Wrist & Hand

Is there any advantage in endoscopic carpal tunnel release?

Does vascularised bone grafting work in scaphoid fractures?

The scaphoid remains a notorious bone to manage. If it fails to heal - not an uncommon event - then bone grafting with fixation is the standard of care across the world. However, this is essentially where the consensus ends, with debate concerning vascularised or non-vascularised graft. Matters are further confounded by the definitions of failure; does it matter if there is ‘avascular necrosis’? Indeed, do we always know whether there is avascular necrosis? A group from Nottingham (UK) undertook a systematic review of the literature concerning bone grafting, particularly focussing on the value of vascularised bone grafting (VBG) versus non-vascularised grafting (NVBG).³ There were a large number of 2710 articles which met the screening criteria; however, just 144 of these studies reported the outcomes of 5464 scaphoid nonunions. The mean union rates when using VBG and NVBG were 84% and 80%, respectively. When considering the value of avascular necrosis of the scaphoid, the proximal pole was identified pre-operatively then the mean union rate was 74% with VBG, compared with 62% with NVBG. The results of this review highlight that perhaps in this setting there is a small advantage in a vascularised graft when there is AVN, but this is a difficult technique which should nowadays mean referral to a specialised centre.

Do we need antibiotics for distal phalanx fractures?

All orthopaedic surgeons must remember their duty as custodians of proper antibiotic use. There is a real threat within just a few years of infections for which there is no cure. Excessive use of antibiotics by doctors will carry much of the blame. So we should take note of this work from Coventry (UK)⁴ in which a meta-analysis of four randomised trials (353 fractures) found that antibiotics made no difference to the infection rate. So we are obliged to take note, to disseminate this work to our colleagues in general practice and emergency departments and to focus on proper washout and to avoid antibiotics.

Nerve conduction studies for carpal tunnel syndrome?

There is much variation in the diagnosis of carpal tunnel syndrome. Patients are usually managed using a standardised treatment pathway, however these pathways often vary from unit to unit, and specifically the routine use of electrodiagnostic studies is particularly controversial. In some units they are used as a gateway for referral, and in others are considered superfluous to requirements and patients can move through the entire pathway including release without any consideration of electrodiagnostic studies. Researchers in Ann Arbor, Michigan (USA) undertook a population-based analysis with the intention of establishing what role, if any, electrodiagnostic tests took in the US population undergoing carpal tunnel release between 2009 and 2013.⁵ Their analysis included three different multivariable analyses with the intention of establishing the relationships between timing of surgical interventions, the number of pre-operative physician visits and the total health economic costs. As is only possible with studies of this size, encompassing 62 894 patients, the authors were able to control for sociodemographic variables, comorbidities, health care insurance and treatment characteristics. Of the study population, 58% underwent pre-operative electrodiagnostic studies. Perhaps unsurprisingly, patients undergoing electromyography (EMG) waited longer for their decompression intervention and as perhaps might be expected, the total health economic costs were higher, with one additional visit and nearly $1000 additionally spent on healthcare provision for the group with the EMGs. The total cost analysis also identified that the use of occupational therapists and steroid injections introduced excess healthcare costs and delayed time to surgery. There is little data in this paper that supports anything other than access directly to carpal tunnel decompression; however it is important to remember that the outcome selected can result in additional costs and delays to treatment, so it isn’t surprising that less intervention hastens treatment and costs less.

Sterilising the hand

Sometimes some of the simplest papers are the most useful. We were interested when this paper from the Rothman Institute, Philadelphia (USA) crossed the desks at 360 HQ. The research team undertook a simple study to determine the effectiveness of skin coverage during surgical preparation of the hand.⁶ The team undertook a comparison of preparation using pre-stick applicators against 4 inch sterile gauze sponges. Their study was a comparison volunteer study, with thirty healthy volunteers having their hands prepped in matched pairs. Both groups were treated with the commercially available ChloraPrep compared to soaked gauzes applied using sterile gloved hands. Outcomes were reviewed using an image analysis technique to assess the number and location of un-prepped areas after both techniques. There were a greater number of unprepped areas in the ChloraPrep group (77 vs 14) and the total percentage of unprepped skin was greater in the ChloraPrep group (0.76% vs 0.15%). There is a clear message here with regards to the total coverage of the skin achieved with each method. However, there is little really to tie this to clinical relevance (either in the literature or in this paper). So although the message appears to be that a ChloraPrep device does not provide as good skin coverage as the traditional swab squares, it is not clear what the effects on the eventual infection rates might be. However, this paper does highlight for us that there are often unforeseen complications from introducing novel technologies.

The biomechanical implications of wrist fusions

Just how good is a wrist arthrodesis?

Wrist arthrodesis is one of those bailout options that exist in all sub-specialities of surgery – “if it all goes wrong we can always fuse it” is something that is perhaps more often thought than said, but is always at the back of the mind when evaluating the difficult-to-treat wrist. As the ‘salvage option’ however, it is far from clear how much is salvaged. The hand surgery team in Canberra (Australia) set out to establish what outcomes could be expected from wrist fusion, specifically according to indication.⁸ Their study reported the results of 77 consecutive patients all of whom underwent a wrist arthrodesis with a pre-contoured dorsal plate. Outcomes were reported using a range of outcome scores with mean scores more than acceptable at final six year follow up (Buck-Gramcko Lohman 9, Disabilities of the Arm, Shoulder 19, Hand and Patient Rated Wrist Evaluation 13). As is always the case, final outcomes were affected adversely by workers’ compensation claims. In general however the cohort did well, demonstrating wrist fusion to be a successful operation even in the days of heavy use at the computer keyboard. Certain subgroups did not do so well, and patients with inflammatory arthritis or of the female sex had a significantly poorer outcome.

Social support and upper limb functions?