“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.