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© 2002 The Journal of Bone and Joint Surgery, Inc.
What’s New in Hand Surgery
Peter C. Amadio, MD This article reviews material presented at the 2001 Annual Meetings of the American Society for Surgery of the Hand (ASSH), American Association for Hand Surgery (AAHS), American Academy of Orthopaedic Surgeons (AAOS), and International Federation of Societies for Surgery of the Hand (IFSSH) as well as articles published in the field of hand surgery (other than those published in The Journal of Bone and Joint Surgery) between August 2000 and July 2001. Many of these articles represented the fruition of papers presented at meetings during the previous year and discussed in the last version of this update, in the March 2001 issue of The Journal of Bone and Joint Surgery. Once again, in 2001 much of interest has occurred in hand surgery. Attracting headlines again was hand transplantation, as the first recipient of a transplanted hand had the hand amputated in mid-2001. All other transplant recipients, including both American patients and at least two patients overseas with a bilateral transplant, appear to be tolerating both their new hands and the anti-rejection regimen needed to maintain the viability of the allograft. However, the late failure of the initially widely trumpeted procedure has dampened enthusiasm in some quarters. The American Society for Surgery of the Hand and the International Federation of Societies for Surgery of the Hand maintain position papers advising caution in adopting this new technology; the ASSH paper is posted on its web site (www.hand-surg.org). A paper presented to the IFSSH emphasized the particular importance of preoperative psychological assessment in identifying appropriate candidates for hand transplantation. Also once again, the topic of cumulative trauma disorders was in the news in 2001. In the waning days of the Clinton administration, the Occupational Safety and Health Administration (OSHA) promulgated a series of regulations aimed at controlling ergonomic risks in the workplace. Although most experts agreed that there was some limit to human endurance and that some jobs might exceed that limit, there was little agreement on what that limit might be, the extent to which ergonomic risks are a problem in the workplace, or whether ergonomic controls would be likely to reduce time lost from the workplace. Consequently, the regulations were withdrawn by the new Bush administration. The Department of Labor is currently considering whether, when, and to what extent ergonomic safeguards should be regulated by OSHA. In the meantime, some clinical evidence has surfaced that casts doubt on the relationship between work and at least one highly controversial malady: carpal tunnel syndrome. Stevens et al.1 reported the results of a survey of frequent computer users. Although nearly 30% complained of hand paresthesias, only 10% met clinical criteria for carpal tunnel syndrome and only 3.5% had electrodiagnostic evidence confirming the clinical picture. Affected and unaffected workers had similar jobs and computer exposure. More importantly, the rate of symptoms, clinical signs, and electrodiagnostic evidence of carpal tunnel syndrome in this cohort was no greater than that seen in the general population. The evidence seems to be pointing more and more toward the concept that the true prevalence of carpal tunnel syndrome in the general population has been underestimated because many people with symptoms do not present for medical care and are detected only in surveys. At least part of the "epidemic" of carpal tunnel syndrome in the workplace may therefore be nothing more than greater recognition of an existing problem as opposed to an incremental disease. Of course, etiological studies are not all that is new in the field of carpal tunnel syndrome, which remains the most common condition seen by hand surgeons. A paper presented to the American Association for Hand Surgery offered a cost-utility analysis of two competing methods of surgical decompression of carpal tunnel syndrome: open and endoscopic release of the flexor retinaculum. Various scenarios were constructed on the basis of different assumptions of direct and indirect costs, complications, and failure rates of the two procedures. The outcome was in some cases very sensitive to these assumptions. For example, an assumed 1% rate of median nerve injury with endoscopic carpal tunnel release resulted in a net benefit of the procedure of more than $30,000 per quality-adjusted life-year, whereas an increase in this rate to 2% resulted in a net loss of more than $200,000 per quality-adjusted life-year. Similarly, although a 1% rate of intraoperative conversion of endoscopic carpal tunnel release was associated with a beneficial cost per quality-adjusted life-year, a rate of 5% resulted in a slightly negative ratio. Thus far, the reported nerve-laceration and conversion rates are below the thresholds reported in this analysis, but the unreported results of endoscopic carpal tunnel release in community practices is unknown. Recent reports comparing rates of failure of joint replacement in clinical trials with those in community practices suggested that the true risk of complications and failure tend to be underestimated in clinical trials, so some degree of caution in interpreting cost-benefit analyses based only on such trials seems justified. As with any procedure, it behooves surgeons to know their own rates of failure and complications for common procedures such as carpal tunnel release and to modify their practice on the basis of these results. An interesting presentation to the AAHS compared symptoms with electrodiagnostic severity in 200 patients with carpal tunnel syndrome. While the findings on electrodiagnostic studies did correlate with age, symptom severity (as measured by a standard questionnaire of proven reliability, validity, and sensitivity) did not correlate with age, electrodiagnostic findings, duration of symptoms, work, or body mass index. This study suggested that the patient’s perception of the severity of carpal tunnel syndrome is not based on the factors measured by electrodiagnostic studies but on some other, as yet unknown, factor or factors. A more prosaic cumulative trauma disorder, trigger finger, has also received attention. Gilberts et al.2 compared open and percutaneous trigger-finger releases in a prospective, randomized trial involving 100 patients. The results were clear: the percutaneous method was faster, cheaper, and less painful than the open release, and there were no failures or complications in either group. Repair of peripheral nerve lacerations may be entering a new era. Weber et al.3 recently reported the results of a multicenter study of the use of a resorbable polyglycolic acid conduit to repair peripheral nerves while leaving a small gap between the nerve ends. The resorbable tube performed as well as or better than direct repair for gaps that had been small prior to the repair, and it performed better than nerve-grafting for gaps that had been >8 mm. Such results had previously been demonstrated in animal models; the benefits of the tube seem to be related to a reduction in scarring at the suture line and also to fewer rotational mismatches in apposition of the nerve ends. Flexor tendon lacerations remain the quintessential hand surgery problem. Current research has focused on reducing adhesion formation after repair as well as on newer and stronger repair methods. The treatment of partial tendon lacerations has always been controversial. Does repair reduce the risk of rupture or increase the risk of scarring? Should flaps of tendon be sutured down or trimmed back? Al-Qattan4 recently reported on a clinical series of fifteen patients with a zone-2 laceration involving 50% to 90% of the cross section of the affected tendon; all were treated with trimming or beveling of the tendon edge, partial pulley excision, and early protected motion. The results were excellent in fourteen patients and good in one; there were no ruptures or late trigger digits in the series. Hand transplantation may be news, but what about replantation? Replantation has been with us for thirty years. The current literature on the subject does not focus so much on newer microsurgical methods or on survival of the replanted part as an end in itself. Instead, attention is now rightly being paid to function and societal impact. One recent paper presented to the ASSH gave the long-term results of twenty-nine successfully replanted upper limbs (proximal to the wrist). Far from being an end point, viability of the replanted part was only a modest predictor of long-term acceptability; eight of the "successfully" replanted limbs were subsequently reamputated, at an average of ten months after replantation, with the main reasons being poor function, pain, and poor cosmetic appearance. Chung et al.5, using a random survey of United States hospitals, investigated the epidemiology and costs of finger replantations performed in 1996. Based on extrapolations from this survey, it appears that approximately 1200 replantations are done annually in the United States. Interestingly, the survey suggests that more than a quarter of replantations are done in hospitals reporting only a single case per year, with perhaps 10% of the total being done in centers reporting more than ten cases per year. The data were not complete enough for the reader to know how many replantations were attempted, because failed replantations were ultimately recorded on dismissal summaries simply as amputations, so it is not possible to calculate success rates from this survey. The treatment of Kienböck disease continues to spark interest in the hand surgery community. Currently, the most common operation appears to be one or another type of joint leveling, either radial shortening or ulnar lengthening. Intercarpal arthrodeses are also popular. There has also been a recent surge of interest in vascularized bone grafts. All of these procedures are associated with a moderate degree of morbidity, however, which makes a recent article by a group from Buenos Aires particularly intriguing6. Twenty-two patients were treated by simple curettage of the distal parts of the radius and ulna through a small incision and then followed for six to sixteen years. Although the Kienböck disease was not cured by this procedure, pain relief was excellent, the morbidity was minimal, and none of the patients required additional surgery. Hand surgery is in large measure trauma surgery, and fracture treatment receives its fair share of study. One recent paper presented to the ASSH (one of the "top ten"; more on that below) concerned a study on the stability of the proximal interphalangeal joint as the size of a fracture of the volar lip of the middle phalanx, such as would commonly occur with dorsal dislocation, was increased in a human cadaver model. As long as >60% of the dorsal base of the middle phalanx was intact, the joint was stable in any position of flexion; if <45% remained, the joint was unstable regardless of the flexion position. The clinical implication is that fractures that affect 50% of the base of the middle phalanx might be better treated with open reduction and internal fixation; we await, however, the companion clinical study to document the results of repairs of such difficult fractures. Distal radial fractures represent a common ground for hand surgeons and general orthopaedic surgeons; both frequently treat this ubiquitous injury. There is increasing evidence that the results, especially for younger patients, are not as good as might be wished and that the functional results are affected by as little as 10° of malalignment. One especially strong predictor of outcome is fracture of the ulnar styloid process. A review of 166 cases followed for twelve months, presented to the ASSH in 2001, showed that a displaced fracture of the base of the ulnar styloid process seen on initial radiographs increased the risk of subsequent instability of the distal radioulnar joint by a highly significant (p < 0.0007) factor of 8. This evidence clearly suggests that such fractures should be reduced and stabilized surgically. The details of treatment of distal radial fractures remain controversial, however. While most surgeons would agree that accurate reduction is important, especially in the younger patient, achieving and maintaining such a reduction is not always easy. There are an increasing number of both external and internal fixation options being offered to improve the quality and reliability of reduction and fixation. However, long-term follow-up studies are not always available, and surgeons must be vigilant with regard to late complications that might alter the effectiveness of a chosen method. One option offered in recent years has been a dorsal titanium plate shaped like the Greek p. Initial results were promising, but recent reports on this device have noted high complication rates, in particular a worrying risk of late extensor tendon rupture7. The source of the problem is unclear, but one report to the AAHS suggested that tendon irritation may occur even when the surgeon is careful to interpose the extensor retinaculum between the plate and tendons, while another report to the ASSH raised the worrisome possibility that the titanium itself may somehow be an irritant to the tendons. For many years, joint replacement in the hand meant a flexible silicone hinge, but hand surgeons continue to experiment with options more similar to those used for joint replacement in other parts of the body. Several newer arthroplasty implants made not only of metal and plastic but also of pyrolytic carbon, and of a less constrained and more anatomic design than previous hand arthroplasty implants, have reached the market. (Please note that the author has a direct financial interest in one of these devices, a metal and plastic trapeziometacarpal replacement.) Preliminary reportsæprimarily from Europe, where these devices have been available for several yearsæhave been presented at international meetings in 2001. These reports have shown that satisfaction, motion, and function after use of these devices are similar to those reported after use of the common alternativesæi.e., silicone implant arthroplasty for the metacarpophalangeal and interphalangeal joints and resection arthroplasty, with or without ligament reconstruction, or arthrodesis for the trapeziometacarpal joint. In the longer term, the outcome is less clear. Implant subsidence and loosening have been reported as problems associated with most if not all of these devices. Also, revision of cemented devices remains a difficult reconstructive challenge. Hand surgeons have also begun a more critical appraisal of the functional outcome of finger joint arthroplasty, focusing less on traditional measures like range of motion and alignment and more on satisfaction and what the patient is actually able to do before and after surgery. One recent presentation showed that postoperative satisfaction was correlated most highly with cosmetic appearance and secondarily with function. Pinch strength correlated with satisfaction regarding the nondominant hand, whereas grip was a more important factor in the satisfaction regarding the dominant hand. Van Lankveld et al.8 evaluated the change in pain and dexterity after a variety of reconstructive procedures in seventy patients with rheumatoid arthritis. At six and twelve months after surgery, the biggest effects were a decrease in pain and an improvement in function after wrist arthrodesis or finger joint arthroplasty. Other interventions, such as synovectomy or other soft-tissue procedures, had smaller impacts. The disability associated with fasciectomy for Dupuytren contracture continues to stimulate a search for alternatives. Enzymatic digestion of the Dupuytren nodule, discussed in the last version of this update, remains under study. Another option, percutaneous fasciotomy, has also been the subject of a recent publication. Foucher et al.9 discussed their results in 211 patients treated with this technique over a five-year period. In this procedure, done in the office or operating room with local anesthesia, a needle is used to rupture cords of Dupuytren disease in the palm or fingers. It is important that the releases be limited to central cords, to avoid injury to digital nerves, and that the skin overlying the cord not be adherent, to avoid tears when the cord is ruptured and the finger is then manually extended. Although the recurrence rate of 60% and the reoperation rate of 20% were higher than has been the norm for open surgery, complications were few and patient satisfaction was high. Gains were far more predictable at the metacarpophalangeal than at the interphalangeal level, and the authors suggested that the ideal candidate is an elderly individual with a bowing cord and isolated involvement of the metacarpophalangeal joint. How to approach surgery for patients with a history of reflex sympathetic dystrophy (or, to use its more current name, chronic regional pain syndrome, or CRPS) is an issue for hand surgeons and orthopaedic surgeons alike. Reuben et al.10 performed a review of 100 patients with a history of chronic regional pain syndrome who required surgery in the affected limb. Two surgeons participated in the study; one always used a postoperative stellate ganglion block, whereas the other never did. Preoperative and postoperative management was otherwise similar for the two groups. Chronic regional pain syndrome recurred in 72% of the patients in whom a postoperative nerve block had not been used but in only 10% of the patients who had received a block. Although the study was not randomized or blinded, the evidence is highly suggestive that postoperative stellate ganglion blocks may be useful in reducing the risk of chronic regional pain syndrome in susceptible patients. Hand surgeons are coming close to an international standard for outcomes assessment. The DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire was codeveloped by the AAOS’s Council of Musculoskeletal Specialty Societies, which includes the ASSH and AAHS among others, and the Ontario Institute of Work and Health. This questionnaire has been extensively validated for a variety of upper-extremity problems, and it seems both sensitive and reliable for most conditions affecting the upper limb. Culturally valid translations of the DASH are now available in French, Italian, German, Swedish, Dutch, and Japanese. However, as shown by a recent paper presented to the ASSH, DASH results require some interpretation, as they are affected by all parts of the upper limb and the instrument was designed with both upper limbs considered to be a single functional unit. While this is a valid assessment of how the upper limbs actually function (it does not matter which hand accomplishes a task, only that the task is done), it complicates assessment when there are multiple problems affecting the upper limb, or a condition is bilateral, but the effects of only a single intervention are of interest. In such situations there are other valid, sensitive, and reliable hand, wrist, and even condition (carpal tunnel syndrome) specific questionnaires in common use, as evidenced not only in recent publications but also in many meeting abstracts. Recent presentations to the ASSH show that hand surgeons are interested in the process of care as well as its outcomes. Telemedicine has proved useful in providing hand surgery consultative services to distant rural clinics in both Minnesota and Texas, allowing surgeons or patients to avoid travel expenses. A survey of ASSH members, with a nearly 60% response rate, provided, for the first time, an estimate of the risk of wrong-site surgery (one in 29,000 procedures). About two-thirds of hand surgeons use the "sign your site" method advocated by the AAOS to avoid wrong-site surgery, which in hand surgery more commonly involves the wrong digit than the wrong limb. Finally, hand surgeons continue the search for better solutions to problems that currently have no, or suboptimal, surgical solutions. From gene therapy to neuroprostheses incorporating the latest in computer technology, there is much that is new and exciting on the frontiers of hand surgery. Recent presentations have discussed the use of gene therapy to reduce adhesions after tendon surgery, the potential of artificial neural networks to improve the functioning of hand prostheses, the use of implanted joint-position sensors and functional electrical stimulation of innervated but paretic muscles to improve function in patients with tetraplegia due to spinal cord injury, and tissue-engineering to improve the results and reduce the morbidity of bone-grafting of hand and upper-limb defects. Each of these treatments is likely to be the subject of a more detailed review in the future, as more data become available and the true role of these interventions is clarified. The fifty-sixth Annual Meeting of the American Society for Surgery of the Hand took place on October 4, 5, and 6, 2001, in Baltimore, Maryland. Despite the horrific events of September 11 and the travel difficulties experienced by the international participants, who typically attend in large numbers, turnout was close to normal levels. One of the meeting highlights was a novel "top ten" clustering of the papers judged by the program committee to be the best, to kick off the meeting, a deviation from the usual topic-oriented approach. The fifty-seventh Annual Meeting of the ASSH will be held in Phoenix, Arizona, on October 3, 4, and 5, 2002. As usual, the ASSH is also offering a variety of continuing medical education programs throughout the year, including programs on workplace disorders (cosponsored with the AAHS), wrist arthroscopy, sports injuries, and the popular annual comprehensive review course. The thirty-second Annual Meeting of the American Association for Hand Surgery took place from January 9 through 12, 2002, in Cancun. Mexico, and, in recognition of the special location, offered programs in both English and Spanish, with simultaneous translation. The thirty-third Annual Meeting of AAHS will be held in Kauai, Hawaii, on January 8 through 11, 2003. In addition to working together on courses of mutual interest, both hand surgery organizations also interact with other specialty societies. In 2002 the American Society for Surgery of the Hand will hold a combined meeting with the South American Society for Surgery of the Hand in Buenos Aires. The 2001 and 2002 Annual Meetings of the American Association for Hand Surgery were 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 and even offering a combined registration option. They will meet together again in 2003. 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, those who have received the Certificate of Added Qualifications in Hand Surgery offered by the American Boards of Orthopaedic Surgery, Plastic Surgery, and Surgery. Further information can be obtained by contacting the organizations directly: American Society for Surgery of the Hand (ASSH): 6300 North River Road, Suite 600, Rosemont, IL 60018-4256. Telephone: (847) 384-8300. Web site: www.hand-surg.org. American Association for Hand Surgery (AAHS): 20 North Michigan Avenue, Suite 700, Chicago, IL 60602. Telephone: (312) 236-3307. Web site: www.handsurgery.org.
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