Background

The material presented at the 2011 annual meetings of the American Society for Surgery of the Hand (ASSH), the American Association for Hand Surgery (AAHS), and the American Academy of Orthopaedic Surgeons (AAOS) and selected articles in the area of hand surgery were reviewed. Updates were noted in skeletal trauma, tendon injury, replantation and microsurgery, other vascular problems, arthritis, Dupuytren contracture, Kienböck disease, and cost-effectiveness in hand surgery.

Updates

With respect to skeletal trauma, updates were found in the management of distal radial fracture, bone quality and bone density in osteoporosis screening, intercarpal ligament and cartilage injuries, carpal tunnel release during volar plating of the distal part of the radius, use of simple distal pole excision for posttraumatic arthritis secondary to scaphoid nonunion, scaphoid fractures, and scapholunate injuries. Tendon injury management may be altered by the ability to practice surgical techniques in benchtop simulations and by active mobilization after repair. Access to replantation services is highly inconsistent and offers challenges to many communities. Toe-to-hand transfer techniques all appear to have comparable outcomes.

Raynaud phenomenon may respond to botulinum toxin type A treatment, but sodium hyaluronate, while safe for arthritis of the thumb, appears ineffective. Implants are similarly ineffective as replacements for the base of the thumb metacarpal in terms of strength and motion. Proximal interphalangeal joint arthroplasty remains problematic. Total wrist arthroplasty with an implant produces high patient satisfaction but not always clinically acceptable results. Collagenase for Dupuytren contracture and other minimally invasive approaches appear to be associated with lower rates of recurrence at the metacarpophalangeal joints than at the proximal interphalangeal joints. However, patients appear to be unconcerned with the degree of contracture, which does not correlate strongly with the degree of functional impairment. Interestingly, hand surgeons cannot agree on the radiographic appearance of Kienböck disease, even with their own previous assessments.

It was pointed out that professionals should be aware of the effectiveness of treatments but also of the cost to patients. Formal hand therapy programs often cost more but are no more effective than informal rehabilitation instructions from the surgeon. Repair of hand fractures in a minor surgical suite appears to be safe and effective and costs much less than care delivered in an operating room. Also, field sterility is sufficient for carpal tunnel surgery, saves time and money, and cuts down on waste. Similar findings were related to antibiotics and pain medications, both of which tend to be overly prescribed. Patients end up with extra medication, which poses a risk for inappropriate use.

Conclusions

Many areas were updated in the annual meetings of the ASSH, AAHS, and AAOS and in hand surgery articles published between August 2010 and July 2011. Keeping abreast of these changes will have an impact on care.

Commentary

The author reviews material presented at the 2011 annual meetings of the American Society for Surgery of the Hand, American Association for Hand Surgery, and the American Academy of Orthopedic Surgeons as well as articles published in the field of hand surgery (other than those published in The Journal of Bone & Joint Surgery ) between August 2010 and July 2011. This is an excellent overview for those wanting to stay current in hand surgery but whose practice is not primarily focused in that area.

Commentary

Pollicization is a powerful technique to construct/reconstruct a lost or missing thumb. The authors outline five technical refinements to improve appearance and function. They are (1) modification of the incisions to produce a well-contoured web space, (2) metacarpal head positioning for optimal recreation of the carpal arch, (3) extrinsic tendon repositioning for improved pronation of the new thumb, (4) intrinsic tendon repositioning for maximal strength, and (5) thenar augmentation with an adipofascial flap in select cases for improved appearance. With 30 years of experience and over more than 300 cases, this is a must-read for anyone doing this surgery.

Commentary

Pollicization is a powerful technique to construct/reconstruct a lost or missing thumb. The authors outline five technical refinements to improve appearance and function. They are (1) modification of the incisions to produce a well-contoured web space, (2) metacarpal head positioning for optimal recreation of the carpal arch, (3) extrinsic tendon repositioning for improved pronation of the new thumb, (4) intrinsic tendon repositioning for maximal strength, and (5) thenar augmentation with an adipofascial flap in select cases for improved appearance. With 30 years of experience and over more than 300 cases, this is a must-read for anyone doing this surgery.

Commentary

Toe-to-hand transfer is indicated for many types of congenital and traumatic thumb absences. The authors emphasize the applications of toe-to-hand transfer and its functional, aesthetic, and psychosocial outcomes. This current concept is complete and concise. This is a nice review for those routinely performing the procedure and is a must-read for those who want to keep current.

Purpose

Despite the growing number of free and local flaps used for repairing defects of the hand, groin flaps are also still widely used. The aims of this study were to evaluate the outcome of a large series of patients whose defects were covered by pedicled groin flaps, and to find out whether it is still indicated in replacing damaged soft tissue of the hand in the era of microsurgery.

Methods

From 1982 to 2009, we treated 85 patients with soft tissue defects on the hand and distal forearm with pedicled groin flaps in our department and recorded them in a prospective database. We interviewed and examined 49 patients in this cohort.

Results

The mean age of the 85 patients was 33 years, the male/female ratio was 4:1, the mean hospital stay was 29 ± 13 days, and the mean follow-up was 9 years. The duration to flap division was 24 ± 5 days. Altogether, we performed a mean of 4.6 operations per patient, including thinning of the flap, deepening of the interdigital fold, and stump and flap revisions. One flap loss occurred. Of the 49 patients, results were mostly classified as good, and 82% of patients would undergo the procedure again. The mean Disabilities of the Arm, Shoulder, and Hand score value was 23 ± 17. The Vancouver Scar Scale showed nearly normal height and vascularity of the groin flap (0.2 ± 0.4 and 0.3 ± 0.6, respectively), pigmentation was slightly abnormal (0.8 ± 0.6), and pliability was evaluated between “supple” and “yielding” (1.5 ± 1.2).

Conclusions

Results achieved with the groin flaps were positive. Most patients were satisfied with the results, and the operation was easily performed when McGregor’s recommendations were followed. Nevertheless, considering the high number of secondary operations, the long hospital stay, and immobilization of the arm, groin flaps should be used only when free flaps or regional pedicle flaps are either not feasible or not indicated.

Type of Study/Level of Evidence

Therapeutic III.

Commentary

The authors present their experience with pedicled groin flaps. Their main indicators for the groin flap instead of free flap were in cases in which the patient’s health is critical (eg, polytrauma), the vessels of the arm are damaged and a loop is not feasible because of a lack of soft-tissue coverage, other microsurgical interventions are likely (eg, second toe transfer), or general anesthesia and long operative time are contraindicated (eg, pregnancy). One nice operative trick is that they recommend thinning should be performed primarily, which also reduces the required distance of vessel ingrowth. This unit has an excellent microsurgery background and success rate. This makes their observations all the more interesting.