What's New in Hand and Wrist Surgery.

Abstract

Carpal Tunnel Syndrome Carpal tunnel syndrome (CTS) is one of the most common problems presenting to the hand surgeon. There has been a continued effort to refine the optimal diagnostic criteria for CTS. The Carpal Tunnel Syndrome-6 (CTS-6) is a validated 26-point scale that incorporates 6 aspects of the history and clinical examination to predict the probability of the presence of CTS1. Recent studies have shown that CTS-6 scores are similar whether they are applied by experienced or inexperienced individuals and when assessment is made via a telemedicine visit, indicating that the CTS-6 is easy to administer and reliable2,3. These findings suggest that the CTS-6 could be used to screen patients prior to a visit with the surgeon. The utility of ultrasound in the diagnosis of CTS continues to evolve. In a retrospective review, Charles et al. compared ultrasound with electrodiagnostic studies (EDS) in confirming the clinical diagnosis of CTS. Patients who had a CTS diagnosis confirmed by the surgeon using ultrasound had 1.8 fewer medical visits and underwent a surgical procedure 3 to 4 weeks earlier than those who had a CTS diagnosis confirmed with EDS4. Furthermore, the severity of CTS as measured by ultrasound positively correlates with the severity as measured on EDS. In 1 study, the cross-sectional area of the median nerve was compared with the severity of changes on EDS based on the American Association of Neuromuscular & Electrodiagnostic Medicine guidelines. There was a significant association (p < 0.0001) between increasing cross-sectional area at the wrist crease and increasing EDS severity, further supplanting the need for EDS5. Carità et al. studied 35 patients with failed carpal tunnel release (CTR). Using high-resolution ultrasound, the authors found that 30 patients (86%) had persistent median nerve compression, with 20 (57%) due to incomplete release of the transverse carpal ligament. Only 1 of the 35 patients had no abnormality on ultrasound that could explain the persistent symptoms6, showing it to be a useful imaging modality in failed CTR. Ultrasound and the CTS-6 have both been shown to be more sensitive and specific in diagnosing CTS than EDS7. In a database study, EDS represented nearly one-half (44.6%) of the cost of the preoperative care in 378,381 patients with CTS8. This information, along with the known delays in care when using EDS as a diagnostic tool4, makes the usefulness of EDS for the routine diagnosis of CTS questionable at best. Nevertheless, its use persists. A survey of members of the American Society for Surgery of the Hand (ASSH) (23.4% response rate) found that 26% of surgeons required EDS before they would grant an appointment and 56% of members order EDS after seeing patients if they do not already have them9. The American Academy of Orthopaedic Surgeons (AAOS) had a clinical practice guideline10 (CPG) on CTS in 2009 that was revised in 201611 to no longer recommend the routine use of EDS for the diagnosis of CTS. In the ASSH member survey, only 38% of the respondents believed that the CPGs were appropriate and 43% reported that they were not aware of the CPGs9. There is strong evidence for the use of corticosteroid injection in the treatment of CTS11. However, the duration of effectiveness is unknown, and a corticosteroid injection is widely believed to be a temporizing measure in the treatment of CTS. Ly-Pen et al. reported the long-term results of a randomized clinical trial comparing a corticosteroid injection with CTR in the treatment of CTS. The authors previously reported that the treatments were equally effective at 1 year12 and the surgical procedure was slightly superior at 2 years13. With 90% follow-up from the original cohort at a mean of 6.3 years, therapeutic failure (defined as any further treatment) occurred in 11.6% of the surgical group and only 41.6% of the injection group14. They pointed out that 58% of patients randomized to corticosteroid injection for CTS needed no further treatment in the 6-year period. Amyloidosis is a potentially lethal systemic condition resulting from extracellular deposition of precursor proteins, including in tenosynovial and cardiac muscle tissues. Although a connection between CTS and amyloidosis was described as early as the 1960s15,16, it has had little attention in recent literature. Lately, advances in treatment for patients with an early diagnosis of amyloidosis have been shown to prevent heart failure and mortality and have resulted in renewed interest in the correlation of CTS and trigger finger with amyloidosis. Recent areas of focus include the prevalence of amyloidosis and which patients benefit from screening. A U.S. Veterans Health Administration (VHA) study of 126,788 patients who underwent CTR, trigger finger release, or both showed that there was a significantly elevated risk of a later diagnosis of amyloidosis compared with a control group. A diagnosis of CTS and/or trigger finger preceded a diagnosis of amyloidosis by as little as 3 years17. DiBenedetto et al. found that tenosynovium from 29% of men ≥50 years of age and women ≥60 years of age tested positive for amyloid on Congo red staining18, and Afshar et al. reported that 7% of 114 patients who were 46 to 80 years of age and had bilateral CTS had amyloid19. Further study is needed to understand how to optimally screen for this condition. Trigger Finger There is a tenet in hand surgery that is more talked about than practiced: when proximal interphalangeal joint (PIPJ) contracture exists in conjunction with trigger finger, surgical treatment must include excision of a slip of the flexor digitorum superficialis (FDS) in addition to an A1 pulley release. Previous literature on this topic has been equivocal. Baek et al. helped to support the abandonment of this practice by randomizing 55 patients with a PIPJ contracture of ≥10° to open A1 pulley release alone or with the excision of the ulnar slip of the FDS. At the 2-week follow-up, the group that had A1 pulley release only had significantly and clinically meaningfully better strength. By 6 weeks, there were no differences in the degree of contracture, pain, or function between the 2 groups. All but 4 (2 in each group) of the PIPJ contractures resolved to <5° at the 1-year follow-up20. Many of us have encountered a patient unhappy about what appear to be new Dupuytren nodules at the site of a healed trigger finger incision. The relationship between Dupuytren nodules and a trigger finger release has now been quantified in a database matched-cohort study. Maasarani et al. found that, within 1 year of a trigger finger diagnosis or intervention, patients treated operatively for a trigger finger were more likely to develop and to be treated for Dupuytren disease than those treated with a corticosteroid injection or no intervention. This increased risk included fewer days to the onset of a new diagnosis of Dupuytren disease and a higher rate of fasciectomy than in all other groups21. Dupuytren Disease There are now quite a few studies that show 5-year results of a collagenase Clostridium histolyticum (CCH) injection for Dupuytren disease compared with other treatment methods, including a randomized controlled trial of 156 patients with 92% follow-up22. The consensus is that CCH provides little to no benefit over percutaneous needle fasciotomy in terms of recurrence or reintervention but is much more expensive22-24. Both treatments have similar 5-year recurrence rates of around 50%; in comparison, the rate after surgical fasciectomy is much lower23,25. There are some circumstances in which percutaneous treatment is not deemed appropriate and open fasciectomy is recommended. One disadvantage of open fasciectomy is that stiffness may affect the recovery of finger motion and function. Kwan et al. reviewed 58 patients who underwent fasciectomy, some of whom received an intraoperative 10-mg intravenous dose of dexamethasone, followed by a 6-day taper of oral methylprednisolone, and some who did not (the control group). At the 2 and 6-week follow-ups, the corticosteroid injection group had significantly better range of motion and hand function (Disabilities of the Arm, Shoulder and Hand [DASH] scores) than the control group26. Trauma Several authors explored radiographic assessment of distal radial fractures. It has become commonplace to use electronic text messaging to send radiographs by smartphone, typically to efficiently assess and coordinate patient care. Adams et al. asked 8 providers (hand surgeons, hand fellows, and residents) to review the radiographs of 28 distal radial fractures to assess the need for a surgical procedure and to classify the fractures on both a smartphone and picture archiving and communication system (PACS). They found that there was excellent intraobserver agreement with regard to the need for a surgical procedure and substantial intraobserver and interobserver agreement on classification, indicating that the evaluation of distal radial fracture radiographs on a smartphone does not hinder decision-making27. Ulnar variance is a common criterion used to assess the need for surgical intervention in distal radial fractures. Johnson et al. reviewed 250 distal radial fractures for ulnar variance by comparing the posteroanterior view and the lateral view for ulnar variance. On the lateral view, the relationship of the palmar and dorsal articular rims of the radius was compared with the distal ulnar articular surface. The authors found that, when assessed on the lateral view, only 5% of distal radial fractures had true ulnar positive variance (both radial articular rims lay proximal to the ulnar articular surface) compared with 32% with apparent ulnar positive variance on the posteroanterior view28. This information may be especially helpful when treating patients ≥70 years of age, in whom it is often difficult to reconcile nonoperative management with radiographic displacement. There is substantial evidence in support of nonoperative management of distal radial fractures in the elderly population29-31, as they have long-term outcomes that are similar to those of patients who are managed with open reduction and internal fixation. One complication of the nonoperative management of distal radial fractures that had not been well described is delayed-onset CTS. Kim et al. evaluated risk factors for delayed-onset CTS in patients ≥60 years of age with distal radial fracture. Of 216 patients treated nonoperatively, 26 (12%) developed subacute CTS. In comparing patients who developed CTS with those who did not, the authors found an association with decreasing volar tilt (mean, 11.1° dorsal tilt compared with 0.1° volar tilt) and decreasing teardrop angle (mean, 48.7° compared with 63.0°)32 on radiographs in those who developed CTS. The mean time to diagnosis of CTS was nearly 3 months (89.9 days), a time after which many patients have been discharged from care. This information should be considered when counseling patients with a highly angulated radiographic malunion. Most metacarpal fractures heal with good function when treated nonoperatively. Several studies have furthered our knowledge of which fractures may be left to heal in situ. France et al. identified 15 patients with a fifth metacarpal neck fracture that healed with angulation of >70° (mean, 73°), one-half of whom were laborers. The mean follow-up was 32 months. Twelve (80%) of 15 patients scored 0 (no disability) on the QuickDASH score (an abbreviated version of the DASH), and all patients scored <10, indicating minimal morbidity33. Pagani et al. reported on 24 Major League Baseball position players with an acute metacarpal fracture, 11 of whom were treated operatively and 13 of whom were treated nonoperatively. Players treated nonoperatively missed significantly fewer games (35.5) than those treated operatively (52.6)34. Although these involved small groups and possibly heterogeneous fracture types, it is suggestive that return to even high-demand function may be quicker with nonoperative management of metacarpal fractures. When fixation of a metacarpal or proximal phalanx fracture is indicated, intramedullary headless compression screw fixation has become increasingly mainstream, with excellent early return to function and range of motion35. This technique usually involves percutaneous retrograde insertion of a guide pin followed by a headless compression screw through the distal articular surface into the medullary canal. Several cadaveric studies examined the damage to the articular surface and extensor tendon using this technique and found that the risk to these structures is low and any damage that does occur is not likely to cause long-term functional disability36,37. Patients with flexor digitorum profundus (FDP) tendon laceration in zone I (distal to the FDS insertion) may present late, after the chance for primary repair has passed. Compton et al. reported the results of 11 patients treated with non-repair (with or without debridement of the tendon) of a zone-I FDP injury compared with 15 patients treated with acute primary repair. They found that the non-repair group had better objective outcomes in terms of the distance from the fingertip to the distal palmar crease (1.1 compared with 1.6 cm) and the number of patients unable to touch the fingertip to the palm (1 compared with 8 patients) than the repair group but had much lower cost and much fewer complications and therapy visits than the group that underwent primary repair. None of the non-repair group had active flexion of the distal interphalangeal joint. Patient-reported outcomes were similar between groups38. At the very least, this suggests that non-repair of an isolated FDP injury is not inferior to acute repair, which may help in counseling patients with delayed presentation. Hand Arthritis Thumb carpometacarpal joint (CMCJ) arthritis is ubiquitous in the surgeon’s office, although most patients with this condition may be successfully managed with nonoperative measures39,40. Since deregulation in 2018, there has been high public interest in cannabidiol (CBD) as an over-the-counter treatment for arthritis-related pain. In a carefully constructed safety and efficacy study, twice-daily topical application of 6.2-mg CBD cream yielded significant and clinically meaningful improvement in pain, with a mean visual analog scale (VAS) for pain (0-to-10 scale) of 5 at baseline, 5 with a control cream, and 2 with the CBD cream. DASH scores were 36 at baseline, 31 with the control cream, and 22 with the CBD cream41. Corticosteroid injection is another pain-relieving modality for which there is strong evidence for use in thumb CMCJ arthritis. Tawfik et al. showed that general use of corticosteroid injections for CMCJ arthritis does not negatively impact the outcomes or rate of complications of CMCJ arthroplasty, even when >3 injections have been given42. Infection There is strong evidence for the use of corticosteroid injections in trigger finger, CTS, and thumb CMCJ arthritis. As in other orthopaedic subspecialties, the correlation between surgical site infection and recent corticosteroid injection has been examined. The rate of surgical site infection or wound complications for CMC arthroplasty was significantly increased when a corticosteroid injection has been administered to the surgical site within 90 days prior to the surgical procedure43. Kirby et al. demonstrated a much higher rate of infection after CTR if a corticosteroid injection had been administered preoperatively (mean, 55 days)44. Suppurative flexor tenosynovitis is a rare but serious complication after trigger finger release surgery45, and corticosteroid injection within 30 days prior to trigger finger release portends an elevated risk of deep infection requiring surgical debridement. In addition, there is an elevated risk of surgical site infection of any type when a corticosteroid injection had been administered within 90 days prior to a trigger finger release surgery46,47. Thus, strong consideration should be given to avoiding ipsilateral hand surgery within 90 days after corticosteroid injection. There has been professional consensus since 201548,49 that has recommended against the use of prophylactic antibiotics for clean hand surgery, citing low rates of surgical site infection whether or not antibiotics are given. Zheng and Fowler further corroborated this information and reported that prophylactic antibiotic administration did not lower the rate of surgical site infection in cubital tunnel surgery50. Even so, in a retrospective chart review, 48.2% of patients still received prophylactic antibiotics before CTR surgery from 2017 to 201851. However, this is an improvement from before the guidelines went into effect, when 83.9% of patients received antibiotics before CTR. Pediatrics Fracture It has repeatedly been shown that buckle fractures of the distal radius may be safely treated with minimal immobilization for comfort and patient-directed return to activity52. The results of a 2020 survey of Pediatric Orthopaedic Society of North America (POSNA) members (21.3% response rate) showed that 69% of respondents had come to favor treatment with a removable brace, although younger members (≤20 years in practice) had a higher likelihood of adhering to the guidelines at 76% than older members at 51%53. This is a dramatic improvement from a similar survey in 2012 when only 29% of respondents used removable splinting for this injury54. There remains unease about how best to treat patients <10 years of age with distal radial fractures that are 100% displaced and overriding, despite evidence from 2012 in favor of in situ immobilization55. A recent study compared a reduction and casting cohort of 50 patients56 with a historic in situ casting cohort of 51 patients55. At the final follow-up, there was significantly worse angulation in the reduction group in both the sagittal plane (13.49° compared with 2.2°) and the coronal plane (8.59° compared with 0.75°). In addition, patients who had closed reduction spent a mean time of 6.6 hours in the emergency department and had more than double the emergency department charges ($7,330) compared with patients treated with in situ casting ($3,500). Furthermore, 36 (72%) of 50 patients in the reduction group had unacceptable alignment at some point in their follow-up requiring additional manipulation or cast modification56. These results beg the question of why a patient should be subjected to conversion of a stable fracture to an unstable fracture, with its inherent costs and complications, if final outcomes are similar. Trigger Digit Trigger fingers are rare in children and are known to be a harbinger for underlying disease such as mucopolysaccharidoses or systemic inflammatory disorders57. However, a systematic review of pediatric trigger finger studies suggested that additional testing does not need to be done if patients present with a single trigger finger. In the review, 54% of the 193 patients in the included studies presented with a single affected finger. Only 29% of patients had an underlying diagnosis, and those patients often had multiple trigger fingers or carpal tunnel syndrome. Some of the 193 patients were treated nonoperatively, but, overall, only 26 children (13%) had satisfactory resolution of symptoms without a surgical procedure58. Pediatric trigger thumb is much more common than trigger finger. Although newer evidence has shown that up to one-third of pediatric trigger thumbs resolve spontaneously within 5 years of presentation59, those children who do undergo a surgical procedure benefit from a local anesthetic injection before incision. A randomized controlled trial in which the anesthesia team was blinded to treatment showed that children required significantly less sevoflurane during the procedure if the surgical site was injected before incision rather than after the procedure60. Ganglion Cyst Children present with ganglion cysts affecting the hand and wrist in a pattern similar to that of adults61. The natural history and indications for surgical excision have not been well-defined for pediatric patients with a wrist ganglion. In 315 children with wrist ganglion cysts and >2-year follow-up, surgical excision yielded the highest rate of resolution at 72.8%, but a relatively high rate of recurrence at 27.2%. For nonoperative management, the highest rates of resolution appeared with observation (44.2%) and use of a wrist orthosis (54.5%), which were not significantly different. Aspiration had the lowest resolution rate at 18%. Children ≤10 years of age had a higher rate of spontaneous resolution than those >10 years of age. Based on the findings, the authors suggested that the expense of a wrist orthosis or cyst aspiration is not warranted over simple observation and that a surgical procedure should be judiciously offered to patients with persistent pain or functional limitations62. Practice Management Patient Communication Effective communication with patients is an enormously important but elusive component of the provider-patient interaction. Several studies were published comparing written and video-based patient educational materials. Patients reported higher satisfaction, better comprehension, safer opioid use, and increased utilization of exercises with video materials compared with written handouts63-66. Postoperative Rehabilitation Wide awake surgery with local anesthesia and no tourniquet (WALANT) has become the standard of care for many hand surgical procedures. Advantages include lower costs67, decreased environmental impact68, and excellent patient satisfaction69. One question that has made surgeons uneasy is whether it is safe for patients to drive after WALANT. A simulation recently showed that driving is theoretically not impaired with a bandaged, numb hand70. Pina et al. reported that 39% of patients admitted having driven to and from the surgical procedure69, and a prospective study revealed that 29.5% of patients anonymously reported that they drove the day of the surgical procedure and 51.4% had returned to driving by the end of postoperative day 1 after outpatient hand surgery, regardless of anesthesia type. Thirty-four percent of patients in that study reported returning to driving while wearing a cast, splint, or sling71. Inroads have been made in determining the optimal use of opioids after hand surgery. Evidence exists that opioid prescription after soft-tissue hand surgery is not indicated72,73. Zohar-Bondar et al. randomized patients to a standard educational group or an enhanced (additional 10 minutes) education group before the patients underwent hand surgery74. The enhanced education group took a median of 0 pills (range, 0 to 13 pills) and the standard group took a still extremely low median of 0.5 pills (range, 1 to 40 pills). In another randomized trial, Vincent et al. highlighted again that patient education reduced the number and duration of pills taken, but there is still a grave overprescription of opioids, as they reported that approximately 50% of prescribed pills went unused75. Additional methods to reduce pills in circulation may be handouts on proper pill disposal76, tiered prescribing guidelines based on procedure type77,78, and prescriptions written in 3 equal distributions79. Environmental Impact of Hand Surgery There has been a surge of interest in the environmental impact of our work. In the United States, the health-care sector is responsible for 10% of the nation’s greenhouse gas emissions80, and medicine, medical equipment, and the supply chain comprise >60% of the health care-related emissions81. Certainly, we all observe the substantial physical waste produced by surgical procedures. Baxter et al. surveyed use of supplies in hand surgery across 35 U.S. surgeons in 19 centers to assess variation. They determined that, with judicious use of 10 key items, carbon dioxide emissions could decrease by 10.9 kg per procedure. Extrapolated across other surgical specialties, they estimated a potential annual avoidance of 800,600 metric tons of carbon emissions82. Certain procedures leave a heavier carbon footprint than others. Endoscopic CTR was estimated to have almost double the carbon footprint as open CTR, for example83. Other studies have highlighted the number of opened but unused items per case (mean, 11.5 items)84 and administrative obstacles to reducing waste and how they may be overcome85, and Dickson et al. outlined 5 priorities that we need to observe to make hand surgery carbon-neutral86. Evidence-Based Orthopaedics The editorial staff of JBJS reviewed a large number of recently published studies related to the musculoskeletal system that received a higher Level of Evidence grade. In addition to articles cited already in this update, 3 other articles with a higher Level of Evidence grade relevant to hand and wrist surgery are appended to this review after the standard bibliography, with a brief commentary about each article to help guide your further reading, in an evidence-based fashion, in this subspecialty area. Evidence-Based Orthopaedics Jung HS, Baek SH, Lee JS. Is a steroid injection in both compartments more effective than an injection in the extensor pollicis brevis subcompartment alone in patients with de Quervain disease? A randomized, controlled trial. Clin Orthop Relat Res. 2022 Apr 1;480(4):762-70. This study examined patients with de Quervain tenosynovitis who had a separate extensor pollicis brevis (EPB) subcompartment. One hundred patients with an ultrasound-confirmed EPB subcompartment were randomized to corticosteroid injection into the subcompartment only or into both the main compartment and the subcompartments of the first extensor compartment. At 6 weeks and 3 months, there was no difference in pain relief between groups. However, there was roughly one-half the incidence of hypopigmentation in the subcompartment-only group. This study is helpful in clarifying that, for patients who have an EPB subcompartment and receive an ultrasound-guided corticosteroid injection, only the EPB subcompartment needs to have the injection. However, the study lacked a comparison group with injection of the main compartment alone. Although ultrasound-guided injections are increasingly mainstream, they also increase the cost of the corticosteroid injection. Furthermore, longer-term follow-up on these cohorts would be helpful. Lawson A, Naylor J, Buchbinder R, Ivers R, Balogh ZJ, Smith P, Xuan W, Howard K, Vafa A, Perriman D, Mittal R, Yates P, Rieger B, Smith G, Adie S, Elkinson I, Kim W, Sungaran J, Latendresse K, Wong J, Viswanathan S, Landale K, Drobetz H, Tran P, Page R, Beattie S, Mulford J, Incoll I, Kale M, Schick B, Li T, Higgs A, Oppy A, Harris IA; Combined Randomised and Observational Study of Surgery for Fractures in the Distal Radius in the Elderly (CROSSFIRE) Study Group. Plating vs closed reduction for fractures in the distal radius in older patients: a secondary analysis of a randomized clinical trial. JAMA Surg. 2022 Jul 1;157(7):563-71. This study showed the 2-year outcomes of the CROSSFIRE trial in which patients ≥60 years of age with displaced distal radial fractures were randomized to closed reduction and casting or volar locking plate treatment. Radiographic outcomes were not reported, but the patients in the casting group were not monitored for fracture settling. There were no significant differences between the groups in terms of patient-reported function, pain, quality of life, or bother with appearance scores between the 2 groups. These findings support the existing evidence that nonoperative management of distal radial fractures in the elderly population restores patients to normal function with minimal risk and lower cost than volar locking plate. Selles CA, Mulders MAM, Winkelhagen J, van Eerten PV, Goslings JC, Schep NWL, VIPAR Collaborators. Volar plate fixation versus cast immobilization in acceptably reduced intra-articular distal radial fractures: a randomized controlled trial. J Bone Joint Surg Am. 2021 Nov 3;103(21):1963-9. Patients who were 18 to 75 years of age and had unstable, intra-articular distal radial fractures with acceptable alignment after closed reduction were randomized to cast management or open reduction and internal fixation with a volar locking plate. The operatively treated group had significantly better function early, but, by 12 months, this difference was no longer clinically meaningful. Thirteen (28%) of 46 patients randomized to cast management fell into unacceptable alignment and had later open reduction and internal fixation or osteotomy for symptomatic malunion. Thus, 72% of patients randomized to cast management avoided a surgical procedure altogether. Overall, there were more complications in the cast management group, although those with secondary displacement were analyzed with that group in the intention-to-treat analysis. It should be noted that there was lower satisfaction with treatment in the group with cast management, primarily from those patients with loss of reduction.