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Minimally Invasive Surgical Techniques of the Hand and Upper Extremities By Ruth Stroud
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 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 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 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.
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.”
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.
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.”
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.
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. |
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Techniques and Technologies of Hand Rehabilitation By Ruth Stroud
Only in the past decade
has the designation of certified hand therapist (CHT) come into existence. To
become a CHT in the 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 Clark, who grew up in Taking multiple
conditions into account is crucial to a successful outcome, 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 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. |