What's new in hand surgery- 2015

JOURNAL PRESENTATIONSpecialty Update

What’s New in Hand SurgeryJBJS Am, 2015 Mar 18; 97 (6): 520- 526. Peter C. Amadio, MD

Presented byDr. Libin Thomas Manathara

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Introduction• This update reviews material

presented at the 2014 annual meetings of

the American Society for Surgery of the Hand (ASSH),

the American Association for Hand Surgery (AAHS), and

the American Academy of Orthopaedic Surgeons (AAOS)

as well as articles published in the field of hand surgery from June 2013 through July 2014

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Topics• Trauma- Finger replantation• Trauma- distal end of radius fractures- volar ulnar corner• Trauma- open reduction of distal radius fractures• Hand transplantation• Tendon injuries• Dupuytren Contracture• Carpal Tunnel Syndrome- surgeons vs patients• Carpal Tunnel Syndrome- trigger finger• Carpal Tunnel Syndrome and work• Arthritis and Other Nontraumatic Conditions• Pediatric Hand Problems• Perioperative Care in Hand Surgery• Evidence-Based Articles Related to Hand Surgery

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Trauma- finger replantation• Finger replantation was one of the

defining procedures of modern hand surgery.

• Many hand surgeons have the impression that this procedure is less commonly performed now than previously, and a recent study presented to the AAHS suggests that this perception is accurate.

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Trauma- finger replantation•Although the total number of amputations was similar (26,668 in 2001 and 24,215 in 2010), the number of replantations in 2001 was 930 compared with 455 in 2010.

•Roughly half of the injuries in both years were fingertip injuries; other than a decrease in the percentage of work-related amputations, no other factor distinguished the two years that might explain the difference in replantation rates.

•The authors were unable, on the basis of their data, to assess reasons for the decline in replantation surgery

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2001 2010

930

455

Finger replantationsTotal amputations

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Trauma- distal end of radius fractures- volar ulnar corner

• Distal radial fractures are a perennial topic for hand surgeons. Particular attention is being paid to fractures involving the volar ulnar corner of the radius, which appear to be more susceptible to loss of fixation and subsidence, due to the frequently small size of the affected fragment.

• A recent study of 52 B3 fractures according to the AO/OTA classification (volar shearing fractures), treated surgically with use of volar plates, identified 7 cases in which reduction was lost postoperatively.

7

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Reduction lostReduction maintained

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• Multivariate analysis showed that preoperative lunate subsidence and the size of the lunate facet fragment were the main factors associated with the loss of reduction.

• All of the fractures that lost reduction were classified as AO/OTA B3.3 (volar comminution with separate lunate and scaphoid facet fragments).

• For such fractures, the authors recommended additional fixation with plate extensions, pins, wires, sutures, wire forms, or mini screws to maintain the reduction.

Trauma- distal end of radius fractures- volar ulnmar corner

23-B partial articular fracture of radius 23-B1 sagittal 23-B2 coronal, dorsal rim 23-B3 coronal, palmar rim

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Trauma- open reduction of distal radius fractures

• One recent study looked at rates of surgery in 2007 for Medicare beneficiaries over the age of sixty-five.

• A total of 90,174 patients with

fractures were identified. In 267, the fracture was due to bone cancer.

• Of the remaining patients, 12,618 had open reduction and internal fixation, while 2084 were treated with external fixation and 4709, with percutaneous pinning.

12,618

2084

4709

ORIFExFixK wire

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• The patients were treated by a total of 12,823 different clinicians, of whom 1194 were identified as hand surgeons.

• Surgeons who were forty years of age or younger and those who were identified as hand surgeons were somewhat more likely to prefer open reduction and internal fixation.

• This data source did not allow an assessment of outcome, but another recent study did.

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• That study used an existing database to match 129 surgically treated patients who were sixty-five years of age or older with 129 nonoperatively treated control patients according to

• fracture severity, • sex, • age, and • energy of injury.

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• The following were monitored up to one year post-injury-

• Functional outcome (measured with use of the Patient-Rated Wrist Evaluation),

• fracture union, • quality of final alignment, • time to union, and • complications

• As in the study above, the majority of patients were treated with open reduction and internal fixation.


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• The results showed that the complication rate was significantly higher (thirty-seven compared with twenty two complications) in the surgical group, while final functional status did not differ between the two groups, despite the higher malunion rate (69% compared with 29%) in the nonoperatively treated group.

• The reoperation rate was similar between the two groups

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• The authors concluded that, for individuals over the age of sixty-five, case matched by age and fracture severity, results are similar but complications are more frequent in surgically treated patients than in patients managed without surgery.

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Hand transplantation• Hand transplantation is becoming

increasingly accepted by the hand-surgery community, and many clinical centers now have hand-transplantation programs, even though many of these programs have yet to actually perform such a procedure.

• Two presentations to the AAHS addressed this topic.

• In one, thirty normal subjects and fifteen hand amputees were asked to rate the utility of hand transplantation and to estimate the resulting quality-adjusted life years (QALYs) associated with hand transplantation.

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Hand transplantation• Interestingly, hand amputees did not show a preference for hand transplantation

• The authors concluded that hand transplantation should still be approached cautiously.

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Hand transplantation• In the other study, twenty-two upper-

limb amputees were interviewed regarding their preference as well as their perception of the risks and benefits of hand transplantation.

• Among unilateral amputees, function was considered a benefit only if it approached that of an intact limb.

• Appearance was a secondary consideration, and sensation was considered less of a benefit if the contralateral limb was intact.

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Hand transplantation• Most subjects emphasized the risks of

immunosuppression and the psychological risks of coping with the possibility of rejection and reamputation.

• Similar to the authors in the first presentation, these authors emphasized caution in proceeding with hand transplantation and emphasized the importance of thoughtful dialogue with patients before making a decision to proceed with such a procedure.

Insert the video of the first bilateral hand transplantation done at Amrita Institute of Medical Sciences on Manu a train accident victim

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Tendon injuries• Hand surgeons continue to seek the best methods of

rehabilitation after flexor tendon injury.

• Two recent large systematic reviews—one of which reviewed nearly 3000 repairs and the other, more than 3500 repairs — have tried to address three important issues:

• whether early active motion is better than early passive motion in reducing the rupture rate,

• whether the use of multistrand (i.e., four or six rather than the usual two strand) repairs reduces the rupture rate, and

• whether early active-motion programs, compared with early passive-motion programs, result in better final motion.

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Tendon injuries• While one study was able to conclude that

“Early passive range of motion protocols had a statistically significantly decreased risk for tendon rupture but an increased risk for postoperative decreased range of motion compared to early active motion protocols, ” neither study could definitely say that multistrand repairs reduced the rupture rate or that final motion was better following early active motion.

• One of the key aspects of any successful tendon repair is the postoperative therapy.

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Tendon injuries• Extensor-tendon rehabilitation, in particular, has been

revolutionized recently by the use of “relative motion splinting” in which the affected digit is held either in relative extension (for sagittal band injuries, for example) or relative flexion (for boutonniere injuries) at the metacarpophalangeal joint, in order to allow active motion while protecting the affected area.

• Simple hand-based splints can be used, greatly facilitating both patient acceptance and function.

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Dupuytren Contracture• The injection of clostridial collagenase is now an

accepted treatment for Dupuytren contracture.

• The disadvantage of this treatment is that it is only approved to treat one affected joint at a time.

• In contrast, alternatives such as needle fasciotomy and surgery can treat all parts of the hand affected by the disease at one time.

• This is a recent study of the efficacy and safety of multiple collagenase injections

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Dupuytren Contracture• In this study, sixty patients received treatment of two joints rather than one, most

commonly • either the MCP and PIP joints of the same digit, or • two MCP joints.

• The rate of clinical success in correcting the contracture was • 76% for the MCP joint and • 33% for the PIP joint, • similar to the rate of correction reported for single injections

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Dupuytren Contracture• While 88% of patients were satisfied, all patients

had at least one recorded adverse event, and there were some major complications, including A2-A4 pulley rupture in one patient and tendon rupture in another.

• Complications such as • pain requiring treatment (83% of subjects

compared with 30% to 40%), • pruritus (33% compared with 11%), • lymphadenopathy (37% compared with 10% to

20%), and • skin tears (25% compared with 5% to 10%)

• Although the authors concluded that two joints can be treated safely with collagenase, the higher rates of adverse events are worrisome with regard to extending this treatment to single-stage, whole-hand treatment.

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Dupuytren Contracture• Splinting after surgery for Dupuytren

contracture is commonly continued for up to three weeks postoperatively, but a recent prospective randomized study calls this practice into question.

• Fifty-six patients were randomized to have either therapy alone or therapy plus night-time splinting for three months postoperatively.

• At the end of the study, the two groups did not differ in terms of final range of motion or flexion contracture.

• The authors concluded that routine splinting after fasciectomy for Dupuytren contracture is not warranted, and should be reserved for patients who develop contractures postoperatively.

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Carpal Tunnel Syndrome- surgeons vs patients

• What do patients want when it comes to the treatment of carpal tunnel syndrome?

• Do patients ’ desires differ from those of hand surgeons?

• A very interesting paper recently addressed both of these questions.

• 79 patients with carpal tunnel syndrome and 103 hand surgeons were surveyed about their priorities and preferences with regard to the treatment of carpal tunnel syndrome.

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Carpal Tunnel Syndrome- surgeons vs patients

• Interestingly, patients were less enthusiastic than were surgeons about all treatment options (splinting, injection, or surgery), with the difference of opinion being greatest with respect to injection.

• Patients were more likely than surgeons to think that electromyography was worthwhile, even though the patients disliked the pain associated with this test.

• Patients were more concerned than were surgeons about the risks of surgery, and they placed more faith in family support and second opinions when making treatment decisions.

• Patients also preferred written material to videos as decision aids.

• Finally, patients wanted to be informed and then make the treatment decision for themselves, while surgeons preferred that the decision be a shared one between patient and surgeon.

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Carpal Tunnel Syndrome- trigger finger

• Many hand surgeons believe that carpal tunnel release increases the risk for subsequent trigger finger, and indeed there are studies that show this association.

• The mechanism, however, has been unclear.

• One study looked at palmar displacement of the flexor digitorum superficialis tendons before and after surgery in 319 patients who had had carpal tunnel release.

• Tendon displacement was noted both at rest and with grip.

• Postoperatively, 47 of these patients developed trigger finger

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Carpal Tunnel Syndrome and work• Interestingly, these patients had a roughly 1-mm greater palmar tendon displacement

postoperatively, a finding that was significant and that suggests that triggering may have been associated with tendon bow stringing in this subset of patients.

• Surgeons do not generally assess bowstringing of tendons after carpal tunnel release (for example, by asking patients under local anesthesia to make a fist after the ligament is released); perhaps they should do so and should consider addressing the bowstringing with a transverse carpal ligament reconstruction if it occurs

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Carpal Tunnel Syndrome and work• The work-relatedness of carpal tunnel

syndrome remains an area of active debate among hand surgeons.

• The main factor predictive of carpal tunnel syndrome was forceful hand exertions, which roughly doubled the risk of carpal tunnel syndrome.

• Other factors, such repetitive activities with low force and the percentage of time in extremes of wrist position, were not associated with any increased risk of carpal tunnel syndrome.

• The authors concluded that workplace prevention of carpal tunnel syndrome should focus on high-force repetitive work.

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Arthritis and Other Nontraumatic Conditions

• The treatment of Kienbock disease remains a challenge for hand surgeons.

• This challenge is only heightened by the advent of newer imaging techniques, which show that the disorder progresses to cartilage loss perhaps faster than previously thought.

• A paper presented to the ASSH reviewed a series of patients with Kienbock disease who underwent imaging with use of both 3-T MRI and ultrathin-section computed tomography (CT), and showed that often, both lunate cartilage thinning and fracture develop within one year of the onset of symptoms.

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• For the past few years, hand therapists have instructed patients in the use of an exercise program to strengthen the first dorsal interosseous muscle, in an effort to reduce thumb carpometacarpal joint pain and subluxation.

• An anatomic study of the effect of first dorsal interosseous muscle contraction on thumb carpometacarpal joint stability was presented to the AAHS and included 17 subjects, 14 of whom had radiographic evidence of thumb carpometacarpal joint subluxation.

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• A companion study presented to the ASSH looked at the biomechanics of this exercise program in a cadaver model.

• Both studies provided strong evidence to support the hypothesis that thumb carpometacarpal joint subluxation was improved with contraction of the first dorsal interosseous muscle

• Therefore strengthening of the first dorsal interosseous muscle is a simple and potentially effective adjunct to the nonsurgical management of thumb carpometacarpal joint instability.

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• What is the best angle to fuse the interphalangeal joint of the thumb?

• Most textbooks suggest that neutral flexion/ extension or slight flexion is preferred, but a study presented to the AAHS suggests that a bit more flexion may be better.

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• Twenty-eight healthy volunteers (11 men and 17 women; mean age, 33.5 years) agreed to have the interphalangeal joint of the thumb splinted at 0, 15, 30, or 45 of flexion.

• They completed various tasks and underwent pinch and grip testing.

• The ideal position for pinch and grip strength was found to be 15 of flexion, and this position was also preferred for the various tasks involving the thumb of the dominant hand; for the thumb of the nondominant hand, a position of 30 was preferred.

• No matter in what position the joint was immobilized, precision tasks, such as buttoning, were more difficult with the joint immobilized than with it free.

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Pediatric Hand Problems• Open Salter-Harris type-I and II fractures of the distal phalanx in children

present as a proximally dislocated fingernail and a flexion deformity of the distal phalanx.

• If radiographs are not obtained, the true nature of this injury as an open fracture may not be appreciated.

• A paper presented to the ASSH looked at the consequences of delayed treatment (greater than forty-eight hours post-injury) as well as at treatment that did not include

• debridement, • open reduction, • nail-bed repair, and • antibiotic therapy.

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Pediatric Hand Problems• The differences were stark.

• Early and appropriate treatment resulted in uniformly good results, with only one superficial wound infection in the 27 patients so treated, while 6 of the 13 patients with delayed treatment had complications, including osteomyelitis in 4 cases.

• The message is clear: it is important that such injuries be diagnosed early and treated surgically.

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Perioperative Care in Hand Surgery

• Is it necessary to discontinue anticoagulants prior to hand surgery in order to reduce the risk of bleeding complications?

• To do so does have risks, including the various thromboembolic events such as stroke or myocardial infarction that the anticoagulants were prescribed to prevent.

• A study presented to the AAOS suggests that these drugs may be continued safely during hand surgical procedures.

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Perioperative Care in Hand Surgery

• In a case-controlled study of 52 patients, 26 of whom were administered warfarin and 26, no anticoagulant, no difference was found in terms of postoperative function, pain, or swelling.

• The extent of ecchymosis was significantly greater in the warfarin group (45 mm compared with 17 mm), but no reoperations were needed in either group.

• The authors concluded that it is safe to continue warfarin in patients during hand surgery.

• A similar study on antiplatelet therapies came to a similar conclusion.

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Evidence-Based Articles Related to Hand Surgery

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Adult Scaphoid FractureCarpenter CR, Pines JM, Schuur JD, Muir M, Calfee RP, Raja AS. Adult scaphoid fracture. Acad Emerg Med. 2014 Feb;21(2):101-21.

• This review included seventy-five studies, of nearly 1000 initially evaluated, that assessed the diagnostic accuracy of various physical findings and imaging studies in cases in which there was a history of an injury involving wrist pain and when initial radiographs were normal.

• The authors concluded that the methodological quality of the studies was low.

• The only physical finding that appeared to be useful was the lack of snuffbox tenderness, which reduced the probability of a fracture being present.

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• Of the imaging studies, MRI had the best overall combination of sensitivity and specificity.

• Comment: The author agrees with these conclusions and believe they are becoming the consensus among hand surgeons.

• Some surgeons may prefer CT imaging, if a

fracture is identified and surgery is planned, because of the better image quality and the ability to create three-dimensional reconstructions, which can aid in surgical planning

• Xray vs MRI T1 vs MRI T2

Adult Scaphoid Fracture

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Dorsal Vascularized Grafting for Scaphoid NonunionCaporrino FA, Dos Santos JB, Penteado FT, de Moraes VY, Belloti JC, Faloppa F. Dorsal vascularized grafting for scaphoid nonunion: a

comparison of two surgical techniques. J Orthop Trauma. 2014 Mar;28(3):e44-8

• Seventy-five patients with scaphoid nonunion were randomized to treatment with either a vascularized pedicle graft or a nonvascularized graft from the distal aspect of the radius.

• Union rates were similar between the two groups, and the authors questioned whether the increased technical difficulty of a vascularized graft was worth the effort.

• Comment: Many hand surgeons reserve vascularized bone grafts for use in more complicated cases with small proximal poles or when there is evidence of osteonecrosis.

• Vascularized grafts may also be useful in reoperations.

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An investigation of the effect of AlloMatrix bone graft in distal radial fracture: a prospective randomised controlled clinical trial.

D’Agostino P, Barbier O. Bone Joint J. 2013 Nov;95(11):1514-20.Treatment of Distal Radial Fractures

• The clinical effectiveness of an injectable demineralized bone-matrix allograft (AlloMatrix; Wright Medical Technologies, Memphis, Tennessee) was studied in fifty patients with an unstable distal radial fracture, randomized to receive either the allograft or no graft.

• All fractures were treated with Kirschner-wire fixation after reduction.

• In comparing the two groups at one, six, and fifty-two weeks of follow-up, no significant differences were found in bone density, function, or speed of recovery.

• Comment: Bone allografts are popular because there is no donor site to worry about, but as this study shows, the benefit may be hard to document, even when the comparator is no graft at all.

• In addition, for application in the hand and wrist, where the voids that might benefit from grafting are small, autologous grafts are nearly always available and, given the small volume needed, the donor morbidity is usually modest.

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Percutaneous fixation with Kirschner wires versus volar locking plate fixation in adults with dorsally displaced fracture of distal radius: randomised controlled trial

Costa ML, Achten J, Parsons NR, Rangan A, Griffin D, Tubeuf S, Lamb SE; DRAFFT Study Group. BMJ. 2014;349:g4807. Epub 2014 Aug 5.

• In this multicenter trial in the U.K., 461 patients with a dorsally displaced distal radial fracture were treated with either volar locking-plate fixation or percutaneous Kirschner-wire fixation.

• The main outcome measure was the Patient-Rated Wrist Evaluation, a validated questionnaire of wrist function.

• There were no differences between the two groups at three, six, or twelve months.

• The authors observed that Kirschner-wire fixation is less expensive and a simpler procedure than volar plating.

• Comment: In general, when simpler methods suffice, they are preferred.

• This article reminds us that the outcomes of distal radial fracture treatment can be quite satisfactory with a variety of methods, especially if function rather than normal anatomy or strength is the primary goal. 4658

Surgical treatment of distal radial fractures with a volar locking plate versus conventional percutaneous methods: a randomized controlled trial

Karantana A, Downing ND, Forward DP, Hatton M, Taylor AM, Scammell BE, Moran CG, Davis TR. J Bone Joint Surg Am. 2013 Oct 2;95(19):1737-44

• This study randomized 130 patients with a displaced distal radial fracture to treatment with either a volar locking plate or a percutaneous method (pins with or without external fixation).

• Patients treated with a plate had a quicker return to function, but functional results were similar between the two groups at three months and one year.

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• Comment: Volar locking plates have become very popular in the surgical treatment of distal radial fractures, and this study demonstrates one reason — there is a faster return to function.

• It is important to remember, however, that the longterm results of volar plating are similar to those achieved with other treatment methods as well, and that these other methods remain acceptable clinical practice at many institutions.

Surgical treatment of distal radial fractures with a volar locking plate versus conventional percutaneous methods: a randomized controlled trial

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Comparison of internal and external fixation of distal radius fractures Xie X, Xie X,Qin H, Shen L, Zhang C. Acta Orthop. 2013 Jun;84(3):286-91. Epub 2013 Apr 18.

• This review considered 770 clinical trials before selecting ten that met the inclusion and exclusion criteria.

• The authors concluded that internal fixation had significantly better results than external fixation with regard to the final DASH (Disabilities of the Arm, Shoulder and Hand) score, motion, anatomic reduction, and strength.

• Comment: The results were significant but perhaps not clinically so.

• The DASH difference was 3 points; however, a clinically important difference is usually considered to be >5 points.

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Trapeziometacarpal Arthrodesis or Trapeziectomy Vermeulen GM, Brink SM, Slijper H, Feitz R, Moojen TM, Hovius SE, Selles RW. Trapeziometacarpal arthrodesis or trapeziectomy with

ligament reconstruction in primary trapeziometacarpal osteoarthritis: a randomized controlled trial. J Bone Joint Surg Am. 2014 May 7;96(9):726-33.

• This randomized controlled trial was designed to assess trapeziectomy with ligament reconstruction compared with trapeziometacarpal arthrodesis with a plate and screws in women with trapeziometacarpal arthritis who were forty years of age or older.

• The study was terminated early because of the high complication rate in the arthrodesis group.

• On the basis of the results of this study, the authors do not recommend routine arthrodesis with plate and screws in women with isolated trapeziometacarpal arthritis who are forty years of age or older.

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Trapeziometacarpal Arthrodesis or Trapeziectomy

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Trapeziometacarpal Arthrodesis or Trapeziectomy

• Comment: Many surgeons prefer trapeziometacarpal arthrodesis for men and arthroplasty for women, believing that arthrodesis yields a stronger thumb and that strength is more important in men than it is in women.

• When one considers sex differences in strength, however, the belief that arthrodesis is the option that delivers the greater strength does not appear to be true, as this study demonstrates.

• Currently, simple trapeziectomy is the procedure that the evidence base suggests is preferred for most patients with trapeziometacarpal arthritis.

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Postoperative Hand Therapy for Basal Joint Arthritis Wolfe T, Chu JY, Woods T, Lubahn JD. A systematic review of postoperative hand therapy management of basal joint arthritis. Clin Orthop

Relat Res. 2014 Apr;472(4):1190-7.

• Nineteen studies were reviewed, and three patterns of postoperative management for patients with basal joint arthritis were identified:

• home instruction alone, • routine referral to a hand therapist, and • home instruction with referral to a therapist as needed.

• Because of the variety of surgical and therapeutic interventions reported in these studies, no conclusions could be drawn as to the relative merits of these three postoperative regimens.

• Comment: When faced with limited data and uncertainty, the author tends to opt for the least complex and least resource-intensive course. In his own practice, he would refer a patient for therapy after basal joint surgery only if the patient is having difficulties regaining motion or strength postoperatively.

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Low-Molecular-Weight Heparin and Replantation Chen YC, Chi CC, Chan FC, Wen YW. . Cochrane Database Syst Rev. 2013;7:CD009894. Epub 2013 Jul 8, Low molecular weight heparin for

prevention of microvascular occlusion in digital replantation

• This Cochrane review could identify only two relevant trials, with a total of 122 digits studied, in comparing subcutaneous low-molecular-weight heparin with unfractionated heparin in the postoperative management of finger replantation.

• No differences were found between the two treatments.

• The authors suggested that additional studies be performed.

• Comment: The use of anticoagulation therapy after finger replantation varies greatly from center to center.

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Open versus endoscopic carpal tunnel release: a metaanalysis of randomized controlled trials

Sayegh ET, Strauch RJ. Clin Orthop Relat Res. 2014 Aug 19

• A total of 1859 subjects were included

• The analysis showed that the endoscopically treated patients had modestly greater strength at early follow-up, but this difference disappeared after six months.

• Endoscopically treated patients went back to work about nine days sooner, and the operative time was about five minutes faster than that for the patients treated with open release.

• The risk of postoperative scar tenderness was about half as great for endoscopically treated patients, while the risk of nerve injury, most often transient, was three times as great in the endoscopic group.

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Open versus endoscopic carpal tunnel release: a metaanalysis of randomized controlled trials

• The risks of pillar pain and reoperation were roughly equal in the two groups.

• The authors recommended future studies on the effect of the learning curve and surgical volume on the rates of complications and the safety of endoscopic carpal tunnel surgery.

• Comment: Open and endoscopic carpal tunnel release have slightly different risk-benefit equations, but the long-term results are similar.

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Insert the video of Zion, the first pediatric bilateral hand transplantation done at the Children's Hospital,

Philadelphia

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THANK YOU

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Health & Medicine

What's new in hand surgery- 2015