Hisham M. Awan

Trends in Carpal Tunnel Surgery: An Online Survey of Members of the American Society for Surgery of the Hand

PURPOSEnTo investigate the current treatment patterns of carpal tunnel surgery by members of the American Society of Surgeons of the Hand today and to assess how several elements of practice vary by surgeon location and experience.nnnMETHODSnAn online survey consisting of 10 questions was sent electronically to members of the American Society of Surgeons of the Hand (Nxa0= 2,413). A brief description of the study and a link were sent to participants by the investigators. Results were anonymously uploaded to an online spreadsheet.nnnRESULTSn716 hand surgeons (30%) responded to the survey. Surgeons were nearly equally represented by region. A wide variation in surgeon experience was observed. A majority (65%) performed most of their surgery at an outpatient surgical center. Preoperative electrodiagnostic testing was used, at least occasionally, by 90% of surgeons. Approximately one-half did not administer preoperative antibiotics at the time of surgery. Intravenous sedation with local anesthesia was the most common practice (43%), followed by Bier block (18%). A mini-open incision was most commonly used (50%). A minority reported using an orthosis postoperatively (29%), and they rarely prescribed a course of postoperative therapy (12%). Postoperative pain management was variable, with hydrocodone and derivatives given most commonly (61%). International practitioners were much less likely to operate in an outpatient surgical center (45%) or use antibiotics (13%). Younger surgeons were more likely to use electrodiagnostic testing (96%) compared with the mean (90%).nnnCONCLUSIONSnWhen compared with several previous similar studies, we noted a trend toward increased use of electrodiagnostic testing and decreased use of postoperative therapy and immobilization.nnnTYPE OF STUDY/LEVEL OF EVIDENCEnEconomic and decision analysis V.

Surgeon Preference, Influence, and Treatment of Thumb Carpometacarpal Arthritis

Background: The purpose of this study was to evaluate current surgical practice patterns, the factors that influence these patterns, and overall trends in the treatment of thumb carpometacarpal osteoarthritis. Methods: An online survey containing 14 questions was sent to all active members of the American Society for Surgery of the Hand. Information on demographics and treatments was collected. Results were anonymously uploaded to an online spreadsheet. Results: A total of 823 responses were recorded. Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) using whole flexor carpi radialis was the most popular technique at 37.44%. In all, 26.38% of surgeons with fewer than 5 years of experience utilize trapeziectomy with suture suspension (bone anchor based or tendon based); 55.76% choose a particular procedure because of “Personal Clinical Experience” over “Current Evidence” and “Training.” In addition, 24.17% of surgeons who have been practicing for longer than 5 years have changed procedures in the last 5 years. In the United States, 97.2% of hand surgeons prescribe either oxycodone or hydrocodone postoperatively compared with just 23.75% of international hand surgeons. Conclusions: The results show that trapeziectomy with LRTI remains the most popular treatment of choice. The use of trapeziectomy with suture suspension is on the rise, particularly in younger surgeons. International hand surgeons rely more on current evidence, utilize less postoperative therapy and opioid medications, and change procedures more often than US hand surgeons.

The Effect of Trigger Finger Injection Site on Injection-Related Pain

Background: Stenosing tenosynovitis, or trigger digit, is a common condition for which patients often seek relief. Corticosteroid injections have been shown to provide relief in many cases, and several different approaches for delivering the injection have been described in the literature. We compared patients’ perception of pain following each of 3 accepted injection methods, namely, palmar proximal, palmar distal, and webspace approaches. Methods: We prospectively followed 38 patients with 39 symptomatic digits in this trial, with varying severities of trigger finger as graded by the Patel and Moradia classification. The patients were divided into 3 groups representing the 3 approaches without randomization, based upon the treating surgeons’ preference. Disabilities of the Arm, Shoulder and Hand and visual analog scale (VAS) pain scores were calculated pre-injection and at 4-week and 8-week follow-up visits. Results: No statistically significant differences in age, sex, affected extremity, grade, or duration of symptoms were observed among the 3 approaches. No statistically significant differences in VAS score were found between the palmar proximal (mean = 6.6, SD = 2.6), palmar distal (mean = 6.0, SD = 2.8), and webspace (mean = 6.8, SD = 1.8) approaches. Conclusion: Our data suggest that injection approach does not affect patient pain perception scores or outcomes. We recommend that the technique that is most comfortable to the surgeon be utilized, with the understanding that one injection alone has a low likelihood of relieving symptoms.

Early Postoperative Improvement in Sleep and Pain After Carpal Tunnel Release

Background: Carpal tunnel syndrome (CTS) is the most common compressive neuropathy of the upper extremity. We sought to assess the subjective improvement in preoperative symptoms related to CTS, particularly those affecting sleep, and describe opioid consumption postoperatively. Methods: All patients undergoing primary carpal tunnel release (CTR) for electromyographically proven CTS were studied prospectively. All procedures were performed by hand surgery fellowship–trained adult orthopedic and plastic surgeons in the outpatient setting. Patients underwent either endoscopic or open CTR from June 2017 to December 2017. Outcomes assessed were pre- and postoperative Quick Disabilities of Arm, Shoulder and Hand (QuickDASH), visual analog scale (VAS), and Pittsburgh Sleep Quality Index (PSQI) scores as well as postoperative pain control. Results: Sixty-one patients were enrolled. At 2 weeks, all showed significant (P < .05) improvement in QuickDASH scores. At 6 weeks, 40 patients were available for follow-up. When compared with preoperative scores, QuickDASH (51 vs 24.5; P < .05), VAS (6.7 vs 2.9; P < .05), and PSQI (10.4 vs 6.4; P < .05) scores continued to improve when compared with preoperative scores. At 2-week follow-up, 39 patients responded to the question, “How soon after your carpal tunnel surgery did you notice an improvement in your sleep?” Seventeen patients (43.6%) reported they had improvement in sleep within 24 hours, 12 patients (30.8%) reported improvement between 2 and 3 days postoperatively, 8 patients (20.5%) reported improvement between 4 and 5 days postoperatively, and 2 patients (5.1%) reported improvement between 6 and 7 days postoperatively. Conclusions: The present study demonstrates rapid and sustained improvement in sleep quality and function following CTR.

Radius and Ulna Fractures

The unique two-bone, dual-joint structure of the forearm allows for rotational motion that increases the ability of the hand to manipulate objects in space. Forearm fractures often result from a high-energy injury and are frequently associated with open injuries and/or compartment syndrome. Restoration of radial bow is crucial to maintaining function. Treatment may consist of nonoperative treatment for select indications; however, operative treatment is usually required. Operative management typically involves open reduction and internal fixation with compression plating.

Monteggia and Galeazzi Fractures

The radius and ulna are only in direct bony contact at the proximal and distal radioulnar joints; however, they are interconnected along their entire length by the interosseous membrane. Given this sophisticated anatomical relationship, any disruption of one bone can affect the other. Therefore, a high index of suspicion is required when evaluating forearm fractures to rule out fracture-dislocations, e.g., Galeazzi and Monteggia fractures. The Bado classification is used to stratify Monteggia fractures. Treatment principles of Galeazzi and Monteggia fracture-dislocations include anatomic reduction and fixation of all fractures, preservation of radiocapitellar contact, and managing the soft tissue injury either via direct repair or immobilization in a reduced position [1, 2, 3, 4].

De Quervain’s Syndrome

The extensor tendons of the wrist are divided into six compartments based on synovial sheaths that extend from the overlying extensor retinaculum. De Quervain’s syndrome is a frequent cause of radial-sided wrist pain that emanates from a narrowing of the first dorsal compartment due to synovial inflammation. The syndrome is common in middle-age women and overuse injuries. Patients complain of wrist pain that worsens with grasping or twisting motions. On physical examination, patients have tenderness to palpation over the APL and EPB tendons at the radial styloid. Furthermore, provocative tests reproduce the patient’s symptoms. Radiographs can help eliminate other causes of radial-sided wrist pain; however, the diagnosis of De Quervain’s syndrome is clinical. First-line treatment is nonoperative management with rest, thumb spica splinting, NSAIDs, and corticosteroid injections. Nonoperative treatment is successful in up to 80% of patients. If conservative measures fail to relieve the symptoms, then operative management can be pursued. The operation involves releasing the extensor retinaculum that forms the roof of the first dorsal compartment and any surrounding septa.

Peri-lunate and Lunate Dislocations

Peri-lunate and lunate dislocations are the result of traumatic disruption of the ligaments and capsular attachments that stabilize the carpus. They are commonly missed on initial presentation, and a delay in diagnosis can have a detrimental effect on patient outcome. A heightened alert must also exist for the concomitant diagnosis of acute carpal tunnel syndrome. Urgent stabilization of the wrist should be carried out, and the patient should be aware that this injury often results in stiffness and degenerative arthritis.

First Metacarpal Base Fractures

Fractures about the base of the thumb are common injuries often sustained after a fall onto an outstretched hand. Extra-articular fractures can often be treated without surgery due to a high tolerance of angulation due to the hypermobility of the carpometacarpal joint. Bennett fractures are intra-articular fractures at the base of the thumb metacarpal with a stable volar-ulnar fragment known as the Bennett fragment. Rolando fractures are Bennett fractures with intra-articular comminution. Both Bennett and Rolando fractures are inherently unstable and often require stabilization either with closed reduction and pinning or open reduction and internal fixation.

Dupuytren Disease (Contracture)

Dupuytren disease occurs when normal fascial bands in the hand become pathologic nodules and cords (of collagen) creating flexion contractures. The stages range from skin changes through more severe joint and soft tissue contractures. During the physical exam, the patient places hand on table palm down to observe MCP or PIP contracture. Collagenase injections are a treatment option for nonoperative cases. Patients with MCP joint contractures of at least 30° and/or any PIP joint contractures with concomitant functional deficiency are surgical candidates. Hematoma and recurrence are the most common surgical complications.