Whats New in Hand and Wrist Surgery

Kakar, Sanjeev MD

Journal of Bone & Joint Surgery - American Volume: 15 March 2017 - Volume 99 - Issue 6 - p 531–537
doi: 10.2106/JBJS.16.01328
Specialty Update
Disclosures

1Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota

E-mail address: Kakar.Sanjeev@mayo.edu

Article Outline

This article presents an overview of several of the developments that have taken place within the field of hand and wrist surgery during the past year. Included are clinical studies in the scientific literature as well as some of the papers read at the annual meetings of the American Academy of Orthopaedic Surgeons (AAOS), the American Society for Surgery of the Hand (ASSH), and the American Association for Hand Surgery (AAHS). This update is not intended to be a comprehensive review but rather is intended to highlight areas for thought and consideration given the advancements made within the field.

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Anesthesia

Since the advent of the “wide awake local anesthesia no tourniquet” (WALANT) technique, there has been a steady adoption among hand surgeons. In order to decrease injection-site discomfort, sodium bicarbonate may be added to the lidocaine with epinephrine1. Ceran et al. conducted a prospective study comparing WALANT with and without selective nerve blocks at the wrist (40 patients in each group) to determine whether the combined usage would improve the pain associated with palmar injections and increase patient satisfaction. The wrist blocks consisted of injections to the median, ulnar, and superficial radial nerves, alone or in combination, in the treatment of common hand surgery conditions. The authors noted that the group that received a combination of selective nerve blocks followed by WALANT reported lower pain scores regarding the anesthetic injection. There was no difference between the 2 treatment groups with respect to the intraoperative and postoperative pain and anxiety levels2. Agrawal and colleagues studied the effects of wrist blocks for postoperative pain management after wrist arthroscopy3. Sixty-six patients were randomized in a double-blinded trial in which intra-articular and portal infiltration was compared with wrist block for analgesia after wrist arthroscopy under general anesthesia. The authors noted that both techniques provided pain relief in the first 24 hours postoperatively but that the wrist block was associated with better pain scores during this time frame. Certainly this may be considered an adjunct for patients who undergo wrist arthroscopy without regional anesthesia and negates the risk of chondrotoxicity that patients can experience with intra-articular injections.

What is the optimal anesthesia technique as it relates to pain control after distal radial fracture fixation? Should patients receive general anesthesia or regional anesthesia, and does this have an effect on postoperative pain control? Galos and colleagues studied 36 patients with an acute distal radial fracture (Orthopaedic Trauma Association [OTA] 23A-C) who were randomized to either general anesthesia or brachial plexus blockade. Results showed that patients who received general anesthesia had significantly worse pain scores and spent more time in the recovery area during the immediate postoperative period. After 12 to 24 hours, those who received the brachial plexus blockade had significantly increased “rebound pain” compared with those who had general anesthesia. Given these findings, patients should be educated preoperatively about the risk of rebound pain and about initiating oral pain medication before the regional blockage starts to wear off4.

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Compression Neuropathy

The AAOS recently published its updated clinical practice guidelines on the evaluation and treatment of carpal tunnel syndrome5. The guidelines were formulated by an expert panel after reviewing the highest quality of scientific literature pertaining to carpal tunnel syndrome. Despite varied methodology, the guidelines provide a useful framework in the management of carpal tunnel syndrome. The recommendations were presented on the basis of the strength of evidence: strong, moderate, or limited. I highly recommend all physicians who treat patients with carpal tunnel syndrome become familiar with the guidelines. While it is not the purview of this article to review every supportive statement, the guidelines do provide solid evidence that, when making a diagnosis, thenar atrophy is strongly associated with ruling in carpal tunnel syndrome but poorly associated with ruling it out. Tests of physical signs, such as the Phalen test and the Tinel sign, should not be used alone in the diagnosis. There is strong evidence to suggest that high body mass index and repetitive hand and wrist actions are associated with an increased risk of developing carpal tunnel syndrome. Surgical division of the transverse carpal ligament should relieve symptoms and improve function compared with nonoperative treatment such as the use of a splint, anti-inflammatory medication, therapy, and a single steroid injection. There was also strong evidence to suggest that there is no benefit to routine postoperative immobilization after surgery5.

Steroid injections are commonly used to treat carpal tunnel syndrome, but what is their long-term efficacy in preventing any further surgical treatment? Atroshi and colleagues conducted a randomized trial investigating 2 different doses of methylprednisolone (40 and 80 mg) compared with saline solution control6. One-hundred and eleven patients, without any evidence of thenar atrophy or sensory deficits, received 1 injection only and were followed for up to 5 years. Results showed that, within the ensuing year, 73% of the patients who received 80 mg of methylprednisolone, 81% of those who received 40 mg of methylprednisolone, and 92% of those in the control group underwent carpal tunnel release. Five years after injection, 10 (9%) of the 111 patients had not undergone surgery (6 had received 80 mg of methylprednisolone, 3 had received 40 mg, and 1 was from the control group (p = 0.04).

In performing surgery for cubital tunnel syndrome, ulnar nerve stability is an important factor to consider when deciding between an in situ and a transposition procedure. Can we predict which nerves will become unstable? Matzon et al. reviewed 363 patients who were considered for an in situ ulnar nerve release7. Eight percent were identified with instability preoperatively, whereas 12% were identified intraoperatively following decompression. It was noted that the strongest predictor of instability was younger, male patients. The authors postulated that this may be due to a larger triceps seen within this patient cohort. Given these findings, the authors counsel their patients that approximately 20% who are considered for an in situ release may require a transposition. Alternatively, excision of a portion of the medial head of the triceps may alleviate its destabilizing effect on the ulnar nerve.

After undergoing in situ ulnar nerve decompression, there is a group of patients who may not recover and for whom revision surgery is indicated. Can we predict which patients? Over a 5-year period, Gaspar and colleagues performed 216 in situ ulnar nerve decompressions for idiopathic cubital tunnel syndrome8. The revision rate was 3%, and the single most important predictor of revision surgery was an age of <50 years. Factors such as sex, diabetes, smoking status, Workers’ Compensation, the McGowan grade, and symptom type were not predictive of revision surgery.

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Wrist

With the advent of “big data,” systematic reviews, and meta-analyses, can the findings guide us in the management of distal radial fractures? Walenkamp and colleagues conducted a systematic review and meta-analysis of 27 studies including 7,574 patients to determine which factors can predict fracture stability9. The authors noted that an age of >60 years, female sex, dorsal comminution, loss of radial inclination, the presence of a volar hook, and AO fracture types IIIA, IIIB, and IIIC were predictors of secondary displacement. Interestingly, the presence of an intra-articular fracture, a distal ulnar fracture, and dorsal angulation of >15° from neutral were not associated with an increased risk of fracture displacement. An important caveat to this study, however, is the definition of “secondary displacement,” which varied in the literature and ranged from a change of 5° to absolute dorsal angulation of 10° or 15° from neutral.

If a distal radial fracture is displaced, it is common practice to attempt a closed reduction. Sometimes the reduction is not adequate, and so should one proceed with a second attempt? Sherman and colleagues reviewed the radiographs of 94 patients with distal radial fractures who underwent 2 closed reduction procedures within the emergency room10. The second reduction attempt improved the mean radial height by 1.1 mm (p = 0.01) and mean volar tilt by 4.2° (p = 0.01) but also increased the mean dorsal comminution length by 1.6 mm (p < 0.01). Eighty-two percent of the patients were deemed surgical candidates after the first reduction, and this did not change after the second reduction. Only 4% of patients who underwent 2 reduction attempts healed in an acceptable alignment and did not require surgery. Given these findings, it was concluded that a second reduction should be avoided.

If the fracture is displaced, should one proceed with operative or nonoperative treatment, especially for elderly patients? Chen et al. conducted a systematic review and meta-analysis to assess the outcomes of 858 patients aged ≥60 years who were treated with or without surgery11. Results demonstrated that grip strength and restoration of radiographic parameters including volar tilt, radial inclination, and ulnar variance as well as the rates of complications requiring surgery were significantly greater for the patients treated operatively than for those treated nonoperatively. The complications were primarily hardware-related, with the most common being symptomatic tendon rupture affecting the extensor pollicis longus. One needs to take these results into account in the context of a patient’s physiologic function, as this can vary, irrespective of age.

If surgery is being considered for the treatment of a distal radial fracture, how should this be done? In a prospective study by Mellstrand Navarro et al., patients aged 50 to 74 years who presented with a dorsally displaced distal radial fracture were randomized to fixation with a volar locking plate or external fixation with supplemental Kirschner wires12. At 6 weeks postoperatively, the patients in the external-fixation group had lower EuroQol-5D scores, but the difference was no longer significant at 3 months. By 3 and 12 months, there were no significant differences between the patient cohorts in terms of Disabilities of the Arm, Shoulder and Hand (DASH) and Patient-Rated Wrist Evaluation (PRWE) scores. Radiographic parameters were better in the volar locking-plate group, and overall range of motion was similar between the 2 groups at 1 year. There was no difference between the groups in terms of total complication rates.

If deciding to proceed with a volar locking plate, one needs to be cognizant of the course of the palmar cutaneous branch of the median nerve (PCBMN) to prevent iatrogenic injury. Jones and colleagues conducted an observational study of 182 volar plates that were applied and noted a 5.5% rate of anomalous anatomy of the PCBMN13. This ranged from the nerve piercing the radial flexor carpi radialis sheath proximally beneath the tendon and traveling distally on the ulnar side, staying within the ulnar or central aspect of the sheath, or splitting into 2 distal branches from radial to ulnar.

Ulnar wrist pain can be a frustrating condition to treat and is commonly considered to be the “low back pain” analog of the wrist. Oftentimes, despite a successful procedure, patients continue to have pain and functional impairment. Given this, the “four-leaf clover” treatment algorithm was proposed as a practical guide to the management of disorders of the distal radioulnar joint14. The framework is based on asking 4 key questions. Is there an osseous deformity? Is there any cartilage damage? Is there a triangular fibrocartilage complex injury? Is there an unstable extensor carpi ulnaris tendon? The answers to these questions guide the practitioner to the treatment plan. It is important to realize that these 4 pathologies are not mutually exclusive and that a patient may have 1 or all of these associated local pathologies. Given this, the algorithm is a tool that acts as a checkpoint to ensure that all different components are considered/addressed to improve the management of ulnar wrist pain.

An ulnar shortening osteotomy can be an excellent procedure to treat ulnar impaction. How much of the ulna should be excised, and should the ulna be shortened to neutral or ulnar-negative variance? In a study by Ferreira and colleagues, 134 consecutive patients underwent a limited step-cut ulnar shortening osteotomy for the treatment of ulnar impaction syndrome15. Union was achieved at a mean time of 8.2 weeks (range, 5 to 18 weeks) in 98.8% of the patients. The modified Mayo wrist score improved from 47.3 preoperatively to 88.8 postoperatively. The mean postoperative distal ulnar variance was 0.2 mm (range, −1 to 1.15 mm), and asymptomatic degenerative changes of the distal radioulnar joint were seen in 5.5% of the patients at a mean follow-up of 62.4 months. The authors concluded that limiting the amount of shortening to 2 to 3 mm appears to lower the rate of distal radioulnar joint degenerative changes.

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Thumb and Digit Arthritis

In the management of basilar thumb joint arthritis, should one consider trapezial-preserving or trapezial-sacrificing procedures if the scaphotrapeziotrapezoid (STT) joint is not involved? In a prospective study by Spekreijse et al., women >40 years of age with primary symptomatic osteoarthritis of the thumb carpometacarpal (CMC) joint (stage 2 or 3 by the Eaton and Glickel classification)16 were randomized to trapeziectomy and suspension arthroplasty or CMC joint arthrodesis17. Seventeen patients were treated with arthrodesis and 21 patients, with trapeziectomy and suspension arthroplasty. The study was prematurely stopped because of the increased complications within the arthrodesis group. After a mean follow-up of 5.3 years (range, 3.9 to 26.3 years), patients who had had a trapeziectomy and suspension arthroplasty had significantly better pain reduction and function, which continued to improve after 1 year postoperatively. Within each treatment group, 1 patient required reoperation secondary to STT joint degeneration.

After trapeziectomy and suspension arthroplasty, should the thumb be immobilized? In a study by Jain et al., 27 patients who underwent trapeziectomy with ligament reconstruction and tendon interposition were randomized to the use of an accelerated rehabilitation program starting at 2 weeks postoperatively or a thumb spica cast or a splint for a total of 6 weeks postoperatively18. After 3 months, there were no significant differences between the 2 cohorts regarding postoperative DASH and pain scores, range of motion, or pinch or grip strength.

In the management of metacarpophalangeal (MCP) joint arthritis, is there a long-term advantage of surgical intervention? Seventy-seven patients with rheumatoid arthritis were treated with MCP joint arthroplasty using silicone implants (25 patients) or nonsilicone implants (52 patients) and were followed for up to 7 years19. Compared with patients treated nonoperatively, those who had undergone MCP joint arthroplasty had improved postoperative Michigan Hand Questionnaire scores and function, cosmesis, and satisfaction domains. Patients with a silicone MCP joint arthroplasty implant had significantly better long-term measurements for ulnar drift, extensor lag, and MCP joint arc of motion compared with those with a nonsilicone implant. There was no significant difference in terms of grip or pinch strength between the implant groups.

Dickson and colleagues reported on 51 pyrocarbon MCP joint arthroplasties in the management of noninflammatory arthritis with an average follow-up of 8.5 years (range, 5 to 14.3 years)20. The average arc of motion was 54° (range, 20° to 80°) and the average QuickDASH score was 29 (range, 0 to 57). There was no difference in grip strength between the operative and contralateral hands. The implant survival rate was 88% at 10 years. There was a 20% complication rate, and all revisions occurred within the first 18 months after surgery. The most common reasons for revision were joint instability and implant loosening.

The index finger is unique given the large lateral and axial joint forces during pinch. Given this, when dealing with proximal interphalangeal (PIP) joint osteoarthritis, should one proceed with joint replacement rather than arthrodesis? Vitale and colleagues studied the outcomes of 79 index finger PIP joints that were treated with either arthroplasty (65) or arthrodesis (14) and had a median of 67 months follow-up21. Despite a loss of PIP joint motion seen within the arthrodesis cohort, there were no differences between the 2 treatment groups in pain relief, satisfaction, or Michigan Hand Questionnaire scores. Of note, patients undergoing arthroplasty had a much higher complication rate (hazard ratio of 4.3) compared with those undergoing a fusion. Given these findings, the decision to perform arthroplasty for PIP joint osteoarthritis of the index finger should be carefully considered.

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Dupuytren Disease

Three types of treatment tend to form the mainstay of Dupuytren disease management, namely collagenase clostridium histolyticum (CCH) injections, needle aponeurotomy or fasciotomy, and palmar fasciectomy. Gaston and colleagues conducted a multicenter open-label, Phase-3b study investigating the efficacy and safety of the concurrent administration of 2 CCH injections (XIAFLEX; Auxilium Pharmaceuticals) to treat 2 joints in the same hand in 714 patients (724 joint pairs)22. The authors noted clinical success in 65% of MCP joints and 29% of PIP joints. The rate of skin tears was 22%, with most adverse effects being swelling of the extremity, bruising, and pain. The mean total range of motion increased from 90° to 156° and, at day 31, the mean total fixed-flexion contractures (sum of 2 treated joints) decreased 74%, from 98° to 27°. Given its efficacy in treating Dupuytren cords, can CCH injections be used to treat Dupuytren nodules? Seventy-six patients with at least 1 palpable palmar nodule were randomized to a single injection of CCH or placebo. Eighty-three percent of the patients who received 0.60 mg of CCH and 89% who received 0.40 mg of CCH were very satisfied with their treatment and had a reduction in surface area, volume, and softening of the treated nodule23.

Given the equivalent outcomes, what is the benefit of 1 treatment over another? Brazzelli et al. reviewed the results of randomized controlled trials, nonrandomized comparative studies, and observational studies involving collagenase and surgical interventions24. In total, 7,657 patients were included. Patients treated with CCH compared with placebo experienced significant reduction in contracture and increased range of motion at the expense of more mild and moderate adverse events. Results of the de novo academic analysis revealed that needle fasciotomy was the lowest-cost treatment option, whereas limited fasciectomy generated the greatest QALY (quality-adjusted life-year) gains. Compared with limited fasciectomy, collagenase was more expensive and generated fewer QALYs. The largest limitation of this study was the paucity of data in studies randomizing patients to CCH versus needle fasciotomy versus limited fasciectomy.

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Quality

As we continue to experience rapid changes within the health-care environment, the terms quality and value have gained increasing importance. Efforts by our national organizations are geared toward promoting the delivery of cost-efficient, high-quality care. What does this mean for hand and wrist surgery? Do we have sufficient quality measures to provide meaningful data on the conditions we treat? In order to meet these deliverables, we may need to change our practice to embrace a culture of quality improvement, balance patient-centered care with efficient use of resources, and develop and promote quality measures. To this end, the ASSH developed the Hand Surgery Quality Consortium to try and help with this process25. Kamal conducted a modified RAND/UCLA Delphi consensus process on 134 quality measures through a systematic review that pertained to disorders of the upper extremity. Consensus was achieved for only 43% of the measures that were deemed important for care, and 86% were rated as feasible to complete. The study concluded that only 25% of current upper-limb quality measures were important, feasible to complete, and suitable for upper-limb surgeon accountability26.

An important component of providing quality care is to define and measure patient satisfaction27. This can be a multifactorial process for which there is no easy answer. Parrish et al. studied 112 consecutive new patients to determine whether patient perception of the time spent with the hand surgeon equated with their satisfaction28. Results showed that patient satisfaction was directly related to surgeon empathy and symptoms of depression and was not linked to visit duration or pre-visit expectations.

There are a myriad of different patient-reported outcome tools for the upper extremity. Which one should be used and for which conditions? Barker et al. studied 4 scoring systems, visual numerical scales, and objective measurements among 116 patients who underwent volar locking-plate fixation for distal radial fractures29. The patient-reported outcome measures that were used included the PRWE and the QuickDASH. The composite system used involved the Gartland and Werley score and the Green and O’Brien score. Results showed that after 6 months, the subjective scoring systems correlated well with each other and with both visual and numerical scores for pain and function. The composite scores and patient-rated outcome measures, however, poorly correlated with the subjective scores. Waljee and colleagues have proposed a unified approach to outcomes assessment for distal radial fractures30. The authors recommended a systematic approach to capture outcomes across 5 domains, namely, range of motion and grip strength, patient-reported outcomes to assess disability and function, complications, pain, and radiographs31. Notwithstanding these parameters, measures of self-efficacy, catastrophic thinking, heightened illness concern, and symptoms of depression may be important, too.

Many of the patient-reported outcome measures involve a barrage of questions that patients find time-consuming and overwhelming. Can we streamline this process in an accurate and reproducible way? The U.S. National Institutes of Health have developed the Patient-Reported Outcomes Measurement Information System (PROMIS), which uses probability-based algorithms to assess patient-reported outcomes. For the upper extremity, there are 2 forms of computerized adaptive tests (CATs): the physical function CAT, which includes questions regarding both the upper and lower extremities, and the upper-extremity CAT, which pertains only to the upper extremity. In order to test the latter’s suitability to the upper extremity, Beckmann and colleagues assessed these 2 forms of CAT compared with the DASH among 379 patients within the hand clinic32. Results demonstrated that the CAT required fewer questions to complete than the DASH, yet maintained excellent personal reliability and item reliability. The upper-extremity CAT compared favorably with the physical function CAT and DASH and warrants further investigation to ensure that its large ceiling effect could be improved.

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Evidence-Based Orthopaedics

The editorial staff of The Journal reviewed a large number of recently published research studies related to the musculoskeletal system that received a higher Level of Evidence grade. In addition to articles cited already in the Update, 10 other articles with a higher Level of Evidence grade were identified that were relevant to hand and wrist 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 guide your further reading, in an evidence-based fashion, in this subspecialty area.

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Evidence-Based Articles Related to Hand and Wrist Surgery

Johnson SP, Chung KC, Zhong L, Shauver MJ, Engelsbe MJ, Brummett C, Waljee JF. Risk of prolonged opioid use among opioid-naïve patients following common hand surgery procedures. J Hand Surg Am. 2016 Sep 7;41:947-57. Epub 2016 Sep 7.

This study evaluated prolonged opioid use among narcotic-naïve patients undergoing common hand surgery procedures in the United States. On the basis of an insurance agency’s claims database between 2010 and 2012, the authors found that 13% of the patients continued to fill their opioid prescriptions 90 days after surgery. Elective surgery, younger age, female sex, lower income, comprehensive insurance, higher Elixhauser Comorbidity Index, mental health disorders, and status as a smoker were associated with prolonged narcotic use. This study highlights the importance of trying to take preventive measures to curb this national epidemic that exists regarding opioid abuse.

Witherow EJ, Peiris CL. Custom made finger orthoses have fewer skin complications than prefabricated finger orthoses in the management of mallet injury: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2015 Oct;96(10):1913-23.e1. Epub 2015 Jul 9.

The nonoperative treatment of mallet injuries involves the use of extension splints. Should these be prefabricated off-the-shelf or custom-made orthoses? Seven studies encompassing 491 patients were included in this analysis and demonstrated that prefabricated splints were associated with a 7-times increased risk of skin complications compared with custom-made thermoplastic orthoses. Treatment outcomes were otherwise similar between the 2 types of splints.

Cousins GR, Gill SL, Tinning CG, Johnson SM, Rickhuss PK. Arm versus forearm tourniquet for carpal tunnel decompression - which is better? A randomized controlled trial. J Hand Surg Eur Vol. 2015 Nov;40(9):961-5. Epub 2015 Jan 14.

One hundred patients undergoing carpal tunnel release were randomized to treatment with use of either a forearm or arm tourniquet. All procedures were performed under local anesthesia. Blood pressure measurement, heart rate, and pain scores as well as the extent of a bloodless field during surgery were recorded during the study. Results showed no difference in terms of patient subjective and objective outcomes and that the type of tourniquet used should be based on surgeon discretion.

Metcalfe D, Aquilina AL, Hedley HM. Prophylactic antibiotics in open distal phalanx fractures: systematic review and meta-analysis. J Hand Surg Eur Vol. 2016 May;41(4):423-30. Epub 2015 Sep 1.

Most distal phalangeal fractures do not require operative treatment and are often treated in the emergency room. Should these patients be placed on routine antibiotics at the time of injury? Metcalfe and colleagues conducted a meta-analysis of 353 open distal phalangeal fractures to determine whether there was a difference in superficial infection rates among patients treated with or without antibiotics. The findings of this study failed to support the routine use of antibiotics, as there were no recorded cases of osteomyelitis or difference in superficial infections following open distal phalangeal fractures that were not grossly contaminated and that underwent prompt and effective wound irrigation and debridement.

Rodrigues JN, Becker GW, Ball C, Zhang W, Giele H, Hobby J, Pratt AL, Davis T. Surgery for Dupuytren’s contracture of the fingers. Cochrane Database Syst Rev. 2015 Dec 9;12:CD010143.

This study examined the outcomes of patients in randomized and controlled clinical trials of surgery for Dupuytren disease of the digits (excluding the thumb) versus control or other interventions. At 5 weeks after treatment, those who had a needle fasciotomy had a 5-point lower DASH score compared with patients who had a fasciectomy. Fasciectomy improved contractures more effectively in severe disease. In long-term follow-up of 5 years after treatment, patient satisfaction was higher and the recurrence rate was lower in the fasciectomy group compared with the needle fasciotomy cohorts. The use of a skin graft did not improve outcomes more than fasciectomy alone.

Wang J, Zhang L, Ma J, Yang Y, Jia H, Ma X. Is intramedullary nailing better than the use of volar locking plates for fractures of the distal radius? A meta-analysis of randomized controlled trials. J Hand Surg Eur Vol. 2016 Jun;41(5):543-52. Epub 2016 Feb 8.

How do intramedullary nails fare in the management of distal radial fractures? Wang et al. conducted a meta-analysis of randomized controlled trials comparing intramedullary nailing with volar locking-plate fixation for the treatment of extra-articular distal radial fractures. In total, there were 5 randomized controlled trials encompassing 369 patients; 188 fractures were treated with use of an intramedullary nail and 181 fractures, with a volar locking plate. Results demonstrated no significant differences between the 2 groups regarding functional outcome scores, radiographic parameters, range of motion, grip strength, and total complication rates. It was noted that both fixation methods achieved equal clinical and functional outcomes, with a slightly higher rate of carpal tunnel syndrome seen in patients who underwent volar locking-plate fixation.

Strömberg J, Ibsen-Sörensen A, Fridén J. Comparison of treatment outcome after collagenase and needle fasciotomy for Dupuytren contracture: a randomized, single-blinded clinical trial with a 1-year follow-up. J Hand Surg Am. 2016 Sep;41(9):873-80. Epub 2016 Jul 27.

Strömberg and colleagues prospectively randomized 69 patients to CCH and 71 to needle fasciotomy for the treatment of an MCP joint contracture of ≥20° in a single finger. There was no difference in short-term results, and after 1 year, 90% of the patients in both groups had full extension of the treated MCP joint, with no differences between the groups in functional outcome or pain scores.

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Additional Studies of Interest

Tham S, Chan S, Harvey J, Sikora SS. SLAC 2 wrist: a randomized controlled trial of 4 corner fusion and radioscapholunate fusion. Read at the American Society for Surgery of the Hand Annual Meeting; 2016 Sep 29-Oct 1; Austin, TX. Paper no. 59.

In the surgical management of scapholunate advanced collapse (SLAC) wrist arthritis, should one proceed with a radioscapholunate (RSL) fusion or a scaphoid excision and 4-corner fusion? Tham and colleagues randomized 12 patients (13 wrists) to these treatments and found that those who underwent RSL fusion to preserve mid-carpal motion had higher rates of complications and conversion to total wrist fusion than those treated with a scaphoid excision and 4-corner fusion. In addition, RSL fusion patients had a lower range of motion and PRWE scores 1 year postoperatively.

Rivlin M, Kachooei A, Wang M, Ilyas A. Electrodiagnostic severity in carpal tunnel release outcomes: a prospective analysis. Read at the American Society for Surgery of the Hand Annual Meeting; 2016 Sep 29-Oct 1; Austin, TX. Paper no. 26.

Does the severity of findings on electromyography (EMG) testing act as a suitable prognostic indicator following carpal tunnel release? Rivlin et al. prospectively followed patients after carpal tunnel release (20 patients with mild, 126 with moderate, and 110 with severe median nerve compression) and noted that functional outcomes improved at 3 months after surgery regardless of the severity of EMG findings. The degree of improvement was not significantly different between the groups with differing levels of compression.

Gao LL, Lin I. Cost utility analysis of clinic-based hand therapy versus home therapy after distal radius fracture. Read at the American Association for Hand Surgery Annual Meeting; 2016 Jan 13-16; Scottsdale, AZ. Paper no. 17.

After surgery, what is the appropriate course of therapy for patients? Gao and Lin developed a decision-tree model that factored in cost, QALYs, health-state probabilities, and incremental cost-effectiveness ratio comparing a home exercise program with clinic-based therapy. They noted that the total cost of a home exercise program was $1,016.09 (USD) compared with $1,796.43 for a clinic-based therapy program and advocate, on the basis of cost, occupational therapy referral for patients who are not achieving the desired functional recovery.

Investigation performed at the Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota

Specialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.

Disclosure: The author received a stipend for this work from JBJS. On the Disclosure of Potential Conflicts of Interest form, which is provided with the online version of the article, the author checked “yes” to indicate that he had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/A156).

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References

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6. Atroshi I, Hofer M, Ranstam J. Randomized controlled trial of local steroid injection in carpal tunnel syndrome: 5 years follow-up. Read at the American Society for Surgery of the Hand Annual Meeting; 2016 Sep 29-Oct 1; Austin, TX. Paper no. 76.
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12. Mellstrand Navarro C, Ahrengart L, Törnqvist H, Ponzer S. Volar locking plate or external fixation with optional addition of K-wires for dorsally displaced distal radius fractures: a randomized controlled study. J Orthop Trauma. 2016 ;30(4):217–24.
13. Jones C, Beredjiklian P, Matzon JL, Kim N, Lutsky K. Incidence of an anomalous course of the palmar cutaneous branch of the median nerve during volar plate fixation to distal radius fractures. J Hand Surg Am. 2016 ;41(8):841–4. Epub 2016 Jun 14.
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