Minimally Invasive Surgical Techniques of the Hand and Upper Extremities

By Ruth Stroud

Arthroscopic and endoscopic procedures improve recovery time in most patients.

Gary Pess, MD (right), and assistant, Robert DeLuca, CST, perform endoscopic carpal tunnel surgery.

Figure 1. Marks for incision for the release of carpal tunnel.

Figure 2. Arthroscope inserted into proximal incision and knife inserted into distal incision (actual release of carpal tunnel).

Figure 3. Sutured incisions.

Figure 4. A set of endoscopic knives.

Figure 5. Shows transverse incision and landmarks.

Figure 6. Trigger release knife releasing A1 pulley.

Figure 7. Small wound sutured.

Figure 8. Trigger release knife.

The past 15 years have seen the inauguration of a whole new era of orthopedic hand and upper-extremity surgery made possible by the adaptation of arthroscopic and endoscopic instruments for the smaller joints and cavities of the hand and wrist. The ability to insert tiny telescopes inside these joints and spaces has done for hand surgery what developments in arthroscopic instrumentation did for knee surgery in the 1970s and shoulder surgery in the 1980s. “It has led to a redefining of intra-articular pathology and joint mechanics,” observes Gregory Hanker, MD, an orthopedic hand specialist at Southern California Orthopedic Institute (SCOI) in Van Nuys. “It has allowed us to treat sophisticated injuries that in the past we couldn’t even discover because we couldn’t see them.” The introduction of these miniaturized cameras has also led to the growing use of minimally invasive techniques to alleviate many common complaints and injuries of the hand and wrist for which open surgery would have previously been indicated.

Probably the most common among these is carpal tunnel syndrome (CTS), a painful and debilitating condition that affects an estimated 1% of the general population and about 10% of those over 40, according to some sources. Some estimates place the number of people treated surgically for CTS at more than 1 million annually.

Early in his practice with Central Jersey Hand Surgery in New Jersey, Gary M. Pess, MD, performed about equal numbers of open and endoscopic surgeries to treat CTS. One of his first patients was a self-employed roofer with CTS in both hands. Pess performed an endoscopic, minimally invasive surgical procedure on both hands, and the roofer was able to return to his job 5 days later. From that point on, he began using endoscopic surgery for CTS almost exclusively, says Pess, who practices with three other orthopedic surgeons, all specializing in minimally invasive surgical techniques to solve problems of the hand, wrist, forearm, and elbow.

Among the most common upper-extremity complaints seen in many general orthopedic practices, CTS affects women in disproportionate numbers—about 3 to 1—with onset usually occurring between the ages of 30 and 50. CTS is frequently seen among those who do repetitive work, such as grocery store checkers, typists, assembly line workers, musicians, accountants, and writers, but medical conditions such as diabetes, rheumatoid arthritis, thyroid disease, and pregnancy may be even more significant in causing the disease. Cases of CTS continue to rise, along with the toll they take in the workplace. One Illinois firm estimated it cost about $37,000 in lost work time, medical treatment, and rehabilitation for each employee who developed CTS. Workers’ compensation figures are estimated at between $6,000 and $10,000 per case, depending on whether the person develops CTS in one or both hands.

CTS symptoms include pain, numbness, and tingling in the hand—occasionally a “pins and needles” sensation, particularly at night—and weakness in the grip that leads to dropping things. The medical cause is a swelling of the flexor tendon sheaths in the carpal tunnel, causing a pinching of the median nerve. This is the nerve that traverses the wrist and provides sensation to the thumb, index and middle fingers, and half of the ring finger. “It’s like being on the 405 [a major north-south freeway artery in Los Angeles] at a point where it narrows from five lanes to three,” Hanker explains. “The same thing happens to the nerve.”

Initially, CTS is treated conservatively with a removable wrist brace, anti-inflammatory medicines, and work-space modifications. Only when these remedies fail is surgery indicated. Until about 15 years ago, open surgery was the surgical method of choice. The procedure involved an incision extending from the wrist to the middle of the palm, “You cut through the skin, fat, fascia, and muscle before you get to what you really want to cut—the transverse carpal ligament,” Pess explains. When the latter is cut, it releases the stricture on the carpal tunnel.

Hanker likens open vs endoscopic CTS surgeries to fixing a leaky pipe in the foundation of a house. “Are you going to rip up the rug, the floor, and the concrete foundation to get to the leak, or are you going to find a way to go in from the side through a tunnel so you don’t have to destroy the house?”

The recovery time from open carpal tunnel release surgery is much longer—about 6 to 8 weeks, compared to 2 weeks or less for endoscopic CTS surgery, Pess estimates. “The key thing with all these minimally invasive procedures is not that the technique is necessarily better, but that it allows the patient to recover much more quickly and get back into action,” he says. Following an open carpal tunnel surgery, the patient would require some type of brace for about 2 weeks, then therapy to recover muscle strength and range of motion, Pess explains. The larger scar would probably lead to greater sensitivity, increased weakness in the hand, and more swelling.

Endoscopic Surgery for CTS

In endoscopic carpal tunnel release surgery, one or two small (a centimeter or less) incisions are made in the wrist and the palm (Pess uses the double-portal approach), and one or two endoscopes—pencil-thin, lighted tubes with cameras—are inserted, allowing the surgeon to view the procedure on a TV monitor. Small, delicate instruments are used to divide the transverse carpal ligament that forms the roof of the carpal tunnel, cutting from the inside out. This allows the tunnel to open up and relieve pressure on the median nerve. But the fascia, muscle, fat, and skin—the parts that would be cut in an open surgery—are left alone.

The surgery can usually be accomplished in less than 20 minutes using a local anesthetic, Pess says. “Most patients take a few pain pills the night of surgery and don’t require therapy afterwards,” he adds. Fewer than 15% of Pess’s patients require therapy for endoscopic CTS surgery, compared to about 85% of those who have the open surgery. (Other surgeons report different results, with at least one suggesting that he sends almost equal numbers of patients with open and endoscopic CTS surgeries for postoperative therapy.) Pess sees the minimally invasive surgery as more economical and less costly to society because of the quicker return of patients to their jobs, although the special surgical knives used in the procedure may be more expensive, he says.

Pess has performed about 1,800 of the endoscopic carpal tunnel release surgeries. Open surgeries are usually indicated for those under 18, since in young patients, CTS is frequently the result of anatomical abnormalities. For example, in one child with CTS whom Pess treated, a flexor tendon had wrapped itself around the median nerve. Pess cut the tendon and sewed it back together so it would not compress the nerve. “If I’d used the endoscopic technique, I would still have had to do an open procedure to fix it,” says Pess. In most cases, he believes open surgery is also indicated for patients with rheumatoid arthritis so that the tendons can be individually cleaned off.

The endoscopic technique is rather new and requires specialized training, Pess says. “It is more difficult and slightly more risky because some of the surgery is done blind and there is an increased chance of injury to the nerve. It needs to be done by someone who has practiced the technique in the lab and really understands the anatomy.”

New Minimally Invasive Trigger Finger Surgery

Pess and his resident, Michael Dunn, MD, have also developed a minimally invasive surgical technique to treat a syndrome called trigger finger, trigger digit, or, in medical journals, stenosing tenosynovitis. The anatomy behind the condition is as follows: The tendons that move along the fingers are held in place on the bones by a series of ligaments called pulleys. The ligaments form an arch on top of the bone that creates a sort of tunnel through which the tendon glides. The tendons are wrapped in a slippery coating called tenosynovium, which reduces the friction and allows the flexor tendons to glide through the tunnel as the hand is used to grasp objects. Trigger finger is caused when the tendons that move along the fingers thicken to form a nodule. This may also cause a thickening of the pulley ligament as well. This swelling constricts smooth gliding of the pulley tendons, affecting the movement that allows the fingers or thumb to move toward the palm of the hand.

Usually examination of the trigger finger or thumb reveals the condition without tests or radiography. Causes may include rheumatoid arthritis, repetitive use of certain power tools or musical instruments, long hours of grasping a steering wheel, and congenital defects, although frequently the cause is unknown. Surgery is considered after conservative treatments, including anti-inflammatory medications, heat, cortisone injections, and splints, fail to alleviate symptoms.

The standard open technique involves making either a longitudinal or transverse incision in the palm, and releasing the pulley that is obstructing the tunnel and preventing the tendon from sliding smoothly.

Using the Pess-Dunn method involves insertion of a small knife, the Trigger Release Tome, which the two surgeons invented, through a small incision (about 3 mm) and releasing the pulley tendon. Another percutaneous technique employs a similar procedure using a needle that is rubbed back and forth until the pulley releases. In a study published in the Journal of Hand Surgery, Pess and Dunn compared their knife to the needle procedure and found that the latter tends to cause tendon damage, while the knife they designed does not. Pess has been using this technique for about 2 years and has performed about 200 operations, he says. Pess and Dunn are currently submitting for publication a clinical study of the success of their knife in the first 200 patients.

Arthroscopic Upper-Extremity Surgery

Most of the arthroscopic instrumentation used to perform minimally invasive surgery on the wrist and elbow has been developed in the past 5 to 7 years. The timing has proved fortunate for Hanker, who completed his residency in 1986 and learned the new techniques almost as they were being invented. Hanker describes several procedures for which he might use arthroscopic surgery.

In each case there must be an indication for surgery. Some examples would be: an intra-articular fracture of the wrist; a ligament tear where the carpal bones are unstable; an injury to the cartilage of the carpal bones; an injury to the triangular fibrocartilage complex (TFCC—an injury of an area analogous to the meniscus of the knee); excising ganglion cysts from the wrist; rheumatoid arthritis; and gout.

In the case of rheumatoid arthritis, the condition produces a profound inflammation inside the wrist that can eventually lead to joint destruction. If the surgeon performs an arthroscopic synovectomy to remove the diseased rheumatoid tissue, this can greatly lessen the patient’s pain, improve wrist motion, and diminish the chance that the arthritis will be more destructive in the future. Before arthroscopy, Hanker explains, the use of arthrotomy to open the joint led to greater pain and higher morbidity. Use of the minimally invasive arthroscopic technique in this case involves two quarter-inch incisions, less pain, and a quicker recovery. Hanker also employs arthroscopy in surgical treatment of painful and unsightly ganglion cysts that may occur on the back of the wrists. A common occurrence, often of unknown cause, the cysts may be the result of overuse or trauma. Sometimes the cysts are painful, and occasionally they are a secondary manifestation of an underlying problem, such as a cartilage injury, where there is already some arthritis developing in the wrist, or a wrist ligament injury, where there is some instability. In this case, Hanker says, arthroscopy is a useful tool to view the wrist joint and make sure there are not other problems. If there are, they can be treated at the same time the cyst is removed from the wrist. In such cases, minimally invasive surgery would allow the surgeon to “provide a tremendous amount of care to a patient with very little risk or pain, and a quick recovery afterwards,” Hanker says.

Some injuries, such as a broken scaphoid bone, the wrist bone at the base of the thumb, are too destructive to be fixed arthroscopically, Hanker says. But arthroscopy can be used for many things and its benefit as a diagnostic tool is remarkable, the surgeon says. “You’re looking at the TV monitor, and you’re seeing what the telescope sees inside the wrist, so you see and do only what you can visualize.”

Arthroscopic Treatment of a TFCC Tear

One typical injury where arthroscopy might be useful is for a TFCC tear. This is a common wrist injury often seen in the workplace: The employee sprains his or her wrist on the job. The injury fails to heal and weeks later, the worker is experiencing difficulty performing daily tasks. After radiography fails to turn up any broken bones, the patient is sent to the orthopedic surgeon. An MRI scan shows that the patient has a TFCC tear. In this case, conservative treatment would include the use of a wrist brace or a cortisone injection. When arthroscopic surgery is used, it includes debriding the tear to smooth the edges; this “smoothing” process is done with special instruments. Small arthroscopic knives are used in the TFCC resection and release of joint adhesions. Usually, this is very successful and can be performed under local anesthetic on an outpatient basis with only two or three small incisions in the wrist. Occasionally, the TFCC can be repaired.

Arthroscopic Elbow Surgery: Pursuing “Loose Bodies”

Many of the same arthroscopic techniques can be applied to surgery of the elbow as for the wrist, Hanker says. When a baseball player suffers from “pitcher’s elbow” after throwing the ball for many years, for example, the surgeon can go in and arthroscopically remove the spurs and improve the function of the joint, Hanker says. After many years of pitching, many of these players get a loose body or a bone spur in their elbow—small pieces of bone that break off inside the joint and get stuck, affecting mobility of the elbow, like a doorstop, he says. Instead of a three-inch incision on the outside of the elbow and limited visualization of the problem, arthroscopy allows the surgeon to put the telescopic tube inside the joint like a snake with a telescopic eye and project images of the bone spurs on the TV screen. Magnified, the bone spurs look like stalagmites and stalactites on the side of a cavern, and the loose “bodies” floating about look like little pearls. With graspers, files, probes, and mini rotating blades attached to suction instruments, you can eliminate the problem, Hanker says.

“It’s a big deal to open up the elbow joint, with a lot of risk and a long recovery time,” he says. “If you can avoid that and just make a tiny tunnel and work through that, it really improves the patient’s recovery.”

The same can be said of most minimally invasive surgical techniques of the hand and wrist—and the techniques are still very new and somewhat crude, Hanker says. “Wrist arthroscopy is technically behind knee and shoulder arthroscopy. The instrumentation is much smaller, and they haven’t been able to miniaturize all the instruments used in the other joints for the wrist, so as these [implements] become more available, the techniques will become more refined and more applicable. There will be a lot of developments in the next 5 to 10 years.”

Ruth Stroud is a contributing writer for Orthopedic Technology Review.


Techniques and Technologies of Hand Rehabilitation

By Ruth Stroud

Certified hand therapists must be able to evaluate multiple conditions to develop individualized programs for a patient’s needs.

Only in the past decade has the designation of certified hand therapist (CHT) come into existence. To become a CHT in the United States, candidates must have been a physical or occupational therapist for a minimum of 5 years in the United States or Canada. In addition, a would-be CHT must have engaged in a minimum of 2,000 hours of hand therapy in the 5 years prior to passing a tough hand therapy certification examination. The examination is offered by the Hand Therapy Certification Commission (HTCC), a not-for-profit corporation established in 1989 for the purpose of sponsoring a voluntary certification program.

The reason that hand therapy has become a specialty, notes Parivash Kashani, OTR, CHT, a certified hand therapist at the UCLA Hand and Work Hardening Program, is the complex structure of the hand. “Everything is in such proximity that every adhesion of scar tissue can really affect the function of the hand,” Kashani explains. “If someone loses 10% of motion in a hip, that doesn’t affect their function as much as someone who loses 10 degrees of motion in one finger.”

The UCLA Hand and Work Hardening Program, part of UCLA Rehabilitation Services, receives a large number of patients with “overuse” injuries, mostly caused by repetitive motions over a long period of time. Kashani estimates that more than 50% of these patients are computer users. In addition to job site evaluations and other conservative measures, nonsurgical treatment for repetitive stress injuries (RSI) may include teaching the patient how to relax specific muscles, use correct posture, modify keyboarding style, stretch, and take regular breaks. Kashani also does a lot of educating on dealing with stress. “A lot of these patients are Type A people. They work harder than most people, are usually perfectionists, and are always in a hurry. That adds up to a lot of stress.”

Tina Clark, OTR, CHT, a certified hand therapist working for the Southern California Orthopedic Institute in the Center for Rehabilitation Medicine in Van Nuys, Calif, agrees that patient education is a big part of hand therapy. “The job of the therapist is to educate patients to understand what they need to do and what their limits are,” she said.

Clark, who grew up in Miamisburg, Ohio, picked her future career when she wrote a high school paper on an occupational therapist. She usually sees her patients two or three times a week after evaluating them and developing their therapy programs. The patient’s progress and response to therapy are monitored at each session. Any problems with swelling or increased pain are addressed during these sessions. The therapist must individualize the patient’s program on the basis of any medical conditions that may complicate or slow recovery.

Taking multiple conditions into account is crucial to a successful outcome, Clark said. Recently, she treated a woman with a fractured wrist complicated by rheumatoid arthritis (RA). Although a simple fracture might warrant exercises to increase strength and range of motion, forcing a lot of “hard grip” exercises on a client with RA might bring on a more rapid progression of the disease, Clark explains.

The goal of hand therapy is to have a hand that works as much as possible the way it did prior to injury and/or surgery. Many of the exercises and splints that Clark devises are aimed at accomplishing that goal. Clark cites the example of her sister, an optometrist, who fell and sprained her left hand. Since her sister’s job required the use of the left small finger to hold the patient’s eye open while performing examinations, her sister’s livelihood was drastically curtailed by this injury. Clark fabricated a custom static progressive splint to use in conjunction with exercises, which helped her sister rapidly regain her range of motion and return to work. The static progressive type of splint permits the application of a low-grade force over a long period of time so that a joint can gain range of motion without increasing pain or swelling, Clark explains. Her sister “went from a person who couldn’t even bend the finger at all to the point where she could use it completely, with full grip strength,” Clark says.

Making custom splints is an important skill of the hand therapist. The splints are made of low-temperature thermoplastics, a combination of plastic and rubber. The material comes in a flat sheet that becomes soft in a hot-water bath at about 160 degrees. The therapist molds the material to the patient’s hand and uses it in place of a cast. The advantage of using a splint is that the patient can remove it and engage in early motion exercises. The reason to move the hand early is to prevent excessive scar formation and decrease stiffness by improving nutrition to the tendons and joints. Different metal or plastic components can be added to the splint to place the hand or fingers in extended or flexed positions to gain range of motion. Springs or rubber bands can be added to the splint to substitute for lost muscle strength.

Making a splint is an art, notes Kashani, as is being a good therapist. One of the favorite aspects of her job is seeing patients move toward independence again and regaining the ability to return to their previous activities. “I love my work,” she says simply.

Ruth Stroud is a contributing writer for Orthopedic Technology Review.