Field Of Hand Surgery Research Articles

Whatʼs New in Hand Surgery

This update reviews material presented at the 2012 annual meetings of the American Society for Surgery of the Hand (ASSH), American Association for Hand Surgery (AAHS), and American Academy of Orthopaedic Surgeons (AAOS) as well as articles published in the field of hand surgery (other than those published in this journal) between August 2011 and July 2012. In addition to the broad focus of the AAOS, both hand surgery organizations feature presentations on shoulder and elbow surgery and general microsurgery, all of which are beyond the scope of this review. If a work was presented at more than one meeting, only the first presentation is described. Meeting abstracts for the ASSH, AAHS, and AAOS annual meetings are maintained online at www.assh.org, www.handsurgery.org, and www.aaos.org, respectively. The treatment of wrist fractures is increasingly surgical. However, several recent studies called into question the benefits of operative treatment as compared with nonoperative treatment. A report that was presented to ASSH reviewed 258 patients over the age of sixty-five years with distal radial fractures that were treated either operatively or nonoperatively. The patients were matched according to AO type, age, and sex. One year after the fracture, Patient Rated Wrist Evaluation (PRWE) scores, wrist motion, and grip strength were similar in the two treatment groups. The operative treatment group had a higher risk of complications (29% compared with 17%; p = 0.03) and a greater need for subsequent surgery (11% compared with 5%; p = 0.1) but had a lower malunion rate (4% compared with 26%) in comparison with the nonoperative treatment group. The authors concluded that surgery improves radiographic appearance but not function in patients over the age of sixty-five years and that these results come at the cost of higher rates of complications and additional surgery. A recent report …

Carpometacarpal and Scaphotrapeziotrapezoid Arthritis: Arthroscopy, Arthroplasty, and Arthrodesis

Osteoarthritis of the first carpometacarpal joint is the second most common site of osteoarthritis in humans. Symptomatic isolated scaphotrapeziotrapezoid joint arthritis, though less common overall, is also frequently observed by the hand surgeon. Investigations on the etiology, pathophysiology, natural history, outcomes of traditional treatments, and new forms of surgical techniques have been attracting more interest in the field of hand surgery. The goal of this article is to sort through the current prevailing ideas using recently available literature and to offer a concise, updated guide to further enhance the understanding of thumb carpometacarpal and scaphotrapeziotrapezoid arthritis.

A re-look at pollicization

One of the most difficult and intricate surgeries in the field of hand surgery is that of Pollicization. It involves transfer of one of the fingers to create a new functioning thumb when it is absent. This elegant surgical technique has evolved over the 100 years from a simple, though unaesthetic transposition of digits to a complex procedure which demands an intelligent use of skin flaps, osteotomy and muscle balancing to create an almost normal looking aesthetic thumb. We present a review of this procedure briefly touching on its historical development, indications, and refinements in the critical steps of the technique, long term results and complications.Pollicization continues to be one of the most useful surgeries in improving the function of the hand and has stood the test of time.

Themenpriorisierung für systematische Literaturanalysen in der Handchirurgie

Systematic reviews are fundamental decision-making tools for the assessment of the effectiveness of healthcare interventions and for determining future research fields. In the field of hand surgery, so far, there exists only a limited number of systematic reviews. According to the diversity and multitude of hand surgical topics, relevant fields for systematic reviews were identified by means of an expert ranking. A catalogue of 24 topics was extracted from publications of representative hand surgical journals. These topics were categorized and integrated into a questionnaire which was presented to 30 experts in the field of hand surgery. Every single topic had to be rated by marks from 1 (very relevant) to 5 (not relevant). Further topics could have been indicated. Averaging of the marks allowed to define a ranking and a prioritisation of the topics. 29 of 30 questionnaires were returned. The ranking showed scapholunate ligament injury, Kienboeck's disease and scaphoid nonunion to have the highest relevance, followed by 5 other topics dealing with wrist problems. The lowest relevance was attributed to neck fractures of the fifth metacarpal, ulnar collateral ligament injury of the thumb metacarpophalangeal joint and postoperative management following replantation. The results of the presented survey allow for a prioritisation of topics for systematic reviews in hand surgery. The ranking of the topics emphasises the particular relevance of injuries and diseases of the wrist.

The Diminishing Presence of Plastic Surgeons in Hand Surgery: A Critical Analysis

A growing trend of diminished presence of plastic surgery within the field of hand surgery has been observed in the membership of the American Society for Surgery of the Hand, applications for Certificate of Added Qualifications in Surgery of the Hand, and applications for hand surgery fellowships. The American Society for Surgery of the Hand resident education subcommittee has investigated this trend, collecting data from the Association of American Medical Colleges, the American Board of Orthopaedic Surgery, the American Board of Plastic Surgery, the National Residency Matching Program, the Accreditation Council for Graduate Medical Education, the American Society for Surgery of the Hand, the American Association of Hand Surgery, and the Certificate of Added Qualifications in Surgery of the Hand and from an online survey of plastic surgery-trained hand surgeons in the United States. These data indicate that the subspecialty of hand surgery enjoys growing popularity with increasing fellowship applicants annually; uses an effective, fair, and multidisciplinary match; and demonstrates continued and healthy growth in its premier academic society. Despite these positive indicators, the percentage of new plastic surgery diplomates obtaining Certificate of Added Qualifications in Surgery of the Hand has decreased from 10 percent (20 applicants per year) to 4 percent (8 applicants per year), the percentage of examinees for the Certificate of Added Qualifications in Surgery of the Hand originating from plastic surgery training backgrounds has decreased from 30 percent to 15 percent, the percentage of the overall body of actively practicing plastic surgeons in the United States that hold Certificate of Added Qualifications in Surgery of the Hand qualifications is steadily decreasing (now to 10 percent), and the plastic surgery membership in the American Society for Surgery of the Hand is demonstrating negligible growth despite the overall expansion of the American Society for Surgery of the Hand. This report serves as a detailed and systematic account of these findings, a balanced interpretation, and a proposal of specific potential solutions. These include recommendations for changes in the structure and content of plastic surgery training programs and the National Residency Matching Program hand surgery fellowship designations.

Ideas and Innovations

Quest for a technique to get a stronger repair to allow early mobilization after primary flexor tenorraphy continues in the field of hand surgery. A new, easy, and surgeon-friendly method of tenorraphy has been described based on strong mechanical and biological principles with the advantage of enabling the surgeon to mobilize actively in early postoperative period to obtain better overall results.

Pioneers in Hand Surgery.

ErikMobergwas, tosaythe least, aunique person and aoneof a kind personality with a multifold of skills. Hiscontributions in the field of hand surgery are well documentedand well known. Less known are maybe his other skills thatrange from archeology and ancient cultures to being a devotedsailor and collector of butterflies. His never-ending curiosityandwillingnesstolearnandrelearninthebroadestaspectoflifeareassetsthatneedtobeemphasizedandhopefullyfollowedbyyounger colleagues. Erik was a true academic and a role modelfor people striving for perfection regardless of topic. He joineddiscussions, often with strong opinions, but with a good moodandopenmind.Hedeliverednumerousmemorablelecturesthatalways took the audience further than expected by provokingthe listener to become active and thoughtful. He was not afraidof challenging the so-called state -of –the-art and he keptstressing that state -of –the-art is a dynamic process that we areall involved in. In other words, the interaction between expertson a regular basis was fundamental for development. In thisintensive process of communication, Erik stressed the need forcollecting information not only from experts but also frompatients and laymen because they may present, directly orindirectly, the key to a major scientific break-through.If one picked a special topic that magnetized Erik Mobergit would no doubt be phenomenon and significance of skinsensation. In his clinical accomplishments sensation certainlyplayed an instrumental role. The following citation representsErik’s interest bordering obsession of sensation as well as hisfirm opinions about how to assess sensation. Or maybe morecorrectly what techniques not to use for evaluating sensation:‘‘It must be emphasized that sensibility is, in my opinion andaccording to my experience, the basis for reconstructivework... for reconstructive surgery, ‘‘feeling’’ is a totallyuseless term, as it covers far too much and distinguisheshardly anything...for examination of useful sensibility inreconstructive hand surgery of all the tests evaluated by theauthors,theonlyonewhichwasfoundtobesignificantisthetwo-pointdiscriminationtestnowperformedwithapaperclip.All other tests of sensory function, in my opinion, should inthis work be abandoned, including cotton wool and paperstrip, pinprick, ordinary tuning fork, the difference betweensharp and blunt, figurewriting, thewrinkling skin test and thetwo-point discrimination test performed with sharp pointedcompass. They are not only useless, they are evenmisleading’’ [7].Erik Moberg graduated from the Faculty of Medicine,UniversityofLundin1932andhisfirstappointmentasadoctorwas in Persia (1932–33) where he met a Swedish nurse, Marta,whomhemarriedin1934.Hedefendedathesisinexperimentalpathology at University of Lund 1936 and began training inorthopaedicsurgery,movedtoGoteborgandtheDepartmentofSurgery at Sahlgrenska Hospital where -in 1942- he became asenior staff member.In 1944, he began to treat hand injuries inspired byDr Bunnell’s principles (Surgery of the Hand, 1944). Heorganizedaseparatewardfortreatmentoffracturesduetotheirwound infections and abscesses. In 1949 he had the first handsurgery ward in Scandinavia fully organized and established atthe Sahlgrenska Hospital.In 1947, Erik spent several months with Dr Sterling Bunnellin the U.S where he observed the post-war treatments at handsurgical centers. Back in Sweden he started the first handsurgical ward in Scandinavia in Goteborg.Erik was always very interested in teaching and especiallyhis new concept of treating hand injuries. He wrote a bookEmergency Surgery of the Hand in 1948, which has beentranslated into many languages and published in severaleditions over the years. Erik Moberg introduced hand surgeryofficially in Sweden in 1948.In 1951, he formed the Nordic Hand Club (now theScandinavian Society for Surgery of the Hand, SSSH). He wasinspired by the American Society for Surgery of the Handwhich was started by Bunnell in 1946. In the early 1970´s the‘‘Moberglecture’’wasfoundedatthesemeetings.In1956,ErikMoberg was given a personal professorship in ExtremitySurgery and in 1958 in Hand Surgery. Erik trained severalsurgeons, and five of them became full time hand surgeons andthemselves established centers in different parts of Sweden.In 1958, Erik attended a meeting of the Second Hand Cluband became one of the first Corresponding Members. This clubeven toured in Scandinavia and was accompanied by manyothers from Europe and the USA in 1961. This was the firstinternationalmeeting andwasorganizedbyErik.Thiswas alsothe foundation for meetings with a high level of scientificpapers. Arthur Barsky, President of the American Society, was

Ultraschallgestützte Blockade des axillären Plexus brachialis in der Handchirurgie

Blockade of the axillary plexus brachialis is an integral part of the anesthetic-specific procedures in the field of hand surgery. Less side-effects with high success rates are demanded of the surgeons and required by the patients. Normally, blockade of the axillary plexus brachialis is performed by using nerve stimulation. An alternative technique described here as a retrospective study uses ultrasound for detection of the nerves. At the level of axilla, anatomical structures (axillary vein and artery, triceps/coracobrachialis muscles, ulnar/radial/median nerves) were visualized by ultrasound (linear scanner, 10-MHz transducer). At this position, a puncture needle was inserted into the nerves and local anesthetics were injected (50 ml prilocaine 1 % or 40 prilocaine 1 % and 20 ropivacaine 0.5 %). Parameters like onset time of blockade (min), complete block (yes/no) and possible complications were documented. In 30 months 221 ultrasound-guided blocks of axillary plexus brachialis were performed by eight anesthetists with different levels of training. In 96.8 % of the documented cases blockade was complete and did not require any supplementation. Only in seven cases was a conversion of the anesthetic technique performed. Adverse effects like toxic-allergic reactions or nerve damage caused by the punctures were not documented in any case. The average time to onset of the blockade was 2.2 minutes. Ultrasound-guided blockade of the axillary plexus brachialis represents an alternative to procedures using nerve stimulation, even in patients with anatomic abnormalities. The described method proved to be effective, especially in the field of hand surgery.

J. William Littler, MD, 1915–2005

J. William Littler, MD, one of the founders of the specialty of hand surgery, former director of the hand surgery service of the St. Luke’s-Roosevelt Hospital Center, and mentor to several generations of American and international hand surgeons, died on February 27, 2005, in Providence, Rhode Island. He had sustained a head injury in a fall in late October 2004. He was 89 years old and he lived a major part of his life in New York City. Dr. Littler was a legend in the field of hand surgery—a true renaissance man who aptly applied a rich background in the classics, mathematics, and engineering with the keen eye of an accomplished artist, to teaching and innovation in upper-extremity surgery. He edited several classic textbooks in hand reconstruction and published over 70 original articles, many of which defined the basic principles in hand surgery: sensory neurovascular island transfers, reconstruction for the absent thumb, and tendon transfers for nerve-damaged arms and hands. His contributions to hand surgery are so fundamental and so fully assimilated into the basic principles of structure and function of the hand, that little thought is given to who originally described them. Dr. Littler was born in Manlius in upstate New York, October 7, 1915, the son of James H. and Adelaide Littler. At age 8 he attended weekend art classes at Syracuse University College of Fine Arts and at 16 he built and flew his own glider. He attended Duke University Medical School, graduating with honors in 1942. His internship was at Johns Hopkins Hospital, where he was awarded the William Halstead Fellowship; however, his formal training was interrupted by World War II. He joined the U.S. Army and was eventually stationed at Cushing Army Hospital outside Boston. He was assigned to the orthopedic service, which was subsequently designated as one of several centers for the late care and reconstruction of upper-extremity injuries. At war’s end he volunteered to complete many complex hand reconstruction procedures on Valley Forge Army Hospital patients. While there, he developed many of the reconstruction principles and techniques that are still in use today. After the war Dr. Littler, although a recognized authority on upper-extremity reconstruction, completed a plastic surgery residency under Jerome Webster, MD, at Columbia University. In 1952 he set up practice at Roosevelt Hospital in New York City and founded a hand surgery fellowship program that continues to this day. Many of the more than 100 graduates have presided over national hand, orthopedic, and plastic societies and have chaired academic departments in these specialties throughout the United States and abroad. The Professor, as he was affectionately known by his students, had a remarkable ability to make rapid, clear sketches as he spoke, making his subject clear and easily remembered. The hallmark of his numerous prestigious national and international lectureships were his remarkable illustrations. His drawings appear in all major hand, plastic, and orthopedic texts and are regarded as classics in hand reconstruction. His sketches have also graced the napkins and tablecloths of many restaurants here and abroad. Dr. Littler was one of the last surviving founding members of the American Society for Surgery of the Hand. He was also a founding member of the Group d’Etude de la Main (GEM) and Sociedad de Cirugia de la Mano del Caribe. Dr. Littler was also a member of the American College of Surgeons, the American Association of Plastic Surgeons, the British Society for Surgery of the Hand, and the Societe International de Chirurgie Orthopedique et de Traumatologie. He was Emeritus Professor of Surgery (Plastic) at Columbia College of Physicians and Surgeons in New York City. Dr. Littler is survived by his daughter, Anne, of Paradise Valley, Nevada; a brother, Ted, in Providence, Rhode Island; his long-time secretary, Joyce Jones Wells; and the Members of the Littler-Eaton Society. At his request there are to be no memorial funds or services in his name.

Outcome Measurement in Hand Surgery: Report of a Consensus Conference

This is a report of the second conference on Outcomes of Hand Surgery that took place at the Pulvertaft Hand Centre, Derby on the 19th-20th May 2001. The first meeting took place in 1993 and the discussions of this meeting led to the publication of a paper (Macey, 1995). The group participating in the second conference comprised surgeons, therapists, researchers, psychologists and a health economist (see Appendix I). The aim of this report is not to give a comprehensive and fully referenced overview, but to provide a summary of the key issues for consideration and to put forward some current views on the topic of outcome measurement in the field of Hand Surgery.

The Application of the Mini-external Fixation in the Mandibular Fracture

From 1998 to 2001, we had applied mini-external fixation in 6 patients as a salvage procedure after failed attempts of mandibular fracture treatment using ORIF and IME, which were complicated with post-operative osteomyelitis. Six patients are all male and the average age was 39 year-old. Only one of these patients had the underlying disease of diabetes mellitus and hypertension. Two cases had concurrent zygomatic fractures, and one patient had sustained traumatic SAH and frontal bone fracture. Postoperative mandibular osteomyelitis was confirmed primarily by pathologic reports, occurring from 13 days or more after surgery. The surgical procedures are as follows: we set up the mini-external fixations as the first step, then we remove the previous lmplants in order to conduct a thorough debridement and eradicate the infectious nidus. The mean follow-up period was 6 months. All patients were free from the infections. And the other achievements were categorized as follows: 1. It provides a good anatomic reduction and stable fixation. 2. It restores an acceptable facial contour even in the face of the serious complications. 3. It helps to maitain a functional occlusion and avoids further neurologic damage. 4. It facilitates post-operative care in oral hygiene and control of the infection. Our mini-xternal fixation has long been used in the field of hand surgery for immobilization of the fractured phalanx or metacapals. Since the mandible is not a heavily weight-bearing flat skeleton, its integrity could be easily maintained by the use of mini-external fixation and the results were encouraging. Herein we like to introduce this materials as an auxillary to treat the complicated mandibular fracture.

Hand surgery in German orthopedics

The intention of this report is to present an overview of the development of hand surgery and its status in German orthopedics. An important role was played by orthopedics in the development of hand surgery: many insights and classifications in this field originate from orthopedic surgeons and retain their validity in this century. In the past few decades, traumatologists and plastic surgeons have become increasingly active in the field of hand surgery and have added to their surgical repertoire some fields formerly regarded as part of classic orthopedics, e.g., correction of malformations of the hand. Although microsurgical techniques of hand surgery were primarily developed by plastic surgeons, the past should nevertheless motivate all orthopedists to continue considering hand surgery the "pearl of orthopedics" in the future.

Variations in the skeletal morphologic features of the wrist.

Increased attention to and interest in the wrist and the field of hand surgery has brought about the discovery, rediscovery, and better description of variations in the skeletal morphologic features of the hand and wrist. In the second through fifth carpometacarpal joints, the fourth carpometacarpal articulation is the area of greatest variability. In the midcarpal joint, the scaphotrapeziotrapezoid and the capitolunate (hamate) articulations are areas of considerable variability in their skeletal morphologic features. New knowledge and awareness of variations in skeletal morphologic features in the carpus offer a better understanding and the opportunity to revisit various injury patterns and/or orthopaedic problems, and normal kinetics and kinematics to assess the effect and any differences that may be related to these different skeletal morphologic features.

ENDOSCOPIC PLASTIC SURGERY

This article discusses three of the most popular endoscopic procedures in plastic surgery. Brow lift, transaxillary breast augmentation, and abdominoplasty are all cosmetic procedures with a high demand on inconspicuous scars; however, many investigators are working on reconstructive endoscopically assisted procedures. The treatment of many facial fractures involving the upper third of the facial skeleton usually requires long bicoronal incisions similar to the incisions used in the traditional brow lift. Attempts are under way to use endoscopically assisted minimal-access techniques to reduce and fixate these fractures. Many flaps used in plastic surgery require long scars for harvest, as in the case of the latissimus dorsi muscle flap. A relatively long incision on the back is needed to gain access to the muscle so that it can be elevated from structures superficial and deep to it. Although it is unpopular, investigators have reported harvesting latissimus dorsi muscle flaps through fairly small incisions with the assistance of balloon dissectors and endoscopes. In the field of hand surgery, carpal tunnel release surgery has had more than one method proposed to transect the carpal ligament using endoscopes and special instrumentation. Although some reported series claim excellent results, many hand surgeons are reluctant to use endoscopes because of associated complications and a high recurrence rate of carpal tunnel syndrome. Plastic surgery has special demands that emphasize aesthetics in cosmetic and reconstructive procedures. Although the lack of natural optical cavities has slowed the incorporation of endoscopic surgery in the specialty, surgically created cavities are used to allow for minimal access incisions. The future of plastic surgery will include an ever-increasing number of endoscopically assisted procedures. Cosmetic and reconstructive procedures will benefit from this new technology.

Classic papers in hand surgery.

Throughout the development of hand surgery as a specialty thousands of papers have been published. This paper identifies the classic papers in 13 categories covering the field of hand surgery. To be named a classic paper, it must meet three criteria: (1) it must establish or refine a technique or concept; (2) the technique must survive the passage of time; and (3) it must change the course of treatment. (J Hand Surg 2000; 25A:14-18.

Detection of Foreign Bodies using Ultrasound: A Possible Pitfall

Recently, a number of reports have brought the use of ultrasound scanning in the detection of foreign bodies to the field of hand surgery. A case is presented in which ultrasound was not able to diagnose the presence of a large (3.5 × 0.5 × 0.5 cm) nonradiopaque wooden foreign body lying between the flexor tendons of the forearm. However, embedded in ultrasound gel, the piece could readily be identified. This report serves as a reminder that the anatomical localization of a foreign body amid structures with vastly different echogenicity from its surroundings (such as flexor tendons of the hand and forearm) may reduce the usefulness of diagnostic ultrasound and that in such circumstances clinical suspicion may be a more reliable indication for exploratory surgery.

Costs, risks, and benefits of hand surgery

The major criticism of all medicine today is spiraling cost of health care. This is fanned in intensity by economists, politicians, and social scientists who add up the costs, which, in fact, have skyrocketed, and they have concluded that it "isn't worth it." The major basis for that conclusion is that despite the fact that health care costs are gobbling up 11% of the gross national product (+189 billion), there has been an increase in life expectancy of only 1 year. Use of life expectancy as the outcome measure is simple-minded, misleading, and inappropriate, and it is used only because the objective data are clear-cut and available. Mortality is a clear endpoint. Some of the greatest advances in medicine and all of those in the field of hand surgery have nothing to do with duration of survival (quantity of life), but contribute with major impact to the productivity, adjustment, and self-satisfaction of patients (quality of life). We have the opportunity to challenge and counter some of the adverse public image that is the current portrait of all of medicine. Much of that image is based on flimsy, inaccurate data that are extrapolated into gross untruth by nonmedical, short-sighted adversaries. Hand surgeons must collect objective evidence of the rehabilitation benefits of hand surgery care to persons suffering deformity and associated disability. Such data may be extrapolated to show the true cost-risk-benefit ratios produced by hand surgeons.

The Injured Hand: A Clinical Handbook for General Surgeons

From the North American viewpoint in 1980 the stated objective of this book is an anachronism, and study of its technical content gives the reader the interesting feeling of being transported in time with an accomplished and thorough surgeon who is providing a sophisticated look at hand surgery as it was practiced ten to 15 years ago. Now in its third printing in Germany, this book was written by a general surgeon and may be regarded as a reference book that covers only those procedures and techniques that my own experience with hand surgery has shown to be practicable even by less experienced surgeons, based on the premise that in the field of hand surgery, there is a general trend toward the increased operative treatment of injuries, conservative and simple operative (and thus lower risk) forms of treatment are unjustly threatened with extinction. The author's approach to reparative hand surgery

The American Society for Surgery of the Handʼs Leadership Role in the Development of the Field of Hand Surgery

The American Society for Surgery of the Handʼs Leadership Role in the Development of the Field of Hand Surgery