baseball or from whatever. And when Ramon De Jesus was with us and during Yvonne Ducek's Peripheral Nerve Fellowship, we started to look at a nerve. And the way I learned that this nerve was there, doing an anterior transposition of the ulnar nerve, I think most of you do, remove the medial intermuscular septum. I sent 20 of those in a row to pathology because with loops, it seemed to me that there was a little nerve fascicle in the medial intermuscular septum. And there shouldn't be a nerve in the medial intermuscular septum. 15 of the 20 came back positive for a nerve. And the remaining five, when they used a special nerve stain, they came back and identified that there was a nerve. So there was a nerve. And where did it come from? And it actually came from the brachial plexus and followed down along the medial intermuscular septum. So here's a young guy who's a high school pitcher. And when he tries to pitch, he has pain right there. Right there. And he doesn't have a Tommy John's lesion and his ulnar nerve is good. So how do we find this nerve? And the medial epicondyle, you can see is labeled there. And there's a little tiny nerve coming down along. We've removed the medial intermuscular septum. And there's another example of this little nerve in a cadaver. And it will spread out to innervate the medial humeral epicondyle. And so in this young fellow, and this is a case where a nerve block is a little dangerous to do because the patient will lose ulnar nerve function and become terrified that that's what will happen if you operate on them. So this is a case where the physical examination is very important and we don't really block next to the ulnar nerve. And the outline where you think the intermuscular septum is where the medial humeral epicondyle is. In its surgery, we remove the medial intermuscular septum. That's it sitting there. And you can find the nerve to the medial humeral epicondyle hidden usually just underneath the intermuscular septum. And you can resect it and put the proximal end into the medial head of the triceps. That's what the clamp is doing there. And then he went back three weeks, eight weeks after surgery. And he's a little hesitant to start throwing. And you'll see as he warms up, he'll start to throw harder and harder. So I think most of the people who are coming to this session are here already. And so we'll end the talk and move on to the lateral humeral epicondyle. And then just as Nick gets to come up here, this lady had ulnar-sided wrist pain. The book downstairs, the American Society for Surgery of the Hand book on ulnar-sided wrist pain has nothing about nerves. It's really a horrible thing. She had a torn triangular fibrocartilage complex and was seen by many people who wanted to do invasive destructive procedures for her. We had to block the posterior interosseous nerve, the anterior interosseous nerve, and branches from the dorsal cutaneous branch of the ulnar nerve. And then she was able to use her wrist like that. So if we have time at the end during questions and answers, we can talk more about the ulnar-sided wrist pain. So thank you very much. And we're going to move to Nick. I think all you have to do, Nick, is click on this thing right there. Perfect. So I'm going to talk about tennis elbow and partial lateral denervation, and a little bit, a few pre-taught questions, lateral epicondylitis, angiofibroblastic degeneration of which tendon origin, innervation of the lateral humeral condyle is through which of the following nerves, and you'll be able to answer this at the end of this talk. And then finally, our study showed that the success rate of partial lateral denervation for lateral epicondylitis is, and that'll be revealed too. So lateral epicondylitis, very controversial topic. There's some who believe, some studies have shown that 80 to 90% of these patients at a year will be pain-free. We used to, a lot of us used to do cortisone shots for these patients. Probably fewer of us do that. Other modalities have come into play, PRP and whatnot. But as we all know, it's an overuse injury of the extensor muscles that originate on the lateral humeral epicondyle region. And it's a, typically a problem involving the ECRB origin. You see microscopic tearing. It's really an angiofibroblastic degeneration of this structure. Sometimes you'll get those patients with a really kind of more of a larger tear off the humeral epicondyle. And it's really sometimes difficult to differentiate some of these patients from those who have radial tunnel syndrome. So for those traditionally who have failed non-operative treatment, the options are percutaneous release, arthroscopic release, or probably the most traditional, the nursial open release or lengthening, which was originally described by nursial that basically is a debridement of the common extensor origin. And some people with the bigger tears will also get a reattachment of this. So as Lee talked about, it's very logical. If you have pain anywhere in your body, how do you perceive that pain? Well, it's a nerve structure that goes from the peripheral joint or whatever from that common extensor origin to your brain. So because we know the common extensor origin isn't per se a critical structure, denervation is optimal for this because you're interrupting those pain signals. So as Lee talked about, Gardner described the elbow joint innervation in 1947. And it's really Wilhelm who first talked about this in 1996, finding that about a 90% success with denervation blindly performed by disinsertion of those certain muscles. So Lee, years ago, looked at six fresh frozen cadaver dissections, and he consistently found that there's a posterior branch of the posterior cutaneous nerve of the forearm that innervates the lateral humeral epicondyle. And really, if you do enough of these, it's sometimes one branch. It sometimes can be two or three branches. With these peripheral nerves, there's just a lot of anatomic variation, and you have to be prepared for that. So this is just a schematic drawing showing that. So the posterior cutaneous nerve of the forearm runs down the dorsal aspect of the forearm, and then these one or two branches come off posteriorly to the lateral humeral epicondyle. And then, now this slide, I always tell people this is not the denervation incision. It's much smaller than this, but this is a dissection that shows in the vascular loop the posterior branch of the posterior cutaneous nerve of the forearm. And this is, you know, perhaps the classic example where you just have one of those branches. So in 2013, we published this in the Journal of Hand Surgery, and our hypothesis was that a partial lateral denervation is an acceptable surgical option in patients with lateral epicondylitis. Our inclusion criteria for that study were ages 18 to 75, symptoms for at least three months, most typically six months or more, failed non-operative treatment, no lateral epicondylitis surgery, or no prior surgery. Now, that's, of course, for this study. Obviously, patients who have had a failed tennis elbow surgery would potentially benefit from a denervation. And then we, for this study, in every patient, did a diagnostic injection with lidocaine and marcaine. And then how we evaluate these patients is we did a subjective pain level, the visual analog scale. We tested grip strength and flexion and extension. As many of you know, when you have people gripped at JMR and full extension, that's a very, very good indicator of tennis elbow. That really drops down in patients with tennis elbow. And then we did PSSD testing and paired T testing to look at our results. We graded our results as excellent if their pain level was a 0 to 1, good if it improved by 4 or greater to a level of 2 to 4, fair if you had improvement but it's still a decently high level, and then failure for anything 5 to 10 without a significant improvement on that VAS scale. We had 29 patients, 29 elbows and 29 patients, average age of about 47. Typical cortisone shots were about 2 per patient. Symptom duration from 3 months to 20 years. I don't know what's going on with that 20-year patient, but that's, you know, certainly somebody who didn't resolve after a year. And then, you know, our inclusion criteria included 50 to 100% improvement with a diagnostic injection. So we basically inject these people, we have them gripped at JMR, we have them go home and do all the things that typically irritate that elbow and report back to us. So the surgical technique, and I do have a video at the end of this because people over the years have asked, are intimidated by this structure, so this surgery. So there is a, it might be a little lengthy for this, but we do have a video on that. But you identify the posterior branches of the nerve, nerve injection with a marcaine and then nerve transection, and you bury it in the triceps. So here's our typical incision. It's two finger breads proximal to the lateral epicondyle, and you have to be very careful because, you know, you really, once you're through the skin, you dissect through that fat to find that nerve. This happens to be a patient with the classic one branch. Once you identify that, you inject it distally, you transect it, sorry, that one's a little out of focus there, and then you bury that finally in the triceps. So you know, the advantage of this or the classic procedure, the immediate range of motion, there's no bracing. We let people go back to tennis or golf at four weeks versus the traditional procedure where you're waiting three to six months and an immediate return to ADL. So our results in that initial study was 25 out of 29 were good to excellent. We did have three failures, and the VASC score improved from 7.86 to 1.91. Strength, particularly extension, which is that very telling thing for tennis elbow improved from 26 to 53, so really doubling. And we had some mild dysthesias or numbness in the dorsal proximal aspect of the form in five of the patients. Really wasn't bothersome to them because it's not a critical area. Interestingly, three of these, the three failures, two of the three improved with a PIND compression, so these were probably unrecognized radial tunnel patients. And one of the three improved with a subsequent PRP injection. So our conclusion was that denervation of the lateral humeral epicondyle by resection of the posterior branches of the posterior cutaneous end of the form is effective in relieving pain and restoring function in 86% of patients. Interestingly, there was a study that came out by Kroslak et al. in 2018 American Journal of Sports Medicine. What they did in this study is they made, it was a placebo surgery where they made an incision and they just cleared off the fat down to the muscle, but they didn't do anything to the tendon and they stated that placebo surgery worked for tennis elbow. What we recognize is this, what they did is a denervation procedure. This wasn't a placebo surgery. They've cleared off, by clearing off the fat, they did a denervation. So we wrote a rebuttal letter to that that was published showing that that placebo surgery wasn't really a placebo surgery, it was actually a denervation procedure. So in your handouts, we have some additional, that's that original study and also the original study in 2013 Journal of Hand Surgery. Of course, it's the ECRB that's degenerated as we talked about. The nerve is the posterior cutaneous nerve of the forearm branches off of that. And then finally, as we talked about, an 86% success rate. So do we have time to watch that surgical video or should we move on? How long does it take? What's that? How long does it take? Well, you know what, it's a six minute video, but the critical part is the first part. So we can, I can just show part of that, if I know how to do that, is the, I don't know where our video guy is. We can wait until he comes back and show it at the end. Perfect. What about the counterforce brace and the radial nerve entrapment? Well, you know, one of the treatments for this is the counterforce brace, as you know, and that, you know, can cause radial nerve entrapment. So, you know, that's something to be cautious of. I've found in patients who, in whom that brace aggravates their symptoms, that's going to be somebody potentially, you're looking for a radial nerve compression. I also went to the ultrasound course here yesterday morning, which was interesting. And they showed how to demonstrate a radial neuropathy, where you could see swelling of that nerve by following that radial nerve through the radial tunnel. So a couple, you know, a couple of tools and hints we have for that radial tunnel condition. So. Okay. We'll wait until he comes back. Perfect. See you then. Thanks everyone. All right, so Dr. Dellon asked me to cover the wrist generally, and then I'm going to spend a little bit more time focusing on the thumb CMC joint, because that's an area of more recent interest, and I think probably less of you are kind of comfortable with the thumb CMC denervation, but I'll first quickly talk about the wrist denervations more generally. So, you know, this is the standard treatment algorithm for painful wrist arthritis, very boiled down, but, you know, you always try to start with conservative measures, and then, you know, when you think about what the surgical approaches are, you're not trying to restore normal anatomy, you're not trying to actually reverse the actual issue at hand. A lot of times the actual surgical treatments are fairly destructive, and they can have significant morbidity, and, you know, prolonged immobilization, and, you know, high risk of failure for a number of reasons. So you know, I think it's important to take a step back and ask ourselves, why do these patients hurt? We're trying to treat pain primarily, we're usually not trying to make substantial improvements in range of motion or function, we're really focusing on pain. And we know that there are a high density of pain receptors, free nerve endings, in the capsule and the articular surfaces of the joints. And those pain signals are transmitted through the articular branches of the peripheral nervous system. And there is no Bluetooth route for these pain signals. So, based on this understanding, that's where the concept of de-nervation comes from, which is to say that if we can successfully interrupt that transmission of pain signals by disconnecting the offending nerve branches, then this could give us a very precise, thoughtful, and less invasive, less morbid way to treat the problem at hand. So, the first total risk de-nervation was performed by Dr. Wilhelm in 1966. And you can see that this was a very involved procedure. And it involved cutting multiple nerve branches, going to the wrist. And this approach is still used somewhat sparingly. And I think it's more popular in Europe right now than it is in the United States, from what I understand. But this approach has been largely replaced by partial risk de-nervation, which I'll cover in a minute here. This was Buck Gramco, who reported a large case series of his patients in addition to Wilhelm's patients. And he performed complete risk de-nervation for a number of different indications. He had an average of four-year follow-up. And you can see the results were okay. They weren't great, but a number of patients did well, or very well. And probably most of you are employing partial risk de-nervations in your practice, if at all. And this, Dr. Dellen takes credit for introducing this approach. And he described doing the AIN and the PIN. He also described doing the AIN and the PIN together. And then Dr. Berger, who recently passed away, further refined the technique and helped also popularize it through a single incision approach. And this is the approach that I think most people are using today. So you can see here, there's a dorsal wrist incision. You go down through the fourth compartment. You can see the PIN at the base of the fourth compartment. You divide it, resect a small portion of it to prevent spontaneous regeneration across the defect you create. And then you can go through the interosseous membrane, find the inter-interosseous nerve, and disconnect that nerve. I think diagnostic nerve blocks are helpful to see which patients are gonna do well and which aren't. And it's very easy to do for this particular surgery, because you can easily localize both of these nerves through a single poke hole. And so here are some more recently described results with the AIN-PIN neurectomies. And you can see this paper by Weinstein and Berger in 2002. Had 20 patients, 31-month follow-up, which is pretty reasonable. 80% with decreased pain, 45% with improved grip strength, 75% returned to work, and 90% were satisfied. And importantly, some of these patients will not do well. Some of these patients will recur. But I think you can frame this surgery at the very least buying time, perhaps getting these patients out of their younger, higher demand age, and then perhaps having to escalate in the future if needed. And Hoffmeister in 2006 reported on 50 patients with 28-month follow-up. And his results were a little bit less impressive, but still had a number of patients who did well. 85% were satisfied, 16 patients failed and went on to further surgeries. Something that's been being reported on more recently, particularly by Dr. Haggart and also Dr. Ladd is this concern about loss of proprioception with denervation. They've shown, in addition to other groups, that there are a number of mechanoreceptors in the joints, which isn't surprising. But when you actually take a step back and think about it, it's hard to understand how this could actually be a clinically important issue, especially when you think about the fact that you're considering other surgical options when you're considering denervation. And these other surgical approaches are things like fusion, joint replacement. And so I think in that context, I think this concern about loss of proprioception with a partial denervation seems less concerning. And also, as Dr. Dallin likes to point out, a lot of the proprioception in your joint actually comes from your overlying skin. And so these patients actually have been shown to not have loss in proprioception clinically. So it's more of an academic question that I don't think has much clinical significance. So now I'm gonna move on to thumb CMC arthritis and a newer approach that I think is gaining momentum now. And I'll start with a couple cases. So this is a 46-year-old female ICU nurse. So fairly young, very high demand on her hands. And she has a very painful symptomatic arthritis in her CMC joint. She also has STD arthritis. She's failed conservative measures. And so I think our standard surgical algorithms are not really adequate for this type of patient. And here's another patient who actually failed surgical treatment with a hemitrapeziectomy, then had a revision LRTI, failed that, she still has severe pain. And we know that when, these primary surgeries involving trapeziectomy are usually successful in treating pain. 85-plus percent of patients do well. But when they don't work, the revision surgeries are more challenging and less likely to succeed. So again, going back to the cause of the pain, just like all the joints in our bodies, we know that there's many free nerve endings that you can find within the joint capsule and the articular surfaces. And so the concept of de-nervation does make sense for this joint also. De-nervation of the thumb CMC joint was described initially in 1998 by Foucher and Laurier. This was in the French literature. It didn't really get much attention until more recently. A few years ago, I wrote up the case series of Scott Lifshay when I was still a resident at Hopkins. And we also included a cadaveric study that was performed by Dr. Dallin and some fellows at the Curtis Hand Center. So we looked at the nerves supplying articular innervation to the CMC joint. And in 10 out of 10 specimens, the LABC sent articular branches to the joint. Seven out of 10 specimens had the palmar cutaneous branch of the median nerve innervating the joint. And the radial sensory nerve innervated the joint in four out of 10 specimens. Importantly, I don't think it really matters much clinically which nerves are innervating the joint. You just have to know where to find the distal articular branches. And you're gonna find some variations. Different studies have shown slightly different innervation patterns. But as long as you know how to access the terminal branches and find those, it doesn't really matter where they're coming from. Here's an interesting picture showing a branch coming directly off the median nerve into the joint. And again, through the surgical approach that we're using, you would find this regardless of whether it carries a normal innervation pattern. So here's the approach that we're using. It's Scott Lifshay started using this approach with a single Wagner incision. And first, you elevate a dorsal skin flap. You raise up the radial sensory nerve with your skin flap. And you'll find two to three crossing branches across your dissection plane going right into the joint capsule. And you can just divide these branches. Then you move into the snuff box. Usually underneath the first dorsal compartment tendons, you'll find the termination of the lateral enterobrachial cutaneous nerve. And then you come along more proximally and ulnarly towards the proximal origin of the thenar muscles. You can sweep these off the capsule. You'll usually find a branch there as well. What I like to do is actually take a bipolar cautery and just gently cauterize the joint capsule to make sure that nothing's sneaking by. And I think it can also give you a little bit of thermal shrinkage, particularly with the volar capsule, which may help with some of the instability. And so here's the first case series that we published a few years ago. And this is a small case series, 13 patients, 16-month follow-up. And in this series, 12 of the 13 patients did very well, had complete or near-complete resolution of pain. One patient went on to an LRTI at 17 months. One of the patients in this study period came back to have her other side done. There was a modest improvement in grip strength, lateral key pinch strength. The only real complication, which is fairly minor, is that most patients will note some patchy numbness, peri-incisional numbness. And it usually gets better with time. It's usually not a concern. And unless you ask the patient about it, most of them won't even mention it. There was one patient who Dr. Lifshay thought had a radial sensory nerve neuroma. He gave the patient a single steroid injection, and these symptoms went away. It's hard to know if this was a neuroma or not. What I would say is, when you're doing the radial sensory nerve denervation, just make sure you follow those branches and make sure that they are not traveling beyond your incision, and just make sure that they're actually terminating in the joint capsule before you cut them. And then if you do that, then this is completely safe. And more recently, Scott put together a prospective comparative study with 50 patients. It's pseudo-randomized in that some of the patients, or some of the surgeons in our practice prefer LRTIs. Some of us prefer denervations. And so depending on who the patient presented to, they were likely to get one procedure versus the other. So not truly randomized, but a randomization of sorts. Two-year follow-up for this study. And this is actually taken from an abstract that was presented at this meeting. And you can see that there were no statistically significant differences in pain between the LRTI patients and the CMC denervation patients. Three of the patients with denervation did go on to have an LRTI. And I do think that there are, in general, that there's a higher recurrence rate that happens sooner with denervations than with the trapeziectomy procedures. So I think the conservative way to present this to patients is to say that you may have long-term benefit, but at the very least, I hope to buy you some years before we have to do something larger, like a trapeziectomy LRTI. So I think if you frame it that way, then you're setting expectations appropriately until we have further data. And you can see now there's, I think there's growing interest and excitement about doing these procedures for the thumb CMC. The main benefit, the most obvious benefit, is the post-op course for these patients. They get a soft dressing for one to two weeks. Sutures are out at the first appointment. You know, they resume normal activity very quickly. And if you compare this to an LRTI, a trapeziectomy, it's, you know, those patients are usually immobilized for many weeks and then have a very difficult recovery course before they start to get better. One question for this is whether you should do a preoperative block. For this particular denervation procedure, I don't think it's important to actually block the nerves proximally. I think you can just infiltrate some lidocaine subcutaneously around the joint and just rule out, you know, some sort of centralized pain. But otherwise, I don't think it's important to actually find all these three nerves and block them. And, you know, that's kind of difficult to do. The patients don't like it, and I don't think it actually serves any meaningful purpose. And something interesting to point out is this problem of STT arthritis. Usually, you know, our standard approach is to do a hemireception to treat this, but we know that this can actually exacerbate carpal instability patterns that exist with STT and CMC arthritis. And so, you know, perhaps denervation procedures are a better approach, particularly for, when STT arthritis is present, to avoid exacerbating this carpal instability. So in conclusion, you know, I think when you're thinking about which are the ideal patients to first try these procedures on, it would be a young, high-demand patient that you hesitate to do an LRTI on, certainly a patient that failed your standard approach. And as you get comfortable with it, I think your indications are gonna start to expand. And at Hopkins, you know, a lot of us are now using this as our first-line option and offering it to most patients. Unless they have deformity, you know, hyperextension of their MP joint, obviously a denervation's not gonna help that. But for most other patients, I think it's a good first-line approach. All right. Thanks. Keyondreas? That was good, Sammy. It was great. How can I come to my presentation, please? I think now everything is closed down, isn't it? Do you wanna see what he's doing? Can you look at the computer with him? I think you closed down the whole thing. And then close that up. Okay. Okay, cool. Thank you. Thank you very much for the invitation to conclude this session with a presentation on a denervation of the MCP and the PIP joint. I have no disclosures. One might think that coming from bigger joints, it's getting even more complicated because the nerves of the fingers are even smaller than in the wrist. But please relax. These procedures are not difficult and beautiful to perform. And I would like to present you with the indications, the surgical techniques, and the outcomes of these procedures. So the indications for the small hand joints are you have severe discomfort or pain, but the joint still works and you want to preserve its movability and you have no instability, so you can use it as an alternative to more invasive procedures. Contraindications include completely destroyed cartilage, stiffness or instability or infection, obviously. You start with a clinical examination. Of course, you get an X-ray. And then you can do a local anesthetic block. And if the pain is reduced significantly, then you can try to do such a denervation procedure. So the innovation pattern of the MCP, the PIP, and also the DIP is similar. Usually the branches from the dorsal and the palmar digital nerves. And the specialty of the MCP is that it has an additional articular branch from the deep branch of the ulnar nerve in the fingers, but not in the thumb. So you do normally a dorsal and a palmar incision. You start from the dorsal aspect and you simply do an incision over the dorsal aspect of the joint and you transect and electrocoagulate the dorsal digital nerve branchlets. Very easy, takes about two minutes. Then the palmar approach is a little more sophisticated because the branches are behind the flexotendons. So you have to take a hook and hold them to the side. And then you can transect and electrocoagulate the radial and the ulnar palmar digital nerve branchlets. And then also you can see the palmar division of the deep ulnar nerve sensory branch and you also have to dissect and then electrocoagulate this little branch. So this is a typical example of a farmer who has an isolated post-traumatic MCP3 osteoarthritis and of course he does not want to have a fusion or an arthroplasty and this joint is able to be moved and it's stable, so we offer the MCP denervation which significantly reduced his pain but also increased his grip strength. There's only a slight temporary complication of a palmar digital neuropraxia. There's another example of a young patient with a high mechanical demand. He has an avascular necrosis of his MC4 head which is a rare disease called Morbus Dietrich and of course he also refused any bony procedures, fusions and he got MCP denervation which decreased his pain markedly. So here you see the procedure with the three steps and I magnified the picture showing the little branch that's coming from the deep ulnar sensory nerve going to the MCP joint. So it's clearly visible if you know where it is and if you have done probably two or three procedures. The innovation of the VIP is not as complicated. It has also the dorsal branchlets and it has branchlets from the palmar digital nerves which are clearly visible here in an atomic specimen. Here in the drawing, use a mid-lateral approach and you can do it on the local, no problem. So you start with an undermining of the skin envelope on the dorsum aspect of the joint which takes about two minutes and then you go to the palmar digital nerve and you look for the small branchlets that go directly to the joint, usually two or three. Can clearly see them and transect them which takes about additional 10 minutes. So this is an example again, a male patient with heavy manual load on his hands as a construction worker, severe pain after a PAP dislocation with a roller lip fracture and persistent pain during work so he could not do anything related with vibration. Hammering was impossible and he waited for almost a year and then we offered him a denervation and it was successful so it reduced his pain to two to 10, increased his grip strength and he was able to resume his original work as a construction worker. The last joint, I have not done it very often, probably six or seven times, is the DIP joint and it works with a flap method that was also described by Agnes Pratt who practices in Great Britain and again, you have small bracelets coming from the pulmonary and also from the dorsal nerves and with the flap technique, you can lift the flap up and dissect and transect the small nerves to the DIP joint. So in conclusion, these operations are minimal invasive and they have a lot of interesting advantages compared to other more invasive procedures and you don't lose anything so you don't burn any bridges for the future. You can still do arthrodesis or arthroplasties later and if you look at the outcome, the follow-up times are sometimes not so long but other studies present results of more than six years and the success rate is above 70%, sometimes even 80 or 90% and it is still a hot topic so if you look at the newest literature, 2020, 21 and, yeah, 21, there are new systematic reviews on these techniques show that they are quite successful. So just as an alternative, you can also think about minimal invasive fat injection in arthrodesis. I adopted it because I know the person who did it the first time and I know that he is not somebody who shows off and he was surprised himself by his results and his initial articles were in the meanwhile confirmed by other studies published even in PRS that show that you have a good, with these very minimal invasive procedures, a good chance to decrease the pain for periods even beyond two or three years. Thank you very much for your attention. I want to summarize. So partial joint invasion of the hand joints are a good alternative concept to treat pain while preserving joint function and you have good indications in patients with preserved motion and function. You have to exclude other causes of neuropathic pain and you don't burn any bridges for the future so still all the other alternatives are possible. Thank you very much. Well, according to the Hand Society's instructions, we've left plenty of time for questions. I want to thank the three panelists who did a wonderful job presenting this. Before we start with the questions, can I just see a show of hands of how many of you have denervated a joint in the upper extremity? Well, that's a very rewarding thing for me personally to see. That's just great. I see Ramon De Jesus has just walked into the back. He's one of our group. The slides that I showed about the nerve that innervates the medial humeral epicondyle, he was one of the authors of that paper. Is Shalman Shai still here? He was here in the beginning. He's one of our orthopedists from Wisconsin. He's done now more than 150 knee denervations. You can just stand up so they can see who you are. If you want to know whether this works in the lower extremity, you're welcome to talk. I think he's now the world record holder in the most knee denervations. I think he is, well, probably second. My partners and I stopped counting after 344. But he's an early adopter in the orthopedic community to doing this knee denervation surgery. I'd like to ask first Nick Rose if he would tell us, when he sees a patient with a tennis elbow, do you examine them at first to see whether they have radial sensory nerve or radial tunnel? And how do you decide whether to operate on the nerve entrapments at the same time as you denervate the elbow or not? Well, you know, the great number of these tennis elbow patients are going to get better with therapy, conservative measures, and whatnot. So the ones that ultimately come to surgery are fairly rare. But I think that injection we do is very valuable because we put that right over the lateral epicondyle over those nerves. And those patients that don't respond to that, I get suspicious about radial tunnel. Other things with radial tunnel are, of course, tenderness over the three-finger breast distal to the radial head. But yeah, everybody gets evaluated for that. But I'm somewhat of a believer that radial tunnel is fairly rare compared to tennis elbow. So I think that for every, you know, I think the ratio of one to the other is very low. Would you do a radial nerve neurolysis at the same time as a tennis elbow denervation or not? Well, I would. I was fortunate when I trained with David Green years ago, over 20 years ago. It was believed at that time that radial tunnel was, it was very popular. And luckily throughout my fellowship, we actually, every tennis elbow patient did a radial nerve decompression. So I saw a lot of that. So absolutely. It's something that we would combine and do at the same time. And I have done that, you know, really it comes down to afterwards. I mean, was it the tennis elbow, was it the radial tunnel? But you're kind of killing two birds with one stone and they get better and you don't really know necessarily, I guess, in the end, which one it was. Yes, sir. Can you just tell us your name so we know? Sure. I'm Glenn Butterball from Pittsburgh. I just wanted to, does anybody have any experience with nonoperative, like radio frequency, non-surgical denervation? I know one of our pain guys is doing that around the knee for degenerative arthritis. Okay, I can speak to that. In 1994, it was not known that there were nerves to the knee joint. And so Greg Horner, who's a member of this society, was a Hopkins medical student then. And we identified in 45 cadavers the innervation of the knee joint. And at that time, I called them retinacular nerves instead of genicular nerves. The geniculate vessels, I could have called them geniculate nerves, but I called them retinacular nerves because we opened the retinaculum to find the nerves that are right underneath. And since the radio frequency ablation is useful if they can find the nerve, these nerves are often a millimeter or less. And with the ultrasound, they may have difficulty finding these nerves. And if you do the radio frequency on the nerve, you can stop nerve function, but you've only injured a millimeter or two of the nerve. And the nerves, as you know, attempt to regenerate. And they'll regenerate right back across the radio frequency ablated part. And so the interventional pain doctors, and they're happy to do this, the patients will have to come back and see them every three, four, six months to have repeated procedures. The same is for back pain with the zygopaphyseal joint. Where radio frequency ablation is done so often. So I think that in surgery where you can visualize the nerve, divide it and implant it into an adjacent muscle will give the patient a chance to just have one operative procedure. But if for some reason the patient's age or they've had their knee operated on multiple times or medical reasons they don't want to undergo surgery, and you have an interventional pain doctor in the community who can actually identify these little nerves on ultrasound, you know, they're welcome to give it a try. That's a very good question. Thank you. Yes. I was wondering if you could elaborate a little more on your indications for the shoulder denervation. Is this most effective for rotary cuff pathology or glenohumeral arthritis or, you know, which are you using it more for? So I guess I'll answer that one as well. Oftentimes the actual shoulder injury that will tear the rotator cuff or then the scope procedure will damage these little tiny branches to the anterior shoulder capsule. And so then as you saw in the patient with the video, they may have had two or three arthroscopic or open procedures. And the shoulder joint is strong. The shoulder joint is strong. I mean, the shoulder surgeons are great at giving you a strong shoulder joint, but the patient may not move it because of the pain. And sometimes we don't know whether it's the initial trauma, the orthopedic intervention, which of course is a form of trauma. And if they have underlying arthritis, as you saw for the small joints in the hand, it can work for that too. And in that case for the shoulder, the nerve block really is quite a critical thing to know. If they have enough arthritis in the shoulder that they need to have some bony recontouring, you'll block their pain, but they still won't be able to lift it because they'll have an arthritic block to the range of motion of the shoulder. So the block is helpful then. And that's how I would answer that question. Is there another question? Yes, sir. Excuse me. Do you mind just standing up and also tell us who you are? As a follow-up for that for shoulder arthroplasty, I mean your examples were regarding arthroscopy where you said the capsule maybe was damaged. But in arthroplasty, if a lot of the capsule is excised, do you think have you treated patients post-arthroplasty, maybe even reverses where there's more traction? With that technique, or do you think the nerves obliterated during the exposure with the capsulectomy? I just recently had someone with a reverse shoulder implant that I think Sammy's going to operate on next week that has an axillary nerve injury. So there can be injuries from those big shoulder operations to major nerves, not just the little ones to the joints. And of course, if you remove part of the joint, a capsule, or shave down the bone, you're going to directly injure those nerves. And the pain afterwards is due to injury to those small nerves. I think that's the best I can answer for that. I'm a little worried if Ramon's going to ask me a question. Just a comment, Dr. Dellon. Exactly 20 years ago, you were looking at a German or French literature. And you came across an anatomical law that every nerve that crosses a joint most likely innervates it. Do you remember the name of that law? Hilton's law. Did I get that right? You've always been interested in innervation of the joints. But I think after that, you've really pushed the envelope in terms of looking more into it. Thank you very much. Andres, do we know who Hilton was? No. No, you know, that's a name we learn, Hilton's law, that any nerve that crosses a joint will innervate that joint. But I actually don't know much about Hilton. Does anybody in the audience know who Hilton was who came up with that law? No. Okay, I have a question for Sammy. Yeah. And I think as all the hand surgeons here know, if you cut through the skin and injure a nerve that innervates the skin, you're likely to get a painful neuroma. Well, why do you think it is when we cauterize these little teeny nerves as you're doing, we don't get painful neuromas and our brains still think we have pain coming from that joint? What is the difference, do you think? You know, I think it's hard to say that with certainty. I think the cutaneous sensory nerves that actually supply the skin have a much higher density of pain fibers, and I'm sure that there's some sort of cortical representation that makes the small neuromas that must certainly form on the ends of these cut articular branches not be painful. I mean, I would also imagine that, you know, when we treat painful neuromas, we're burying them deep, and most of these denervation procedures deal with deeper nerves. And I know with the partial denervation of the elbow, we're burying it in the triceps, so it could have to do with the proximity to the surface of the skin. Yeah. But I do think it's important before you cut any nerves, especially off a nerve like the radial sensory nerve, that you really follow it down to the joint capsule and make sure that it's not seemingly going there, but actually kind of heading past your incision. I think one of the answers might be that as Sammy just said, if you follow the nerve down to the joint capsule and you cut it, the teeny little nerve that does have pain fibers and probably does sprout, it doesn't sprout into a scar. You haven't opened the joint. It's sitting in a little subcutaneous tissue without any distal nerve sending nerve growth factor in its way calling it to grow back into an area, and that may be part of the reason we sort of, quote, get away with just as Andrea showed you also. We're very close to the surface of the skin, especially down in the finger joints. Nothing's deep. Yes, sir. I want to put in a plug for the denervations that Andreas was talking about because those are very satisfying. You can get all the way around the joint. You know that you're not going to miss anything, and so that's always the question. You know, theoretically, if you completely disconnect all the nerves going to a joint, then there should be no pain coming from that joint, and, you know, I've been doing the PIP, MP, DIP denervations recently, and I always find them to be very satisfying because I know that there's no stones left unturned. Yes, sir. Can you tell us your name? Bill Clark from Seattle, and I had a question about the CMC denervation. We all do a lot of CMC arthroplasty, and part of that, at least I mobilized a nerve and get it out of the way, therefore cutting the branches to the capsule, and then when I open the capsule, I make transverse incision at the CMC and STT joint and a vertical incision to get the capsule off to take the trapezium out, so I'm kind of obliterating all the nerves in the capsule. So, you know, it brings me to wonder, well, maybe I'm just doing a glorified denervectomy procedure and everything else is unnecessary, but then it brings me to the question that there's always failures, you know, a small percentage, but, you know, in thinking of the denervation, I'm thinking, well, this would be a great option for a revision CMC, but I'm wondering if a lot of these patients already have had that, and it might not work as well, so I guess my question is, what's your success rate in revision, treating revision CMCs with denervectomy, and have you found that to be a problem, and how do you know that it's denerved, because you can't really, it might be a little harder to inject around an arthroplasty area? You know, I agree with what you said first in that perhaps the common pathway for all these procedures that all seem to work about 85% of the time is the fact that you're creating a denervation of sorts, and you see that in all kinds of different pain syndromes, you know, in the wrist and hand. Some of these procedures seem kind of wacky and not really intuitive, but they all seem to work most of the time, and I think the surgical exposure and everything that you're doing is probably disrupting the nerve supply to the joint, and why the failures are there, it's hard to say for sure, but, you know, it's hard to imagine a scenario where you've disrupted all the nerve supply to a joint, and it still is painful. There's no Bluetooth, there's no, you know, the only way for these pain signals to get from the joint to your brain is through the peripheral nervous system, so one way or another, there must be some nerve there that's kind of still transmitting signals. Yeah. So what I'd like to say, just to follow up on that, is with the finger joints, I think the nerve block is actually very important. You do the block, and they say their pain is gone, that's great, but then can they move the joint, because some of the joints that are post-traumatic, their pain may be gone, but they may not move, and then the patient didn't really want to have a fusion, but you're not going to know whether they're able to move the joint or not until after the block. If you do the block and their pain goes away, but they still can't move their finger, then you're letting them know that if you denervate them, their pain's gone, but they're going to have a stiff finger, the same as if they'd had a fusion, so that should be part of the informed consent, I would say. And Xiaomenshi, would you like to ask us a question? I'm Xiaomenshi from the Department of Orthopedic Surgery in Medical College of Wisconsin. I just want to mention that, and since the year 2011, I started doing the knee denervation. Until now, I did 268 cases now, all of the patients after TKA, and why we do that, just because in the beginning, we find that our patient did a revision three times, four times, but still have lots of pain. At that time, you know, we saw that patient, and I learned from Dr. Dellin, from his article, we just injected, you know, painful spots, and the patient is completely pain-free. So that's how we started doing that. The nerve, we do the lateral, median and the lateral femoral cutaneous nerve, two branches, and another two branches is the median and the lateral retinical joint branch, and the third one, most like, we do most important to infrall patellar nerve. That's very important. And the overall results is 84%, good and excellent results, and some recurrent patient. And right now, we develop a neuroma clinic every Wednesday, so that's why we have five-state patients in the referral, and all patients from orthopedics. So, and Dr. Dellin, I have a question for you. You just mentioned the shoulder denervation, and we try to do that. When we're doing the surgery, we find the lateral pectoral nerve, when you dissect it, pretty long. And my question for you, do you do it only just cut or bury it? Okay, thank you. What I said when I presented it is you retract the pectoralis major, you find the little nerve next to a vessel, block it so the patient doesn't have pain from cutting the nerve, which is preemptive anesthesia, if you will, and I take the end and I tuck it back into the pectoralis muscle medially, as far as I can reach for that. Thank you for your comments. We have three very experienced European colleagues with us. Bruno Battistone is probably the most famous hand surgeon from Italy. Paco Penal, same thing from Spain. And Hank Court, who, despite being a plastic surgeon, is a major leader in wrist arthroscopy and is the chief of plastic surgery in Utrecht. I wonder if the three of you would tell us, is total wrist denervation becoming a thing of the past in Europe and we're moving towards partial? Or how are you seeing the innervation of joints in your respective countries? Can you come up to the microphone? Bruno is very soft-spoken. And I am. I think it's a question of indication and it depends on the country. In Germany, they do a lot. In Italy, we do few. So, it depends also on the, we can call the market, because in reality, a lot of orthopedic surgeons doing hand surgery, they prefer sometimes doing classical joint procedure. So, it depends. But for people doing denervation in our country, well, they, the patient may be procedure going and giving result for some period. So, the patient accept or do not accept the intervention. So, this is the way to correctly inform patients for us. Thank you. Hank? You know, we mostly do partial denervation also because you can do the proper block and see if they do well. I think it's hard to do for a total joint. So, I think I hardly do total, but mostly partial. And it works quite well. Yeah. Paco is one of the leaders in saying that most patients with chronic regional pain syndrome really, in fact, have underlying injuries to nerves. And Paco, do you ever use joint denervation in your approach to the patient with chronic regional pain? We were fellows together a long time ago. So anyway, so that CRPS, what I've found is that they all have a reason for the pain, as you first of all said. And about 30% is medical error. You know, we don't want to see what is behind. And a large part is capotuner, but the other part is neuromas and things that they have behind. That, you know, the cat nerves and, you know, part of a branch of the medial nerve. Many, many, many branches that they are around, that they are responsible for those pain. And I do denervation too, but I'm an arthroscopist and I try to solve the problem from a mechanical standpoint. So I do partial denervation, you know, a little bit like Hank said. Well, thank you. If there are no more questions, it's just about 6.15, and I want to thank you all for attending our instructional course, and good luck with your patients. Put it in there a bit. The block does, it's not that painful. So you're not blocking it down with the condom. No, I'm going, so basically what I do, so here's how I have the condom, two finger breaths, and basically I start here, I go this way, and this way. And I'm, just a few. I'm not going any deeper than that. And it's not a painful injection. And I leave them in the room. No. That hurts. Yeah. Because I hate doing steroids on them. And I've got a friend coming in for a biologic medicine and I think I would rather just try that on. Yeah, yeah, it's very easy. I mean, I just, it's just, you know, enter here and then you just direct the needle here, subcues, subcues, you raise a, you know, this whole thing. You're getting all those posterior branches. And then I leave them in the room for 10 minutes, go see one or two other patients, and then come back, do the grip strength, I do a before and after. And I know, you know, I just know right there. Correct. Correct. And I'll tell you, I mean, you know, when I first did these denervations, I was tempted to go, oh, the tendon's right there. Maybe I should debride the tendon a little bit. I, you know, but I, you know, it's just been fine. Right. Absolutely. Well, and here's something to give you confidence. I think the reason people are reluctant to do that surgery is sometimes you don't find the nerve. I sometimes don't find it. But if you clear, it's like the, like they do, the firefighters do, you know, they clear all the brush. If you basically have a centimeter wide of all, you're down to muscle and there's no fat here, you've denervated. And I've, that's important to notice, to give you confidence, like, okay, what if I don't find this nerve? But if you don't, and you've cleared that off, that's a denervation. Sometimes it's big, sometimes it's three smaller branches. But if you just got to be patient. Well, so this is, so you're, you're, this is the, you got to make sure it's not going in this direction. When you find that nerve, you got to tug on it. You've got to make sure it's coming down. You do not want to be up here and get that posterior cutaneous. If you come up here and there's a nerve, this direction is thick. That's your posterior cutaneous. The branch that comes posterior to that, yeah. Right. Yeah, just look for it and go find it. But I mean, it's, but that, that's the thing that I've tried to express to people. And I do have a video. We didn't really have time to show it, but no, but you know, I could send it to you if you have it. Yeah. I think that video would have been helpful because that's one thing I added, but send me. Well, you know, it's amazing. What's, what makes no sense to me is people are so always doing AI and PIN, but they just haven't come around to the denervation here. And it's like, okay, if, if you've accepted it here, why are you not accepting it in the shoulder and the elbow and the fingers and the CMC? I think that the CMC is, is, is being met with that. But, you know, it's interesting to me that for 10, 10 is just such an odd thing, but just people just haven't caught on to it. And it's just, I mean, it's been great in my practice, you know, so. Right. You could. Well, the problem is if that's going to obscure your vision of the nerves and that's, so if you're trying to find the nerves, I think that's going to give you a hard time. So what's your, what's your email? Perfect. There it is. No, I do. And I do, you know, I think that if I'm doing a. It's really that medial intervertebral septum, that nerve is on that septum. So all of us have taken out that septum. So it's just something taken out, but this will be the same on it. So if you really want to do what's the equivalent of a. You know, it's the lateral that we talked about, and then take out the intervertebral septum. Right. I mean, if you have an, like, if you have a. Right. And I think, you know, of course, if you're exposed and you're going to. It seems like you're going to have to jump to a step. How can you not? I mean, you have all, again, so much disagreements surrounding it. So I think we end up intervening the one. The only issue with the medial septum is you've got to dissect the. He's so young and that's so bad that I think even if he's, like, eight years old, he's probably been running around and writing together. But you don't have to see that nerve. I mean, you, but, you know, I mean, all you have to find is that septum. You just take out that much of it. Yeah, I take out about. Yeah, I think. Yeah, I think you're right. That's a tough book. Yeah, I know. He's, I mean, it's really just, he's a forefront of all this stuff. No, I know. I think you're right. It's a whole different side of things that. Yeah, I've done. I've done. I've had a second. And we're just like, fuse the bone. Take the bone. Right, right, right. Deconstruct it. We're just not geared towards soft tissue. Has that. Do you do any shoulder work? Sutured in. I do. That's been working really well. So you could focus on the bone. Try to re-anchor it. I've got traction. I also tend to go and do a scan of the suprascapular nerve. I've got your suprascapular nerve. That helped her a little bit. Yeah. Yeah, that's, I haven't encountered. Dr. Guy. Problems. He's had a scope on reverses sometimes. They're not easy. Scoping. I just go through regular times. Right. That's a hard, it's a hard problem. Yeah. I'm putting traction. Oh, yeah. Yeah, my pleasure. For that next, I'm gonna do it in my next book. Yeah, I understand. No, thank you. There. Right. On top of the portable facility. It's kind of a no-brainer. Yeah, his book has all that stuff in it. Right. And then I think what would be helpful, and I should, I have to think of where I should upload that video. In those cases, I'm pretty sure. Canopy or something like that. Absolutely. Yeah. With a five-quarter convoy. It's funny, I was wondering, like, do people submit that to you? Electrocautery, yeah. I only interviewed a couple of patients. Yeah, that was gone. One in five.

joint denervation

surgical option

patients

joint pain

pain signals

wrist joint denervation

thumb CMC joint

decreased pain

improved grip strength

numbness

less invasive alternative

patient selection