In Office Trigger Finger Surgery

Do you have a trigger finger? That is to say, a finger that is locking and popping and causing you pain?

In the past, when you needed surgery for this condition, a surgeon would take you to the operating room, which means you had to fast overnight before the surgery, go to hospital, get a ride there and back, take off your clothes, have an IV started, get sedation (which means you would be mentally cloudy the rest of the day),  take the whole day off of work ( and sometimes the next day fever nauseated from the sedation),  and  essentially, spent two whole days preparing and recovering from a surgery that takes 5 minutes.

 Does not make any sense?

It did make sense to a lot of hand surgeons, so they started doing surgery in the office with just local anesthesia.  And gets what?  It worked perfectly.

This is the hardest part  of the surgery.  I inject local anesthesia which is mildly painful.  But once that is done the surgery is a breeze and literally takes less than 5 minutes for most patients.

  Once  I make the incision, I dissect down to the A1 pulley which was released and freed up the finger.  Patient can literally see their finger stp popping right in front of theri eyes.  Fingers they have not moved in weeks can now be used to make a full fist.

Once the A1 pulley was released, I checked to make sure that the patient could make a full fist without any popping or trigger.  Once this was verified, and the triggering was corrected with surgery, I began to close with a few stitches.

The patient can wash their hand that night and use their hand that night.

Many patients who have a desk job just go back to work and work the rest of the day.

It has been an excellent procedure for many of my patients.

Endoscopic Carpal Tunnel Release

Endoscopic carpal tunnel release is one of the great advances in  hand surgery carpal tunnel surgery.

It allows for quick recovery after surgery, so you can get back to your life in your job, sometimes within days.

The incision is literally 1 cm (compared to 3-4 cm in the palm with traditional techniques), and you can use your hand that night. You can drive the next day, and ahower and wash normally within hours. (The video below will show you where the incsion is.)

It take about 10 minutes in the operating room.

You don't always need sedation/anesthesia (though most people prefer that).

It is quick and easy to perform by doctors like myself who are extensively trained in hand surgery. A hand surgeon like myself will be able to do testing the office for carpal tunnel syndrome, as well as treatment that is non surgical (including steroid injections, splinting, and therapy). I will also be able to determine if other issues exist like arthritis and tendinitis, and treat those as well.

I use the Arthrex Centerline system, which looks like this:

I use this system simply because I feel most comfortable with it. Though I think it confers a significant advantage compared to other techniques, I have done 1500 of these cases in roughly the last 4-5 years. There have been no major issues, and most patients recover to a functional status in a matter of hours, and often return to work (depending on what they do) in a matter of days.

If you have questions, then please contact me through the website.

Enscopic carpal tunnel surgery: A few things you can expect

Since coming to  Muskegon in August of 2015, I have performed nearly 1500 endoscopic carpal tunnel releases.  This is a very safe and effective technique, that can reduce recovery time immensely compared to the traditional open technique.

In the past, I performed many carpal tunnel releases utilizing the open technique.  I utilized a large incision with multiple sutures that required 2-3 weeks of healing.  In addition people needed additional 2-3 weeks to recover after that to go back to their work.  This was for even light duty jobs that do not require a lot of lifting. Its a lot of time off for most people, especially if they work with their hands.

 All that has changed with the endoscopic (minimally invasive) technique.

What should I expect during carpal tunnel surgery? 

The surgery itself takes only about 10 minutes.  It could be done in a hospital setting under light sedation or even local anesthesia.  If  you choose to undergo  surgery using sedation, then you will need to fast the night before and not eat anything the day of surgery, as well as getting someone to drive you to the hospital and back.  Otherwise, if you use local anesthesia you could do the surgery without fasting and drive yourself home from the hospital.  Although,  a driver is always preferred when possible.

Currently, techniques are being developed in order to be able to do the surgery in an in-office setting.  (We are very close to having that become a reality in the next 3-6 months, that will be available at a fixed price like the Oklahoma Surgery Center,  so stayed tuned in future blog posts.)

What to expect after endoscopic carpal tunnel surgery? 

What I tell patients is:  after they go home from surgery, in the evening, they can take the dressing off, wash their hands normally, and if they feel good they can even go out to dinner.  The next day they can drive, and run errands if they need to. They can lifting up to 10 lbs., which is about a gallon of milk. They can shower normally. Bathing and soaking of the hand is prohibited. They can call with any other questions they have, and they should return for suture removal in about 10-14 days.

In regards to pain, most patients do not need pain meds for more than one night, and  often ibuprofen or tylenol is more than enough.

In regards to carpal tunnel symptoms, although some residual numbness may remain for a period opf time as the nerve is healing, nighttime numbness and pain (that wakes people up from sleep and is a major reason why patients seek medical care in the first place) is gone the very first night.

In regards to a return to work, I have had a numbe of patients who hold deskjobs or lighter demand jobs go back on a Monday after Friday surgery. This is not unusual. For heavier demand jobs, it really does depend on the individual, but once again, many patients will go back after a week, with stitches still in, and perform perfectly well. This is also not unsual.

In my medical opinion, I see virtually no reason to ever perform open carpal tunnel release for carpal tunnel syndrome anymore, as long as the surgeon is a hand surgeon trained in the technique.

Nail health...Is Jell-O the way to G-O?

Most people are familiar with gelatin either through eating Jell-O, or if you have Scandinavian/Northern European roots through eating aspic. One is generally considered very tasty and the other one--well, not so much. So as not to offend anyone, I will let the reader make the decision as to which they prefer.

Now, as a child, one of my favorite things to do was to make Jell-O with my mother. After boiling it and placing it in the mold, I remember anxiously waiting for it to magically set in the refrigerator.

Well, it turns out that Charles Knox, who developed gelatin in 1890 as a byproduct from slaughterhouse waste (I could have used a euphemism, I guess...), also found another way to market gelatin aside from it being fun to make, fun to jiggle, and  fun to eat (when it is sweet of course, right?!). Knox marketed gelatin by claiming it had nail enhancing benefits.

The logic was as follows: Since it was made from animals such as cows and pigs who had very strong hooves, eating gelatin (which is made from hooves) will make your nails stronger.  Sound a bit fishy (which I happen to eat and am no better a swimmer as a result!),  but in spite of this faulty logic, that still did not prevent gelatin from be coming the popular treat that it is.

The reality is that gelatin, although it is full of protein and collagen, is not in a form that is usable by humans. And soaking your nails and gelatin won't do a bit of good, either.

So, if you want great nails, it's obvious that eating boxes and boxes of Jell-O or consuming plates and plates of aspic will not help.

But what actually does make your nails healthier?

From the perspective of a hand surgeon, deformities of the nails are a result from local problems, such as arthritis, trauma, infections, cysts, and tumors. Or they can also be the result of systemic problems such as malnutrition or cancer. In this case, the nails can be a window into the general health of a person, and they are very important to examine for both the hand surgeon as well as the general practitioner.

What to do if you want beautiful nails? Well, unless you have some of the conditions that I have previously mentioned,which require medical attention, then you might be best served by seeing a good manicurist.

Otherwise, take care of your hands by protecting them, resting them when necessary, washing and moisturizing them properly, and using common sense and good judgement, which may include avoiding that second helping of aspic or lime Jell-O during Christmas time!

Natural Arthritis remedies: Boswellia

Boswellia, also known as Indian Frankincense, is a traditional ayurvedic medicine that has been used for all sorts of conditions from coughs and sores to snakebites and colic, and of course, it has also been used as treatment for arthritis pain, as well. But does it really work? And is there any basis for it working at all?

Generally speaking, these are the critical questions that you must always ask when you are considering taking supplements, like Boswellia, along with added questions of safety and interactions with any current medications/medical conditions that you may be taking, so it's important to always consult with your physician.

It appears that in the case of Boswellia, the answer seems to be that it may in fact, be helpful to some degree with alleviation arthritis pain, even though unlike most arthritis treatments (like NSAIDS for instance, Boswella is neither an anti-pyretic (helps reduce fever) or an analgesic (helps reduce pain topically like a mentholated cream).

Boswellic acid, which is the major constituent, seems to have an anti-inflammatory effect, inhibiting the production of several inflammatory cytokines such as NF-KB and TNF-alpha, which are powerful cytokines that can produce fever, cell death, and sepsis. Likewise, Boswella may help reduce the production of inflammatory molecules called eicosinoids by inhibiting enzyme called 5-lipoxygenase. This may help relieve the pain of osteoarthritis, (1) as eiconosoids modification can be helpful in lessening the pain from arthritis. This is what Omega-3 fatty acids are thought to do, that is they help modify the eiconsoids metabolism/milieu so it is more generally anti-inflammatory.

Still, some skepticism should be applied, if not liberally, as other studies have been less enthusiastic in proclaiming a pain relieving effect. (2) In this study, ASU's (which are derived from soybean and avocado oil) have been shown to be much more effective in the treatment of arthritis pain, which is what I typically recommend for most patients, along with several other supplements and dietary strategies, to help attempt to naturally relieve some of the symptoms of arthritis.

Is Boswella then right for you? Hard to say, really. Although it does not appear to be harmful, it may not be all that helpful compared to some of the other more well known and well-studied supplements available, such as chondroitin, MSM, and glucosamine.  That being said, it may be worthwhile to consider this supplement (under your doctor's supervision is always preferable) if these other more well known supplements fail to help relieve the pain you have.

References: 

Sengupta K, Alluri KV, Satish AR, et al. A double blind, randomized, placebo controlled study of the efficacy and safety of 5-Loxin(R) for treatment of osteoarthritis of the knee. Arthritis Res Ther. Jul 30 2008;10(4):R85.

Chrubasik JE, Roufogalis BD, Chrubasik S. Evidence of effectiveness of herbal antiinflammatory drugs in the treatment of painful osteoarthritis and chronic low back pain. Phytother Res. Jul 2007;21(7):675-683.

Supplements for arthritis

If you have pain, especially in your hands, and you have been told it's not carpal tunnel syndrome, but rather what you have is arthritis, there are several things that you can do. If it's really bad, surgery is an option. If it's only moderately bad, then a steroid injection can help, but if you are like the majority of patients that I see on a daily basis, then you are neither a candidate for surgery or steroids. 

Most doctors will then put you in the 'not much to do right now' category, and see you when the condition gets worse. But the fact is, when you have pain, most people would like to do something before it actually gets worse, and one of the roads that I recommend to patients is supplements. 

Now, I always say, supplements are only one aspect, that is, one road to take. The others are things like exercise, diet, and ergonomic modfications, but the fact is, supplements do help, and they can help a lot. 

I have written about this before in my other blog, but the information is constantly changing, as new products are coming out and new scientific knowledge is being discovered. 

Here is a update:

The most well known supplements today are:

1. Glucosamine is a supplement which is thought to decrease inflammation in the articular cartilage (the cartilage of joints that move, or articulate, like your knee and thumb, for instance) and it also seems to help prevent degradation of the articular cartilage. Glucosamine is a pre-cursor to molecules known as  glycosaminoglycans, which are part protein and part sugar molecule. GAG's are also known as mucopolysaccharides, and  they are important to joint health because they provide both the lubricating fluid and the cushioning aspect of the joint itself. If you think of it in terms of a car, it's like having the oil for your pistons and shock-absorbers. Studies have shown that Glucosamine appears to effective in helping treat osteoarthritis, and as a result, it is still a popular supplement which I recommend to all of my patients. 
2. Chondroitin sulfate is also a GAG, but it contains sulfur in its structure, which makes it unique. Sulfur is a very important micronutrient for a wide variety of procesess in the body, and it can help a great deal in relieving joint pain. (I have written about it before) In fact, many spa and mineral springs that have been in use for hundreds (and sometimes thousands) of years, have very high sulfur content in their water, suggesting that although the ancients may have not known the exact process by which they were deriving benefits from mineral springs, they were certainly observing results, which is probably one of the reasons why they were (and are in many cases, still) so popular. Chondroitin sulfate is thought to reduce some of the expression of anti-inflammatory substances within the joint thereby relieving joint pain.
3. A combination of glucosamine and chondroitin sulfate.  Although I discussed each of these supplements separately, it is important to note that these supplements are often sold together in combination, and this is because the combination is thought to work synergistically to help alleviate joint pain.
4. A special 'supplement' that deserves mention within this blog is hyaluronic acid, which like Glucosamine and Chondrotion sulfate which can be taken in supplement form, but now is more commonly given alone in the form a joint injection called Synvisc (but there are many other similar brands available). I give Synvisc injections for thumb arthritis pain quite frequently, but it is important to note that since this drug is still under patent, and can be rather expensive. You want to make sure that your insurance plan covers it, and if not, then you can often negotiate a payment plan with affordable rates with your doctor. 
5. Omega 3 fatty acids are essential fatty acids (mostly obtained from fish sources) which are important for a wide variety of function within the body, especially in the development and maintenance and health of neural tissue, but they also help a great deal with joint pain, as they tend to be anti-inflammatory.  Krill oil supplements  appear to be exceptionally helpful for joint pain when combined with hyaluronic acid, as they contain a natural anti-oxidant called astaxanthin, which helps prevent the Omega-3 fatty acids from going rancid, which they frequently do, if they are cheap or not used within a reasonable time frame. Likewise, astaxanthin may have some significant benefits as an anti-oxidant in itself. In either cases, krill oil may be a better choice when choosing Omega-3 supplements, and can help reduce chronic inflammation and joint pain.
6. A relatively new supplement called ASU, has become very popular over the last several years, and has been shown to help alleviate joint very effrectively for many people. ASU stands for avocado and soybean unsaponifiable fractions. It works in many of the same ways that glucosamine and chondroitin do, and can be added to glucosamine and chondroitin to help reduce pain. In regards to its overall safety, in 2002, the Cochrane Review, an independent health organization based in Oxford, England, examined herbal therapies for OA and found conclusive evidence concerning ASU. Specifically, a 2003 study published in the Journal of Rheumatology reported ASU inhibited not only the breakdown of cartilage but also promoted repair within the joint. The French government has tracked ASU’s safety record for more than 15 years and has yet to find any significant problems. 

Django Reinhardt: A Gypsy Guitar Magician

When people think of great guitarists of the 20th century, often names like Les Paul, Jimi Hendrix, Jeff Beck, and Jimmy Page come to mind. Indeed, all of these men were are  great guitarists, but they were  also all masters of the modern electric guitar, which, in many ways,  is a completely different animal than an acoustic guitar. 

Having played the guitar on and off through my youth and adult life, I have learned that although both electric and acoustic guitars are difficult to play well, but in terms of the physical hand and finger strength necessary, I really believe that the acoustic guitar is, on the whole, much harder to play.

And this is just one of the things that makes a man like Django Reinhardt such an unusual on so many levels. Reinhardt is generally regarded as one of the greatest, if not the greatest guitar player of the 20th century, and he gained this fame by playing the acoustic guitar and not the electric guitar.

The acoustic guitar was not even the dominant instrument during the time he played (in the early 20s and 30s).  Much of reason of the acoustic guitar's lack of popularity had to do with the simple fact that an acoustic guitar was simply not very loud, certainly when compared to horns and drums. 

Once electric amplification came along, the guitar soon became the dominant instrument not only in jazz but in popular music as well.  In fact, the electric guitar became a cultural icon representing strength, power, glory and an almost transcendent element, heralding the age of the so-called 'Guitar God'. And certainly, when the future looks back to discuss 20th century music,  it seems undeniable that the electric guitar, in all of its various roles, will be a big part of that discussion. 

Furthermore, as you can see by the photograph above, Django playing hand was severely crippled as a result of  a burn sustained in a house fire. This makes everything that Django Reinhardt accomplished all the more amazing, especially from a hand surgeon's perspective, because I still can't figure out how on earth he created some of the sounds he did with such a severe contracture of his ring and small finger.

 Jazz in particular, relies on a much more complex chords and chord arrangements which usually require the ring and the small finger to produce. But Danjos ring and small finger were not only crooked, they didn't even move! It really defines logic and explanation on many levels, as does Reinhardt as a person himself.

---

Born in 1910 in Brussels, Django was a gypsy from the Manouche tribe of gypsies known for their musical ability. In his native language, Roma, Django means hope, which I think is an appropriate name for this singularly talented virtuoso.

In his early twenties, as I've mentioned, Django was badly burned in a house fire, which resulted in the loss of his left ring and small fingers. Teaming up with violinist Stephane Grappelli to form the Hot Club Quintet of France, Danjo  made numerous memorable albums with Django that are now considered classic of Jazz.

Django Reinhardt was both a complicated and colorful man, outside his musical talent and gifts. For instance, He never learned to read or write, and loved to gamble, carrying a roll of cash with him wherever his went that was usually much fatter the night before! But money was never all that important to Django Reinhardt as he loved to paint, and like to play his music on his terms, sleeping in, and missing gigs frequently when it was his will.

And Danjo was a very fine painter indeed, and probably, a good lover too if you study his paintings as most of them are nude portraits of women!

But above all, it was the guitar which ruled his passions and desires. Django would play incessantly, until his fingers bled, at all hours day or night. And even though he appears, by all accounts to be somewhat unruly and difficult to deal with, as artists of Django's caliber are wont to act, we are all blessed ultimately by the wonderful legacy of music he left behind for us to enjoy.

Sadly, Django died of a cerbral hemorrhage when in 1953 when he was just 43. His legacy, though, lives on through his music.

As a hand surgeon, I see devastating injuries of the hand frequently, and the emotional shock of the loss is often overwhelming, and can cause depression. However, if there is anything beyond music that Django Reinhardt's music and life can teach us is the resilience of the human spirit--how it is not easily quashed, and how music comes, not from the actual physical creation of notes, but from the soul itself, and it will inevitably find a way to express itself in spite of enormous obstacles.