Year: 2019
Type: article
Abstract: It is my distinct pleasure to provide an overview of the hand and wrist surgery literature published in the last year. I would like to thank Sanjeev Kakar, MD, for his thoughtful updates over the past 3 years. In this Update, I have summarized articles published from October 2017 to September 2018 in The Journal of Hand Surgery (American), The Journal of Hand Surgery (European), and HAND. Distal Radial Fractures In a prospective randomized trial, Martinez-Mendez et al. compared volar plate fixation and cast management in patients who were >60 years of age and had AO type-C distal radial fractures1. At the time of the final follow-up, at least 24 months after the injury, the primary outcome measure (Patient-Rated Wrist Evaluation total score) was lower (indicating less disability) in the group randomized to volar plating. There were no losses of reduction in the volar plating group, but loss of reduction did occur in 26% (12 of 47) of the patients in the casting group. This Level-I evidence of superior patient-reported outcomes with volar plating for patients who were ≥60 years of age is contrary to a prior Level-I study conducted in Austria by Arora et al. published in The Journal of Bone and Joint Surgery (American volume) in 20112. There are interesting contrasts between the 2 studies: Arora et al. included patients who were ≥65 years of age and also included both AO type-A and type-C fractures. Interestingly, the mean Patient-Rated Wrist Evaluation scores reported at 12 months in both the volar plating group (12.8 points) and the casting group (14.6 points) in the study by Arora et al. were lower than those reported in both the volar plating group (17 points) and the casting group (30 points) in the study by Martinez-Mendez et al. at ≥24 months, suggesting that there are patient-level and surgeon-level differences between the 2 environments in which the studies were conducted. Baseline activity levels were not assessed in either study, with age and radiographic criteria used to determine eligibility; however, bias from differences in baseline activity was likely to have been accounted for in randomization. Based on recent literature, many surgeons treat distal radial fractures in elderly patients with cast management, regardless of fracture appearance on radiographs. In many cases, both the surgeon and the patient expect a malunion that is unlikely to impede function. More information about the prevalence and natural history of these anticipated malunions can aid in patient counseling. Wadsten et al.3 examined 175 patients with distal radial fractures treated nonoperatively who had 3-month radiographic follow-up and 1-year clinical follow-up. Only patients with a radiographically acceptable reduction at 1 to 2 weeks were included in the study. At the 3-month follow-up, 28% of patients had late displacement or malunion. Cases with late displacement or malunion had lower grip strength and a loss of the total wrist range of motion. However, there was no difference in patient-reported functional measures between late displacement or malunion and non-malunion groups. The most common complication was carpal tunnel syndrome, occurring in 19% of the overall cohort (with no difference between the 2 groups). Concerns remain with regard to potential complications involving extensor and flexor tendons after volar plating. In a prospective evaluation of patients with unicortical fixation in the distal row, Dardas et al. demonstrated that this strategy can effectively maintain reduction, with only 2 cases (of 75 total cases) with loss of reduction4. There were no cases of extensor tendon rupture or extensor tenosynovitis. The positioning of the volar plate relative to the watershed line is often discussed as a risk factor for flexor tendon irritation. In a cadaveric study, Wurtzel et al. demonstrated that increased contact between the flexor plexus longus and the volar plate is dependent not only on the position of the plate, but also on the residual sagittal angulation (maintenance or loss of volar tilt)5. With a distally positioned plate and a neutral volar tilt, contact between the flexor plexus longus and the volar plate occurred at approximately 45° of wrist extension. Contact between the flexor pollicis longus and the volar plate occurs at even lower amounts of wrist extension when there is a dorsal malunion, suggesting that surgeons should closely monitor for flexor plexus longus irritation as patients recover wrist flexion if the volar plate has been placed distally and/or if anatomic volar tilt has not been restored. Scaphoid Fractures Given the understandable concerns for nonunion, a common question in practice is the amount of cortical healing of a scaphoid fracture needed to allow unrestricted activity. In a biomechanical cadaver model, Guss et al. compared the load to failure of an intact scaphoid, of a 50% osteotomy without a compression screw, of a 50% osteotomy with a compression screw, of a 25% osteotomy with a compression screw, and of a 75% osteotomy with a compression screw6. There was no difference in load to failure between the intact scaphoid group and the 50% osteotomy and compression screw group. However, load to failure in the 75% osteotomy and compression screw group was lower than that in the intact scaphoid group. These findings suggest that 50% cortical healing is sufficient to allow unrestricted activity after scaphoid open reduction and internal fixation with a compression screw. The indications for a nonvascularized bone graft, pedicled vascularized bone flap, or free bone flap remain debatable for the management of scaphoid nonunions. Rancy et al. challenged the traditional importance placed on the assessment of the proximal pole vascularity7. In their study of scaphoid nonunions treated with nonvascularized bone-grafting and a headless compression screw, Rancy et al. showed that 33 of 35 fractures went on to union (defined by the authors as ≥50% bridging the cortical bone) demonstrated by computed tomography (CT), despite evidence of compromised proximal pole vascularity in 14 of 32 patients with histopathological data available. Although no data are available to examine the effectiveness of nonvascularized bone-grafting relative to other techniques, the union rate in this series suggests that there may be a role for this treatment in the majority of scaphoid fractures. Additional series published in the past year using exclusively nonvascularized grafting and screw fixation by Kim et al. (union in 22 of 24 patients with scaphoid nonunions, all of which had magnetic resonance imaging [MRI]-demonstrated osteonecrosis in the proximal pole before the surgical procedure)8 and Luchetti et al. (union in 18 of 20 proximal pole fractures)9 corroborated the findings from Rancy et al. The reported success of nonvascularized bone graft in the treatment of scaphoid nonunion and osteonecrosis demonstrates the need for prospective, comparative studies to determine the most appropriate surgical techniques. Thumb Ulnar Collateral Ligament One popular technique to treat thumb ulnar collateral ligament injuries is to reattach the ligament to its insertion on the proximal phalanx using a single suture anchor. However, this technique does not restore the mechanical strength of the native ulnar collateral ligament at time zero, necessitating a period of immobilization and restricted activity. Gil et al. evaluated the biomechanical properties of a 2-anchor repair technique, finding that the yield load, maximum load at failure, and stiffness were lower following a 2-anchor repair compared with the intact ulnar collateral ligament10. One technique that is gaining interest to augment the strength of ulnar collateral ligament repairs is the addition of a thick suture tape to act as an internal brace. Shin et al. compared a single anchor repair with a single anchor and suture tape repair and found a higher load to failure in the latter group11. They did not compare the repair techniques with the intact ulnar collateral ligament, limiting the ability to discern whether the technique of the single anchor with suture tape could be strong enough to eliminate or decrease the need for postoperative immobilization and activity modification in the clinical application of this technique. Thumb Arthritis Almost one-fourth of the American Society for Surgery of the Hand (ASSH) survey respondents in practice for at least 5 years have changed their treatment preference for thumb arthritis within the 5 years prior to survey administration, demonstrating that many surgeons are still seeking the optimal procedure for their practice12. In a prospective randomized trial, Marks et al. compared patients who underwent trapeziectomy and suspension arthroplasty using either half of the flexor carpi radialis or a tendon allograft13. Clinical outcomes at 12 months were similar between the 2 groups. However, there were 7 cases of partial tendon rupture in the allograft group (among the 29 patients in this group). On the basis of similar clinical outcomes and higher complication risk with allograft, Marks et al. abandoned the use of the allograft in a primary trapeziometacarpal surgical procedure. However, the same allograft material has been used as an interposition arthroplasty material after arthroscopic partial trapeziectomy. Logli et al. reported their 5-year results using this technique, with improvements in pain scores and scores for the QuickDASH (abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH] Scale) compared with the preoperative assessment14. None of the 24 patients available for the 5-year follow-up had undergone a revision trapeziometacarpal surgical procedure, but 1 patient had developed painful instability and subsidence (but declined further treatment). No inflammatory reactions were reported from the interposition allograft. As historically noted, the reoperation rate after trapeziometacarpal arthroplasty is relatively low. This has been substantiated by a case series from Wilkens et al.15, in which the authors noted that 4% of 458 trapeziometacarpals underwent an unplanned reoperation (two-thirds of which occurred within a year of the original surgical procedure). The risk factors associated with an unplanned reoperation were younger patient age, surgeon experience of <12 years in practice, and the type of technique used (higher risk with trapezium excision and interposition alone, without ligament reconstruction or suspensionplasty). Historically, the patient-reported outcomes after a revision trapeziometacarpal surgical procedure are suboptimal16. Papatheodorou et al. reported a case series of 32 patients who underwent a revision surgical procedure to address a combination of recurrent subsidence, scaphotrapezoidal arthritis, and metacarpophalangeal deformity after a prior trapeziometacarpal arthroplasty17. At a mean follow-up of nearly 5 years (minimum, 2 years), pain levels were reduced, and grip and pinch measures were improved. However, there is no comparison group to contextualize these results. Wrist Arthroplasty The utilization of total wrist arthroplasty has been limited by concerns for complications such as distal implant loosening. Kennedy et al. provided a mean 7-year follow-up following the implantation of the Universal 2 total wrist arthroplasty (Integra LifeSciences) (48 wrists in 46 patients), noting improvements in patient-reported outcomes, satisfaction, and range of motion18. However, half of the patients had radiographically detectable loosening in the wrist; 6 of these cases were noted as having symptomatic loosening. Seven wrists underwent revision arthroplasty or arthrodesis and 4 were diagnosed with carpal tunnel syndrome (2 had carpal tunnel release). Despite the promising clinical outcomes, the complication risk should be noted when counseling patients about their treatment options. In an effort to address the shortcomings of total wrist arthroplasty, a hemiarthroplasty that replaces the proximal carpal row and preserves the midcarpal joint has been introduced. Among the 20 patients who had a mean follow-up of 4 years, Anneberg et al. demonstrated improvements in wrist flexion and extension, radial and ulnar deviation, grip strength, and patient-reported outcomes19. Three patients underwent a manipulation under anesthesia for stiffness, 1 patient underwent a conversion to total wrist arthroplasty due to component loosening, and 1 patient had a wrist arthrodesis to treat ulnar-sided wrist pain. Although these results are promising, long-term results and reproducibility by other centers are needed before recommending widespread use. Triangular Fibrocartilage Complex Our collective understanding of the anatomy and pathophysiology of the triangular fibrocartilage complex continues to grow. Recent studies have examined some of the fundamental beliefs in the assessment of ulnar-sided wrist pain. Park et al. evaluated the interrater reliability of wrist arthroscopy to diagnosis triangular fibrocartilage complex injuries, demonstrating modest agreement among 3 observers as to whether a triangular fibrocartilage complex tear was present, whether a trampoline test was considered positive, and the location of a tear20. The results of this study suggest that wrist arthroscopy may not be an appropriate reference standard for the diagnosis of triangular fibrocartilage complex tears. In a cadaver model, Trehan et al. also demonstrated suboptimal performance of the trampoline test among 3 reviewers, with the arthroscopic hook test being a more reliable and highly sensitive and specific marker for isolated triangular fibrocartilage complex foveal detachment21. Although MRI has an established role in aiding the diagnosis of ulnar-sided wrist pain, relatively little information exists about the likelihood of incidental findings. A review of 1,134 wrist MRI scans demonstrated that 28% had incidental triangular fibrocartilage complex signal changes, with the frequency of incidental findings increasing with patient age22. These findings corroborate other studies describing the frequency of incidental degenerative changes with advanced imaging and provide a reference that can guide clinical decision-making. Microsurgery Despite their growing popularity, there is little information about electronic cigarettes to guide hand surgeons and microsurgeons with regard to electronic cigarettes’ effect on circulation. Pywell et al. measured hand microcirculation in smokers after smoking an electronic cigarette with 24 mg of nicotine, demonstrating a maximum reduction of 77% in superficial flow and 29% in deep flow within 20 minutes of inhalation23. These reductions are similar to those seen with conventional cigarettes, suggesting that the clinical implications of potentially compromised healing capacity with continued nicotine use are the same. The time to the surgical procedure has traditionally been considered a critical factor in the likelihood of digital survival after replantation. In a retrospective cohort study, Cavadas et al. questioned whether replantation outcomes differ on the basis of the time to the surgical procedure24. They compared 185 digital replantations that were performed in a delayed time frame (performed the following with digital replantations performed There were no differences noted in patient age, of or of between the 2 groups. survival were in both in the replantation group and in the delayed replantation group). Although these findings interest in delayed replantation at other the survival reported those reported in the suggesting that a of success is the ability of the surgical at this in a is needed to that are available to to delayed replantation. The role of studies in the diagnosis and management of carpal tunnel syndrome continues to Although the American of has in its clinical practice that studies are not to a diagnosis of carpal tunnel syndrome, many surgeons to use studies as a of to carpal tunnel In their prospective study, et al. demonstrated in functional and patient-reported outcomes at 3 months after carpal tunnel in patients with studies as and carpal tunnel There was no difference in the of among the 3 suggesting that studies may not be a for patient-reported after carpal tunnel outcomes such as strength and were not increased on the of and factors is in a series of published articles on carpal tunnel In prospective both Shin et and et demonstrated that decrease after carpal tunnel and are with improvements in patient-reported et al. also found carpal tunnel syndrome to be a of and using These findings suggest that there is a between carpal tunnel syndrome and that this further in studies and the for an increased role of evaluation surgical In their evaluation of et al. found that patients from of higher had scores for pain and from of higher were also more likely to have a higher and were more likely to use both of which may potentially outcomes after carpal tunnel syndrome be to for when outcomes, not only to address but also to provide appropriate risk in There is continued in the treatment of tunnel A survey of the conducted by et al. demonstrated a preference for in ulnar in a of clinical from to One of in is the In their prospective cohort study patients in and those ulnar et al. demonstrated that patients had patient-reported at time to weeks after the surgical but that these differences at the time of final follow-up weeks after the surgical and were also in the group. Although that study did not long-term clinical follow-up data to aid in the most appropriate treatment for tunnel syndrome, the results provided were in counseling patients about the postoperative after surgical procedure. and techniques to restore have in recent years. et al. a series of patients in which the distal tendon was to the flexor and flexor pollicis with an tendon A as flexion of the within of the was in 6 of In the 4 a distal was with in in all Although this technique may not be available in cases with is a to restore and thumb A free functional has also been used to restore In some plexus cases, the use of a free functional may be limited of a of available et al. reported the use of as for free functional plexus cadaveric study demonstrated that were with of the the of the and The potential need for may the of but the limited clinical results demonstrated outcomes that are with conventional The of after a has been to the to the et al. a distal of the of the ulnar to the of the demonstrated the ability to a with similar for the 2 case series provided promising with in and strength at a mean of months after the surgical procedure. Although this is not an in plexus injuries involving the lower may in in which the is available. to other of for patients with plexus injuries, et al. used an to that and occur in patients with plexus with plexus injuries were more likely than and to and et al. reported similar findings in a retrospective series from a single for to treatment of plexus continues in the for optimal outcomes after flexor tendon There are relatively comparative studies of the most popular postoperative with prior Level-I evidence demonstrating of over motion. However, et al. provided the Level-I comparison of with In their prospective randomized trial, patients with flexor tendon repairs were randomized to flexion and or a extension and flexion with a There were no differences in total at the time of final follow-up (12 but functional outcomes in the group were seen at 1 This difference was not at and 12 et al. the of and suture as reported a series of flexor tendon repairs treated with a repair technique without an with of the and and with of the had to outcomes using the with no promising results have been reported using a for thumb flexor tendon repairs by et suggesting that a may be in the treatment of flexor tendon The in the has increased about for after a surgical procedure. A prospective cohort study by et al. demonstrated that mean after carpal tunnel was for and mean was for et al. reported many patients carpal tunnel at their were of or more than half of the patients In a study, et al. reported similar after carpal tunnel and performed under anesthesia or et al. evaluated the role of in an hand surgical procedure, but found no difference in when the group and the of these studies the relative of after hand surgical with regard to both and of The of The Journal a of published studies to the that a higher of In addition to articles in the Update, 3 other articles with a higher of were that were to hand A of those is to this review after the standard have provided a about of the articles to guide further in an in this Logli A prospective, randomized of after tunnel Hand 2018 2018 The use of postoperative immobilization after carpal tunnel the hand surgery Logli et al. provided Level-I evidence demonstrating no difference in patient-reported outcomes at 12 months after carpal tunnel among patients randomized to no a or a The findings of this study are with the clinical practice which were the of the study. The effect of on the clinical and radiographic outcomes of distal fractures in Hand 2018 2017 With an increased on bone in patients with a the question of whether to treatment may et al. demonstrated similar union when patients who continued after a distal radial fracture with patients without were treated with cast to fracture union was the primary with patients in group to a mean difference in 14 for time to radiographic union was not measured by to but was assessed by the of patients at time follow-up and 12 weeks and 1 There were no differences in the of patients with fracture union at but the study was to differences and 22 patients in group). Given the of difference between in the patient-reported outcomes measured (Patient-Rated Wrist Evaluation and at all the authors that could be continued in patients with a distal radial fracture treated of a for risk in patients surgical management of distal fractures. Hand 2018 2018 the of the prospective et al. examined the for patients who were years of age and underwent open reduction and internal fixation of a distal radial The authors the for history of failure, history of or and functional within prior to the surgical and evaluated the likelihood of complications with and The rate of these was but the risk was more than in patients with a of than in those with a of The of and the likelihood of to a location other than were also in those with a of Although studies of this are to examine about the to increased complications and as this study provided a of a risk of complications after open reduction and internal fixation of a distal radial fracture and should be the
Author: Christopher J. Dy
Institution: Washington University in St. Louis
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2931316486