{"version":"1.0.0","segments":[{"speaker":"Charles A. Goldfarb","startTime":3.63,"endTime":5.61,"body":"Welcome to"},{"speaker":"Charles A. Goldfarb","startTime":3.63,"endTime":5.61,"body":"the upper hand podcast where"},{"speaker":"Charles A. Goldfarb","startTime":5.61,"endTime":7.56,"body":"Chuck and Chris talk Hand"},{"speaker":"Charles A. Goldfarb","startTime":5.61,"endTime":7.56,"body":"Surgery."},{"speaker":"Chris Dy","startTime":7.89,"endTime":9.72,"body":"We are two hand"},{"speaker":"Chris Dy","startTime":7.89,"endTime":9.72,"body":"surgeons at Washington"},{"speaker":"Chris Dy","startTime":9.72,"endTime":12.33,"body":"University in St. Louis here to"},{"speaker":"Chris Dy","startTime":9.72,"endTime":12.33,"body":"talk about all things hand"},{"speaker":"Chris Dy","startTime":12.33,"endTime":14.64,"body":"surgery related from technical"},{"speaker":"Chris Dy","startTime":12.33,"endTime":14.64,"body":"to personal."},{"speaker":"Charles A. Goldfarb","startTime":15.329,"endTime":17.429,"body":"Please"},{"speaker":"Charles A. Goldfarb","startTime":15.329,"endTime":17.429,"body":"subscribe wherever you get your"},{"speaker":"Charles A. Goldfarb","startTime":17.429,"endTime":18.179,"body":"podcasts."},{"speaker":"Chris Dy","startTime":18.929,"endTime":21.299,"body":"And thank you in"},{"speaker":"Chris Dy","startTime":18.929,"endTime":21.299,"body":"advance for leaving a review and"},{"speaker":"Chris Dy","startTime":21.299,"endTime":23.579,"body":"leaving a rating wherever you"},{"speaker":"Chris Dy","startTime":21.299,"endTime":23.579,"body":"get your podcast."},{"speaker":"Charles A. Goldfarb","startTime":23.969,"endTime":24.929,"body":"Hey, Chris."},{"speaker":"Chris Dy","startTime":25.409,"endTime":26.549,"body":"Hey, Chuck, how are"},{"speaker":"Chris Dy","startTime":25.409,"endTime":26.549,"body":"you?"},{"speaker":"Charles A. Goldfarb","startTime":26.94,"endTime":29.31,"body":"I am great."},{"speaker":"Charles A. Goldfarb","startTime":26.94,"endTime":29.31,"body":"Welcome to 2022."},{"speaker":"Chris Dy","startTime":29.819,"endTime":32.609,"body":"Welcome, welcome, and"},{"speaker":"Chris Dy","startTime":29.819,"endTime":32.609,"body":"welcome to a freshly recorded"},{"speaker":"Chris Dy","startTime":32.609,"endTime":34.529,"body":"intro only took one take. Right?"},{"speaker":"Charles A. Goldfarb","startTime":34.68,"endTime":36.36,"body":"You had"},{"speaker":"Charles A. Goldfarb","startTime":34.68,"endTime":36.36,"body":"just just one, just one."},{"speaker":"Chris Dy","startTime":38.22,"endTime":39.81,"body":"We'll see if that one"},{"speaker":"Chris Dy","startTime":38.22,"endTime":39.81,"body":"actually worked out."},{"speaker":"Charles A. Goldfarb","startTime":40.38,"endTime":42.78,"body":"Yes, it'll"},{"speaker":"Charles A. Goldfarb","startTime":40.38,"endTime":42.78,"body":"be beautiful. So this is season"},{"speaker":"Charles A. Goldfarb","startTime":42.78,"endTime":44.58,"body":"three. Pretty crazy."},{"speaker":"Chris Dy","startTime":45.03,"endTime":47.1,"body":"Are you keeping track"},{"speaker":"Chris Dy","startTime":45.03,"endTime":47.1,"body":"of seasons? How does this even"},{"speaker":"Chris Dy","startTime":47.1,"endTime":48.0,"body":"work with seasons?"},{"speaker":"Charles A. Goldfarb","startTime":48.33,"endTime":51.51,"body":"I don't"},{"speaker":"Charles A. Goldfarb","startTime":48.33,"endTime":51.51,"body":"know. I think it is our third"},{"speaker":"Charles A. Goldfarb","startTime":51.51,"endTime":54.48,"body":"year. Maybe our seasons are"},{"speaker":"Charles A. Goldfarb","startTime":51.51,"endTime":54.48,"body":"annual."},{"speaker":"Chris Dy","startTime":55.38,"endTime":59.22,"body":"We started what"},{"speaker":"Chris Dy","startTime":55.38,"endTime":59.22,"body":"January of 2008. Okay, sure. So"},{"speaker":"Chris Dy","startTime":59.22,"endTime":60.84,"body":"this is our third season. Okay."},{"speaker":"Charles A. Goldfarb","startTime":61.2,"endTime":63.9,"body":"Yeah, I"},{"speaker":"Charles A. Goldfarb","startTime":61.2,"endTime":63.9,"body":"think, you know, most podcasts"},{"speaker":"Charles A. Goldfarb","startTime":63.9,"endTime":68.16,"body":"don't get out of into double"},{"speaker":"Charles A. Goldfarb","startTime":63.9,"endTime":68.16,"body":"digit episode recording. So"},{"speaker":"Charles A. Goldfarb","startTime":68.16,"endTime":72.66,"body":"we've we've crossed a few"},{"speaker":"Charles A. Goldfarb","startTime":68.16,"endTime":72.66,"body":"barriers and, and we have done"},{"speaker":"Charles A. Goldfarb","startTime":72.66,"endTime":76.08,"body":"some soul searching about what"},{"speaker":"Charles A. Goldfarb","startTime":72.66,"endTime":76.08,"body":"we want this podcast to be. And"},{"speaker":"Charles A. Goldfarb","startTime":76.11,"endTime":76.8,"body":"here we are."},{"speaker":"Chris Dy","startTime":77.61,"endTime":79.11,"body":"Well, we can keep"},{"speaker":"Chris Dy","startTime":77.61,"endTime":79.11,"body":"putting out episodes, I don't"},{"speaker":"Chris Dy","startTime":79.11,"endTime":81.72,"body":"know if anybody's gonna keep"},{"speaker":"Chris Dy","startTime":79.11,"endTime":81.72,"body":"listening. But it's not hard to"},{"speaker":"Chris Dy","startTime":81.72,"endTime":84.09,"body":"get out of double digits. If you"},{"speaker":"Chris Dy","startTime":81.72,"endTime":84.09,"body":"just put your head down and do"},{"speaker":"Chris Dy","startTime":84.09,"endTime":85.77,"body":"the work, like one of my mentors"},{"speaker":"Chris Dy","startTime":84.09,"endTime":85.77,"body":"tells me"},{"speaker":"Charles A. Goldfarb","startTime":86.1,"endTime":88.05,"body":"that that"},{"speaker":"Charles A. Goldfarb","startTime":86.1,"endTime":88.05,"body":"is true. Just put your head down"},{"speaker":"Charles A. Goldfarb","startTime":88.05,"endTime":89.19,"body":"and keep on plugging."},{"speaker":"Chris Dy","startTime":91.5,"endTime":92.94,"body":"You got to put your"},{"speaker":"Chris Dy","startTime":91.5,"endTime":92.94,"body":"hand up at some point and see"},{"speaker":"Chris Dy","startTime":92.94,"endTime":96.42,"body":"the forest from the trees. But"},{"speaker":"Chris Dy","startTime":92.94,"endTime":96.42,"body":"yes, it's been. It's been nice"},{"speaker":"Chris Dy","startTime":96.42,"endTime":98.85,"body":"to have a little time off. He"},{"speaker":"Chris Dy","startTime":96.42,"endTime":98.85,"body":"has you know, December is a"},{"speaker":"Chris Dy","startTime":98.85,"endTime":101.34,"body":"crazy time from a practice"},{"speaker":"Chris Dy","startTime":98.85,"endTime":101.34,"body":"perspective. And it's just a"},{"speaker":"Chris Dy","startTime":101.34,"endTime":103.65,"body":"crazy time from a personal"},{"speaker":"Chris Dy","startTime":101.34,"endTime":103.65,"body":"perspective with everything"},{"speaker":"Chris Dy","startTime":103.65,"endTime":107.31,"body":"going on and certainly has not"},{"speaker":"Chris Dy","startTime":103.65,"endTime":107.31,"body":"done us any favors."},{"speaker":"Charles A. Goldfarb","startTime":107.61,"endTime":109.38,"body":"Yeah, I"},{"speaker":"Charles A. Goldfarb","startTime":107.61,"endTime":109.38,"body":"think you and I had talked about"},{"speaker":"Charles A. Goldfarb","startTime":109.38,"endTime":112.35,"body":"taking a couple of weeks around"},{"speaker":"Charles A. Goldfarb","startTime":109.38,"endTime":112.35,"body":"the holidays. And then yet this"},{"speaker":"Charles A. Goldfarb","startTime":112.35,"endTime":116.46,"body":"this small COVID thing has"},{"speaker":"Charles A. Goldfarb","startTime":112.35,"endTime":116.46,"body":"interrupted our cadence a little"},{"speaker":"Charles A. Goldfarb","startTime":116.46,"endTime":121.2,"body":"bit, but we are back. And we are"},{"speaker":"Charles A. Goldfarb","startTime":116.46,"endTime":121.2,"body":"we have a good plan to move"},{"speaker":"Charles A. Goldfarb","startTime":121.2,"endTime":121.59,"body":"forward."},{"speaker":"Chris Dy","startTime":122.25,"endTime":125.49,"body":"We do and it's so it's"},{"speaker":"Chris Dy","startTime":122.25,"endTime":125.49,"body":"the middle of January. And I'm"},{"speaker":"Chris Dy","startTime":125.49,"endTime":128.61,"body":"supposed to be in California"},{"speaker":"Chris Dy","startTime":125.49,"endTime":128.61,"body":"right now at the ASP and"},{"speaker":"Chris Dy","startTime":128.61,"endTime":131.88,"body":"meeting. But I'm not so for"},{"speaker":"Chris Dy","startTime":128.61,"endTime":131.88,"body":"those of you that did make it to"},{"speaker":"Chris Dy","startTime":131.88,"endTime":134.61,"body":"the meeting, I'm sorry, I"},{"speaker":"Chris Dy","startTime":131.88,"endTime":134.61,"body":"couldn't make it. It is one of"},{"speaker":"Chris Dy","startTime":134.61,"endTime":137.25,"body":"those things where it's actually"},{"speaker":"Chris Dy","startTime":134.61,"endTime":137.25,"body":"a meeting, I look forward to the"},{"speaker":"Chris Dy","startTime":137.25,"endTime":140.7,"body":"most of the year because I get"},{"speaker":"Chris Dy","startTime":137.25,"endTime":140.7,"body":"to learn so much. And I get to"},{"speaker":"Chris Dy","startTime":140.7,"endTime":144.0,"body":"meet people that I want to talk"},{"speaker":"Chris Dy","startTime":140.7,"endTime":144.0,"body":"to and clearly that was going to"},{"speaker":"Chris Dy","startTime":144.0,"endTime":148.26,"body":"be stunted by the everything"},{"speaker":"Chris Dy","startTime":144.0,"endTime":148.26,"body":"going on with with Omicron and"},{"speaker":"Chris Dy","startTime":148.26,"endTime":150.75,"body":"then washy with for issued its"},{"speaker":"Chris Dy","startTime":148.26,"endTime":150.75,"body":"own travel restriction."},{"speaker":"Charles A. Goldfarb","startTime":151.59,"endTime":153.0,"body":"Yes,"},{"speaker":"Charles A. Goldfarb","startTime":151.59,"endTime":153.0,"body":"interesting. I've never been to"},{"speaker":"Charles A. Goldfarb","startTime":153.0,"endTime":156.36,"body":"that meeting. I know that people"},{"speaker":"Charles A. Goldfarb","startTime":153.0,"endTime":156.36,"body":"who go feel strongly about it."},{"speaker":"Charles A. Goldfarb","startTime":157.62,"endTime":161.25,"body":"And I really feel for the"},{"speaker":"Charles A. Goldfarb","startTime":157.62,"endTime":161.25,"body":"meeting organizers because I"},{"speaker":"Charles A. Goldfarb","startTime":161.25,"endTime":164.52,"body":"think in the fall, we all felt"},{"speaker":"Charles A. Goldfarb","startTime":161.25,"endTime":164.52,"body":"pretty good about where we were"},{"speaker":"Charles A. Goldfarb","startTime":164.52,"endTime":167.88,"body":"and prospects for meetings. And"},{"speaker":"Charles A. Goldfarb","startTime":164.52,"endTime":167.88,"body":"I still haven't been to a major"},{"speaker":"Charles A. Goldfarb","startTime":167.88,"endTime":171.96,"body":"meeting since I guess hand"},{"speaker":"Charles A. Goldfarb","startTime":167.88,"endTime":171.96,"body":"society 2019"},{"speaker":"Chris Dy","startTime":173.43,"endTime":175.86,"body":"Feels like a long"},{"speaker":"Chris Dy","startTime":173.43,"endTime":175.86,"body":"time. That said before you were"},{"speaker":"Chris Dy","startTime":175.86,"endTime":177.24,"body":"a famous podcaster."},{"speaker":"Charles A. Goldfarb","startTime":177.66,"endTime":181.05,"body":"That is"},{"speaker":"Charles A. Goldfarb","startTime":177.66,"endTime":181.05,"body":"very true. Very true. I don't"},{"speaker":"Charles A. Goldfarb","startTime":181.05,"endTime":183.75,"body":"know what it'll be like, I may"},{"speaker":"Charles A. Goldfarb","startTime":181.05,"endTime":183.75,"body":"have to wear sunglasses, right?"},{"speaker":"Unknown","startTime":183.0,"endTime":190.2,"body":"I think you'll be okay."},{"speaker":"Unknown","startTime":183.0,"endTime":190.2,"body":"So I you know, I have a really"},{"speaker":"Unknown","startTime":190.2,"endTime":193.95,"body":"interesting case that came into"},{"speaker":"Unknown","startTime":190.2,"endTime":193.95,"body":"my clinic recently. And I know"},{"speaker":"Unknown","startTime":193.95,"endTime":196.92,"body":"that you've probably treated"},{"speaker":"Unknown","startTime":193.95,"endTime":196.92,"body":"some similar cases, but I had a"},{"speaker":"Unknown","startTime":196.92,"endTime":202.89,"body":"case of Kienbocks come in. And"},{"speaker":"Unknown","startTime":196.92,"endTime":202.89,"body":"she is in her 60s. And was"},{"speaker":"Unknown","startTime":202.89,"endTime":205.83,"body":"referred to me because, you"},{"speaker":"Unknown","startTime":202.89,"endTime":205.83,"body":"know, the surgeon who was seeing"},{"speaker":"Unknown","startTime":205.83,"endTime":209.7,"body":"her wasn't quite sure what to"},{"speaker":"Unknown","startTime":205.83,"endTime":209.7,"body":"do. And she has wrist pain,"},{"speaker":"Unknown","startTime":209.73,"endTime":213.36,"body":"that's dorsal and Central. She's"},{"speaker":"Unknown","startTime":209.73,"endTime":213.36,"body":"had it on and off, but really"},{"speaker":"Unknown","startTime":213.36,"endTime":217.83,"body":"gotten worse in the last few"},{"speaker":"Unknown","startTime":213.36,"endTime":217.83,"body":"months. And you examine her so"},{"speaker":"Unknown","startTime":217.83,"endTime":220.95,"body":"she was exquisitely tender over"},{"speaker":"Unknown","startTime":217.83,"endTime":220.95,"body":"her lunate hurts whenever you"},{"speaker":"Unknown","startTime":220.95,"endTime":225.27,"body":"passively move her wrist. And on"},{"speaker":"Unknown","startTime":220.95,"endTime":225.27,"body":"her radiographs. She's got a"},{"speaker":"Unknown","startTime":225.27,"endTime":227.34,"body":"little bit of sign of collapse."},{"speaker":"Unknown","startTime":225.27,"endTime":227.34,"body":"But the thing that was most"},{"speaker":"Unknown","startTime":227.34,"endTime":230.01,"body":"striking to me is that her"},{"speaker":"Unknown","startTime":227.34,"endTime":230.01,"body":"radioscaphoid angle is about 80"},{"speaker":"Unknown","startTime":230.01,"endTime":233.49,"body":"degrees. She came in with an"},{"speaker":"Unknown","startTime":230.01,"endTime":233.49,"body":"MRI. So we reviewed it together."},{"speaker":"Unknown","startTime":233.61,"endTime":237.84,"body":"And she's clearly got no signal"},{"speaker":"Unknown","startTime":233.61,"endTime":237.84,"body":"in the lunate  relative to her"},{"speaker":"Unknown","startTime":237.84,"endTime":243.06,"body":"adjacent purpose. So she's 60"},{"speaker":"Unknown","startTime":237.84,"endTime":243.06,"body":"ish. What did you do? I know"},{"speaker":"Unknown","startTime":243.06,"endTime":247.44,"body":"that doesn't seem like you know,"},{"speaker":"Unknown","startTime":243.06,"endTime":247.44,"body":"very old compared to you. But,"},{"speaker":"Unknown","startTime":247.59,"endTime":251.16,"body":"you know, what do you do in that"},{"speaker":"Unknown","startTime":247.59,"endTime":251.16,"body":"case? Oh, and I should say she's"},{"speaker":"Unknown","startTime":251.55,"endTime":253.2,"body":"on their neutral? Yeah, well,"},{"speaker":"Charles A. Goldfarb","startTime":253.2,"endTime":255.48,"body":"60 does not"},{"speaker":"Charles A. Goldfarb","startTime":253.2,"endTime":255.48,"body":"seem far away. It's right around"},{"speaker":"Charles A. Goldfarb","startTime":255.48,"endTime":260.85,"body":"the next bend. Actually. It's a"},{"speaker":"Charles A. Goldfarb","startTime":255.48,"endTime":260.85,"body":"great case. I think there are,"},{"speaker":"Charles A. Goldfarb","startTime":261.42,"endTime":264.06,"body":"if you this is one of those"},{"speaker":"Charles A. Goldfarb","startTime":261.42,"endTime":264.06,"body":"situations and I do say this in"},{"speaker":"Charles A. Goldfarb","startTime":264.06,"endTime":267.9,"body":"clinic to people. If you talk to"},{"speaker":"Charles A. Goldfarb","startTime":264.06,"endTime":267.9,"body":"10 hand surgeons, you will very"},{"speaker":"Charles A. Goldfarb","startTime":267.9,"endTime":270.15,"body":"likely get three different"},{"speaker":"Charles A. Goldfarb","startTime":267.9,"endTime":270.15,"body":"answers to this clinical"},{"speaker":"Charles A. Goldfarb","startTime":270.15,"endTime":273.51,"body":"scenario. And then I would go on"},{"speaker":"Charles A. Goldfarb","startTime":270.15,"endTime":273.51,"body":"to say here's why I think this"},{"speaker":"Charles A. Goldfarb","startTime":273.51,"endTime":276.57,"body":"option makes sense for you. But"},{"speaker":"Charles A. Goldfarb","startTime":273.51,"endTime":276.57,"body":"I would share different options."},{"speaker":"Charles A. Goldfarb","startTime":276.78,"endTime":277.17,"body":"And at"},{"speaker":"Chris Dy","startTime":277.17,"endTime":279.06,"body":"that time that I would"},{"speaker":"Chris Dy","startTime":277.17,"endTime":279.06,"body":"probably say if you talk to 10"},{"speaker":"Chris Dy","startTime":279.06,"endTime":281.37,"body":"Hand Surgeons is you're gonna"},{"speaker":"Chris Dy","startTime":279.06,"endTime":281.37,"body":"get 13 opinions. That's what"},{"speaker":"Chris Dy","startTime":281.37,"endTime":283.53,"body":"that's the line that I use and"},{"speaker":"Chris Dy","startTime":281.37,"endTime":283.53,"body":"actually use that last week and"},{"speaker":"Chris Dy","startTime":283.53,"endTime":284.04,"body":"click"},{"speaker":"Charles A. Goldfarb","startTime":285.48,"endTime":288.66,"body":"through all"},{"speaker":"Charles A. Goldfarb","startTime":285.48,"endTime":288.66,"body":"that you want to talk through"},{"speaker":"Charles A. Goldfarb","startTime":288.69,"endTime":292.08,"body":"the options we would consider"},{"speaker":"Charles A. Goldfarb","startTime":288.69,"endTime":292.08,"body":"for this and then you can guys"},{"speaker":"Charles A. Goldfarb","startTime":292.08,"endTime":295.02,"body":"zero in on the one that appeals"},{"speaker":"Charles A. Goldfarb","startTime":292.08,"endTime":295.02,"body":"to you and I can share the one"},{"speaker":"Charles A. Goldfarb","startTime":295.02,"endTime":296.01,"body":"that appeals most to me."},{"speaker":"Chris Dy","startTime":296.55,"endTime":298.08,"body":"Sure. Well, I mean,"},{"speaker":"Chris Dy","startTime":296.55,"endTime":298.08,"body":"the first one that's on the"},{"speaker":"Chris Dy","startTime":298.08,"endTime":301.41,"body":"table is non operative"},{"speaker":"Chris Dy","startTime":298.08,"endTime":301.41,"body":"treatment. You kind of know"},{"speaker":"Chris Dy","startTime":301.41,"endTime":305.52,"body":"where this story's going. But at"},{"speaker":"Chris Dy","startTime":301.41,"endTime":305.52,"body":"the end of the day, in my book,"},{"speaker":"Chris Dy","startTime":305.52,"endTime":307.65,"body":"she's going to get the same"},{"speaker":"Chris Dy","startTime":305.52,"endTime":307.65,"body":"treatment, whether I do it next"},{"speaker":"Chris Dy","startTime":307.65,"endTime":311.76,"body":"week, or in five years. And I"},{"speaker":"Chris Dy","startTime":307.65,"endTime":311.76,"body":"would include things like"},{"speaker":"Chris Dy","startTime":311.76,"endTime":316.56,"body":"adaptive, you know, modalities"},{"speaker":"Chris Dy","startTime":311.76,"endTime":316.56,"body":"and stuff with therapy, you"},{"speaker":"Chris Dy","startTime":316.56,"endTime":320.43,"body":"know, my activity modification,"},{"speaker":"Chris Dy","startTime":316.56,"endTime":320.43,"body":"and also steroid injection, I"},{"speaker":"Chris Dy","startTime":320.43,"endTime":323.04,"body":"think that is clearly a"},{"speaker":"Chris Dy","startTime":320.43,"endTime":323.04,"body":"reasonable way to go in a"},{"speaker":"Chris Dy","startTime":323.04,"endTime":326.82,"body":"patient of this age, with keen"},{"speaker":"Chris Dy","startTime":323.04,"endTime":326.82,"body":"box disease that's looking a"},{"speaker":"Chris Dy","startTime":326.82,"endTime":330.12,"body":"little more advanced. So that's"},{"speaker":"Chris Dy","startTime":326.82,"endTime":330.12,"body":"where I would honestly start,"},{"speaker":"Chris Dy","startTime":330.12,"endTime":331.2,"body":"and I offer that to her."},{"speaker":"Charles A. Goldfarb","startTime":331.799,"endTime":333.659,"body":"I think"},{"speaker":"Charles A. Goldfarb","startTime":331.799,"endTime":333.659,"body":"that's very reasonable, it does"},{"speaker":"Charles A. Goldfarb","startTime":333.659,"endTime":340.079,"body":"raise the question of Natural"},{"speaker":"Charles A. Goldfarb","startTime":333.659,"endTime":340.079,"body":"History, and age based"},{"speaker":"Charles A. Goldfarb","startTime":340.079,"endTime":343.439,"body":"determination of treatment. And"},{"speaker":"Charles A. Goldfarb","startTime":340.079,"endTime":343.439,"body":"so, you know, I don't think I"},{"speaker":"Charles A. Goldfarb","startTime":343.439,"endTime":347.879,"body":"would start there with a 15 year"},{"speaker":"Charles A. Goldfarb","startTime":343.439,"endTime":347.879,"body":"old. And I certainly don't have"},{"speaker":"Charles A. Goldfarb","startTime":347.879,"endTime":351.179,"body":"much of a role for steroid"},{"speaker":"Charles A. Goldfarb","startTime":347.879,"endTime":351.179,"body":"injections in younger patients,"},{"speaker":"Charles A. Goldfarb","startTime":351.179,"endTime":356.099,"body":"although one to me is never an"},{"speaker":"Charles A. Goldfarb","startTime":351.179,"endTime":356.099,"body":"issue. But totally agree with"},{"speaker":"Charles A. Goldfarb","startTime":356.099,"endTime":359.219,"body":"that as a starting point for"},{"speaker":"Charles A. Goldfarb","startTime":356.099,"endTime":359.219,"body":"management in this patient,"},{"speaker":"Charles A. Goldfarb","startTime":359.219,"endTime":363.119,"body":"especially given that her SL"},{"speaker":"Charles A. Goldfarb","startTime":359.219,"endTime":363.119,"body":"angle, I'm sorry, her radio"},{"speaker":"Charles A. Goldfarb","startTime":363.119,"endTime":365.549,"body":"scaphoid angle is a degrees."},{"speaker":"Chris Dy","startTime":366.21,"endTime":368.43,"body":"So I mean, before we"},{"speaker":"Chris Dy","startTime":366.21,"endTime":368.43,"body":"dive into the other treatment"},{"speaker":"Chris Dy","startTime":368.43,"endTime":371.37,"body":"options, how do you think about"},{"speaker":"Chris Dy","startTime":368.43,"endTime":371.37,"body":"the natural history of this"},{"speaker":"Chris Dy","startTime":371.37,"endTime":373.8,"body":"condition? I mean, how do you"},{"speaker":"Chris Dy","startTime":371.37,"endTime":373.8,"body":"think about the pathogenesis of"},{"speaker":"Chris Dy","startTime":373.8,"endTime":376.08,"body":"this condition? One of our"},{"speaker":"Chris Dy","startTime":373.8,"endTime":376.08,"body":"listeners and friends of the"},{"speaker":"Chris Dy","startTime":376.08,"endTime":379.98,"body":"podcast, Rob Gray, told me on a"},{"speaker":"Chris Dy","startTime":376.08,"endTime":379.98,"body":"tweet that he thinks COVID is"},{"speaker":"Chris Dy","startTime":379.98,"endTime":382.62,"body":"going to lead to a bunch of"},{"speaker":"Chris Dy","startTime":379.98,"endTime":382.62,"body":"ischemic related conditions like"},{"speaker":"Chris Dy","startTime":382.62,"endTime":385.26,"body":"kidbox. And he thinks he's"},{"speaker":"Chris Dy","startTime":382.62,"endTime":385.26,"body":"right. I mean, Rob thinks he's"},{"speaker":"Chris Dy","startTime":385.26,"endTime":387.27,"body":"right all the time. I love your"},{"speaker":"Chris Dy","startTime":385.26,"endTime":387.27,"body":"job. But you know, you're never"},{"speaker":"Chris Dy","startTime":387.27,"endTime":387.84,"body":"wrong. Right."},{"speaker":"Charles A. Goldfarb","startTime":388.35,"endTime":389.7,"body":"It's a"},{"speaker":"Charles A. Goldfarb","startTime":388.35,"endTime":389.7,"body":"great question. I don't know"},{"speaker":"Charles A. Goldfarb","startTime":389.7,"endTime":391.65,"body":"that I disagree with Rob, I"},{"speaker":"Charles A. Goldfarb","startTime":389.7,"endTime":391.65,"body":"certainly have been seeing"},{"speaker":"Charles A. Goldfarb","startTime":391.65,"endTime":394.02,"body":"Kienbocks, but I haven't"},{"speaker":"Charles A. Goldfarb","startTime":391.65,"endTime":394.02,"body":"necessarily attributed that to"},{"speaker":"Charles A. Goldfarb","startTime":394.02,"endTime":399.06,"body":"COVID. I, I've been, you know,"},{"speaker":"Charles A. Goldfarb","startTime":394.02,"endTime":399.06,"body":"one a month, I think over the"},{"speaker":"Charles A. Goldfarb","startTime":399.06,"endTime":403.65,"body":"last six to nine months, which"},{"speaker":"Charles A. Goldfarb","startTime":399.06,"endTime":403.65,"body":"to me feels like a lot of keybox"},{"speaker":"Charles A. Goldfarb","startTime":404.4,"endTime":407.01,"body":"have not directly related to"},{"speaker":"Charles A. Goldfarb","startTime":404.4,"endTime":407.01,"body":"whether they've been positive"},{"speaker":"Charles A. Goldfarb","startTime":407.01,"endTime":411.57,"body":"for COVID or not. There's no"},{"speaker":"Charles A. Goldfarb","startTime":407.01,"endTime":411.57,"body":"great that there's no good"},{"speaker":"Charles A. Goldfarb","startTime":411.6,"endTime":415.23,"body":"natural history studies out"},{"speaker":"Charles A. Goldfarb","startTime":411.6,"endTime":415.23,"body":"there. I think our assumption is"},{"speaker":"Charles A. Goldfarb","startTime":415.44,"endTime":419.61,"body":"that whatever the ideology, and"},{"speaker":"Charles A. Goldfarb","startTime":415.44,"endTime":419.61,"body":"we can make all kind of"},{"speaker":"Charles A. Goldfarb","startTime":420.27,"endTime":422.7,"body":"hypotheses, I think it certainly"},{"speaker":"Charles A. Goldfarb","startTime":420.27,"endTime":422.7,"body":"there are some that are"},{"speaker":"Charles A. Goldfarb","startTime":422.7,"endTime":427.47,"body":"idiopathic that are some that"},{"speaker":"Charles A. Goldfarb","startTime":422.7,"endTime":427.47,"body":"are steroid related. And there's"},{"speaker":"Charles A. Goldfarb","startTime":427.47,"endTime":429.54,"body":"some potentially or post"},{"speaker":"Charles A. Goldfarb","startTime":427.47,"endTime":429.54,"body":"traumatic, but whatever the"},{"speaker":"Charles A. Goldfarb","startTime":429.54,"endTime":436.56,"body":"ideology. You know, the worry is"},{"speaker":"Charles A. Goldfarb","startTime":429.54,"endTime":436.56,"body":"when the loonie collapses, then"},{"speaker":"Charles A. Goldfarb","startTime":436.56,"endTime":441.6,"body":"you have essentially flexion of"},{"speaker":"Charles A. Goldfarb","startTime":436.56,"endTime":441.6,"body":"the scaphoid. And the"},{"speaker":"Charles A. Goldfarb","startTime":441.6,"endTime":445.14,"body":"biomechanics of the wrist change"},{"speaker":"Charles A. Goldfarb","startTime":441.6,"endTime":445.14,"body":"in arthritis ultimately"},{"speaker":"Charles A. Goldfarb","startTime":445.14,"endTime":450.81,"body":"develops. And so seeing that"},{"speaker":"Charles A. Goldfarb","startTime":445.14,"endTime":450.81,"body":"early patient, especially in the"},{"speaker":"Charles A. Goldfarb","startTime":450.81,"endTime":455.61,"body":"younger age group worries me"},{"speaker":"Charles A. Goldfarb","startTime":450.81,"endTime":455.61,"body":"that if I don't treat them"},{"speaker":"Charles A. Goldfarb","startTime":455.61,"endTime":458.31,"body":"proactively, I could regret it."},{"speaker":"Chris Dy","startTime":459.54,"endTime":462.45,"body":"Yeah, so I mean, I"},{"speaker":"Chris Dy","startTime":459.54,"endTime":462.45,"body":"think that for those listeners"},{"speaker":"Chris Dy","startTime":462.45,"endTime":464.85,"body":"that are not as familiar with"},{"speaker":"Chris Dy","startTime":462.45,"endTime":464.85,"body":"Kienbocks, we're talking about,"},{"speaker":"Chris Dy","startTime":464.88,"endTime":467.82,"body":"you know, in a vascular necrosis"},{"speaker":"Chris Dy","startTime":464.88,"endTime":467.82,"body":"of the loonie, so blood supply"},{"speaker":"Chris Dy","startTime":467.82,"endTime":471.66,"body":"for whatever reason gets cut off"},{"speaker":"Chris Dy","startTime":467.82,"endTime":471.66,"body":"to the lunate. The lunate is"},{"speaker":"Chris Dy","startTime":471.69,"endTime":474.54,"body":"dying, a slow death, usually a"},{"speaker":"Chris Dy","startTime":471.69,"endTime":474.54,"body":"slow death, maybe a fast one"},{"speaker":"Chris Dy","startTime":474.54,"endTime":478.14,"body":"sometimes. And you know, just"},{"speaker":"Chris Dy","startTime":474.54,"endTime":478.14,"body":"like all the other conditions we"},{"speaker":"Chris Dy","startTime":478.14,"endTime":483.69,"body":"talked about related to the"},{"speaker":"Chris Dy","startTime":478.14,"endTime":483.69,"body":"scapholunate joint , anytime"},{"speaker":"Chris Dy","startTime":483.69,"endTime":486.33,"body":"there's a break in the integrity"},{"speaker":"Chris Dy","startTime":483.69,"endTime":486.33,"body":"of the scaphoid and lunate"},{"speaker":"Chris Dy","startTime":486.36,"endTime":489.96,"body":"whether it's through a scaphoid"},{"speaker":"Chris Dy","startTime":486.36,"endTime":489.96,"body":"nonunion or through an SL"},{"speaker":"Chris Dy","startTime":489.96,"endTime":493.65,"body":"ligament tear, or through"},{"speaker":"Chris Dy","startTime":489.96,"endTime":493.65,"body":"Kienbocks escape, little flex,"},{"speaker":"Chris Dy","startTime":493.68,"endTime":495.75,"body":"and when the scaffold flexes, it"},{"speaker":"Chris Dy","startTime":493.68,"endTime":495.75,"body":"does bad things."},{"speaker":"Charles A. Goldfarb","startTime":496.53,"endTime":497.82,"body":"I think"},{"speaker":"Charles A. Goldfarb","startTime":496.53,"endTime":497.82,"body":"that's well summarized,"},{"speaker":"Charles A. Goldfarb","startTime":497.88,"endTime":501.09,"body":"absolutely well summarized. And"},{"speaker":"Charles A. Goldfarb","startTime":497.88,"endTime":501.09,"body":"so, you know, some of our"},{"speaker":"Charles A. Goldfarb","startTime":501.09,"endTime":506.4,"body":"treatments are designed to save"},{"speaker":"Charles A. Goldfarb","startTime":501.09,"endTime":506.4,"body":"the lemonade, so to speak. And"},{"speaker":"Charles A. Goldfarb","startTime":506.4,"endTime":510.63,"body":"some of our treatments are"},{"speaker":"Charles A. Goldfarb","startTime":506.4,"endTime":510.63,"body":"almost ignoring the lemonade,"},{"speaker":"Charles A. Goldfarb","startTime":510.87,"endTime":516.54,"body":"and trying to take care of the"},{"speaker":"Charles A. Goldfarb","startTime":510.87,"endTime":516.54,"body":"pain only. And so that's why the"},{"speaker":"Charles A. Goldfarb","startTime":516.54,"endTime":520.95,"body":"suggestion of non surgical care"},{"speaker":"Charles A. Goldfarb","startTime":516.54,"endTime":520.95,"body":"is really trying to just"},{"speaker":"Charles A. Goldfarb","startTime":520.95,"endTime":524.43,"body":"modulate the pain without doing"},{"speaker":"Charles A. Goldfarb","startTime":520.95,"endTime":524.43,"body":"anything specifically different."},{"speaker":"Unknown","startTime":525.08,"endTime":527.69,"body":"How do you think about"},{"speaker":"Unknown","startTime":525.08,"endTime":527.69,"body":"the the role of ulnar variants"},{"speaker":"Unknown","startTime":527.69,"endTime":530.39,"body":"and Kienbocks? Because one of"},{"speaker":"Unknown","startTime":527.69,"endTime":530.39,"body":"our mentors had, you know,"},{"speaker":"Unknown","startTime":530.57,"endTime":533.24,"body":"Richard Gelberman had talked"},{"speaker":"Unknown","startTime":530.57,"endTime":533.24,"body":"about had written some papers"},{"speaker":"Unknown","startTime":533.24,"endTime":535.91,"body":"about the role of potentially"},{"speaker":"Unknown","startTime":533.24,"endTime":535.91,"body":"have all their negative variants"},{"speaker":"Unknown","startTime":535.91,"endTime":538.76,"body":"contributing to keen box"},{"speaker":"Unknown","startTime":535.91,"endTime":538.76,"body":"disease. But there's also been,"},{"speaker":"Unknown","startTime":538.94,"endTime":542.6,"body":"in decades later, contradictory"},{"speaker":"Unknown","startTime":538.94,"endTime":542.6,"body":"evidence about all their"},{"speaker":"Unknown","startTime":542.6,"endTime":545.9,"body":"positive variants contributing"},{"speaker":"Unknown","startTime":542.6,"endTime":545.9,"body":"to the inbox disease. Now one of"},{"speaker":"Unknown","startTime":545.9,"endTime":548.72,"body":"the underpinnings of treatment"},{"speaker":"Unknown","startTime":545.9,"endTime":548.72,"body":"is radial shortening osteotomy"},{"speaker":"Unknown","startTime":548.72,"endTime":551.93,"body":"in the setting of another"},{"speaker":"Unknown","startTime":548.72,"endTime":551.93,"body":"negative variance. How do you"},{"speaker":"Unknown","startTime":551.93,"endTime":555.71,"body":"view that conflicting literature"},{"speaker":"Unknown","startTime":551.93,"endTime":555.71,"body":"in 2022?"},{"speaker":"Unknown","startTime":556.79,"endTime":559.82,"body":"I don't think any of our"},{"speaker":"Unknown","startTime":556.79,"endTime":559.82,"body":"listeners or anyone who knows"},{"speaker":"Unknown","startTime":559.82,"endTime":565.13,"body":"the literature would argue that"},{"speaker":"Unknown","startTime":559.82,"endTime":565.13,"body":"shortening the radius helps"},{"speaker":"Unknown","startTime":565.16,"endTime":569.24,"body":"symptomatically with gearboxes,"},{"speaker":"Unknown","startTime":565.16,"endTime":569.24,"body":"it absolutely helps with the"},{"speaker":"Unknown","startTime":569.24,"endTime":572.15,"body":"pain. It's a very reliable"},{"speaker":"Unknown","startTime":569.24,"endTime":572.15,"body":"treatments not perfect. It's a"},{"speaker":"Unknown","startTime":572.15,"endTime":578.57,"body":"very reliable treatment. I"},{"speaker":"Unknown","startTime":572.15,"endTime":578.57,"body":"certainly haven't. I wouldn't"},{"speaker":"Unknown","startTime":578.57,"endTime":582.89,"body":"say that I truly understand the"},{"speaker":"Unknown","startTime":578.57,"endTime":582.89,"body":"role of owner variants. In the"},{"speaker":"Unknown","startTime":582.89,"endTime":587.03,"body":"development of Kienbocks, I"},{"speaker":"Unknown","startTime":582.89,"endTime":587.03,"body":"simplify it for my own mind and"},{"speaker":"Unknown","startTime":587.03,"endTime":590.69,"body":"for discussion with patients in"},{"speaker":"Unknown","startTime":587.03,"endTime":590.69,"body":"that when I shorten the radius,"},{"speaker":"Unknown","startTime":590.75,"endTime":595.16,"body":"I changed the loading of the"},{"speaker":"Unknown","startTime":590.75,"endTime":595.16,"body":"lunate and therefore help pain"},{"speaker":"Unknown","startTime":595.16,"endTime":598.76,"body":"and hopefully modulate the"},{"speaker":"Unknown","startTime":595.16,"endTime":598.76,"body":"natural history."},{"speaker":"Unknown","startTime":600.02,"endTime":603.8,"body":"So yeah, I think you said it"},{"speaker":"Unknown","startTime":600.02,"endTime":603.8,"body":"very carefully, which is"},{"speaker":"Unknown","startTime":603.8,"endTime":607.76,"body":"important to distinguish. It"},{"speaker":"Unknown","startTime":603.8,"endTime":607.76,"body":"helps with symptoms. I don't"},{"speaker":"Unknown","startTime":607.76,"endTime":610.55,"body":"know whether it changes the"},{"speaker":"Unknown","startTime":607.76,"endTime":610.55,"body":"natural history, I think that we"},{"speaker":"Unknown","startTime":610.55,"endTime":612.83,"body":"have a good sense that, you"},{"speaker":"Unknown","startTime":610.55,"endTime":612.83,"body":"know, you exam somebody with"},{"speaker":"Unknown","startTime":612.83,"endTime":615.74,"body":"cane box. And if they're pre"},{"speaker":"Unknown","startTime":612.83,"endTime":615.74,"body":"collapse, and they're tender"},{"speaker":"Unknown","startTime":615.74,"endTime":618.77,"body":"over their lunate, you change"},{"speaker":"Unknown","startTime":615.74,"endTime":618.77,"body":"the variance, however you change"},{"speaker":"Unknown","startTime":618.77,"endTime":622.19,"body":"it. Usually they get better in"},{"speaker":"Unknown","startTime":618.77,"endTime":622.19,"body":"terms of not being tender. And"},{"speaker":"Unknown","startTime":622.19,"endTime":624.02,"body":"some would argue you don't even"},{"speaker":"Unknown","startTime":622.19,"endTime":624.02,"body":"need to change a variance, you"},{"speaker":"Unknown","startTime":624.02,"endTime":626.72,"body":"could potentially just do a"},{"speaker":"Unknown","startTime":624.02,"endTime":626.72,"body":"metaphyseal core decompression"},{"speaker":"Unknown","startTime":626.72,"endTime":628.85,"body":"of the distal radius. I know"},{"speaker":"Unknown","startTime":626.72,"endTime":628.85,"body":"there's literature out there for"},{"speaker":"Unknown","startTime":628.85,"endTime":631.79,"body":"that. I mean, what do you think"},{"speaker":"Unknown","startTime":628.85,"endTime":631.79,"body":"about first off the core"},{"speaker":"Unknown","startTime":631.79,"endTime":633.92,"body":"decompression technique? And"},{"speaker":"Unknown","startTime":631.79,"endTime":633.92,"body":"then second off, if you have"},{"speaker":"Unknown","startTime":633.92,"endTime":636.62,"body":"somebody on their positive, do"},{"speaker":"Unknown","startTime":633.92,"endTime":636.62,"body":"you just shorten the ulna?"},{"speaker":"Unknown","startTime":638.48,"endTime":642.65,"body":"Okay, so, yeah, so there's a lot"},{"speaker":"Unknown","startTime":638.48,"endTime":642.65,"body":"there. So I guess I would say"},{"speaker":"Unknown","startTime":642.65,"endTime":645.5,"body":"part of my challenge with"},{"speaker":"Unknown","startTime":642.65,"endTime":645.5,"body":"Kienbocks, and part of the"},{"speaker":"Unknown","startTime":645.5,"endTime":650.33,"body":"challenge of reporting outcomes"},{"speaker":"Unknown","startTime":645.5,"endTime":650.33,"body":"is, at least in my hands, I"},{"speaker":"Unknown","startTime":650.36,"endTime":655.61,"body":"often offer more than one"},{"speaker":"Unknown","startTime":650.36,"endTime":655.61,"body":"treatment simultaneously. And so"},{"speaker":"Unknown","startTime":655.61,"endTime":659.42,"body":"in a younger patient, who is"},{"speaker":"Unknown","startTime":655.61,"endTime":659.42,"body":"ulnar negative, and so again,"},{"speaker":"Unknown","startTime":659.42,"endTime":661.91,"body":"just to be clear, for those"},{"speaker":"Unknown","startTime":659.42,"endTime":661.91,"body":"listeners who are not 100%, with"},{"speaker":"Unknown","startTime":661.91,"endTime":665.3,"body":"us, all their negative is"},{"speaker":"Unknown","startTime":661.91,"endTime":665.3,"body":"obviously that the ulna is"},{"speaker":"Unknown","startTime":665.3,"endTime":668.93,"body":"shorter than the radius. And so"},{"speaker":"Unknown","startTime":665.3,"endTime":668.93,"body":"you can then shorten the radius"},{"speaker":"Unknown","startTime":668.93,"endTime":671.24,"body":"by a couple of millimeters, I"},{"speaker":"Unknown","startTime":668.93,"endTime":671.24,"body":"don't think anyone's ever"},{"speaker":"Unknown","startTime":671.51,"endTime":674.6,"body":"concluded that the amount"},{"speaker":"Unknown","startTime":671.51,"endTime":674.6,"body":"shorten matters is just the fact"},{"speaker":"Unknown","startTime":674.6,"endTime":677.57,"body":"that you are shortening the"},{"speaker":"Unknown","startTime":674.6,"endTime":677.57,"body":"radius. And you can do so"},{"speaker":"Unknown","startTime":677.57,"endTime":680.45,"body":"without risking on a carpal"},{"speaker":"Unknown","startTime":677.57,"endTime":680.45,"body":"impaction, or owner side of"},{"speaker":"Unknown","startTime":680.45,"endTime":685.46,"body":"wrist pain. But what I often do"},{"speaker":"Unknown","startTime":680.45,"endTime":685.46,"body":"is I combined treatments. So in"},{"speaker":"Unknown","startTime":685.46,"endTime":689.57,"body":"my in my, in the last year, at"},{"speaker":"Unknown","startTime":685.46,"endTime":689.57,"body":"least a half dozen times, and"},{"speaker":"Unknown","startTime":689.57,"endTime":693.62,"body":"some of it colored by our, our"},{"speaker":"Unknown","startTime":689.57,"endTime":693.62,"body":"Outstanding Guest, Steve Moran,"},{"speaker":"Unknown","startTime":693.8,"endTime":697.73,"body":"I often perform a radius"},{"speaker":"Unknown","startTime":693.8,"endTime":697.73,"body":"shortening, osteotomy and a"},{"speaker":"Unknown","startTime":697.73,"endTime":702.83,"body":"revascularisation of the lunate."},{"speaker":"Unknown","startTime":697.73,"endTime":702.83,"body":"I think that shortening the"},{"speaker":"Unknown","startTime":702.83,"endTime":706.79,"body":"radius, a core decompression,"},{"speaker":"Unknown","startTime":702.83,"endTime":706.79,"body":"and we should probably explain"},{"speaker":"Unknown","startTime":706.79,"endTime":710.15,"body":"what that means. And"},{"speaker":"Unknown","startTime":706.79,"endTime":710.15,"body":"traditionally, people talk about"},{"speaker":"Unknown","startTime":710.15,"endTime":714.32,"body":"a closing wedge osteotomy to"},{"speaker":"Unknown","startTime":710.15,"endTime":714.32,"body":"decrease the the inclination of"},{"speaker":"Unknown","startTime":714.32,"endTime":718.25,"body":"the radius, all achieve the same"},{"speaker":"Unknown","startTime":714.32,"endTime":718.25,"body":"goal, which is somehow or"},{"speaker":"Unknown","startTime":718.25,"endTime":721.73,"body":"another, changing loading"},{"speaker":"Unknown","startTime":718.25,"endTime":721.73,"body":"patterns changing vascularity in"},{"speaker":"Unknown","startTime":721.73,"endTime":722.6,"body":"the area of ballooning."},{"speaker":"Chris Dy","startTime":723.17,"endTime":724.43,"body":"Feel very sportsy."},{"speaker":"Charles A. Goldfarb","startTime":726.05,"endTime":727.19,"body":"That's"},{"speaker":"Charles A. Goldfarb","startTime":726.05,"endTime":727.19,"body":"dangerous."},{"speaker":"Unknown","startTime":727.49,"endTime":730.46,"body":"That's why you like it."},{"speaker":"Unknown","startTime":727.49,"endTime":730.46,"body":"That's why you like it. Yeah, it"},{"speaker":"Unknown","startTime":730.46,"endTime":733.25,"body":"works. Honestly, it works. And I"},{"speaker":"Unknown","startTime":730.46,"endTime":733.25,"body":"think that if there's a bright"},{"speaker":"Unknown","startTime":733.25,"endTime":736.28,"body":"young hand therapist or hand"},{"speaker":"Unknown","startTime":733.25,"endTime":736.28,"body":"surgeon and wants to study this,"},{"speaker":"Unknown","startTime":736.31,"endTime":739.67,"body":"I mean, it's it's a condition"},{"speaker":"Unknown","startTime":736.31,"endTime":739.67,"body":"that'll it'll be around. And,"},{"speaker":"Unknown","startTime":739.94,"endTime":743.3,"body":"you know, I think you can learn"},{"speaker":"Unknown","startTime":739.94,"endTime":743.3,"body":"a lot about the carpus through"},{"speaker":"Unknown","startTime":743.3,"endTime":747.65,"body":"with keen box as the lens. And"},{"speaker":"Unknown","startTime":743.3,"endTime":747.65,"body":"it's very, you can tell a very"},{"speaker":"Unknown","startTime":747.65,"endTime":750.05,"body":"compelling story with Kienbocks"},{"speaker":"Unknown","startTime":747.65,"endTime":750.05,"body":"in terms of the images and"},{"speaker":"Unknown","startTime":750.05,"endTime":752.03,"body":"pictures. I'm just thinking"},{"speaker":"Unknown","startTime":750.05,"endTime":752.03,"body":"about writing how you could"},{"speaker":"Unknown","startTime":752.03,"endTime":753.83,"body":"write a grant or something like"},{"speaker":"Unknown","startTime":752.03,"endTime":753.83,"body":"that. But you could definitely"},{"speaker":"Unknown","startTime":753.83,"endTime":755.21,"body":"tell a story with Kienbocks."},{"speaker":"Unknown","startTime":755.69,"endTime":761.24,"body":"For sure. One of the challenges"},{"speaker":"Unknown","startTime":755.69,"endTime":761.24,"body":"that I think our group helped"},{"speaker":"Unknown","startTime":761.24,"endTime":766.52,"body":"with was how do you even"},{"speaker":"Unknown","startTime":761.24,"endTime":766.52,"body":"quantify whether the loon aid"},{"speaker":"Unknown","startTime":766.52,"endTime":769.28,"body":"has collapsed and whether the"},{"speaker":"Unknown","startTime":766.52,"endTime":769.28,"body":"carpus has collapsed around it,"},{"speaker":"Unknown","startTime":769.28,"endTime":773.09,"body":"which was Dr. Gelberman impetus"},{"speaker":"Unknown","startTime":769.28,"endTime":773.09,"body":"for kind of leading the effort"},{"speaker":"Unknown","startTime":773.09,"endTime":776.72,"body":"to show that the radioscaphoid"},{"speaker":"Unknown","startTime":773.09,"endTime":776.72,"body":"angle could be used as a proxy"},{"speaker":"Unknown","startTime":776.96,"endTime":779.93,"body":"to understand whether the carpus"},{"speaker":"Unknown","startTime":776.96,"endTime":779.93,"body":"was collapsing?"},{"speaker":"Chris Dy","startTime":780.2,"endTime":783.32,"body":"Now, let's not be too"},{"speaker":"Chris Dy","startTime":780.2,"endTime":783.32,"body":"humble, let's let's be honest,"},{"speaker":"Chris Dy","startTime":783.32,"endTime":786.47,"body":"who the first author on that"},{"speaker":"Chris Dy","startTime":783.32,"endTime":786.47,"body":"paper was it was a workman just"},{"speaker":"Chris Dy","startTime":786.47,"endTime":789.95,"body":"hammering nails, none other than"},{"speaker":"Chris Dy","startTime":786.47,"endTime":789.95,"body":"my co host. Chuck Goldfarb was"},{"speaker":"Chris Dy","startTime":789.95,"endTime":791.42,"body":"the lead author on that paper."},{"speaker":"Unknown","startTime":792.08,"endTime":794.45,"body":"Well, thank you, I'm"},{"speaker":"Unknown","startTime":792.08,"endTime":794.45,"body":"humbled, but I was just a worker"},{"speaker":"Unknown","startTime":794.45,"endTime":799.61,"body":"bee, let's be honest. But that's"},{"speaker":"Unknown","startTime":794.45,"endTime":799.61,"body":"a good example of why having a"},{"speaker":"Unknown","startTime":799.61,"endTime":802.88,"body":"senior partner like Dr."},{"speaker":"Unknown","startTime":799.61,"endTime":802.88,"body":"Gelberman, who could, you know,"},{"speaker":"Unknown","startTime":802.88,"endTime":807.08,"body":"had a had a vision. And I do"},{"speaker":"Unknown","startTime":802.88,"endTime":807.08,"body":"think it was impactful paper"},{"speaker":"Unknown","startTime":807.08,"endTime":812.78,"body":"certainly affected how you and I"},{"speaker":"Unknown","startTime":807.08,"endTime":812.78,"body":"think about defining carpal"},{"speaker":"Unknown","startTime":812.78,"endTime":815.03,"body":"collapse in Kienbocks."},{"speaker":"Unknown","startTime":815.87,"endTime":818.72,"body":"So looking for context, you"},{"speaker":"Unknown","startTime":815.87,"endTime":818.72,"body":"know, prior to the paper that"},{"speaker":"Unknown","startTime":818.96,"endTime":822.59,"body":"that Chuck and Dr. Gelberman"},{"speaker":"Unknown","startTime":818.96,"endTime":822.59,"body":"wrote, you would look at various"},{"speaker":"Unknown","startTime":822.59,"endTime":825.62,"body":"stages of collapse based on"},{"speaker":"Unknown","startTime":822.59,"endTime":825.62,"body":"carpal height. So you would look"},{"speaker":"Unknown","startTime":825.62,"endTime":829.37,"body":"at on like the PA radiograph of"},{"speaker":"Unknown","startTime":825.62,"endTime":829.37,"body":"the wrist, you would see, you"},{"speaker":"Unknown","startTime":829.37,"endTime":833.36,"body":"know how how much has the lunate"},{"speaker":"Unknown","startTime":829.37,"endTime":833.36,"body":"shrunk how much as the carpus as"},{"speaker":"Unknown","startTime":833.36,"endTime":836.36,"body":"a unit shrunk relative to"},{"speaker":"Unknown","startTime":833.36,"endTime":836.36,"body":"something constant, like the"},{"speaker":"Unknown","startTime":836.39,"endTime":840.44,"body":"length of the metacarpals. And"},{"speaker":"Unknown","startTime":836.39,"endTime":840.44,"body":"that ratio was always a little"},{"speaker":"Unknown","startTime":840.44,"endTime":842.87,"body":"bit tricky. And then on the"},{"speaker":"Unknown","startTime":840.44,"endTime":842.87,"body":"lateral view, you would try to"},{"speaker":"Unknown","startTime":842.87,"endTime":845.6,"body":"look at something like, you"},{"speaker":"Unknown","startTime":842.87,"endTime":845.6,"body":"know, the interest scaphoid"},{"speaker":"Unknown","startTime":845.6,"endTime":849.2,"body":"angle or the SL angle. But that"},{"speaker":"Unknown","startTime":845.6,"endTime":849.2,"body":"was always messy because you're"},{"speaker":"Unknown","startTime":849.2,"endTime":851.6,"body":"lunate. It's not normal. So how"},{"speaker":"Unknown","startTime":849.2,"endTime":851.6,"body":"could you rely on your say your"},{"speaker":"Unknown","startTime":851.6,"endTime":854.78,"body":"SL angle? So your Scaphoid"},{"speaker":"Unknown","startTime":851.6,"endTime":854.78,"body":"should be relatively"},{"speaker":"Unknown","startTime":854.84,"endTime":858.05,"body":"anatomically normal, although"},{"speaker":"Unknown","startTime":854.84,"endTime":858.05,"body":"it's going to be flexed down and"},{"speaker":"Unknown","startTime":858.05,"endTime":860.48,"body":"your radius is going to be"},{"speaker":"Unknown","startTime":858.05,"endTime":860.48,"body":"radius. But if you're looking at"},{"speaker":"Unknown","startTime":860.48,"endTime":863.24,"body":"the indirect effects, and the"},{"speaker":"Unknown","startTime":860.48,"endTime":863.24,"body":"long term effects of this of"},{"speaker":"Unknown","startTime":863.24,"endTime":867.2,"body":"keybox re escape what angles way"},{"speaker":"Unknown","startTime":863.24,"endTime":867.2,"body":"easier to measure? And what was"},{"speaker":"Unknown","startTime":867.2,"endTime":869.36,"body":"the number that you came up with"},{"speaker":"Unknown","startTime":867.2,"endTime":869.36,"body":"in terms of you know, whether"},{"speaker":"Unknown","startTime":869.36,"endTime":871.67,"body":"something was, you know, more"},{"speaker":"Unknown","startTime":869.36,"endTime":871.67,"body":"advanced or not, was it"},{"speaker":"Unknown","startTime":871.67,"endTime":873.14,"body":"something over 60 degrees, I"},{"speaker":"Unknown","startTime":871.67,"endTime":873.14,"body":"think,"},{"speaker":"Charles A. Goldfarb","startTime":873.53,"endTime":876.89,"body":"I think it"},{"speaker":"Charles A. Goldfarb","startTime":873.53,"endTime":876.89,"body":"was over 60 degrees. It's not a"},{"speaker":"Charles A. Goldfarb","startTime":876.89,"endTime":879.86,"body":"long time, but I think it was"},{"speaker":"Charles A. Goldfarb","startTime":876.89,"endTime":879.86,"body":"over 60 degrees. But the other"},{"speaker":"Charles A. Goldfarb","startTime":879.86,"endTime":884.51,"body":"interesting thing is one of the"},{"speaker":"Charles A. Goldfarb","startTime":879.86,"endTime":884.51,"body":"things that impeded research on"},{"speaker":"Charles A. Goldfarb","startTime":884.51,"endTime":888.11,"body":"this topic was the original"},{"speaker":"Charles A. Goldfarb","startTime":884.51,"endTime":888.11,"body":"requirement that you had to see"},{"speaker":"Charles A. Goldfarb","startTime":888.11,"endTime":891.71,"body":"the entire length of the third"},{"speaker":"Charles A. Goldfarb","startTime":888.11,"endTime":891.71,"body":"metacarpal. So right, right, in"},{"speaker":"Charles A. Goldfarb","startTime":891.71,"endTime":894.5,"body":"the olden days, when people like"},{"speaker":"Charles A. Goldfarb","startTime":891.71,"endTime":894.5,"body":"me would go look at the, you"},{"speaker":"Charles A. Goldfarb","startTime":894.5,"endTime":898.25,"body":"know, we'd pull all the X rays,"},{"speaker":"Charles A. Goldfarb","startTime":894.5,"endTime":898.25,"body":"we'd have a huge bundle of X"},{"speaker":"Charles A. Goldfarb","startTime":898.25,"endTime":900.71,"body":"rays, and we'd go pull out the"},{"speaker":"Charles A. Goldfarb","startTime":898.25,"endTime":900.71,"body":"we'd be Looking for a"},{"speaker":"Charles A. Goldfarb","startTime":900.71,"endTime":903.32,"body":"preoperative X ray, where you"},{"speaker":"Charles A. Goldfarb","startTime":900.71,"endTime":903.32,"body":"can see the whole third"},{"speaker":"Charles A. Goldfarb","startTime":903.32,"endTime":905.36,"body":"metacarpal and you wouldn't"},{"speaker":"Charles A. Goldfarb","startTime":903.32,"endTime":905.36,"body":"always see it so you could never"},{"speaker":"Charles A. Goldfarb","startTime":905.36,"endTime":908.42,"body":"calculate the angle. It's just"},{"speaker":"Charles A. Goldfarb","startTime":905.36,"endTime":908.42,"body":"interesting how very practical"},{"speaker":"Charles A. Goldfarb","startTime":908.42,"endTime":910.07,"body":"considerations affect our"},{"speaker":"Charles A. Goldfarb","startTime":908.42,"endTime":910.07,"body":"ability to"},{"speaker":"Unknown","startTime":910.07,"endTime":913.16,"body":"move the field forward."},{"speaker":"Unknown","startTime":910.07,"endTime":913.16,"body":"Absolutely. So actually, you"},{"speaker":"Unknown","startTime":913.16,"endTime":916.46,"body":"know, in preparation for this"},{"speaker":"Unknown","startTime":913.16,"endTime":916.46,"body":"episode, I talk a lot with our"},{"speaker":"Unknown","startTime":916.46,"endTime":919.58,"body":"residents and fellows about"},{"speaker":"Unknown","startTime":916.46,"endTime":919.58,"body":"taking notes. I pulled up my"},{"speaker":"Unknown","startTime":919.61,"endTime":924.8,"body":"Kienbocks disease notes from"},{"speaker":"Unknown","startTime":919.61,"endTime":924.8,"body":"last edit was on March 25 2015."},{"speaker":"Unknown","startTime":924.86,"endTime":928.97,"body":"And it says here, the Stahl"},{"speaker":"Unknown","startTime":924.86,"endTime":928.97,"body":"ratio, the modified carpal"},{"speaker":"Unknown","startTime":928.97,"endTime":932.39,"body":"hightened scaphoid ring sign are"},{"speaker":"Unknown","startTime":928.97,"endTime":932.39,"body":"not reliably different in 3A"},{"speaker":"Unknown","startTime":932.39,"endTime":938.87,"body":"versus 3b, Goldfarb, JHS 2003."},{"speaker":"Unknown","startTime":932.39,"endTime":938.87,"body":"So there you go. This is the"},{"speaker":"Unknown","startTime":938.87,"endTime":940.22,"body":"best measure radial scaphoid"},{"speaker":"Unknown","startTime":938.87,"endTime":940.22,"body":"angle."},{"speaker":"Charles A. Goldfarb","startTime":940.79,"endTime":943.1,"body":"Thank you."},{"speaker":"Charles A. Goldfarb","startTime":940.79,"endTime":943.1,"body":"I appreciate that. I don't know"},{"speaker":"Charles A. Goldfarb","startTime":943.1,"endTime":945.92,"body":"if it's widely accepted or not."},{"speaker":"Charles A. Goldfarb","startTime":943.1,"endTime":945.92,"body":"I don't have a sense of whether"},{"speaker":"Charles A. Goldfarb","startTime":945.92,"endTime":948.05,"body":"people use that to help their"},{"speaker":"Charles A. Goldfarb","startTime":945.92,"endTime":948.05,"body":"treatment."},{"speaker":"Unknown","startTime":949.13,"endTime":950.69,"body":"Well, so how do you"},{"speaker":"Unknown","startTime":949.13,"endTime":950.69,"body":"think about treatments? I mean,"},{"speaker":"Unknown","startTime":950.69,"endTime":953.45,"body":"so when is you mentioned this"},{"speaker":"Unknown","startTime":950.69,"endTime":953.45,"body":"big kind of is lunate"},{"speaker":"Unknown","startTime":953.45,"endTime":956.9,"body":"salvageable, are you going to"},{"speaker":"Unknown","startTime":953.45,"endTime":956.9,"body":"try to salvage the lunate? When"},{"speaker":"Unknown","startTime":956.9,"endTime":959.84,"body":"is it just too far gone? When"},{"speaker":"Unknown","startTime":956.9,"endTime":959.84,"body":"you no longer going to try"},{"speaker":"Unknown","startTime":959.84,"endTime":962.45,"body":"radial shortening alone? When do"},{"speaker":"Unknown","startTime":959.84,"endTime":962.45,"body":"you maybe need to bring"},{"speaker":"Unknown","startTime":962.45,"endTime":965.48,"body":"something some blood supply in"},{"speaker":"Unknown","startTime":962.45,"endTime":965.48,"body":"or when is that not even an"},{"speaker":"Unknown","startTime":965.48,"endTime":965.9,"body":"option?"},{"speaker":"Charles A. Goldfarb","startTime":967.07,"endTime":970.82,"body":"So, in"},{"speaker":"Charles A. Goldfarb","startTime":967.07,"endTime":970.82,"body":"patients with me, we just run"},{"speaker":"Charles A. Goldfarb","startTime":970.82,"endTime":976.52,"body":"through the the grading system"},{"speaker":"Charles A. Goldfarb","startTime":970.82,"endTime":976.52,"body":"real quickly. So the basis is"},{"speaker":"Charles A. Goldfarb","startTime":976.52,"endTime":981.8,"body":"the liquid classification right."},{"speaker":"Charles A. Goldfarb","startTime":976.52,"endTime":981.8,"body":"So stage one is radiographs, may"},{"speaker":"Charles A. Goldfarb","startTime":981.8,"endTime":984.14,"body":"we can just go back and forth"},{"speaker":"Charles A. Goldfarb","startTime":981.8,"endTime":984.14,"body":"stage one is radiographs look"},{"speaker":"Charles A. Goldfarb","startTime":984.14,"endTime":988.67,"body":"fine. But on MRI, you can see"},{"speaker":"Charles A. Goldfarb","startTime":984.14,"endTime":988.67,"body":"changes in the loonie."},{"speaker":"Chris Dy","startTime":989.54,"endTime":992.03,"body":"Or if you didn't have"},{"speaker":"Chris Dy","startTime":989.54,"endTime":992.03,"body":"an MRI back when things are"},{"speaker":"Chris Dy","startTime":992.03,"endTime":994.58,"body":"being described, perhaps just a"},{"speaker":"Chris Dy","startTime":992.03,"endTime":994.58,"body":"bone scan being positive. That's"},{"speaker":"Chris Dy","startTime":994.58,"endTime":998.87,"body":"what I have in my notes here."},{"speaker":"Chris Dy","startTime":994.58,"endTime":998.87,"body":"Yeah, back in a day. So then I"},{"speaker":"Chris Dy","startTime":998.87,"endTime":1002.11,"body":"have here as a stage to being"},{"speaker":"Chris Dy","startTime":998.87,"endTime":1002.11,"body":"you're seeing some sclerosis on"},{"speaker":"Chris Dy","startTime":1002.11,"endTime":1005.89,"body":"the plane films. And there's"},{"speaker":"Chris Dy","startTime":1002.11,"endTime":1005.89,"body":"some more density and illuminate"},{"speaker":"Chris Dy","startTime":1005.89,"endTime":1008.8,"body":"but there's no collapse and no"},{"speaker":"Chris Dy","startTime":1005.89,"endTime":1008.8,"body":"bleak films can be helpful for"},{"speaker":"Chris Dy","startTime":1008.8,"endTime":1012.1,"body":"that. Right And sorry, stage"},{"speaker":"Chris Dy","startTime":1008.8,"endTime":1012.1,"body":"three, we start to get into some"},{"speaker":"Chris Dy","startTime":1012.1,"endTime":1012.64,"body":"collapse."},{"speaker":"Unknown","startTime":1012.97,"endTime":1015.94,"body":"Right and stage three"},{"speaker":"Unknown","startTime":1012.97,"endTime":1015.94,"body":"has lunate collapse. And the"},{"speaker":"Unknown","startTime":1015.94,"endTime":1019.96,"body":"question is does it also have"},{"speaker":"Unknown","startTime":1015.94,"endTime":1019.96,"body":"scaphoid flexion. Or some would"},{"speaker":"Unknown","startTime":1019.96,"endTime":1023.26,"body":"say scaphoid rotation. And"},{"speaker":"Unknown","startTime":1019.96,"endTime":1023.26,"body":"again, that's what Krishna just"},{"speaker":"Unknown","startTime":1023.26,"endTime":1025.75,"body":"described how you decide. So"},{"speaker":"Unknown","startTime":1023.26,"endTime":1025.75,"body":"three A is illuminate is"},{"speaker":"Unknown","startTime":1025.75,"endTime":1029.62,"body":"collapsed. This scaphiod  is"},{"speaker":"Unknown","startTime":1025.75,"endTime":1029.62,"body":"maintained in his position. In"},{"speaker":"Unknown","startTime":1029.62,"endTime":1032.89,"body":"stage 3 B's the lunate has"},{"speaker":"Unknown","startTime":1029.62,"endTime":1032.89,"body":"collapsed, but the scaphoid has"},{"speaker":"Unknown","startTime":1032.89,"endTime":1034.15,"body":"also flexed."},{"speaker":"Unknown","startTime":1035.14,"endTime":1037.72,"body":"And then stage four is the"},{"speaker":"Unknown","startTime":1035.14,"endTime":1037.72,"body":"consequence you get whenever the"},{"speaker":"Unknown","startTime":1037.72,"endTime":1041.23,"body":"scaphoid flexes when it's not"},{"speaker":"Unknown","startTime":1037.72,"endTime":1041.23,"body":"supposed to. And that's when you"},{"speaker":"Unknown","startTime":1041.23,"endTime":1042.76,"body":"get the pan carpal arthritis."},{"speaker":"Charles A. Goldfarb","startTime":1043.27,"endTime":1045.07,"body":"Right. So"},{"speaker":"Charles A. Goldfarb","startTime":1043.27,"endTime":1045.07,"body":"let's go you want to go stage by"},{"speaker":"Charles A. Goldfarb","startTime":1045.07,"endTime":1048.1,"body":"stage? Sure. Yeah, that's the"},{"speaker":"Charles A. Goldfarb","startTime":1045.07,"endTime":1048.1,"body":"thing. It's a good way think"},{"speaker":"Charles A. Goldfarb","startTime":1048.1,"endTime":1051.31,"body":"about it. Okay, which makes this"},{"speaker":"Charles A. Goldfarb","startTime":1048.1,"endTime":1051.31,"body":"a good classification, right? I"},{"speaker":"Charles A. Goldfarb","startTime":1051.31,"endTime":1055.24,"body":"mean, it does, it does help. Not"},{"speaker":"Charles A. Goldfarb","startTime":1051.31,"endTime":1055.24,"body":"all our classifications do that."},{"speaker":"Chris Dy","startTime":1055.6,"endTime":1057.85,"body":"The Lichtman"},{"speaker":"Chris Dy","startTime":1055.6,"endTime":1057.85,"body":"classification as modified by"},{"speaker":"Chris Dy","startTime":1057.85,"endTime":1058.39,"body":"Goldfarb."},{"speaker":"Charles A. Goldfarb","startTime":1059.02,"endTime":1062.05,"body":"Thank you."},{"speaker":"Charles A. Goldfarb","startTime":1059.02,"endTime":1062.05,"body":"Thank you. So stage one is"},{"speaker":"Charles A. Goldfarb","startTime":1062.05,"endTime":1065.74,"body":"really radiographs look, okay,"},{"speaker":"Charles A. Goldfarb","startTime":1062.05,"endTime":1065.74,"body":"MRI or bone scan, if you know"},{"speaker":"Charles A. Goldfarb","startTime":1065.74,"endTime":1068.74,"body":"what that is, or can access one"},{"speaker":"Charles A. Goldfarb","startTime":1065.74,"endTime":1068.74,"body":"which most of us can no longer"},{"speaker":"Charles A. Goldfarb","startTime":1068.74,"endTime":1072.64,"body":"get bone scans. And those"},{"speaker":"Charles A. Goldfarb","startTime":1068.74,"endTime":1072.64,"body":"patients who fail conservative"},{"speaker":"Charles A. Goldfarb","startTime":1072.64,"endTime":1076.39,"body":"treatment, I think that is a"},{"speaker":"Charles A. Goldfarb","startTime":1072.64,"endTime":1076.39,"body":"fantastic candidate for"},{"speaker":"Charles A. Goldfarb","startTime":1076.39,"endTime":1079.24,"body":"vascularized ambassadors bone"},{"speaker":"Charles A. Goldfarb","startTime":1076.39,"endTime":1079.24,"body":"graft procedure,"},{"speaker":"Chris Dy","startTime":1079.87,"endTime":1081.76,"body":"how many injections"},{"speaker":"Chris Dy","startTime":1079.87,"endTime":1081.76,"body":"will you give them, you know,"},{"speaker":"Chris Dy","startTime":1081.76,"endTime":1083.59,"body":"phrase in terms of non operative"},{"speaker":"Chris Dy","startTime":1081.76,"endTime":1083.59,"body":"treatment?"},{"speaker":"Charles A. Goldfarb","startTime":1084.22,"endTime":1086.02,"body":"Oh, I don't"},{"speaker":"Charles A. Goldfarb","startTime":1084.22,"endTime":1086.02,"body":"think continued injections are"},{"speaker":"Charles A. Goldfarb","startTime":1086.02,"endTime":1088.72,"body":"my solution to this problem. I"},{"speaker":"Charles A. Goldfarb","startTime":1086.02,"endTime":1088.72,"body":"would be given them one"},{"speaker":"Charles A. Goldfarb","startTime":1088.72,"endTime":1091.78,"body":"injection, then I would move on."},{"speaker":"Charles A. Goldfarb","startTime":1088.72,"endTime":1091.78,"body":"Is this someone you'd consider"},{"speaker":"Charles A. Goldfarb","startTime":1091.78,"endTime":1092.38,"body":"something different?"},{"speaker":"Unknown","startTime":1093.61,"endTime":1096.16,"body":"I don't know. I mean,"},{"speaker":"Unknown","startTime":1093.61,"endTime":1096.16,"body":"you know, we talked about, you"},{"speaker":"Unknown","startTime":1096.16,"endTime":1098.83,"body":"know, obviously, steroid"},{"speaker":"Unknown","startTime":1096.16,"endTime":1098.83,"body":"injections and the local"},{"speaker":"Unknown","startTime":1098.83,"endTime":1102.49,"body":"anesthetic that accompanies them"},{"speaker":"Unknown","startTime":1098.83,"endTime":1102.49,"body":"usually are not benign to the"},{"speaker":"Unknown","startTime":1102.49,"endTime":1106.72,"body":"cartilage. So certainly, you"},{"speaker":"Unknown","startTime":1102.49,"endTime":1106.72,"body":"know, keep that in mind. But I"},{"speaker":"Unknown","startTime":1106.72,"endTime":1109.57,"body":"think that, you know, somebody"},{"speaker":"Unknown","startTime":1106.72,"endTime":1109.57,"body":"is doing well with injections,"},{"speaker":"Unknown","startTime":1109.6,"endTime":1112.66,"body":"I'd be hard pressed to steer"},{"speaker":"Unknown","startTime":1109.6,"endTime":1112.66,"body":"them towards surgery, I'd be"},{"speaker":"Unknown","startTime":1112.66,"endTime":1116.38,"body":"probably, depending on the age"},{"speaker":"Unknown","startTime":1112.66,"endTime":1116.38,"body":"would would influence me. I"},{"speaker":"Unknown","startTime":1116.38,"endTime":1119.98,"body":"mean, I think in a 16 year old,"},{"speaker":"Unknown","startTime":1116.38,"endTime":1119.98,"body":"if there's somebody with stage"},{"speaker":"Unknown","startTime":1119.98,"endTime":1123.28,"body":"one disease, I probably would"},{"speaker":"Unknown","startTime":1119.98,"endTime":1123.28,"body":"give them injections until the"},{"speaker":"Unknown","startTime":1123.28,"endTime":1127.78,"body":"cows came home. Now 15, 20, 30"},{"speaker":"Unknown","startTime":1123.28,"endTime":1127.78,"body":"year old, maybe one or two?"},{"speaker":"Charles A. Goldfarb","startTime":1128.93,"endTime":1130.43,"body":"Yeah, you"},{"speaker":"Charles A. Goldfarb","startTime":1128.93,"endTime":1130.43,"body":"know, I meant to I meant to"},{"speaker":"Charles A. Goldfarb","startTime":1130.43,"endTime":1133.58,"body":"share with our listeners that I"},{"speaker":"Charles A. Goldfarb","startTime":1130.43,"endTime":1133.58,"body":"received an email, which"},{"speaker":"Charles A. Goldfarb","startTime":1133.58,"endTime":1139.79,"body":"suggested that it was past time"},{"speaker":"Charles A. Goldfarb","startTime":1133.58,"endTime":1139.79,"body":"for Chris to, to hold himself"},{"speaker":"Charles A. Goldfarb","startTime":1139.91,"endTime":1147.29,"body":"out as a junior attending and a"},{"speaker":"Charles A. Goldfarb","startTime":1139.91,"endTime":1147.29,"body":"young professor. So they"},{"speaker":"Charles A. Goldfarb","startTime":1147.29,"endTime":1151.82,"body":"suggested that I'm not that old."},{"speaker":"Charles A. Goldfarb","startTime":1147.29,"endTime":1151.82,"body":"And Chris is not that young. And"},{"speaker":"Charles A. Goldfarb","startTime":1151.82,"endTime":1153.38,"body":"so I just want to get that out"},{"speaker":"Charles A. Goldfarb","startTime":1151.82,"endTime":1153.38,"body":"there."},{"speaker":"Chris Dy","startTime":1153.41,"endTime":1157.88,"body":"I refuse to put my age"},{"speaker":"Chris Dy","startTime":1153.41,"endTime":1157.88,"body":"in my file, because I'm getting"},{"speaker":"Chris Dy","startTime":1157.88,"endTime":1159.89,"body":"close to 40. And I don't want to"},{"speaker":"Chris Dy","startTime":1157.88,"endTime":1159.89,"body":"admit that"},{"speaker":"Charles A. Goldfarb","startTime":1160.4,"endTime":1162.5,"body":"through"},{"speaker":"Charles A. Goldfarb","startTime":1160.4,"endTime":1162.5,"body":"funny. I totally agree. younger"},{"speaker":"Charles A. Goldfarb","startTime":1162.5,"endTime":1168.41,"body":"patients, less have an interest"},{"speaker":"Charles A. Goldfarb","startTime":1162.5,"endTime":1168.41,"body":"in giving any steroid injections"},{"speaker":"Charles A. Goldfarb","startTime":1168.44,"endTime":1170.75,"body":"or certainly repetitive steroid"},{"speaker":"Charles A. Goldfarb","startTime":1168.44,"endTime":1170.75,"body":"injections as patients get"},{"speaker":"Charles A. Goldfarb","startTime":1170.75,"endTime":1172.46,"body":"older. I'm much more comfortable"},{"speaker":"Charles A. Goldfarb","startTime":1170.75,"endTime":1172.46,"body":"with it."},{"speaker":"Chris Dy","startTime":1173.059,"endTime":1175.789,"body":"Okay, so we said"},{"speaker":"Chris Dy","startTime":1173.059,"endTime":1175.789,"body":"already that if this was an"},{"speaker":"Chris Dy","startTime":1175.819,"endTime":1179.959,"body":"owner swimming on their negative"},{"speaker":"Chris Dy","startTime":1175.819,"endTime":1179.959,"body":"variance that you would shorten"},{"speaker":"Chris Dy","startTime":1179.959,"endTime":1182.779,"body":"the radius. What if it was on"},{"speaker":"Chris Dy","startTime":1179.959,"endTime":1182.779,"body":"their neutral or on their"},{"speaker":"Chris Dy","startTime":1182.779,"endTime":1183.319,"body":"positive?"},{"speaker":"Unknown","startTime":1184.11,"endTime":1187.5,"body":"Yeah, so for stage one"},{"speaker":"Unknown","startTime":1184.11,"endTime":1187.5,"body":"and stage two and I often lumped"},{"speaker":"Unknown","startTime":1187.5,"endTime":1190.59,"body":"them together if they fail"},{"speaker":"Unknown","startTime":1187.5,"endTime":1190.59,"body":"conservative treatment. If they"},{"speaker":"Unknown","startTime":1190.59,"endTime":1193.59,"body":"are older, negative, I will"},{"speaker":"Unknown","startTime":1190.59,"endTime":1193.59,"body":"shorten the radius. I don't"},{"speaker":"Unknown","startTime":1193.59,"endTime":1196.86,"body":"think the amount of shortening"},{"speaker":"Unknown","startTime":1193.59,"endTime":1196.86,"body":"matters that much. I don't want"},{"speaker":"Unknown","startTime":1196.86,"endTime":1199.77,"body":"to over shorten it obviously."},{"speaker":"Unknown","startTime":1196.86,"endTime":1199.77,"body":"millimeter two is usually"},{"speaker":"Unknown","startTime":1199.77,"endTime":1205.32,"body":"something And that's what the"},{"speaker":"Unknown","startTime":1199.77,"endTime":1205.32,"body":"volar approach, oscillating saw"},{"speaker":"Unknown","startTime":1205.38,"endTime":1208.44,"body":"removal of a segment of bone,"},{"speaker":"Unknown","startTime":1205.38,"endTime":1208.44,"body":"and then compression plating."},{"speaker":"Unknown","startTime":1208.74,"endTime":1213.63,"body":"And then I use a four or five"},{"speaker":"Unknown","startTime":1208.74,"endTime":1213.63,"body":"vascularized bone graft, and"},{"speaker":"Unknown","startTime":1213.63,"endTime":1215.88,"body":"insert that into the lunate,"},{"speaker":"Unknown","startTime":1213.63,"endTime":1215.88,"body":"which has not collapsed. So"},{"speaker":"Unknown","startTime":1215.88,"endTime":1217.89,"body":"basically, you're just creating"},{"speaker":"Unknown","startTime":1215.88,"endTime":1217.89,"body":"a hole in the lunate. Inserting"},{"speaker":"Unknown","startTime":1217.89,"endTime":1219.81,"body":"the bone graft, as we have"},{"speaker":"Unknown","startTime":1217.89,"endTime":1219.81,"body":"discussed with Dr Moran"},{"speaker":"Unknown","startTime":1219.81,"endTime":1222.33,"body":"do you really need to do that"},{"speaker":"Unknown","startTime":1219.81,"endTime":1222.33,"body":"though? You really got to do"},{"speaker":"Unknown","startTime":1222.33,"endTime":1222.72,"body":"that?"},{"speaker":"Unknown","startTime":1223.29,"endTime":1225.66,"body":"I don't know. I don't know the"},{"speaker":"Unknown","startTime":1223.29,"endTime":1225.66,"body":"answer."},{"speaker":"Unknown","startTime":1226.83,"endTime":1227.91,"body":"belt and suspenders."},{"speaker":"Unknown","startTime":1228.66,"endTime":1230.55,"body":"I feel like it is belt and"},{"speaker":"Unknown","startTime":1228.66,"endTime":1230.55,"body":"suspenders, I think you're"},{"speaker":"Unknown","startTime":1230.55,"endTime":1233.13,"body":"getting your immediate pain"},{"speaker":"Unknown","startTime":1230.55,"endTime":1233.13,"body":"relief from the shortening. And"},{"speaker":"Unknown","startTime":1233.13,"endTime":1236.64,"body":"hopefully you're getting your"},{"speaker":"Unknown","startTime":1233.13,"endTime":1236.64,"body":"long term viability or improved"},{"speaker":"Unknown","startTime":1236.64,"endTime":1238.38,"body":"viability with the bone graft."},{"speaker":"Chris Dy","startTime":1239.25,"endTime":1241.92,"body":"You think that your"},{"speaker":"Chris Dy","startTime":1239.25,"endTime":1241.92,"body":"ability to offer the pedicle"},{"speaker":"Chris Dy","startTime":1241.92,"endTime":1245.46,"body":"bone flap graft, whatever you"},{"speaker":"Chris Dy","startTime":1241.92,"endTime":1245.46,"body":"want to call it in the future is"},{"speaker":"Chris Dy","startTime":1245.46,"endTime":1248.97,"body":"affected by your radial"},{"speaker":"Chris Dy","startTime":1245.46,"endTime":1248.97,"body":"shortening at time zero? Is it"},{"speaker":"Chris Dy","startTime":1248.97,"endTime":1251.55,"body":"more of a psychological thing?"},{"speaker":"Chris Dy","startTime":1248.97,"endTime":1251.55,"body":"I'm not the patient not wanting"},{"speaker":"Chris Dy","startTime":1251.55,"endTime":1254.1,"body":"to surgery? Is you not wanting"},{"speaker":"Chris Dy","startTime":1251.55,"endTime":1254.1,"body":"to have to do two surgeries?"},{"speaker":"Charles A. Goldfarb","startTime":1254.94,"endTime":1256.59,"body":"I think"},{"speaker":"Charles A. Goldfarb","startTime":1254.94,"endTime":1256.59,"body":"it's the latter. I don't think"},{"speaker":"Charles A. Goldfarb","startTime":1256.62,"endTime":1259.53,"body":"doing the shortening affects my"},{"speaker":"Charles A. Goldfarb","startTime":1256.62,"endTime":1259.53,"body":"ability to do a bone graft. I"},{"speaker":"Charles A. Goldfarb","startTime":1259.53,"endTime":1264.12,"body":"just so I've always been a"},{"speaker":"Charles A. Goldfarb","startTime":1259.53,"endTime":1264.12,"body":"believer that if you can offer"},{"speaker":"Charles A. Goldfarb","startTime":1264.12,"endTime":1266.91,"body":"multiple interventions that same"},{"speaker":"Charles A. Goldfarb","startTime":1264.12,"endTime":1266.91,"body":"time is better for the patients"},{"speaker":"Charles A. Goldfarb","startTime":1266.91,"endTime":1270.0,"body":"better for society. So I'm a"},{"speaker":"Charles A. Goldfarb","startTime":1266.91,"endTime":1270.0,"body":"believer in bilateral carpal"},{"speaker":"Charles A. Goldfarb","startTime":1270.0,"endTime":1273.21,"body":"tunnel surgery for as an"},{"speaker":"Charles A. Goldfarb","startTime":1270.0,"endTime":1273.21,"body":"example. And I'm a believer and"},{"speaker":"Charles A. Goldfarb","startTime":1273.21,"endTime":1275.43,"body":"doing both of these procedures"},{"speaker":"Charles A. Goldfarb","startTime":1273.21,"endTime":1275.43,"body":"at the same time, would you"},{"speaker":"Charles A. Goldfarb","startTime":1275.43,"endTime":1276.54,"body":"stage them potentially?"},{"speaker":"Chris Dy","startTime":1277.71,"endTime":1279.6,"body":"I don't know. I mean,"},{"speaker":"Chris Dy","startTime":1277.71,"endTime":1279.6,"body":"you know, I think if you believe"},{"speaker":"Chris Dy","startTime":1279.6,"endTime":1282.39,"body":"the data, and I think it's out"},{"speaker":"Chris Dy","startTime":1279.6,"endTime":1282.39,"body":"of Argentina, accord"},{"speaker":"Chris Dy","startTime":1282.39,"endTime":1284.58,"body":"decompression alone might be"},{"speaker":"Chris Dy","startTime":1282.39,"endTime":1284.58,"body":"enough. So I think if you're"},{"speaker":"Chris Dy","startTime":1284.58,"endTime":1287.55,"body":"looking for a relatively"},{"speaker":"Chris Dy","startTime":1284.58,"endTime":1287.55,"body":"minimally invasive, quick thing"},{"speaker":"Chris Dy","startTime":1287.55,"endTime":1291.6,"body":"you can do that might offer nice"},{"speaker":"Chris Dy","startTime":1287.55,"endTime":1291.6,"body":"symptom resolution, that patient"},{"speaker":"Chris Dy","startTime":1291.63,"endTime":1295.53,"body":"I haven't seen that patient in a"},{"speaker":"Chris Dy","startTime":1291.63,"endTime":1295.53,"body":"long time, I would honestly"},{"speaker":"Chris Dy","startTime":1295.53,"endTime":1299.4,"body":"consider doing a metathesis"},{"speaker":"Chris Dy","startTime":1295.53,"endTime":1299.4,"body":"decompression. And then if"},{"speaker":"Chris Dy","startTime":1299.43,"endTime":1303.93,"body":"things didn't work out the way"},{"speaker":"Chris Dy","startTime":1299.43,"endTime":1303.93,"body":"that we expected, going to doing"},{"speaker":"Chris Dy","startTime":1303.93,"endTime":1305.64,"body":"the combo procedure that you"},{"speaker":"Chris Dy","startTime":1303.93,"endTime":1305.64,"body":"described."},{"speaker":"Unknown","startTime":1306.57,"endTime":1313.32,"body":"So Chris, when all your"},{"speaker":"Unknown","startTime":1306.57,"endTime":1313.32,"body":"world is a hammer, everything"},{"speaker":"Unknown","startTime":1313.35,"endTime":1316.86,"body":"looks like a nail. I know you"},{"speaker":"Unknown","startTime":1313.35,"endTime":1316.86,"body":"know where I'm going with this."},{"speaker":"Unknown","startTime":1317.04,"endTime":1321.48,"body":"arthroscopy has a role in the"},{"speaker":"Unknown","startTime":1317.04,"endTime":1321.48,"body":"treatment of Kienbocks disease."},{"speaker":"Chris Dy","startTime":1321.51,"endTime":1323.37,"body":"That's actually not"},{"speaker":"Chris Dy","startTime":1321.51,"endTime":1323.37,"body":"where I thought you were going,"},{"speaker":"Chris Dy","startTime":1323.37,"endTime":1329.07,"body":"I thought you're going to ask me"},{"speaker":"Chris Dy","startTime":1323.37,"endTime":1329.07,"body":"about denervation. So what's the"},{"speaker":"Chris Dy","startTime":1329.07,"endTime":1330.27,"body":"role of arthroscopy?"},{"speaker":"Unknown","startTime":1330.72,"endTime":1335.22,"body":"There's a couple of"},{"speaker":"Unknown","startTime":1330.72,"endTime":1335.22,"body":"good manuscripts that describe"},{"speaker":"Unknown","startTime":1335.28,"endTime":1339.48,"body":"arthroscopic debris money and"},{"speaker":"Unknown","startTime":1335.28,"endTime":1339.48,"body":"you know, it'll give you a good"},{"speaker":"Unknown","startTime":1339.48,"endTime":1342.9,"body":"visualization of SL LT"},{"speaker":"Unknown","startTime":1339.48,"endTime":1342.9,"body":"ligaments, you get in a sense of"},{"speaker":"Unknown","startTime":1342.9,"endTime":1345.42,"body":"the cartilage both on the"},{"speaker":"Unknown","startTime":1342.9,"endTime":1345.42,"body":"proximal surface and the distal"},{"speaker":"Unknown","startTime":1345.42,"endTime":1348.24,"body":"surface of the loon eight you"},{"speaker":"Unknown","startTime":1345.42,"endTime":1348.24,"body":"can understand loon eight"},{"speaker":"Unknown","startTime":1348.24,"endTime":1351.6,"body":"fractures. And if you believe in"},{"speaker":"Unknown","startTime":1348.24,"endTime":1351.6,"body":"fixing those, you could you"},{"speaker":"Unknown","startTime":1351.6,"endTime":1354.96,"body":"know, you can arthroscopically"},{"speaker":"Unknown","startTime":1351.6,"endTime":1354.96,"body":"assisted screw fixation of the"},{"speaker":"Unknown","startTime":1354.96,"endTime":1360.69,"body":"luante. I don't ever truly"},{"speaker":"Unknown","startTime":1354.96,"endTime":1360.69,"body":"understand why it seems to help."},{"speaker":"Unknown","startTime":1360.72,"endTime":1365.31,"body":"But it actually can be effective"},{"speaker":"Unknown","startTime":1360.72,"endTime":1365.31,"body":"as an I think, as an adjunct"},{"speaker":"Unknown","startTime":1365.31,"endTime":1369.03,"body":"treatment, perhaps, along with"},{"speaker":"Unknown","startTime":1365.31,"endTime":1369.03,"body":"something else. And so, again,"},{"speaker":"Unknown","startTime":1369.03,"endTime":1372.87,"body":"the literature is not"},{"speaker":"Unknown","startTime":1369.03,"endTime":1372.87,"body":"unreasonable. It doesn't make"},{"speaker":"Unknown","startTime":1372.9,"endTime":1377.13,"body":"enough sense for me to do it"},{"speaker":"Unknown","startTime":1372.9,"endTime":1377.13,"body":"regularly. But I think it's,"},{"speaker":"Unknown","startTime":1377.4,"endTime":1379.98,"body":"it's about as useful as your"},{"speaker":"Unknown","startTime":1377.4,"endTime":1379.98,"body":"favorite procedure, which is"},{"speaker":"Unknown","startTime":1379.98,"endTime":1380.64,"body":"innovation."},{"speaker":"Chris Dy","startTime":1381.51,"endTime":1383.73,"body":"I think that you can"},{"speaker":"Chris Dy","startTime":1381.51,"endTime":1383.73,"body":"get all the information you just"},{"speaker":"Chris Dy","startTime":1383.73,"endTime":1387.63,"body":"described from an MRI. So I"},{"speaker":"Chris Dy","startTime":1383.73,"endTime":1387.63,"body":"don't know why you're trotting"},{"speaker":"Chris Dy","startTime":1387.63,"endTime":1391.86,"body":"out the scope. Love yet love ya"},{"speaker":"Chris Dy","startTime":1387.63,"endTime":1391.86,"body":"Conmed and your cool new tower"},{"speaker":"Chris Dy","startTime":1391.86,"endTime":1395.4,"body":"and all that stuff. But I don't"},{"speaker":"Chris Dy","startTime":1391.86,"endTime":1395.4,"body":"think you need the scope for"},{"speaker":"Chris Dy","startTime":1395.4,"endTime":1398.85,"body":"this one. Now, I really want you"},{"speaker":"Chris Dy","startTime":1395.4,"endTime":1398.85,"body":"to answer me on this one. I'm"},{"speaker":"Chris Dy","startTime":1398.85,"endTime":1401.79,"body":"gonna ask you the third time if"},{"speaker":"Chris Dy","startTime":1398.85,"endTime":1401.79,"body":"the owner is positive, are you"},{"speaker":"Chris Dy","startTime":1401.79,"endTime":1402.66,"body":"shortening the owner?"},{"speaker":"Unknown","startTime":1403.05,"endTime":1405.87,"body":"No, I am absolutely not"},{"speaker":"Unknown","startTime":1403.05,"endTime":1405.87,"body":"shortening on I do not believe"},{"speaker":"Unknown","startTime":1405.87,"endTime":1408.99,"body":"that has any role in the"},{"speaker":"Unknown","startTime":1405.87,"endTime":1408.99,"body":"development of key inbox. Now"},{"speaker":"Unknown","startTime":1408.99,"endTime":1413.31,"body":"let's be clear. And for some of"},{"speaker":"Unknown","startTime":1408.99,"endTime":1413.31,"body":"the residents listening or"},{"speaker":"Unknown","startTime":1413.31,"endTime":1419.25,"body":"fellows, we think of ulnocarpal,"},{"speaker":"Unknown","startTime":1413.31,"endTime":1419.25,"body":"impaction and cane box disease"},{"speaker":"Unknown","startTime":1419.52,"endTime":1423.66,"body":"as well, like a world of"},{"speaker":"Unknown","startTime":1419.52,"endTime":1423.66,"body":"difference diagnostically. It is"},{"speaker":"Unknown","startTime":1423.66,"endTime":1428.22,"body":"not always true. Sometimes the"},{"speaker":"Unknown","startTime":1423.66,"endTime":1428.22,"body":"diagnosis is you know, the"},{"speaker":"Unknown","startTime":1428.22,"endTime":1432.57,"body":"differential diagnosis is not"},{"speaker":"Unknown","startTime":1428.22,"endTime":1432.57,"body":"completely clear. So in other"},{"speaker":"Unknown","startTime":1432.57,"endTime":1436.62,"body":"words, if you have edema, in the"},{"speaker":"Unknown","startTime":1432.57,"endTime":1436.62,"body":"owner aspect of the lunate, you"},{"speaker":"Unknown","startTime":1436.62,"endTime":1441.57,"body":"have no collapse of the lunate,"},{"speaker":"Unknown","startTime":1436.62,"endTime":1441.57,"body":"and you have a long owner is"},{"speaker":"Unknown","startTime":1441.57,"endTime":1445.74,"body":"that impaction? Yeah, probably."},{"speaker":"Unknown","startTime":1441.57,"endTime":1445.74,"body":"But if that same patient, same"},{"speaker":"Unknown","startTime":1445.74,"endTime":1449.37,"body":"radiographic appearance exists"},{"speaker":"Unknown","startTime":1445.74,"endTime":1449.37,"body":"in a patient where the edema is"},{"speaker":"Unknown","startTime":1449.37,"endTime":1451.74,"body":"in the entire lunate. All the"},{"speaker":"Unknown","startTime":1449.37,"endTime":1451.74,"body":"sudden you're calling it"},{"speaker":"Unknown","startTime":1451.77,"endTime":1455.46,"body":"Kienbocks. So it usually is"},{"speaker":"Unknown","startTime":1451.77,"endTime":1455.46,"body":"clear, but it's not always."},{"speaker":"Unknown","startTime":1456.06,"endTime":1458.73,"body":"Yeah, I guess I haven't seen"},{"speaker":"Unknown","startTime":1456.06,"endTime":1458.73,"body":"enough MRIs of patients with"},{"speaker":"Unknown","startTime":1458.73,"endTime":1465.63,"body":"impaction to understand whether"},{"speaker":"Unknown","startTime":1458.73,"endTime":1465.63,"body":"whether that edema pattern is"},{"speaker":"Unknown","startTime":1465.72,"endTime":1469.05,"body":"purely along kind of that on"},{"speaker":"Unknown","startTime":1465.72,"endTime":1469.05,"body":"their border of the lunate or"},{"speaker":"Unknown","startTime":1469.05,"endTime":1472.56,"body":"whether you could see"},{"speaker":"Unknown","startTime":1469.05,"endTime":1472.56,"body":"theoretically, edema within the"},{"speaker":"Unknown","startTime":1472.56,"endTime":1474.51,"body":"entirety of the lunate with just"},{"speaker":"Unknown","startTime":1472.56,"endTime":1474.51,"body":"impaction."},{"speaker":"Unknown","startTime":1475.47,"endTime":1479.64,"body":"I do believe that when it's"},{"speaker":"Unknown","startTime":1475.47,"endTime":1479.64,"body":"impaction as the true diagnosis,"},{"speaker":"Unknown","startTime":1479.64,"endTime":1484.62,"body":"it really is that volar owner"},{"speaker":"Unknown","startTime":1479.64,"endTime":1484.62,"body":"will not say volar but it's the"},{"speaker":"Unknown","startTime":1484.62,"endTime":1488.22,"body":"owner corner of the lemonade,"},{"speaker":"Unknown","startTime":1484.62,"endTime":1488.22,"body":"and it really is typically"},{"speaker":"Unknown","startTime":1488.22,"endTime":1492.36,"body":"discreet. But sometimes I think"},{"speaker":"Unknown","startTime":1488.22,"endTime":1492.36,"body":"about it because it's not always"},{"speaker":"Unknown","startTime":1492.39,"endTime":1495.12,"body":"in again. Sometimes it's clearly"},{"speaker":"Unknown","startTime":1492.39,"endTime":1495.12,"body":"impaction and sometimes is"},{"speaker":"Unknown","startTime":1495.12,"endTime":1497.97,"body":"clearly Kienbocks but there can"},{"speaker":"Unknown","startTime":1495.12,"endTime":1497.97,"body":"be cases where it's not crystal"},{"speaker":"Unknown","startTime":1497.97,"endTime":1499.47,"body":"clear what the diagnosis is."},{"speaker":"Unknown","startTime":1500.31,"endTime":1503.07,"body":"So when is it too far gone to"},{"speaker":"Unknown","startTime":1500.31,"endTime":1503.07,"body":"try what you've described for"},{"speaker":"Unknown","startTime":1503.07,"endTime":1505.95,"body":"your for your stage one and"},{"speaker":"Unknown","startTime":1503.07,"endTime":1505.95,"body":"stage two. So stay, you say you"},{"speaker":"Unknown","startTime":1505.95,"endTime":1509.79,"body":"get to stage three A, you don't"},{"speaker":"Unknown","startTime":1505.95,"endTime":1509.79,"body":"have a lot, you have some claps"},{"speaker":"Unknown","startTime":1509.79,"endTime":1514.29,"body":"present. But you don't have any"},{"speaker":"Unknown","startTime":1509.79,"endTime":1514.29,"body":"scaphoid, flexion and rotation,"},{"speaker":"Unknown","startTime":1514.86,"endTime":1516.09,"body":"still doing the same thing."},{"speaker":"Unknown","startTime":1516.63,"endTime":1519.36,"body":"I'm still doing the same thing."},{"speaker":"Unknown","startTime":1516.63,"endTime":1519.36,"body":"I'm still showing the radius,"},{"speaker":"Unknown","startTime":1519.36,"endTime":1522.51,"body":"I'm still performing"},{"speaker":"Unknown","startTime":1519.36,"endTime":1522.51,"body":"vascularized bone flap as you"},{"speaker":"Unknown","startTime":1522.51,"endTime":1527.07,"body":"make me call it. But I don't"},{"speaker":"Unknown","startTime":1522.51,"endTime":1527.07,"body":"know that I agree with Dr."},{"speaker":"Unknown","startTime":1527.07,"endTime":1531.3,"body":"Moran, who shared on our program"},{"speaker":"Unknown","startTime":1527.07,"endTime":1531.3,"body":"that he felt like he could"},{"speaker":"Unknown","startTime":1531.54,"endTime":1537.03,"body":"expand the loon eight with a"},{"speaker":"Unknown","startTime":1531.54,"endTime":1537.03,"body":"laminar spreader or whatever,"},{"speaker":"Unknown","startTime":1537.03,"endTime":1541.89,"body":"I've not been successful. So if"},{"speaker":"Unknown","startTime":1537.03,"endTime":1541.89,"body":"the lunate is reasonable and its"},{"speaker":"Unknown","startTime":1541.89,"endTime":1545.34,"body":"size and shape, I will"},{"speaker":"Unknown","startTime":1541.89,"endTime":1545.34,"body":"absolutely do the same procedure"},{"speaker":"Unknown","startTime":1545.34,"endTime":1546.15,"body":"for stage three."},{"speaker":"Chris Dy","startTime":1547.11,"endTime":1551.46,"body":"Okay, and then at some"},{"speaker":"Chris Dy","startTime":1547.11,"endTime":1551.46,"body":"point, when is it just too far"},{"speaker":"Chris Dy","startTime":1551.46,"endTime":1551.85,"body":"gone?"},{"speaker":"Unknown","startTime":1553.83,"endTime":1556.59,"body":"depends a little bit on"},{"speaker":"Unknown","startTime":1553.83,"endTime":1556.59,"body":"the patient. depends a little"},{"speaker":"Unknown","startTime":1556.59,"endTime":1560.25,"body":"bit on the the relative length"},{"speaker":"Unknown","startTime":1556.59,"endTime":1560.25,"body":"of the radius compared to the"},{"speaker":"Unknown","startTime":1560.25,"endTime":1566.46,"body":"ulna. Dr. Calfee in combination"},{"speaker":"Unknown","startTime":1560.25,"endTime":1566.46,"body":"effort, as you know, between"},{"speaker":"Unknown","startTime":1566.46,"endTime":1570.24,"body":"WashU and HSS, I don't when were"},{"speaker":"Unknown","startTime":1566.46,"endTime":1570.24,"body":"you involved with that effort?"},{"speaker":"Chris Dy","startTime":1570.69,"endTime":1573.72,"body":"I was not. So"},{"speaker":"Chris Dy","startTime":1570.69,"endTime":1573.72,"body":"basically, it was looking"},{"speaker":"Unknown","startTime":1573.0,"endTime":1577.17,"body":"at stage shortening for"},{"speaker":"Unknown","startTime":1573.0,"endTime":1577.17,"body":"Stage Three B. And I think our"},{"speaker":"Unknown","startTime":1577.17,"endTime":1580.41,"body":"perception is it can be a"},{"speaker":"Unknown","startTime":1577.17,"endTime":1580.41,"body":"successful operation, but it's"},{"speaker":"Unknown","startTime":1580.41,"endTime":1585.0,"body":"not quite as reliable. And I"},{"speaker":"Unknown","startTime":1580.41,"endTime":1585.0,"body":"think there can be a role for"},{"speaker":"Unknown","startTime":1585.0,"endTime":1588.15,"body":"that in certain patients, given"},{"speaker":"Unknown","startTime":1585.0,"endTime":1588.15,"body":"that the procedure is"},{"speaker":"Unknown","startTime":1588.18,"endTime":1591.51,"body":"predictable, generally reliable"},{"speaker":"Unknown","startTime":1588.18,"endTime":1591.51,"body":"and can be a good option. But"},{"speaker":"Unknown","startTime":1591.51,"endTime":1598.26,"body":"once once you know, once the"},{"speaker":"Unknown","startTime":1591.51,"endTime":1598.26,"body":"carpus collapses, I have less"},{"speaker":"Unknown","startTime":1598.26,"endTime":1602.49,"body":"faith in revascularisation. I"},{"speaker":"Unknown","startTime":1598.26,"endTime":1602.49,"body":"have less faith in shortening"},{"speaker":"Unknown","startTime":1602.49,"endTime":1604.74,"body":"the radius. And I do think about"},{"speaker":"Unknown","startTime":1602.49,"endTime":1604.74,"body":"salvage procedures."},{"speaker":"Unknown","startTime":1606.12,"endTime":1610.83,"body":"So um, I guess one thing before"},{"speaker":"Unknown","startTime":1606.12,"endTime":1610.83,"body":"we get into salvage procedures,"},{"speaker":"Unknown","startTime":1610.89,"endTime":1613.74,"body":"there is an increasing amount of"},{"speaker":"Unknown","startTime":1610.89,"endTime":1613.74,"body":"literature, at least for the"},{"speaker":"Unknown","startTime":1613.74,"endTime":1616.38,"body":"scaphoid non union group, and"},{"speaker":"Unknown","startTime":1613.74,"endTime":1616.38,"body":"then you could apply some of"},{"speaker":"Unknown","startTime":1616.38,"endTime":1622.5,"body":"this to Kienbocks for a free MFT"},{"speaker":"Unknown","startTime":1616.38,"endTime":1622.5,"body":"like a medial femoral trochlear"},{"speaker":"Unknown","startTime":1622.5,"endTime":1628.32,"body":"kind of free flap coming in. I"},{"speaker":"Unknown","startTime":1622.5,"endTime":1628.32,"body":"know that both of us don't have"},{"speaker":"Unknown","startTime":1628.38,"endTime":1630.96,"body":"personal experience doing that."},{"speaker":"Unknown","startTime":1628.38,"endTime":1630.96,"body":"Are there any patients that you"},{"speaker":"Unknown","startTime":1630.96,"endTime":1633.78,"body":"see that you know, you might"},{"speaker":"Unknown","startTime":1630.96,"endTime":1633.78,"body":"send to you know, for example,"},{"speaker":"Unknown","startTime":1633.78,"endTime":1636.39,"body":"David Brogan, one of our"},{"speaker":"Unknown","startTime":1633.78,"endTime":1636.39,"body":"microsurgery partners for that,"},{"speaker":"Unknown","startTime":1637.83,"endTime":1643.68,"body":"I certainly would consider"},{"speaker":"Unknown","startTime":1637.83,"endTime":1643.68,"body":"sending a patient if there was a"},{"speaker":"Unknown","startTime":1643.68,"endTime":1647.31,"body":"I mean, really what we're what"},{"speaker":"Unknown","startTime":1643.68,"endTime":1647.31,"body":"we're needing in those"},{"speaker":"Unknown","startTime":1647.31,"endTime":1652.05,"body":"situations would be good"},{"speaker":"Unknown","startTime":1647.31,"endTime":1652.05,"body":"cartilage, and a need for"},{"speaker":"Unknown","startTime":1652.05,"endTime":1656.01,"body":"obviously vascularity to support"},{"speaker":"Unknown","startTime":1652.05,"endTime":1656.01,"body":"the rest of the loony bone. I"},{"speaker":"Unknown","startTime":1656.01,"endTime":1659.64,"body":"have a hard time envisioning"},{"speaker":"Unknown","startTime":1656.01,"endTime":1659.64,"body":"that situation for Kienbocks for"},{"speaker":"Unknown","startTime":1659.64,"endTime":1665.07,"body":"approximately the scaphoid."},{"speaker":"Unknown","startTime":1659.64,"endTime":1665.07,"body":"Maybe, but it it does enter my"},{"speaker":"Unknown","startTime":1665.07,"endTime":1668.34,"body":"discussion with the patient. And"},{"speaker":"Unknown","startTime":1665.07,"endTime":1668.34,"body":"I think an honest conversation"},{"speaker":"Unknown","startTime":1668.34,"endTime":1670.74,"body":"with David can be helpful for"},{"speaker":"Unknown","startTime":1668.34,"endTime":1670.74,"body":"some patients to see if that's"},{"speaker":"Unknown","startTime":1670.74,"endTime":1671.91,"body":"the direction they want to"},{"speaker":"Unknown","startTime":1670.74,"endTime":1671.91,"body":"track."},{"speaker":"Chris Dy","startTime":1672.87,"endTime":1676.53,"body":"Got it. Now as we come"},{"speaker":"Chris Dy","startTime":1672.87,"endTime":1676.53,"body":"to a close, we talk about"},{"speaker":"Chris Dy","startTime":1676.53,"endTime":1680.16,"body":"salvages. Are there any role in"},{"speaker":"Chris Dy","startTime":1676.53,"endTime":1680.16,"body":"your practice for limited inner"},{"speaker":"Chris Dy","startTime":1680.16,"endTime":1683.22,"body":"carpal fusions like an stt or an"},{"speaker":"Chris Dy","startTime":1680.16,"endTime":1683.22,"body":"SC or something like that."},{"speaker":"Unknown","startTime":1683.67,"endTime":1686.04,"body":"So when I was a"},{"speaker":"Unknown","startTime":1683.67,"endTime":1686.04,"body":"resident back in the day, and"},{"speaker":"Unknown","startTime":1686.04,"endTime":1689.82,"body":"let's be clear, that wasn't in"},{"speaker":"Unknown","startTime":1686.04,"endTime":1689.82,"body":"the late 90s, that treatment was"},{"speaker":"Unknown","startTime":1689.82,"endTime":1693.57,"body":"regularly offered. I do not"},{"speaker":"Unknown","startTime":1689.82,"endTime":1693.57,"body":"think there's any role for that"},{"speaker":"Unknown","startTime":1693.57,"endTime":1696.3,"body":"treatment today. In my hands, I"},{"speaker":"Unknown","startTime":1693.57,"endTime":1696.3,"body":"recognize that some people will"},{"speaker":"Unknown","startTime":1696.3,"endTime":1700.65,"body":"still use a scaphocapitate  or"},{"speaker":"Unknown","startTime":1696.3,"endTime":1700.65,"body":"an STT. But it's so limiting for"},{"speaker":"Unknown","startTime":1700.65,"endTime":1704.79,"body":"wrist motion. That for me"},{"speaker":"Unknown","startTime":1700.65,"endTime":1704.79,"body":"thetreatment, which is not"},{"speaker":"Unknown","startTime":1704.79,"endTime":1709.56,"body":"always a cure, let's be honest."},{"speaker":"Unknown","startTime":1704.79,"endTime":1709.56,"body":"But the treatment for phase 3 B"},{"speaker":"Unknown","startTime":1709.56,"endTime":1712.05,"body":"or 4 is proximal row carpectomy."},{"speaker":"Unknown","startTime":1712.05,"endTime":1714.6,"body":"corpectomy. How's that not a"},{"speaker":"Unknown","startTime":1712.05,"endTime":1714.6,"body":"cure?"},{"speaker":"Unknown","startTime":1715.29,"endTime":1719.43,"body":"It does not resolve the pain and"},{"speaker":"Unknown","startTime":1715.29,"endTime":1719.43,"body":"every patient. Unfortunately,"},{"speaker":"Unknown","startTime":1719.43,"endTime":1721.02,"body":"I've been there. That's"},{"speaker":"Unknown","startTime":1721.02,"endTime":1722.49,"body":"really that's really"},{"speaker":"Unknown","startTime":1721.02,"endTime":1722.49,"body":"interesting, because you'd think"},{"speaker":"Unknown","startTime":1722.49,"endTime":1725.58,"body":"by getting rid of lunate"},{"speaker":"Unknown","startTime":1722.49,"endTime":1725.58,"body":"resetting the mechanics of the"},{"speaker":"Unknown","startTime":1725.58,"endTime":1729.39,"body":"carpus that that's as reliable"},{"speaker":"Unknown","startTime":1725.58,"endTime":1729.39,"body":"as it would come. But that's"},{"speaker":"Unknown","startTime":1729.42,"endTime":1732.48,"body":"that's educational for me to"},{"speaker":"Unknown","startTime":1729.42,"endTime":1732.48,"body":"learn, because perhaps I should"},{"speaker":"Unknown","startTime":1733.14,"endTime":1735.24,"body":"set my expectations more"},{"speaker":"Unknown","startTime":1733.14,"endTime":1735.24,"body":"appropriately."},{"speaker":"Unknown","startTime":1735.99,"endTime":1739.35,"body":"Yeah, I wouldn't. I wouldn't"},{"speaker":"Unknown","startTime":1735.99,"endTime":1739.35,"body":"have a discussion with the"},{"speaker":"Unknown","startTime":1739.35,"endTime":1743.13,"body":"patient, you know, suggesting"},{"speaker":"Unknown","startTime":1739.35,"endTime":1743.13,"body":"that this will be a cure. I"},{"speaker":"Unknown","startTime":1743.13,"endTime":1746.55,"body":"generally temper that when I"},{"speaker":"Unknown","startTime":1743.13,"endTime":1746.55,"body":"discussed with the patient, even"},{"speaker":"Unknown","startTime":1746.55,"endTime":1750.33,"body":"though to both sides of the"},{"speaker":"Unknown","startTime":1746.55,"endTime":1750.33,"body":"table. We all think a giver, the"},{"speaker":"Unknown","startTime":1750.33,"endTime":1752.73,"body":"lunate is going to be great. And"},{"speaker":"Unknown","startTime":1750.33,"endTime":1752.73,"body":"hopefully it will be but it"},{"speaker":"Unknown","startTime":1752.73,"endTime":1754.47,"body":"doesn't always work that way in"},{"speaker":"Unknown","startTime":1752.73,"endTime":1754.47,"body":"my experience."},{"speaker":"Unknown","startTime":1754.92,"endTime":1756.63,"body":"So pyrocarbon lunate , what do"},{"speaker":"Unknown","startTime":1754.92,"endTime":1756.63,"body":"you think?"},{"speaker":"Charles A. Goldfarb","startTime":1757.46,"endTime":1758.45,"body":"Not ready"},{"speaker":"Charles A. Goldfarb","startTime":1757.46,"endTime":1758.45,"body":"for me?"},{"speaker":"Chris Dy","startTime":1761.329,"endTime":1763.549,"body":"So you know, just to"},{"speaker":"Chris Dy","startTime":1761.329,"endTime":1763.549,"body":"bring it to a wrap on this"},{"speaker":"Chris Dy","startTime":1763.549,"endTime":1767.419,"body":"patient? You know, I have not,"},{"speaker":"Chris Dy","startTime":1763.549,"endTime":1767.419,"body":"you know, we haven't gone down"},{"speaker":"Chris Dy","startTime":1767.419,"endTime":1770.959,"body":"the road of treatment yet. But I"},{"speaker":"Chris Dy","startTime":1767.419,"endTime":1770.959,"body":"ended up offering her knee"},{"speaker":"Chris Dy","startTime":1770.989,"endTime":1773.479,"body":"supportive measures with a"},{"speaker":"Chris Dy","startTime":1770.989,"endTime":1773.479,"body":"steroid injection and a wrist"},{"speaker":"Chris Dy","startTime":1773.479,"endTime":1776.029,"body":"brace. And then when she's good"},{"speaker":"Chris Dy","startTime":1773.479,"endTime":1776.029,"body":"and ready, we'll have a talk"},{"speaker":"Chris Dy","startTime":1776.029,"endTime":1776.779,"body":"about a PRC."},{"speaker":"Charles A. Goldfarb","startTime":1777.71,"endTime":1779.42,"body":"I think"},{"speaker":"Charles A. Goldfarb","startTime":1777.71,"endTime":1779.42,"body":"that's fantastic. It's"},{"speaker":"Charles A. Goldfarb","startTime":1779.42,"endTime":1782.39,"body":"appropriate. And, you know, if"},{"speaker":"Charles A. Goldfarb","startTime":1779.42,"endTime":1782.39,"body":"you want to scope it, certainly"},{"speaker":"Charles A. Goldfarb","startTime":1782.39,"endTime":1784.22,"body":"there's a lot of good"},{"speaker":"Charles A. Goldfarb","startTime":1782.39,"endTime":1784.22,"body":"indications for it."},{"speaker":"Chris Dy","startTime":1784.76,"endTime":1788.93,"body":"Are there really"},{"speaker":"Chris Dy","startTime":1784.76,"endTime":1788.93,"body":"though, are there so well, so"},{"speaker":"Chris Dy","startTime":1788.93,"endTime":1792.08,"body":"let's talk one more. One of the"},{"speaker":"Chris Dy","startTime":1788.93,"endTime":1792.08,"body":"things so you know, as we talked"},{"speaker":"Chris Dy","startTime":1792.08,"endTime":1796.7,"body":"about our podcasts and reflected"},{"speaker":"Chris Dy","startTime":1792.08,"endTime":1796.7,"body":"I think it'd be nice to end the"},{"speaker":"Chris Dy","startTime":1796.7,"endTime":1800.15,"body":"episode on a positive note. So"},{"speaker":"Chris Dy","startTime":1796.7,"endTime":1800.15,"body":"what's what's one win that"},{"speaker":"Chris Dy","startTime":1800.15,"endTime":1803.03,"body":"you've had in the world of Chuck"},{"speaker":"Chris Dy","startTime":1800.15,"endTime":1803.03,"body":"Goldfarb in the last week or so,"}]}