Sunday, November 20, 2016

Clasped Thumb Follow Up

I have posted several times on clasped thumb, a rare condition in which the muscles that straighten the thumb are slow to develop and the thumb rests across the thumb.  It must be differentiated from several other diagnoses included trigger thumb and spastic thumb (in which the tight muscles pull the thumb down).  Here are links to the other two posts: Post 1 and Post 2.

In, this post, I wanted to briefly share the early results after surgical treatment for clasped thumb.  Surgery is usually not required.  In most cases, support in the form of a soft splint or hard splint allow the thumb muscles time to develop.  However, for the rare child, those muscles don't develop and we perform a tendon transfer- where we move a muscle/ tendon from one position to the thumb to improve the strength of extension.  Good results are expected and, at early follow- up, here at 3 months, good results have been obtained.  Remember, it is not easy to capture pictures of a very active 2 year old but I believe we can see the results!

Patient doing well after clasped thumb surgery

Excellent thumb straightening 3 months after clasped thumb surgery.

Charles A. Goldfarb, MD
My Bio at Washington University

Saturday, November 19, 2016

Patient Pollicization Testimonial

Gracie is an 11- year old who had a pollicization 3 months ago for her hypoplastic (small) thumb. Compared to the typical patient treated with a pollicization, Gracie is unusual because she was much older at the time of her surgery.  Gracie's age at the time of surgery does bring a few challenges mainly because she has been using her four finger hand with her 'small' thumb for her entire 11 years. However, she came to realize the challenges of life without a highly functional thumb- her thumb did not function .  The thumb is key for large object grasp such as grasping a soda can which is impossible with the fingers for most of us.  Additionally, the thumb allows fine pinch- also very difficult with the fingers.  Gracie and her family elected to proceed with the surgery.  Below find pictures before and immediately after surgery.

Hypoplastic thumb before surgery
Hypoplastic thumb before surgery

New thumb immediately after surgery
New thumb immediately after surgery

New thumb immediately after surgery

I recently saw Gracie in the office 3- months after her surgery.  She is an impressive and dynamic 11 year old and agreed to share her thoughts on video.  She is very excited about the results of the surgery.  Her thumb is working great and will continue to get better.  I wanted to capture Gracie on video as her words may help parents considering this surgery for their child.

I hope these pictures and, more importantly, this video are both helpful for families considering the pollicization procedure!

Charles A. Goldfarb, MD
My Bio at Washington University

Surgery Ecosystem

There are many factors for families to consider as they choose a surgeon and a hospital.  There is no perfect path to making these choices but some factors that I believe are important include:

1) Surgeon.  I have previously blogged about choosing-your-childs-surgeon  and this is a key factor for consideration.   I believe that the surgeon must be committed to the care of kids' upper extremities, be involved in the community of doctors who care for these types of patients, and be committed to advancing the field.  I believe surgeons who only occasionally treat kids are not ideally suited to take care of your child with a birth difference of the upper extremity.

2) Hospital.  Utilizing a children's hospital that takes care of kids 100% of the time is an important criteria, as everything the hospital offers is specifically for children.  The anesthesia is more routine, the nurses more familiar, the whole process easier.  This does not mean that you can't get good care in a hospital that treats all aged patients, it just means that if you have a choice, pick a hospital that has specific expertise in pediatric and adolescent patients.

3) Therapy.  We tend to focus on surgery as the most important step in treatment.  And it often is critical, but in many conditions, therapy can be effective instead of surgery and therapy is almost always utilized after surgery.  Therapy matters and therapist experience matters.  You want a team taking care of your child that has experience in your child's specific condition. Splints, exercises, and wound/scar care all effect outcome.

4) Communication.  I strongly believe that when a physician takes care of kids, they should provide increased access for families.  While this can mean the opportunity for thorough office visits, it also means availability to communicate via phone or email.  I understand that decisions about surgery can be challenging for families, and having all questions answered and feeling comfortable help to make the decision easier.  While not every doctor will share his/ her email or cell phone, many will.  Consider this in your decision.

5) Research.  While taking care of the patient is and should be the primary 'job' of any doctor or surgeon, research is another consideration.  Some doctors focus on patient care, but others take care of patients AND teach and conduct research.  Research has the potential to change our understanding of birth differences, change our treatments, and improve outcomes.  Research is ultimately the way we can positively affect all kids born with upper extremity differences.  I feel this is a critically important goal.  It is important for families to understand that research can be done in a way that does affect their child's care in any way as most research is simply observational (we watch and understand how certain treatments affect outcome).  Participating in research offers the hope of a future with increased knowledge of best practices for kids with birth differences of the upper extremity.

There are many factors for families to consider as they pick a team to care for their child.  I hope my brief discussion of a few of these factors is helpful.

Charles A. Goldfarb, MD
My Bio at Washington University

Friday, October 28, 2016

Buenos Aires IFSSH Meeting

It was my pleasure to attend the 50th anniversary meeting of the IFSSH- the International Federation of Societies for Surgery of the Hand.  This international organization meets every three years (previous meetings in South Korea and India, next meeting in Germany) with a weeklong exchange and dialog on hand surgery.  I was pleased to have the opportunity to be a part of a great symposium as well as share our work in 3 scientific presentations.

Steve Moran organized a great congenital hand symposium including Scott Oishi (USA), Michael Tonkin (Australia), Goo Hyun Baek (South Korea), Miguel Hernandez (Mexico), and Neil Jones (USA) discussing late complications after a variety of congenital procedures.  I was pleased to participate and discuss late complications after syndactyly reconstruction.  I shared our experience in St Louis including the early positive findings with hyalomatrix.  Great symposium!

We also shared our experience in scientific presentations for
1) humerus rotational osteotomy for internal rotation posture in arthrogryposis
2) hyalomatrix early outcomes with syndactyly reconstruction
3) Elbow release procedures

Buenos Aires is an amazing city which I was briefly able to tour. A few of the sites:

One of the many beautiful churches in Buenos Aires

The widest avenue in the world with the Obelisk in the distance

One of the few "Thinker" statues by Rodin, in Buenos Aires.

In short, while my trip was brief, it was both a great cultural experience and scientific experience!

Charles A. Goldfarb, MD
My Bio at Washington University

Saturday, October 8, 2016

ASSH Annual Meeting 2016

I recently returned from Austin Texas, site of the American Society for Surgery of the Hand Annual Meeting.  This was the first time the meeting was held in Austin but I am sure we will be back.  I thought the overall meeting was really well done with a great mix of scientific content and review materials.

I want to briefly highlight some of the events regarding congenital hand and upper extremity differences.

Scott Oishi from Texas Scottish Rite Hospital in Dallas led a Symposium on "What I Have Learned' on Congenital Differences.  There were talks on the timing of surgery, (Oishi) radial polydactyly (thumb duplication) (Steven Hovius from Rotterdam, The Netherlands), radial longitudinal dysplasia (Michelle James, Northern California Shriners Hospital), toe transfers (Scott Kozin, Philadelphia Shriners Hospital) and syndactyly (mine).  I learned from each speaker including new techniques.

We had an Instructional Course on What Works for Congenital Differences.  This was a great course with participants Doug Hutchinson, Michelle James, Ann Van Heest, and Darryl Chew (Singapore) with talks on common issues (trigger thumb) and rare conditions (central polydactyly).

Group for ICL

And finally, I was able to present the Manske Award for the Best Congenital Hand Surgery Manuscript for 2015.  This award is presented on behalf on the Pediatric Hand Study Group and former fellows of Dr Manske.  This is the fifth year of the award with previous winners from across the world (Sweden, India, and England) on topics such as radial deficiency, multiple hereditary exostosis, and social adaptation.  This year's winner was "Tendon Transfer Surgery in Upper-Extremity Cerebral Palsy Is More Effective Than Botulinum Toxin Injections or Regular, Ongoing Therapy" by authors Van Heest, Bagley, Molitor, and James.  The paper found that surgery provided improved outcomes (modest) compared to botulinum toxin and ongoing therapy.  Ann Van Heest accepted the award on behalf of her co-authors.

Manske Award Presentation to Ann Van Heest

Charles A. Goldfarb, MD
My Bio at Washington University

Saturday, September 24, 2016

Hand Camp 2016

Once a year, Hand Camp is held in Pitosi, Missouri at Camp Lakewood.  This is a wonderful opportunity for 15 kids with hand and arm differences to come to camp with their entire family (parents, siblings).  The kids get a chance to meet and socialize with kids with similar brith differences but also work with junior counselors who are similarly affected.  This years' junior counselors were all once campers themselves- how exciting!  So the kids have a great chance to socialize and also engage in great activities.  The parents have the chance to meet other parents and learn from each other.  And lastly, there is the camp staff.  The staff is a mixture of nurses, recreational therapists, physical therapists, and hand therapists all spending time away from home and 'working' the camp.  But, the camp is a great experience for them as well- a chance to interact with kids and families away from the hospital and be reminded of how amazing these kids (and their families) can be!

A few pictures of the Hand Camp 2016 Attendees.

Camp Lakewood in Pitosi Missouri

The lake

Hand tracings of some of the kids.

The whole crew including campers, families, junior counselors, and staff at Hand Camp 2016.

Hand Camp 2016 campers and junior counselors.

The Hand Camp 2016 Staff.  All are so generous with time and spirit.

Charles A. Goldfarb, MD
My Bio at Washington University