Non-invasive vs. Invasive Hand Surgeries

Episode 35 - Non-invasive vs. Invasive Hand Surgeries

Dr. Chehab: [00:00:00] Welcome to IBJI's OrthoInform, where we talk all things orthopedics that help you move better, live better. I'm your host, Dr. Eric Chehab. With OrthoInform, our goal is to provide you with an in-depth resource about common orthopedic procedures that we perform every day. Today it's my pleasure to welcome Dr. Craig Phillips, who will be speaking about minimally invasive procedures of the hand., Craig, welcome to IBJI OrthInform. Thanks for having me here, Eric. So,, I just wanted to go through a little bit of your background. It's, more colored and interesting than most of the surgeons we speak with. You did your medical degree in Johannesburg? 

Dr. Phillips: Yep. That is correct. As you can hear from my accent, it's a little different. I grew up and trained in South Africa. I did my medical school there at the University of Wit wa Rand, and then I started my residency in South Africa and then I came to the States. And 

Dr. Chehab: when you arrived in the 

Dr. Phillips: States, you did a research fellowship for a couple of years.

I did, I [00:01:00] researched, uh, flex tendon and healing, and I put all growth factors into little Petri dishes to see how the tendons grew or didn't grow. Gave me a lot of insight into how things heal in orthopedics, and I did that for almost two years at the University of Chicago. 

Dr. Chehab: And then you stayed at UFC for your internship and residency.

And were there from 94 to 99, 

Dr. Phillips: correct? Yeah. 

Dr. Chehab: Okay. 

Dr. Phillips: And then afterwards did my fellowship in the hand and upper extremity in Baltimore. It was a great year. I worked at, , union Memorial where some of the giants of hand surgery trained and taught and also worked at Hopkins there with some of the nerve gurus.

Great year operated. , Had a great time, although my wife, , had to bring up our kids alone, but it was a fantastic year for me. Okay. 

Dr. Chehab: And then in terms of the Giants of hand surgery, who are some of those? 

Dr. Phillips: So the biggest one is a guy by the name of Raymond Curtis, who he discovered a lot of things with the fingers.

And the other one was a guy by the name of Shaw Olgas who ran the fellowship and he was very big into vascular things in the [00:02:00] hand. , He was a general surgeon who, , basically fathered himself into hand surgery and he was like head of the hand society and he was a, , ominous force in hand surgery in his day.

Both have passed. 

Dr. Chehab: Oh, okay. I was just gonna ask you if they're still at it, but obviously not. Yeah. And then, , after your fellowship in Baltimore, you came back to the Chicago area. 

Dr. Phillips: I did, I came back and, , was an attending at the University of Chicago. , Spent three and a half years in orthopedics. I did up extremity primarily, a little bit of general, , for about three and a half, three and a half years at the University of Chicago, as well as one of the, north shore campuses called Weiss Hospital.

And then in January of 2004, I joined IBJ, where I've been for the last 21 years. 

Dr. Chehab: Great. And then, uh, I, I'm sure you're too humble to mention this, but you were awarded Teacher of the Year in 2001, 2002 for the Department of Orthopedic Surgery. 

Dr. Phillips: That is correct. 

Dr. Chehab: Yeah. Congratulations. That's actually a big deal when the residents and the medical students recognize you for your teaching [00:03:00] and, um, I think it's fair to say you've treated.

Thousands and thousands of patients with disorders of the hand and upper extremity. I can say from my own personal experience, I view as a trusted colleague and a mentor and a fantastic surgeon who would take care of anybody in my family. So today we were gonna talk about minimally invasive approaches for hand conditions and injuries.

And some of the topics we were gonna focus on are, number one, carpal tunnel syndrome fractures of the hand and innovations with. Minimally invasive procedures there, fractures of the wrist, and then finally, dupuytren's contracture. So let's start with carpal tunnel of the hand. Craig, give a brief description of carpal tunnel, what it is, and, and how patients present.

Dr. Phillips: Carpal tunnel is the most common nerve compression problem that humans face in this day and age that affects about three to 4% of adults. It's most common in middle aged females. Usually postmenopausal, uh, many other factors can play a role in carpal tunnel, but what people typically present with is numbness and [00:04:00] tingling in the fingers.

Usually the little finger is spared, usually wakes people up at night. If you're not sleeping at night, 'cause you're waking up and shaking your hand or. Hanging it over the bed, people get pretty miserable pretty quickly. You need a good night's sleep to function. Uh, sometimes it extends to become numb during the day and when it gets real bad, you can get weakness in the hand and drop things.

One of the hallmarks of carpal tunnel is people have a hard time doing buttons because they can't feel or picking little things off the table. Older people can have a hard time manipulating medication 'cause they're small and they can't feel it, and you have to look at them. So it can become a real problem for people if you let it go ignored.

So it's best to treat it and get it done, and there's many ways you can do that. 

Dr. Chehab: And, um, when someone presents with carpal tunnel, what are some of the non-invasive measures that you can do to help treat it? Reverse it or, or stem the tide. 

Dr. Phillips: So long as people don't have weakness, there's always a chance that non-invasive things can help.

And the most common one is a brace that you wear at night. Uh, the theory is that when we sleep at night, most of [00:05:00] us sleep in a fetal position with a wrist bent. And having the wrist bent for six to eight hours a night will oftentimes cause the nerve to become more irritated. And that's why people wake up at night and shake their hands around.

So by sleeping with a rigid brace on your wrist at night, you stop sleeping with a wrist in a bent position and it can help minimize or. Kind of eliminate the symptoms. The other common things that help is a cortisone injection. It's a little more invasive, but a cortisone injection will take away the inflammation from the nerve, and that can be dramatic.

It can kick in a couple of days. Problem is that if the brace doesn't completely work or if the cortisone injection works temporarily, so a few months, it usually implies that the problem, the carpal tunnel, the fact that the nerve is being compressed is more severe, and then instead of ignoring it, you've gotta do something like surgical things.

Dr. Chehab: Okay, so let's go to , the surgical options. Um, we're here to talk about minimally invasive procedures, but let's start with the open procedure. Describe that and what the typical recovery is like for that. Some of the potential [00:06:00] complications for an open carpal tunnel procedure. 

Dr. Phillips: So, open carpal tunnel procedures have been done for a long time and it's, uh, been the gold standard.

And all you're doing simply put the carpal tunnel is a little canal. It's like a tube, and all you're doing is you're cutting the roof of the canal to let the components, uh, have more space. So basically when you cut the roof of the canal, everything spreads apart and it heals in a wider position. And studies have shown.

Tills about 30% more space in the carpal tunnel. To do that, you have to make an incision in the palm, and it can vary from being an inch to two inches depending on the doctor and his preferences. But any incision on the palm is gonna be sensitive because it's a place where there's a lot of. Nerve endings and so it's pretty sensitive.

Not to mention the fact that wounds in the palm have a hard time healing because you're using your hand afterwards. We want you to use your hand. One of the biggest concerns of any hand problem and surgery is swelling and stiffness. And so we encourage patients to use their fingers and their wrist early on, and sometimes the wounds open up.

When you get delayed healing, you [00:07:00] get thick scar, you get more swelling, which promotes more stiffness. So there can be problems associated with that. The surgery itself is quick but there's stitches in the palm. Uh, risk of infection is relatively small with an open carpal tunnel as long as done appropriately, it's a successful way of treating carpal tunnel syndrome.

The recovery though, can take a couple of months because you've gotta wait for the scar to mature, the swelling to go down. And it can be painful. So in the early eighties, doctors developed an endoscopical minimally in way of doing the same procedure without any incisions in the palm. 

Dr. Chehab: So let's talk about that.

That's the minimally invasive approach you're talking about the endoscope being a means of visualizing inside the wrist with a small camera, that's the endoscope, and then having instrumentation to perform the same surgery without having. An open incision. So describe that that, that procedure, that minimally invasive approach.

Dr. Phillips: So one of the most important things doing when doing any hand surgery is you've gotta see something before you cut it. The idea of [00:08:00] doing blind surgery and hand surgery is precarious because sometimes you can inadvertently damage structures. So the nice thing about the endoscopic procedures, you're using a camera, like you said, it's like an arthroscopy of the knee or the shoulder where you're actually seeing things.

Before you cut them. So what you do is you make a small transverse incision in the wrist crease. So basically upstream from the palm. You bury it in the crease, so it's not very visible, it's measured, it's about a centimeter. From that incision, you basically dissect down and you identify the entrance to the carpal tunnel.

You make a little incision in the. Entrance to the carpet tunnel, and you raise a trap door and you hold the trap door up, and then you insert a a camera and you look around in the canal if everything's where it should be. And there's nothing unusual, like any aberrant nerve branches or vessel branches or masses.

Then through that same incision and through the camera itself, you use a knife that deploys just like a gun to cut the ligament, and basically by withdrawing the camera, you cut the ligament from the end to [00:09:00] the. To the forearm side, and you watch it separate and it's pretty satisfying and you're looking at the nerve at the same time to make sure the nerve doesn't get injured.

Once the ligament or the roof of the canal is open, then the job is done and the nerve has more room. But what's nice is that you haven't cut the skin in the palm of the hand or the tissue underneath it that houses a lot of these subcutaneous nerves. So you don't get the sensitivity in the palm. You don't get the pain.

There's an entity that was. Described after carpal tunnel surgery called pillar pain, pillar being the pillars of a house, the sides of the house. And when you do an open release, a fair amount of people will get pain at the bottom of their thumb and towards the base of the little finger from the arch changing and from the significance of the surgery.

With endoscopic, you don't get that because you're leaving a lot of the soft tissue structures that you don't need to cut intact. 

Dr. Chehab: So when you do the um, endoscopic procedure, do you get the same volume expansion that you get with the open procedure in the carpal tunnel? 

Dr. Phillips: You do. 

Dr. Chehab: And that's been shown [00:10:00] how 

Dr. Phillips: with MRI studies post-op.

Dr. Chehab: Okay. So the scarring that happens on the palm of the ham with the open procedure though, it can cause the pillar pain and the widening there doesn't necessarily translate into being more room within the carpal tunnel. 

Dr. Phillips: No, they were both caused, they both allow for the same room afterwards. Just the one is a smaller incision and Okay.

Yeah. 

Dr. Chehab: And then in terms of who could, would be an appropriate candidate for the open procedure, who's an appropriate candidate for the endoscopic procedure? Is everybody basically a candidate for both and it's surgeon preference or are there some reasons why you would consider an open versus an endoscopic for given individual?

Dr. Phillips: That's a good question. The. Basically prerequisite for any endoscopic or open procedures, you've gotta see something before you cut it. So people who have a lot of inflammation of the tendons. So what we call 10 synovitis. And who might that be? People with active rheumatoid arthritis or gout where everything's swollen.

, You may not be able to see the structures clearly. That would be a relative contraindication to doing an endoscopic caral tunnel release. [00:11:00] So many a surgeon might err on the side of doing the open and saying. It's safer because safety comes first, second, and third. And, uh, if it's safer, we always abide by the most safe route.

And so some people might do it open. The other indication for an open technique would be if you have a bad fracture. Let's say you have carpal tunnel syndrome and you've broken your wrist and everything's deformed. Uh, while you can try an endoscopic again, if the anatomy's distorted and you don't have good visualization of what you need to see, you can't see the nerve, the tendons, the ligament, or the roof of the canal.

Then you shouldn't do it endoscopically. So, people would probably err on the side of maybe doing that more open. And because you're gonna treat the wrist fracture surgically at the same time, you're still gonna have the wounds to heal. And it'll be a little bit of a prolonged recovery, but it's safer.

Yeah. 

Dr. Chehab: And then is in the published literature, is there a difference in the complication rate between open and endoscopic carpal tunnel release? 

Dr. Phillips: So people have looked at this at length and they found that the complication rate is similar. [00:12:00] So the complication rate for any potential nerve tendon vessel injuries less than 1%, and it's about the same with open endoscopic.

But what they've shown is wound complications are much higher with the open technique because to get that one centimeter. Wound in the crease to heal is a no brainer. It takes a week or two and it's pretty easy. Uh, wound, uh, dehi opening up of the wound, so people who are active. I had a lady once who I had to do an open carp tunnel release because I couldn't see things clearly.

It doesn't happen frequently, but it'll happen. Didn't open carp tunnel release and she went and was using a snowblower. Five days later she called me to say her wound was open and we saw her back and it was so I had to go take her back to the operating room and close it. So it's a big deal. People have also shown outcomes, so besides the risk and complications people have shown at three months and beyond, they both do the same, but for the first three months.

In most of the studies the endoscopic by far was, uh, easier recovery, less pain, swelling, less need for pain medicines, [00:13:00] and a much more rapid recovery and return to work. No need for occupational therapy. One of the nemesis is hand surgery, as we spoke, is swelling. Swelling and scar are bad because swelling and scar limit mobility and function.

If you get a lot of swelling in your palm of your hand, people are pretty miserable. You can't move your fingers because it hurts Sometimes you have to do occupational therapy for, uh, open car tunnel. I can tell you that the times I've had to prescribe occupational therapy for an endoscopic release, I can count on one hand in the years.

It's very uncommon. 

Dr. Chehab: To be honest with you, listen to this, I, I don't see any downside to the endoscopic approach and you know, if it were my own hand that needed a carpal tunnel release. Sure. Sounds like the endoscopic is the way to go. 

Dr. Phillips: There's no question the endoscopic is the way to do that.

That's the only way I would have it. But the one, uh, hitch is that you have to be trained in it. Yeah. So I wouldn't wanna be somebody's first endoscopic technique. There's a learning curve, obviously. Yeah. Used to teach people, they would come into the hour and watch me do an endoscopic and we'd teach them and we'd put on courses, [00:14:00] and I always wondered who's gonna be their first endoscopic, because it's a little scary.

So I was taught in my fellowship, which is nice. And I teach the residents and fellows, and when I ask them when they leave. And I say, what are you gonna do? I tell you, 90% of them say they're gonna do endoscopic. Yeah. Because, you know, postoperatively, it's so much easier. The patients are a happy, they're less worried, they're shocked that they had, they didn't take any pain medicines.

They took one Advil the day of surgery. 'cause I tell them to, and they're shocked and amazed at how quickly they get their finger motion back. So if I was having it done, it's a no brainer. I would have, it's like who would have an open surgery on their shoulder or their knee if they didn't have to? I mean, nobody would.

It doesn't make sense. 

Dr. Chehab: Okay, let's pivot now to, the next topic, uh, which would be fractures of the hand. , And there's some minimally EVA approaches that have been helpful at treating common fractures of the hand that have been problematic with traditional open treatments. So. What are some of the frac, well, let's go through some of the more common fractures of the hand that would require a surgery, [00:15:00] and what would the indications be for surgery in general.

And then again, we'll discuss the differences between a traditional open approach and a more percutaneous, minimally invasive approach. 

Dr. Phillips: So common fractures involve the opals, which are the bones that communicate between the wrist and the fingers. So the metacarpals have to be well aligned, they have to have the appropriate length, uh, so that the tendons aren't loose.

And ideally, you want them to heal in the quickest possible fashion. If a metacarpal fascia fracture is rotated, that means the finger's gonna cross over when you make a fist, and it's gonna lead to functional problems. If a metacarpal fracture is shortened more than a few millimeters, your finger's gonna droop.

It might be acceptable to some unacceptable to many. Same goes true with phalangeal fractures, which are the bones in the fingers. So the proximal phx is the most common one that we do because, uh, the proximal phx is the most important of the three bones in the finger. If it's angled or rotated, it leads to functional problems.

The other thing about these fractures is you wanna make sure they heal and then. You wanna make sure you [00:16:00] don't demobilize people too long 'cause they're gonna get stiff again. Yeah. And if you get stiff, then you're looking at months of therapy and dysfunction and frustration and anxiety and you can't work and it becomes , a kind of a significant issue.

Dr. Chehab: Okay. So , let's talk about the bones between the wrist and the. In the hand the wrist and the fingers, the metacarpals, , and let's say there's a fracture that's short or rotated or angulated and would typically require a operative repair go through the traditional approach of that fracture and then we'll talk about the minimally invasive approach.

Dr. Phillips: So typically when you had a fracture of a metacarpal that needed surgery, you would have to go to the operating room. Be anesthetized or the arm would go to sleep and then you'd have to straighten the fracture. And typically we would keep the fracture in the correct position, either through a plate and screw.

So you would make an incision, uh, just like with a carpal tunnel. You'd dissect down to the bone, you'd move the nerves, which can get injured. You'd move the tendons out of the way. You would reduce the [00:17:00] fracture and you would hold it in place with a plate and lots of screws that go on either side of the fracture then you would close everything up, put it in a splint, and then you'd have to start therapy because there's a high risk of scar forming around the tendons, around the plate.

And then sometimes you need to take the plate out because it abraids or rubs on the tendon and it can cause it to become weak, inflamed, and things like that. The other way, and it's what I would call an inferior way. Sometimes people who are concerned about making incisions would put K wires, which are tiny little wires, uh, across the fracture to stabilize it.

But the problem with that is, A, they're sticking outta the skin. B, they can get infected. And C, you can't move early on. So now you've got the problem of these wires sticking out and you're still in a cast and you can't move and the fracture has to heal. And so that's. Historically met with a lot of problems.

People do it, but it's certainly not ideal if you are looking at the ultimate goal is early active motion. So moving your hand, uh, minimizing rehab, going back to normal function in the rapidest possible way. So those are the. Traditional [00:18:00] ways, up until recently you had what you had and you had to deal it the way we could.

But now there's been some a advances. 

Dr. Chehab: Okay. And the, these plates , are very thin plates. They have to be. 'cause there's not a lot of soft tissue envelope between the bone , and the back of the skin. And I assume you're not approaching these through the palm of the hand, is that correct?

Dr. Phillips: Correct. But the plate's still two millimeters is two millimeters more than you had before. So. Most people would put a two or 2.4 millimeter plate on he metacarpal, and it doesn't seem like much, but in the hand where you don't have padding on the top of the hand and the tendons run directly, uh, on top of the bone, that two and a half millimeters can be the difference.

Dr. Chehab: And do you end up taking out a lot of those plates? Ultimately when the fractures heal, 

Dr. Phillips: I think you end up taking about 15 to 20% of them out because patients hate them. And they sometimes irritate tendons. Yes. Okay. 

Dr. Chehab: If a patient gets a, a plated. Metacarpal fracture, are they able to return activities more quickly than if they just let it heal on its own?

Dr. Phillips: Typically you can. Uh, it depends on the fracture, but yeah, if you can put a plate and screws on, you're probably taking a three month [00:19:00] recovery down to a two month recovery. Okay. 

Dr. Chehab: So shaving some time off, but ultimately not a huge difference. And then ultimate outcomes with that open approach. Obviously it seems to.

Do very well. Is there a big difference between an open approach versus non-operative approach for, I guess it would be if a fracture short, you'd have the strength deficits and, and if it's rotated, you have the alignment deficits. You won't, don't really have much of a choice. But to do some sort of operative fixation in those cases, 

Dr. Phillips: right?

So if there's a need to do surgery, so it's angled, shortened, uh, rotated, uh, you're gonna do surgery and you historically, we either them or we put plates and screws in. If you treat it nonsurgically, you get a brace or a cast. But usually that's because it's not too rotated or angled. Ideally you would like to not operate on patients because they heal.

Better without incisions, especially in the hand incisions in the hand, hardware in the hand leads to scar swelling, stiffness leads to tendon scarring down. So you a ideally want to avoid that if you can, but if you can't, you've gotta do what you've gotta do. Yep. 

Dr. Chehab: [00:20:00] And so now let's go to the minimally invasive approaches for these same metacarpal fractures.

So describe the hardware that's being used in these minimally invasive approaches, and then how you would. Them in and why that would be advantageous potentially. 

Dr. Phillips: So what we do with the minimally invasive approach is you make a tiny little incision to access the bone on either side. Uh, ignore the fracture so we don't go near the fracture.

Once we make a little incision, you put a, sorry, either side on the wrist side or on the knuckle side, is that what you mean? Correct. We, for a metacarpal, we'll usually go on the knuckle side. Um, you'll make a little incision, you'll move the tendon out of the way. We're talking about a less than one centimeter incision.

And then. Using X-ray guidance, you'll put a pin to, uh, down the middle of the shaft of the bone. Then you'll reduce the bone without exposing it by manipulating it either with various instruments or just simply with brute force. And then you'll advance that wire across the fracture so that it bypasses the fracture, so the wire sits in the middle of the bone and then.

Over that [00:21:00] wire in the middle of the bone, you'll put a screw, metallic screw that doesn't have a head. So normally when you're boating a bookshelf or whatever, you'll put a screw in and it has a big head. You can't use a headed screw 'cause it's gonna stick out. Mm-hmm. So you use a headless screw and ideally you use a screw that doesn't compress the bone.

So it depends on the pitch and thread of the screws. And um, so you thread it over the K-wire over the little wire. And once that screw. Is in the middle of the bone and bypasses the fracture on either side. You take out the pin and then the fracture is stable as can be, and then you take out the pin, you repair the little incision, put people in a bulky dressing, and then three or four days later they're off to the races.

They can move it and use it as I was previously saying that, couple months ago, there was a college foot college baseball player that fractured his metacarpal. It was rotated, it was angled. He needed to have surgery. We put in the screw. Two weeks later, he was playing in college baseball again. So that in terms of recovery, was a big deal.

I was more nervous than he was, [00:22:00] but, uh, he came back a month later, the fractured, healed, the screw was there. He was playing baseball, he was , very happy. So it minimizes the postoperative recovery. It minimizes scar tissue. You don't need therapy for it. It truly is a game changer in terms of fixing metacarpal fractures.

It's catching on like wildfire. 

Dr. Chehab: I can imagine. I mean, honestly, it sounds like just the smaller version of. I am riding a femur and the challenge with the femur is rotation. And how do you manage that challenge with the hand, with those special instruments or again, manipulating with your own hands as the surgeon?

Dr. Phillips: Yeah, I think it's a little bit of manipulation. It's using the instruments and it's x-ray guidance to make sure that everything lines up, uh, as it should. And then it's a matter of clinically bending and straightening the finger to make sure they align where they should and flex where they should. I mean, once in a blue moon, if something's very common, unitd, so let's say you have a common unitd shaft fracture where there's tons of pieces.

It's very hard to. Align each of those P pieces anatomically. So what you end up doing is you end up with the pin in, you [00:23:00] align everything as you can, and then you look at what the clinical judgment is. You straighten it in extension and you bend it and flex it, and you make sure that it's not mal rotated and then you thread the screw over and you just let it heal.

There used to be a technique that people used years ago and still sometimes for really bad conditions called a Maslow technique, which is basically a soft tissue covering of. A bone deficit and then you fill it with all pieces of bone and you plate it on either side and you let the body heal the bone from side to side.

And that's the same concept, is if you don't disrupt the fracture site, uh, it'll heal by itself. That there's an entity that we all have to abide by. Biology versus biomechanics. The biology is the most important. So if you do an open surgery and you open a fracture, you take away some of the blood supply, you take away the hematoma, you take away, uh, the important growth fractures you need to heal the fracture.

You negate that by putting a plates and screws, which stabilizes it and allows the fracture to heal over time. With an intermediary screw, you're not messing with the [00:24:00] biology, so your body's gonna heal that super fast as long as you don't mess with that. Now adding the stability of the mechanics without messing with the biology.

And that's the key to getting this kind of the holy grail of it. It's the holy grail. 

Dr. Chehab: Yeah. And um, again, potential complications of the minimally invasive approach. 

Dr. Phillips: Very small studies just published that are reviewed for the general hand surgery recently very small, , less than 1% risk of infection.

If you extend the indications. And you don't do it for the right indications. If you, uh, screw fractures that are too close to the joint, you have to be careful, but that you get adequate purchase. And uh, that was what the study was about is how far can you be from the joint to have this To make it work.

Yeah. To make it work. Yeah. And, , besides that, there's nothing, I mean, sometimes compliance. So, I had a person once who fell on her hand post-op and bent the intary screw. That was a problem. Getting it out can be challenging, but that's pretty rare. 

Dr. Chehab: And sometimes you have to remove hardware of these I am [00:25:00] rods in larger bones.

Have you ever had to take out one of these metacarpal pins? 

Dr. Phillips: I've never had to. Yep. 

Dr. Chehab: Okay um, again, that sounds like another no-brainer. If I had a choice between plating my metacarpal or putting an I am rod, and I assume the similar principles for the smaller bones in the hand, and particularly the proximal failings.

Dr. Phillips: So similar principles. One of the problems with proximal failings fractures is we typically would put pins in KY. And they would lead to a lot of stiffness. And some people have actually gone away from treating these surgically because they get so, so, so stiff. If you can't move the fingers, they get stiff.

So a lot of people have gone to either treating it in a brace and just accepting the angle or the shortening or drooping or the weakness and said, it's better than having a stiff finger. Now with these screws, you can advance them through either side of the bone, sometimes even through the joint.

Beyond where the finger is broken, the knuckle between the big knuckle and the little one in your fingers and you make a lot incision and you split the tendon and then advance them in. And it's amazing how [00:26:00] stable these make these fractures. 

Dr. Chehab: Do they have any sort of bend of them If you're 

Dr. Phillips: The screws have no bend.

No bend. I mean they come in titanium and stainless, but they're originally described ones are stainless, they're incredibly hard to bend. You'd need to put a lot of force fall on it like that lady 

Dr. Chehab: did. So any other insights into. Fractures of the hand and some of the advances of minimally invasive surgery that you'd like to share?

Dr. Phillips: No, I think for the most part, this is catching on big and it's gotta become the mainstay of treatment for metacarpals and what we call flange fractures. Tunnel incisions, threading screws down. Uh, negates the need for a lot of therapy or any therapy. People just become functional quicker and it's, it's just a better way of doing the same thing that we've done for decades because we've gotten smarter, we've got better instruments, better techniques it's better and it's extending to the rest and as well.

Dr. Chehab: Yeah. So let's, let's go to the wrist. And one of the most common fractures in the wrist is of the escape void. And that surgery has been, revolutionized also by minimally [00:27:00] invasive techniques. , So describe , the scape void, the, , how it presents again, um, what you do to diagnose it and treatment options for it, including non-operative and operative.

And then when we get to the operative side open versus, uh. Minimally invasive techniques. 

Dr. Phillips: So eight bones in the wrist. The scarfo is the most common bone. It lives underneath the thumb at four, the there's most common bone broken, most common bone broken in the wrist. Thank you. Um, there's basically two rows in the wrist.

There's a row that's upstream and a row that's downstream, and the scarfo looks like a kidney bean shaped bone, and it communicates between the upstream and the downstream row of bones. It's critical to the function of the wrist. When you fall on, uh, your wrist and hyperextended it's like a nutcracker where the scaphoid that's bent, uh, eventually undergoes stress and breaks usually in the middle.

The scaphoid is unique because not only is it the most important bone in the wrist, but it has a very bad blood supply. So you talked about treatment historically. If you have a bone that's [00:28:00] broken that's non-displaced, we would typically buy. Premise of orthopedics is not treated with surgery. It will heal by itself.

So people have historically casted scaphoid fractures, and there was a study at the Mayo Clinic that even in non-displaced scaphoid waist fractures, it takes a minimum of three months for it to heal. So you're talking about three months in a cast. Followed by a few months of therapy brace, getting your motion back, your strength back.

So if you're a young, active person, you're talking five to six months before you're back doing normal things. That could be a game changer for a lot of people. When you're 16, it's fine because everybody thinks having a cast on is cool for a few weeks, but after a few months it becomes frustrating. You gotta get outside, you gotta play sports.

And if you can't, kids get frustrated. Adults get more frustrated. But it's better not to operate when you don't have to. Uh, historically when you had a broken scour that was displaced or people didn't have the five months, you would typically do an open approach. So what does that mean? Well, it's a pretty big surgery.

You gotta make big [00:29:00] incisions in the palm of the hand and the forearm. Then you've gotta put the bone in place and then you've gotta put screws in there. And you, what we spoke about before with the biology, you disrupt the biology and the blood supply in a bone that already has a precarious blood supply.

And then even then, are 90% of the bones healed. So in the early two thousands, in about 2004 five, the US Navy. In San Diego got tired of their recruits, who broke their scour bones. Were out of military duty for six months and that's you on my tax paying dollars, paying for them to sit around and do nothing.

So they invented this way where you could do this minimally invasive, percutaneous scour technique where there's no incisions. You make a tiny little nick, uh, you float to kir in just like you do with the metacarpal. You have to get it in the right angle on x-rays, and then you thread the screw over it.

Dr. Chehab: So again, just for the listener, that K-wire is the wire you're placing in the bone over which the screw is going to go. It's a tiny, 

Dr. Phillips: [00:30:00] little thin, like a nail or a needle or if you will, it's about one and a half millimeters thick. 

Dr. Chehab: Yeah. And that's the key to the procedure, putting that in the 

Dr. Phillips: right place, the key to the whole procedure for 

Dr. Chehab: sure.

And then the screw goes over that. So the middle of the screw is hollow. You can just thread it over. Yes. The middle wire. And then use the screw to compress it. Correct. So, and does this screw special as well? Like the one in the metacarpal? 

Dr. Phillips: Same concept. No head on the screw, no head hole in the middle.

Cannulated what we call so we can put it over the little wire. And also again, because this one has a different pitch and thread. It actually compresses the fracture as you alluded to. So sometimes with these fractures there's a little gap at the fracture site. So by putting these screws in, it compresses it and it can realign it in a better position and there's nothing sticking out.

So you can start moving it immediately so that US Naval studies showed that people were going back to doing light normal activities at four months and back to basic training at two months, it was a game changer. That is a game changer. Healing rate went up to [00:31:00] 98%. 

Dr. Chehab: So quicker recovery, better healing.

No brainer. No brainer. Once again, absolutely no brainer. Yeah, 

Dr. Phillips: The only thing is, again, it's hard because you need, uh, technical e expertise. You need to understand how the bone is curved. More complications with this one because if you don't get it perfect and you put the screw in, you can cause problems.

And what are those? So the screw can protrude. If you put the screw on the bottom of the bone and not on the top of the bone, it'll compress and cause the bone to bend in the wrong direction. The bone can collapse. The screw has to be the right length to make sure that you've got it on both sides of the fracture.

That can be a little challenge, and you all have to do this through X-ray guidance. Yeah, so that definitely, and there's a, , when I did started doing this years ago. When it came out a lot of x-rays. So you kinda have to be prepared to do a lot of x-rays where lead patient has to have lead on because otherwise you're getting a lot of x-ray exposure.

Yeah. As time goes on, you get better and, , but still it's a challenge. So I think, again, there's a big learning curve. Again, it has to do with the biology [00:32:00] versus the mechanics. I remember. Uh, when I joined IBJ and I was telling one of the other hand surgeons about this technique, and he said, yeah, he does a similar technique.

And I said, oh, how so? He says, well, he exposes it. He does a big open incision, looks at the fracture, but he just doesn't do as big of an exposure. Okay. I said, no, no, no different technique, because once you open the fracture site, you disrupt the biology, the hematoma, the growth factors, the good healing stuff.

So the benefit of the percutaneous technique besides stabilizing it, you've got all the healthy things and you don't disrupt the blood supply. Scaphoid, lunar bone in the foot, they, there's a couple of bones in the body that have a very precarious blood supply. You don't mess with the blood supply if you don't have to.

Dr. Chehab: With this technique being so useful in terms of reducing the time to get back to normal activity is cast treatment of non-displaced scaphoid obsolete or is that still used routinely 

Dr. Phillips: so used routinely in certain [00:33:00] individuals, younger people. People who have high morbidity and it's certainly there's less risk in a cast.

If people wanna be risk averse, it's absolutely fine. I want to be, I'm very risk averse. Personally. I'm, uh, don't like to incur any risk as I think most people don't want to unless they have to. So some people, I would rather take three months, four months in a cast. Get an 85 90% union rate and then rehab it and they say, so be it.

They have the time and it's still a fine way of treating and we treat a lot of people in casts and they do fine. But then some people are athletes. Cadets for me not to be, for you not to be able to operate for four months Right. Would be financially devastating for you. Uh, so there's still real implications of that.

Imagine if you could have that done and be operating two weeks later. It's a, it's, that's a game changer. Yes. Right. 

Dr. Chehab: And then ultimately the outcomes 

Dr. Phillips: better with a screw than with cast. Uh, then with cats, because you're compressing the fracture and you get better motion, quicker motion. So the Mayo study showed a 90% at three months with the [00:34:00] study from the Naval Academy, 95 to 98% union rate.

Dr. Chehab: So from an outcome standpoint, the minimally invasive percutaneous groove fixation is the best in terms of union rates, meaning the bone healing functionality of the wrist, and, um. I guess pain or whatever other measure that would be. 

Dr. Phillips: Yeah. No, all functional, uh, all functional outcomes are better, but more risk.

Okay. And it has to be done right. If you do it wrong, there can be problems. 

Dr. Chehab: Okay. So finally, um, a very common condition, Dupuytren's contracture. I don't understand where it comes from or how it occurs. I'm not sure anybody. Really understands it, but the process is well known. We see it a lot. Can you describe what Dupuytren is, how it is what again, the treatment options are and when you consider surgery or?

Minimally invasive measures to treat it. 

Dr. Phillips: So Dupuytren also affects about 2% of the people. And the reason you don't know where it comes from is because you're not, Nordic happens more common in people with Nordic descent, so they call it [00:35:00] Viking hand because studies have shown that when the Vikings invaded the Nordic countries, they spread this.

And so what happens for no good reason. The tissue underneath the skin of the hand is like a tablecloth. It's like a thickened, uh, network lattice of tissue that stops the skin from moving. When you grab objects and because of this genetic predisposition, you get little nodules form and little chords, which are thickenings in the palm of the hand and in the fingers, and sometimes they happen fortuitously, sometimes they can happen after a.

A per a, uh, distant trauma sometimes they can happen on some medication. And, frequently , they'll cause no problems. But sometimes those little cords contract because they like cells that wanna be muscle cells, but they aren't. But they can contract and they cause the fingers to bend down and then you take it more seriously because then it becomes dysfunctional.

Dupuytren isn't a painful condition, but it's a dysfunctional condition. 

Dr. Chehab: Okay. And then so when the finger is bent to a [00:36:00] certain degree, that's when you would consider an intervention short of surgical or minimally invasive interventions. Is there any sort of splinting that is actually helpful or in the end it's gonna follow whatever course it follows?

Dr. Phillips: Good question. They've done lots of studies that have looked at medicines, therapy, splinting, and there is no benefit to it. The only thing it does is it makes you anxious and it. Kinda that takes away from the functionality of your hand by having a splint on your hand. The Dupuytren is gonna do what it's gonna do, and there's nothing you and I or anyone can do to change it, except when it becomes dysfunctional.

And then you can do some of these interventions 

Dr. Chehab: And just, if I have a dupuytren contracture today, am I gonna have it five years, 10 years? Is it forever once it starts, or does it resolve on its own spontaneously in some patients? 

Dr. Phillips: Yeah. Very rarely does it resolve spontaneously. And the true incidence isn't really known, but it's 1% of people will get a little bit better and the majority of people, it just stays there or it gets worse, and it's hard to predict who it's gonna get worse in.

And the one [00:37:00] thing that's unique about Dupuytren is it can be so variable, even in people with their own hands, how it affects the right versus the left side. Oh, interesting. How it affects siblings. Very different. And it's gotta do with what they call the penetrance of the gene. And so some people can come in and have horrendous DePuy called a DePuy diathesis, and some people will have it very mild within the same family.

And, um, so people historically with, and this I learned from a patient years ago, Irish descent. I said to this patient in the office, it happens more in Nordic. People and do you have any Nordic blood? And the guy said to me, do you know where most of the Irish people came from? And I said, I didn't. And he said a lot from the Nordic countries, which is why it's more common in Irish people, which was interesting.

Uh, but anyway, so people have followed the genealogy there, but there's nothing we can do to stop dupuytren from doing what it's gonna do. And because it's in our DNA, you cannot get rid of it. You just can't. Even when you cut it out, the historically old fashioned way of. Dealing with Dupuytren. , Even when you cut it out, there's still gonna be some dupuytren there.

[00:38:00] Get a little thick scar and it might not cause a contracture, but it'll still be there. 

Dr. Chehab: Okay. And so, when someone has that functional, uh, limitation from the bending from the dupuytren's contracture, that's a very technically challenging procedure from my vantage point as a non hand surgeon.

Describe that. 

Dr. Phillips: So from my vantage point, as a hand surgeon, it's a very technically challenging surgery as well. So no non hand surgeon is gonna do dupuytren and hand surgery was developed for few reasons, nerves. Tendons 'cause they did lia and dupuytren. It's say, an extraordinarily challenging surgery because the disease, dupuytren's tissue looks like scar tissue and it winds around the nerves and you spend more time making sure the nerves are safe.

Then worrying about the duyn, and once the nerve's safe, you remove the duyn and you straighten the finger and it's very satisfying. But there's risks, nerve injuries, vessel injuries, and most importantly, recurrence. And then you've gotta do therapy and the wounds have to heal. It's an extraordinarily challenging surgery for even for hand surgeons.

And the worst, the [00:39:00] bend. The more challenging the surgery. 

Dr. Chehab: Yeah. So all the same issues that happen with the open carpal tunnel and the palm of the hand with some of the wound dehiscence and wound complications. And 

Dr. Phillips: the difference here is anybody can do a carpal tunnel release 'cause it's not that mentally and challenging dupuytren's, the anatomy is so distorted you people who do that need to be.

Uh, versed and trained and adept in knowing what to expect. Otherwise, it becomes overwhelming. Dupuytren surgery is challenging. Yep. 

Dr. Chehab: So let's, uh, move to minimally invasive treatments of dupuytren's. Describe that. What they are, how they were developed when they came into more widespread use and, and what the advantages and disadvantages may be.

Dr. Phillips: Uh, there was a doc in New Yorker who ran a lab and they figured out that this enzyme called Clostridium histolytica grown in a Petri dish can dissolve collagen. Collagen is a building block of our body. Everything is made up of collagen, our tendons, our bones, our nerves, everything. And they found that [00:40:00] then when they grew this clostridium histolytica and injected into the collagen of the dupuytren's abnormal tissue, which has an abnormal amount of.

The wrong collagen, but when they injected into it, they found that it dissolved the cord where they injected. So they did studies looking at safety. They looked, did studies, looking at doses, and then they released it to the market on a trial basis. And then the results were overwhelmingly excellent. So they did these two studies called the chord one and Chord two study chord.

One study was in the states and chord two study was in Australia. And it, uh. Basically stand for contracture associated with dupuytren's disease. But so they looked at about a couple of hundred patients and they selected doctors all across the country to do a trial on five patients. And then they looked at their results and complications and what have you, and they found that the results were, very good.

They found the complication rate was lower than surgery. But what they also found, and over the years it's been released for the last 15 or so years that the FDA released it as a [00:41:00] safe treatment. But what we have found is the recurrence rate is higher amongst people who have the minimally invasive way.

, So if you look at contemporary literature, let's say at about five years, and the literature's, , varies, but let's say at five years I do surgery on someone and five years later. There's probably about a 10% chance of it coming back in your palm, a little higher in the finger with the Xiaflex or with the enzyme.

It's probably about 30% . Of a chance coming back. So it's a little higher. But the interesting thing is that after you do the Xiaflex which dissolves the cord is there's no therapy. There's, , a week off work, and then you're back doing stuff. There's no wounds to heal typically. People are generally very happy.

The technical aspects of the Xiaflex are challenging. So on day one you basically inject the cord three times. With this medicine, it's literally a tiny amount of the medicine. It's less than a quarter of a cc, and you inject it in three areas, and you gotta make sure you don't inject anywhere near the tendons or the nerves because if [00:42:00] you inject into the tendons or the nerve.

I was just gonna ask, I was gonna ask how 

Dr. Chehab: is this selective? How is it selected not to dissolve the tendons 

Dr. Phillips: not to. So the way that we do it is knowledge and knowing where the cords and feelings. So there has to be a palpable cord. You can feel touch, see, you can't just inject it blindly. Same reason why you can't do any surgery blindly in hand.

So you put the needle into the cord and then you have the person flex and extend their finger. If you're too close to the tendon, the needle will. If the needle stays where you put it and it doesn't move, it means you're not where the tend, where the tendon is. So then you inject it. Some people use ultrasound guidance as well.

Uh, I can tell you that when. The FDA re-released Xiaflex, the company that's changed now a few times, but the original company released it to everyone. So they thought it would be like Botox. Yeah, and they said primary care docs, rheumatologists, hand surgeons inject away because they obviously stood to make profit.

So primary care docs aren't crazy. They said, this is not in my wheelhouse. I'm not doing this. But [00:43:00] rheumatologists did, and I was intimately involved with, with the company, 'cause they asked me to come and be one of their first guys. There were two guys from Chicago and they flew us to Atlanta and showed us how to do this stuff.

And there's two things. Number one is. They released it to rheumatologists and they found that the tendon rupture rates, so exactly what we spoke about, went up astronomically. Wow. So they stopped. They said, we are not gonna allow anyone except orthopods and hand surgeons and plastic surgeons, people who know the anatomy to do it, number one.

And number two, the complic. The side effects are quite dramatic. I mean, people swell. People swell, sometimes mildly, but sometimes 16 inch softball swell. Their hands get 

Dr. Chehab: huge. Immune mediated. Or immune mediated. Okay. 

Dr. Phillips: Completely. And they get streaks up their arm to their armpit because that's where the lymphatics of system lives.

It sees the protein that's foreign. It's like a bee sting on steroids. And so people will swell, get blood blisters, get a little pain where we injected it and streaks up their arm. But the interesting thing, within seven to 10 days gone. Hmm. So, and do you 

Dr. Chehab: do anything steroids or do you give any [00:44:00] sort of treatment?

Just let 'em run its course. And that's that, 

Dr. Phillips: no, you read, I haven't ever done steroids after Xiaflex. 

Dr. Chehab: And is this an in-office injection or do you do take people to the operating room for a little anesthetic so that they're not moving or No. How do, how do you perform the injection 

Dr. Phillips: all done in the office if you.

There's no reason to do anything under sedation, although sometimes if patients are more anxious, I'll have them take a Valium before. Okay, so on day one, you bring them in, and that's not too painful, but you inject the cord three times. The FDA is now released. You can do two cords, so you can inject two areas, three times each.

It's not fun, but it's doable. On day two, they come back, their hand's gonna be swollen, it's gonna be painful. The cord is usually liquified, so if you feel the cord, it feels like jello. And then there's only one guy in the history of, and I've done a lot of these that can let me or manipulate it himself.

It's incredibly painful. So we usually inject local in the office, wait about 10 minutes, the finger's numb, and then you manipulate it and it's satisfying and stressful at the same time because as you manipulate it, it suddenly pops. [00:45:00] And there's an audible pop as the cord breaks and you think, oh my God, did I rupture the tendon?

Did I break the bone fingers straight? But then invariably the people can bend right away. Wow. That's very satisfying. Patients are very happy. It works. About 95% of the time there are risks. What we spoke about, the tendon people swell up a light pain. Sometimes if there's a really, really bad co contracture and you manipulate it, you can tear the skin because you're going from bent to straights in seconds and then people have to do dressing changes and it can bleed a fair amount.

So yeah, you have to be prepared and patients need to be educated. They have a nice. Brochure and website, the company who makes this stuff. So people should do this. They should all educate themselves before, 'cause it's not for everyone 

Dr. Chehab: now, like you said, it's not for everybody. But neither is the open procedure.

The open procedure's not. Easily tolerated as well. 

Dr. Phillips: So the open procedure, you're talking about a couple of months of therapy, you're talking about wounds that need to heal with the risks we spoke about. You're talking about surgeons doing it and it's sometimes [00:46:00] challenging to get the fingers straight and not damage nerves and vessels and tendons.

So, yeah, and um, it's certainly a much, much longer recovery, the open technique without a doubt. 

Dr. Chehab: Okay. 

Dr. Phillips: Again, for the same reasons we spoke about the scaphoid and the metacarpal and the carpal tunnel. So if I had dupuytren, and again, taking time off work is uh, not something I'd like to do, so I would want.

Do it. And if I'm back to work in a week, I would take that with the open procedure. I can't be working scribing doing surgery for weeks or months, 

Dr. Chehab: but it's a process with the, even with the percutaneous, it's getting the dupuytren cord injected, letting it liquefy with the enzyme, doing its work under the skin, coming back to have the manipulation to break the dupuytren, and then being able to use the hand pretty normally, shortly thereafter.

A hundred percent. It's a process. Yes. Okay. Well, um. Any other tidbits or pearls that you would like to share about minimally invasive procedures of the hand and the wrist? 

Dr. Phillips: Yeah, I mean, the ultimate premise is [00:47:00] we all would like to induce minimum scarring, minimum pain. And, um, if we can do that effectively without cutting corners, without injuring anything, to me it's a no brainer.

If you can safely and effectively do a procedure and effectively. Achieve the goal, stabilizing whatever or whatever the goal is without causing pain, swelling, stiffness, without the need for a prolonged recovery. No brainer in my mind. Yeah, 

Dr. Chehab: no, I mean, what you've described today are equivalent or even better outcomes of procedures that are, have way fewer side effects than, than what we've done for many years.

So this is terrific. These are wonderful insights and a minimally invasive techniques for. Problems of the hand and the wrist. My guest today is Dr. Craig Phillips. Uh, Craig, thanks for being on Ortho Forum Is Tom. Thanks for having me. Thank you for listening to IBS Ortho Form, brought to you by the Illinois Bone and Joint Institute, where our goal is to always help you move better, live better.

If you would like to learn more about [00:48:00] IBJI and our comprehensive musculoskeletal services, please visit our website@ibj.com. The discussion in this podcast is for general information and entertainment purposes only regarding musculoskeletal conditions. The information provided does not constitute the practice of medicine or other healthcare professional services, including the giving of medical advice and no doctor-patient relationship is formed.

Listeners with musculoskeletal conditions should seek the advice of their healthcare professionals without delay for any condition they have. The use of the information in this podcast is that the listener's own risk. The content is not intended to replace diagnosis, treatment, or medical advice from your treating healthcare professional.