What’s New in Hand and Wrist Surgery

This Guest Editorial provides an overview of the latest articles in the hand and wrist literature from 2023 to 2024, mostly from The Journal of Hand Surgery, The Journal of Hand Surgery (European Volume), HAND, Plastic and Reconstructive Surgery, and The Journal of Bone & Joint Surgery. The intent is to provide an update for the practicing general orthopaedic surgeon regarding the latest findings and innovations in the hand and wrist literature. Carpus Scaphoid Nonunion In the treatment of scaphoid nonunions, there continues to be controversy on various types of surgical interventions and methods to augment healing1,2. In recent years, there has been much attention to key surgical factors that contribute to improved healing rates. Carpal malalignment as the result of scaphoid nonunion involving a humpback flexed deformity with dorsal intercalated segment instability3 has been traditionally thought to be the key instability to correct during nonunion surgery4. However, little is known regarding whether various bone-grafting techniques can correct carpal malignment or if nonunion healing is dependent on the correction of the carpal alignment. In a study of 59 scaphoid waist nonunions treated volarly with a tricortical nonvascularized autograft, sustained correction of carpal alignment only occurred in 54% of patients5. Furthermore, in the 73% of fractures that united at a mean of 4.4 months, the correction of carpal alignment did not correlate with union. This highlights that our understanding of scaphoid nonunion healing and of the contribution of mechanical alignment is still in its infancy. Low-intensity pulsed ultrasound (LIPUS) was traditionally thought to be a useful and noninvasive adjunct to improve bone healing6,7. In scaphoid nonunions, it was even shown to potentially shorten the time to union after surgical treatment in an underpowered prospective trial8. White et al. performed a randomized controlled trial (RCT) of 142 patients treated surgically for scaphoid nonunions comparing LIPUS with a sham intervention3. There ultimately were no differences in the time to union, total union rate, patient-reported outcome measures, or wrist function, with the authors concluding that this intervention is not indicated for scaphoid nonunions. Reconstruction of Nonsalvageable Osteonecrosis Osteonecrosis of the carpal bones represents very challenging pathologies treated by hand surgeons. Nonunions of the proximal pole of the scaphoid are particularly problematic, given their compromised vascularity, limited bone stock, and biomechanical issues2. When deemed nonsalvageable, surgical options include rib9 or proximal hamate10 nonvascularized autografts as well as medial femoral trochlea vascularized autografts11. When attempting to treat patients with unsalvageable proximal pole nonunions, there remains controversy on the optimal technique or evidence-based algorithm. The proximal hamate as a nonvascularized option continues to have more evidence to support its use, with a study of 14 patients showing a 100% union rate and promising restoration of wrist function and patient-reported outcome measures12. Alternatively, the same international collaboration that popularized the medial femoral trochlea procedure described 17 patients who underwent a lateral femoral trochlea vascularized osteochondral flap, who had a high healing rate and predictable restoration of wrist function13. In a similar study of patients with nonsalvageable lunates with coronal split fractures from Kienböck disease, the medial femoral trochlea osteochondral flap demonstrated promise in 33 patients, yielding a >90% union rate14. These studies highlight the ongoing need to better elucidate an algorithm for these challenging fractures. Scapholunate Ligament Chronic scapholunate ligament injuries remain one of the most challenging pathologies faced by hand surgeons, without evidence-based algorithms guiding their treatment. There are many types of scapholunate ligament reconstructions, each attempting to reconstruct both the intrinsic and extrinsic stabilizers of the scapholunate ligament articulation. An excellent example of the controversy is highlighted in a study of 3 common reconstruction techniques15, including dorsal capsulodesis16,17 with a mean follow-up of 11.8 years, tri-ligament Brunelli tenodesis18 with a mean follow-up of 5.9 years, and bone-ligament-bone reconstruction19 with a mean follow-up of 8.9 years. Over the long-term follow-up, every technique showed radiographic deterioration that did not correlate with functional outcomes15. There also were no difference in clinical outcomes between the 3 techniques. Another example of an emerging technique is anatomical front-and-back reconstruction, targeting an open reconstruction of many of the critical extrinsic ligaments associated with the scaphoid and the lunate20. In a study of 21 anatomical front-and-back reconstructions with a minimum 1-year follow-up, both clinical and radiographic outcomes improved, with 2 reoperations21. In another study by the same group, anatomical front-and-back reconstruction appeared to yield better radiographic correction at 1 year compared with Brunelli tri-ligament tenodesis22. However, as with the previously mentioned techniques, it remains to be seen if long-term outcomes of this or any other emerging scapholunate ligament reconstruction technique will hold up. Compressive Neuropathy Carpal Tunnel Syndrome One of the major innovations in recent years has been the use of ultrasound to diagnose carpal tunnel syndrome23,24. It has yielded superior results when used in place of nerve conduction studies23 and to complement the CTS-6 (6-item Carpal Tunnel Syndrome) diagnostic criteria25. For example, ultrasound has been shown to predict the more symptomatic side in bilateral carpal tunnel syndrome26. However, the ability of either ultrasound or nerve conduction studies to predict the response to surgery remains unclear. In a study comparing patients with “clear” and “borderline” diagnoses of carpal tunnel syndrome on nerve conduction studies or ultrasound, it was found that these did not correlate with overall surgical improvement26. However, the cross-sectional area of the nerve on ultrasound does initially decrease after the surgical procedure and appears to remain smaller across longitudinal follow-up in the short term27. The optimal type of carpal tunnel release has been a matter of debate for the last 2 decades, particularly comparing open and endoscopic techniques. Although there were higher rates of complications early in the learning curve for endoscopic techniques28, no major differences between endoscopic and open techniques remained when surgeon experience was equivalent29. This was further reinforced by Schroeder et al., who examined 634 endoscopic releases compared with 491 open releases, finding no differences in terms of pain medications, patient phone calls, or therapy referrals30. There was a lower likelihood of needing therapy with the endoscopic approach. Furthermore, the rate of intraoperative conversion to open release was 1% in a retrospective review of 892 cases and 0.62% in a systematic review of 40,351 cases31. Also, the risks of conversion to open release or of complications do not appear to be associated with resident involvement31. Taken together, this explains the exponential increase in endoscopic carpal tunnel releases being performed, from 9.1% of total carpal tunnel releases in 2012 to 25.2% in 2020. The association with carpal tunnel syndrome and amyloidosis remains an emerging area of investigation, as the formation of amyloid deposits in musculoskeletal tissues is likely to be present 5 to 10 years prior to cardiac disease32. As a result of many recent reviews, the criteria for biopsy during carpal tunnel release include bilateral symptoms and age of ≥60 years for women and ≥50 for men32,33. In a recent study, the addition of patients with spinal stenosis and cardiac disease satisfying the prior 2 screening questions increased the percentage of positive biopsies to 22.5%34. Furthermore, another recent study demonstrated that a single biopsy specimen source, either the tenosynovium or the transverse carpal ligament, is adequate35. Diagnosis of carpal tunnel syndrome using the CTS-6 screening test has been established as a reliable method that can be administered by therapists and medical students and via telemedicine36,37. A recent study from the same group demonstrated high sensitivity and specificity when administered by medical assistants as well as by therapists35, setting the foundation for its use as a screening program and in conjunction with future artificial intelligence (AI) applications. Cubital Tunnel Syndrome Failure of a cubital tunnel surgery due to recurrent symptoms can be a complicated problem to treat, given its multiple possible etiologies. Many surgeons prefer to perform a transposition, either subcutaneous or submuscular, in this setting. In a recent meta-analysis, these 2 techniques were compared across 20 studies and 471 patients, demonstrating more reliable improvement in those who underwent a submuscular transposition38. Distal Radius Osteotomy Distal radial malunions can lead to poor clinical outcomes due to malalignment of the carpus or distal radioulnar joint malalignment. Surgical correction is often necessary in younger, more active patients39, with controversy regarding whether the optimal treatment approach involves a volar or dorsal osteotomy. A recent meta-analysis of 403 patients comparing these 2 approaches showed fewer complications and reoperations with the volar approach40. Although the approach should be tailored to the patient’s specific malunion, this highlights what underlies the recent shift toward the volar approach for many of these malunions. When performing the volar approach, studies have demonstrated that, as long as there is cortical contact volarly, there is no need for a bone graft41,42. A recent study took this a step further, showing that cortical contact might not even be necessary when using volar osteotomy43. These are important steps to developing an algorithmic approach to these challenging pathologies. Age and Radiographic Factors Guidelines for the treatment of acute distal radial fractures, dependent on many fracture and patient factors, continue to evolve44. Despite poor radiographic alignment being associated with poor clinical outcomes45, there still remains a lack of consensus on the critical radiographic outcomes for acceptable alignment. In a retrospective study of 1,319 women treated nonoperatively or operatively for distal radial fractures, exceeding radiographic thresholds of a volar tilt of 25°, dorsal tilt of 10°, or ulnar variance of 7 mm was correlated with worsening post-treatment outcomes46. In a recent study of 366 patients, dorsal tilt of >5° was found to be the strongest factor that correlated with worsening clinical outcomes in most patients47. It should be noted that the exception was for patients >75 years of age, in whom it was not until dorsal tilt was >20° that a clinical difference was experienced. Another recent study supported the tolerance of malunions by these older patients, showing worse clinical outcomes at 3 months but no difference in clinical outcomes at 1 year after the injury48. Another recent study reinforced the diminishing benefit of surgery for patients >80 years of age, showing that they will likely not achieve a clinically meaningful benefit from surgical treatment49. This and other factors can be utilized to develop and improve patient decision aids for patients with distal radial fractures, as a recent study showed the importance of these aids in improving the patient decision-making process50. When treating distal radial fractures surgically, a recent study showed a low overall complication rate of 12.3%, including a 2.7% implant removal rate and a 1.9% rate of carpal tunnel surgery51. As highlighted by the studies above, optimizing the restoration of volar tilt remains a critical aspect of the surgical outcome. Not only is this critical to optimize wrist function47, but failure to do so puts increased pressure on the flexor pollicis longus tendon52. Such pressure is particularly concerning given that the plate is placed distal to the watershed line. Ultimately, adequately performed surgical correction does appear to maintain functional outcomes over a long-term follow-up period, even in spite of a 6% risk of osteoarthritis47. Finger and Thumb Arthritis Proximal Interphalangeal (PIP) Joint Arthroplasty PIP joint arthroplasty remains controversial with regard to indications, patient factors, and implant choice53. There remain evolving considerations regarding controversial indications for PIP joint arthroplasty, including border digits54 and young age55, but patients’ ability to return to heavy labor or regular work appears to be predictable in a recent study56. With regard to patient choice, silicone arthroplasty has remained the gold standard for many patients. 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