Specialty Update What s New in Hand Surgery

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1 569 COPYRIGHT Ó 2012 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED Specialty Upate Peter C. Amaio, MD This upate reviews material presente at the 2011 annual meetings of the American Society for Surgery of the Han (ASSH), American Association for Han Surgery (AAHS), an the American Acaemy of Orthopaeic Surgeons (AAOS) as well as articles publishe in the fiel of han surgery (other than those publishe in this journal) between August 2010 an July In aition to the broa focus of the AAOS, both han surgery organizations feature presentations on shouler an elbow surgery an general microsurgery, all of which are beyon the scope of this review. If a work was presente at more than one meeting, only the first presentation is escribe. Meeting abstracts for the annual meetings of the American Society for Surgery of the Han, American Association for Han Surgery, an American Acaemy of Orthopaeic Surgeons are maintaine online at an respectively. Skeletal Trauma More an more institutions are employing registries to monitor certain classes of patients. Attenees at the AAHS meeting learne how one such registry was use as the basis of a multivariate regression moel of outcome after istal raial fracture. All patients ha regular outcome assessment with the Disabilities of the Arm, Shouler an Han (DASH) questionnaire, a measure of upper limb isability, an a visual analogue scale (VAS) for pain. The moel showe that fully 47% of the DASH score coul be explaine by just three variables: the amount of pain, grip strength, an supination. No other aspect of motion correlate with the DASH score. The authors conclue that restoration of supination shoul be an important goal after istal raial fracture. The authors of a stuy that was presente to the AAOS came to a similar conclusion about the impact of supination eficits on outcome an correlate a Specialty Upate has been evelope in collaboration with the Boar of Specialty Societies (BOS) of the American Acaemy of Orthopaeic Surgeons. loss of supination with resiual isplacement of the palmar ulnar corner of the istal raial articular surface. Increasingly, enocrinologists are focusing on bone quality in aition to bone ensity. A report that was presente to the ASSH suggeste that trabecular ensity may be better than mineral ensity for preicting the risk of istal raial fracture. Fourteen premenopausal women with istal raial fractures were matche with forty-four control subjects. While bone mineral ensity was similar in the two groups, the patients with fractures ha 14% lower trabecular ensity; this ifference was significant (p < 0.05). The authors recommene that, in the future, osteoporosis screening shoul assess both the microarchitecture as well as the ensity of bone. Han surgeons shoul be aware of this when evaluating patients who have apparent fragility fractures. Patients with aequate bone mineral ensity may still be at risk if the trabecular ensity is eficient. Do intercarpal ligament injuries preict outcome after istal raial fractures? This question was the subject of a secon report to the AAHS. In this prospective stuy, thirty-six patients ha a systematic wrist arthroscopy at the time of surgical treatment of a istal raial fracture. Patients were followe for one year. Many injuries were note on arthroscopy, with 44% of the patients having a scapholunate injury, 44% having an injury to the triangular fibrocartilage complex, an 25% having an injury to the articular cartilage. After controlling for AO fracture type, none of these injuries were correlate with the latest VAS score for pain, the DASH score, or wrist motion. The authors conclue that intercarpal ligament an cartilage injuries are commonly associate with istal raial fractures but that such injuries onotpreictoutcome,atleastintheshortterm.shoulsuch injuries, then, be repaire if note? Stay tune for future stuies. To release or not to release the carpal tunnel is the question when plating a raial fracture through an anterior volar surgical approach. The authors of a report that was presente to the ASSH attempte to answer this question in a retrospective stuy of 199 consecutive patients who were seen at a single institution. Disclosure: The author receive payments or services, either irectly or inirectly (i.e., via his institution), from a thir party in support of an aspect of this work. In aition, the author, or his institution, has ha a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomeical arena that coul be perceive to influence or have the potential to influence what is written in this work. The author has not ha any other relationships, or has engage in any other activities, that coul be perceive to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitte by the authors are always provie with the online version of the article. J Bone Joint Surg Am. 2012;94:

2 570 Of these, seventeen ha an acute carpal tunnel synrome at the time of presentation. All seventeen patients ha release of the carpal tunnel, an fifteen ha improvement following the release. None of the other patients ha release of the carpal tunnel in the course of the surgical exposure. Fifteen of these patients evelope symptoms of carpal tunnel synrome, but all symptoms resolve with nonoperative treatment. The authors conclue that routine release of the carpal tunnel is not necessary when performing volar plating of the istal part of the raius. When scaphoi nonunions result in posttraumatic arthritis, treatment frequently involves excision of the arthritic istal pole of the scaphoi, with or without aitional proceures such as micarpal arthroesis. A report that was presente to the AAOS escribe the long-term (eleven to twenty-oneyear) results of simple istal pole excision. Of the nineteen patients who unerwent the proceure, eighteen coul be followe an only one require aitional surgery. While one-thir of the remaining patients ha some evience of capitolunate arthritis at the time of the latest follow-up, none of them complaine of wrist pain. The authors conclue that simple istal pole excision can be an effective long-term solution to posttraumatic arthritis seconary to scaphoi nonunion. In many cases, han surgeons fix scaphoi fractures with a percutaneously place screw. However, the surgical approaches have problems; the proximal-to-istal approach must violate the proximal scaphoi articular surface, whereas the istal approach goes through the scaphotrapezial joint. The authors of a stuy that was presente to the AAOS reporte the four to nine-year results for thirty-four patients who ha unergone percutaneous scaphoi screw fixation through a istal approach. While three patients ha raiographic evience of scaphotrapezial arthritis, two of the three patients ha symmetrical finings in the contralateral wrist an none of the three patients were symptomatic. A common surgical aage is that nothing spoils a goo result more than longer follow-up. The treatment of scapholunate injuries remains problematic for han surgeons, an the problem seems to be getting worse as follow-up increases. A recent report that was presente to the ASSH escribe the four to twelve-year results for fifty-nine patients who ha ha a orsal capsuloesis for the treatment of scapholunate injury. Although the initial postoperative raiographs showe goo improvement, the preoperative eformity ha completely recurre by the time of the latest followup. More than 80% of the patients ha posttraumatic arthritis. Kaplan-Meier analysis showe a 50% probability of a salvage proceure being performe within ten years, with most of those proceures being neee in the first three years. Unfortunately, even the salvage proceures are problematic; the authors of a recent report 1 on proximal row carpectomy note that fifteen of the thirtyone patients ha persistent moerate or severe pain postoperatively. The search for a urable solution to this problem continues. Tenon Injury It is commonly sai that practice makes perfect, an surgical simulation techniques now make it possible to practice our surgical techniques in benchtop simulations rather than in caaver moels (or in patients!). Two papers that were presente to the AAHS were relevant to improving the quality of tenon repair through the use of such surgical simulations. In one, a tutorial significantly improve both loa to gap an loa to failure of a simulate tenon repair. In the other, the issue of knot security was investigate, also in a simulation moel. Regarless of suture material or iameter, a minimum of five flat square knot throws were neee in the simulation before the knot faile by breakage rather than slippage. The role of active mobilization following tenon repair with use of contemporary techniques was the subject of both a systematic review 2 an a prospective stuy 3. Both stuies showe that early active motion was associate with superior clinical results. The authors of the systematic review mae the important observation that most stuies focuse nearly exclusively on finger motion an complications such as rupture of the repair while there were few ata to escribe the impact of these injuries on the patient s quality of life 2. Replantation an Microsurgery Upper extremity replantation is an establishe proceure, but a stuy that was presente to the ASSH suggeste that replantation services are inconsistently available. In that stuy, a survey asking about the availability of replantation services was sent to all level- 1 an level-2 trauma centers in the Unite States. Over 85% of the centers respone. Only 54% of the 117 level-1 centers an 29% of the 132 level-2 centers provie continuous replantation coverage. Some of the other centers offere intermittent replantation coverage, but over half of the level-1 an 2 centers ha no specific replantation coverage protocols. The authors conclue that access to replantation services is a challenge in many communities in the Unite States. Some han surgeons may believe that access is limite because the meical liability risk of such proceures is high. However, a recent report from a major trauma center in New York City suggeste that such proceures have a relatively low risk of averse legal outcomes 4. Following >200 replantation attempts, only five lawsuits were file, an none was successful. Among the twenty-three lawsuits that were file in cases of han trauma, the only successful lawsuit was for the loss of a nonreplantable part. One of the most common elective han microsurgical proceures is toe-to-han transfer. Several options are available, incluing the great toe, secon toe, trimme great toe, an great toe wrap. Iniviual stuies usually evaluate just one of these options, making a comparison of the relative benefits ifficult. The authors of a systematic review that was presente to the ASSH attempte to resolve this uncertainty by analyzing 450 patients from twenty-five stuies that inclue ata on functional outcome, morbiity, an patient satisfaction. The authors foun that all proceures ha similar results in terms of survival, motion, strength, an sensibility. They conclue that the choice of proceure shoul be base on the expertise of the surgeon an the preference of the patient, especially in terms of onor site trae-offs, wherein the proceures iffer the most.

3 571 Other Vascular Problems Raynau phenomenon may be a source of severe pain an also may cause igital ulcers. While many treatments are available, none are uniformly effective. The authors of a recent report 5 suggeste that injection of botulinum toxin type A (Botox; Allergan, Irvine, California) may be effective. Between 2004 an 2010, a total of twenty-nine patients were manage with an injection of fifty to 100 units of botulinum toxin type A in the palm at the base of each affecte igit. Twenty-three patients note pain reuction, which laste an average of twenty months; of the seventeen igital ulcers, fifteen heale within sixty ays of injection. The authors conclue that botulinum toxin type A may be a useful treatment for selecte patients with more severe manifestations of Raynau phenomenon. Arthritis Is soium hyaluronate safe an effective for the treatment of arthritis of the thumb carpometacarpal joint? A stuy that was presente to the AAOS suggeste that the treatment is safe but not effective. A total of twenty-seven patients were enrolle in a prospective, ranomize, placebo (saline solution)-controlle trial in which affecte joints were treate with a series of three weekly injections an then were followe for one year. Averse events, pain, strength, motion, raiographs, an the DASH score were evaluate at one, three, six, an twelve months. There was no significant ifference in any of the outcome measures at any time point. While meta-analyses 6 anranomizetrialscontinueto 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 stuy that was reporte to the AAOS escribe the results of a pyrolytic carbon sale-shape implant esigne to replace the base of the thumb metacarpal. A total of nineteen patients were followe for an average of six years. While there was significant improvement in terms of pain compare with preoperative levels, there was no improvement in terms of strength or motion, an five patients require a revision proceure uring the follow-up perio. In aition, the implants were subluxate in four patients. The authors of that stuy conclue that longer-term stuies were neee, something that was also recommene by the authors of a recent systematic review 6. Han surgeons continue to search for a reliable arthroplasty for the proximal interphalangeal joint. A recent report to the ASSH suggeste that han surgeons still have a istance to travel. A review of 294 nonconstraine implants (203 pyrolytic carbon implants an ninety-one metal an plastic implants) showe that seventy-six fingers require one or more reoperations, primarily for the treatment of flexion contractures, loosening, an instability. Six fingers eventually require amputation. The orsal approach was more likely to be associate with complications. A publishe stuy of fifty-one silicone implants that were inserte through a lateral approach 7 also reviewe complications, with a 10% reoperation rate at an average of three years of follow-up. A recent report escribe the results of total wrist arthroplasty for twenty-one patients who ha been manage with the Universal 2 implant (Integra LifeSciences, Plainsboro, New Jersey) 8.Afterthree to eight years of follow-up, three patients ha signs of osteolysis or loosening, all but one of the patients were satisfie with the proceure, an there ha been no reoperations. The same implant was the subject of another report that was presente to the ASSH. In that report, thirty patients who ha the evice inserte without cement were followe for one to nine years. Three proceures were revisions of a previous cemente implant. Two patients require revision surgery, an raiolucent lines were observe aroun ten of the sixty components at the time of the latest follow-up. Dupuytren Contracture The role of collagenase (Xiaflex; Auxilium Pharmaceuticals, Malvern, Pennsylvania) in the treatment of Dupuytren contracture continues to gather attention. A report that was presente to the AAHS summarize the results of five Phase-III trials in which collagenase was use to treat Dupuytren contracture. A total of 950 patients were manage with collagenase, but only 634 complete enough follow-up to be evaluate. Recurrence was efine as an increase in contracture of 20 after an initial correction of the contracture to 5. After a mean uration of follow-up of 2.1 years, Kaplan-Meier analysis estimate 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 structure review comparing reports of fasciectomy an fasciotomy also evaluate recurrence rates; at an average of four years, the recurrence rate average 39% in the fasciectomy reports an 62% in the fasciotomy reports 9. A report that was presente to the ASSH focuse on another minimally invasive approach to the treatment of Dupuytren isease: percutaneous neele fasciotomy. In this proceure, instea of the neele being use to introuce collagenase, the neele tipisuseasaknifetoiviethedupuytrencor.theseries inclue 200 treate igits that were followe for a minimum of six months. The overall total passive extension eficit average 150 preoperatively an 60 at the time of the latest follow-up. Complications inclue two nerve injuries an four infections. As is the case with collagenase treatment, better gains were achieve at the metacarpophalangeal joint than at the proximal interphalangeal joint. How much oes this matter to patients? Interestingly, the egree of contracture oes not appear to correlate very strongly with the egree of functional impairment. In a recent stuy, the DASH questionnaire was aministere to 154 patients with Dupuytren contracture an the correlation between the DASH scoreantheegreeofcontracture,eitheroverallorbyigit,was evaluate 10. The correlations were all very weak, an the average functional score was consistent with a mil impairment of function. Kienböck Disease 2010 was the centenary of Robert Kienböck s lanmark paper; in its secon century, the conition continues to provoke the interest of han surgeons 11. However, two recent publications

4 572 suggeste that the current staging system, which forms the basis for many treatment ecisions, is flawe: han surgeons cannot always agree, when given ientical raiographs to interpret, which stage of the isease is present 12,13. One of the reports also showe a wie egree of variability when the same surgeon reinterprete the same image at a ifferent time 13. Cost Effectiveness in Han Surgery One of the tenets of meical professionalism 14,15 is justice in the health care system, incluing the fair istribution of health care resources 14. In other wors, professionals shoul be minful not only of the effectiveness but also the cost of the services provie to patients in their care. The concept of value 16 (quality of outcome, safety, an satisfaction, ivie by cost over time) relates irectly to this tenet. Several han surgery presentations in 2011 aresse this issue. The role of han therapy after istal raial fractures was the subject of a prospective ranomize trial that was presente to the ASSH. Ninety-six patients were ranomize, after volar plating for the treatment of a istal raial fracture, to either (1) a formal han therapy program or (2) informal rehabilitation instructions provie by the surgeon. There was no ifference between the groups in termsoffunctionasmeasurewiththedashscoreatthetimeof the latest follow-up, an the surgeon-irecte patients actually ha better strength an motion at both three an six months postoperatively. The authors conclue that formal therapy oes not improve outcomes after volar plating of istal raial fractures; inee, given worse function an higher costs, it is clear that the han therapy provie in that stuy i not create value, as efine above. One report that was presente to the AAHS compare the costs an outcomes associate with han fractures that were treate with use of local anesthesia in a minor proceure room (n = 72) with those associate with han fractures that were treate with use of general anesthesia in a stanar operating room (n = 54). Outcomes were similar in the two groups, but costs were eight times higher for the group that ha been treate in the operating room, primarily as a result of hospitalization, anesthesia, an operating room fees. The authors conclue that repair of han fractures in a minor surgical suite is safe an effective. The authors of another recent publication came to a similar conclusion after comparing costs for similar han surgical proceures in hospitals an ambulatory care centers 17. A secon stuy that was presente to the AAHS evaluate woun infection rates in a multicenter trial of a fiel sterility protocol for patients unergoing carpal tunnel release. In the protocol, the han was prepare with chlorhexiine or ioine, a single towel was use, an the surgeon use a mask an gloves but no gown. No antibiotics were given. A total of 1504 patients were enrolle. A total of six superficial woun infections were note; there were no eep infections. All of the superficial infections resolve; only four require treatment with oral antibiotic therapy. The authors conclue that fiel sterility is sufficient for carpal tunnel surgery an that it results in consierable savings not only in time an money but also in waste as there is only a single small rape to iscar or launer. The authors of a recent report 18 came to a similar conclusion regaring the use of antibiotics. A total of 1340 patients were ranomize either to receive or not to receive preoperative antibiotics. There was no ifference between the two groups in terms of the rate of infection, even when comparing patients who ha contaminate traumatic wouns or when comparing patients who ha proceures lasting for more than two hours. Do han surgeons overprescribe pain meication postoperatively? This was the provocative subject of a report that was presente to the ASSH. A total of 250 patients were followe after a variety of elective outpatient han surgery proceures, incluing both soft-tissue an osseous proceures. The most commonly prescribe narcotics were oxycoone, hyrocoone, an propoxyphene, an the usual number of pills prescribe was thirty. The patients use an average of only ten of the thirty pills prescribe, with patients who ha fractures consuming an average of fifteen pills. Patients receiving Meicai reporte taking an average of twenty-six pills; patients receiving Meicare, seven. One-fourth of the patients took no narcotics at all. The authors conclue that the customary prescription amount of thirty pills may be excessive an unnecessary, especially for elerly patients manage with soft-tissue proceures. The authors also note that the unuse pills pose a risk for inappropriate use. Upcoming Events The sixty-seventh Annual Meeting of the American Society for Surgery of the Han (ASSH) will be hel in Chicago, from September 5 through 8, The ASSH will also have a combine meeting with the Australian Han Surgery Society in Kauai, Hawaii, from March 22 through 25, In aition, the ASSH will sponsor the following programs in 2012: Electives in Han Surgery (to be hel on February 24 an 25, in New Orleans), Avances in Brachial Plexus Reconstruction (to be hel on April 20 an 21, in Rochester, Minnesota); Comprehensive Review in Han Surgery (to be hel on July 13 through 15, in Chicago, Illinois); an Tenon Repair an Reconstruction (to be hel on August 3 to 4, in Rosemont, Illinois). The forty-thir Annual Meeting of the American Association for Han Surgery (AAHS) will be hel in Naples, Floria, from January 9 through 12, The annual meetings of the AAHS are always hel in combination with the annual meetings of the American Society for Reconstructive Microsurgery an the American Society for Peripheral Nerve. All of the above meetings are open to all intereste parties. Further etails will be forthcoming on the society web sites, liste below. The annual meetings of both the ASSH an the AAHS accept free papers an also feature a wie variety of instructional courses an symposia, many with hans-on sessions. Membership in the two han surgery societies is restricte to those who have ha specific han surgery training an, in the case of the ASSH, those who have receive the Certificate of Ae Qualification in Han Surgery offere by

5 573 the American Boars of Orthopaeic Surgery, Plastic Surgery, an Surgery. Further information on membership as well as any of the above meetings can be obtaine by contacting the organizations irectly. Finally, both organizations maintain active web sites, with eucational an informational content irecte to the public an intereste meical professionals, as well as members. American Society for Surgery of the Han 6300 North River Roa, Suite 600 Rosemont, IL Phone: (847) Evience-Base Orthopaeics Over the past year, the eitorial staff of The Journal reviewe a large number of recently publishe research stuies relate to the musculoskeletal system that receive a Level of Evience grae of I. Over 100 meical journals were reviewe to ientify these articles, which all have high-quality stuy esign. In aition to articles publishe previously in this journal or those cite previously in this Upate, one Level-I stuy was ientifie that was relevant to han surgery. We have provie a brief commentary about this article after the stanar bibliography to help to guie your further reaing, in an evience-base fashion, in this subspecialty area. American Association for Han Surgery 500 Cummings Center Suite 4550 Beverly, MA Phone: (978) Peter C. Amaio, MD Department of Orthopeics, Mayo Clinic, 200 First Street SW, Rochester, MN aress: pamaio@mayo.eu References 1. Elfar JC, Stern PJ. Proximal row carpectomy for scapholunate issociation. J Han Surg Eur Vol. 2011;36: Chesney A, Chauhan A, Kattan A, Farrokhyar F, Thoma A. Systematic review of flexor tenon rehabilitation protocols in zone II of the han. Plast Reconstr Surg. 2011;127: Sanow MJ, McMahon M. Active mobilisation following single cross grasp fourstran flexor tenorrhaphy (Aelaie repair). J Han Surg Eur Vol. 2011;36: Bastias N, Cassiy L, Hoffman L, Sharma S. A single-institution experience of han surgery litigation in a major replantation center. Plast Reconstr Surg. 2011; 127: Neumeister MW. Botulinum toxin type A in the treatment of Raynau s phenomenon. J Han Surg Am. 2010;35: Vermeulen GM, Slijper H, Feitz R, Hovius SE, Moojen TM, Selles RW. Surgical management of primary thumb carpometacarpal osteoarthritis: a systematic review. J Han Surg Am. 2011;36: Merle M, Villani F, Lalleman B, Vaienti L. Proximal interphalangeal joint arthroplasty with silicone implants (NeuFlex) by a lateral approach: a series of 51 cases. J Han Surg Eur Vol Jul 1 [Epub ahea of print]. 8. Ferreres A, Lluch A, Del Valle M. Universal total wrist arthroplasty: miterm followup stuy. J Han Surg Am. 2011;36: Crean SM, Gerber RA, Le Graveran MP, Boy DM, Cappelleri JC. The efficacy an safety of fasciectomy an fasciotomy for Dupuytren s contracture in European patients: a structure review of publishe stuies. J Han Surg Eur Vol. 2011;36: Jerosch-Herol C, Shepstone L, Chojnowski A, Larson D. Severity of contracture an self-reporte isability in patients with Dupuytren s contracture referre for surgery. J Han Ther. 2011;24: Chochole M. Robert Kienbock: the man an his work. J Han Surg Eur Vol. 2010;35: Goeminne S, Degreef I, De Smet L. Reliability an reproucibility of Kienbock s isease staging. J Han Surg Eur Vol. 2010;35: Shin M, Tatebe M, Hirata H, Koh S, Shinohara T. Reliability of Lichtman s classification for Kienböck s isease in 99 subjects. Han Surg. 2011;16: ABIM Founation. American Boar of Internal Meicine; ACP-ASIM Founation. American College of Physicians-American Society of Internal Meicine; European Feeration of Internal Meicine. Meical professionalism in the new millennium: a physician charter. Ann Intern Me. 2002;136: Rayan G, Glickel S. Ethics an professionalism for han surgeons. J Han Surg Am. 2010;35: Smolt R. Pay for value. Stu Health Technol Inform. 2010;153: Mather RC 3r, Wysocki RW, Mack Alrige J 3r, Pietrobon R, Nunley JA. Effect of facility on the operative costs of istal raius fractures. J Han Surg Am. 2011; 36: Ayın N,Uraloğlu M, Yılmaz Burhanoğlu AD, Sensöz O. A prospective trial on the use of antibiotics in han surgery. Plast Reconstr Surg. 2010;126: Evience-Base Article Relate To Han Surgery O Brien LJ, Bailey MJ. Single blin, prospective, ranomize controlle trial comparing orsal aluminum an custom thermoplastic splints to stack splint for acute mallet finger. Arch Phys Me Rehabil. 2011;92: This multicenter ranomize controlle trial evaluate sixty-four patients with acute mallet finger. All splints were worn for eight weeks continuously, with a four-week grauate withrawal an exercise program. There was no ifference in extensor lag between groups, but the Stack an orsal splints ha significantly higher rates of treatment failure (23.8% in both groups) as compare with the thermoplastic group (0%) (p = 0.04). The authors conclue that custom-mae thermoplastic splints were significantly less likely to result in treatment failure.