Upper Extremity Update: Part 2

From the University of Toronto Faculty of Medicine’s 25th Annual Upper Extremity Update

Educational Objectives

The goal of this program is to improve functional outcomes after upper extremity surgery. After hearing and assimi­lating this program, the clinician will be better able to:

1.   Assess stability of the proximal interphalangeal (PIP) joint.

2.   Detail approaches for stabilizing an unstable PIP joint.

3.   Discuss the role of hand surgery in patients with rheumatoid arthritis.

4.   Recognize and manage postoperative infections.

5.   Discuss the shortcomings and complications associated with wrist surgery.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and plan­ning committee reported nothing to disclose.

Acknowledgments

Drs. Stern and Mahoney were recorded at 25th Annual Upper Extremity Update, presented by the Faculty of Medi­cine, University of Toronto, and held April 3, 2009 in Toronto, ON. The Audio-Digest Foundation thanks the speak­ers and the University of Toronto for their cooperation in the production of this program.

Small Joint Injuries and Arthrosis

Peter J. Stern, MD, Professor and Chair, Department of Orthopaedic Surgery, University of Cincinnati, College of Medicine, Cincinnati, OH

Distal interphalangeal (IP) joint: complaints  —  pain; cosmesis; instability and decreased range of motion (ROM) less common (especially if ROM of proximal joints preserved)

Arthrodesis of distal IP joint: fusion  —  rates similar across techniques (eg, crossed pins; cannulated screws; longi­tudinal pin with cerclage wire); complications  —  nonunion (12%), especially problematic if patient has poor bone stock; position  —  slight flexion (improves grip); extension (good function; improved appearance)

Proximal interphalangeal (PIP) joint: vulnerable to dislocation because of long lever arm and limited capacity to compensate for angular, axial, and rotational stresses

Assessing PIP joint stability: volar base fracture  —fractures involving <25% of volar base of middle phalanx gener­ally stable after reduction; fractures involving >50% of volar base generally unstable; subsequent dislocation likely; surgical repair often required; radiography  —  on lateral view, dorsal cortex of proximal and middle phalanges should be collinear; when reduced, head of proximal phalanx is concentric with base of middle phalanx; physical examination  —  after reducing joint, have patient flex and extend finger; terminal extension causes dorsal sublux­ation in unstable joints; stability and ROM influence approach to management (examination critical)

Reduction of PIP joints: successful reduction more important than anatomic reconstitution of base of middle pha­lanx; dorsal subluxation may result in abnormal hinging, degenerative arthritis, pain, and limited ROM

Stable joints: speaker prefers figure-8 splints (block extension; provide medial-lateral stability; allow movement); complications of injury include stiffness, flexion contracture, swan-neck deformity, and painful swelling

Unstable joints: extension-block splinting  —  forearm-based splint with dorsal extension holds joint in flexed posi­tion; extension increased over 3 to 4 wk; placing pins in head of proximal phalanx also restricts extension while allowing flexion; traction  —  many techniques; Schenk dynamic traction device effective but cumbersome; sim­ple traction effective in patients with axial loading injuries; external fixation  —  good option for acute injuries; some devices have static and dynamic (passive and/or active flexion and extension) modes; not effective for chronic dislocations; problems include pin tract infections and loosening; force-couple splints  —  simple; allow immediate motion but do not achieve anatomic reduction; pin tract infections may occur; internal fixation  —  especially useful for unstable joints without comminution (technique requires intact dorsal cortex); newer im­plant technology allows reconstitution of contour of base of middle phalanx; difficult technique, associated with fractures and other complications

PIP arthroplasty: volar plate arthroplasty  —  used for comminuted fracture dislocations with unstable base of PIP joint; fragments excised; volar plate advanced into defect; high rate of subsequent dislocation in patients with sig­nificant fractures; force couple created by sublimis and extensor tendons results in instability; bone graft restores contour of joint and prevents head of proximal phalanx from becoming displaced; hemihamate arthroplasty  —restores contour of base of middle phalanx using osteocartilaginous autograft from distal articular surface of ha­mate; indicated for severe dislocations; effective, but technically challenging; joint exposed; A3 pulley incised; vo­lar plate exposed; joint opened; autograft harvested, then screwed in place, restoring contour; case series shows good union and ROM, minimal pain, and high level of patient satisfaction

PIP joint replacement: silicone arthroplasty  —  used for patients with osteoarthritis (OA) or inflammatory arthritis; results generally good initially, but failure often occurs after »10 yr; resurfacing arthroplasty  —  primarily used for patients with OA; implants made of pyrolytic carbon or metal and polyethylene, designed to increase intrinsic sta­bility; when using uncemented implants, intact radial and ulnar collateral ligaments required; problems include squeaking with movement (important to inform patients) and loosening; stems must be centered in canal, otherwise implant displaces dorsally (risk for erosion); outcomes  —both types of implants result in similar degrees of ROM; resurfacing arthroplasty results in superior correction of coronal plane

Arthrodesis: for salvage of PIP joint; predictable durable results; disadvantages include reduced mobility and grip power; many techniques available (speaker prefers tension-band wiring)

Metacarpophalangeal (MCP) joint: effective medical therapies for rheumatoid arthritis (RA) decrease disease pro­gression and reduce need for surgery

Flexible implant arthroplasty: technique replaced resection arthroplasty (procedure resulted in joint instability); flexible-hinge implant well-suited for MCP joint; dynamic extension splinting increases ROM; physical therapy important; outcomes  —  variable; ulnar drift typical; ROM good initially, but decreases over time; one study re­ported 40% patient satisfaction (only 28% of patients remained pain-free during follow-up); if implant becomes infected, may require explantation; case  —  extensive reconstruction (including 3 MCP arthroplasties) after trau­matic injury resulted in excellent long-term outcome

Resurfacing arthroplasty: mixed results in patients with RA; problems include implant dislocation; good option for patients with OA (idiopathic or posttraumatic) and intact collateral ligaments; implants often associated with mild persistent swelling

Upper Extremity Infection

James Mahoney, MD, Associate Professor, Department of Surgery, Division of Plastic Surgery, University of Toronto, St. Michael’s Hospital, Toronto, ON

Introduction: acute wounds  —  preventing infection relies primarily on debridement and appropriate use of antibiot­ics; chronic wounds  —  long-term use or repeated courses of antibiotics may lead to bacterial colonization and anti­biotic resistance; trends  —  changing demographics of patients (and pathogens) affect patterns of resistance; new initiatives focus on reducing incidence of surgical site infections

Acute infections: traumatic wound  —  concern about contamination; radical debridement sometimes necessary; anti­biotic prophylaxis with goal of preventing complications (eg, soft tissue necrosis); surgical site  —  goal is early identification; initial signs and symptoms include erythema, pain, and purulent drainage (latter may indicate infec­tion, even in absence of other signs or symptoms); early and judicious use of antibiotics may prevent progression; superficial  —infection develops £30 days after procedure; diagnostic criteria include purulent drainage, positive culture, and/or signs and symptoms consistent with infection (open to interpretation)

Prophylactic antibiotics: administer £30 min before surgical incision (quality measure in Canada); indications for use in hand surgery  —  significant preexisting disease (eg, diabetes); RA or corticosteroid therapy; use of K-wires or implants; surgery lasting >2 hr (consider single dose); dirty wounds, surgery lasting >6 hr, or open fractures (consider 2- to 5-day course); use of tourniquet (intravenous [IV] dose given before inflation)

Rates of postoperative infection: »2% of clean wounds; 7.1% of dirty wounds; hand surgery  —  rates generally higher, but vary with surgical procedure (eg, 0.4%-2% after carpal tunnel release; »55% after zone-1 tendon re­pair); higher rates associated with ambulatory surgery, because of poorer follow-up

Methicillin-resistant Staphylococcus aureus (MRSA): increasing incidence of postoperative infections with MRSA; colonization rates in Canada estimated at 5% in general population and 30% in patients with chronic wounds; colonization increases risk for contamination of surgical site; management  —  aggressive debridement; vancomycin often required (some infections respond to clindamycin); MRSA cellulitis  —  management includes an­tibiotic therapy, splinting, and elevation; outcomes  —  sometimes poor, even after aggressive management; extended course of IV antibiotics sometimes required

Necrotizing fasciitis: case  —  homeless patient with grossly swollen forearm with erythema (progressing proxi­mally), disproportionate pain, fever, highly elevated white blood cell count, and bullae (common with necrotizing fasciitis caused by group A streptococci); supportive therapy required (enterotoxin produced by bacteria may cause renal or respiratory failure); culture results showed resistance to clindamycin and erythromycin and susceptibility to penicillin, but patient allergic; desensitization protocol used to safely treat patient with penicillin (surgery also required)

Differential diagnosis: for patients unresponsive to antibiotic therapy, consider squamous cell carcinoma or pyo­derma gangrenosum (necrotizing loss of skin after trivial trauma, despite antibiotics and supportive therapy); wound biopsy helpful (for tissue culture and pathology)

My Ten Worst Wrist Procedures

Dr. Stern

Management of failed Darrach procedure: although Darrach procedure easy to do, has “stood test of time,” and has multiple indications, not recommended in younger patients or in those with lax ligaments; removing ulnar head may result in instability of ulnar stump (dorsal-volar instability or convergence, leading to impingement); tech­niques for stabilizing ulnar stump  —  tenodesis; prostheses; allografts; functional braces; extended Darrach proce­dure; all have variable results; implants may dislocate; coupled implants that link radius and ulna may loosen and cause problems; persistent complications may necessitate conversion to one-bone forearm

Silicone implants: silicone implants effective as hinges in MCP and PIP joints; silicone carpal implants  —  success rates vary when used in management of Keinbock’s disease (original proponent later retracted support for proce­dure)

Vascularized bone grafting: 1,2-intercompartmental supraretinacular artery (ICSRA) grafting  —  initial results suc­cessful in patients with scaphoid nonunions and osteonecrosis of proximal pole; technique less successful in other series; reported rates of union vary from 50% to 88%; complications common and include graft extrusion, infec­tion, and fixation failure; new technique  —  prevascularized graft taken from medial distal femur off descending ge­niculate artery; considerations  —  nonunion of proximal pole difficult to treat; assessment of union requires computed tomography; adequate stability achieved with screws in some patients; more data needed on outcomes after bone grafting

Excision of metacarpal boss: dorsal bump (osseus, cartilaginous, or fibrous) at base of second and third metacarpals; pain or synovitis may develop when extensor tendons move over boss (eg, when wrist deviates radially or ulnarly); surgery associated with variable rates of success; reasons to avoid excision  —  cosmesis, not pain, primary com­plaint in some patients; postoperative pain may occur; hypertrophic scar and residual bump may develop; poor pa­tient satisfaction

Surgery for cheiralgia paresthetica: syndrome  —  irritation of dorsal sensory branch of radial nerve as it pierces bra­chioradialis; associated with diabetes; may occur after misplaced IV line or injection of steroids, after attachment of external fixture (nerve spinning), or after release of first dorsal compartment (nerve injury); surgical exploration  —may identify source of neuropathy (eg, nerve pierces tendinous portion of brachioradialis; impinge­ment by scar tissue); neural decompression may be effective, but many complications possible

Prosthetic replacement of trapeziometacarpal (TMC) joint: implants  —  silicone; cemented metal and polyethyl­ene; ceramic (eg, Orthrosphere implant); pyrocarbon hemiarthroplasties; procedures  —  trapezial resections effec­tive; problems with implant arthroplasty include wear debris, loosening, implant deformation or dislocation, and sepsis

Four corner fusion with circular plate: preserves anatomy of capitolunate joint; maintains carpal height; problems include loosened screws, nonunion, and hardware impingement (eg, plate may impinge on dorsal lip of radius); simpler techniques (eg, use of cannulated screws) may be effective with fewer complications

Scapholunate reconstruction for static instability: approaches  —  placing cannulated screws between scaphoid and lunate; dorsal capsulodesis with or without repair of scapholunate interosseus ligament; bone-ligament-bone re­pairs; “tendon grab” procedures, including Brunelli tenodesis (corrects sagittal plane deformity and reconstructs scapholunate ligament); capsulodesis procedures associated with high rate of recurrence, especially if scapholunate gap larger than 3 to 4 mm and in young active people; however, some patients with radiographic abnormalities (af­ter repair) do not report problematic symptoms

Scaphotrapeziotrapezoidal (STT) fusion: initial series reported high rate of success; case  —  man, 30 yr of age, with scapholunate dissociation; STT fusion with pins resulted in good initial outcome; 13 yr later, ROM significantly de­creased; radiographs showed narrowed radioscaphoid joint and beaking of styloid process; styloidectomy (may be performed during fusion procedure) did not improve symptoms; patient ultimately required wrist fusion

Surgical management of Madelung’s deformity: surgery may improve cosmesis and reduce prominence of ulnar head, but unable to correct deformity; surgery may benefit young patients with Vickers ligament; speaker recom­mends using casts and corticosteroid injections in adults

Suggested Reading

Bravo CJ et al: Pyrolytic carbon proximal interphalangeal joint arthroplasty: results with minimum two-year follow-up evaluation. J Hand Surg Am 32:1, 2007; Branam BR et al: Resurfacing arthroplasty vs silicone arthroplasty for proximal interphalangeal joint osteoarthritis. J Hand Surg Am 32:775, 2007; Casey AL, Elliot TS: Progress in the prevention of surgical site infection. Curr Opin Infect Dis 22:370, 2009; Chung KC et al: A multicenter clinical trial in rheumatoid arthritis comparing silicone metacarpophalangeal joint arthroplasty with medical treatment. J Hand Surg Am 34:815, 2009; Goldman SB et al: James traction splinting for PIP fractures. J Hand Ther 21:209, 2008; Kleinman WB: Salvage procedures for the distal end of the ulna: there is no magic. Am J Orthop 38:172, 2009; Lar­son AN et al: Free medial femoral condyle bone grafting for scaphoid nonunions with humpback deformity and proximal pole avascular necrosis. Tech Hand Up Extrem Surg 11:246, 2007; Lee SK, Hausman MR: Management of the distal radioulnar joint in rheumatoid arthritis. Hand Clin 21:577, 2005; Lin SY et al: Volar plate interposition ar­throplasty for posttraumatic arthritis of the finger joints. J Hand Surg Am 33:35, 2008; Namdari S, Weiss AP: Ana­tomically neutral silicone small joint arthroplasty for osteoarthritis. J Hand Surg Am 34:292, 2009; Ruland RT et al: Use of dynamic distraction external fixation for unstable fracture-dislocations of the proximal interphalangeal joint. J Hand Surg Am 33:19, 2008; Tanner J et al: Surgical hand antisepsis to reduce surgical site infection. Cochrane Da­tabase Syst Rev 1:CD004288, 2008; Wilson PC, Rinker B: The incidence of methicillin-resistant Staphylococcus aureus in community-acquired hand infections. Ann Plast Surg 62:513, 2009.