X-ref For other Roundups in this issue that cross-reference with Wrist & Hand see: Trauma Roundup 8.
Salvaging collagenases
While not exactly a pandemic shift or sea change, there is a steady creep of evolution in the treatment of Dupuytren’s disease with more and more surgeons and patients alike utilising less invasive approaches to early Dupuytren’s such as needle fasciotomy and collagenase treatments. Collagenases such as Xiapex (CCH) is an enzymatic treatment which is becoming widely used, and although we already know that it is very effective and patient satisfaction levels are high, there remain question marks over its longer-term effectiveness. We have previously reported in 360 the high recurrence rates observed in some studies and therefore, as time passes, we will all be faced with patients with recurrent disease following Xiapex treatment. Surgeons from Boston (USA) have addressed the question as to what exactly happens when patients require revision surgery following Xiapex treatment.1 Although a very small series of just 19 joints in 11 patients, this paper is important as it is the first to describe revision fasciotomy following CCH treatment. The revision surgery was undertaken on average just 12 months following the initial injection, and although the surgery is described as challenging with a loss of soft-tissue plains and extensive scarring, the clinical results were good with release of MCP joints from 42° to 0° and PIP joints from 60° to 21°. These clinical results are comparable with what should be expected from a primary fasciectomy, so surgeons should be aware of the difficulties associated with CCH revision and make sure that it is only performed by someone particularly adept at complex secondary surgery.
Rehabilitation following extensor tendon injury
Extensor tendon injuries are common. Surgical repair and post-operative management of said injury is generally less challenging than for the bête noire of hand surgery: the flexor tendon injury. Despite the common nature of the injury and ease of surgical repair, there is little consensus as to what represents the best form of post-surgical rehabilitation. Researchers from Manchester (UK) undertook a comprehensive systematic review using all the usual academic indices.2 Their review team was only able to find five adequate RCTs suitable for inclusion in such a review. The RCTs themselves were found to be rather limited in their methods of reporting, however, some inferences could be drawn about the commonest forms of rehabilitation, i.e. static immobilisation, dynamic splinting and early active motion programmes. Overall, patients’ recovery of active motion arc improved with time with all the regimes. However, based on the available evidence, the review team was able to conclude that early active motion is preferable to both dynamic and static splinting. Although the longer-term outcome remains similar, there is a quicker recovery of functional range of motion.
Complications from ulnar shortening
Ulnar shortening is an effective operation for ulnocarpal impaction but of course, like any operation, it carries risks such as infection and (perhaps most feared) that of provoking complex regional pain syndrome (CRPS) as a result of damage to the dorsal branch of the ulnar nerve. The advent of the new purpose-designed ulnar osteotomy plates have both simplified the procedure somewhat and also increased its popularity as a surgical option. Another complication of this procedure is nonunion of the ulna, and little is known about its incidence or risk factors, especially in light of newer (often locked) ulnar osteotomy plates. From the surgeon’s perspective, meticulous technique with a cooled saw and minimal periosteal stripping should help reduce the incidence of nonunion, and various cutting guides and specialised plates are available commercially to help secure a stable construct and produce a matching osteotomy to further minimise this risk. Nevertheless, nonunion still occurs and researchers from Philadelphia (USA) have focused on this in their retrospective review of 72 patients, all undergoing ulnar shortening osteotomy over a five-year period.3 The authors report an 11% incidence of delayed union. They attempted to establish what the causes of this might be, and were able to identify smoking and diabetes as predominant risk factors. So yet again these two factors, one of which is unavoidable and one of which must be strongly discouraged, can spoil our orthopaedic results. Clearly, as in any fracture surgery, optimisation of diabetic control and commencement of a smoking cessation programme would reduce a serious risk from what is otherwise a successful operation.
Outcomes following ulnar osteotomy
Here at 360 we are not only worried that nonunion in ulnar shortening remains a very significant early risk, we also wonder about the longer-term risk of arthritis given the alteration of the forearm biomechanics. We were interested to read this report from researchers in Nancy (France).4 The authors reviewed 46 patients with clinical examination and radiographs at ten years following their initial surgery. The research team established that 63% of these 46 patients who had ulnar shortening developed arthritis, and that this was especially common in those with a type I (reverse oblique) joint. Their study nicely demonstrates what we might have predicted, that when the congruency and articulating surface area of the distal radioulnar joint is altered, subsequently developing arthritis is not uncommon. Based on their results, the authors sensibly recommend that ulnar shortening should be limited to the minimum needed.
Buddy strap boxer’s fractures
Boxer’s fractures are one of the most common injuries the world over, so researchers from Switzerland and USA combined to perform a randomised study evaluating the outcomes of 68 patients randomised to either plaster immobilisation following manipulation, or simple buddy strapping.5 Patients were enrolled with a simple boxer’s fracture with less than 70°of palmar angulation and randomised to one or other treatment. Outcomes were assessed using the QuickDASH at four months. The study established that simple buddy strapping was not inferior to plaster immobilisation in any recorded outcome measure (pain, deformity, radiography), yet the patients were back to work on average 11 days earlier. So the message is clear - there is no place for plaster in the management of boxer’s fractures.
How to satisfy the hand patient?
Surgeons need to know this. The most important thing a patient wants from their doctor is not their time, but their empathy. A group from Boston (USA) studied the expectations of 122 patients before and after their visit to the outpatient clinic, although these factors can sometimes be rather nebulous and difficult to establish.6 The study team recorded a range of objective variables including waiting times and consultation times. A sociodemographic survey, the Consultation and Relational Empathy Measure, the Newest Vital Sign Health Literacy test and a range of upper limb PROMS measures were recorded. The investigators undertook a range of analyses to see which were the predictors of patient satisfaction and perceived ‘surgeon rush’. Despite the time pressures that many clinicians find themselves under while in clinic, the key determinant of satisfaction was not the time spent with the patient. In fact, these researchers identified that the patient only thought the visit was too short if the surgeon did not provide empathy. Patients themselves were slightly different in their expectations, with the more poorly-educated and depressed patients having expectations of longer consultations. The message is clear - be empathetic and your clinic patients will be more satisfied, even if you are short of time.
How common is incidental Kienböck’s disease?
One of the difficulties with all types of osteonecrosis is that they can be incidental findings, and sometimes asymptomatic. Kienböck’s disease is a tricky diagnosis to treat, with a number of options ranging from fusion to shortening, all of which involve a significant surgical insult. In practice, many patients with low grades of Kienböck’s disease are treated expectantly and make a reasonable recovery. Researchers in Boston (USA) ask the not unreasonable question, what is the rate of subclinical Kienböck’s disease? In an attempt to establish the prevalence of the disease, the study team undertook a review of 51 071 patients over an 11-year period, using the digital reports to screen for signs of AVN of the lunate on plain films, CTs and MRI scans of the wrist.7 They then reviewed the individual positive scans/imaging and the notes associated with the patient admission. Despite the wide-ranging methodology of the search, the authors identified just 51 cases of incidental Kienböck’s disease and 87 cases of symptomatic disease. As perhaps would be expected, higher Lichtman grades were associated with symptomatic disease and the incidence of lunate collapse was higher in the symptomatic group (51% versus 18%). It is startling to see that Kienböck’s disease is asymptomatic nearly 50% of the time, and, in addition, the observation that lunate collapse may be present in asymptomatic hands causes us to re-evaluate our understanding of the disease, and in particular the relationship between severity of collapse and symptomatology. We would love to see a review of those asymptomatic patients with interval imaging which would go a long way to increasing our understanding of how the disease progresses.
A triumph of technique over sense? Arthroscopic scaphoid nonunion surgery X-ref
Hand and wrist surgeons are moving more and more towards arthroscopic techniques. With the exponential advantages of small incisions, the possibility of better outcomes, and the ability to visualise structures without disruption to the overlying soft tissues, there is plenty of sense in trying to develop these techniques. However, there is also the concern that making a reliable operation more technically challenging could affect the reliability of the results. Researchers in Seoul (South Korea) report their own results of arthroscopic scaphoid nonunion surgery in an attempt to prove that it’s not a triumph of technique over sense.8 The authors describe their experience of 80 patients with mixed open (n = 35) and arthroscopically treated (n = 45) scaphoid nonunions managed over a four-year period. Follow-up was achieved to an average of just over 30 months and evaluation included a CT scan, clinical review and patient scoring. There were no differences in union rates between the two groups, with 97% achieving union and both groups achieving improvements in strength and pain scores, as would be expected. The authors make the point that, in their experience, scaphoid nonunions can only be managed arthroscopically when there is no significant deformity or arthritis. While this paper has demonstrated that this is technically achievable without compromising results, it does beg the question, why put the scope in at all? Percutaneous compression screws work perfectly well in the same patient group in other series.
References
1 Eberlin KR , KobraeiEM, NyameTT, BloomJM, UptonJIII. Salvage palmar fasciectomy after initial treatment with collagenase clostridium histolyticum. Plast Reconstr Surg2015;135:1000e-1006e.CrossrefPubMed Google Scholar
2 Ng CY , ChalmerJ, MacdonaldDJ, et al.. Rehabilitation regimens following surgical repair of extensor tendon injuries of the hand-a systematic review of controlled trials. J Hand Microsurg2012;4:65-73.CrossrefPubMed Google Scholar
3 Gaspar MP , KanePM, ZohnRC, et al.. Variables prognostic for delayed union and nonunion following ulnar shortening fixed with a dedicated osteotomy plate. J Hand Surg Am2016;41:237-243.e2.CrossrefPubMed Google Scholar
4 de Runz A , PauchardN, SorinT, DapF, DautelG. Ulna-shortening osteotomy: outcome and repercussion of the distal radioulnar joint osteoarthritis. Plast Reconstr Surg2016;137:175-184.CrossrefPubMed Google Scholar
5 van Aaken J , FusettiC, LuchinaS, et al.. Fifth metacarpal neck fractures treated with soft wrap/buddy taping compared to reduction and casting: results of a prospective, multicenter, randomized trial. Arch Orthop Trauma Surg2016;136:135-142.CrossrefPubMed Google Scholar
6 Parrish RC 2nd , MenendezME, MudgalCS, et al.. Patient satisfaction and its relation to perceived visit duration with a hand surgeon. J Hand Surg Am2016;41:257-262.CrossrefPubMed Google Scholar
7 van Leeuwen WF , JanssenSJ, Ter MeulenDP, RingD. What is the radiographic prevalence of incidental Kienböck disease?Clin Orthop Relat Res2016;474:808-813.CrossrefPubMed Google Scholar
8 Kang HJ , ChunYM, KohIH, ParkJH, ChoiYR. Is arthroscopic bone graft and fixation for scaphoid nonunions effective?Clin Orthop Relat Res2016;474:204/12.CrossrefPubMed Google Scholar
