Intra-articular corticosteroid injections to manage trapeziometacarpal osteoarthritis-a systematic review.

BACKGROUND: Osteoarthritis of the trapeziometacarpal joint (TMJ) is a common condition causing significant disability. The aim of this study is to ascertain whether an intra-articular corticosteroid injection leads to pain relief and increased function and what is the duration and magnitude of this effect. METHODS: A systematic review with a critical appraisal of identified studies that met the inclusion criteria was performed. Two authors performed the literature review by independently searching the Cochrane, PubMed and Google Scholar databases. RESULTS: A total of 118 relevant articles were found, but only nine studies met the inclusion criteria which included 4 double-blinded randomised control trials (RCTs) and 5 prospective case series. There is some evidence in the literature to support the efficacy of steroid injections into the TMJ. Most studies do suggest a good short-term benefit. However, one identifies no benefit over placebo but two studies found a benefit lasting at least 6 months. CONCLUSIONS: This study demonstrates that there are potentially significant although short-term benefits to be gained from steroid injections into the TMJ. They can lead to pain relief and improved function, certainly in the first 1 to 3 months post-injection. Steroid injections are a low-risk procedure and are helpful in delaying or avoiding the need for surgery.

Wound healing with medications for rheumatoid arthritis in hand surgery.

Introduction. Medications used to treat rheumatoid arthritis, such as corticosteroids, disease-modifying agents (DMARDs), and injectable biological agents (anti-TNFα), may have widespread effects on wound healing. In hand surgery, it is important to balance the risks of poor wound healing from continuing a medication against the risks of a flare of rheumatoid arthritis if a drug is temporarily discontinued. Materials and Methods. A United Kingdom (UK) group of 28 patients had metacarpophalangeal joint replacement surgery in 35 hands (140 wounds). All medication for rheumatoid arthritis was continued perioperatively, except for the injectable biological agents. Results. There were no instances of wound dehiscence or deep infection and only one episode of minor superficial infection. Conclusions. We conclude that provided care is taken to identify and treat any problems promptly, it is appropriate to continue most antirheumatoid medications in the perioperative period during hand surgery to reduce the risk of destabilising the patients' overall rheumatoid disease control.

The formation of the Hand Club: a 60th anniversary.

The formation of the Hand Club: a 60th anniversary.

Wrist denervation in isolation: a prospective outcome study with patient selection by wrist blockade.

Surgical wrist denervation involves division of the anterior and posterior interosseous nerves and articular branches of the superficial radial nerve. In this outcome study, 37 patients were individually assessed and deemed suitable for denervation surgery due to appreciable symptom resolution following a local anesthetic wrist block. At a mean of 18 months following denervation surgery, median activity pain scores had decreased by 60% (p < 0.001) from initial assessment levels, and more than three quarters (30/37) of patients reported continued improvement in their activity pain (p < 0.001). More than two thirds of patients had a satisfaction VAS of greater than 50, with less postoperative resting pain and a greater reduction in postoperative activity pain as the important predictors of patient satisfaction. Thirty-one out of the 37 patients had not represented to our department for revision wrist surgery by a mean of 10.3 years follow-up. We have found this procedure useful in ameliorating symptoms for some patients who would conventionally have required partial or total wrist fusions with greater residual functional limitation.

Rheumatoid hand surgery: differing perceptions amongst surgeons, rheumatologists and therapists in the UK.

Rheumatoid arthritis is a systemic disease that requires coordinated management by rheumatologists, surgical specialists and therapists working in a multidisciplinary team. Differences of opinion within the team may adversely affect patient care. Our aim was to assess differences in perception about rheumatoid hand surgery between rheumatologists, hand surgeons and hand therapists in the UK. We used a postal questionnaire to assess commonly performed rheumatoid hand operations. For each procedure, respondents rated the most important indication for surgery and scored effectiveness at reducing pain, improving function and aesthetics, and preventing deformity. Statistically significant differences were found between all three groups with regards to expected outcome and main indications for surgery. We concluded that significant differences do exist in the perceptions of rheumatologists, surgeons and therapists. Rheumatoid hand operations require more detailed study, clarifying indications and outcome to allow consistent advice to patients from all members of the multidisciplinary team.

A 6-year outcome of patients who cancelled carpal tunnel surgery.

The long-term outcomes of patients with carpal tunnel syndrome who were scheduled for release but did not proceed to surgery were compared to patients who underwent surgery, matched on preoperative symptom scores. Both groups completed the Levine-Katz questionnaire 6 years after enrolment to our multicentre carpal tunnel syndrome outcomes database. Symptom and function scores improved for the surgical (n = 24) and non-surgical (n = 36) groups (p < 0.001). Improvement in symptom scores was greater in surgical patients compared to non-surgical patients (n = 24 matched pairs; p = 0.007) but improvement in function scores between groups was not significantly different (p = 0.13). For surgical patients, function and symptom scores improved by 6 months and were unchanged at 6 years. Patients planning surgical release can expect symptomatic and functional benefits within 6 months. Overall improvement was experienced by both groups, with a superior outcome achieved with surgery. The symptoms of carpal tunnel syndrome may improve without surgery, but further studies are needed to understand the natural history of the disorder.

The use of the mini C-arm in the outpatient setting: evolving practice.

The mini C-arm image intensifier (mini C-arm) has now become an established diagnostic tool in the hand surgery outpatient department. This study reviews the use of the mini C-arm and formal radiographs (X-rays) in the outpatient hand surgery setting. X-rays provide a standard image whereas the mini C-arm can obtain non-standard images to aid diagnosis and treatment. The mini C-arm enables the clinician to obtain dynamic images and perform interventions such as manipulations or injections. The mini C-arm results in a significantly lower radiation exposure for the patients than a formal X-ray. Use of the mini C-arm may be cheaper, and can lead to a shorter outpatient visit with less travel between hospital departments.

Geoffrey Fisk and a hitherto unknown contribution to the treatment of carpal instability.

We describe two films made by Geoffrey Fisk in 1973 that record midcarpal instability and its surgical treatment.

The benefit of radiologically-guided steroid injections for trapeziometacarpal osteoarthritis.

INTRODUCTION: Osteoarthritis of the trapeziometacarpal joint (TMJ) is a common condition causing significant disability. Conservative treatments include intra-articular steroid injections. PATIENTS AND METHODS: This clinical, observational study prospectively reviewed the longevity of benefit of steroid injections into the TMJ. Eighty-three patients were recruited with a median age of 62 years and injected with steroid and local anaesthetic under radioscopic guidance. They were followed up until the analgesic effects ceased with a questionnaire including visual analogue scores. RESULTS: Two-thirds of patients were improved at 2 months, with nearly half having a 3-month improvement. One in six patients had a 6-month benefit, with some patients still improved 2 years after injection. Previously injected patients had a reduced duration of benefit compared to their previous injection. Severity of osteoarthritis did not affect the injection efficacy. CONCLUSIONS: Based on this study, we recommend steroid injections in all degrees of TMJ osteoarthritis.

Guy Pulvertaft--an appreciation.

The life and times of Guy Pulvertaft. His contribution to the development of hand surgery.

The clinical significance of malunion of fractures of the neck and shaft of the little finger metacarpal.

The outcomes of 218 little finger metacarpal shaft and neck fractures that had been treated non-operatively, with no attempt at fracture reduction, were compared with those of 44 that had been treated operatively with fracture reduction and fixation (plates or K-wires). Outcome measures included the grip strength of the little finger and the DASH score. Fracture malunion was assessed by clinical measurement of little finger ray shortening and measurement of palmar angulation on the initial radiographs. The severity of palmar angular deformity did not affect the outcome of the 105 metacarpal neck or 113 metacarpal shaft fractures that had been treated non-operatively. There were no differences between the outcomes of the 18 metacarpal neck fractures treated operatively and the 105 treated non-operatively. The DASH score (P = 0.001) and aesthetic outcome (P = 0.013) were significantly better for the 113 metacarpal shaft fractures treated non-operatively than for the 26 treated operatively.

Long-term outcome after carpal tunnel decompression - a prospective randomised study of the Indiana Tome and a standard limited palmar incision.

This randomised trial compared the results of carpal tunnel decompression using the TM Indiana Tome (Biomet, Warsaw, Indiana, USA) and a standard limited palmar open incision. Two hundred patients were randomly selected to have a carpal tunnel decompression with either the Indiana Tome or a limited palmar technique. They were assessed clinically for 3 months and using the Levine-Katz self-assessment evaluation for 7 years. After 7 years, there were 62 returned questionnaires from the open group and 53 from the Tome group. There were no significant differences in functional scores, pain, scar tenderness, pinch and grip strength at 3 months. There were two complications in the open group and nine in the Tome group, including one median nerve injury. There was both a higher rate of immediate complications, and more recurrences and persisting symptoms at 7 years in the Indiana Tome group.

Fractures of the tubular bones of the hand.

Age related differences in demographics, morphology, treatment and outcome were investigated in 701 fractures of the metacarpals or phalanges, including fracture-dislocations, in 655 patients. Fractures mainly due to sport occurred in 184 children, usually after 10 years of age. The base of the proximal phalanx was especially vulnerable. Thirty-seven percent of 256 young adults fractured their fifth metacarpal. The thumb was rarely involved. Half of these two groups fractured the fifth ray. Older adults had more fractures of the distal phalanx and displaced extraarticular fractures requiring stabilisation. Women predominated in the patients over 65. Forty percent of this group sustained their fracture on the road and more fractures involved the thumb, were oblique, intraarticular or multiple than in other groups. Detailed analysis of 423 X-rays demonstrated that only 10% of 70 intraarticular fractures and 19% of 363 extraarticular fractures were completely undisplaced. Patient response to postal questionnaire based outcome assessment using SF-12, MHQ was very poor.

Study to assess differences in outcome following open carpal tunnel decompressions performed by surgeons of differing grade.

INTRODUCTION: Carpal tunnel decompression is the most commonly performed surgical procedure within a hand unit. Although very effective, the complications following the procedure can be significant. In an attempt to identify the causes of such complications, we assessed whether seniority of the surgeon impacts on outcome for open carpal tunnel decompression. PATIENTS AND METHODS: Data were jointly and prospectively gathered from two units from either side of the Atlantic - the Pulvertaft Hand Center, UK and the Curtis Hand Center, USA. The aim of the study was to assess outcome following carpal tunnel decompression. Completed data were gathered following open carpal tunnel decompression on 352 hands. Surgeons of a consultant grade had performed 123 of these procedures whilst surgical trainees had performed 229 of the procedures. Assessment was by Levine Katz questionnaire results, Semmes-Weinstein testing, grip strength and pinch grip strength testing performed both pre-operatively and 6 months' postoperatively. Complications following the procedure were also recorded. RESULTS: Mean results were found to be better in those patients where the surgeon was of a consultant grade. However, this was only found to be of statistical significance on Semmes-Weinstein testing. Complications following the procedure were also noted to be higher in the group of patients operated on by trainee grades. CONCLUSIONS: Our results show the carpal tunnel decompression performed by a surgeon of consultant grade offers slightly better results in objective neurological testing when compared with those performed by a more junior grade.

An assessment of the effects of exposure to vibration, smoking, alcohol and diabetes on the prevalence of Dupuytren's disease in 97,537 miners.

A consecutive sample of 97,537 miners seeking compensation for Hand-Arm Vibration Syndrome were examined in a medical assessment process which included documentation of age, hand dominance, Dupuytren's disease, years of vibration exposure, history of diabetes, smoking habits and units of alcohol consumption per week. The prime determinant of prevalence of Dupuytren's disease was age, and all other factors investigated were corrected for age. There was no statistically significant correlation between years of exposure to vibration and the prevalence of Dupuytren's disease. There was a statistically significant association with smoking, alcohol consumption and diabetes mellitus, with the heaviest smokers having an odds ratio (OR) of 1.31 (95% CI, 1.17, 1.47), the heaviest drinkers (in excess of 22 units a week) having an OR of 1.59 (95% CI, 1.47, 1.72) and diabetes mellitus patients having an increase in the odds of having Dupuytren's disease of 1.52 (95% CI 1.30, 1.77).

An audit of the safe use of the mini c-arm image intensifier in the out-patient setting.

Mini C-arm image intensifiers are used commonly in surgery of the upper limb. With relatively low doses of emitted ionising radiation, portability and superior quality of image, they are a useful aid to the operating surgeon. However, these benefits are not so often used outside the theatre setting. This paper examines the use of a mini C-arm image intensifier in the out-patient clinic and presents an audit of 100 consecutive out-patients. We reviewed the potential benefits and effects on their care pathway. We also look at the specific radiation protection issues of the mini C-arm image intensifier in the out-patients clinic. We believe use of the mini C-arm image intensifier in the out-patient setting may speed treatment and reduce the cost of treatment.

A technique to facilitate symmetrical and atraumatic placement of the core suture during flexor tendon repair.

We present a technique aiding symmetrical accurate and atraumatic placement of the core suture during tendon repair. This technique facilitates a neat repair and avoids unnecessary contact with the tendon during the insertion of the core suture.

Social deprivation and hand injury.

This study investigated the relationship between socioeconomic deprivation and the incidence, patterns of injury, process of care and outcome of hand trauma using data collected prospectively on 1234 injuries presented during six months. The Index of Multiple Deprivation 2004 was derived from census data and postcodes. Socioeconomic deprivation is significantly associated with hand trauma. The odds ratio for suffering hand injuries in the most deprived quintile is 1.6 (SE 0.09 95% CI 1.45, 1.83) compared to the least deprived quintile. This is most marked among older children and adults. Fractures, sprains and ligament injuries showed the strongest association with the degree of deprivation. Injuries related to sport were not associated with deprivation. Surgical time utilised is greater in more deprived patients and their self reported physical outcome is worse. Hand surgery units working in areas of high socioeconomic deprivation will have higher trauma workloads and unit costs. Social deprivation may also influence physical outcomes.