What’s New in Hand Surgery

“Anything you can do to help would be very…..helpful”

from Monty Python’s “The Search for the Holy Grail”

To be honest with you things tend to change very slowly in the field of hand surgery.  Most of the treatment I provide are not much different from what I learned during my hand fellowship almost 30 years ago.  In general this is not a bad thing since most of these treatments have stood the test of time and have been proven to be predictable and reliable.

However over the past several years several new treatments have become available that have changed the way I treat several conditions and perform surgery.  I’m excited about these changes and I wanted to share them with you so you can be aware of what’s new in hand surgery.

The most dramatic change has come in the treatment of Dupuytren’s disease.  I touched on this on an earlier post about Dupuytren’s and you can refer to that post for more information.  The change has come with the discovery of a medicine that can be injected into a cord and allow us to disrupt the cord and straighten the finger without surgery.  Before the creation of this medicine, called Xiaflex, surgery was usually the only option for treatment for a patient with Dupuytren’s who had a cord that was pulling their finger down and causing difficulty in using their hand.  The surgery was usually successful, but it was a long, difficult and demanding procedure both for the surgeon and the patient.  Recovery usually took several months, and there was a significant chance of damaging a nerve and causing numbness after the surgery.  With Xiaflex the entire process of disrupting the cord and straightening a finger is much easier on the patient and the recovery process is much shorter and simpler.  The results are similar to those seen with surgery.  I’ve taken care of patients who had surgery on one hand and then had xiaflex on another hand, and they are amazed at the difference and how much simpler that procedure is.  Xiaflex doesn’t work in every case, but overall I think it’s been a tremendous improvement in the care of the patients I see with Dupuytrens disease.

Another new and innovative treatment that has come about is the use of an ultrasound probe for the treatment of chronic tendonosis of the elbow, known as tennis elbow and golfers elbow.  I’ve discussed both conditions in previous blogs and you can refer back to those posts for more information.  These problems affect of lot of people as they reach their 40’s and 50’s and can affect people during a lot of activities they like to do.  Rest, exercises and an occasional cortisone injection can take care of most of these problems, but in some people the pain persists to the point that they need something more done.  In the past the only other option was to make an incision and surgically remove the damaged tendon tissue.  This surgery worked pretty well, but it usually took 3 to 4 months to recover and regain strength and use of the arm.  Some inventive physicians from the Mayo clinic theorized that you could use ultrasound to remove the damaged tendon tissue through a small puncture wound rather than a large incision.  They developed what is called the FAST procedure (F-focused A-aspiration of S-scar T-tissue).  A small ultrasound probe is placed through a tiny stab wound directly into the area of damaged tendon, which is seen and localized on an ultrasound machine similar to what people use to see unborn babies in the womb.  The entire procedure only takes a couple of minutes and can be done under local anesthesia.  I think the FAST procedure works very well, but doesn’t help every patient.  The open procedure may work a little better, but the FAST procedure usually results in a quicker recovery and much less down time.  It’s nice to have something to offer patients who have chronic elbow problems without having to resort to pretty big surgical procedure.

The third change has been in the improvement in the use of local anesthesia in hand surgery.  In the past we have been able to numb fingers very well, but it was difficult to use local anesthesia for many cases.  The hand bleeds very much, which means we have to use a tourniquet to control the bleeding.  A tourniquet is like a blood pressure cuff, and most people can’t stand it for more the 3 or 4 minutes before it becomes very uncomfortable.  However a hand surgeon in Canada figured out that , contrary to what was commonly thought, it was safe to use local anesthesia with epinephrine in the hand.  Epinephrine controls bleeding, and it allows the surgeon to operate on the hand and control the bleeding without the use of a tourniquet.  This has allowed me to do a number of procedures such as carpal tunnel release, trigger finger release and Dequervain’s surgery under local anesthesia.  A lot of patients choose this option and almost universally they enjoy the experience and have no problems with the surgery.  It’s nice for the patients to have options about not only their treatment but also about the way the treatment is done.

Dequervain’s Tendonitis: De ker what?

Standing beside the ocean, looking across the water

Everything is beautiful here but I still don’t feel like I oughta

from the song “Dancing the Night Away” by the Amazing Rhythm Aces

 

One of the most common conditions that involves inflammation, or swelling, in the hand and wrist is called “Dequervain’s Tendonitis”.  The names comes from a Swiss physician who first described the problem way back in 1895.  People pronounce this in various ways, most commonly something like De-kwer-vains.  The problem involves a group of tendons that help to move the thumb.  The tendons get irritated as they pass through a sheath that helps hold them close to the bone.   Most patients have pain with movement of their thumbs and swelling in their wrists on the side of the wrist near the thumb.  Most of the time the swollen area if very tender.  Some patients will get popping of their thumbs when they move their thumb because the tendons are so swollen they are popping as they pass in and out of their sheath.

As far as anatomy goes, there are 6 groups of tendons that pass through compartments in the wrist.  The tendons involved in Dequervain’s are in the first compartment so Dequervain’s is also known as first dorsal compartment tendonitis.  There are two tendons involved with the elegant names of the abductor pollicis longus and the extensor pollicis brevis.  The help move the thumb away from the other fingers and lift the thumb away from the palm.  Most people have one compartment for both tendons, but people who have Dequervain’s can have two seperate compartments, one for each tendon.

Most of the time there is no known cause and the symptoms seem to appear out of nowhere.  Some patients recall a minor injury, while others relate the problem to increased use and repetitive activity of the thumb and wrist.  In all likelihood the tendons get inflamed through some change in activity and then the repetitive use probably doesn’t allow the tendon to heal and rest.  In patients with two separate compartments, as mentioned above, I think the tendons just don’t have enough room to heal when they get irritated and inflamed.

It’s usually not too hard to diagnose the problem.  Patients usually have pain with movement of both the thumb and wrist, and most of the time there are very specific activities that aggravate the problem.  Swelling and tenderness over the first dorsal compartment is usually seen as well.  There is a specific test to help diagnose the problem which is known as Finklestein’s test.  The best way to describe how to do this test would be to bend you thumb into the palm, grab the thumb with your fingers, then make a motion like you are casting a fishing pole.  If you have Dequervain’s that test should reproduce the pain and discomfort that you are having.

Initial treatment usually consists of rest, ice, over the counter non-steroidals like Aleve or Advil and avoiding as much as possible the activities that aggravate the problem.  If these don’t work a brace that immobilized the thumb is a good idea.  I see a lot of patients who have braces the hold the wrist still but don’t do anything to the thumb and rarely do these help at all.  The thumb has to be pretty still for the brace to work, and the splints often are called thumb spica splints.

If these initial treatments don’t work and the symptoms persist and cause problems, then the next most reasonable options are cortisone injections or surgery.  I haven’t tried creams or rubs very much because most patients don’t seem to be helped by them, but it’s an option if the patient wants to avoid something invasive.

Cortisone shots work fairly well for Dequervain’s.  Probably 70% or more of the patients who receive an injection will get relief of their symptoms, often without any further problems.  If the shot works initially and then the symptoms recur then another injection is a reasonable way to go.  If the shots fail to work or quit working then surgery is an option.  The surgery involves opening up the sheath where the tendons are inflamed and cleaning out the inflamed tissue.  The surgery can be done as an outpatient under local anesthesia with or without sedation and is usually successful with few complications.

Dequervain’s tendonitis is a common condition that can be successfully treated without surgery, but surgery is an option if other treatments don’t work.

 

Dupuytren’s Disease: What do I do about it?

He’s old enough to know what’s right but young enough not to choose it.

from the song “New World Man” by Rush

Once a patient has been told they have Dupuytren’s disease the next question is what to do about it.  In general patients that develop cords will get a contracturewhich causes the finger to bend will need some form of treatment.  It’s usually best to wait until a contracture has progressed a little bit before considering treatment since mild contractures really don’t get in the way of hand function.  A joint usually has to contract about 30 to 40 degrees before it starts getting in the way and that’s the point that most patients start to think about getting something done.

In the past the most common treatment was excision of the cord by surgery.  While this sounds fairly simple, in reality I always found this to be one of the hardest surgeries I did.  The cord, although well defined, was often tightly connected to the skin so it required a great deal of skill and patience to remove the cord from the skin.  What was even more difficult, however, was the fact that the cords often wrapped around the nerves and arteries to the finger, and it was very difficult to free the cord from the nerves and arteries.  Although I’ve never cut a nerve during a Dupuytren’s surgery I think it is something that could happen even with a careful and skilled surgeon.  The care after surgery is also very difficult since the extensive surgery required to excise the cord caused a good deal of swelling.  Many patients require therapy and the recovery from the surgery often takes several months.  That being said, surgery is usually very successful in removing the dupuytren’s tissue and straightening out the finger.  Dupuytren’s can come back after surgery and the surgery for recurrent disease is even more difficult than the original surgery.

In order to avoid many of the difficulties of surgery several surgeons tried something a little less invasive.  Instead of removing the entire cord they began cutting the cord with a sharp needle under local anesthesia.  In medical terms this is known as a needle aponeurotomy.  Many hand surgeons utilize this technique and have good results with the procedure.  It can be done in the office under local anesthesia and is much less invasive than the surgery that is done to remove the cord.  In addition recovery is much quicker than with surgery.  Personally I have never done this procedure because of my fear of damaging a nerve or artery with the needle.  It also seems that the recurrence rate after needle aponeurotomy is pretty high, which is to be expected since the dupuytren’s tissue causing the cord is not removed.  I think this is a good choice for patients as long as the treating physician has a lot of experience with the technique.  Needle aponeurotomy makes me a little nervous so I don’t do it, but I understand the reasons people choose to have this done.

A third option has now been available for the past 6 years.  Several physicians worked to develop a drug which , when injected into the cord, could cause the cord to start to unravel and allow the cord to be separated, allowing the finger to be straightened.  The cords are made out of a material called collagen, and the medicine is a protein that eats up or lyses the collagen.  In medical terms the medicine is called a collagenase, and the medicine we used is known as Xiaflex.  Xiaflex was introduced in 2010 and this has been my first choice for the treatment of symptomatic cords since that time.  The medicine is first injected into the cord, and then at a point 24 to 72 hours after the injection the finger is straightened out, which causes the cord to tear and disrupt.  The Xiaflex continues to work even after the cord is straightened, so that in a lot of cases the dupuytren’s tissue eventually dissolves.  The results from Xiaflex treatment seem to be similar to surgery.  The biggest downside is the cost of the drug.  Most of the time insurance covers most of the cost but patients can be stuck with a significant bill.  My office has a lot of experience in dealing with Xiaflex so we can usually get a pretty good idea of the financial aspects involved in the treatment.

In summary, in the past surgery was about your only choice to remove dupuytren’s disease and straighten out a crooked finger.  Less invasive techniques such as needle aponuerotomy and collagenase injection (Xiaflex) have been developed so that patients now have a choice of treatments that they can discuss with their physician and decide which one suites them best.

 

Dupuytren’s Disease: What is it?

I’ve got vision and the rest of the world’s wearing bifocals.

Paul Newman as Butch Cassidy in “Butch Cassidy and the Sundance Kid”

One of the more interesting problems a hand surgeon encounters is a rather unusual condition know as Dupuytren’s disease.  This is a condition where the normal tissue in the palm of your hand becomes thicker and can sometimes progress and cause the fingers to pull down and contract.  Dupuytren’s disease usually starts as a nodule in the palm of the hand.  This can occur at the base of any finger, including the thumb.  In some cases the nodule can be painful and tender, but generally the pain and tenderness go away and the patient is left with a small painless knot in their hand.

Most patients are usually first seen by their primary care physicians for this problem.  Most of the time it’s not hard to diagnose the problem, but sometimes the nodule can be confused for a cyst in the hand, and cysts do occur in the same area.  However if you’re carefully examined a physician can usually tell the difference between a cyst and a dupuytren’s nodule. Patients are usually sent to a hand surgeon for evaluation and recommendations for treatment.

There is no single cause for Dupuytren’s disease.  Some patients will have family members who have had the problem, but the majority of the time patients don’t know or can’t remember any relatives who had the problem.  The disease does seem to be more closely associated with certain ethnic groups, although Dupuytrens’ has been seen in patients of all races and cultures.  The most common association is with people of Northern European descent, so much so that one of the names for Dupuytren’s disease is “Viking Disease”.  Trauma, either acute or repetitive, does not cause Dupuytren’s disease.  So most of the time the nodules just appear, seemingly out of nowhere.  The disease occurs in both men and women, but is much more common in men, probably by a ratio of 2:1 or higher.

If you have a nodule, there is a pretty decent chance that a contracture, or pulling down of the finger, will never occur.  The best estimate is that only 50% of people who develop a nodule, or bump, will ever go on to have a contracture that will bother them or require treatment.  There is no treatment that can affect the progression of the disease.  No medicine, diet, exercise or anything else will have any affect at all on this process.  The one thing that can make it worse is to operate on a nodule before it causes a contracture, since that can sometimes cause a progression of the disease and further problems.  I’ll talk about that more in my next post, when I’ll talk about the treatment of the disease.

Some factors do raise a red flag and indicate that a patient may develop a contracture that will cause problems and require treatment.  The most important is probably a strong family history of the disease.  If Dad or an uncle had a bad contracture, then the odds are pretty good that if you develop the disease then you will have a significant contracture as well.  Another bad sign would be if you have similar nodules elsewhere in your body.  The most common area is the bottom of the feet.  Also, some patients all develop tender areas on top of their fingers called “knuckle pads”, and if you have these that can be a sign that the disease may progress.  The third factor would be developing the problems at a younger age, younger in this case being below the age of 50.

My next blog will discuss the treatment of Dupuytren’s disease.  There have been some exciting advances in treatment and some new, non-surgical treatments are available that I will discuss in detail.