What’s New in Hand and Wrist Surgery

It is my distinct pleasure to provide an overview of recently published literature on hand and wrist surgery, from 2018 to September 2019.

Arthritis

Thumb carpometacarpal (CMC) joint arthritis is one of the most preference-sensitive conditions treated by hand surgeons. Given the variable levels of symptom intensity associated with this condition, patient education and communication about treatment options are key influencers of satisfaction. Wilkens et al. demonstrated that a decision aid administered in the clinic waiting room decreases decision conflict compared with passive education via an informational brochure¹. The study did not account for how surgeons describe treatment options, which likely has a large influence on ultimate treatment options. However, this increases the generalizability of using the decision aid to reduce decision conflict and ultimately increase patient satisfaction.

There continues to be wide variation in surgical techniques used to treat thumb CMC joint arthritis. In a systematic review of 158 articles from 2007 to 2018, Ganhewa et al. reported that the failure rate per 100 procedure-years is lowest for nonimplant surgery, with nearly all types of implants used for arthroplasty having a failure rate that was greater than twice that of ligament reconstruction and tendon interposition². On the basis of failure rates, contemporary literature does not support the use of implant arthroplasty². While simple trapeziectomy has traditionally produced consistent clinical outcomes with low failure rates, many surgeons continue to use an additional technique to minimize the chances of thumb metacarpal subsidence. Ligament reconstruction and tendon interposition (LRTI) requires another incision for tendon harvest and the creation of bone tunnels, which add to the surgical time and perioperative risk. In a 2009 report, DelSignore and Accardi described a “suspensionplasty” using a thick suture tied between the abductor pollicis longus (APL) and flexor carpi radialis (FCR) tendons after simple trapeziectomy³. This apposition acts as a “hammock” sling to support the thumb metacarpal. In their report of 320 patients, Weiss et al. reported their results with this technique, with pain eliminated in 84% and minimal in 15% of patients⁴. Two patients underwent revision surgery after painful metacarpal subsidence. DeGeorge et al. described their experience using a similar suspensionplasty in 39 patients, with improvement in visual analog scale (VAS) pain score and appositional pinch⁵. They also described the addition of a suture-button technique to the ligament suspensionplasty. There were similar improvements in pain reduction in both groups and no discernible differences between suspensionplasty with and without the suture-button technique with respect to pain reduction, grip strength, pinch strength, and thumb motion. There was a radiographic advantage to adding the suture-button technique, as the maintenance of trapezial height was better. However, the risk of metacarpal fracture with suture-button suspensionplasty technique has been described⁶. Grasu et al. tested the mechanical properties of a technique modification that uses a smaller-diameter tunnel in the thumb and index metacarpals⁷. There were no differences in load to failure, thumb metacarpal subsidence, and simulated dynamic pinch between a 4-strand technique (2.7-mm tunnel) and a 2-strand technique (2.1-mm tunnel), suggesting that the latter may help to mitigate the risk of metacarpal fracture after suture-button suspensionplasty.

Denervation has been proposed for treating thumb CMC joint arthritis, with Tuffaha et al. demonstrating pain relief in 11 of 12 patients who underwent transection of articular terminations of the lateral antebrachial cutaneous nerve, the palmar cutaneous branch of the median nerve, and the superficial branch of the radial nerve⁸. However, Mobargha et al. corroborated prior work in other joints by showing that stability of the thumb CMC joint relies on interactions between periarticular ligaments and surrounding musculature. These findings suggest that preservation of joint innervation may have a role in mitigating subsequent effects after joint trauma or in the early stages of joint degeneration⁹.

Management of thumb CMC joint arthritis in younger patients remains a challenge. Arthrodesis is considered for younger patient cohorts, but the high nonunion rate is concerning. Conversely, the potential for thumb metacarpal subsidence and poor results after revision thumb CMC joint surgery must be mentioned when discussing options. Rhee et al. reported results of thumb CMC joint surgery in patients ≤55 years of age, reporting revision-free survival of 100% at 10 years and 86% at 15 years. While metacarpal subsidence is expected (the exact frequency in this study was not included), it was not associated with poorer patient-reported or functional outcomes¹⁰.

Distal Radial Fractures

The appropriateness of closed management versus surgical treatment of distal radial fractures remains a topic of intense debate, with those in favor of surgical treatment advocating that it results in earlier return to function and mitigation of the risk of long-term dysfunction. Indeed, in a recent evaluation of patients in Sweden who had poor outcomes at 1 year after fracture (27% [of 269] who were treated surgically), Landgren et al. found that 53% of 269 had continued major disability at 2 to 12-year follow-up¹¹. These data support the argument for “getting it right” at earlier points in treatment, potentially with surgical intervention. However, risks of surgery must be included in decision-making. A prior systematic review of volar locking-plate removal showed a mean hardware removal rate of 9% (3% in the U.S.)¹². However, in another randomized trial from Sweden evaluating the use of a volar locking plate versus external fixation in the treatment of unstable dorsally displaced distal radial fractures, the rate of volar locking-plate removal was 18%. Five cases of plate removal occurred in the second and third years after initial fixation. There were no differences in patient-reported outcomes, grip strength, range of motion, and radiographic outcomes between the volar locking-plate and external-fixation groups¹³. As more work from various groups shows a lack of difference in functional and radiographic results between different modes of fixation, it is important to consider the risk profile of each technique. Many surgeons use a radial column plate as an adjunct or main mode of fixation for distal radial fracture. The subcutaneous positioning of the plate adjacent to the first dorsal compartment suggests that subsequent removal of hardware may frequently be required, which may factor into preoperative counseling. Of 61 patients with a radial column plate, 17 (28%) underwent removal of hardware, including 8 for de Quervain-type symptoms and 2 for superficial radial sensory neuritis¹⁴. These data are useful in describing the likelihood of future surgery for patients undergoing distal radial fracture-fixation surgery with use of a radial column plate.

Aside from fracture- and technique-related factors, many patient characteristics may influence outcomes following distal radial fracture. In an international randomized trial, Chung et al. demonstrated that younger patients, those with higher pain scores after reduction, and those with lower education levels were more likely to have poorer functional outcomes¹⁵. It is possible that hand surgeons and hand therapists can use these patient characteristics to identify at-risk patients, dedicating specific resources toward improving outcomes in this group. Among the elderly, patients who more often sustain fragility fractures, malnutrition also carries a particular risk. From an analysis of administrative data, Wilson et al. demonstrated that patients with hypoalbuminemia are at increased risk of 30-day postoperative morbidity and mortality¹⁶. While additional work is needed to determine the role of hand surgeons in addressing nutritional status, increased awareness is warranted given the emphasis of hand-surgeon involvement in bone health¹⁷.

Wrist

The treatment of scaphoid nonunion remains a challenge to hand surgeons. In many cases, the choice of operative procedure will hinge on factors including the location of the fracture, proximal pole osteonecrosis, carpal collapse, and prior surgery. Interpretation of the literature must take into account these variables. In their retrospective case series, Aibinder et al. presented their experience treating scaphoid nonunion with iliac crest bone graft (ICBG; 31 patients), 1,2 intercompartmental supraretinacular artery (1,2-ICSRA) flap (33 patients), and a free vascularized medial femoral condyle (MFC) flap (45 patients)¹⁸. The groups were distinct in terms of the factors listed above. ICBG was largely used for patients with carpal collapse, no prior surgery, and preserved proximal pole vascularity. The union rate in this group was 71%, with a time-to-union of 19 weeks and a reoperation rate for revision/salvage of 23%. The 1,2-ICSRA flaps were largely used in cases of scaphoid nonunion with osteonecrosis of the proximal pole; half had carpal collapse, and one-third had prior surgery. The union rate was 79%, with a time-to-union of 26 weeks and a reoperation rate for revision/salvage of 12%. MFC flap was used largely in patients with carpal collapse and osteonecrosis; 65% of the patients had prior surgery. The union rate was 89%, with a time-to-union of 16 weeks and a reoperation rate for revision/salvage of 16%. Comparative analysis among groups is challenging to interpret given the relatively high number of potential confounders. Viewed as a whole, these results are useful when counseling patients about time-to-union, risk of nonunion, and rates of subsequent surgery.

Alternative strategies for treating scaphoid nonunion continue to emerge. Putnam et al. reported cancellous autograft packing and volar-plate fixation for 13 patients with scaphoid nonunion and osteonecrosis¹⁹. All patients had fracture union, with the majority achieving union within 18 weeks. There was 1 reoperation for hardware removal. While these results are promising, measures of preoperative carpal collapse were not reported. This makes it difficult to understand the role of this procedure in the treatment of patients with osteonecrosis and carpal collapse.

Denervation can be used as a motion-sparing procedure for patients with chronic wrist pain, typically with the acknowledgment that future surgery may be indicated as underlying pathophysiology worsens. O’Shaughnessy et al. reported long-term results after partial denervation of the wrist (anterior and posterior interosseous neurectomies)²⁰. The majority were treated because of arthritis-related pain (37% of the total group of 100 wrists involved SLAC [scaphoid lunate advanced collapse] or SNAC [scaphoid nonunion advanced collapse]; 21% of the total group had non-SLAC or non-SNAC arthritis). The overall reoperation rate was 31% at an average of 26 months after denervation. The highest rate of revision surgery (43%) was in patients with a SLAC or SNAC wrist, while 9% of patients with non-SLAC and non-SNAC arthritis had revision surgery. Seven patients had idiopathic wrist pain, with a revision rate of 14% and estimated 86% 10-year survivorship. Sgromolo et al. reported on denervation among active-duty military patients with idiopathic wrist pain²¹. Of 13 patients, 2 returned to active-duty work, 5 had a medical discharge, and 6 were placed on permanent duty restrictions. These data can inform discussions with patients about the duration of symptom relief and the risk of reoperation following denervation.

Tendon

While many surgeons utilize multiple corticosteroid injections to treat trigger finger, some recommend surgical release after a single injection. In their economic analysis, Halim et al. demonstrated that a second injection (rather than proceeding to surgery after 1 injection) would save $484 per digit and that a third injection (rather than proceeding to surgery after 2 injections) would save $284 per digit²². The third injection had an efficacy rate of 29% in their series, and their sensitivity analysis indicated that any efficacy rate of >10.3% for a third injection would be cost-effective. Although many patients undergoing surgical release for trigger finger see near-immediate improvement, Baek et al. reported that 19% of 109 patients experienced symptoms >8 weeks after surgery²³. Among those with prolonged postoperative symptoms, symptom relief occurred at a mean (and standard deviation) of 14.0 ± 6.4 weeks. A longer duration of preoperative symptoms, the presence of a proximal interphalangeal (PIP) joint contracture, and a greater number of corticosteroid injections were risk factors for prolonged symptoms. These findings demonstrate wide variability in outcomes among patients undergoing release for trigger finger. While using multiple corticosteroid injections can be cost-effective and efficacious for patients, the possibility of prolonged symptom duration if surgery is ultimately chosen should be discussed, especially if a PIP joint contracture is present.

The challenge of treating patients with zone-2 flexor tendon injuries continues to drive investigation into improvements for tenorrhaphy. In an analysis of factors that may drive variation in mechanical strength of tendon repairs, Linnanmäki et al. reported that surgical performance (such as consistency in placement of core sutures) accounted for approximately half of the variation in yield load (the time-zero strength of the tendon repair; if exceeded, gapping may occur)²⁴. Emphasis on consistent surgical technique may decrease the variation in the mechanical strength of tendon repairs, which may be of particular importance when considering skill simulation protocols for trainees and practicing surgeons. While emphasis on technique is paramount in the treatment of flexor tendon injuries, the type of suture material plays an early role in tendon strength until healing is complete. Wallace et al. examined the mechanical strength of a 1-mm mesh suture, in which multiple polypropylene filaments are woven into a cross-hatched cylinder, in a flexor tendon model compared with 3-0 and 4-0 braided sutures²⁵. While yield load and ultimate load were higher with the mesh suture compared with both braided sutures, there is concern that increased repair-site bulk in the former may limit its ability to glide freely. Future in vivo studies will be helpful to determine the role that mesh sutures may have in flexor tendon repair.

Prompted by the recent emphasis in clinical research on patient-reported outcomes, Karjalainen et al. examined the correlation between traditional outcomes assessment (such as individual finger joint motion) and patient-reported measures²⁶. They found that active distal interphalangeal (DIP) joint motion and total composite finger motion were strongly and moderately, respectively, correlated with patient-reported function and disability scores. Each 10° improvement in DIP motion increased perceived function by 9.5 points on a 100-point scale. These findings can guide intraoperative decision-making (particularly for wide-awake tendon repair under local anesthesia), perioperative counseling, and communication between hand surgeons and hand therapists.

While relative motion splinting is commonly used for extensor tendon injuries, it may have utility in flexor tendon injuries. Chung et al. demonstrated that a relative motion splint for zone-3 flexor tendon repair can decrease repair elongation and gapping while allowing motion of the repaired tendon²⁷. Further testing in zone-2 flexor tendon repair models is needed. However, the introduction of relative motion protocols may allow continued protection of the repair while (1) allowing patients to perform light activities and (2) minimizing stiffness in adjacent digits.

Replantation

The frequency and success rates of finger replantation have been decreasing in the U.S. From their analysis of administrative data from the National (Nationwide) Inpatient Sample, Cho et al. reported that 11.2% of adult patients with a single traumatic digit amputation underwent an attempt at replantation²⁸. Replantation was less likely to be attempted in older patients, those with private insurance, those with higher income levels, and those with greater comorbidities. These characteristics suggest selection biases and preferences for attempted replantation among both surgeons and patients. While an increasing proportion of cases were treated at urban teaching hospitals over time, hospital volume and type were not predictive of successful replantation. These findings indicate that the regionalization of replantation to designated hand trauma centers may not provide anticipated improvements in replantation success if prior success rates are not considered. Furthermore, efforts to increase replantation success should acknowledge and incorporate financial considerations for all parties (surgeons, hospital system, and patients) that may contribute to the decision to attempt replantation. Subsequent work demonstrated that replantation has lower reimbursement per work relative value unit than do revision amputation, carpal tunnel release, trigger finger surgery, and many other common hand surgeries²⁹. This relative devaluation of physician work for replantation may influence attitudes toward replantation in the U.S.

Metacarpal Fractures

Surgical treatment of metacarpal fractures can facilitate early motion, accelerate rehabilitation, and lead to earlier return to activity. Many surgeons opt for plate fixation and headless compression screws because of the potential for increased mechanical stability. In a comparison of mechanical properties of these constructs, Jones et al. found that a 2.0-mm locking plate was the strongest and allowed the least displacement with cyclic loading to 40 N³⁰. The mechanical properties of the 3.0-mm headless compression screw were similar to two 1.2-mm (0.045-in) Kirschner wires, suggesting that surgeons looking for maximal stability should consider locking plates in patients involved in high-demand activities seeking immediate return to activity, such as athletes.

Nerve

One challenge in treating carpal tunnel syndrome is predicting postoperative recovery and the optimal timing for surgery. If treated late, the median nerve may have undergone irreversible internal fibrosis. For many patients, it is difficult to predict whether thenar atrophy and weakness can be reversed. Garg et al. reported increases in pinch strength and compound motor action potentials for the abductor pollicis brevis after carpal tunnel release in patients with preoperative atrophy³¹. Jansen et al. noted that patients with a high severity of preoperative symptoms had notable relief in symptoms after undergoing carpal tunnel release but had a substantial amount of residual symptoms³². Jansen et al. also reported that patients with concurrent comorbidities of the hand (such as thumb arthritis, trigger finger, and ulnar neuropathy) were likely to see less overall symptom improvement³². These findings are useful in counseling patients regarding the timing of surgery and expectations for recovery after carpal tunnel release.

The optimization of outcomes after carpal tunnel release includes the avoidance of postoperative complications such as infection. While surgical site infection (SSI) after carpal tunnel release is remarkably low, diabetic patients are at increased risk for SSI. Using administrative data, Werner et al. examined hemoglobin A1c levels of nearly 8,000 diabetic patients prior to carpal tunnel release and found that a level of >8 mg/dL significantly increased the risk of SSI³³. In addition to informing preoperative counseling, this suggests a role for preoperative screening to assess and optimize glycemic control prior to carpal tunnel release.

While the diagnosis of carpal tunnel syndrome is often made from clinical criteria, electrodiagnostic studies are commonly used as a confirmatory test. However, ultrasound is increasingly used in this role because it is noninvasive and less costly. Fowler et al. demonstrated fewer false-positive results with ultrasound than with electrodiagnostic studies³⁴. Among patients with no symptoms of carpal tunnel syndrome, 43% of electrodiagnostic studies and 23% of ultrasound studies were falsely positive for carpal tunnel syndrome. While ultrasound performs better than electrodiagnostic studies, the false-positive rate was still nearly one-quarter, suggesting that physicians should continue to rely on history and physical examination to aid in diagnosis and treatment.

Hand surgeons are also increasingly utilizing ultrasound in the management of cubital tunnel syndrome. Rutter et al. demonstrated that preoperative dynamic ultrasound was far more reliable (88% match with intraoperative findings) than was preoperative clinical examination (12% match with intraoperative findings) in predicting ulnar nerve stability within the cubital tunnel³⁵. On the basis of this finding, surgeons may find value in using preoperative ultrasound to counsel patients about the likelihood of ulnar nerve instability (and the need for subsequent transposition).

Increasing attention is being directed to psychological recovery after brachial plexus injury. Yannascoli et al. demonstrated that over half of adult patients with traumatic brachial plexus injury had depression or anxiety before surgical reconstruction and that rates of new-onset depression and anxiety were 12% and 20%, respectively, following reconstruction³⁶. Landers and colleagues also reported that one-third of patients with brachial plexus injury expressed suicidal ideation, and one-fifth met criteria for posttraumatic stress disorder³⁷. In another study, nearly one-third of patients with brachial plexus injury had prolonged opioid prescriptions after surgery, despite recommendation that opioids be used as third-line agents for neuropathic pain³⁸. Taken as a whole, these results suggest that continued integration of care with colleagues in pain management, psychology, psychiatry, and social work will provide meaningful improvements in quality of life for patients recovering from brachial plexus injury.

General

The stewardship of opioids remains a topic of intense interest to hand surgeons. Stepan et al. demonstrated that a standardized prescribing protocol can have an enduring effect on decreasing the number of opioids prescribed after hand surgery³⁹. Alternative prescribing regimens have shown promise, with Weinheimer et al. reporting no difference in pain control between acetaminophen + ibuprofen and acetaminophen + hydrocodone after soft-tissue surgery (carpal tunnel release, first dorsal compartment release, ganglion excision, and trigger finger release)⁴⁰. Despite general decreases in opioid prescriptions, it is important to note that the findings of 1 recent study showed that 28% of 118 surveyed patients believe that opioids are effective for long-term pain control⁴¹. Higher levels of pain catastrophizing were seen among patients with increased opioid consumption after surgery⁴², suggesting that assessment and modification of psychological characteristics may help minimize opioid dependence. Surgeons should account for variation in patient attitudes toward pain and consider psychological characteristics. This will help balance the delivery of effective postoperative analgesia with the avoidance of opioid dependence and diversion.

The expected shift in the U.S. toward value-based payment has kept patient satisfaction at the forefront in discussions about quality of care. Patients prioritize preparedness in their encounters with hand surgeons⁴³, with many patients researching their symptoms and their hand surgeons ahead of office visits^44,45. In their interactions with hand surgeons, patients report being more satisfied with care if their office-visit wait times are shorter. While this finding is intuitive, each 1-minute increase in wait time was found to decrease the odds of satisfaction by 3%⁴⁶. This is particularly salient to surgeons who practice in environments that rely on similar patient-satisfaction surveys as a measure of quality of care.

Socioeconomic status has a distinct influence on outcomes in hand surgery. Wright et al. demonstrated that, among patients seeking treatment for carpal tunnel syndrome, those from areas of increased social deprivation had worse physical function, pain interference, anxiety, and depression than patients from more affluent areas⁴⁷. These findings are compounded by barriers that less affluent patients may encounter when seeking care. In their analysis of administrative claims data, Zhuang et al. demonstrated that patients with Medicaid managed care plans experienced greater delays in obtaining electrodiagnostic studies and in undergoing carpal tunnel release compared with patients with Medicare and private insurance plans⁴⁸. While hand surgeons are unable to modify a patient’s socioeconomic status and insurance type, it is important that surgeons acknowledge and consider their impact.

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

Gao B, Dwivedi S, DeFroda S, Bokshan S, Ready LV, Cole BJ, Owens BD. The therapeutic benefits of saline solution injection for lateral epicondylitis: a meta-analysis of randomized controlled trials comparing saline injections with nonsurgical injection therapies. Arthroscopy. 2019 Jun;35(6):1847-1859.e12. Epub 2019 May 6.

In this meta-analysis of 10 Level-I and II studies, the authors found that saline solution injections used as a placebo treatment for lateral epicondylitis resulted in an effect at 6 and 12 months that exceeded the minimal clinically important difference (MCID) for the Disabilities of the Arm, Shoulder and Hand (DASH). The effect of saline solution injections exceeds those seen in prior studies of eccentric exercises and nonsteroidal anti-inflammatory medications. These results demonstrate the potential therapeutic effect of saline solution injections and call into question their role as a placebo treatment in future tendinopathy studies.

Mulders MAM, Walenkamp MMJ, van Dieren S, Goslings JC, Schep NWL; VIPER Trial Collaborators. Volar plate fixation versus plaster immobilization in acceptably reduced extra-articular distal radial fractures: a multicenter randomized controlled trial. J Bone Joint Surg Am. 2019 May 1;101(9):787-96.

In this randomized controlled trial conducted in 14 centers in the Netherlands, the authors found that patients treated operatively for an acceptably reduced distal radial fracture had significantly lower DASH scores at all follow-up points (including 3 weeks, 6 weeks, 3 months, and 12 months). However, the differences in DASH scores were less than the MCID threshold at 6 and 12-month intervals. Of the 48 patients who underwent surgery, there were 9 cases of implant removal and 3 cases of extensor pollicis longus rupture.

Saving J, Severin Wahlgren S, Olsson K, Enocson A, Ponzer S, Sköldenberg O, Wilcke M, Mellstrand Navarro C. Nonoperative treatment compared with volar locking plate fixation for dorsally displaced distal radial fractures in the elderly: a randomized controlled trial. J Bone Joint Surg Am. 2019 Jun 5;101(11):961-9.

In this trial from Sweden, patients >70 years of age were randomized to volar-plate fixation or nonoperative immobilization for the treatment of dorsally displaced distal radial fractures. Median DASH scores were significantly better in the volar-plating group at 3 and 12 months, exceeding the MCID threshold at both time points. Of the 56 patients treated with volar plating with 1-year follow-up, 4 underwent hardware removal. Of the 63 patients who underwent nonoperative management and had 1-year follow-up, 5 had subsequent carpal tunnel release and 3 underwent corrective osteotomies. This information can be used to counsel elderly patients about the expected treatment courses for both operative and nonoperative management.