This update reviews material presented at the 2010 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 this journal) between August 2009 and July 2010. 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-continuing medical education (non-CME) credit, industry-sponsored workshops in facilities adjacent to the accredited scientific meeting. In addition, both hand surgery organizations feature presentations on shoulder and elbow surgery and general microsurgery that are beyond the scope of this review.
Meeting abstracts for the American Society for Surgery of the Hand and American Academy of Orthopaedic Surgeons annual meetings are maintained online at www.assh.org and www.aaos.org, respectively.
Are prophylactic antibiotics useful in clean, elective hand surgery cases? Maybe not. A study presented to the ASSH reviewed the results of over 8000 clean, elective hand surgical cases done in an outpatient surgical center. One-third of the patients had been given preoperative prophylactic antibiotics. Postoperatively, the overall wound infection rate was 0.35%. The rate was not significantly different between the patients who received antibiotics and those who did not. Although antibiotic use was not randomized, the two groups did not differ significantly in terms of age, sex, smoking history, or the presence of comorbid conditions such as diabetes. While smoking, the duration of the procedure, and diabetes all were positively associated with an increased risk of infection, the use of preoperative antibiotics did not reduce these risks. The authors concluded that, in clean, elective outpatient hand surgery cases, prophylactic antibiotics were of limited value. A recent report on postoperative infection in >3000 patients who were managed with carpal tunnel surgery demonstrated very similar results, with an overall wound infection rate of 0.36% and no difference in the infection rate between patients managed with and without prophylactic antibiotics1.
Magnetic resonance imaging (MRI) is often recommended to diagnose scaphoid fractures, and a recent meta-analysis demonstrated that MRI was the most sensitive and specific modality available to diagnose scaphoid fractures2. However, the sensitivity and specificity of this technology were assessed in a different way in a study that was presented to the ASSH. Instead of simply assessing patients who had been referred for the suspicion of a scaphoid fracture, the investigators performed bilateral MRI of the wrist for thirty-two normal volunteers and mixed those sixty-four MRI scans with those of sixty patients who had normal radiographs but were suspected of having a scaphoid fracture. The 124 sets of images were then blindly reviewed by five radiologists. Thirteen “fractures” were diagnosed among the sixty-four normal MRI scans. Interobserver correlation was only moderate. The authors concluded that MRI was an unreliable standard, with a notable risk of false-positive results. This study calls into question the conventional wisdom that MRI is a sensitive and specific tool for use in the diagnosis of occult scaphoid fractures. Hand surgeons should consider the results of this study when assessing scaphoid images with MRI. While the risks of overtreatment of a false-positive reading with immobilization are relatively low, the costs in terms of repeat imaging as well as treatment are substantial. A single unpublished study does not automatically overturn a body of published literature, and we must await validation of these results by other authors and publication of the work in a peer-reviewed journal.
Distal Radial Fractures
Do initially undisplaced radial fractures later displace? This question was addressed in a study that was presented to the ASSH. A total of 116 initially undisplaced distal radial fractures were reviewed; none subsequently displaced. The authors concluded that initially undisplaced radial fractures can be treated with symptomatic protection and that close radiographic follow-up is unlikely to be necessary.
Whether to treat or not to treat ulnar styloid fractures is an enduring controversy among hand surgeons. In a study that was presented to the ASSH, 320 patients with distal radial fractures were reviewed. Patients with ulnar styloid fractures had significantly more residual pain at the time of the latest follow-up (p < 0.05). This was true whether or not the styloid fracture had healed. The patients with fractures at the base of the ulnar styloid had the most pain at the time of the latest follow-up. The authors concluded that ulnar styloid fracture, especially fracture of the styloid base, is a marker of a more severe injury and a predictor of more postfracture symptoms but that union of the fracture does not improve outcome. The authors of a recent report on a smaller series of thirty-six patients came to a similar conclusion3. A second study involving 144 patients with distal radial fractures, eighty-eight of whom had ulnar styloid fractures, also demonstrated no difference in patient-reported outcomes on the basis of ulnar fracture location, size, displacement, or union4.
If ulnar styloid fracture union does not predict patient outcomes, what does? A recent study evaluated predictors of patient satisfaction in 125 patients with distal radial fractures and demonstrated that patients were more likely to be satisfied if they had recovered at least 65% of normal grip strength and 95% of normal motion5. The authors noted that the patient's expectations regarding motion (95% of the normal arc) were far in excess of what is considered a “functional” range of motion, i.e., the motion needed to perform most activities of daily living, which is closer to 50% of the normal arc. Hand surgeons should be aware that patient expectations for motion exceed this functional benchmark and should address these expectations early.
While the results of finger flexor tendon repair certainly have improved over the years, rupture of the repaired tendon remains a concern, particularly with postoperative active motion rehabilitation protocols. A recent study that was presented to the AAHS suggested a way around this problem. A series of eighteen patients with thirty-four affected digits were managed postoperatively with the injection of botulinum toxin into the forearm flexor muscles to weaken the force of active motion. Their results were then compared with those for a previous cohort of fifty-three patients with 104 repaired digits in which botulinum toxin was not used. At the time of the latest follow-up, eighteen months after the injury, the total active motion (metacarpophalangeal plus interphalangeal arcs) in the botulinum toxin-treated fingers was 244°, with 94% excellent and 6% good results. There were no ruptures, and no tenolyses were necessary. In contrast, the control tendons had a 14% rate of fair and poor results. Botulinum toxin chemoprotection may have a role in postoperative treatment following flexor tendon surgery, particularly in cases in which postoperative compliance may be a concern.
Septic arthritis can be a devastating problem in the hand. A series of 118 infected finger joints that were treated over a thirty-year period was presented to the ASSH. The study showed that 15% of patients ultimately required arthrodesis and 12% ultimately required amputation. Older and immunosuppressed patients and those with polymicrobial infections had higher risks of these complications. Early and aggressive treatment, including debridement and intravenous antibiotics, was associated with better outcomes.
2010 was the centennial of the publication of the paper in which Robert Kienböck first described the condition that now bears his name6. Kienböck hypothesized that the condition was the result of a combination of injury and avascularity, which continues to be the most commonly accepted theory. It is unclear which comes first, whether it is necessary that both occur together, or whether repeated traumatic episodes are necessary to create the characteristic eventual findings of lunate sclerosis, fragmentation, and collapse. The roles of systemic factors and local anatomy also remain unclear. All of these issues were discussed at a centennial symposium, held in Kienböck's home town of Vienna, Austria, in May 20107. Recent publications have also reviewed the results of treatment. The authors of a literature review concluded that there was little evidence of publication bias8 in the literature on Kienböck disease; both successful and unsuccessful treatments appeared to be presented in proportions similar to those in a review of meeting abstracts. Other studies have emphasized the excellent results when Kienböck disease occurs in adolescents, regardless of whether the treatment is complex, is associated with complications9, or is as simple as immobilization10.
The most common location for surgically treated arthritis in the hand is at the base of the thumb. Numerous studies have confirmed simple trapeziectomy as the standard procedure; adjuncts such as interposition and stabilization by various means seem to do little to improve the long-term results and may result in a greater number of complications related to the greater complexity of the adjunctive procedures. Now, hand surgeons are studying minimally invasive trapeziectomy and partial trapeziectomy and are reporting similar results to those obtained with open surgery. In a recent series, twenty-three patients were managed with arthroscopic hemitrapeziectomy without interposition and were followed for a minimum of four years11. DASH (Disabilities of the Arm, Shoulder and Hand) scores, strength, motion, and satisfaction were similar to those reported historically for patients managed with open trapeziectomy. The operative time in that series averaged twenty-eight minutes.
For less severe arthritis at the base of the thumb, a dorsal closing-wedge osteotomy of the metacarpal is sometimes performed, but the results may be unpredictable. A large series that was presented to the AAHS suggested that the addition of a thorough debridement of palmar and volar osteophytes from the base of the thumb metacarpal may improve the predictability of this procedure. In a series of 125 patients who were managed in this way, 110 patients were followed for a minimum of forty-five months. All patients had satisfactory motion, no patient had moderate or severe pain, and pinch strength averaged 6 kg (88% of that on the contralateral, unaffected side). This procedure may be particularly useful for younger patients, with trapeziectomy being held in reserve for later disease progression.
The lack of benefit from procedures performed in addition to trapeziectomy was demonstrated in a study that was presented to the AAHS in which eighteen patients who had trapeziectomy were compared with eighteen patients who had trapeziectomy and insertion of a Pi2 pyrolytic carbon implant (Tornier, Edina, Minnesota). DASH scores, pain relief, and satisfaction were all better in the trapeziectomy-only group.
A study that was presented to the AAOS evaluated the results of wrist arthroplasty in twenty-three patients who were followed for five to ten years. Twenty patients had rheumatoid arthritis. At the time of the latest follow-up, the mean arc of flexion-extension motion was 64° and the mean DASH score had improved from 58 to 35 points. (The DASH is a disability scale, with a lower score representing a better outcome.) However, nine of the twenty implants in the patients with rheumatoid arthritis required revision, and two more were loose. All of these complications involved the carpal component; the radial component remained well fixed. The authors concluded that good outcomes were possible following total wrist arthroplasty but that carpal component fixation remained a substantial problem in patients with rheumatoid arthritis.
A study that was presented to the ASSH reviewed the results of thirty-one pyrolytic carbon arthroplasties of the proximal interphalangeal joint after an average duration of follow-up of five years (minimum, two years). The authors concluded that the operation is “not all it's cracked up to be.” The motion at the time of the latest follow-up was only half of the preoperative value, there were thirty-four complications in the thirty-one fingers, and six fingers required reoperation within the follow-up period. Half of the implants were loose at the time of the latest follow-up. At the AAHS meeting, a different group of authors presented similar results in a study in which the results of 164 arthroplasties of the proximal interphalangeal joint were evaluated after a mean duration of follow-up of two years. The second study also demonstrated a steady loss of motion with increasing follow-up. Despite the much shorter duration of follow-up in the second study, one-third of the fingers in that series also required additional surgery of some sort; 17% of the implants were revised during the follow-up period.
Another study that was presented to the ASSH evaluated the long-term results of distal radioulnar joint arthroplasty with an ulnar head endoprosthesis. Ninety-five patients were followed for two to ten years. While pain decreased over time, only half of the implants were still in place after nine years of follow-up; the five-year implant survival rate was 78%. It is clear that hand surgery has a long way to go yet before achieving implant survival rates comparable with those that are expected after hip or knee arthroplasty.
What is the natural history of carpal tunnel syndrome? It is unlikely that hand surgeons will ever randomly assign patients to either surgery or no treatment or that many patients would agree to participate in such a study if offered. However, occasional “natural experiments” occur when patients, for various reasons, refuse a recommendation of surgery. A report that was presented to the ASSH described such a natural experiment, in which twenty-four of 800 patients who had been advised to have surgery chose not to proceed. These twenty-four patients were then matched, according to age, sex, and symptom severity, with patients who did have surgery. Both groups were reviewed for residual symptoms at an average of six years after the initial presentation. Interestingly, both groups had improvement (p < 0.05), with about a 20% reduction in the Levine-Katz symptom score in the patients who chose no treatment, compared with a 40% improvement in the patients who chose surgical treatment. The authors concluded that a conservative approach may sometimes be warranted for patients with milder symptoms and that the risk of symptomatic progression appears to be low.
Two years ago in this review, I discussed a report, presented to the ASSH, that documented extremely high pressures within the carpal tunnel in patients with carpal tunnel syndrome that could exceed 1000 mm Hg with certain activity/wrist position combinations. That work has now been published12 and should serve as a useful reference for hand surgeons.
The etiology of Dupuytren disease is unknown. A report that was presented to the AAHS suggested that Dupuytren disease may be a disorder that is caused not by local fibroblasts gone awry but rather by circulating bone marrow-derived fibroblast precursors. Such cells have been shown to be important in the development of pulmonary fibrosis and keloid scars, arriving from the marrow via the bloodstream in response to local elevations in stromal-derived factor-1 (SDF-1). In a study of five patients with Dupuytren disease and twelve controls, the concentration of circulating fibrocytes was ten times higher, and circulating SDF-1 was sevenfold greater, in the patients with Dupuytren disease. Both differences were significant (p < 0.05). On the basis of those data, the authors plan to look for elevated levels of SDF-1 in early Dupuytren nodules. If it is present, then it may be possible to treat Dupuytren disease medically by blocking SDF-1 locally.
After many years of clinical trials, clostridial collagenase (Xiaflex; Auxilium, Malvern, Pennsylvania) was finally released for clinical use for the treatment of Dupuytren contracture in 2010. While it is too soon to know the ultimate place for this new treatment for this old disease, the early results are promising, at least for patients with metacarpophalangeal joint contractures13. In a group of six patients who were followed for eight years, four had recurrences, but the average contracture was 23° at the time of the latest follow-up, compared with 57° prior to collagenase injection. The results for the two patients with proximal interphalangeal joint contractures who were followed for eight years were less satisfying. While the initial average contracture of 45° had improved to just 15° at one year, it had worsened to 60° by eight years.
One concern about the new collagenase treatment is its cost. A study that was presented to the ASSH evaluated the comparative effectiveness of three common treatments for Dupuytren contracture: open fasciectomy, collagenase injection, and another newer treatment, percutaneous needle fasciotomy. A survey was administered to fifty patients to determine the values that they placed on the various outcomes and complications of treatment of Dupuytren contracture. On the basis of the available Medicare cost data for the two surgical procedures and the market cost of the new drug, the authors estimated that open surgery was the least cost-effective, with a cost of more than $800,000 per quality-adjusted life year (QALY) gained. Needle fasciotomy was the most cost-effective, at just under $100,000 per QALY, whereas the injection procedure, at the current cost of $5400 per injection, was intermediate at $166,000 per QALY. However, none of the procedures met the authors' definition of cost-effectiveness, which they had set, on the basis of commonly accepted thresholds, at $50,000 per QALY.
Residency and Board Certification in Hand Surgery
Currently, hand surgery training consists of a one-year fellowship following primary specialty training in orthopaedic surgery, plastic surgery, or general surgery. Diplomates of any of those three primary Boards who have completed an approved hand surgery fellowship may then apply for a certificate of added qualifications in hand surgery. The 2010 ASSH Presidential Address raised the question of whether the growth of hand surgery as a specialty is now sufficient to justify a separate and independent Board of Hand Surgery, with approved residency training in hand surgery that would not require passing through one of the three current primary specialties. It is likely that this topic will receive more attention in the future.
The sixty-sixth Annual Meeting of the American Society for Surgery of the Hand will be held in Las Vegas, Nevada, from September 8 to 10, 2011. The ASSH will also offer a General Orthopaedic Review, cosponsored by the AAOS, in Chicago, Illinois, on July 14, 2011; a Comprehensive Review in Hand and Upper Extremity, in Chicago, Illinois, from July 15 to 17, 2011; and a Master Skills Course in Arthroplasties of the Hand, Wrist and Elbow, in Rosemont, Illinois, from November 4 to 5, 2011.
The forty-second Annual Meeting of the American Association for Hand Surgery will be held in Las Vegas, Nevada, from January 11 to 14, 2012. The annual meetings of the American Association for Hand Surgery are always held in combination with the annual meetings of the American Society for Reconstructive Microsurgery and the American Society for Peripheral Nerve.
All of the above meetings are open to all interested parties. Further details will be forthcoming on the society web sites, listed below. The annual meetings of both the American Society for Surgery of the Hand and the American Association for Hand Surgery accept free papers and also feature a wide variety of instructional courses and symposia, many 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 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:
6300 North River Road, Suite 600
Rosemont, IL 60018-4256
Phone: (847) 384-8300
American Association for Hand Surgery:
444 East Algonquin Road
Arlington Heights, IL 60005
Phone: (312) 236-3307
Over the past year, the editorial staff of The Journal reviewed a large number of recently published research studies related to the musculoskeletal system that received a Level of Evidence grade of I. Over 100 medical journals were reviewed to identify these articles, which all have high-quality study design. In addition to the articles already cited in this Update, eight level-I articles were identified that were relevant to hand surgery. A list of these titles is appended to this review following the standard bibliography. We have provided a brief commentary about each of these articles to help to guide your further reading, in an evidence-based fashion, in this subspecialty area.
Specialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.
1. Harness NG Inacio MC Pfeil FF Paxton LW. Rate of infection after carpal tunnel release surgery and effect of antibiotic prophylaxis. J Hand Surg Am. 2010;35:189–96.
2. Yin ZG Zhang JB Kan SL Wang XG. Diagnosing suspected scaphoid fractures: a systematic review and meta-analysis. Clin Orthop Relat Res. 2010;468:723–34.
3. Buijze GA Ring D. Clinical impact of united versus nonunited fractures of the proximal half of the ulnar styloid following volar plate fixation of the distal radius. J Hand Surg Am. 2010;35:223–7.
4. Sammer DM Shah HM Shauver MJ Chung KC. The effect of ulnar styloid fractures on patient-rated outcomes after volar locking plating of distal radius fractures. J Hand Surg Am. 2009;34:1595–602.
5. Chung KC Haas A. Relationship between patient satisfaction and objective functional outcome after surgical treatment for distal radius fractures. J Hand Ther. 2009;22:302–7; quiz 308.
6. Kienböck R. Uber traumatische Malazie des Mondbeins und ihre Folgezustande: Entartungsformen und Kompressionsfrakturen. Fortschritte auf dem Gebiete der Röntgenstrahlen. 1910;16:78–103.
8. Squitieri L Petruska E Chung KC. Publication bias in Kienböck's disease: systematic review. J Hand Surg Am. 2010;35:359-67.e5.
9. Matsuhashi T Iwasaki N Oizumi N Kato H Minami M Minami A. Radial overgrowth after radial shortening osteotomies for skeletally immature patients with Kienböck's disease. J Hand Surg Am. 2009;34:1242–7.
10. Ando Y Yasuda M Kazuki K Hidaka N Yoshinaka Y. Temporary scaphotrapezoidal joint fixation for adolescent Kienböck's disease. J Hand Surg Am. 2009;34:14–9.
11. Edwards SG Ramsey PN. Prospective outcomes of stage III thumb carpometacarpal arthritis treated with arthroscopic hemitrapeziectomy and thermal capsular modification without interposition. J Hand Surg Am. 2010;35:566–71.
12. Goss BC Agee JM. Dynamics of intracarpal tunnel pressure in patients with carpal tunnel syndrome. J Hand Surg Am. 2010;35:197–206.
13. Watt AJ Curtin CM Hentz VR. Collagenase injection as nonsurgical treatment of Dupuytren's disease: 8-year follow-up. J Hand Surg Am. 2010;35:534–9, 539.e1.
Evidence-Based Articles Related to Hand Surgery
Moe RH Kjeken I Uhlig T Hagen KB. There is inadequate evidence to determine the effectiveness of nonpharmacological and nonsurgical interventions for hand osteoarthritis: an overview of high-quality systematic reviews. Phys Ther. 2009;89:1363–70.
This Cochrane Review update included nine studies involving 477 participants. As in the previous review of this subject, no single procedure (including several variations of trapeziectomy with or without interposition, arthroplasty, and arthrodesis) was better than the others in terms of outcomes, whereas simple trapeziectomy without ligament reconstruction or interposition had the lowest rate of complications. Wajon A Carr E Edmunds I Ada L. Surgery for thumb (trapeziometacarpal joint) osteoarthritis. Cochrane Database Syst Rev. 2009;4:CD004631.
Abramo A Kopylov P Geijer M Tägil M. Open reduction and internal fixation compared to closed reduction and external fixation in distal radial fractures: a randomized study of 50 patients. Acta Orthop. 2009;80:478–85.
van der Giesen FJ van Lankveld WJ Kremers-Selten C Peeters AJ Stern EB Le Cessie S Nelissen RG Vliet Vlieland TP. Effectiveness of two finger splints for swan neck deformity in patients with rheumatoid arthritis: a randomized, crossover trial. Arthritis Rheum. 2009;61:1025–31.
Chao M Wu S Yan T. The effect of miniscalpel-needle versus steroid injection for trigger thumb release. J Hand Surg Eur Vol. 2009;34:522–5.
Yin ZG Zhang JB Kan SL Wang XG. Diagnosing suspected scaphoid fractures: a systematic review and meta-analysis. Clin Orthop Relat Res. 2010;468:723–34.
Nilsson A Wiig M Alnehill H Berggren M Björnum S Geijer M Kopylov P Sollerman C. The Artelon CMC spacer compared with tendon interposition arthroplasty. Acta Orthop. 2010;81:237–44.
Imasogie N Ganapathy S Singh S Armstrong K Armstrong P. A prospective, randomized, double-blind comparison of ultrasound-guided axillary brachial plexus blocks using 2 versus 4 injections. Anesth Analg. 2010;110:1222–6.
Disclosure: The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.