Wrist & Hand

Who is satisfied after fasciectomy?

As surgeons, we have a moral obligation to consider custodianship of scarce healthcare resources; treatment for cosmetic reasons alone may well not be justified. However, the flip side to that coin is that we also have to be aware that patient satisfaction is becoming recognised as an important an outcome as more objective doctor-orientated measures such as range of movement. Dupuytren’s contracture is one of those diseases in which decision making is increasingly difficult with patient expectations rather high and the evidence sometimes somewhat equivocal as to who will benefit, and who won’t, from fasciectomy. A study team in Rotterdam and Hilversum (The Netherlands)¹ set out to establish what the predictors are of patient satisfaction following fasciectomy. They undertook an analysis of 194 patients, all of whom completed the Michigan Hand Outcomes Questionnaire (MHQ), and collated a range of demographic and disease-specific factors. They performed a multivariate analysis, and the factors predictive of the satisfaction outcome question on the MHQ were the post-operative residual contracture, complications, a better pre-operative functional score and male gender. The bottom line appears to be that if you want your Dupuytren’s patients to be satisfied then the key is contracture correction and absence of complications; appearance was the strongest predictor of patient satisfaction. Patients really do care about cosmesis and so should we if we want satisfied patients.

Arthroscopic resection of occult dorsal wrist ganglia

We should always try to treat conditions in simpler and safer ways, with quicker post-operative recovery. Whilst larger ganglia are often asymptomatic, smaller “occult” ganglia can be very painful, especially when present on the dorsal aspect. The ganglia can be ‘nipped’ between the capitate and dorsal rim of the radius on hyperextension, leading to symptoms. The difficulty with open surgery has always been the magnitude of the operation to solve a simple problem and the risk of recurrence. In a study of 30 patients from Baden-Baden (Germany),² the author asks whether these smaller occult ganglia can be successfully treated using an arthroscopic approach. In their reported series of 40 wrists treated in 39 patients, all with occult ganglia confirmed on MRI scanning, and treated with an arthroscopic procedure. Ganglia were identifiable in 25 patients at surgery and were addressed arthroscopically. Given that all but one patient were satisfied with symptom relief by arthroscopic excision of a capsular window through a midcarpal and radiocarpal window, this paper is far from definitive but it does make the point that this treatment is an option. So this technique appears to be an appropriate option for those small ganglia which need treating, avoiding the detriment of an open approach.

Needle or limited fasciectomy?

Continuing 360’s theme of minimally invasive treatment, a study from Rotterdam (The Netherlands)³ set out to compare the effectiveness of needle aponeurotomy and limited fasciectomy. Until a large RCT reports a comparison between a variety of different treatments, either in a stepwise two-armed approach or with a more complex factorial design, we must base our treatment decisions and set patients’ expectations on large comparison studies like this one. The authors report treatment of percutaneous needle aponeurotomy or limited fasciectomy in six hand units, all within The Netherlands. Outcomes were assessed in terms of active extension deficit, the Michigan Hand Outcomes Questionnaire and all importantly reported outcomes of complications at between six and 12 weeks post-operatively. Their matched comparison was of nearly 200 patients treated with either needle fasciotomy or surgery. The simple percutaneous technique produced an equivalent measured correction with a much lower reported mild complication rate (5% vs 24%). However, patients reported a much higher satisfaction rate and more rapid return to function. In the spirit of proper informed consent, these advantages must be carefully explained to patients before promoting surgery. Although the caveat, as always, must be the very high recurrence rate seen with needle fasciotomy consistently shown in other papers and in the relatively short follow-up reported here.

Is wrist arthroscopy really safe?

Wrist arthroscopy is becoming a more and more widely performed technique, with growth in both numbers performed and what is considered an arthroscopically amenable lesion. Everything from arthroscopic-assisted distal radial fracture fixations to the triangular fibrocartilage complex (TFCC), arthritis and ganglia are now within the remit of the arthroscopic wrist surgeon. As the number of patients treated increases it becomes possible to quantify more precisely the risks associated with these procedures, requiring large numbers of patients to accurately assess risks and surgeons of sufficient standing to happily disclose their complications. A group in Paris (France)⁴ undertook a cross-sectional survey-based analysis of members of the European Wrist Arthroscopy Society. The study was questionnaire-based and was designed to establish the rate of complications and the learning curve associated with wrist arthroscopy. The study reports the outcomes of 36 personal series comprising 10 107 wrist arthroscopies in which there was a complication rate of 6% (n = 605), with an overall serious complication rate of 5% with the most frequent complications including failure to complete the procedure (1.16%), nerve injury (1.17%), cartilage injury (0.5%) and CRPS (0.5%). When the study team undertook a more comprehensive analysis, they established that the rate of complications rose significantly in less experienced surgeons – less experienced both in terms of volume and years in practice. Surgery carries risks and we must inform patients of those risks. So, what are the risks of something “simple” like arthroscopy? A group of “experts” from the European Wrist Arthroscopy Society were surveyed and they disclosed a 5% risk of serious complications, such as nerve lesions, stiffness, and tendon lacerations. The reported complication rate was lower if the surgeon performed more than 25 arthroscopies per year and/or had more than five years’ experience. So a wrist arthroscopy, even amongst experts, has a material risk and less experienced surgeons would be wise to consent accordingly.

Pin site infection in Kirschner wires

ESWT in trigger finger

New non-operative treatments need scrupulous assessment, and there are innumerable examples in the literature of attempts to find novel uses for existing interventions (think PRP, amongst others, which to a certain extent is a treatment looking for an indication). Whilst there is ample good evidence that trigger finger can be treated successfully with one or two steroid injections in the majority of patients, some patients are averse to injections, or have a contraindication to steroid injections. There is also a side-effect profile; although relatively safe, depigmentation and fat necrosis can occur. Extracorporeal shock wave therapy (ESWT) has been investigated previously for many other conditions in orthopaedics, urology and cardiology. In this novel randomised controlled trial, a group from Kocaeli (Turkey)⁶ set out to evaluate the efficacy of ESWT when compared with what is now the standard of corticosteroid injections. The study team designed their randomised controlled trial to report cure rates, frequency of triggering and functional impact. They recruited 40 patients to have ESWT or a steroid injection, and followed them up for six months post intervention. The authors were unable to establish any differences in cure rates, pain, and functional status at follow-up. We do always, however, have some concerns about very small RCTs reporting ’no difference’. This study is likely to be underpowered and, as such, one may well not expect to see a significant difference between the two groups in any case.

Cost effectiveness of trigger finger treatment strategies

Staying with the trigger finger and non-operative themes in the previous couple of articles, these days cost effectiveness must always be considered. Non-operative treatment can fail and when it does, despite the cheaper cost, the cost of surgery will need to be added after all. This of course resets the economic balance, and is one of the reasons why longer-term health economic analysis must be considered. A group from Boston, Massachusetts (USA)⁷ compared the approaches of steroid injection, immediate surgery in theatre, and immediate surgery in the clinic. The authors conducted a literature review to establish the success rates and the complications of the various treatments, and set out to establish what the cost implications may be of the various treatment strategies. The message is pretty clear - assuming a corticosteroid injection failure rate of at least 34%, the most cost-effective treatment is immediate surgical release in the clinic. For each patient, employment of this strategy appears to save around 35% of the total healthcare delivery cost.

Step-cut ulnar shortening osteotomy

There are many ways to skin the proverbial cat when it comes to the ulnar osteotomy, ranging from the cheap and cheerful transverse osteotomy to the much more expensive custom jig and plate options. The step-cut osteotomy offers a potential middle ground with some intrinsic stability, and avoids the need for a custom plate. Surgeons in Pittsburgh, Pennsylvania (USA)⁸ have been using the ulnar step-cut osteotomy for a number of years and are the first group to report their long-term outcomes in a reasonable number of patients. Their series reports 164 patients, all of whom underwent a step-cut ulnar shortening osteotomy. The authors report follow-up to a minimum of 24 months and were able to report an impressive 98.8% union rate with their strategy of a palmar plate and lag screw construct. Across the whole series, there were just two cases of nonunion and all of the patients were able to return to their pre-morbid conditions within four months. There was, however, an appreciable incidence of symptomatic metalwork, with 12 patients complaining of plate-related symptoms and requiring their metalwork to be removed.