What’s New in Hand and Wrist Surgery 2018

Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.

This month, Sanjeev Kakar, MD, author of the March 21, 2018 Specialty Update on Hand and Wrist Surgery, selected the five most clinically compelling findings from among the nearly 40 studies summarized in the Specialty Update.

Distal Radius Fractures

—When can a patient safely drive after surgical treatment of a distal radial fracture? According to a prospective study by Jones et al.¹, most patients can do so within 3 weeks following surgery. Twenty-three patients had their driving evaluated 2 and 4 weeks after volar plating. Sixteen of the 23 patients drove safely on a closed course with both hands on their first attempt, which averaged 18 days after surgery.

Scaphoid Fractures

—One factor contributing to scaphoid nonunion is impaired vascularity. So, if the proximal pole of the scaphoid is avascular, is the use of vascularized bone grafting mandatory? No, according to a prospective study by Rancy et al.², which followed 35 scaphoid nonunion patients treated with curettage, nonvascularized bone grafting, and headless screw fixation. Nine of 23 proximal pole fractures demonstrated ischemia on MRI imaging; 28 of 33 were found to have impaired intraoperative punctate bleeding; and 18 patients had ≥50% tissue necrosis on pathological analysis. CT analysis revealed that 33 of the 35 scaphoids had healed by three months, leading the authors to conclude that nonvascularized bone grafting can suffice as long as the fracture is appropriately reduced and stabilized.

Kienbock Disease

—Lichtman et al.³ introduced a new algorithm for Kienbock disease management that incorporates previous classification systems plus 5 treatment-guiding questions:

• How old is the patient?
• What is the effect of the disease on the lunate?
• How does the disease affect the wrist?
• What treatments are available?
• What are the patient’s requirements?

Depending on the answers, the authors present treatment options ranging from lunate reconstruction to wrist salvage.

Ulnar Impaction

—Some surgeons view radiographic evidence of a reverse oblique inclination in the sigmoid notch as a contraindication for ulnar shortening in patients with ulnar impaction. However, using MRI, Ross et al.⁴ noted that reverse oblique inclinations of the distal radioulnar joint, as seen on plain radiographs, were not evident when coronal MRI scans were analyzed. They concluded that some patients previously thought to have contraindications to ulnar shortening may in fact be suitable candidates for that procedure.

Prescribing Opioids

—Dwyer et al.⁵ evaluated an opioid-reduction strategy for patients undergoing carpal tunnel release or volar locking-plate fixation of distal radius fractures. Patients received education and encouragement to use over-the-counter (OTC) medications along with opioids. Among the carpal tunnel cohort (n = 121), the average opioid prescription was for 10 pills compared with 22 in the previous year. Average actual consumption was 3 opioid pills and 11 OTC pills. In the distal radius fracture group (n = 24), the average opioid prescription was 25 pills compared with 39 the year before. These patients consumed on average 16 opioid pills with 20 OTC pills. Patient satisfaction was high in both groups. The authors recommend that physicians prescribe 5 to 10 opioid pills for carpal tunnel release and 20 to 30 pills after volar plating for distal radius fractures.

References

1. Jones CM, Ramsey RW, Ilyas A, Abboudi J, Kirkpatrick W, Kalina T, Leinberry C. Safe return to driving after volar plating of distal radius fractures. J Hand Surg Am. 2017 Sep;42(9):700-704.e2.
2. Rancy SK, Swanstrom MM, DiCarlo EF, Sneag DB, Lee SK, Wolfe SW, Scaphoid Nonunion Consortium. Success of scaphoid nonunion surgery is independent of proximal pole vascularity. J Hand Surg Eur Vol. 2017 Jan 1;1753193417732003.
3. Lichtman DM, Pientka WF 2nd, Bain GI. Kienböck disease: a new algorithm for the 21st century. J Wrist Surg. 2017 Feb;6(1):2-10. Epub 2016 Oct 27.
4. Ross M, Wiemann M, Peters SE, Benson R, Couzens GB. The influence of cartilage thickness at the sigmoid notch on inclination at the distal radioulnar joint. Bone Joint J. 2017 Mar;99-B(3):369-75.
5. Dwyer CL, Soong MC, Hunter AA, Dashe J, Tolo ET, Kastayan NG. Prospective evaluation of an opioid reduction protocol in hand surgery. Read at the American Society for Surgery of the Hand Annual Meeting; 2017 Sep 7-9; San Francisco, CA. Paper no. 5.