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Fragility Fracture Workshop & Symposium—June 28 & 29, 2018

ownbone_logo-rOn Thursday evening, June 28 and all day Friday, June 29 in Boston, The American Orthopaedic Association (AOA) and the National Association of Orthopaedic Nurses (NAON) will present two educational/networking events concentrating on secondary fragility fracture prevention.

The Thursday evening Workshop, available only to those attending the Friday Symposium, will convene clinicians with expertise in counseling and treating fragility fracture patients. “This new two-hour workshop provides an additional opportunity to learn more about identifying, assessing, counseling, and treating fragility fracture patients,” said program co-chair Debra Sietsema, PhD, RN. “The Workshop also includes special breakout stations on calcium, FRAX, and the AOA’s ‘Own the Bone’ initiative.”

The all-day Symposium on Friday focuses on how to establish a multidisciplinary secondary fragility fracture program. In addition, the Symposium will include relevant case studies demonstrating how to translate the principles into hospital, private-practice, or clinic settings. “This Symposium is a great opportunity for orthopaedic surgeons and allied health professionals to get the full picture in one day,” said Dr. Sietsema. “Attendees will gain both basic and expanded knowledge to put their programs in place.”

Register by May 15 to receive early-bird pricing for these important events. NAON members and clinicians from enrolled Own the Bone institutions save an additional $50.

A Video Approach to Improving Outcomes in Digit Replantation

Anastomosis Refill for OBuzzArterial and venous reperfusion problems are common causes of failure in digit replantation, so excellent vascular anastomotic technique is crucial during these operations. One way to assess the patency of vascular anastomoses intraoperatively is to estimate refilling velocity with the naked eye. An even better way is described by Zhu et al. in the May 2, 2018 edition of The Journal of Bone & Joint Surgery.

The authors divided their study into two phases. During phase I, they found that a slower refilling velocity ratio (RVR) in 103 replanted digits, calculated with the aid of videos recorded at 1,000 frames per second, was associated with replantation failure. In phase II, the authors applied RVR goals established from phase I to another 79 replanted digits to determine whether the additional objective guidance increased the replantation survival rate compared with historical controls.

Based on phase I results, Zhu et al. set the arterial RVR goal to 0.4 and the venous RVR sum goal to 1.0. Using those goals for guidance, the authors found that the phase II success rate (96%) was significantly higher than that among historical controls (87%). In several phase I cases, intraoperative observations of specialists considered anastomoses to be acceptable, but the high-speed video data revealed that improvements were required.

One downside to obtaining this objective video data about anastomotic quality is that it adds 10 to 15 minutes to operative time. Consequently, the authors cite the need for a “well-designed, randomized, double-blinded clinical trial…to provide stronger evidence of this assessment technique.”

Association Between Distal Radial Fracture Malunion and Patient-Reported Activity Limitations

The long-term effect of distal radial fracture malunion on activity limitations is unknown. https://bit.ly/2qYgOMh #JBJS

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What’s New in Hand and Wrist Surgery 2018

Human Hand Anatomy IllustrationEvery 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.

Fixation Costs for Distal Radial Fracture

There is no consensus on the optimal fixation method for patients who require a surgical procedure for distal radial fractures. We used cost-effectiveness analyses to determine which of 3 modalities offers the best value. https://goo.gl/mos4dc 

JBJS 100: Carpal Tunnel and THA

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal constituted Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

The Carpal Tunnel Syndrome: Seventeen Years’ Experience in Diagnosis and Treatment of 654 Hands
George S. Phalen: JBJS, 1966 March; 48 (2): 211
Everything Phalen presented about carpal tunnel syndrome in 1966 holds true more than 50 years later. This includes his descriptions of the anatomical, epidemiologic, histologic, and clinical features of carpal tunnel syndrome and his emphasis on careful history-taking and physical examination.

Periprosthetic Bone Loss in Total Hip Arthroplasty: Polyethylene Wear Debris and the Concept of the Effective Joint Space
T P Schmalzried, M Jasty, W H Harris: JBJS, 1992 Jan; 74 (6): 849
The insights offered by these authors radically altered our thoughts about osteolysis. Using this concept of effective joint space, subsequent investigators and innovators identified methods and designs of hip replacements to retard osteolysis by limiting the generation and spread of particulate debris.

Fracture Liaison Service Boosts Patient Engagement with Secondary Prevention

fragility fractures for O'Buzz.pngOrthoBuzz has published several posts about osteoporosis, fragility fractures, and secondary fracture prevention. In the May 17, 2017 edition of JBJS, Bogoch et al. add to evidence suggesting that a coordinator-based fracture liaison service (FLS) improves engagement with secondary-prevention practices among inpatients and outpatients with a fragility fracture.

The Division of Orthopaedic Surgery at the University of Toronto initiated a coordinator-based FLS in 2002 to educate patients with a fragility fracture and refer them for BMD testing and management, including pharmacotherapy if appropriate. Bogoch et al. analyzed key clinical outcomes from 2002 to 2013 among a cohort of 2,191 patients who were not undergoing pharmacotherapy when they initially presented with a fragility fracture.

  • Eighty-four percent of inpatients and 85% of outpatients completed BMD tests as recommended.
  • Eighty-five percent of inpatients and 79% of outpatients who were referred to follow-up bone health management were assessed by a specialist or primary care physician.
  • Among those who attended the referral appointment, 73% of inpatients and 52% of outpatients received a prescription for anti-osteoporosis medication.

The authors conclude that “a coordinator-based fracture liaison service, with an engaged group of orthopaedic surgeons and consultants…achieved a relatively high rate of patient investigation and pharmacotherapy for patients with a fragility fracture.”

Unplanned Readmissions After Outpatient Hand and Elbow Surgery

swiontkowski-marc-colorIn the April 5, 2017 issue of The Journal, Noureldin et al. analyzed more than 14,000 procedures from the NSQIP database to determine the rate of unplanned 30-day readmission after outpatient surgical procedures of the hand and elbow. The 1.2% rate seems well within the range of acceptability, particularly because the more than 450 institutions contributing to this database probably serve populations who don’t have the best overall health and comorbidity profiles.

Missing causes for about one-third of the readmissions illustrate one issue with data accuracy in these large administrative datasets. While the authors acknowledged a “lack of granularity” as the greatest limitation in analyzing large databases, they added that the readmissions with no listed cause “were likely unrelated to the principal procedure.”

It was not surprising that infection was the most common cause for readmission. However, it would have been nice to know the rate of confirmed infection via positive cultures, as I suspect many of these patients were readmitted for erythema, swelling, warmth, and discomfort associated with postoperative hematoma rather than infection.

Regardless of the need for higher-quality data on complications following outpatient orthopaedic surgical procedures, this analysis gives us more confidence that the move toward outpatient surgical care in our specialty is warranted. I think most patients would rather sleep in their own home as long as preoperative comorbidities and ASA levels are considered and adequate postoperative pain control can be achieved in an outpatient setting. The trend toward outpatient orthopaedic treatment is likely to continue as we gather higher-quality data and better understand the risk-benefit profile.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

What’s New in Hand and Wrist Surgery

Hand Wrist for O'Buzz.jpegEvery month, JBJS publishes a Specialty Update—a review of some of the most pertinent and impactful studies published in one of 13 orthopaedic subspecialties during the previous year. Click here for a collection of all OrthoBuzz Specialty Update summaries.

This month, OrthoBuzz asked Sanjeev Kakar, MD, the author of the March 15, 2017 Specialty Update on hand and wrist surgery, to select five of the most clinically compelling findings from among the more than 40 he cited in the article.

Carpal Tunnel Syndrome

—The AAOS published updated clinical practice guidelines on the evaluation and treatment of carpal tunnel syndrome (CTS). Among the conclusions are the following:

  • Thenar atrophy is strongly associated with ruling in carpal tunnel syndrome but poorly associated with ruling it out.
  • High body mass index and repetitive hand and wrist actions are associated with an increased risk of developing CTS.
  • Surgical division of the transverse carpal ligament should relieve symptoms and improve function compared with nonoperative treatment.
  • There is no benefit to routine postoperative immobilization after CTS surgery.

Wrist Fracture

—If a distal radius fracture is displaced, especially in an elderly patient, should one proceed with nonoperative or operative treatment? A systematic review/meta-analysis1 involving more than 800 patients 60 years of age or older found that operatively treated patients had greater grip strength and better restoration of radiographic parameters than nonoperatively treated patients. However, those who underwent surgery also experienced more complications (primarily hardware-related) that required surgery.

Thumb and Digit Arthritis

—There are a myriad of treatments for the management of basilar thumb arthritis, ranging from trapeziectomy to fusion. Which one is better, especially if the scaphotrapeziotrapezoid joint is not involved? A prospective study was conducted randomizing women older than 40 with basal thumb joint arthritis to trapeziectomy and suspension arthroplasty or carpometacarpal joint arthrodesis. After a mean follow-up of 5.3 years, those in the trapeziectomy-suspension arthroplasty group had significantly better pain reduction and function.2 Researchers halted the study prematurely due to increased complications in the arthrodesis group.

Outcome Measurement Tools

—Among the many patient-reported outcome measures for the upper extremity, which should be used for which conditions? For distal radius fractures, a systematic approach has been proposed3 that captures outcomes across five domains: range of motion and grip strength, patient-reported scores of disability and function, complications, pain, and radiographs.4

—Is there any way to make the collection of patient-reported outcomes easier and less time-consuming? An assessment that compared two forms of computerized adaptive tests (CATs) with the DASH (Disabilities of the Arm, Shoulder and Hand) measure among 379 hand-clinic patients found that the CAT required fewer questions to complete than the DASH, yet maintained excellent reliability.5

References

  1. Chen Y, Chen X, Li Z, Yan H, Zhou F, Gao W. Safety and efficacy of operative versus nonsurgical management of distal radius fractures in elderly patients. A systematic review and meta-analysis. J Hand Surg Am. 2016 ;41(3):404–13. Epub 2016 Jan 20.
  2. Spekreijse KR, Selles RW, Kedilioglu MA, Slijper HP, Feitz R, Hovius SE, Vermeulen GM. Trapeziometacarpal arthrodesis or trapeziectomy with ligament reconstruction in primary trapeziometacarpal osteoarthritis: a 5-year follow-up. J Hand Surg Am. 2016 ;41(9):910–6.
  3. Teunis T, Ring D. Comprehensive outcome assessment after distal radius fracture. J Hand Surg Am. 2016 ;41(8):e257. Epub 2016 Jun 11.
  4. Waljee JF, Ladd A, MacDermid JC, Rozental TD, Wolfe SW, Distal Radius Outcomes Consortium. A unified approach to outcomes assessment for distal radius fractures. J Hand Surg Am. 2016;41(4):565–73.
  5. Beckmann JT, Hung M, Voss MW, Crum AB, Bounsanga J, Tyser AR. Evaluation of the patient-reported outcomes measurement information system upper extremity computer adaptive test. J Hand Surg Am. 2016 ;41(7):739–744.e4. Epub 2016 Jun 3.

JBJS Classics: Pollicization of the Index Finger

JBJS Classics Logo.pngOrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.

Even before hand surgery became a specialty, the characteristics of the thumb that enabled pad-to-pad opposition (and therefore fine motor function) were well-recognized:  shorter length, fewer bony segments, and pronated position relative to the fingers; a wide first web space; and intrinsic muscle control of abduction, rotation, and pinch.  Although these principles were used to devise surgical procedures to restore thumb function prior to Buck-Gramcko’s landmark JBJS article in 1971, most were used for a small number of patients, with limited information available about outcomes.  Thumb absence is uncommon, and no hand surgeon was able to gain sufficient experience with index pollicization to refine and enhance the technique until the confluence of Buck-Gramcko’s exceptional skill and one of the major medical catastrophes of the 20th century.

Dieter Buck-Gramcko was born in Hamburg, Germany in 1927.  Following World War II, he trained in general and trauma surgery and became one of the first hand surgeons in Germany.1  Between 1957 and 1962, thalidomide was marketed in Germany as a sedative, but it also inhibited angiogenesis, causing limb malformations, including thumb deficiency, when fetuses were exposed to the drug during limb development.2  The resulting large number of German infants with thumb deficiency provided Buck-Gramcko with the opportunity to modify the technique of index pollicization and study the outcomes of his modifications to improve results. He described his findings and results in this landmark article.

His careful description of index pollicization includes the principles and techniques that remain the hallmarks of this operation.  His diagram of reduction of bones and joints (Figure 3 of his classic article, shown below) is a simple and elegant depiction of the principles of this complex operation.  His rigorous follow-up, measurement of outcomes, and propensity to criticize his own work to improve results are all apparent in this article, which provides an excellent example of applying the scientific method. Not surprisingly, Buck-Gramcko remained rigorous and objective throughout his long career; 20 years later, he published another article focused on complications and poor outcomes after index-finger pollicization.3James Classic Image.png

Index pollicization is one of the paramount operations of hand surgery, largely because Buck-Gramcko applied theoretical principles of thumb function, methodically and meticulously refined the technique of pollicization, studied the outcomes of his work, and passed this valuable information along in this classic article.  It remains a useful guide to the performance of this operation almost half a century later.  The thalidomide tragedy had a silver lining, thanks to Buck-Gramcko’s surgical skills, methodologic rigor, and scientific objectivity.

Michelle A. James, MD
JBJS Deputy Editor

References

  1. Hoffmann R, Lubahn JD. First Hand: Dieter Buck-Gramcko. Journal of Hand Surgery. 2013;38(5):988-90.
  2. Stephens T, Brynner R. Dark remedy: the impact of thalidomide and its revival as a vital medicine. Basic Books, N.Y.; 2009.
  3. Buck-Gramcko D. Complications and bad results in pollicization of the index finger (in congenital cases). Annales de Chirurgie de la Main et du Membre Supérieur 1991;10 (6):506-512).