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© 2004 The Journal of Bone and Joint Surgery, Inc. What's New in Hand Surgery1 Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address: amadio.peter{at}mayo.edu
Specialty Update has been developed in collaboration with the Council of
Musculoskeletal Specialty Societies (COMSS) of the American Academy of
Orthopaedic Surgeons.
This update reviews material presented at the 2003 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 2002 and July 2003. Abstracts for the ASSH and AAOS annual meetings are maintained online at www.hand-surg.org and www.aaos.org, respectively. The most common conditions treated by hand surgeons are carpal tunnel syndrome and fractures of the distal part of the radius. It should not be surprising, therefore, that these two topics were once again heavily represented in 2003. Hand trauma and its sequelae were also common themes. It is often asserted, but on the basis of little evidence, that repetitive activity might lead to carpal tunnel syndrome. Freeland et al.1 studied the synovium of patients with idiopathic carpal tunnel syndrome and found evidence, in the presence of interleukin-6 and malondialdehyde and in the absence of interleukin-1, to suggest that the initial pathology may be an ischemia-reperfusion injury. Repeated episodes of ischemia and reperfusion could explain these findings as well as the typical noninflammatory synovial thickening that typically is seen in patients with carpal tunnel syndrome. As it is already known that prolonged activity can raise the pressure within the carpal tunnel above mean capillary pressure, a mechanism to explain the ischemia is also available. Much research needs to be done, but this work is certainly thought-provoking and raises the possibility that carpal tunnel syndrome can be managed medically by blocking some of the tissue responses to the ischemia-reperfusion injury pattern. The role of steroid injection in the treatment of carpal tunnel syndrome is somewhat controversial, but Edgell et al.2 showed that the response to injection is an excellent predictor of the response to surgery. In a case-controlled study of fifty-seven patients, those who had some symptomatic relief following steroid injection had a significantly higher rate of successful results after surgery than those who had no response to injection (87% compared with 54%). Thus, even though steroid injection typically provides temporary rather than permanent relief of symptoms, the use of steroid injection in the management of carpal tunnel syndrome does appear to be useful, particularly as a prognostic tool. With regard to surgery itself, a Cochrane systematic review of the literature3 supported surgery as significantly more effective than splinting (relative risk, 1.38; 95% confidence interval, 1.08 to 1.53). Unfortunately, the investigators who performed this systematic review of the literature found only two relevant prospective, randomized trials on which to base this conclusion. As in many areas of medicine, the level of available evidence is far less than one might hope, especially given the volume of available publications. Macdermid et al.4, in a prospective, randomized trial comparing open and endoscopic carpal tunnel release, showed that the endoscopic treatment group had slightly less pain and more grip strength than did the open treatment group at one and six weeks but that these differences had disappeared by twelve weeks. Furthermore, the two-year follow-up showed significantly less satisfaction in the endoscopic treatment group; this finding was attributed to the fact that the rate of reoperation in the endoscopic treatment group (5%) was higher than that in the open treatment group (0%). As a result of that study, the surgeons at that center greatly reduced the number of endoscopic releases that they perform. There may be some medicolegal differences between endoscopic and open carpal tunnel release as well. An interesting paper presented to the ASSH raised additional concerns regarding the relative merits of endoscopic as compared with open release, at least with regard to one very rare complication. In the past, the results of questionnaire surveys had suggested that the risk of iatrogenic nerve injury was similar for open and endoscopic releases. Indeed, a literature review presented at the AAOS annual meeting in 2003 came to just that conclusion. As noted in the Cochrane review cited above, however, the quality of evidence in reviews of nonrandomized, retrospective case series is often rather weak. What makes the ASSH paper interesting is that it included all New York State medical malpractice claims from 1975 through 2002 and that the authors also had access to a statewide claims database of nearly 300,000 carpal tunnel procedures performed from 1984 through 2002. This seems about as close to a 100% sample as one is likely to get. Among these cases, endoscopic carpal tunnel release was disproportionately represented among the lawsuit claims. In the period from 1992 through 2002, endoscopic release represented 15% of the carpal tunnel procedures but was responsible for 46% of the claims, including five of the six cases of complete nerve transection (p < 0.01). Two conclusions can be drawn from these data. First, it is likely that the rate of serious complications is higher in association with endoscopic surgery than it is in association with open carpal tunnel surgery. Second, for both procedures, the rate of catastrophic nerve injury must be exceedingly small— somewhere in the range of one in 10,000, or less, if one assumes that all patients with complete iatrogenic median nerve lacerations in New York State filed a lawsuit. Much has been written over the years about fractures of the distal part of the radius. It seems clear, though, that there is still much to learn. Graham5 focused attention on comminuted fractures of the palmar rim of the radius that occur in association with radial and ulnar styloid fractures. He terms this pattern of association an inferior arc injury, to draw an analogy to the combined osseous and soft-tissue injuries characteristic of greater and lesser arc perilunate injuries. In inferior arc injuries, the major palmar ligaments of the wrist are disrupted; therefore, even undisplaced and relatively small fragments may signal the presence of clinically important instability. Combinations of internal and external fixation may be necessary to restore alignment and stability in patients with inferior arc injuries. Hand surgeons and orthopaedic surgeons should be on the lookout for these deceptively innocuous-appearing injuries. Cochrane systematic reviews of the published literature that were performed over the past year also focused on fractures of the distal part of the radius. In an analysis that focused on prospective, randomized trials, Handoll and Madhok6 found some evidence to support the effectiveness of external fixation or percutaneous pin fixation, as opposed to closed treatment, in improving anatomical outcomes. Unfortunately, major differences in participant characteristics, interventions, and outcome measures made it impossible to correlate anatomical and functional outcomes across studies. Several other Cochrane reviews demonstrated an inability to distinguish various operative or nonoperative treatments from each other, again because of the poor methodological quality of the studies involved. The lack of good-quality outcomes studies has not stifled innovation in the treatment of distal radial fractures. Many new fixation systems featuring lower profile implants, modular implants, blade or rake plates, and fixed-angle locking plate-and-screw devices have been developed over the past few years. These systems have expanded the possibilities for surgical fixation and even have allowed for the use of some counterintuitive options, such as the treatment of dorsally displaced and angulated fractures with a plate on the palmar surface of the radius. In one report presented to the AAHS, forty-six patients with dorsally angulated complex intraarticular distal radial fractures were treated with a palmar fixed-angle plate. This device was found to provide excellent results, both anatomically and functionally. In another study, Konrath and Bahler7 reported good results in association with a modular device that employs a combination of pins, plates, and wire forms to achieve fixation. However, neither of those studies included a control or comparison group. Hand surgeons often disagree about the best method of treatment of the distal part of the ulna following a distal radial fracture that has healed with shortening, resulting in pain and limitation of forearm rotation. A paper presented to the ASSH compared the Darrach procedure (distal radioulnar joint resection arthroplasty) with the Sauvé-Kapandji procedure (distal radioulnar arthrodesis with proximal segmental resection to allow forearm rotation) in a group of fifty patients who were younger than fifty years of age. Although the Sauvé-Kapandji procedure is commonly recommended for younger patients on the grounds that it provides better stability with forearm rotation, both procedures were associated with similar rates of complications and similar postoperative functional scores. The authors concluded that there was no advantage of one operation over the other in this group of patients. Other trauma-related topics were also addressed in the literature. Brydie and Raby8 described the use of magnetic resonance imaging for the early detection of scaphoid fractures in a study of 195 patients with a history of wrist trauma who had normal findings on initial radiographs. Magnetic resonance imaging demonstrated thirty-seven scaphoid fractures, twenty-eight distal radial fractures, and nine fractures of other carpal bones. While magnetic resonance imaging does not provide the same level of osseous detail as computerized tomographic scanning does, it has some advantages in the early assessment of posttraumatic wrist pain in that soft-tissue injuries such as ganglia and ligament injuries can also be seen. In comparison with bone scanning, magnetic resonance imaging provides the added benefit of delineating fracture anatomy, which facilitates treatment planning. Magnetic resonance imaging appears to be particularly useful for identifying undisplaced fractures, which can be distinguished by a characteristic marrow edema signal. For patients who are found to have an undisplaced fracture of the scaphoid, a question often arises as to the best treatment. Immobilization in an above-the-elbow cast or a below-the-elbow cast, thumb-spica protection, and surgical fixation all have their proponents. In a study presented to the AAOS, fifty-eight patients with an undisplaced scaphoid fracture were randomized to either cast treatment or percutaneous screw fixation. Patients were evaluated at eight, twelve, sixteen, twenty-six, and fifty-two weeks. In the surgical treatment group, there was one wound infection but there were no nonunions. In the cast treatment group, there were five nonunions (prevalence, 17%) and two cases of reflex sympathetic dystrophy. The surgical treatment group had better results in terms of strength, motion, and return to work or sports at every time-point. The authors concluded that surgical treatment was indicated for patients with undisplaced scaphoid fractures who desired an early return to work or sports and who were willing to accept the risks of surgery. Fracture-dislocations of the proximal interphalangeal joint remain problematic for hand surgeons, especially when the fractured surface is comminuted and exceeds 50% of the articular surface. Such fractures are often unstable. Internal fixation is difficult because of the small size of the fragments, and salvage operations, such as volar plate arthroplasty, often are proposed. In an interesting paper presented to the AAOS, a clever new solution was offered. That report described thirteen patients in whom an ipsilateral osteoarticular autograft was harvested from the dorsal aspect of the distal part of the hamate and was used to replace the damaged palmar articular surface of the base of the middle phalanx. Fixation was achieved with a small lag screw. After a mean duration of follow-up of six months, all grafts had healed. The mean arc of motion of the proximal interphalangeal joint was 80°, and all patients were pleased with the result. There was no donorsite morbidity, even though the donor site included a part of the fourth and fifth carpometacarpal joints. This type of graft matches the size and shape of the base of the proximal phalanx almost exactly and appears to be a useful solution to a challenging problem. Hand transplantations continue to be performed. One of the highlights of the 2003 ASSH annual meeting was the report by the Bunnell traveling fellow, W.P. Andrew Lee, MD, who traveled to six medical centers around the world and examined eleven patients who had undergone hand transplantation. His observations aptly summarize the current state of this new procedure. Eighteen transplantation procedures have been performed since 1998, of which six have been bilateral. Two hands have been reamputated, and several others have had major complications, such as skin necrosis and osteomyelitis, that have required prolonged hospitalization. All patients have continued to receive systemic immunosuppressive medications. Most patients were hospitalized for several months after surgery, and daily hand therapy continued for six to twelve months. All but one of the patients have had rejection episodes, and only two have had any evidence of intrinsic muscle reinnervation. Most patients have recovered protective sensation, but only about half can localize sensation to a digit. The results for the few patients who have had functional testing have been similar to those for the typical hand replantation patient (although the typical hand replantation patient does not receive daily hand therapy for a year). For many unilateral amputees, the main benefit appears to have been in self image, but for others, and for most bilateral amputees, the main benefit was in physical function. This procedure clearly is associated with high risks, some of which may not yet be known, such as those associated with prolonged immunosuppression. The benefits are real, but the results are far from normal. While long-term function and the side effects of antirejection therapy are unknown, there are some interesting research data that suggest that limb transplantation may pose different, and perhaps less severe, immunological challenges than solid organ transplantation does. In a paper presented to the ASSH, it was demonstrated that, at least in a rat model of limb transplantation, short-term immunosuppression was associated with the development of long-term tolerance for chimerism, even after immunosuppressive therapy had stopped. Donor-specific tolerance and immunocompetence were confirmed when it was shown that the recipient would still reject third-party grafts and would mount an immunological response to third-party antigens while mounting no response to further antigen challenge from the limb donor. Alternatives to hand transplantation are also being explored. Another paper presented to the ASSH described the preliminary results in the creation of a neurally controlled artificial hand with sensory feedback. With electrodes implanted in peripheral nerves of upper-extremity amputees, it was possible to train motor impulses in nerves whose end organs had been amputated to control prosthetic pincer grip controls and for sensors on the terminal device to activate sensory axons and to be perceived by the amputee as a tactile stimulus. While a functioning neurally controlled prosthesis is not yet available, such results suggest that one is certainly a possibility. Research also continues in the biology of nerve grafts. In a paper presented to the AAHS, a biodegradable tissue-engineered nerve conduit that had been seeded with Schwann cells was reported to promote bridging of 20-mm defects with well-myelinated axons in rat sciatic nerves. Similar conduits without Schwann cells showed no such bridging. Proximal interphalangeal joint contractures can be a vexing late sequela of many injuries. Houshian et al.9 described their use of the Compass PIP Hinge (Smith and Nephew Richards, Memphis, Tennessee) for the closed treatment of twenty-seven proximal interphalangeal joint injuries. The fixator, which is adjustable and allows active motion as well as passive correction, was kept in place for a mean of thirty-three days. After a mean duration of follow-up of twenty-one months, the arc of motion had improved by a mean of 38°. Pin-track infection was the most common complication. The treatment of arthritic disorders of the hand represents another major domain of hand surgery. The surgical treatment of the hand in patients with rheumatoid arthritis remains controversial, with hand surgeons and rheumatologists often disagreeing over indications. In a fascinating survey, Alderman et al.10 mailed a questionnaire to 500 hand surgeons and 500 rheumatologists to document exactly where the controversies lay. While 82% of hand surgeons thought that metacarpophalangeal joint arthroplasty improved hand function, only 34% of rheumatologists agreed; similar discordance was noted in the attitudes toward synovectomy. In what can be considered almost a companion paper, Mandl et al.11 attempted to correlate outcome with satisfaction in a study of twenty-six patients with rheumatoid arthritis who had had metacarpophalangeal joint arthroplasties with use of silicone implants. Overall satisfaction was highly correlated with improved appearance and pain relief. Satisfaction was only weakly correlated with function. Other treatments for rheumatoid arthritis are also controversial. Hand surgeons often disagree with regard to the indications for wrist arthrodesis and wrist arthroplasty in these patients. In a paper presented to the AAHS, forty-six patients who had had a total of twenty-four wrist arthrodeses and twenty-seven wrist arthroplasties were reviewed with use of the Disabilities of the Arm, Shoulder and Hand (DASH) and Patient-Rated Wrist Evaluation questionnaires after one to five years of follow-up. There was no significant difference between the groups, but the authors noted that, because of the large variation in results between patients, roughly 300 patients would be needed to have an 80% chance of detecting a difference at the p < 0.05 level, assuming that such a difference actually existed. It is truly said that the hand begins at the brain and that therefore the domain of the hand surgeon must include the central control of hand function. A number of research papers have focused on this aspect of hand surgery, as discussed below. Focal dystonia is a poorly understood movement disorder that is characterized by involuntary muscular contraction of agonists and antagonists during complex movements. Focal dystonia in the hand is responsible for many cases of so-called writer's cramp as well as more dramatic examples that have afflicted musicians over the years, most notably, perhaps, the Canadian pianist Glenn Gould. Recently, research has documented specific electroencephalographic and somatosensory-evoked-potential changes in the cerebral cortex of patients with focal dystonia that are not present in individuals without the disorder. Byl et al.12 studied seventeen patients with focal dystonia and seventeen case-matched controls. The ability to perform standardized motor and sensory tasks was proportional to the degree of severity of the dystonia. More interestingly, the localization of cortical activation with hand movement and the sequence of activation was markedly different in patients with dystonia. Patients with the most severe dystonia had the largest amplitude of somatosensory evoked field responses, the shortest latency, and the smallest evoked field size. This evidence suggests that patients with focal dystonia have a specific sensorimotor dysfunction characterized by cortical dedifferentiation, in which the normal homuncular arrangement of cortical representation is disordered. The somatosensory evoked field response might be a useful tool with which to monitor reeducation of such patients. That such therapy can be effective was the subject of another interesting paper, by Candia et al.13, in which ten musicians with focal dystonia were treated with sensorimotor retraining and were monitored with magnetoencephalography. Before treatment, the patterns of somatosensory relationships of the various fingers were asymmetrical when the affected and unaffected sides were compared. With effective treatment, the two finger representation patterns became symmetrical and ordered according to homuncular principles. These findings suggest not only that focal dystonia is in fact treatable but also that the adult brain continues to exhibit considerable cortical plasticity. This plasticity was also evident in a paper presented to the AAHS, in which positron emission tomography was used to study the cortical representation of finger movement in patients who had had flexor tendon laceration. A regional increase in cerebral perfusion was used as an indicator of local neuronal activation. The first study was done when the patient had completed initial therapy, six weeks after the injury. The second study was done six weeks later. In the initial study, movement-related uptake covered a larger area on the affected side. These differences disappeared at the second reading, six weeks later. These findings are the opposite of those seen in association with dystonia. In the case of dystonia, finger movement produces an excessively intense and very localized response on the affected side as compared with the normal side; in the case of tendon injury, the response is excessively diffuse on the affected side as compared with the normal side. The tendon laceration study also suggested that neural plasticity occurs in fairly short time-frames and, as is the case with dystonia, that learned abnormal behaviors can be unlearned. Through such insights, hand therapy (and, with it, hand surgery) improves. The Fifty-eighth Annual Meeting of the ASSH took place on September 17 through 20, 2003, in Chicago, Illinois. The Fifty-ninth Annual Meeting of the ASSH will be held in New York, NY, on September 8 through 11, 2004. As usual, the ASSH is also offering a variety of continuing medical education (CME) programs throughout the year, including a program on electives in hand surgery, to be held on February 20 and 21, 2004, in Orlando, Florida; a program on wrist anatomy and surgery, to be held on April 29 through May 2, 2004, in Rochester, Minnesota; a comprehensive hand surgery review course, to be held on July 23 through 25, 2004, in Dallas, Texas; and a wrist arthroscopy course, cosponsored with AAOS, to be held on August 6 and 7, 2004, in Rosemont, Illinois. The Thirty-third Annual Meeting of the AAHS was held on January 8 through 11, 2003, in Kauai, Hawaii. The Thirty-fourth Annual meeting was held on January 14 through 17, 2004, in Palm Springs, California. The Thirty-fifth Annual Meeting of the AAHS will be held on Sanibel Island, Florida, on January 12 through 15, 2005. The 2003 and 2004 meetings of the AAHS 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, even offering a combined registration option. They will meet together again in 2005. In addition to these meetings, in 2004 the AAHS will offer a continuing education program on cumulative trauma disorders of the hand and wrist, to be held on May 21 through 23, 2004, in Chicago. This meeting will be 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, and the next one will be in Budapest, Hungary, on June 13 through 17, 2004. A post-congress program sponsored by the AAHS and the Romanian Society for Surgery of the Hand will be held in Bucharest, Romania, on June 19 through 21, 2004. Topics of the post-congress meeting will include elbow surgery, skin coverage in the upper extremity, functional and nonfunctional free flaps, and wrist surgery. Information on both of these meetings is available through the ASSH and the AAHS as well as the IFSSH and is posted on all three society web sites. Besides working together on courses of mutual interest, the two American hand surgery organizations also interact with other specialty societies. In March 2005, the ASSH will hold a combined meeting with the Japanese Society for Surgery of the Hand in Honolulu, Hawaii. 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 several instructional courses and symposia, many with hands-on sessions. Over the years, as with other maturing organizations, the trend has been for fewer free papers and more symposia and hands-on workshops, including many non-CME-credit industry-sponsored workshops in facilities adjacent to the accredited scientific meeting. Membership in the two hand surgery societies is restricted to those who have had specific hand surgery training and, in the case of the ASSH, 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 on any of the above meetings can be obtained by contacting the organizations directly. Finally, both organizations maintain active web sites, with educational and informational content directed to 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. 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. International Federation of Societies for Surgery of the Hand [IFSSH]: Web site: www.ifssh2004.com.
During 2002, the editorial staff of The Journal reviewed a large number of research studies related to the musculoskeletal system that received a Level of Evidence grade of I. Over forty medical journals were reviewed to identify these articles, all of which shave a high-quality study design. In addition to articles published previously in this journal or cited already in this Update, eleven Grade-I articles were identified that were relevant to hand surgery. A list of those titles is appended to this review after the standard bibliography. We have provided a brief commentary about each of the articles to help to guide your further reading, in an evidence-based fashion, in this subspecialty area.
Brashear A, Gordon MF, Elovic E, Kassicieh VD, Marciniak C, Do M, Lee CH, Jenkins S, Turkel C; Botox Post-Stroke Spasticity Study Group. Intramuscular injection of botulinum toxin for the treatment of wrist and finger spasticity after a stroke. N Engl J Med. 2002;347:395-400. Intramuscular injections of botulinum toxin A significantly reduced flexor tone and improved self-care at six weeks after treatment when compared with placebo. Ferdinand RD, MacLean JG. Endoscopic versus open carpal tunnel release in bilateral carpal tunnel syndrome. A prospective, randomised, blinded assessment. J Bone Joint Surg Br. 2002;84:375-9. Twenty-five patients with bilateral carpal tunnel syndrome were randomized to treatment with an Agee-type endoscopic release on one side and an open release on the other. Both operations were done on the same day. Follow-up evaluations at six, twelve, twenty-six, and fifty-two weeks were performed by a hand therapist who was blinded to the type of procedure. The duration of the operation was two minutes longer on the side that was treated endoscopically. There was no difference between the two procedures with regard to strength, sensibility, relief of symptoms, function, complications, or satisfaction. Return to work could not be assessed because the two operations were done on the same day. Handoll HH, Madhok R, Dodds C. Anaesthesia for treating distal radial fracture in adults. Cochrane Database Syst Rev. 2002;3:CD003320. Five trials provided evidence that a better reduction could be obtained with use of intravenous regional anesthesia than with use of hematoma block. There was insufficient evidence to compare the effectiveness of other methods of anesthesia. Handoll HH, Madhok R. Conservative interventions lessen for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2003;2:CD000314. This updated review added two more trials to an existing meta-analysis of thirty-one studies. There remains insufficient evidence to recommend specific methods of conservative treatment because of the poor quality of the published literature on this subject. Harris PC, Scott S, Evans RA. Hand exsanguination: prospective randomised blind study of an established versus a modified technique. J Hand Surg [Br]. 2002;27:361-2. The modified technique consisted of placing a 500-mL bag of intravenous fluid in the hand before exsanguination and wrapping over it. There was no difference in the quality of exsanguination between the two methods. Jarvik JG, Yuen E, Haynor DR, Bradley CM, Fulton-Kehoe D, Smith-Weller T, Wu R, Kliot M, Kraft G, Wang L, Erlich V, Heagerty PJ, Franklin GM. MR nerve imaging in a prospective cohort of patients with suspected carpal tunnel syndrome. Neurology. 2002;58:1597-602. One hundred and twenty patients with clinically suspected carpal tunnel syndrome were evaluated with use of magnetic resonance imaging, electromyography, a nerve-conduction study, a hand diagram, and a clinical examination. The intrareader reliability of the magnetic resonance images was good (kappa, 0.76 to 0.88), as was the interreader reliability (kappa, 0.60 to 0.67). Compared with the gold standard of a classic hand diagram and abnormal electrodiagnostic findings, magnetic resonance imaging had a sensitivity of 96% and a specificity of no more than 38%. Lawrence TM, Desai VV. Topical anaesthesia to reduce pain associated with carpal tunnel surgery. J Hand Surg [Br]. 2002;27:462-4. The addition of topical anesthetic significantly reduced the pain associated with needle insertion and injection of local anesthetic. Livingstone JA, Atkins RM. Intravenous regional guanethidine blockade in the treatment of post-traumatic complex regional pain syndrome type 1 (algodystrophy) of the hand. J Bone Joint Surg Br. 2002;84:380-6. Fifty-seven patients with complex regional pain syndrome were randomized to receive intravenous regional blocks with either guanethidine or a placebo (saline solution). At six months, the guanethidine group had more pain and vasomotor instability than the placebo group did. The use of guanethidine appeared to delay recovery in this group of patients. Machold W, Kwasny O, Eisenhardt P, Kolonja A, Bauer E, Lehr S, Mayr W, Fuchs M. Reduction of severe wrist injuries in snowboarding by an optimized wrist protection device: a prospective randomized trial. J Trauma. 2002;52:517-20. Seven hundred and twenty-one snowboarders were randomized to treatment with or without a rigid wrist orthosis. After more than 5000 half-days of exposure, there were nine wrist fractures in the group treated without wrist protectors, compared with only one fracture in the group treated with wrist protectors. The hazard ratio of 0.13 for the protectors was highly significant, but the 95% confidence limits did overlap 1.0 (range, 0.02 to 1.04). The use of wrist protectors during snowboarding appears to be an effective intervention to reduce the risk of wrist fractures. Scholten RJ, Gerritsen AA, Uitdehaag BM, van Geldere D, de Vet HC, Bouter LM. Surgical treatment options for carpal tunnel syndrome. Cochrane Database Syst Rev. 2002;4: CD003905. Sixteen studies were reviewed. Pooling was hampered by the variety of outcome measures used. None of the alternatives to open release were associated with better symptomatic relief in either the short term or the long term. There was conflicting evidence about whether patients managed with endoscopic release were able to return to work earlier than those managed with open release. Tagil M, Kopylov P. Swanson versus APL arthroplasty in the treatment of osteoarthritis of the trapeziometacarpal joint: a prospective and randomized study in 26 patients. J Hand Surg [Br]. 2002;27:452-6. Twenty-six patients with osteoarthritis were randomized to treatment with trapeziectomy and either insertion of a Swanson silicone implant or interposition arthroplasty with use of a strip of the abductor pollicis longus tendon. There was no difference between the two groups in terms of the primary outcome (pinch strength) at four years. However, the group treated with abductor pollicis longus interposition had better motion. In addition, five of the Swanson implants subluxated and all of the patients who had received the Swanson implant had cyst formation consistent with silicone synovitis.
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