What’s New in Hand and Wrist Surgery

Abstract

It is my pleasure to provide an overview of the hand and wrist literature published from 2019 to 2020 in the Journal of Hand Surgery (American), the Journal of Hand Surgery (European), and HAND. Carpal Tunnel Syndrome The role of electrodiagnostic studies (EDX) in the management of carpal tunnel syndrome continues to evolve. Many surgeons use EDX to guide counseling and management, given that response to treatment and treatment recommendations may vary in more severe cases of carpal tunnel syndrome. Nkrumah et al.1 demonstrated that the severity of carpal tunnel syndrome can be established using sonographic measurement of the median nerve at the carpal tunnel inlet. A cross-sectional diameter of >12 mm was found to be a highly specific predictor of severe carpal tunnel syndrome (defined by the absence of measurable distal motor latency or distal sensory latency on EDX), suggesting that ultrasound can reliably be used for this purpose. For many surgeons, corticosteroid injection has a role in the management of carpal tunnel syndrome. The accuracy of this injection is critically important, as a misplaced injection can lead to the failure of relief or nerve injury. Prior to performing open carpal tunnel release, Green et al.2 placed a 25-gauge needle into the carpal tunnel to simulate an injection. Needle position was confirmed intraoperatively. Of 756 simulated injections, 572 (76%) were correctly placed. In 66 cases (8.7%), the needle was placed into the median nerve, and the carpal tunnel was missed 118 times (15.6%). These results provide an important reminder of the limitations of relying on surface landmarks and quantify the risk of interfascicular injection. The opioid epidemic has led physicians to consider alternative forms of analgesia, including gabapentinoids. Although gabapentinoids are not approved by the U.S. Food and Drug Administration for carpal tunnel syndrome, Billig et al.3 found that 6% of patients undergoing carpal tunnel release were prescribed gabapentinoids prior to surgery. Patients placed on gabapentinoids <3 months prior to carpal tunnel release were more likely to have continued postoperative gabapentinoid and opioid prescriptions >90 days postoperatively. Surgeons must be aware of misuse of gabapentinoids given their addictive potential and implications for substance abuse. Carpal tunnel release is considered a highly effective treatment for improving quality of life. Niedermeier et al.4 reported that, of the 39 patients who responded to a survey question regarding when and how carpal tunnel release improved their sleep, all reported improvement in sleep at 2-week follow-up (in addition to improvements in disability, as measured by the QuickDASH [abbreviated version of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire]). Nearly 50% of the patients had improvement in their sleep within 24 hours following surgery, while the remainder had improvement within 1 week. Although their analysis was not stratified by the severity of disease or preoperative quality of sleep, these data can help surgeons in counseling patients. Following carpal tunnel release, there is varying utilization of formal hand therapy evaluation and treatment. Using an administrative data set, Shah et al.5 found that approximately 18% of the patients had formal therapy after carpal tunnel release, adding approximately $400 to the total cost of care, with an average of 5 to 6 visits following surgery. The value provided by such formal sessions has been questioned, as Gil et al.6 performed a randomized controlled trial of therapy after carpal tunnel release. Patients who underwent mini-open carpal tunnel release were randomized to 1 of 3 groups: no therapy; 1 therapy session on postoperative day 10; or 6 weeks of standard, formal therapy. They did not find a difference in outcomes and return-to-work time, although their study was underpowered and there was substantial crossover among the groups. The average return-to-work time ranged from 16.6 to 21.8 days, which can be useful in counseling patients regarding postoperative expectations. Cubital Tunnel Syndrome Debate continues regarding in situ decompression versus anterior transposition to treat cubital tunnel syndrome. Given revision rates after in situ decompression that are higher than previously reported7 and the modest improvements reported after revision surgery8, in situ decompression may be inadequate for patients with advanced ulnar neuropathy. Yeoman et al.9 found that the vast majority of patients (86%) were satisfied after in situ decompression. However, all patients who were not satisfied had preoperative weakness of the muscles innervated by the ulnar nerve. These findings can aid surgeons in decision-making and in setting expectations; if in situ decompression is pursued for a patient with preoperative muscle weakness (presumably reflecting more advanced disease), there is an increased chance of dissatisfaction. Felder et al.10 reported results after using “cross” grafts from the median to the ulnar nerve in the palm to improve sensation in advanced stages of cubital tunnel syndrome with profound sensory loss. While there was improvement in sensation to a varying degree in all patients, most (87%) of the patients regained protective sensation alone and did not experience improvement in light touch sensation, static 2-point discrimination, or monofilament testing results. While the results are intriguing, the authors did not provide a comparison group without cross grafts. Furthermore, their ability to discern whether improvement was due to the cross grafts or from concurrently performed procedures (such as primary or revision ulnar nerve transposition) was limited. Distal Radial Fractures Many surgeons use the fixed-angle feature of the volar locking plate to guide restoration of sagittal tilt in the treatment of distal radial fractures. This technique presumes that the implant’s sagittal tilt angle matches the patient’s physiologic tilt. Gandhi et al.11 examined radiographs of 273 uninjured adult distal radii and found that the volar cortical angle (VCA) ranged from 23° to 43°, with a mean of 32°. Given that most volar locking plates have a fixed angle of 18° to 30°, there is a substantial chance that there will be a mismatch between the patient’s VCA and the implant. If the patient’s VCA exceeds the plate’s fixed angle, this may lead to undercorrection of sagittal tilt if the plate is used as a reduction guide. Coupled with the work of Wurtzel et al.12, who demonstrated that undercorrected sagittal tilt may increase contact pressure on the flexor pollicis longus, surgeons may wish to reconsider reliance on the fixed-angle feature of the volar locking plate for reduction during distal radial fracture fixation. Another recognized complication of volar locking-plate fixation is irritation and rupture of the extensor tendons. To mitigate this risk, many surgeons recommend placing unicortical screws in the subchondral bone. While this protects the extensor tendons from dorsally prominent screws, it also decreases the ability to secure dorsally based fragments through an implant applied from the volar surface of the radius. Zimmer et al.13 used computed tomography (CT) to quantify the size of the dorsal-ulnar corner fragment, which may hold particular importance in the maintenance of sagittal reduction and the stability of the distal radioulnar joint. They demonstrated that the dorsal-ulnar corner fragment of the distal part of the radius comprises 24% of the articular surface, suggesting that unicortical subchondral screws that are <75% of the width of the radius will not reliably secure this fragment and that longer screws may be desired. If the surgeon deems the dorsal-ulnar corner fragment to be of importance in maintaining the reduction but wishes to minimize the risk of a dorsally prominent screw tip, other strategies beyond volar locking-plate fixation alone may be used. Fragment-specific fixation can be employed but may also lead to implant prominence or additional stiffness due to multiple surgical approaches. As an alternative, Ruch et al.14 reported on the use of a dorsally based screw threaded into 1 of the distal screw holes in a volar locking plate, with satisfactory clinical and radiographic outcomes among 12 patients. While the particular technique they used is proprietary, the principles from this study and the findings of Zimmer et al.13 suggest that a limited approach using interfragmentary fixation of the dorsal-ulnar corner fragment may be beneficial. As surgeons’ practices reflect recent literature supporting initial nonoperative treatment for distal radial fractures (particularly in elderly patients), there is a possibility that more symptomatic malunions may need to be addressed surgically in the future. While an osteotomy to treat symptomatic malunion of the radius is generally considered a reliable procedure, Haghverdian et al.15 reported that 10 of 60 patients who underwent a corrective osteotomy had difficulties with osseous healing. This was more likely to occur if a distraction-type technique was used (bicortical osteotomy with bone-grafting) as opposed to a hinged-type technique (the volar cortex was left in continuity). The vast majority (55 of 60) of the patients were treated with use of a volar locking plate, and notably, there were 3 cases of volar locking-plate removal (5.5% of the 55 volar locking-plate cases) and 3 cases of delayed extensor pollicis longus rupture (5.5% of the 55 volar locking-plate cases). Schurko et al.16 also reported their experience with corrective osteotomy for symptomatic malunion of the distal part of the radius. Their osseous union rate was higher than that of Haghverdian et al.15 (1 nonunion among 53 total cases), but the complication rate associated with the use of a volar locking plate was also higher (4 implant removals among 37 cases treated with a volar locking plate). The overall complication rate was higher in cases treated with dorsal plating (including 6 implant removals among 16 cases treated with dorsal plating). Peripheral Nerve and Brachial Plexus Injury When available, nerve transfer using a flexor carpi ulnaris (FCU) branch of the ulnar nerve as a donor nerve is the most reliable method for restoring elbow flexion in patients with brachial plexus injury (BPI). The high success rate seen with this transfer17 has led peripheral nerve surgeons to consider an FCU branch as a donor nerve even when it is compromised18. However, results reported by Lovy et al.19 may cause surgeons to reconsider the use of a compromised FCU branch. Among 91 cases in which an FCU branch was used to restore elbow flexion (among a variety of injury patterns and within the context of different surgical strategies), 18 (20%) of the cases were considered unsuccessful (<M3 elbow flexion at the time of final follow-up). Among these 18 cases, 14 patients had preoperative FCU weakness on manual muscle testing. These findings led Lovy et al.19 to urge surgeons to consider alternative strategies for restoring elbow flexion if there is preoperative FCU weakness. One traditionally considered option is the transfer of 2 or 3 intercostal nerves to the musculocutaneous nerve, which was associated with a success rate of 72% with ≥M3 elbow flexion in a prior systematic review of internationally reported results20. Comparing outcomes of FCU branch nerve transfer versus intercostal nerve transfer, Chia et al.21 reported reliable restoration of elbow flexion using either technique. With intercostal nerve transfer, 15 of 15 cases had ≥M3 elbow flexion, with 10 of these cases achieving ≥M4 elbow flexion. While the overall magnitude of elbow flexion strength (as measured by dynamometry) is weaker with intercostal donor nerve compared with FCU donor nerve, the latter remains a reliable nerve transfer to restore elbow flexion. There is growing enthusiasm for the use of nerve transfer procedures in the treatment of patients with radial nerve injuries. Bertelli22 reported the results of a study in which 14 patients who presented <12 months from injury were treated with nerve transfer and 13 patients who presented >15 months from injury were treated with tendon transfer. The restoration of wrist extension was reliable after both techniques, but a greater arc of motion was seen among the patients who had nerve transfer. Finger extension was reliably restored (M4) in all patients with tendon transfer. Among the patients who underwent nerve transfer, 12 had M4 finger extension, but there were 2 cases of complete treatment failure with regard to finger extension; there was no description of how these failures were later treated. In both groups, full thumb metacarpophalangeal joint (MPJ) extension was not restored, with an average lag of 30°. To address this shortcoming in restoring thumb MPJ extension, Bertelli et al.23 reported transfer of the distal branch of the anterior interosseous nerve (transected just prior to its innervation of the pronator quadratus) to the deep branch of the posterior interosseous nerve (prior to its innervation to the muscles of the first, second, and third dorsal compartments) at the level of the mid-forearm. Their cadaveric dissection demonstrated that tension-free end-to-end coaptation can be performed with an appropriate size match and a 0.65:1 donor-to-recipient-axon ratio. Among their 5 cases, full thumb MPJ extension was demonstrated in 2 cases and MPJ extension lags of 15°, 15°, and 20° were seen in the remaining 3 cases. While these studies22,23 support the ability to restore radial nerve function with nerve transfer (and perhaps to a level that exceeds tendon transfer), further work is needed to clarify the indications for nerve transfer rather than tendon transfer with regard to timing and patient expectations. With respect to the former, I am not aware of any comparative studies to have assessed nerve versus tendon transfer in an early time frame (<1 year from injury) where both options were viable treatment strategies. For the latter, current literature demonstrates that a longer time frame is needed to see results from nerve transfer (typically at least 1 year following surgery) versus tendon transfer (in which results stabilize within 3 to 4 months after surgery). More information, perhaps in the form of a decision aid, would be helpful to assist surgeons, therapists, and patients in choosing the most appropriate treatment for radial nerve palsy. The use of “supercharged” (reverse end-to-side [RETS]) nerve transfer of the anterior interosseous nerve in the treatment of ulnar nerve injuries continues to grow. Koriem et al.24 reported their experience with treating 21 ulnar nerve injuries, 10 treated with repair alone and 11 treated with repair and RETS. No patient underwent an end-to-end nerve transfer. Patients were included in this randomized study if their injury was above the elbow or up to 10 cm distal to the medial epicondyle. While the authors’ results from RETS suggest its superiority over ulnar nerve repair alone, the broad inclusion criteria with regard to the location of injury and the lack of comparison with patients with end-to-end transfer leave an important question unanswered: when is it appropriate to perform an end-to-end or RETS procedure? Flexor Tendon Repair While many suture configurations have been described for flexor tendon repair, Irwin et al.25 compared the biomechanical properties of repair using either a tendon coupling device (a low-profile stainless steel staple plate in each tendon stump, bridged by polyethylene thread) or an 8-strand locking-cruciate repair. The 2 repair techniques performed similarly with regard to gapping after 2,000 cycles of loading, although the study was underpowered to detect a significant difference for this comparison. The mean load to failure was significantly higher for tendons fixed with the coupling device (77 N) compared with tendons fixed with an 8-strand locking cruciate repair (55 N). Coupler repair was 4 times faster than 8-strand locking-cruciate repair, adding to the former’s appeal. However, further study is needed to determine how coupler repair performs with regard to gliding and adhesion formation, which are critically important elements in flexor tendon repair. Dupuytren Contracture Leafblad et al.26 evaluated a single surgeon’s experience with needle aponeurotomy, collagenase injection, and surgical fasciectomy over an 11-year time frame in the treatment of Dupuytren contracture. The rates of reintervention after needle aponeurotomy were 24% at 2 years and 61% at 5 years (mean time to reintervention, 1.8 years). The rates of reintervention after collagenase injection at the same time points were 41% and 55%, respectively (mean time to reintervention, 0.95 year), and after surgical fasciectomy, the rate of reintervention was 4% at both 2 and 5 years (mean time to reintervention, 0.92 year). The authors also included cost data. Given the 6.7-times-higher initial direct cost of collagenase injection compared with needle aponeurotomy, it appears that the latter is a high-value intervention that may have a lasting role in the treatment of Dupuytren contracture (alongside surgical fasciectomy for select cases). Trigger Finger Corticosteroid injections are viewed as an effective initial treatment for trigger finger, with surgical release offered if lasting relief is not obtained. Given concerns for wound-healing issues and infections, many surgeons delay surgery after the last injection. Two recent studies have examined the relationship between corticosteroid injection and subsequent infection after trigger-finger release. Matzon et al.27 analyzed 2,480 digits among 1,857 patients who underwent trigger-finger release. Of 53 infections (2.1% of the digits), 41 were superficial and 12 were deep (involving reoperation). If corticosteroid injection was performed <90 days before surgery, the likelihood of having a deep infection was 6.5 times greater than if the corticosteroid injection was performed ≥90 days before surgery. Using a broader definition of infection and less rigorous methodology, Ng et al.28 reported a similar overall rate of injection (2.6% [26 cases among 999 trigger finger releases]) and a similar relationship between corticosteroid injection and postoperative infection. Although the overall risk of infection is low, surgeons may wish to consider waiting to perform surgery until at least 90 days after corticosteroid injection. Basal Joint Arthritis There is continued debate over the most appropriate method for treating patients with painful thumb carpometacarpal joint arthritis. In a survey of 126 hand surgeons, Ottenhoff et al.29 found low agreement among surgeons as to which type of treatment to offer. When assessing clinical scenarios, surgeons are most likely to recommend operative treatment in situations in which patients report more severe pain, have not seen relief with prior intra-articular steroid injections, or have more severe radiographic arthrosis. Surgeon respondents were less likely to recommend surgery if patients exhibited substantial depressive symptoms, suggesting that surgeons are aware of the influence of mental health on prognosis after treatment. Despite continued reported success seen with trapezium excision alone, many surgeons (including 72% of the respondents in the survey of Ottenhoff et al.29) prefer ligament reconstruction and tendon interposition (LRTI). This preference for LRTI over trapezium excision is substantiated by the study by Shah et al.30 demonstrating that LRTI (with split flexor carpi radialis [FCR] tendon) more closely resembled intact forces in the muscles crossing the wrist compared with trapezium excision, suture suspension arthroplasty, and silicone implant arthroplasty. While the applicability of these findings is limited given their in vitro nature, maximum restoration of wrist biomechanics provides the theoretical advantage of increasing longevity of the success of the procedure, particularly in younger and more active patients. Despite continuing debate as to which surgery to perform, Lane et al.31 demonstrated in an analysis of prospectively collected U.K. Hand Registry data that both trapezium excision alone and LRTI led to improvements in patient-reported outcomes and health utility. While there was no meaningful difference between the techniques, their study supports the value of surgical intervention. Although the majority of improvement in patient-reported outcome scores and health utility was noted within the first 3 months, improvement continued until 1 year after surgery, which may be helpful for surgeons in counseling patients. Wrist By using micro-CT scans, Morsy et al.32 examined the intraosseous vascularity of the scaphoid with greater sophistication than possible with prior methods. Their findings confirmed that inflow from the dorsal ridge supplies the vast majority (83%) of the scaphoid, but also demonstrated 2 distinct scaphoid morphologies, with 1 having a less robust network of intraosseous vascularity. Their work may be foundational for future investigation to guide the prognosis and management of scaphoid fractures and nonunions, as treatment of the latter continues to evolve. Pet et al.33 reported the results of 21 patients who received an osteochondral free flap from the medial femoral trochlea to treat proximal pole nonunions. Union was achieved in all but 1 patient, and there was 1 reoperation for thrombosis. There was also improvement in carpal alignment (measured by the radiolunate angle). Decreases in patient-reported outcome measures for donor knee function were noted, but these changes did not meet the threshold for clinical importance. Concern for donor-site morbidity is one of the reasons that Sommerkamp et al.34 advocate for a palmar radiocarpal artery vascularized bone flap. Among 15 cases with “humpback” deformity and an avascular proximal pole, all cases went on to osseous union, and radiographic carpal alignment was improved. The lack of donor-site morbidity and the avoidance of complexities associated with free tissue transfer make this an appealing option, but it is reassuring to know that surgeons have many options, both pedicled and free tissue, for these challenging cases. The treatment of pre-arthritic scapholunate dissociation continues to challenge surgeons. Sandow and Fisher35 presented a novel reconstruction technique, weaving a double strand of suture tape (anchored in the trapezium) and a distally based strip of tendon autograft (FCR) from volar to dorsal within the scaphoid, then passing it from dorsal to volar through the lunate, and anchoring it volarly in the radial styloid (with an interference screw inserted from dorsal to volar in the radius). At 24 months, their reconstruction provided restoration of static scapholunate stability (as measured on radiographs). While the anecdotal outcomes reported by the authors are impressive, they should be interpreted with caution given that clinical outcome measures were not robustly collected. Their report is intriguing, but as with other types of scapholunate reconstruction, the technical complexity will likely limit its widespread adoption until results can be reproduced broadly. Blackburn et al.36 compiled the results of another reconstructive technique, 3-ligament tenodesis, in 203 patients treated by a consortium of 20 surgeons. While there was improvement in patient-reported outcomes at 1 year for 79% of the patients, 10% had no change and 11% had worse patient-reported outcomes. These results suggest that the indications for 3-ligament tenodesis need further clarification. When attempting repair of the scapholunate interosseous ligament (SLIL), there is increasing interest in suture-tape augmentation of the native ligament. In their biomechanical study, Park et al.37 demonstrated that specimens with suture-tape augmentation of SLIL repair demonstrated higher load to failure than those treated with repair alone, but did not replicate the failure loads of the native ligament. It should be noted that the testing setup was oriented perpendicular to the SLIL and the authors assessed tensile strength in the coronal plane only; they did not evaluate response in other planes (i.e., with motion of the scaphoid in the sagittal plane). In addition, as disclosed in the report, 2 of the authors were paid consultants, speakers, or presenters for the manufacturer of the suture tape that was tested. 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 Linnanmäki L, Kanto K, Karjalainen T, Leppänen OV, Lehtinen J. Platelet-rich plasma or autologous blood do not reduce pain or improve function in patients with lateral epicondylitis: a randomized controlled trial. Clin Orthop Relat Res. 2020 Aug;478(8):1892-900. In this randomized controlled trial, patients were randomized to receive a saline solution injection, a platelet-rich plasma injection, or an autologous blood injection to treat lateral epicondylitis. There were no clinically important differences among the treatment groups with respect to pain or patient-reported outcome at any time point assessed. Reid SA, Andersen JM, Vicenzino B. Adding mobilisation with movement to exercise and advice hastens the improvement in range, pain and function after non-operative cast immobilisation for distal radius fracture: a multicentre, randomised trial. J Physiother. 2020 Apr;66(2):105-12. Epub 2020 Apr 11. This randomized trial included patients who were treated nonoperatively for a distal radial fracture. Patients whose exercise program included the addition of manual therapy for wrist extension and supination had improved patient-reported outcomes and forearm/wrist motion at both 4 and 12 weeks compared with those who had a more traditional home exercise program. Rundgren J, Mellstrand Navarro C, Ponzer S, Regberg A, Serenius S, Enocson A. Regional or general anesthesia in the surgical treatment of distal radial fractures: a randomized clinical trial. J Bone Joint Surg Am. 2019 Jul 3;101(13):1168-76. In this randomized trial of regional or general anesthesia in the surgical treatment of distal radial fracture, the authors found that patients who had regional anesthesia had lower opioid consumption and delayed onset of maximum pain. There was no difference in patient-reported outcomes or quality of life at 6 months following surgery.