This update reviews material presented at the 2005 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 (other than those
published in this journal) between August 2004 and July 2005. Meeting
abstracts for the ASSH and AAOS annual meetings are maintained online at
Hand surgery was developed as a specialty to cope with the devastating
results of hand injuries in World War II. Sixty years later, trauma remains a
prime concern of the hand surgeon and is the focus of much discussion at
One of the basic tenets of hand surgery has been that accurate surgery
requires excellent hemostasis. The metaphor of the watchmaker working in an
inkwell was used by Bunnell to convey the point with great effectiveness.
Traditionally, tourniquets have been used to achieve hemostasis in the hand.
Anecdotes, perhaps apocryphal, of digital loss following the use of local
anesthesia with epinephrine have proved effective to discourage the practice
for most (but not all) hand surgeons. In a fascinating invited lecture that
was delivered to the AAHS, the results of a prospective multicenter study of
>3000 cases of hand surgery performed with the patient under local
anesthesia with epinephrine (at a concentration of 1:100,000 or less) and the
results of a larger retrospective review were presented. The results indicated
that hemostasis was excellent without the use of a tourniquet. There were no
ischemic complications, even in patients undergoing distal surgery involving
the fingers. Procedures performed in this way included flexor tendon repairs
(with the benefit of using active motion intraoperatively to check for the
integrity of the repair and proper tendon-gliding), fracture fixation, and a
variety of soft-tissue procedures. An additional benefit was prolonged
postoperative pain relief, without the need for perioperative narcotics. There
may be more than one way to drain the inkwell.
Another hand surgery tradition has been the use of skin sutures. This, too,
is coming under challenge. In a prospective, randomized trial that was
presented to the AAOS, thirty-six patients with nailbed lacerations were
randomly assigned to repair with suture or simple cyanoacrylate surgical
adhesive. The cosmetic results in the two groups were identical. The
cyanoacrylate repair took an average of nine minutes, whereas the suture
repair took an average of twenty-seven minutes.
The quintessential subject related to hand surgery research is flexor
tendon healing. It is well known that the major problem associated with tendon
repair is adhesion formation, i.e., excessive scarring. It is also well known
that fetal tissue heals without scar. In a fascinating study presented to the
AAHS, researchers sought to determine what would happen if fetal tendon cells
were introduced into an adult environment. Was the scar-free healing a
property of the cells, their environment, or a result of the interaction of
the two? In a model in which adult and fetal sheep tendons were wounded and
then implanted into an immunocompromised mouse host, it appears that the
property is inherent in the cells: the fetal tendons healed without fibrosis,
whereas the adult tendons showed the usual scar reaction, raising the
possibility of using fetal cells (or adult cells engineered to behave like
fetal cells) to reduce scarring after tendon (or other) injury.
Most hand surgeons would agree that the final result after tendon injury is
partly dependent on the nature of the injury, partly dependent on the type and
quality of surgical repair performed, and partly dependent on the nature and
quality of the postoperative rehabilitation. A prospective, randomized trial
compared the results of immobilization with those of early motion in forty-six
patients with extensor tendon
injuries1. At twelve
weeks, there was no difference in terms of final total active motion between
the groups, but the early mobilization group had better return of grip
strength than the immobilization group did. In a recent Cochrane review, Thien
et al. studied the evidence supporting specific therapy strategies after
Insufficient evidence was found to support any specific rehabilitation
program. Thus, while there has clearly been an improvement in outcome in going
from immobilization (i.e., no therapy, the standard before 1960) to some form
of mobilization (the current standard), at present there is little evidence on
which to base a preference for specific mobilization protocols.
The treatment of fractures of the distal part of the radius continues to
stimulate much research. Several prospective, randomized trials were published
recently, all of which resulted in similar conclusions: while more aggressive
treatment may result in small but significant differences in anatomic results,
functional results are not significantly different, regardless of whether one
compares percutaneous pin fixation with internal fixation through a dorsal
percutaneous pin fixation with external
percutaneous pins and cast
retrospective series led to similar conclusions regarding external fixation
and volar fixed-angle plate
another retrospective comparison presented to the ASSH demonstrated no
difference in functional or radiographic outcome when percutaneous pin
fixation was compared with fragment-specific internal fixation. A comparative
series of dorsal and palmar plating, presented to the ASSH, showed similar
complication rates in association with these two approaches. Thus, while
surgery is becoming an increasingly popular option, with case series of
various distal radial implants representing fully 20% of the papers presented
to the ASSH and several more to the AAOS, evidence to support this clinical
choice remains largely limited to case series, with studies with a higher
level of evidence demonstrating no or only small clinical differences.
Insurance carriers often wonder whether hand therapy improves outcomes. In
the case of distal radial fractures, it appears that the key factor may be
adherence to a home exercise program rather than attendance at regular therapy
sessions. In a retrospective study of fifteen patients who had been referred
for hand therapy after a distal radial fracture, multiple regression analysis
showed that more than half of the difference in final motion, hand function,
and symptoms could be attributed to the diligence with which the patients
adhered to their home exercise program (as recorded in a diary kept by the
One explanation for the lack of difference in the clinical outcome
associated with the various treatments of distal radial fractures, despite
small but significant differences in radiographic parameters, may be found in
an interesting presentation to the AAOS, in which fifteen young adults were
evaluated thirteen to seventeen years after open reduction and internal
fixation of an intra-articular distal radial fracture. All fifteen patients
had evidence of posttraumatic arthritis, but the functional results, as
assessed with the Musculoskeletal Functional Assessment (MFA) questionnaire,
demonstrated that all patients retained good or excellent function. The
quality of the final reduction correlated well with the severity of arthritis,
but not with function.
Carpal instability is another favorite topic of hand surgeons. One recent
study of thirty-one patients who were managed with dorsal capsulodesis for the
treatment of chronic static scapholunate dissociation (i.e., a fixed
scapholunate gap and scaphoid malrotation on radiographs of the unstressed
wrist) suggested that we still have far to
go8. Although pain
was reduced, strength was unimproved and both motion and scaphoid alignment
were worse at a minimum of two years of follow-up. A larger series of 162
patients that was presented to the ASSH demonstrated similar results, while
another study that was presented to the AAHS suggested that, whatever its
defects, dorsal capsulodesis might still be preferred to other options, such
as scaphotrapezial arthrodesis. This latter study was a retrospective review
in which fifty-two patients who had been managed with dorsal capsulodesis were
compared with thirty-five patients who had been managed with arthrodesis.
While pain relief was good in both groups, functional improvement was greater
and complications were fewer in the capsulodesis group. Another study of
partial scapholunate injuries (i.e., injuries associated with pain and
arthroscopically demonstrated scapholunate laxity without radiographic
evidence of a scapholunate gap or scaphoid malrotation) suggested that
arthroscopic capsular shrinkage may be an option for less severe degrees of
instability. In that study, which was presented to the AAHS, good pain relief
was reported in fourteen of sixteen patients at an average of nineteen months
In patients with scapholunate instability, the scaphoid is hyperflexed. The
opposite displacement, scaphoid extension, occurs in patients with
scaphotrapezial arthritis. The reason for this difference has never been
clear, but a recent study that was presented to the AAHS suggested a possible
explanation. In that cadaveric study, serial sectioning of the palmar
scaphotrapezial joint capsule and the flexor carpi radialis insertion was
performed to assess the impact on scaphoid rotation. Interestingly, the
principal effect appeared to come when the flexor carpi radialis was
transected or unloaded. Of course, scaphotrapezial arthritis and flexor carpi
radialis tendinopathy are frequently found together. The interesting question
is, which comes first? That study suggested that scaphotrapezial arthropathy
could be a consequence as well as a cause of flexor carpi radialis
Does vascularized bone-grafting actually revascularize the lunate affected
by Kienböck disease? That was the topic of a study of twenty-six patients
who were followed for an average of thirty-one months after treatment with a
vascularized graft from the dorsal aspect of the
radius9. In addition
to symptomatic improvement, 71% of the patients had evidence of
revascularization on postoperative magnetic resonance imaging.
As noted in last year's review, arthroscopy is being increasingly used to
treat dorsal carpal ganglia. In a recent retrospective series that was
presented to the AAOS, open and arthroscopic methods of ganglion excision were
compared. Forty-one open and thirty-one arthroscopic excisions were compared
at one, four, and eight weeks and at one year after surgery. There was no
difference between the two groups with regard to pain, function, or recurrence
at any time-point.
Adjacent to the wrist is the often troublesome distal radioulnar joint. In
the past, reconstruction has been unreliable for the treatment of distal
radioulnar joint instability. More recently, however, anatomic reconstruction
of the dorsal and palmar radioulnar ligaments with a tendon graft passed
through the fovea at the base of the ulnar styloid, with dorsal and palmar
limbs fixed to the distal part of the radius, has been tried. A recent study
demonstrated excellent results in seven of nine patients who had been managed
in this way10.
When the unstable distal radioulnar joint is affected by arthritis,
ligament reconstruction alone will not be sufficient to decrease symptoms and
improve function and resection arthroplasty may aggravate the instability of
the ulnar stump. In such cases, implant hemiarthroplasty is now an option. A
metallic distal ulnar prosthesis is available. In a report to the ASSH, this
implant was shown to have good short-term results in twenty-six patients, with
all patients reporting a reduction in pain from the preoperative status and
with 80% of the patients being satisfied with the result after an average
duration of follow-up of thirty months. Implant loosening and
"collar" resorption were the main complications, occurring in four
and eight cases, respectively. Clearly, though, the high rate of loosening and
resorption after a relatively short duration of follow-up should lead to some
caution in the use of this device at the present time.
Fracture-dislocations of the proximal interphalangeal joint are often
troublesome. Treatment options range from closed reduction and extension block
splinting to open reduction and internal fixation to acute osteoarticular
grafting. A recent report suggested that, in the case of these
fracture-dislocations, less may be
patients were followed for a minimum of six years after either closed
reduction and percutaneous transarticular pin fixation or open reduction and
internal fixation. At the time of the most recent follow-up, the patients who
had been managed with closed reduction had less pain, less cold intolerance,
and better motion, despite having poorer-quality reductions. In that series,
the morbidity associated with open reduction appeared to outweigh its
advantages in terms of reduction quality.
Year in and year out, carpal tunnel release is the most common surgical
procedure on the hand. It stands to reason, then, that carpal tunnel syndrome
would be the subject of much research and that there would be something new to
report from the past year. One of the more controversial reports was a
prospective trial of 101 patients with electrodiagnostically confirmed carpal
tunnel syndrome who were randomized to treatment with either steroid injection
Patients who had had a previous injection, who had thenar atrophy, or who had
conditions known to be associated with carpal tunnel syndrome, such as
diabetes mellitus, were excluded. While previous studies had suggested that
surgery was a more effective treatment for carpal tunnel syndrome, the results
of that report suggested that injection was significantly more effective than
surgery in terms of the primary outcome of relief from nocturnal paresthesias
at three months. There was no difference between the injection and surgery
groups at six and twelve months.
Carpal tunnel syndrome is primarily a condition of middle age, with a peak
prevalence between the ages of forty-five and fifty-four years. When younger
individuals are affected, there is often a precipitating cause. An interesting
report that was presented to the ASSH described the first population-based
study of carpal tunnel syndrome during pregnancy. In that study, 12% of more
than 2000 pregnant women had development of symptoms of carpal tunnel
syndrome, most typically between twenty-eight and thirty-two weeks of
gestation. Symptoms persisted post partum in 36% of affected women and, of
those, 34% ultimately required surgery. An early return to work outside the
home appeared to be associated with persisting symptoms.
Arthritis of the trapeziometacarpal joint is a common ailment, remarkable
for the variety of surgical treatment options available; osteotomy, resection
arthroplasty of all or part of the trapezium (with or without various ligament
reconstruction options), implant arthroplasty with varying designs and
materials, and arthrodesis each have their proponents. Several of these
options were studied over the past year. In a paper that was presented to the
ASSH, the results associated with a new spherical ceramic implant were
reported. A total of fifty implants were reviewed after a minimum duration of
follow-up of one year. Symptomatic relief and functional results were good,
but nearly all patients who had been followed for two years or more showed
evidence of implant subsidence, with trapezial fractures in fifteen patients
and complete trapezial resorption in one. Interestingly, these complications
were not associated with corresponding symptoms or functional loss. A Cochrane
review identified seven randomized, quasi-randomized, or controlled trials
investigating the surgical treatment of trapeziometacarpal
These trials comprised 384 patients who had been managed with trapeziectomy,
trapeziectomy with interpositional arthroplasty, trapeziectomy with ligament
reconstruction, trapeziectomy with ligament reconstruction and tendon
interposition, or joint replacement. The minimum duration of follow-up was one
year. Overall, functional results were rather similar among the various
treatments, but simple trapeziectomy was associated with significantly fewer
complications whereas the ligament reconstruction and tendon interposition
procedure was associated with significantly more. Another group of
investigators compared the outcomes of trapeziometacarpal arthrodesis,
trapeziectomy, and silicone implant arthroplasty in a study of eighty-three
patients and concluded that, while clinical outcomes were similar, the
complication rate was higher in the arthrodesis
A prospective study that was presented to the ASSH evaluated a new method
for the nonoperative treatment of trapeziometacarpal arthritis, namely, the
injection of hyaluronic acid in the form of hylan G-F 20 (Synvisc). In that
study, sixty patients with symptomatic trapeziometacarpal osteoarthritis were
randomized to treatment with placebo, steroid, or hylan injections. At one
month, both the placebo and steroid groups demonstrated significant pain
relief compared with baseline. At six months, only the hylan group
demonstrated significant pain relief compared with baseline. However, none of
the differences between the treatment groups themselves, at either time point,
reached significance. Thus, while hylan was certainly not worse than placebo
or steroid injection, it was not better, either. Clearly, there is room for
improvement in the treatment of trapeziometacarpal arthritis.
Finger joint arthroplasty continues to undergo a slow evolution. A recent
study evaluated seventy silicone proximal interphalangeal joint implants after
a minimum duration of follow-up of three
degenerative, and inflammatory arthritis were all represented. The results
were mediocre, with no net change in active range of motion. Nine of the
seventy implants were revised surgically; a total of eleven implants were
fractured at the time of the most recent follow-up. A presentation to the AAHS
suggested that newer pyrolytic carbon implants may be better, at least when
cemented. A total of twenty-seven cemented and twenty-two uncemented implants
were reviewed. After a minimum duration of follow-up of three years, only one
of the cemented implants had loosened, while ten of the uncemented implants
had loosened and subsided. Final motion and patient satisfaction were not
In the treatment of Dupuytren disease, it is well known that the ability to
correct deformity is greater at the metacarpophalangeal joint than at the
proximal interphalangeal joint. Does this difference matter to the quality of
the result as perceived by the patient? A recent study suggested that it
does16. In that
study, hand function was measured six and twelve months after surgery in
thirty patients with Dupuytren disease. At both six and twelve months, there
was a significant correlation between proximal interphalangeal joint
correction and hand function but there was no such correlation between
metacarpophalangeal joint correction and hand function.
Chronic pain is not typically considered to be an indication for surgery.
But what if the pain has elements consistent with nerve compression? A recent
review of eight patients (five men and three women) who had development of
complex regional pain syndrome after upper-extremity surgery addressed this
patients were found to have distal nerve compression, confirmed with
electrodiagnostic testing. Decompression of the affected nerves in these
patients was associated with dramatic improvements in terms of pain and
function: the average score on the Disabilities of the Arm, Shoulder and Hand
(DASH) questionnaire decreased from 71 to 30. Improvement was observed in
terms of hypersensitivity to touch, hyperhydrosis, swelling, cold sensitivity,
range of motion, and grip strength. These results suggest that at least some
cases of chronic regional pain may represent extreme manifestations of
nerve-compression syndromes and that if the evidence to support the diagnosis
of nerve compression is strong, surgery may well be an appropriate
The last edition of this review mentioned the declining numbers of
applicants for hand fellowships. This situation seems to have stabilized, but
part of the reason may be a change in the emphasis of hand fellowships, which
increasingly provide education for surgery of the entire upper extremity. This
matches the interest of many fellowship applicants, who prefer an ultimate
practice focused on the entire upper limb, rather than just the most distal
part of it. The American Society for Surgery of the Hand has long recognized
this trend and now offers continuing education programs in elbow surgery as
well as the more traditional hand topics. Fully 25% of the original scientific
papers presented to the ASSH in 2005 focused on the shoulder and elbow (and
are thus not properly the subject of this review).
The 2003 edition of this report mentioned that Medicare was considering
rules that might impair the ability of hand therapists to fabricate splints.
This is now much closer to reality as the window for comments on a proposed
new Medicare rule on the provision of durable medical equipment closed on
November 25, 2005. The proposed rule covers everything from wheelchairs and
limb prostheses to prefabricated orthoses. Currently, many hand splints are
fabricated out of thermoplastic materials by the therapist treating the
patient. This ensures a custom fit and perfect integration with the therapy
program. The proposed rule would restrict all splint-making to certified
orthotists and prosthetists, who currently have a limited role in the
fabrication of splints used in conjunction with hand therapy. The likelihood
that therapists could, in the future, forge treatment teams with orthotists
and prosthetists is also limited as the rule requires competitive bidding for
such durable medical equipment and the only quality standard is the
requirement that a certified orthotist or prosthetist be involved. Provision
of splints would thus be based on price rather than the presence of some sort
of therapeutic relationship or any patient-focused quality measure. It will
likely be some time before we know the content of the final rule and more time
yet before the new rule will take effect. However, it seems likely that hand
surgeons and hand therapists will need to consider new ways to provide splints
for their patients in the future.
The Sixty-first Annual Meeting of the American Society for Surgery of the
Hand will be held on September 7, 8, and 9, 2006, in Washington, DC. As usual,
the ASSH is also offering a variety of continuing medical education (CME)
programs throughout the year, including a comprehensive hand surgery review
course, to be held on July 14, 15, and 16, 2006, in Chicago, Illinois. The
ASSH will also cosponsor courses with the AAHS (see below), the Philadelphia
Hand Rehabilitation Foundation, and the AAOS in 2006.
The Thirty-seventh Annual Meeting of the American Association for Hand
Surgery will be held January 10 through 13, 2007, in Rio Grande, Puerto Rico.
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. These three organizations also share
certain management functions, permitting closer integration of their meetings,
even offering a combined registration option. They will meet together again in
2008. In 2006, the AAHS will also sponsor a CME program on advances in
brachial plexus reconstruction, to be held on April 28, 29, and 30, in
All of these 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 American Society for Surgery of the Hand and the American
Association for Hand Surgery accept free papers and also feature a wide
variety of instructional courses and symposia, many with hands-on sessions.
Over the years, as with other maturing organizations, the trend has been for
fewer free papers and more symposia and hands-on workshops, including many
non-CME-credit industry-sponsored workshops in facilities adjacent to the
accredited scientific meeting.
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, 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
Rosemont, IL 60018-4256
American Association for Hand Surgery
20 North Michigan Avenue, Suite
Chicago, IL 60602
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 cited already
in this Update, eight level-I articles were identified that were relevant to
hand surgery. A list of those titles is appended to this review after the
standard bibliography. We have provided a brief commentary about each of the
articles to help to guide your further reading, in an evidence-based fashion,
in this subspecialty area.
Whittaker JP, Nancarrow JD, Sterne
GD. The role of antibiotic prophylaxis in clean incised hand injuries: a
prospective randomized placebo controlled double blind trial.
Hand Surg [Br].2005;30:162-7.
One hundred and seventy patients with clean hand injuries were randomize to
one of three groups: Group A (one dose of intravenous flucloxacillin followed
by oral placebo), Group B (one dose of intravenous flucloxacillin followed by
oral flucloxacillin for five days), or Group C (oral placebo only). Exclusion
criteria included open fractures, an immunocompromised status, bite wounds,
crush wounds, or wounds that were grossly contaminated with soil or grass. The
rate of infection (defined as the presence of gross purulence, erythema,
swelling, and/or a positive wound culture at one, two, or four weeks) was 13%
in Group A, 4% in Group B, and 15% in Group C. None of the differences were
significant. A power analysis had assumed an overall infection rate of 5%; the
actual rate was 10%. The take-home message from this study is that clean hand
wounds may well be more likely to have wound-healing problems, including
infection, than is commonly assumed. The trend toward fewer infections in
association with the use of antibiotics is certainly logical and supports the
common practice of using such drugs. However, additional studies involving
more patients are needed to determine the optimal treatment of clean hand
Jeong GK, Kaplan FT, Liporace F,
Paksima N, Koval KJ. An evaluation of two scoring systems to predict
instability in fractures of the distal radius.
One hundred and five patients were prospectively scored with use of the
Adolphson and MacKenney formulae to calculate the probability of fracture
instability on the basis of presentation parameters. The predicted probability
was then compared with the actual results. Ultimately, roughly half of the
fractures were found to be unstable after closed reduction. Both systems
underestimated the actual instability, with negative predictive values of
roughly 50% each. These scoring systems are imperfect guides to treatment.
Similar observations have been made in association with other scoring systems.
It remains difficult to accurately predict which distal radial fractures will
demonstrate instability after closed reduction.
Kharwadkar N, Naique S, Molitor PJ.
Prospective randomized trial comparing absorbable and non-absorbable sutures
in open carpal tunnel release.
J Hand Surg [Br].2005;30:92-5.
Forty hands were randomized to subcuticular closure with either 3-0
polyglactin 910 (Vicryl) or 3-0 polypropylene (Prolene). There was no
difference in scar tenderness between the two groups at two, six, or twelve
weeks postoperatively. While most hand surgeons use nonabsorbable skin sutures
in the hand, this study suggests that subcuticular closure with absorbable
suture is a reasonable alternative.
Moller K, Sollerman C, Geijer M,
Kopylov P, Tagil M. Avanta versus Swanson silicone implants in the MCP
joint—a prospective, randomized comparison of 30 patients followed for 2
J Hand Surg [Br].2005;30:8-13.
All patients had rheumatoid arthritis. Four fingers were operatively
treated in all patients. No difference was noted between the two groups in
terms of postoperative pain, function, alignment, or fracture rate. The
results were not reported separately by digit. These two implants appear to be
roughly similar in terms of the benefit that they offer to patients with
Delaney R, Trail IA, Nuttall D. A
comparative study of outcome between the Neuflex and Swanson
metacarpophalangeal joint replacements.
J Hand Surg
In this prospective, double-blind trial, twenty-two patients with
rheumatoid arthritis were randomized to treatment with either Neuflex or
Swanson implants and were evaluated at two years by blinded observers. There
was no difference between the two groups in terms of arc of motion, ulnar
deviation, grip, function, or implant fracture. There was a significant
difference in terms of active flexion, which measured 72° in the Neuflex
group and 59° in the Swanson group. As in the study by Moller et al.,
described above, there appeared to be little difference in outcome among the
various designs of hinged silicone metacarpophalangeal joint implants.
Handoll HH, Vaghela MV.
Interventions for treating mallet finger injuries.
Database Syst Rev.2004;3:CD004574.
Four trials were identified, but all were methodologically flawed. There
was insufficient evidence to determine if any particular type of splint was
better than the others or when surgery might be indicated. Once again, we find
that the literature is not sufficiently robust to identify the optimal
treatment even for very common conditions such as a mallet finger.
Hargreaves DG, Drew SJ, Eckersley
R. Kirschner wire pin tract infection rates: a randomized controlled trial
between percutaneous and buried wires.
J Hand Surg
A total of fifty-six patients for whom Kirschner wire fixation was
indicated for the treatment of distal radial fractures were randomized to have
the tips of the wires either buried or left percutaneous with the end bent
over to prevent migration. Ten of the twenty-nine wires that were left
percutaneous were associated with the development of infection, compared with
two of the twenty-seven wires that were buried. The difference was significant
(p < 0.05). Unless an infection developed, all pins were left in place for
six weeks. While almost all of the percutaneous pins could be removed in the
clinic, two-thirds of the buried pins were removed in a day-surgery unit.
While the cost of removal of buried pins may be greater, the risk of infection
associated with unburied pins is substantial and should be considered,
especially when pins are left in place for periods of six weeks or more.
Fagan DJ, Evans A, Ghandour A,
Prabhkaran P, Clay NR. A controlled clinical trial of postoperative hand
elevation at home following day-case surgery.
J Hand Surg
In this study of forty-three patients undergoing carpal tunnel surgery,
there was no difference in terms of hand swelling (measured volumetrically) or
pain at five days postoperatively when patients who had been managed with a
sling were compared with those who had been managed with high elevation of the
upper extremity by suspension to an intravenous pole.
Bulstrode NW, Burr N, Pratt AL,
Grobbelaar AO. Extensor tendon rehabilitation a prospective trial comparing
three rehabilitation regimes. J Hand Surg [Br].
Thien TB, Becker JH, Theis JC.
Rehabilitation after surgery for flexor tendon injuries in the hand.
Cochrane Database Syst Rev.
Kreder HJ, Hanel DP, Agel J, McKee M,
Schemitsch EH, Trumble TE, Stephen D. Indirect reduction and percutaneous
fixation versus open reduction and internal fixation for displaced
intra-articular fractures of the distal radius: a randomised, controlled
trial. J Bone Joint Surg Br.
Harley BJ, Scharfenberger A, Beaupre LA,
Jomha N, Weber DW. Augmented external fixation versus percutaneous pinning and
casting for unstable fractures of the distal radius—a prospective
randomized trial. J Hand Surg [Am].
Azzopardi T, Ehrendorfer S, Coulton T,
Abela M. Unstable extra-articular fractures of the distal radius: a
prospective, randomised study of immobilisation in a cast versus supplementary
percutaneous pinning. J Bone Joint Surg Br.
Wright TW, Horodyski M, Smith DW.
Functional outcome of unstable distal radius fractures: ORIF with a volar
fixed-angle tine plate versus external fixation. J Hand Surg
289-99. Erratum in: J Hand Surg [Am].
Lyngcoln A, Taylor N, Pizzari T, Baskus
K. The relationship between adherence to hand therapy and short-term outcome
after distal radius fracture. J Hand Ther.
Moran SL, Cooney WP, Berger RA,
Strickland J. Capsulodesis for the treatment of chronic scapholunate
instability. J Hand Surg [Am].
Moran SL, Cooney WP, Berger RA, Bishop
AT, Shin AY. The use of the 4 + 5 extensor compartmental vascularized bone
graft for the treatment of Kienbock's disease. J Hand Surg
Teoh LC, Yam AK. Anatomic reconstruction
of the distal radioulnar ligaments: long-term results. J Hand Surg
Aladin A, Davis TR. Dorsal
fracture-dislocation of the proximal interphalangeal joint: a comparative
study of percutaneous Kirschner wire fixation versus open reduction and
internal fixation. J Hand Surg [Br].
Ly-Pen D, Andreu JL, de Blas G,
Sanchez-Olaso A, Millan I. Surgical decompression versus local steroid
injection in carpal tunnel syndrome: a one-year, prospective, randomized,
open, controlled clinical trial. Arthritis Rheum.
Wajon A, Ada L, Edmunds I. Surgery for
thumb (trapeziometacarpal joint) osteoarthritis. Cochrane Database Syst
Taylor EJ, Desari K, D'Arcy JC, Bonnici
AV. A comparison of fusion, trapeziectomy and silastic replacement for the
treatment of osteoarthritis of the trapeziometacarpal joint. J Hand
Surg [Br]. 2005;30:
Takigawa S, Meletiou S, Sauerbier M,
Cooney WP. Long-term assessment of Swanson implant arthroplasty in the
proximal interphalangeal joint of the hand. J Hand Surg [Am].
Draviaraj KP, Chakrabarti I. Functional
outcome after surgery for Dupuytren's contracture: a prospective study.
J Hand Surg [Am]. 2004;29:
Placzek JD, Boyer MI, Gelberman RH, Sopp
B, Goldfarb CA. Nerve decompression for complex regional pain syndrome type II
following upper extremity surgery. J Hand Surg [Am].