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Taking it back: Surgeons retract podium statements to reflect new practices
Hand surgeons change course on casting the scaphoid, endoscopy for CTS, and cement use.
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WASHINGTON — Evolving surgical techniques and technologies can lead to changes in treatment modalities for various conditions, leading surgeons to adjust their practices accordingly even after they may have presented them publicly.
For that reason, the American Society for Surgery of the Hand (ASSH) introduced a symposium in 2005 that gave surgeons the opportunity to retract statements previously made while at the podium.
At the ASSH 61st Annual Meeting, here, three surgeons retracted statements on closed treatment of nondisplaced scaphoid fractures, using the endoscope for carpal tunnel syndrome, and using cement in the hand and wrist.
Nondisplaced fractures
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Two years ago, Scott Wolfe, MD, endorsed treating nondisplaced scaphoid fractures with an above-elbow cast for 6 weeks and then a below-elbow cast for 6 weeks until the patient healed.
Now, "I would ... recommend immediate surgery as the most expeditious and cost-effective form of treatment," Wolfe said in a retraction at the ASSH meeting.
In the past 4 years, four separate studies totaling more than 100 patients treated with immediate percutaneous fixation of scaphoid fractures demonstrated a 100% union rate — with one patient requiring screw removal, Wolfe said. And, although some researchers have presented upwards of 95% union rates with cast treatment of scaphoid fractures, Wolfe presented evidence to suggest otherwise.
In a 1999 prospective study, Nicholas Barton and colleagues found an 11% nonunion rate with cast treatment and Alho and colleagues confirmed an 8% nonunion rate in 100 consecutively casted patients. Harris Gellman and colleagues found a 4% nonunion and 16% delayed union rate when comparing long- and short-arm cast treatments in 1989.
Cast-treated patients may also continue to experience deficits in strength and motion as shown in a 2-year post-healing evaluation by Charles Bond and colleagues in 2001.
In addition, patients lose extra time from work and sports with cast treatment. "All authors would agree that up to 7 weeks of increased disability time from work and sports is necessitated by closed treatment," Wolfe said.
Doing away with cast treatment could also save money in the long run, Wolfe said. In a 2006 study, Kevin Chung and colleagues estimated that in the United States could be saved nearly $6,000 per individual by treating them with immediate operative fixation of nondisplaced scaphoid fractures and doing away with extra disability time and nonunions.
Two-portal endoscope method
Orthopedic surgeons have known for years that open carpal tunnel release and endoscopic carpal tunnel release carry the same inherent risks. In this case, they rely on the risk-benefit ratio to point them to the right treatment.
That's exactly what Thomas J. Fischer, MD, did when he re-evaluated his practice and whether to use open or endoscopic techniques for carpal tunnel syndrome.
He retracted his statement that the Chow two-portal method of endoscopic carpal tunnel release was efficacious. Although several other orthopedic surgeons have been successful with the technique, Fischer said a review of his own use of the technique found
that he could not adapt exit portal control according to the anatomic variations in the mid-palm.
Fischer stressed to Orthopedics Today that the technique is safe. "Many practitioners still perform the method safely and there are articles that speak to that fact," he said.
"All of the important anatomic variations that we know of occur at the distal end of the carpal tunnel," Fischer said. "In my hands, I could not control the exact size of the exit portal and its relation to the superficial arch, third common digital nerve and the various ulnar anastomoses in the palm."
Fischer also evaluated the practical considerations for performing the endoscopic technique and found that the extra equipment, operative turnover time and operating room time with the endoscopic technique did not provide better patient outcomes.
"The investment of these additional resources to achieve the same outcome was not sustainable," Fischer said. "Furthermore, the knowledge that more catastrophic, complete median nerve transections had been reported with endoscopic techniques than what I could find with open technique altered my risk-benefit argument."
Cement in the upper extremity
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Robert D. Beckenbaugh, MD, began his early work and research with the first report on 2,012 cemented total hip arthroplasties in the United States that led to the legal approval for cement use for the procedure.
Because failures and fractures with silicone implants in the hand and wrist were also a problem at this time, Beckenbaugh and colleagues attempted to apply hip cementing technology to total arthroplasties of the wrist and hand joints.
Beckenbaugh retracted a statement he made in 1979 that the future of cemented wrist prostheses was "sound" and that the problems of loosening with cemented wrist arthroplasty were not as significant as in other areas. Shortly after making the claim, Beckenbaugh and his colleagues found a 20% loosening rate, 64% of which were in failed silicone, at 5 years after biaxial wrist arthroplasty. In addition, the researchers found unanticipated wear factors with the cemented implants. After an orthopedic surgeon in the Netherlands used the Beckenbaugh-designed wrist implant without cement, he found a 5% loosening rate and only a 2% reoperation rate.
"The conversion of hip technology in total joint arthroplasty to the hand and wrist with cement fixation has not been successful," Beckenbaugh said. "Constrained cemented implants in the hand and wrist have very high stress shielding and failure rates. Cemented implants in the finger and wrist may still be considered in more physiologic nonconstrained devices."
Beckenbaugh noted that surgeons might use cement in the hand and wrist in salvage situations with large bone deficits and in failed arthroplasties with a lack of bone stock.
For more information:
- Beckenbaugh R. Cement in the hand and wrist Symposium #4. Presented at the American Society for Surgery of the Hand 61st Annual Meeting. Sept. 7-9, 2006. Washington.
- Fischer T. Endoscope for carpal tunnel syndrome. Presented at the American Society for Surgery of the Hand 61st Annual Meeting. Sept. 7-9, 2006. Washington.
- Wolfe S. Closed treatment of nondisplaced scaphoid fractures. Symposium #4: The Journal of Retraction. Presented at the American Society for Surgery of the Hand 61st Annual Meeting. Sept. 7-9, 2006. Washington.
- Scott Wolfe, MD, Hospital for Special Surgery, 523 E. 72nd Street, East River Professional Building, 4th Floor, Vilar Hand Center, New York, NY 10021; 212 606-1529; wolfes@hss.edu. Thomas J. Fischer, MD, The Indiana Hand Center, 8501 Harcourt Road, Indianapolis, IN 46280; 317-875-9105; tjfischerhand@att.net. Robert D. Beckenbaugh, MD, Mayo Clinic, 200 1st Street SW, Rochester, MN 55902; 507-284-2431; robert.beckenbaugh@mayo.edu.