The Future of Hand Surgery Mark Wilczynski, MD Tria Hand Therapy Conference 9 November 2018 No Disclosures Study the past if you would define the future. Confucius In the future Evolution of previous techniques Continued trends of early motions Clinic based procedures Integrative approach to hand illness Manipulation of the biological milieu 1
Early Motion Early Motion Early motion following ligament repair and reconstruction has been avoided Creep Soft tissues stretch out The mantra has been prolonged immobilization The result is stiffness No Seat Belt Seat Belt Internal Brace Definition Ulnar Collateral Ligament An internal brace is a tether made of a strong polymer. It is anchored to the bone at the origin AND insertion of a repaired or reconstructed ligament. It acts as a check reign to prevent creep. It does not represent a new procedure. Instead, it is the next phase in the evolution of current procedures. Injury occurs as the result of excessive abduction at the MP joint Acute = Skier s Thumb Chronic = Gamekeeper s Thumb Surgery is indicated for complete tears or injuries that demonstrate >15 degrees of instability relative to the contralateral side 2
11/16/2018 Traditional Ulnar Collateral Ligament Repair Ulnar Collateral Ligament Repair with Internal Brace 3
11/16/2018 Post Op Protocol Hand based thumb spica splint with the IP joint free Active and active assisted MP flexion and extension 3-5 days after surgery Passive range of motion in all planes 4 weeks after surgery Return to sport 6 weeks after surgery 4
No Pins Cast immobilization for 4 weeks Then begin dart thrower motion FCR and ECRL strengthening Other Applications Radial collateral ligament repair of the thumb Dorsal wrist capsulodesis Thumb CMC arthroplasty Thumb MP joint hyperextension deformity (zcollapse) Clinic Based Procedures Swan neck 5
The Epinepherine Myth Clinic Based Procedures An all purpose clinic room Does not require laminar air flow Field sterility No cardiopulmonary monitoring The cost of a carpal tunnel release is nearly 4x more expensive in the operating room ($2273) than in the clinic ($985). No intravenous use 6
70-85% savings compared to traditional operating room CTR: $1,110 vs $7,385 TF: $1,960 vs $6,565 94% of patients said they would have surgery with WALANT again if it were an option Integrative Care The Opioid Epidemic ~30% of patients prescribed opioids for chronic pain misuse them ~10% develop an opioid use disorder ~5% who misuse prescription opioids transition to heroin ~80% of people who use heroin first misused prescription opioids The tissue is not the issue Sarah Martin, PA-C Among the non-pathophysiological factors that contribute to patient-to-patient variation in MHQ scores, the measures of less effective coping strategies and symptoms of depression were most influential. Our data add to the evidence of the pivotal role of emotional health in upper extremity symptoms and limitations and the importance of psychosocial considerations in the care of hand illness. 7
Psychologic and social factors are more consistently associated with disability than factors related to impairment. Further research involving the assessment of depression, anxiety, and coping strategies may support decision-making regarding the provision of emotional support and psychologic therapies during recovery. Satisfaction with life appears to buffer the effect of pain in individuals with upper extremity musculoskeletal illness clinical interventions focused on increasing satisfaction with life, such as acceptance and commitment therapy, mindfulness training, gratitude and other positive psychology skills may improve outcomes Top-Down Approach Resources Therapeutic Neuroscience Education Adrian Louwe Up coming course in St. Louis Park Minfulness Based Stress Reduction (MBSR) Jon Kabat Zinn The Biological Milieu University of Minnesota Sarah Martin, PA-C 8
Orthobiologic Definition Platelet-Rich Plasma (PRP) Orthobiologics are biological substances that are used to help injuries to heal more quickly. Orthobiologics are used to improve the healing of fractures, injured muscles, tendons, and ligaments. They are made from substances that naturally occur in the body. When they are used in higher concentrations, they MAY help to hasten the healing process Autologous blood that contains platelets in higher than normal concentrations is commonly referred to as platelet-rich plasma Platelet-Rich Plasma (PRP) Chemokines and cytokines are bio-active proteins, such as growth factors, found in the granules of platelets. Platelets are essential in the healing process because they release these growth factors and bio-active proteins upon activation. Platelet-Rich Plasma (PRP) Platelets secrete several growth factors to the site of injury Platelet Derived Growth Factor (PDGF) Vascular Endothelial Growth Factor (VEGF) Transforming Growth Factor Beta (TGF-B) Epithelial Growth Factor Platelet-Rich Plasma (PRP) PRP represents growth factor therapy PRP has been shown to Attract mesenchymal stem cells, macrophages, and fibroblasts Cell proliferation and extracellular matrix protein production Pleuripotent cells Stem Cells 1. Ability to reproduce 2. Ability to differentiate 3. Ability to mobilize 4. Ability to control cells within their environment (paracrine) 9
Stem Cells Results Lateral Epicondylosis Significantly better VAS scores with PRP at every time point up two 2 years Clinical scores in the CSI group declined at the 1 and 2 year date points while those of the PRP group were maintained PRP injections provided significantly better VAS scores when compared to steroids (2.02) PRP and autologous blood injections had the same VAS improvement PRP had significantly better DASH scores than steroid and autologous blood Arirachakaran et al. (2016) Platelet-rich plasma vs. autologous blood vs. steroid injection in lateral epicondylitis: systemic review and network meta-analysis. Journal of Orthopedic Traumatology 17(2), 101-112. Lateral Epicondylosis Other Applications? PRP compared to autologous blood injection and dry needling PRP provided no additional functional outcome benefit at 3 months Basal Joint Arthritis Works best for early stages of arthritis Flexor tendon repair Mixed results Moraes et al. (2014) Platelet-rich therapies for platelet rich soft tissue injuries. Coc 10
Stem Cells Stem Cells Most hand related research has been done in animal models No appreciable effect on tendon healing in horse models Neovascularization and maintenance of carpal height in a rabbit Keinbock s model Orthobiologics Evolving science which has promise Data demonstrates mixed results We need more and better research Thank You 11