GP Dr John Couch talks to consultant hand surgeon Mr David Evans about recent reconstructive techniques for a wide variety of conditions
What has been the most important development in hand surgery in recent years?
I think the introduction of transplantation has been the most significant. This has mainly been due to developments in immunosuppression because it has now become possible to consider these techniques for non-lifesaving purposes. Until now the use of immunosuppressants has brought high complication rates, hardly justified for hand transplantation. The new regimes are less toxic. There have been seven or eight hand transplants so far worldwide. Some are showing good function.
Important information has emerged from them. It is relatively easier to maintain immunosuppression in skin than was expected. Signs of rejection are much more visible than with organ transplants. Also there is better nerve regeneration than was expected and it is possible that immunosuppression may have a beneficial effect. Although it is far too early to tell, this may have a knock-on effect in nerve regeneration generally after nerve injury or repair.
When is transplantation indicated and
how is it done?
It has only been done for traumatic amputation, especially in a bilateral amputee. The patient's age and general fitness are an additional factor. The organisation is complex, as two theatres and teams must be set up, one for the recipient and one for the donor, who will still be on life support up to surgery. Unlike re-attachment (see page 52), there are usually no problems with getting enough tissue.
Skeletal attachment is done first. This is normally followed by revascularisation, then attachment of nerves, tendons, muscle and finally skin.
What surgical treatments are currently available for hand osteoarthritis?
Starting with the carpometacarpal joint of the thumb, for sufficiently symptomatic patients trapeziectomy is the most tried and tested method. It has the advantage of removing the joint between the scaphoid and trapezium as well as that between trapezium and thumb metacarpal, both of which can be involved. It is often combined with a stabilising procedure, using the tendon of flexor carpi radialis. Pain relief is good, but to regain good pinch function can take up to six months. There is an artificial joint replacement that can work well but has a fairly high dislocation rate. Silicone replacement of the trapezium can give good early results but in the longer term silicone can fragment and cause a particulate synovitis.
All the metacarpophalangeal (MP) joints can be replaced. The older Swanson silicone prosthesis is not very good for isolated joint osteoarthritis, unlike in rheumatoid arthritis. There are joint resurfacing procedures for MP and proximal interphalangeal (PIP) joints that have been available for some years. These preserve the joint capsule and ligaments and are very successful. They are not usually used in the MP joint of the thumb, which needs little or no mobility, as arthrodesis is more effective.
What surgical indications and treatments are currently available for the rheumatoid hand?
The presentation of rheumatoid arthritis in the hands is very variable, and is reflected in the number of treatments. Synovitis affects the free movement of flexor and extensor tendons and can lead to rupture. Significant unresolving synovitis, around flexor tendons especially, should be treated by synovectomy to prevent rupture. This may need to be done quite extensively in the carpal tunnel and finger flexors. If rupture does occur, it is usually not possible to repair tendons directly. In this case it is necessary to resort to tendon transfers. Even this may not be easy as rheumatoid arthritis often affects several tendons. Earlier synovectomy to prevent rupture is extremely important.
Nerves, while not involved in the disease, can be involved through pressure. Carpal tunnel decompression may be necessary.
Joint surgery and replacement is another important treatment for severe deformity that limits function. The commonest are the MP joints. Prevention can involve soft tissue reconstruction to realign the joint, providing the joint surface is intact. If the joint surface is affected, reconstruction using silicone prostheses is the best option, as resurfacing may not be possible. PIP joints may need similar surgery.
The wrist is often affected but joint damage may leave arthrodesis as the only option. The distal end of the ulna can produce pain from erosion and loss of rotation. It can also become sharp, eroding extensor tendons, so excision of this can be very helpful.
What surgical sequence is followed in the assessment of, and surgery for, traumatic amputation of the hand?
The first priority is advanced life support as these can be life-threatening injuries. The amputated part must be retrieved, cooled but not frozen and placed in a clean polythene bag surrounded by ice. It is important not to promise anything to the patient, as the amputated part may not be suitable for reattachment. The patient must be transferred urgently to a replantation centre.
If there is extensive avulsion or crushing, reattachment may be unviable. If the warm ischaemia time is excessive, revascularisation of muscle can lead to renal failure and even death. Even a cooled limb needs to be reattached within three hours unless extracorporeal circulation can be established.
For the hand a clean amputation is usually required. For multiple digits, reattachment is attempted if they are suitable. Single digit amputation is more controversial although the thumb, and the left ring finger especially of a woman, would usually be reattached if possible. The latter is partly done for social reasons and also because injuries to ring fingers are often a degloving type, with skeletal preservation, so soft tissue replacement can give a good result. In children one would attempt to reattach any part if feasible. Adults with special functional requirements such as musicians would be similar, but with a guarded prognosis.
How common are hand neuromas?
They are common after nerve injury, presenting as tender lumps. Physiotherapy can help. Surgical treatment includes nerve repair, nerve grafting or burying the neuroma in bone.
What are the problems and future prospects for nerve repair?
In nerve repair the limitations are physiological rather than surgical. Many factors apply including age, the characteristics of the injury and whether there is any traction. Rehabilitation including sensory re-education plays a significant part. One advance that may prove significant is tissue glue. Unfortunately it is only available on special licence so is not used widely. Immunosuppressants, as mentioned earlier, could be another important advance.
Which are the commonest 'donor sites' for grafting skin, bone, tendons or nerves to the hand?
Split skin grafts are normally used in the hand for burns or other large areas of skin loss. The arms or thighs are the commonest sites. Full thickness skin grafts are normally for smaller areas. The latter have better characteristics including the quality of the skin, mobility and resistance to contraction. They can also be taken from elsewhere in the arm. I often use the elbow crease. The groin can be used although the colour may be a little yellow on the hand. In children especially it can be difficult to avoid later hair growth when using groin skin.
Bone grafts can be taken from distal arm bones, usually the radius. The iliac crest can provide larger amounts if needed. With tendons palmaris longus, present in 80 per cent of patients, is the most popular. In the leg the plantaris tendon, toe extensors and strips of fascia lata can all be used.
With nerves the medial cutaneous nerve of the arm is useful. The posterior interosseus nerve on the dorsal aspect of the wrist can provide a small graft and has no residual defect such as loss of sensation. The sural nerve from the leg is useful for longer grafts.
How do you minimise scarring from trauma, burns and skin grafting?
If there is a choice of where to place a scar, skin creases or areas that are not under tension give better results. Longitudinal scars on the flexor surface of the hand should be avoided, as they tend to contract. With any wound primary healing should be encouraged as delayed secondary healing, especially with infection, increases scar tissue. If the scars are due to burns the quicker they heal the less scarring there will be. Good dressing and sterile techniques to avoid infection are therefore important.
With skin grafting, thicker grafts produce a better scar than thin ones. If keloid scars do occur, pressure garments or silicone material under splints or a garment can reduce the hypertrophy.
What is the importance of post-surgical physiotherapy?
Post-operative physiotherapy and occupational therapy are vital to restore movement. We aim for early mobilisation within the safety requirement of the type of surgery. Physiotherapists seeing patients regularly can often detect complications that otherwise go unnoticed such as infection, rupture of repaired structures or early reflex sympathetic dystrophy.
What are the features of reflex sympathetic dystrophy?
This can have a very insidious onset. The syndrome is not fully understood. It has been attributed to sympathetic nerve over-activity but there is no real evidence for this.
It comprises post-operative or post-injury cold intolerance, increasing discomfort, localised sweating, increased hair growth, a blue discolouration and oedema. It is very destructive to recovery and needs energetic physiotherapy with medication.
Antidepressants such as amitriptyline can be very effective. The condition responds faster if treated early and although most patients recover eventually some can be left with stiffness.
Advances in surgical procedures on the hand
Advances in surgical procedures on the hand
lTransplantation and re-attachments for traumatic amputation have had some success
lJoint removal combined with stabilisation can relieve pain from osteoarthritis
lJoint replacement is an important option for severe rheumatoid problems
lPhysiotherapy helps detect post-surgical complications and treat neuromas
lCareful consideration is needed when choosing donor sites for tissue grafting