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© 2001 The Journal of Bone and Joint Surgery, Inc.
What’s New in Hand Surgery
Peter C. Amadio, MD
Mayo Clinic
200 First Street, SW
Rochester, MN 55905
No benefits in any form have been received or will be received from
a commercial party related directly or indirectly to the subject
of this
article. No funds were received in support of this study. 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.
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