This article reviews material presented at the 2000 Annual
Meetings of the American Society for Surgery of the Hand, the American
Association for Hand Surgery, and the American Academy of Orthopaedic
Surgeons as well as articles published in the field of hand surgery
between August 1999 and July 2000. During that time, much interesting
and important material had appeared, but perhaps none is more interesting
or controversial than that related to the new prospect of hand transplantation.
On September 23, 1998, in Lyons, France, the distal aspect of the
right forearm and the right hand of a brain-dead forty-one-year-old
motorcycle-accident victim was transplanted to the right forearm
of a forty-eight-year-old man who had had a traumatic amputation
of the right hand some years previously. Immunosuppressive therapy
included prednisone, mycophenolate, mofetil, FK-506, and antithymocyte
globulins.
On January 24, 1999, a second transplantation was performed in
Louisville, Kentucky. Additional hand transplantations, including
at least one bilateral procedure, were performed subsequently in
other parts of the world. To date, all of the transplanted parts
are viable, and, in the case of the patient in Louisville, there has
been some evidence of functional recovery1. However, the original
transplant recipient recently requested that the transplanted hand
be amputated, partly because of loss of function and partly because
of side effects of the antirejection drugs, which included diabetes,
nausea, and weight loss.
As can be imagined, the performance of hand transplantation has
sparked considerable discussion in the field of hand surgery. The
American Society for Surgery of the Hand published a position paper
advocating a cautious attitude toward hand transplantation on the
basis of the risk-benefit ratio. The risks of side effects from
immunosuppression have certainly been reduced over time but still
exist; they include the induction or exacerbation of diseases such
as diabetes and cancer, unusual infections, and even death. The
financial and medical resources that must be marshaled for such
a procedure are also considerable, and their use may be questioned
in an era of waiting lists for medical care in many countries, even
some of the more developed ones. The benefits are likely to be limited,
as the procedure yields a less-than-normal limb even under the best
of circumstances, and the functional capabilities of individuals
with unilateral amputation are generally quite good. As most hand-transplantation
cases to date have been performed on people with unilateral amputation
and a normal contralateral limb, the incremental functional benefit
of the replanted part certainly would not reach the level of importance
of a solid-organ transplantation, which in most cases is lifesaving.
Much of the benefit may indeed be an improved sense of well-being
and an improved self-image1. Nonetheless, it is likely that the
procedures will continue to be done, as the surgical technique is really
no different from that of well-accepted hand-replantation
procedures. At this point, a cautious attitude appears to remain
appropriate, as advocated by the American Society for Surgery of
the Hand.
The management of Dupuytren contracture, for which the standard
of care for many years has been surgical excision of the diseased
tissue, has undergone some changes recently. Although surgical fasciectomy
is currently the accepted treatment, other options are beginning
to be proposed. Badalamente and Hurst2 recently reported good results
in a series of thirty-five patients who had been given injections
of 10,000 units of clostridial collagenase that, in effect, dissolved
the
Dupuytren cords. The technique appeared to be more appropriate for
disease limited to the palm, with twenty-eight of thirty-four metacarpophalangeal
joint contractures corrected to normal within fourteen days after
injection. The fingers did not respond as well, with only four of
nine proximal interphalangeal contractures corrected to normal.
The results persisted for more than one year, and the patients experienced
no major complications.
The management of problems in the pediatric hand remains a challenge
for the hand surgeon. Among the most difficult conditions are those
involving spasticity of the upper limb. Autti-Ramo et al.3, in a series
of eight cases, recently found that the use of botulinum toxin injections
preoperatively helped them to better predict the results of surgery
and thus led to better patient selection.
Microsurgery continues to be the mainstay of many hand-surgery
procedures. Toe-to-hand transfer can be performed for both traumatic
and congenital anomalies. Bellew and Kay4, reporting on thirty-seven
children who underwent toe-to-hand transfer, found that preoperative
psychological counseling was helpful both for the parents and the
child. In general, although both the patients and their parents were
pleased with the outcome of surgery, the children tended to be more
positive in their responses than their parents were.
Microsurgery is, of course, useful in other areas as well. New
types of vascularized bone-grafting now permit surgical revascularization
of the lunate bone in patients with Kienböck disease as
well as improved treatment of nonunion of the scaphoid bone. Vascularized
bone-grafting appears to
improve healing rates substantially, particularly for scaphoid nonunions.
In a recent series5, all ten patients with a longstanding scaphoid
nonunion associated with osteonecrosis of the proximal pole went
on to have union at an average of twelve weeks after surgery. The
most common procedure for vascularized bone-grafting of a scaphoid
nonunion involves raising a block of bone from the dorsum of the
distal part of the radius, in continuity with a predictable arterial
branch between the first and second extensor compartments, based
distally on a radial artery pedicle.
Microsurgery can also be used to reduce hand ischemia in patients
with collagen vascular disease. Digital sympathectomy
can be helpful in cases of scleroderma or CREST syndrome, although
the favorable results seen early postoperatively may not persist
over the long term. Digital ulcerations in particular can be treated
by these procedures, provided that proximal vessels are patent or
can be reconstructed. In a recently reported series, fifteen of
nineteen patients had improved digital blood flow, pain relief,
and healing of digital ulcers at an average of forty-five months
after surgery; women were more likely to have improvement than were men.
Treatment of arthritis at the base of the thumb has not progressed
greatly for many years. Excision of the trapezium remains the benchmark
procedure. Papers presented at meetings of the American Society
for Surgery of the Hand, the American Academy of Orthopaedic Surgeons,
and the American Association for Hand Surgery have summarized the current
knowledge in this area. Variations such as excision of part of the
trapezium and various types of capsular augmentation appear to give
similar results. Trapeziometacarpal arthrodesis also appears to
give results similar to those of resection arthroplasty. In some
cases, partial excision also can be used to treat scaphotrapezial
arthritis, by removal of either the proximal aspect of the trapezium
or the distal aspect of the scaphoid. As is the case with trapeziometacarpal
arthrodesis, scaphotrapezial arthrodesis appears to give reasonably
successful results in patients with scaphotrapezial disease.
Much attention has been focused on the hand-surgery aspects of
disorders associated with repetitive activity. Several questions
have been addressed, the principal one being whether repetitive
activity can cause physical abnormality and, if so, under what circumstances.
Several papers presented at the Annual Meetings of the American
Society for Surgery of the Hand, the American Association for Hand
Surgery, and the American Society of Hand Therapists have addressed
this issue. It does appear that elevated carpal tunnel pressures
caused by abnormal wrist postures or other factors can induce carpal
tunnel syndrome. In one study, twenty-seven asymptomatic women were
asked to perform repetitive activities at various intensities and
durations. Median-nerve conduction was monitored at regular intervals.
A dose-response relationship between work and nerve conduction was
demonstrated. In another study, rats were encouraged to reach repetitively
for food at a rate of four times a minute for two hours a day, three
days a week, for up to eight weeks. As the duration of activity
increased, the amount of histologically confirmed inflammation in
upper-limb tendons also increased, to the point where, after the
fourth week, the rats used a different and less effective form of
prehension to reach their food. In a third study, in which synovial biopsy
specimens from patients with carpal tunnel syndrome were examined,
the levels of interleukin-1, an inflammatory mediator, were normal,
while the levels of interleukin-6, a mediator of fibroplasia, were
elevated, as were the levels of lipid peroxidase, an inhibitor of
oxidative stress, and prostaglandin E2, a vasodilator. These findings
are consistent with the hypothesis that ischemia and reperfusion
injury may cause the noninflammatory fibrosis typically seen in
carpal tunnel syndrome. In 1995, the American Society for Surgery
of the Hand published a position statement on the relationship between
repetitive activity and specific disease entities and advised caution
in regulating this area, pending better scientific studies. Research such
as that described above may go far toward lessening the degree of
caution.
With regard to the clinical aspects of carpal tunnel surgery,
a paper presented to the American Society for Surgery of the Hand
appeared to show fairly conclusively that flexor tenosynovectomy
does not improve the results of carpal tunnel surgery in patients
without inflammatory arthritis, while another paper suggested that
hourglass deformity of the nerve, a sign of chronic compression,
also does not correlate with the outcome. These observations suggest,
in agreement with some earlier work, that simple decompression of
the
carpal tunnel remains the preferred procedure for the surgical management
of carpal tunnel syndrome, even in advanced cases.
The subject of cumulative trauma is, of course, not limited to
carpal tunnel syndrome. Many other diagnoses are often made in these
cases. In a study presented to the American Association for Hand Surgery,
100 patients with a variety of cumulative-trauma-related diagnoses
were administered a battery of psychological tests. Many patients
were found to have abnormalities on standard psychometric testing.
Patients with normal profiles had an improved prognosis for
return to work, but 67% of those with abnormalities on
psychometric testing also returned to work.
Many hand surgeons believe that the coefficient of variation
of rapid repetitive or alternating grip is a useful clinical sign
demonstrating sincerity of effort. Although there is a significant
correlation between the amount of variability in repetitive gripping
and sincerity of effort, with more variability correlating with
an insincere effort by volunteers told to simulate a weak effort,
the range of variation with sincere effort is so great that there
is considerable overlap between the two groups, making reliance
on this measure inappropriate clinically6.
Hand surgeons spend a good deal of time worrying about rehabilitation
after hand injuries and hand surgery. In a recent study, active
motion exercises were compared with passive motion exercises after zone-II
flexor-tendon repair. Therapy with active motion provided greater
final total motion than did passive motion exercises. As with many
other conditions, smoking was correlated with a poorer functional
outcome in both groups. The authors of this paper concluded that
the treatment of zone-II flexor-tendon injuries could be improved
by early active motion therapy in compliant patients. It may also
be necessary to use stronger types of tendon repairs in such patients.
It has been shown fairly conclusively that suture techniques that
employ locking loops and multiple (four or more) strands crossing
the repair site provide much stronger repairs than the traditional
two-strand modified Kessler repair7.
In contrast to the above methods, early active motion does not
necessarily improve the results after metacarpophalangeal joint
arthroplasty. In one study, a simpler regimen of immobilization
for several weeks after the arthroplasty yielded results quite similar
to those associated with the more traditional dynamic extension
splinting program. This is good news for patients with rheumatoid
hand deformities, as problems with general mobility often make it
difficult for them to return for frequent therapy visits.
Also of note in these studies, as well as in many others,
is the increasing use of validated measures of clinical status,
such as the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.
These tools seem to be finding increasing acceptance among hand
surgeons as a standard
measure of symptomatic and functional outcomes. Of course, more
traditional measures of physical and biological outcomes, such as
radiographic, strength, and laboratory measures, continue to play a
critical role in the overall assessment of outcome as well.
The treatment of scaphoid fractures continues to receive attention
aside from that related to new microsurgical options. Patients with
acute nondisplaced fractures, which have traditionally been managed
nonoperatively, may benefit from early surgical stabilization. In
one study, twenty-five patients with acute nondisplaced scaphoid-waist fractures
were randomized to surgical or nonsurgical treatment. There were
no complications from surgery. The fractures in the surgically treated group
united at an average of seven weeks compared with an average of
twelve weeks for the fractures that were treated with a cast; the
earlier union permitted a much more rapid return to work or sports
in the surgically treated group. This may be important for patients
with scaphoid fractures, who are typically young, active men. However,
other options are available for these patients. Low-intensity ultrasound
therapy can also accelerate fracture-healing; in a prospective,
randomized trial reported on recently at the Annual Meeting of the
American Academy of Orthopaedic Surgeons, fractures treated with
ultrasound healed at an average of six weeks compared with an average
of nine weeks for fractures treated with a cast alone. Whichever option
is chosen, it appears that progress is being made in the management
of these challenging injuries.
Carpal instability continues to be a difficult treatment problem
for the hand surgeon. In a recent study, patients with isolated
static scapholunate instability without radiographic evidence of
arthrosis were treated with intercarpal arthrodesis, proximal row
carpectomy, or scapholunate ligament reconstruction. There was a
high rate of failure in both the intercarpal fusion and the ligament
reconstruction group, primarily due to progressive arthrosis, but
not in the proximal row carpectomy group. Other reports have suggested
that proximal row carpectomy may also be a good option for the treatment
of chronic perilunate dislocations, but, interestingly, it may not
be as good a choice for Kienböck disease, perhaps because
the deformity of the lunate damages the articulating surfaces of the
capitate and radius, which are essential to proper functioning after
proximal row carpectomy. A very interesting salvage option that
has recently been discussed is partial wrist denervation, in which
the anterior and posterior interosseous nerves are resected just
proximal to the wrist. Preoperative anesthetic injections are used
to determine whether blocking these nerves decreases wrist pain
and improves grip strength. If the nerve block is effective, then
surgical excision of the terminal portions of the nerves can be
helpful. In a study of twenty-three patients who were followed for
an average of more than two years, pain relief was maintained in
75% and strength improved in nearly half. This procedure
can be done under a local anesthetic and may be worth trying in
patients for whom the alternative may be a salvage procedure such
as wrist arthrodesis.
Problems related to the distal radioulnar joint continue to attract
the attention of hand surgeons. A new ulnar head prosthesis may
provide better results than either traditional resection arthroplasty (the
Darrach procedure) or a silicone ulnar head replacement. In a series
of twenty-three patients with painful instability following total
or partial resection of the ulnar head, insertion of an ulnar head
prosthesis improved stability and relieved pain in all patients
at an average of two years8.
Management of complete brachial plexus injuries has also received
attention and was the subject of a recent American Society for Surgery
of the Hand symposium. It now seems clear that patients with birth
palsy should be observed for no more than six months. Normal function
is the rule if the patient begins to recover biceps function by
the third month of life. Children in whom recovery begins in the
fourth or fifth month of life do not attain normal function, and
the functional results of microsurgical exploration at six months,
although far from normal, are better than the natural history of
patients who begin to recover function spontaneously
after five months. For adults with complete brachial plexus injury,
the results are even less satisfactory. Grafts can restore useful
elbow flexion about two-thirds of the time; triceps function, one-third
of the time; and wrist function, less than one-fifth of the time.
Although microsurgical reconstruction is rewarding in many cases,
less than half of the adults who
are treated with nerve grafts express satisfaction with the
final result.
Fracture of the distal aspect of the radius is a topic of great
interest to both hand surgeons and orthopaedic surgeons. In a recent
paper, twenty patients with osteoporosis were randomly assigned
to treatment with either uncoated or hydroxyapatite-coated tapered
external fixator pins; the results were gauged by insertion and
extraction torques as a measure of loosening. The stability of external
fixation was improved in the group in which the hydroxyapatite-coated
pins had been used. In another study, a new mini-plate system of
fixation with wire-form buttresses provided improved support compared
with external fixation in vitro. Long-term clinical
results are not available, but it seems that this new method of
internal fixation bears watching.
Perhaps the most important issue with regard to distal radial
fractures, at least from a societal perspective, is reducing fracture
risk. These fractures typically occur in elderly women, many of
whom have osteoporosis. Freedman et al.9 reported on women fifty-five
years of age or older who sustained a distal radial fracture over
a three-year period. Only patients with at least six months of continuous
medical and pharmaceutical health-care coverage were included, to
ensure that access to care was not an issue. This cohort was then
evaluated to determine the proportion that had had either evaluation
or treatment for osteoporosis. Of 1162 women identified, only 24% met
either criterion. This represents a considerable opportunity for orthopaedic
surgeons and hand surgeons to identify women who are at risk for
osteoporosis and to refer them for proper evaluation and treatment,
or to assume responsibility for this evaluation and treatment as
part of the orthopaedic management of these common injuries.
Wrist arthroscopy is gaining increasing acceptance among hand
surgeons. In many centers, this procedure has
replaced wrist arthrography as the preferred diagnostic test, just
as, in the past, knee arthroscopy gradually supplanted knee arthrography.
More importantly, the therapeutic uses
of wrist arthroscopy are increasing. This procedure is now commonly
used to debride or repair injuries of the triangular fibrocartilage
and even to excise the distal end of the ulna.
Arthroscopically assisted internal fixation of scaphoid fractures
and, especially, of distal radial fractures has also gained acceptance.
A newer use of wrist arthroscopy is for the excision of ganglia10.
In a recent series, thirty-four patients had
arthroscopic excision of a ganglion. There were two recurrences,
about the same rate as for open excision, and no
complications.
Hand surgery is unique among orthopaedic subspecialties in that
additional board certification is possible. Since 1989, a total
of 2174 individuals have passed the Certificate of Added Qualifications examination
in hand surgery offered by the American Boards of Orthopaedic Surgery,
Plastic Surgery, and Surgery. Eligibility is based on the number
and distribution of hand cases. Since 1999, completion of an accredited
hand fellowship has been required as well. About two-thirds of those who
take the test are orthopaedic surgeons. Pass rates are strongly
correlated with completion of a hand fellowship, the number of cases
treated per year, and the proportion of hand surgery in the practice.
As this certificate is time-limited, recertification is required
if one wishes to maintain a valid certificate. Since 1996, 510 individuals
have been recertified in hand surgery.
Hand surgery is not unique among orthopaedic subspecialties in
that there is more than one subspecialty society available for hand
surgeons. There are two main societies in the United States. The American
Society for Surgery of the Hand is the older of the two, having
been founded in 1946. The Fifty-fifth Annual Meeting of the American
Society for Surgery of the Hand took place on October 4 through
7, 2000, in Seattle, and the Fifty-sixth Annual Meeting will be
held in Baltimore on October 3 through 6, 2001. The American Association for
Hand Surgery was founded in 1970; it held its Thirtieth Annual Meeting
on January 5 through 8, 2000, in Miami Beach. The Thirty-first Annual Meeting
of the American Association for Hand Surgery took place on January
11 through 13, 2001, in San Diego.
Both hand surgery organizations have developed affiliations with
other hand-related organizations. The 2000 Annual Meeting of the
American Society for Surgery of the Hand was held in conjunction with
the Annual Meeting of the American Society of Hand Therapists. The
2000 Annual Meeting of the American Association for Hand Surgery
was held in conjunction with the Annual Meeting of the American
Society for
Reconstructive Microsurgery. These affiliations are likely to persist.
Every three years, the International Federation of Societies
for Surgery of the Hand holds a meeting, uniting more than fifty
national hand organizations and representing all six inhabited continents.
In 2001, the International Federation will convene in Istanbul on
June 9 through 13. The American Society for Surgery of the Hand
is cosponsoring a post-
Congress course on minimally invasive surgery with its Italian counterpart,
in Rome, on June 15 through 17, 2001.
All of these meetings are open to all interested parties, although
membership in the two hand surgery societies is restricted to those
who have had specific hand surgery training and, in the case of
the American Society for Surgery of the Hand, to those who have
received the Certificate of Added Qualifications in hand surgery.
Additional information can be obtained by contacting the organizations directly.
The American Society for Surgery of the Hand can be contacted
at 6300 North River Road, Suite 600, Rosemont, IL 60018-4256. Phone:
(847) 384-8300. Web site: www.hand-surg.org. The American Association
for Hand Surgery can be contacted at 20 North Michigan Avenue, Suite
700, Chicago, IL 60602. Phone: (312) 236-3307. Web site: www.handsurgery.org.