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© 2003 The Journal of Bone and Joint Surgery, Inc.
What's New in Hand SurgeryThis update reviews material presented at the 2002 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 The Journal of Bone and Joint Surgery ) between August 2001 and July 2002. As has been the case in the past, these articles often represented the fruition of papers presented at meetings in previous years and discussed in earlier editions of this update. Hand surgeons have forged close relationships over the years with hand therapists, who are members of a recognized subspecialty (complete with its own Board-certifying and recertifying examinations) of occupational and physical therapy. New Medicare rules may soon affect this relationship. Under the Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP) Benefits Improvement and Protection Act (BIPA), a Negotiated Rulemaking Committee was mandated to set standards for fabrication, fitting, and Medicare billing for prosthetic devices and some orthotic devices. It is possible that this rule may limit the ability of therapists to make splints. A second issue involves proposed legislation in the House and Senate dealing with the development of a competitive bidding system for the supply of Part-B Medicare services. While the House version of the bill authorizes the development of a competitive bidding system for off-the-shelf orthotic devices, the Senate version is less specific, and it is possible that the fabrication and modification of hand splints for Medicare patients could also be relegated to the lowest bidder. Finally, the Senate bill also authorizes demonstration projects in which all therapy services could be put out to competitive bid. Rather than allowing hand surgeons and their Medicare patients to choose relationships with specific hand therapists, the choice might be limited to therapists who have survived the competitive bidding process, with the selection being driven by price rather than quality. These issues are all unresolved at the present time, but it seems clear that in addition to tort reform, the Emergency Medical Treatment and Active Labor Act (EMTALA), and Medicare reimbursement, there are many other ways in which pending legislation and government regulations may affect the practice of hand surgery in the future. Hand transplants remain in the news, even if the number of such procedures performed in 2002 seems to have only held steady with previous years. The cumulative experience with more than a dozen patients, some of whom had bilateral involvement, has led to new reflection about the procedure, especially with regard to its ethical implications. Summaries of the experience to date were presented at both the ASSH and the AAHS meeting. In addition, Lanzetta et al. 1 provided an excellent summary of the functional, immunological, and ethical issues concerning hand transplantation. While the ultimate role of this procedure remains unclear today, it is certain that advances in immunology will make it technically more feasible in the future. Fractures of the distal part of the radius probably represent the largest nexus between hand surgeons and general orthopaedists. Recent advances in fracture fixation have greatly increased the number of treatment options that are available for these common injuries. Whereas residual deformity was once the expected outcome, rigid fixation has now made stable reduction a realistic option in many cases. In one report presented to the AAOS, ninety-two patients were treated with a new modular fixation system from TriMed (Valencia, California) that permits early motion in most cases. After a minimum duration of follow-up of six months, the average motion and alignment were excellent. The most common complication, noted in twenty-one patients, was the need for implant removal, although two patients did require late arthrodesis. While technically challenging to use, this new device clearly expands our surgical armamentarium. In addition, less invasive methods are also gaining popularity. Edwards et al. 2 compared the accuracy of arthroscopically and fluoroscopically assisted reduction and percutaneous fixation of intra-articular distal radial fractures. The arthroscopic method seemed clearly superior for identifying and reducing gaps in the articular surface. Fixation options for distal radial fractures in patients with osteoporotic bone are also improving. In one report presented to the ASSH, twenty-one patients who were more than seventy-five years of age were treated with open reduction of the distal part of the radius with use of a new plate that was inserted through a palmar approach. All of the fractures united without loss of fixation or reduction, and most of the procedures were done on an outpatient basis. While the issues of patient selection and technical expertise are clearly important, this and other new devices have expanded the options available to the surgeon who is faced with a patient who has a difficult distal radial fracture. The need for caution during the treatment of distal radial fractures in elderly patients was emphasized in another report that was presented to the ASSH. That study examined mortality over a seven-year period following distal radial fractures in 325 patients who were more than sixty-five years old. While the expected seven-year survival rate was 71%, the actual survival rate was just 57%. In addition to the fracture itself, other risk factors for mortality included male gender and the presence of medical comorbidities. Vascularized bone-grafting with use of pedicled grafts from the distal part of the radius is becoming more widely accepted as a valuable adjunct in the treatment of carpal abnormalities. A paper presented at the AAOS and ASSH meetings described promising results in the treatment of Kienböck disease, with twenty-one of twenty-two lunates with stage-I and II lesions (i.e., without collapse) healing and eighteen of twenty-two showing evidence of revascularization on magnetic resonance imaging. Steinmann et al. 3 reported similarly excellent results in a study of established scaphoid nonunions, with fourteen of fourteen nonunions uniting at an average of eleven weeks after vascularized bone-grafting. Scaphoid fractures can be treated with a variety of methods, but percutaneous methods received new attention during the past year. In one series presented to the AAOS, thirty-two patients in whom scaphoid fractures were treated with fluoroscopically controlled percutaneous Acutrak screw fixation were compared with patients in whom similar fractures were treated with a cast. The union rate was greater (100% compared with 78%) and the mean times to union (seven compared with twelve weeks) and return to work (2.5 compared with thirteen weeks) were shorter in the operative group than in the nonoperative group. Similarly, Yip et al. 4 reported union of forty-nine of forty-nine scaphoid fractures that had been treated percutaneously with a cannulated Synthes or Alphatec screw. In papers presented to both the ASSH and the AAHS, arthroscopy was used to control the reduction for percutaneous screw fixation in fifteen patients with scaphoid nonunions, which had not collapsed and which therefore did not require bone-grafting. All fractures united, and both motion and function were excellent. The treatment of severely comminuted carpal fracture-dislocations was the topic of an interesting paper presented to the AAHS. Instead of embarking on a difficult repair, the surgeon performed a primary proximal row carpectomy for twelve patients, with surprisingly good results. Although two patients were not able to return to their previous employment, no patient required additional surgery after one to five years of follow-up. While clearly not the first-line treatment, early proximal row carpectomy seems to be worth consideration when severe carpal fracture-dislocations preclude stable reduction or fixation. Severely comminuted dorsal fracture-dislocations of the proximal interphalangeal joint can also be difficult management problems. One clever solution to the problem was presented to the ASSH. For patients with comminution of the palmar half of the base of the middle phalanx, excision of the fracture fragments and replacement with an osteoarticular graft harvested from the hamate can provide good results in selected cases. For the twelve patients in that report (all of whom were young adults), the final motion of the proximal interphalangeal joint averaged 80°, and only one patient was dissatisfied with the result because of substantial pain. Carpal tunnel syndrome is the most common surgical diagnosis among patients treated by hand surgeons, yet controversy persists regarding the role of surgery as a first-line treatment. In most cases, nonoperative therapy such as splinting, injection, or activity modification is tried first. In an interesting and very useful paper from the Netherlands, Gerritsen et al. 5 reported the results of a prospective, randomized multicenter trial in which surgery was compared with splinting for the treatment of clinically and electrophysiologically confirmed carpal tunnel syndrome. The main outcome measures were symptom severity and frequency. A total of 176 patients, with a mean age of forty-nine years, were enrolled at thirteen neurology clinics. In the intention-to-treat analysis, surgery was more effective in terms of all outcome measures, with significant improvement at three months in 80% of the patients in the surgery group and 54% of those in the splinting group. At sixteen months, the success rate had climbed to 90% in the surgery group and to 75% in the splinting group. By that time, however, nearly half of the patients in the splinting group had opted for surgery, and the 75% figure includes the results of those surgical procedures. Thus, surgery was the more effective therapy. Moreover, splinting provided long-term relief in fewer than one-third of the patients who had been randomized to that arm of the study. Thus, if one chooses to treat carpal tunnel syndrome nonoperatively, there seems little benefit to prolonging the nonoperative therapy if symptomatic improvement is not obtained within the first few weeks or if symptoms recur after initial improvement. Do elderly patients with carpal tunnel syndrome improve after surgery as well as younger patients do? That was the question that prompted a study of forty-five patients with carpal tunnel syndrome who were more than sixty-five years old, all of whom were treated with open carpal tunnel release. Significant improvement was noted in terms of pain, numbness, paresthesias, pinch, grip, and two-point discrimination. In addition, a validated quality-of-life questionnaire focusing on the hand showed significant improvement in terms of activities of daily living and satisfaction with hand function. Regardless of age, it appears that, at least in 2002, the preferred treatment for carpal tunnel syndrome remained surgical. The unstable distal radioulnar joint has been to some extent an unsolved problem for hand surgeons. Many procedures have been tried, but all have been found to be wanting in one way or another. Now, there is a new kid on the block, with pretty good credentials at least. Adams and Berger 6 described an anatomic reconstruction of the distal radioulnar joint ligaments based on a thoughtful analysis of ligament function and joint kinematics. They validated their theory on the basis of the results for fourteen patients, twelve of whom had a stable joint with an excellent range of motion at one to four years of follow-up. The procedure involves the use of a tendon graft to restore the normal lines of pull of the dorsal and palmar distal radioulnar joint ligaments. The graft passes through a dorsopalmar drill-hole in the distal part of the radius, parallel to the sigmoid notch. The dorsal and palmar limbs of the graft are then routed through another drill-hole at the base of the ulnar styloid, which is the normal insertion of the distal radioulnar joint ligaments; the graft is then tightened and tied around the distal part of the ulna. Additional elements essential to a successful reconstruction of the distal radioulnar joint are an intact ulnar head that is free of arthritic changes, a congruent sigmoid notch, and an intact ulnar styloid. When the ulnar head is arthritic, restoration of instability is likely to aggravate the symptoms associated with distal radioulnar joint arthritis. In such cases, a hemiarthroplasty of the ulnar head may be a useful adjunct. In one series presented to the ASSH, fourteen patients were treated with a new prosthesis that was fixed by means of osseointegration to a stem that fit within the distal part of the ulnar shaft. At two to five years of follow-up, there was improvement in terms of pain, motion, and function, and all implants were well fixed. Whether these results will hold up over the long term, however, is not clear, as ten patients showed some resorption around the ulnar stem and four had osteophytes around the sigmoid notch. Although surgery for rheumatoid arthritis has been a common topic at hand surgery meetings for decades and implants to replace deformed rheumatoid joints have been in use since the 1960s, it is commonly believed that hand surgeons and rheumatologists do not see eye to eye when it comes to the indications for hand surgery in patients with rheumatoid arthritis. How divergent these views actually are was the subject of an interesting paper, presented to the ASSH, that gave the results of a survey of hand surgeons and rheumatologists on the subject of the management of rheumatoid hand deformities. In a random national survey, only 15% of 500 rheumatologists believed that quality information exists regarding rheumatoid hand surgery while 70% considered hand surgeons to be deficient in their understanding of the medical treatment of rheumatoid arthritis. Surgeons were equally skeptical of their medical colleagues, with two-thirds of surgeons believing that rheumatologists were too passive in the treatment of rheumatoid hand deformities and inappropriate in the timing of referrals. Rheumatologists and hand surgeons diverged greatly in their opinions on the usefulness of metacarpophalangeal joint arthroplasty for improving hand function, the ability of extensor synovectomy to prevent tendon rupture, and the ability of synovectomy to delay joint destruction. While these differences make it seem that rheumatologists and hand surgeons must be analyzing different sets of data, the problem may be related more to the interpretation of the data than to the data themselves. The same authors, in a second presentation to the ASSH, reviewed the short-term results for seventeen patients with rheumatoid arthritis who were treated with metacarpophalangeal joint arthroplasty with use of the Swanson silicone implant. At six months postoperatively, the Jebsen-Taylor test revealed little improvement in strength or dexterity while a validated quality-of-life questionnaire administered to the patients before and after surgery showed large and significant improvements in the ease of performing activities of daily living, in appearance, and in overall satisfaction with the procedure. These data suggest that the difference between surgeons and rheumatologists may be that the surgeons are responding more to the patient's perception while the rheumatologists are relying more on physical measurements to form their opinions. Recent modifications in stem design appear to have improved the results of total wrist arthroplasty. In two series presented to the ASSH, comprising more than 100 patients treated with either the Universal implant (Kineticos Medical, San Diego, California) or the Biax implant (DePuy Orthopaedics, Warsaw, Indiana), no loosening was noted and function was notably improved at one to six years of follow-up. However, six of the eighty-two patients who had been treated with the Universal prosthesis had problems with implant dislocation, and two ultimately needed arthrodesis. Divelbiss et al. 7 reported similar results in a study of nineteen patients with severe rheumatoid arthritis who were treated with the Universal prosthesis. While functional scores improved in all patients, three of the twenty-two implants became unstable and necessitated additional surgery at a minimum of one year follow-up. Given that the alternative to arthroplasty is arthrodesis in many cases, these results appear to offer some place for metal-on-plastic wrist arthroplasty, but long-term follow-up studies are clearly needed before the true role of these devices can be known. Collagenase injection appears to be coming closer to being approved for the treatment of Dupuytren contracture. A paper presented to the ASSH described the results of a phase-II clinical trial in which eighty patients received a single 10,000-unit injection of collagenase. Ninety percent of metacarpophalangeal joint deformities and 70% of proximal interphalangeal joint deformities were completely corrected within thirty days after injection, with the benefit lasting for the twelve months of the study. There were no adverse reactions in any of the patients. The use of digital periarterial sympathectomy to treat digital ischemia in patients with scleroderma is controversial. Ruch et al. 8 , in a study of twenty-nine hands in twenty-two patients with nonhealing finger ulcerations resulting from scleroderma, investigated the outcome of digital sympathectomy on the basis of sophisticated measures of digital blood flow, quality of life, and patient satisfaction. After a mean duration of follow-up of thirty-one months, finger skin temperature did not change, but microvascular perfusion improved, pain was reduced in eighteen of the twenty-two patients, and six patients remained ulcer-free. While the clinical results were clearly variable, surgical morbidity was minimal and digital sympathectomy seems to be worth consideration for the treatment of patients with ulcers due to scleroderma. Hand surgeons also deal with the nerves of the upper limb, but nowhere more dramatically than in the effort to restore function to the paralyzed limb. There are two major advances to consider in this arena. For patients with complete brachial plexopathy, treatment options have been limited. With the nerve roots avulsed from the spinal cord, a new source of healthy axons is needed. Those available from cranial or intercostal nerves are limited in quantity. While it seems heretical to take axons away from the healthy contralateral limb, there is increasing evidence that the penalty for such an approach may be small indeed. Songcharoen et al. 9 reported on the use of the contralateral, healthy seventh cervical nerve root in a study of 111 patients. Amazingly, the donor defect, which would be expected to affect the median nerve substantially, was actually quite mild, and in all but one case was not detectable on sensory or motor examination of the donor limb after three months. The impact on the recipient side was more substantial, although still far from excellent: the transfer, performed into the median nerve to provide hand sensation and motor function, succeeded in restoring weak finger motion and protective sensation in fewer than half of the patients. These modest results should certainly temper one's enthusiasm for what is still a complex and time-consuming surgical procedure that requires years for nerve regeneration, but the fact that so many axons apparently can be taken from the healthy limb with so little functional penalty may stimulate further innovation in the uses to which those axons are put. For patients with tetraplegia due to spinal cord injury, the reconstructive options have been limited to a transfer of normal local muscles, if any, to substitute for the function of muscles that were either denervated or disconnected from the central nervous system by the spinal cord injury. In the past, it made little difference whether the muscle had been denervated or had lost its central connection, except that in the latter case the muscle might be affected by spasticity. Now that difference can make a difference, thanks to an implanted nerve stimulator that, when connected to the right muscles and programmed properly, can activate them to pinch or grip. Peckham et al. 10 described the use of this device in a study of fifty-one patients with paralysis at the fifth or sixth cervical level. Traditional methods would be able to restore a tenodesis pinch in such patients, but with use of the ten programmable channels of the implanted nerve stimulator it is possible to achieve a form of active pinch and grip, which the patient can initiate with shoulder movements (somewhat similar to the way in which an amputee can activate the hand unit of an upper limb prosthesis). Significant functional improvements were noted in all patients, and the long-term results appeared to be stable. Unfortunately, at the present time, this implant remains something of an "orphan" device, without a commercial provider, so that distribution is limited to a few centers. The potential market is relatively small, so we can only hope that some firm will see the humanitarian benefit inherent in this implant so that it can reach a wider audience. Finally, no report of what is new in hand surgery would be complete without at least some mention of flexor tendon injury. The current fashion is to perform multistrand repairs; that is, repairs in which the suture crosses the laceration site more than two times. Such repairs, being stronger than the more traditional two-strand repairs, can tolerate some protected early active motion. One of the more popular four-strand repairs is the Massachusetts General Hospital (MGH) repair, in which two longitudinal criss-cross stitches of 3-0 or 4-0 polypropylene are placed along the sides of the injured tendon. In a series presented to the AAHS, 105 such repairs were performed in thirty-five patients who were, as usual, mostly young men. While three repairs ruptured, the average final total active motion (that is, the sum of metacarpophalangeal and interphalangeal motion) measured 240° (normal, 270°), which easily exceeded the typically reported average of 200° to 220° for two-strand repairs combined with passive-motion therapy. It seems clear that better repairs and innovative rehabilitation will continue to improve the results for these nettlesome injuries while we await definitive help in the form of tissue and genetic engineering to speed the healing process while blocking adhesion formation. So much to look forward to! The Fifty-eighth Annual Meeting of the ASSH will be held in Chicago, Illinois, on September 18, 19, and 20, 2003. As usual, the ASSH is also offering a variety of continuing medical education (CME) programs throughout the year, including a hands-on course on brachial plexus reconstruction; a course on joint replacement and its alternatives in the upper limb, also with a hands-on component; and the popular annual comprehensive hand surgery review course. The Thirty-fourth Annual Meeting of the AAHS will be held in Palm Springs, California, on January 14 through 17, 2004. In addition to these meetings, the AAHS will offer a continuing education program on soft-tissue reconstruction for hand and wrist injuries in April 2003. This course is cosponsored by the ASSH. Both the ASSH and the AAHS are components of the International Federation of Societies of Surgery of the Hand (IFSSH). The IFSSH holds triennial congresses; the next IFSSH Congress will be held in Budapest, Hungary, on June 13 through 17, 2004. Information on this meeting is available through both the ASSH and the AAHS and is posted on their web sites. As well as working together on courses of mutual interest, the two American hand surgery organizations also interact with other specialty societies. In April 2003, the American Society for Surgery of the Hand will hold a combined meeting with the British Society for Surgery of the Hand in Cambridge, England. The 2002 and 2003 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 2004. All of these meetings are open to all interested parties. The annual meetings of both the ASSH and the AAHS accept free papers, but both also offer many instructional courses and symposia, several with hands-on sessions. 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. Both organizations also maintain active web sites, with educational and informational content directed at the public and interested medical professionals as well as members. 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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