A power point based on the article in JBJS by Peter C. Amadio on updates in hand surgery.

1. JOURNAL PRESENTATION
Specialty Update
What’s New in Hand Surgery
JBJS Am, 2015 Mar 18; 97 (6): 520- 526. Peter C. Amadio, MD
Presented by
Dr. Libin Thomas Manathara
158

2. Introduction
• This update reviews material
presented at the 2014 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)
as well as articles published in the field of
hand surgery from June 2013 through
July 2014
258

3. Topics
• Trauma- Finger replantation
• Trauma- distal end of radius fractures- volar ulnar corner
• Trauma- open reduction of distal radius fractures
• Hand transplantation
• Tendon injuries
• Dupuytren Contracture
• Carpal Tunnel Syndrome- surgeons vs patients
• Carpal Tunnel Syndrome- trigger finger
• Carpal Tunnel Syndrome and work
• Arthritis and Other Nontraumatic Conditions
• Pediatric Hand Problems
• Perioperative Care in Hand Surgery
• Evidence-Based Articles Related to Hand Surgery
358

4. Trauma- finger replantation
• Finger replantation was one of the
defining procedures of modern
hand surgery.
• Many hand surgeons have the
impression that this procedure is
less commonly performed now
than previously, and a recent
study presented to the AAHS
suggests that this perception is
accurate.
458

5. Trauma- finger replantation
•Although the total number of amputations was
similar (26,668 in 2001 and 24,215 in 2010), the
number of replantations in 2001 was 930
compared with 455 in 2010.
•Roughly half of the injuries in both years were
fingertip injuries; other than a decrease in the
percentage of work-related amputations, no
other factor distinguished the two years that
might explain the difference in replantation rates.
•The authors were unable, on the basis of their
data, to assess reasons for the decline in
replantation surgery
22000
23000
24000
25000
26000
27000
28000
2001 2010
930
455
Finger replanta
tions
Total amputatio
ns
558

6. Trauma- distal end of radius
fractures- volar ulnar corner
• Distal radial fractures are a perennial
topic for hand surgeons. Particular
attention is being paid to fractures
involving the volar ulnar corner of the
radius, which appear to be more
susceptible to loss of fixation and
subsidence, due to the frequently
small size of the affected fragment.
• A recent study of 52 B3 fractures
according to the AO/OTA classification
(volar shearing fractures), treated
surgically with use of volar plates,
identified 7 cases in which reduction
was lost postoperatively.
7
45
Reduction lost
Reduction maintained
658

7. • Multivariate analysis showed that
preoperative lunate subsidence and
the size of the lunate facet fragment
were the main factors associated with
the loss of reduction.
• All of the fractures that lost reduction
were classified as AO/OTA B3.3 (volar
comminution with separate lunate and
scaphoid facet fragments).
• For such fractures, the authors
recommended additional fixation with
plate extensions, pins, wires, sutures,
wire forms, or mini screws to maintain
the reduction.
Trauma- distal end of radius
fractures- volar ulnmar corner
23-B
partial articular fracture of
radius
23-B1 sagittal
23-B2 coronal, dorsal rim
23-B3 coronal, palmar rim
758

8. Trauma- distal end of radius
fractures- volar ulnar corner
858

9. Trauma- distal end of radius
fractures- volar ulnar corner
958

10. Trauma- open reduction of distal
radius fractures
• One recent study looked at rates of
surgery in 2007 for Medicare
beneficiaries over the age of sixty-five.
• A total of 90,174 patients with
fractures were identified. In 267, the
fracture was due to bone cancer.
• Of the remaining patients, 12,618 had
open reduction and internal fixation,
while 2084 were treated with external
fixation and 4709, with percutaneous
pinning.
12,618
2084
4709
ORIF
ExFix
K wire
1058

11. Trauma- open reduction of
distal radius fractures
• The patients were treated by a total of 12,823 different clinicians, of whom
1194 were identified as hand surgeons.
• Surgeons who were forty years of age or younger and those who were
identified as hand surgeons were somewhat more likely to prefer open
reduction and internal fixation.
• This data source did not allow an assessment of outcome, but another
recent study did.
1158

12. Trauma- open reduction of distal
radius fractures
• That study used an existing database
to match 129 surgically treated
patients who were sixty-five years of
age or older with 129 nonoperatively
treated control patients according to
• fracture severity,
• sex,
• age, and
• energy of injury.
1258

13. • The following were monitored up to
one year post-injury-
• Functional outcome (measured with
use of the Patient-Rated Wrist
Evaluation),
• fracture union,
• quality of final alignment,
• time to union, and
• complications
• As in the study above, the majority of
patients were treated with open
reduction and internal fixation.
Trauma- open reduction of
distal radius fractures
1358

14. Trauma- open reduction of
distal radius fractures
• The results showed that the
complication rate was significantly
higher (thirty-seven compared with
twenty two complications) in the
surgical group, while final functional
status did not differ between the two
groups, despite the higher malunion
rate (69% compared with 29%) in the
nonoperatively treated group.
• The reoperation rate was similar
between the two groups
1458

15. Trauma- open reduction of
distal radius fractures
• The authors concluded that, for individuals over the age of sixty-five, case
matched by age and fracture severity, results are similar but complications
are more frequent in surgically treated patients than in patients managed
without surgery.
1558

16. Hand transplantation
• Hand transplantation is becoming
increasingly accepted by the hand-
surgery community, and many clinical
centers now have hand-transplantation
programs, even though many of these
programs have yet to actually perform
such a procedure.
• Two presentations to the AAHS
addressed this topic.
• In one, thirty normal subjects and
fifteen hand amputees were asked to
rate the utility of hand transplantation
and to estimate the resulting quality-
adjusted life years (QALYs) associated
with hand transplantation.
1658

17. Hand transplantation
• Interestingly, hand amputees did not show a preference for hand transplantation
• The authors concluded that hand transplantation should still be approached
cautiously.
1758

18. Hand transplantation
• In the other study, twenty-two upper-
limb amputees were interviewed
regarding their preference as well as
their perception of the risks and
benefits of hand transplantation.
• Among unilateral amputees, function
was considered a benefit only if it
approached that of an intact limb.
• Appearance was a secondary
consideration, and sensation was
considered less of a benefit if the
contralateral limb was intact.
1858

19. Hand transplantation
• Most subjects emphasized the risks of
immunosuppression and the psychological
risks of coping with the possibility of
rejection and reamputation.
• Similar to the authors in the first
presentation, these authors emphasized
caution in proceeding with hand
transplantation and emphasized the
importance of thoughtful dialogue with
patients before making a decision to
proceed with such a procedure.
Insert the video of the first
bilateral hand transplantation
done at Amrita Institute of
Medical Sciences on Manu a
train accident victim
1958

20. Tendon injuries
• Hand surgeons continue to seek the best methods of
rehabilitation after flexor tendon injury.
• Two recent large systematic reviews—one of which
reviewed nearly 3000 repairs and the other, more
than 3500 repairs — have tried to address three
important issues:
• whether early active motion is better than early
passive motion in reducing the rupture rate,
• whether the use of multistrand (i.e., four or six rather
than the usual two strand) repairs reduces the
rupture rate, and
• whether early active-motion programs, compared
with early passive-motion programs, result in better
final motion.
2058

21. Tendon injuries
• While one study was able to conclude that
“Early passive range of motion protocols had
a statistically significantly decreased risk for
tendon rupture but an increased risk for
postoperative decreased range of motion
compared to early active motion protocols,”
neither study could definitely say that
multistrand repairs reduced the rupture rate
or that final motion was better following early
active motion.
• One of the key aspects of any successful
tendon repair is the postoperative therapy.
2158

22. Tendon injuries
• Extensor-tendon rehabilitation, in particular, has been
revolutionized recently by the use of “relative motion splinting” in
which the affected digit is held either in relative extension (for
sagittal band injuries, for example) or relative flexion (for
boutonniere injuries) at the metacarpophalangeal joint, in order to
allow active motion while protecting the affected area.
• Simple hand-based splints can be used, greatly facilitating both
patient acceptance and function.
2258

23. Dupuytren Contracture
• The injection of clostridial collagenase is now an
accepted treatment for Dupuytren contracture.
• The disadvantage of this treatment is that it is
only approved to treat one affected joint at a time.
• In contrast, alternatives such as needle
fasciotomy and surgery can treat all parts of the
hand affected by the disease at one time.
• This is a recent study of the efficacy and safety of
multiple collagenase injections
2358

24. Dupuytren Contracture
• In this study, sixty patients received treatment of two joints rather than one, most
commonly
• either the MCP and PIP joints of the same digit, or
• two MCP joints.
• The rate of clinical success in correcting the contracture was
• 76% for the MCP joint and
• 33% for the PIP joint,
• similar to the rate of correction reported for single injections
2458

25. Dupuytren Contracture
• While 88% of patients were satisfied, all patients
had at least one recorded adverse event, and
there were some major complications, including
A2-A4 pulley rupture in one patient and tendon
rupture in another.
• Complications such as
• pain requiring treatment (83% of subjects
compared with 30% to 40%),
• pruritus (33% compared with 11%),
• lymphadenopathy (37% compared with 10% to
20%), and
• skin tears (25% compared with 5% to 10%)
• Although the authors concluded that two joints
can be treated safely with collagenase, the
higher rates of adverse events are worrisome
with regard to extending this treatment to single-
stage, whole-hand treatment.
2558

26. Dupuytren Contracture
• Splinting after surgery for Dupuytren
contracture is commonly continued for
up to three weeks postoperatively, but
a recent prospective randomized study
calls this practice into question.
• Fifty-six patients were randomized to
have either therapy alone or therapy
plus night-time splinting for three
months postoperatively.
• At the end of the study, the two groups
did not differ in terms of final range of
motion or flexion contracture.
• The authors concluded that routine
splinting after fasciectomy for
Dupuytren contracture is not
warranted, and should be reserved for
patients who develop contractures
postoperatively.
2658

27. Carpal Tunnel Syndrome-
surgeons vs patients
• What do patients want when it comes
to the treatment of carpal tunnel
syndrome?
• Do patients ’ desires differ from those
of hand surgeons?
• A very interesting paper recently
addressed both of these questions.
• 79 patients with carpal tunnel
syndrome and 103 hand surgeons
were surveyed about their priorities
and preferences with regard to the
treatment of carpal tunnel syndrome.
2758

28. Carpal Tunnel Syndrome-
surgeons vs patients
• Interestingly, patients were less enthusiastic than were surgeons about all treatment
options (splinting, injection, or surgery), with the difference of opinion being greatest
with respect to injection.
• Patients were more likely than surgeons to think that electromyography was
worthwhile, even though the patients disliked the pain associated with this test.
• Patients were more concerned than were surgeons about the risks of surgery, and
they placed more faith in family support and second opinions when making treatment
decisions.
• Patients also preferred written material to videos as decision aids.
• Finally, patients wanted to be informed and then make the treatment decision for
themselves, while surgeons preferred that the decision be a shared one between
patient and surgeon.
2858

29. Carpal Tunnel Syndrome- trigger
finger
• Many hand surgeons believe that carpal
tunnel release increases the risk for
subsequent trigger finger, and indeed there
are studies that show this association.
• The mechanism, however, has been unclear.
• One study looked at palmar displacement of
the flexor digitorum superficialis tendons
before and after surgery in 319 patients who
had had carpal tunnel release.
• Tendon displacement was noted both at rest
and with grip.
• Postoperatively, 47 of these patients
developed trigger finger
2958

30. Carpal Tunnel Syndrome and work
• Interestingly, these patients had a roughly 1-mm greater palmar tendon displacement
postoperatively, a finding that was significant and that suggests that triggering may have been
associated with tendon bow stringing in this subset of patients.
• Surgeons do not generally assess bowstringing of tendons after carpal tunnel release (for
example, by asking patients under local anesthesia to make a fist after the ligament is released);
perhaps they should do so and should consider addressing the bowstringing with a transverse
carpal ligament reconstruction if it occurs
3058

31. Carpal Tunnel Syndrome and work
• The work-relatedness of carpal tunnel
syndrome remains an area of active debate
among hand surgeons.
• The main factor predictive of carpal tunnel
syndrome was forceful hand exertions,
which roughly doubled the risk of carpal
tunnel syndrome.
• Other factors, such repetitive activities with
low force and the percentage of time in
extremes of wrist position, were not
associated with any increased risk of carpal
tunnel syndrome.
• The authors concluded that workplace
prevention of carpal tunnel syndrome
should focus on high-force repetitive work.
3158

32. Arthritis and Other Nontraumatic
Conditions
• The treatment of Kienbock disease
remains a challenge for hand surgeons.
• This challenge is only heightened by the
advent of newer imaging techniques,
which show that the disorder progresses
to cartilage loss perhaps faster than
previously thought.
• A paper presented to the ASSH
reviewed a series of patients with
Kienbock disease who underwent
imaging with use of both 3-T MRI and
ultrathin-section computed tomography
(CT), and showed that often, both lunate
cartilage thinning and fracture develop
within one year of the onset of
symptoms.
3258

33. Arthritis and Other Nontraumatic
Conditions
• For the past few years, hand
therapists have instructed patients in
the use of an exercise program to
strengthen the first dorsal interosseous
muscle, in an effort to reduce thumb
carpometacarpal joint pain and
subluxation.
• An anatomic study of the effect of first
dorsal interosseous muscle contraction
on thumb carpometacarpal joint
stability was presented to the AAHS
and included 17 subjects, 14 of whom
had radiographic evidence of thumb
carpometacarpal joint subluxation.
3358

34. Arthritis and Other Nontraumatic
Conditions
• A companion study presented to the ASSH looked at the biomechanics of this
exercise program in a cadaver model.
• Both studies provided strong evidence to support the hypothesis that thumb
carpometacarpal joint subluxation was improved with contraction of the first dorsal
interosseous muscle
• Therefore strengthening of the first dorsal interosseous muscle is a simple and
potentially effective adjunct to the nonsurgical management of thumb
carpometacarpal joint instability.
3458

35. Arthritis and Other Nontraumatic
Conditions
• What is the best angle to fuse the
interphalangeal joint of the thumb?
• Most textbooks suggest that neutral
flexion/ extension or slight flexion is
preferred, but a study presented to the
AAHS suggests that a bit more flexion
may be better.
3558

36. Arthritis and Other Nontraumatic
Conditions
• Twenty-eight healthy volunteers (11 men and 17 women; mean age, 33.5 years)
agreed to have the interphalangeal joint of the thumb splinted at 0, 15, 30, or 45 of
flexion.
• They completed various tasks and underwent pinch and grip testing.
• The ideal position for pinch and grip strength was found to be 15 of flexion, and this
position was also preferred for the various tasks involving the thumb of the dominant
hand; for the thumb of the nondominant hand, a position of 30 was preferred.
• No matter in what position the joint was immobilized, precision tasks, such as
buttoning, were more difficult with the joint immobilized than with it free.
3658

37. Pediatric Hand Problems
• Open Salter-Harris type-I and II fractures of the distal phalanx in children
present as a proximally dislocated fingernail and a flexion deformity of the
distal phalanx.
• If radiographs are not obtained, the true nature of this injury as an open
fracture may not be appreciated.
• A paper presented to the ASSH looked at the consequences of delayed
treatment (greater than forty-eight hours post-injury) as well as at treatment
that did not include
• debridement,
• open reduction,
• nail-bed repair, and
• antibiotic therapy.
3758

38. Pediatric Hand Problems
• The differences were stark.
• Early and appropriate treatment resulted in uniformly good results, with only
one superficial wound infection in the 27 patients so treated, while 6 of the
13 patients with delayed treatment had complications, including
osteomyelitis in 4 cases.
• The message is clear: it is important that such injuries be diagnosed early
and treated surgically.
58 38

39. Perioperative Care in Hand
Surgery
• Is it necessary to discontinue anticoagulants prior to hand surgery in order
to reduce the risk of bleeding complications?
• To do so does have risks, including the various thromboembolic events
such as stroke or myocardial infarction that the anticoagulants were
prescribed to prevent.
• A study presented to the AAOS suggests that these drugs may be
continued safely during hand surgical procedures.
3958

40. Perioperative Care in Hand
Surgery
• In a case-controlled study of 52 patients, 26 of whom were administered
warfarin and 26, no anticoagulant, no difference was found in terms of
postoperative function, pain, or swelling.
• The extent of ecchymosis was significantly greater in the warfarin group (45
mm compared with 17 mm), but no reoperations were needed in either
group.
• The authors concluded that it is safe to continue warfarin in patients during
hand surgery.
• A similar study on antiplatelet therapies came to a similar conclusion.
58 40

41. Evidence-Based Articles
Related to Hand Surgery
4158

42. Adult Scaphoid Fracture
Carpenter CR, Pines JM, Schuur JD, Muir M, Calfee RP, Raja AS. Adult scaphoid fracture. Acad Emerg Med. 2014 Feb;21(2):101-21.
• This review included seventy-five studies, of
nearly 1000 initially evaluated, that
assessed the diagnostic accuracy of various
physical findings and imaging studies in
cases in which there was a history of an
injury involving wrist pain and when initial
radiographs were normal.
• The authors concluded that the
methodological quality of the studies was
low.
• The only physical finding that appeared to
be useful was the lack of snuffbox
tenderness, which reduced the probability of
a fracture being present.
4258

43. • Of the imaging studies, MRI had the best
overall combination of sensitivity and
specificity.
• Comment: The author agrees with these
conclusions and believe they are becoming
the consensus among hand surgeons.
• Some surgeons may prefer CT imaging, if a
fracture is identified and surgery is planned,
because of the better image quality and the
ability to create three-dimensional
reconstructions, which can aid in surgical
planning
• Xray vs MRI T1 vs MRI T2
Adult Scaphoid Fracture
4358

44. Dorsal Vascularized Grafting for Scaphoid Nonunion
Caporrino FA, Dos Santos JB, Penteado FT, de Moraes VY, Belloti JC, Faloppa F. Dorsal vascularized grafting for scaphoid nonunion: a
comparison of two surgical techniques. J Orthop Trauma. 2014 Mar;28(3):e44-8
• Seventy-five patients with scaphoid
nonunion were randomized to
treatment with either a vascularized
pedicle graft or a nonvascularized graft
from the distal aspect of the radius.
• Union rates were similar between the
two groups, and the authors
questioned whether the increased
technical difficulty of a vascularized
graft was worth the effort.
• Comment: Many hand surgeons
reserve vascularized bone grafts for
use in more complicated cases with
small proximal poles or when there is
evidence of osteonecrosis.
• Vascularized grafts may also be useful
in reoperations.
4458

45. An investigation of the effect of AlloMatrix bone graft in distal radial fracture: a
prospective randomised controlled clinical trial.
D’Agostino P, Barbier O. Bone Joint J. 2013 Nov;95(11):1514-20.Treatment of Distal Radial Fractures
• The clinical effectiveness of an injectable
demineralized bone-matrix allograft (AlloMatrix;
Wright Medical Technologies, Memphis,
Tennessee) was studied in fifty patients with an
unstable distal radial fracture, randomized to
receive either the allograft or no graft.
• All fractures were treated with Kirschner-wire
fixation after reduction.
• In comparing the two groups at one, six, and fifty-
two weeks of follow-up, no significant differences
were found in bone density, function, or speed of
recovery.
• Comment: Bone allografts are popular because
there is no donor site to worry about, but as this
study shows, the benefit may be hard to document,
even when the comparator is no graft at all.
• In addition, for application in the hand and wrist,
where the voids that might benefit from grafting are
small, autologous grafts are nearly always available
and, given the small volume needed, the donor
morbidity is usually modest.
4558

46. Percutaneous fixation with Kirschner wires versus volar locking plate fixation in adults
with dorsally displaced fracture of distal radius: randomised controlled trial
Costa ML, Achten J, Parsons NR, Rangan A, Griffin D, Tubeuf S, Lamb SE; DRAFFT Study Group. BMJ. 2014;349:g4807. Epub 2014 Aug 5.
• In this multicenter trial in the U.K., 461
patients with a dorsally displaced distal
radial fracture were treated with either volar
locking-plate fixation or percutaneous
Kirschner-wire fixation.
• The main outcome measure was the
Patient-Rated Wrist Evaluation, a validated
questionnaire of wrist function.
• There were no differences between the two
groups at three, six, or twelve months.
• The authors observed that Kirschner-wire
fixation is less expensive and a simpler
procedure than volar plating.
• Comment: In general, when simpler
methods suffice, they are preferred.
• This article reminds us that the outcomes of
distal radial fracture treatment can be quite
satisfactory with a variety of methods,
especially if function rather than normal
anatomy or strength is the primary goal. 4658

47. Surgical treatment of distal radial fractures with a volar locking plate versus
conventional percutaneous methods: a randomized controlled trial
Karantana A, Downing ND, Forward DP, Hatton M, Taylor AM, Scammell BE, Moran CG, Davis TR. J Bone Joint Surg Am. 2013 Oct
2;95(19):1737-44
• This study randomized 130 patients with a
displaced distal radial fracture to treatment
with either a volar locking plate or a
percutaneous method (pins with or without
external fixation).
• Patients treated with a plate had a quicker
return to function, but functional results were
similar between the two groups at three
months and one year.
4758

48. • Comment: Volar locking
plates have become very
popular in the surgical
treatment of distal radial
fractures, and this study
demonstrates one
reason — there is a faster
return to function.
• It is important to remember,
however, that the longterm
results of volar plating are
similar to those achieved
with other treatment
methods as well, and that
these other methods
remain acceptable clinical
practice at many institutions.
Surgical treatment of distal radial fractures with a volar locking plate versus
conventional percutaneous methods: a randomized controlled trial
4858

49. Comparison of internal and external fixation of distal radius fractures
Xie X, Xie X,Qin H, Shen L, Zhang C. Acta Orthop. 2013 Jun;84(3):286-91. Epub 2013 Apr 18.
• This review considered 770 clinical trials
before selecting ten that met the inclusion
and exclusion criteria.
• The authors concluded that internal fixation
had significantly better results than external
fixation with regard to the final DASH
(Disabilities of the Arm, Shoulder and Hand)
score, motion, anatomic reduction, and
strength.
• Comment: The results were significant but
perhaps not clinically so.
• The DASH difference was 3 points; however,
a clinically important difference is usually
considered to be >5 points.
4958

50. Trapeziometacarpal Arthrodesis or Trapeziectomy
Vermeulen GM, Brink SM, Slijper H, Feitz R, Moojen TM, Hovius SE, Selles RW. Trapeziometacarpal arthrodesis or trapeziectomy with
ligament reconstruction in primary trapeziometacarpal osteoarthritis: a randomized controlled trial. J Bone Joint Surg Am. 2014 May
7;96(9):726-33.
• This randomized controlled trial was designed to
assess trapeziectomy with ligament
reconstruction compared with
trapeziometacarpal arthrodesis with a plate and
screws in women with trapeziometacarpal
arthritis who were forty years of age or older.
• The study was terminated early because of the
high complication rate in the arthrodesis group.
• On the basis of the results of this study, the
authors do not recommend routine arthrodesis
with plate and screws in women with isolated
trapeziometacarpal arthritis who are forty years
of age or older.
5058

51. Trapeziometacarpal Arthrodesis or
Trapeziectomy
5158

52. Trapeziometacarpal Arthrodesis or
Trapeziectomy
• Comment: Many surgeons prefer trapeziometacarpal arthrodesis for men and arthroplasty for
women, believing that arthrodesis yields a stronger thumb and that strength is more important in
men than it is in women.
• When one considers sex differences in strength, however, the belief that arthrodesis is the option
that delivers the greater strength does not appear to be true, as this study demonstrates.
• Currently, simple trapeziectomy is the procedure that the evidence base suggests is preferred for
most patients with trapeziometacarpal arthritis.
5258

53. Postoperative Hand Therapy for Basal Joint Arthritis
Wolfe T, Chu JY, Woods T, Lubahn JD. A systematic review of postoperative hand therapy management of basal joint arthritis. Clin Orthop
Relat Res. 2014 Apr;472(4):1190-7.
• Nineteen studies were reviewed, and three patterns of postoperative
management for patients with basal joint arthritis were identified:
• home instruction alone,
• routine referral to a hand therapist, and
• home instruction with referral to a therapist as needed.
• Because of the variety of surgical and therapeutic interventions reported
in these studies, no conclusions could be drawn as to the relative merits
of these three postoperative regimens.
• Comment: When faced with limited data and uncertainty, the author
tends to opt for the least complex and least resource-intensive course. In
his own practice, he would refer a patient for therapy after basal joint
surgery only if the patient is having difficulties regaining motion or
strength postoperatively.
5358

54. Low-Molecular-Weight Heparin and Replantation
Chen YC, Chi CC, Chan FC, Wen YW. . Cochrane Database Syst Rev. 2013;7:CD009894. Epub 2013 Jul 8, Low molecular weight heparin for
prevention of microvascular occlusion in digital replantation
• This Cochrane review could identify only two
relevant trials, with a total of 122 digits
studied, in comparing subcutaneous low-
molecular-weight heparin with
unfractionated heparin in the postoperative
management of finger replantation.
• No differences were found between the two
treatments.
• The authors suggested that additional
studies be performed.
• Comment: The use of anticoagulation
therapy after finger replantation varies
greatly from center to center.
5458

55. Open versus endoscopic carpal tunnel release: a metaanalysis of randomized
controlled trials
Sayegh ET, Strauch RJ. Clin Orthop Relat Res. 2014 Aug 19
• A total of 1859 subjects were included
• The analysis showed that the endoscopically
treated patients had modestly greater
strength at early follow-up, but this
difference disappeared after six months.
• Endoscopically treated patients went back to
work about nine days sooner, and the
operative time was about five minutes faster
than that for the patients treated with open
release.
• The risk of postoperative scar tenderness
was about half as great for endoscopically
treated patients, while the risk of nerve injury,
most often transient, was three times as
great in the endoscopic group.
5558

56. Open versus endoscopic carpal tunnel release: a metaanalysis of
randomized controlled trials
• The risks of pillar pain and reoperation were roughly equal in the
two groups.
• The authors recommended future studies on the effect of the
learning curve and surgical volume on the rates of complications
and the safety of endoscopic carpal tunnel surgery.
• Comment: Open and endoscopic carpal tunnel release have
slightly different risk-benefit equations, but the long-term results
are similar.
5658

57. Insert the video of Zion, the first pediatric bilateral hand
transplantation done at the Children's Hospital,
Philadelphia
58 57

58. THANK YOU
5858