Extract
This update reviews material presented at the 2011 annual meetings of the American Society for Surgery of the Hand (ASSH), 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 (other than those published in this journal) between August 2010 and July 2011. In addition to the broad focus of the AAOS, both hand surgery organizations feature presentations on shoulder and elbow surgery and general microsurgery, all of which are beyond the scope of this review. If a work was presented at more than one meeting, only the first presentation is described.
This update reviews material presented at the 2011 annual meetings of the American Society for Surgery of the Hand (ASSH), 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 (other than those published in this journal) between August 2010 and July 2011. In addition to the broad focus of the AAOS, both hand surgery organizations feature presentations on shoulder and elbow surgery and general microsurgery, all of which are beyond the scope of this review. If a work was presented at more than one meeting, only the first presentation is described.
Meeting abstracts for the annual meetings of the American Society for Surgery of the Hand, American Association for Hand Surgery, and American Academy of Orthopaedic Surgeons are maintained online at www.assh.org, www.handsurgery.org, and www.aaos.org, respectively.
More and more institutions are employing registries to monitor certain classes of patients. Attendees at the AAHS meeting learned how one such registry was used as the basis of a multivariate regression model of outcome after distal radial fracture. All patients had regular outcome assessment with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, a measure of upper limb disability, and a visual analogue scale (VAS) for pain. The model showed that fully 47% of the DASH score could be explained by just three variables: the amount of pain, grip strength, and supination. No other aspect of motion correlated with the DASH score. The authors concluded that restoration of supination should be an important goal after distal radial fracture. The authors of a study that was presented to the AAOS came to a similar conclusion about the impact of supination deficits on outcome and correlated a loss of supination with residual displacement of the palmar ulnar corner of the distal radial articular surface.
Increasingly, endocrinologists are focusing on bone quality in addition to bone density. A report that was presented to the ASSH suggested that trabecular density may be better than mineral density for predicting the risk of distal radial fracture. Fourteen premenopausal women with distal radial fractures were matched with forty-four control subjects. While bone mineral density was similar in the two groups, the patients with fractures had 14% lower trabecular density; this difference was significant (p < 0.05). The authors recommended that, in the future, osteoporosis screening should assess both the microarchitecture as well as the density of bone. Hand surgeons should be aware of this when evaluating patients who have apparent fragility fractures. Patients with adequate bone mineral density may still be at risk if the trabecular density is deficient.
Do intercarpal ligament injuries predict outcome after distal radial fractures? This question was the subject of a second report to the AAHS. In this prospective study, thirty-six patients had a systematic wrist arthroscopy at the time of surgical treatment of a distal radial fracture. Patients were followed for one year. Many injuries were noted on arthroscopy, with 44% of the patients having a scapholunate injury, 44% having an injury to the triangular fibrocartilage complex, and 25% having an injury to the articular cartilage. After controlling for AO fracture type, none of these injuries were correlated with the latest VAS score for pain, the DASH score, or wrist motion. The authors concluded that intercarpal ligament and cartilage injuries are commonly associated with distal radial fractures but that such injuries do not predict outcome, at least in the short term. Should such injuries, then, be repaired if noted? Stay tuned for future studies.
To release or not to release the carpal tunnel is the question when plating a radial fracture through an anterior volar surgical approach. The authors of a report that was presented to the ASSH attempted to answer this question in a retrospective study of 199 consecutive patients who were seen at a single institution. Of these, seventeen had an acute carpal tunnel syndrome at the time of presentation. All seventeen patients had release of the carpal tunnel, and fifteen had improvement following the release. None of the other patients had release of the carpal tunnel in the course of the surgical exposure. Fifteen of these patients developed symptoms of carpal tunnel syndrome, but all symptoms resolved with nonoperative treatment. The authors concluded that routine release of the carpal tunnel is not necessary when performing volar plating of the distal part of the radius.
When scaphoid nonunions result in posttraumatic arthritis, treatment frequently involves excision of the arthritic distal pole of the scaphoid, with or without additional procedures such as midcarpal arthrodesis. A report that was presented to the AAOS described the long-term (eleven to twenty-one-year) results of simple distal pole excision. Of the nineteen patients who underwent the procedure, eighteen could be followed and only one required additional surgery. While one-third of the remaining patients had some evidence of capitolunate arthritis at the time of the latest follow-up, none of them complained of wrist pain. The authors concluded that simple distal pole excision can be an effective long-term solution to posttraumatic arthritis secondary to scaphoid nonunion.
In many cases, hand surgeons fix scaphoid fractures with a percutaneously placed screw. However, the surgical approaches have problems; the proximal-to-distal approach must violate the proximal scaphoid articular surface, whereas the distal approach goes through the scaphotrapezial joint. The authors of a study that was presented to the AAOS reported the four to nine-year results for thirty-four patients who had undergone percutaneous scaphoid screw fixation through a distal approach. While three patients had radiographic evidence of scaphotrapezial arthritis, two of the three patients had symmetrical findings in the contralateral wrist and none of the three patients were symptomatic.
A common surgical adage is that “nothing spoils a good result more than longer follow-up.” The treatment of scapholunate injuries remains problematic for hand surgeons, and the problem seems to be getting worse as follow-up increases. A recent report that was presented to the ASSH described the four to twelve-year results for fifty-nine patients who had had a dorsal capsulodesis for the treatment of scapholunate injury. Although the initial postoperative radiographs showed good improvement, the preoperative deformity had completely recurred by the time of the latest follow-up. More than 80% of the patients had posttraumatic arthritis. Kaplan-Meier analysis showed a 50% probability of a salvage procedure being performed within ten years, with most of those procedures being needed in the first three years. Unfortunately, even the salvage procedures are problematic; the authors of a recent report1 on proximal row carpectomy noted that fifteen of the thirty-one patients had persistent moderate or severe pain postoperatively. The search for a durable solution to this problem continues.
It is commonly said that practice makes perfect, and surgical simulation techniques now make it possible to practice our surgical techniques in benchtop simulations rather than in cadaver models (or in patients!). Two papers that were presented to the AAHS were relevant to improving the quality of tendon repair through the use of such surgical simulations. In one, a tutorial significantly improved both load to gap and load to failure of a simulated tendon repair. In the other, the issue of knot security was investigated, also in a simulation model. Regardless of suture material or diameter, a minimum of five flat square knot throws were needed in the simulation before the knot failed by breakage rather than slippage.
The role of active mobilization following tendon repair with use of contemporary techniques was the subject of both a systematic review2 and a prospective study3. Both studies showed that early active motion was associated with superior clinical results. The authors of the systematic review made the important observation that most studies focused nearly exclusively on finger motion and complications such as rupture of the repair while there were few data to describe the impact of these injuries on the patient’s quality of life2.
Upper extremity replantation is an established procedure, but a study that was presented to the ASSH suggested that replantation services are inconsistently available. In that study, a survey asking about the availability of replantation services was sent to all level-1 and level-2 trauma centers in the United States. Over 85% of the centers responded. Only 54% of the 117 level-1 centers and 29% of the 132 level-2 centers provided continuous replantation coverage. Some of the other centers offered intermittent replantation coverage, but over half of the level-1 and 2 centers had no specific replantation coverage protocols. The authors concluded that access to replantation services is a challenge in many communities in the United States. Some hand surgeons may believe that access is limited because the medical liability risk of such procedures is high. However, a recent report from a major trauma center in New York City suggested that such procedures have a relatively low risk of adverse legal outcomes4. Following >200 replantation attempts, only five lawsuits were filed, and none was successful. Among the twenty-three lawsuits that were filed in cases of hand trauma, the only successful lawsuit was for the loss of a nonreplantable part.
One of the most common elective hand microsurgical procedures is toe-to-hand transfer. Several options are available, including the great toe, second toe, trimmed great toe, and great toe wrap. Individual studies usually evaluate just one of these options, making a comparison of the relative benefits difficult. The authors of a systematic review that was presented to the ASSH attempted to resolve this uncertainty by analyzing 450 patients from twenty-five studies that included data on functional outcome, morbidity, and patient satisfaction. The authors found that all procedures had similar results in terms of survival, motion, strength, and sensibility. They concluded that the choice of procedure should be based on the expertise of the surgeon and the preference of the patient, especially in terms of donor site trade-offs, wherein the procedures differ the most.
Raynaud phenomenon may be a source of severe pain and also may cause digital ulcers. While many treatments are available, none are uniformly effective. The authors of a recent report5 suggested that injection of botulinum toxin type A (Botox; Allergan, Irvine, California) may be effective. Between 2004 and 2010, a total of twenty-nine patients were managed with an injection of fifty to 100 units of botulinum toxin type A in the palm at the base of each affected digit. Twenty-three patients noted pain reduction, which lasted an average of twenty months; of the seventeen digital ulcers, fifteen healed within sixty days of injection. The authors concluded that botulinum toxin type A may be a useful treatment for selected patients with more severe manifestations of Raynaud phenomenon.
Is sodium hyaluronate safe and effective for the treatment of arthritis of the thumb carpometacarpal joint? A study that was presented to the AAOS suggested that the treatment is safe but not effective. A total of twenty-seven patients were enrolled in a prospective, randomized, placebo (saline solution)-controlled trial in which affected joints were treated with a series of three weekly injections and then were followed for one year. Adverse events, pain, strength, motion, radiographs, and the DASH score were evaluated at one, three, six, and twelve months. There was no significant difference in any of the outcome measures at any time point.
While meta-analyses6 and randomized trials continue to show that simple excision of the trapezium is as effective as other alternatives for the treatment of thumb carpometacarpal arthritis, surgeons continue to seek more anatomic alternatives. A study that was reported to the AAOS described the results of a pyrolytic carbon saddle-shaped implant designed to replace the base of the thumb metacarpal. A total of nineteen patients were followed for an average of six years. While there was significant improvement in terms of pain compared with preoperative levels, there was no improvement in terms of strength or motion, and five patients required a revision procedure during the follow-up period. In addition, the implants were subluxated in four patients. The authors of that study concluded that longer-term studies were needed, something that was also recommended by the authors of a recent systematic review6. Hand surgeons continue to search for a reliable arthroplasty for the proximal interphalangeal joint. A recent report to the ASSH suggested that hand surgeons still have a distance to travel. A review of 294 nonconstrained implants (203 pyrolytic carbon implants and ninety-one metal and plastic implants) showed that seventy-six fingers required one or more reoperations, primarily for the treatment of flexion contractures, loosening, and instability. Six fingers eventually required amputation. The dorsal approach was more likely to be associated with complications. A published study of fifty-one silicone implants that were inserted through a lateral approach7 also reviewed complications, with a 10% reoperation rate at an average of three years of follow-up.
A recent report described the results of total wrist arthroplasty for twenty-one patients who had been managed with the Universal 2 implant (Integra LifeSciences, Plainsboro, New Jersey)8. After three to eight years of follow-up, three patients had signs of osteolysis or loosening, all but one of the patients were satisfied with the procedure, and there had been no reoperations. The same implant was the subject of another report that was presented to the ASSH. In that report, thirty patients who had the device inserted without cement were followed for one to nine years. Three procedures were revisions of a previous cemented implant. Two patients required revision surgery, and radiolucent lines were observed around ten of the sixty components at the time of the latest follow-up.
The role of collagenase (Xiaflex; Auxilium Pharmaceuticals, Malvern, Pennsylvania) in the treatment of Dupuytren contracture continues to gather attention. A report that was presented to the AAHS summarized the results of five Phase-III trials in which collagenase was used to treat Dupuytren contracture. A total of 950 patients were managed with collagenase, but only 634 completed enough follow-up to be evaluated. Recurrence was defined as an increase in contracture of ≥20° after an initial correction of the contracture to ≤5°. After a mean duration of follow-up of 2.1 years, Kaplan-Meier analysis estimated the two-year recurrence rate to be 24% overall. The rate of recurrence was much lower at the metacarpophalangeal joints (17.6%) than at the proximal interphalangeal joints (41.4%). A recent structured review comparing reports of fasciectomy and fasciotomy also evaluated recurrence rates; at an average of four years, the recurrence rate averaged 39% in the fasciectomy reports and 62% in the fasciotomy reports9.
A report that was presented to the ASSH focused on another minimally invasive approach to the treatment of Dupuytren disease: percutaneous needle fasciotomy. In this procedure, instead of the needle being used to introduce collagenase, the needle tip is used as a knife to divide the Dupuytren cord. The series included 200 treated digits that were followed for a minimum of six months. The overall total passive extension deficit averaged 150° preoperatively and 60° at the time of the latest follow-up. Complications included two nerve injuries and four infections. As is the case with collagenase treatment, better gains were achieved at the metacarpophalangeal joint than at the proximal interphalangeal joint.
How much does this matter to patients? Interestingly, the degree of contracture does not appear to correlate very strongly with the degree of functional impairment. In a recent study, the DASH questionnaire was administered to 154 patients with Dupuytren contracture and the correlation between the DASH score and the degree of contracture, either overall or by digit, was evaluated10. The correlations were all very weak, and the average functional score was consistent with a mild impairment of function.
2010 was the centenary of Robert Kienböck’s landmark paper; in its second century, the condition continues to provoke the interest of hand surgeons11. However, two recent publications suggested that the current staging system, which forms the basis for many treatment decisions, is flawed: hand surgeons cannot always agree, when given identical radiographs to interpret, which stage of the disease is present12,13. One of the reports also showed a wide degree of variability when the same surgeon reinterpreted the same image at a different time13.
One of the tenets of medical professionalism14,15 is “justice in the health care system, including the fair distribution of health care resources”14. In other words, professionals should be mindful not only of the effectiveness but also the cost of the services provided to patients in their care. The concept of value16 (quality of outcome, safety, and satisfaction, divided by cost over time) relates directly to this tenet. Several hand surgery presentations in 2011 addressed this issue.
The role of hand therapy after distal radial fractures was the subject of a prospective randomized trial that was presented to the ASSH. Ninety-six patients were randomized, after volar plating for the treatment of a distal radial fracture, to either (1) a formal hand therapy program or (2) informal rehabilitation instructions provided by the surgeon. There was no difference between the groups in terms of function as measured with the DASH score at the time of the latest follow-up, and the surgeon-directed patients actually had better strength and motion at both three and six months postoperatively. The authors concluded that formal therapy does not improve outcomes after volar plating of distal radial fractures; indeed, given worse function and higher costs, it is clear that the hand therapy provided in that study did not create value, as defined above.
One report that was presented to the AAHS compared the costs and outcomes associated with hand fractures that were treated with use of local anesthesia in a minor procedure room (n = 72) with those associated with hand fractures that were treated with use of general anesthesia in a standard operating room (n = 54). Outcomes were similar in the two groups, but costs were eight times higher for the group that had been treated in the operating room, primarily as a result of hospitalization, anesthesia, and operating room fees. The authors concluded that repair of hand fractures in a minor surgical suite is safe and effective. The authors of another recent publication came to a similar conclusion after comparing costs for similar hand surgical procedures in hospitals and ambulatory care centers17.
A second study that was presented to the AAHS evaluated wound infection rates in a multicenter trial of a field sterility protocol for patients undergoing carpal tunnel release. In the protocol, the hand was prepared with chlorhexidine or iodine, a single towel was used, and the surgeon used a mask and gloves but no gown. No antibiotics were given. A total of 1504 patients were enrolled. A total of six superficial wound infections were noted; there were no deep infections. All of the superficial infections resolved; only four required treatment with oral antibiotic therapy. The authors concluded that field sterility is sufficient for carpal tunnel surgery and that it results in considerable savings not only in time and money but also in waste as there is only a single small drape to discard or launder. The authors of a recent report18 came to a similar conclusion regarding the use of antibiotics. A total of 1340 patients were randomized either to receive or not to receive preoperative antibiotics. There was no difference between the two groups in terms of the rate of infection, even when comparing patients who had contaminated traumatic wounds or when comparing patients who had procedures lasting for more than two hours.
Do hand surgeons overprescribe pain medication postoperatively? This was the provocative subject of a report that was presented to the ASSH. A total of 250 patients were followed after a variety of elective outpatient hand surgery procedures, including both soft-tissue and osseous procedures. The most commonly prescribed narcotics were oxycodone, hydrocodone, and propoxyphene, and the usual number of pills prescribed was thirty. The patients used an average of only ten of the thirty pills prescribed, with patients who had fractures consuming an average of fifteen pills. Patients receiving Medicaid reported taking an average of twenty-six pills; patients receiving Medicare, seven. One-fourth of the patients took no narcotics at all. The authors concluded that the customary prescription amount of thirty pills may be excessive and unnecessary, especially for elderly patients managed with soft-tissue procedures. The authors also noted that the unused pills posed a risk for inappropriate use.
The sixty-seventh Annual Meeting of the American Society for Surgery of the Hand (ASSH) will be held in Chicago, from September 5 through 8, 2012. The ASSH will also have a combined meeting with the Australian Hand Surgery Society in Kauai, Hawaii, from March 22 through 25, 2012. In addition, the ASSH will sponsor the following programs in 2012: Electives in Hand Surgery (to be held on February 24 and 25, in New Orleans), Advances in Brachial Plexus Reconstruction (to be held on April 20 and 21, in Rochester, Minnesota); Comprehensive Review in Hand Surgery (to be held on July 13 through 15, in Chicago, Illinois); and Tendon Repair and Reconstruction (to be held on August 3 to 4, in Rosemont, Illinois).
The forty-third Annual Meeting of the American Association for Hand Surgery (AAHS) will be held in Naples, Florida, from January 9 through 12, 2013. The annual meetings of the AAHS are always held in combination with the annual meetings of the American Society for Reconstructive Microsurgery and the American Society for Peripheral Nerve.
All of the above meetings are open to all interested parties. Further details will be forthcoming on the society web sites, listed below. The annual meetings of both the ASSH and the AAHS accept free papers and also feature a wide variety of instructional courses and symposia, many with hands-on sessions.
Membership in the two hand surgery societies is restricted to those who have had specific hand surgery training and, in the case of the ASSH, those who have received the Certificate of Added Qualification in Hand Surgery offered by the American Boards of Orthopaedic Surgery, Plastic Surgery, and Surgery. Further information on membership as well as any of the above meetings can be obtained by contacting the organizations directly. Finally, both organizations maintain active web sites, with educational and informational content directed to the public and interested medical professionals, as well as members.
American Society for Surgery of the Hand
6300 North River Road, Suite 600
Rosemont, IL 60018-4256
Phone: (847) 384-8300
American Association for Hand Surgery
500 Cummings Center
Suite 4550
Beverly, MA 01915
Phone: (978) 927-8330
Over the past year, the editorial staff of The Journal reviewed a large number of recently published research studies related to the musculoskeletal system that received a Level of Evidence grade of I. Over 100 medical journals were reviewed to identify these articles, which all have high-quality study design. In addition to articles published previously in this journal or those cited previously in this Update, one Level-I study was identified that was relevant to hand surgery. We have provided a brief commentary about this article after the standard bibliography to help to guide your further reading, in an evidence-based fashion, in this subspecialty area.
Elfar
JC;
Stern
PJ. Proximal row carpectomy for scapholunate dissociation. J Hand Surg Eur Vol.
2011;36:111-5.
Chesney
A;
Chauhan
A;
Kattan
A;
Farrokhyar
F;
Thoma
A. Systematic review of flexor tendon rehabilitation protocols in zone II of the hand. Plast Reconstr Surg.
2011;127:1583-92.
Sandow
MJ;
McMahon
M. Active mobilisation following single cross grasp four-strand flexor tenorrhaphy (Adelaide repair). J Hand Surg Eur Vol.
2011;36:467-75.
Bastidas
N;
Cassidy
L;
Hoffman
L;
Sharma
S. A single-institution experience of hand surgery litigation in a major replantation center. Plast Reconstr Surg.
2011;127:284-92.
Neumeister
MW. Botulinum toxin type A in the treatment of Raynaud’s phenomenon. J Hand Surg Am.
2010;35:2085-92.
Vermeulen
GM;
Slijper
H;
Feitz
R;
Hovius
SE;
Moojen
TM;
Selles
RW. Surgical management of primary thumb carpometacarpal osteoarthritis: a systematic review. J Hand Surg Am.
2011;36:157-69.
Merle
M;
Villani
F;
Lallemand
B;
Vaienti
L. Proximal interphalangeal joint arthroplasty with silicone implants (NeuFlex) by a lateral approach: a series of 51 cases. J Hand Surg Eur Vol.
.
Ferreres
A;
Lluch
A;
Del Valle
M. Universal total wrist arthroplasty: midterm follow-up study. J Hand Surg Am.
2011;36:967-73.
Crean
SM;
Gerber
RA;
Le Graverand
MP;
Boyd
DM;
Cappelleri
JC. The efficacy and safety of fasciectomy and fasciotomy for Dupuytren’s contracture in European patients: a structured review of published studies. J Hand Surg Eur Vol.
2011;36:396-407.
Jerosch-Herold
C;
Shepstone
L;
Chojnowski
A;
Larson
D. Severity of contracture and self-reported disability in patients with Dupuytren’s contracture referred for surgery. J Hand Ther.
2011;24:6-10.
Chochole
M. Robert Kienbock: the man and his work. J Hand Surg Eur Vol.
2010;35:534-7.
Goeminne
S;
Degreef
I;
De Smet
L. Reliability and reproducibility of Kienbock’s disease staging. J Hand Surg Eur Vol.
2010;35:555-7.
Shin
M;
Tatebe
M;
Hirata
H;
Koh
S;
Shinohara
T. Reliability of Lichtman’s classification for Kienböck’s disease in 99 subjects. Hand Surg.
2011;16:15-8.
ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med.
2002;136:243-6.
Rayan
G;
Glickel
S. Ethics and professionalism for hand surgeons. J Hand Surg Am.
2010;35:1554-5.
Smoldt
R. Pay for value. Stud Health Technol Inform.
2010;153:195-207.
Mather
RC
3rd;
Wysocki
RW;
Mack Aldridge
J
3rd;
Pietrobon
R;
Nunley
JA. Effect of facility on the operative costs of distal radius fractures. J Hand Surg Am.
2011;36:1142-8.
Aydın
N;
Uraloğlu
M;
Yılmaz Burhanoğlu
AD;
Sensöz
O. A prospective trial on the use of antibiotics in hand surgery. Plast Reconstr Surg.
2010;126:1617-23.
O’Brien
LJ;
Bailey
MJ. Single blind, prospective, randomized controlled trial comparing dorsal aluminum and custom thermoplastic splints to stack splint for acute mallet finger. Arch Phys Med Rehabil.
2011;92:191-8.This multicenter randomized controlled trial evaluated sixty-four patients with acute mallet finger. All splints were worn for eight weeks continuously, with a four-week graduated withdrawal and exercise program. There was no difference in extensor lag between groups, but the Stack and dorsal splints had significantly higher rates of treatment failure (23.8% in both groups) as compared with the thermoplastic group (0%) (p = 0.04). The authors concluded that custom-made thermoplastic splints were significantly less likely to result in treatment failure.
Disclosure: The author received payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of an aspect of this work. In addition, the author, or his institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. The author has not had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by the authors are always provided with the online version of the article.