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500 Cummings Center
Suite 4550
Beverly, MA 01915
(978) 927-8330
(978) 524-8890/FAX
www.handsurgery.org
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A publication of the
American Association for Hand Surgery
Winter2014
MESSAGE FROM THE PRESIDENT
INSIDE THIS ISSUE
Annual Meeting Schedule at a Glance 2
From the Editor’s Desk 3
Hand Therapist’s Corner 4
Calendar 6
Coding Corner 7
Discussion: Finger Arthritis 8
AAOS Clinician Scholar Program 17
AAHS Job Board 18
Hand SurgeryEndowment 18
A Report from Ghana 19
Leadership Profiles 20
Board of Directors 21
(continued on page 6)
Missed the plane for Hawaii this January?I hope not. We have excellent education in hand surgery and
therapy lined up with great front edge of the wave speakers. Youwill learn all the latest tricks in Dupuytrens treatment withcollagenase, needle aponeurotomy (with and without fat graft-ing), and manipulation of cords with digit widget, splinting andstretching. The latest in wide awake hand surgery and trueactive movement in flexor tendon repair. What about actuallyfixing boutonniere or working splints that allow movement withat 3 days after repair with extensor tendon with relative motionsplining, or chronic paronychia busting with gentian violet?Great tips in hand surgery and hand therapy from the best? BillMagee will give a heartwarming talk of interest to all. All thisand more in the paradise setting of Kauai.
If you did miss the boat, you can come to the Bahamas next year, which will be awe-some as well.
Reverse Fellowship in Kumasi Ghana; Great Opportunity for AAHS and ASSH Surgeonsand Therapists
Neil Salyapongse was teaching hand surgery to one of the very few hand surgeons inWest Africa in September (see a summary of his trip in this issue.) Details on how to getinvolved aer available on the website: http://handsurgery.org/volunteerism/kumasi.cgi. Hewent as part of our new reverse fellowship program designed to send the teachers to thefellows to avoid the brain drain of traditional fellowships. Since I went there before Neil toset up the fellowship, they have started having one of the physiotherapists regularly attendthe hand surgery clinics for the first time ever. The time is ripe for a surgeon and histherapist to help start hand therapy in West Africa, where it is sorely needed.
Donald H. Lalonde, M.D.
ANNUAL MEETING SCHEDULE AT A GLANCE ON PAGE 2
Hand
Surgery
Quarterly
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WEDNESDAY, JANUARY 8, 2014
6:30 am-8:00 Continental BreakfastGrand Promenade
6:30 am-7:45 Instructional CoursesGrand & Kauai Ballrooms
8:00 am-8:05 President & Program Chair WelcomeGrand Ballroom I
8:05 am-8:20 Invited ASHT SpeakerGrand Ballroom I
8:10 am-8:20 Vargas Award PresentationGrand Ballroom I
8:30 am-9:15 Panel: Things that Therapists KnowGrand Ballroom I
9:15 am-10:00 Panel: Dupuytren’sGrand Ballroom I
10:00 am-10:30 Coffee BreakGrand Promenade & Garden
10:30 am-11:45 Panel: Tendon InjuriesGrand Ballroom I
11:45 am-12:15 Invited Guest Lecture: Jim Bo Tang, MDGrand Ballroom I
12:30 pm-5:00 Hands-On Surgeons DevelopmentWorkshop Kauai Ballroom I
12:30 pm-5:00 Hands-On Therapists DevelopmentWorkshop Kauai Ballroom II & III
5:00 pm-6:00 Mentors ReceptionGazebo Grand Lawn
6:30 pm-8:30 Welcome ReceptionGrand Promenade & Garden
THURSDAY, JANUARY 9, 2014
6:00 am-8:00 Continental Breakfast with ExhibitorsGrand Promenade & Garden
6:15 am-7:45 MOC Instructional CourseGrand Ballroom III
6:30 am-7:45 Instructional CoursesGrand & Kauai Ballrooms
8:00 am-8:10 President & Program Chair WelcomeGrand Ballroom I
8:10 am-8:15 ASSH President WelcomeGrand Ballroom I
8:15 am-10:00 Concurrent Session 1: Arthritis/TraumaGrand Ballroom I
8:15 am-10:00 Concurrent Session 2:Tendon/CongenitalGrand Ballroom III
10:00 am-10:30 Coffee Break With ExhibitorsGrande Promenade & Garden
10:30 am-11:45 Concurrent Session 3: Microvascular/Flaps Grand Ballroom I
10:30 am-11:45 Concurrent Session 4: Dupuytrens/Tumor Grand Ballroom III
11:45 am-12:15 Presidential Address: Donald H.Lalonde, MD Grand Ballroom I
12:15 pm-1:00 Invited Guest Speaker: William P. Magee,Jr., MD Grand Ballroom I
1:00 pm-2:30 Lunch Symposium: AuxiliumPharmaceuticals Grand Ballroom I
Lunch Symposium: AxoGen, Inc.Grand Ballroom III
2:30 pm-4:30pm Hands-On Skills Lab: Supported byMircoAire Kauai Ballroom II-IV
FRIDAY, JANUARY 10, 2014
6:00 am-8:00 Continental Breakfast with ExhibitorsGrand Promenade & Garden
6:30 am-7:45 AAHS/ ASPN Instructional CoursesGrand & Kauai Ballrooms
8:00 am-9:15 Concurrent Session 5: Writs/DRUJGrand Ballroom I
8:00 am- 9:15 Concurrent Session 6: NerveGrand Ballroom III
9:15 am-9:45 Coffee Break with ExhibitorsGrand Promenade & Garden
9:45 am-11:00 Panel: My Best Trick(s)Grand Ballroom I
11:00 am-11:10 Hand Surgery Endowment (HSE)President Report Grand Ballroom I
11:15 am-11:45 Danyo Lecture: Elisabet Hagert, MD, PhDGrand Ballroom I
11:45 am-12:15 Joint AAHS/ ASPN Panel: Radial NerveTransfer vs. Tendon TransferGrand Ballroom I
12:45 pm-1:30 Annual Business Meeting (AAHS Members Only)
Grand Ballroom I12:45 pm-2:00 Lunch with Exhibitors
Grand Promenade & Garden1:30 pm-5:45 Comprehensive Hand Review Course
Kauai Ballroom II-IV7:00 pm-10:00 Annual Meeting Luau
Ilima Garden
SATURDAY, JANUARY 11, 2014
6:00 am-8:00 Continental Breakfast with ExhibitorsGrand Promenade & Garden
6:30 am-7:30 AAHS/ASPN/ASRM InstructionalCourses Grand & Kauai Ballrooms
7:45 am-8:00 AAHS/ASPN/ASRM President’s WelcomeGrand Ballroom I
8:15 am-9:30 AAHS/ASPN/ASRM Panel: HandTransplant vs. ProstheticsGrand Ballroom I
9:30 am-10:00 Coffee Break with ExhibitorsGrand Promenade & Garden
10:00 am-11:00 AAHS/ASPN/ASRM Joint OutstandingPapers Grand Ballroom I
11:00 am-12:00 AAHS/ASPN/ASRM Joint PresidentialKeynote Lecture: Peter Galpin, MD,FACS Grand Ballroom I
Hand
Surgery
Quarterly
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3
FROM THE EDITOR’S DESK
Thomas Hughes, MD
Simulating the SurgicalExperience
The changes in resident educa-tion have been coming fast andfurious. While we are all probablyaware of the 80-hour workweek,and the “Core Competencies”;fewer have heard of the newMilestone program for residencyprogram evaluation and the re-quirement to use surgical simula-tion in training programs. Whilevarious oversight groups havemade these changes to improve thetraining of our future colleagues,few of these organizations havelooked closely at how costly theserequirements are, how they detractfrom more traditional teachingmodalities, and how effective theyare at training competent physicians.
To that end, the AmericanAcademy of Orthopaedic Surgery(AAOS) held their SimulationSummit II this past November inChicago. While many generationsof orthopaedic residents have been
trained using sawbones to simulatefracture care, the orthopaediccommunity lags far behind ourgeneral surgery colleagues in theuse of surgical simulation. Aspeaker who was an expert inurologic simulations presented verysophisticated models of soft tissuesurgeries including prostatectomyand inferior vena cava repairlaproscopically. Additionally, VirtualReality (VR) simulators have beendeveloped in many fields.
In orthopaedics, the VR optionsare more limited and newer. Themajority attempt to teach basicarthroscopy (Figure 1) and fluoros-copy skills. There are variety ofvery advanced simulators, how-ever, the cost is still an issue. Onesystem I looked at was $97,000 for asingle station Another, low costoption is being marketed by theSawbones Company. It is in the$3,000 range, but is far less sophisti-cated (Figure 2). One programdeveloped a compartment syn-drome model using and orange anda blood pressure cuff (Fgure 3).(FYI, I would like to disclose that Ihave no conflicts or involvement inany of these simulation companies).
Most importantly, there is littledata yet available on how effectivethese techniques are at improvingsurgical skills and ultimatelysurgical outcomes. Some prelimi-nary data from general surgery
does show that aftersimulation experiencesPGY 1 residents canperform at the level of aPGY3 resident that hasnot had the simulationtraining. The morecomplicated VR systemscan give significantfeedback about how thesurgeon has performed.It can show how muchcartilage damage wasdone by the surgeon
during the arthroscopy, can mea-sure surgical times and efficiency ofmovement. This allows compari-sons and evaluation of residentprogress.
There may also be an opportu-nity to use these VR and simulationtechniques to teach new surgicaltechniques to established surgeons.This certainly makes more sensethan reading about a new proce-dure, never being mentored in thetechniques, and then dealing withthe complications afterwards (think“endoscopic carpal tunnel syn-drome”).
So it is very likely that futureCME may involve surgical simula-tion or virtual reality. It may not beat this year’s annual meeting inKauai, but it will be there eventually.
Figure 3. A simple CompartmentSyndrome Model
Figure 2. The Sawbones FAST Arthroscopy TrainingWorkstation.
Figure 1. The VIRTAMED virtualreality arthroscopy simulator.
Hand
Surgery
Quarterly
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4
HAND THERAPISTS CORNER: The Difficult Task ofManaging Focal Dystonia in the Hand
Saba Kamal,OTR, CHTINTRODUCTIONWhat is Focal Dystonia?
Dystonia is a movementdisorder that causes the muscles tocontract and spasm involuntarily.The neurological mechanism thatmakes muscles relax when they arenot in use does not function prop-erly. Opposing muscles oftencontract simultaneously as if theyare ‘competing’ for control of abody part. The involuntary musclecontractions force the body intorepetitive and often twistingmovements as well as awkward,irregular postures.
There are multiple forms ofdystonia, and dozens of diseasesand conditions include dystonia asa major symptom. Dystonia mayaffect a single body area or begeneralized throughout multiplemuscle groups. Dystonia affectsmen, women, and children of allages and backgrounds. Estimatessuggest that no fewer than 300,000people in North America areaffected. Dystonia causes varyingdegrees of disability and pain, frommild to severe. There is presentlyno cure, but multiple treatmentoptions exist and scientists aroundthe world are actively pursuingresearch toward new therapies.Although there are multiple formsof dystonia and the symptoms ofthese forms may outwardly appearquite different, the element that allforms share is the repetitive,patterned, and often twistinginvoluntary muscle contractions.
DIAGNOSING DYSTONIAAt this time, there is no single
test to confirm the diagnosis ofdystonia. Instead, the diagnosisrests in a physician’s ability toobserve symptoms of dystonia andobtain a thorough patient history. In
order to correctly diagnose dysto-nia, doctors must be able to recog-nize the physical signs and befamiliar with the symptoms. Incertain instances, tests may beordered to rule out other conditionsor disorders. The kind of physicianwho is typically in the best positionto diagnose dystonia is a movementdisorder neurologist.
The dystonia diagnosticprocess may include:
Patient history, Family history,Laboratory studies such as bloodand urine tests, and analysis ofcerebrospinal fluid, electromyogra-phy (EMG) or electroencephal-ography (EEG), Genetic testing forspecific forms of dystonia, Othertests and screenings intended to ruleout other conditions or disorders
To accurately describe the formor type of dystonia that an indi-vidual has, at least four specificpieces of information must beaccounted for: The age at which thesymptoms started, how the body isaffected, what is known about thecause, if the dystonia occurs withsymptoms of additional neurologi-cal disorders
If an individual developssymptoms prior to approximatelyage 30, it may be referred to asearly-onset. If symptoms developafter the age of 30, it is called late-onset or adult-onset. In this article wewill be discussing late onset dysto-nia: Hand dystonia (writer’scramp)
How is the body affected byDystonia?
When dystonia affects only onepart of the body, it is called focaldystonia. Other types of dystoniainclude: Segmental dystonia,Multifocal dystonia, Generalizeddystonia, Axial dystonia,Hemidystonia, Task-specific dystonia,Paroxysmal dystonia
CAUSEThe cause of dystonia is not yet
known because scientists have notyet identified the precise biochemi-cal process in the body that triggersthe symptoms.On the other hand, dystonia canoccur as a result of trauma, certainmedications, and mutated genes.The mutated DYT1 gene or physicaltrauma can cause dystonia, but theseexplanations do not address thetrue origin of the dystonia andwhat happens inside the body toproduce the symptoms.
Cause may be characterized asprimary, secondary, or dystonia-plus.
Primary Dystonia: The dysto-nia is the only neurological disor-der that the person has. Primarydystonias include some geneticforms (such as DYT1 dystonia inwhich a gene has been identified)and forms for which a cause is notusually found (such as most focaldystonias).
Secondary dystonias: Casesthat can be attributed to drugexposure, trauma, or anotherdisease or condition. Secondarydystonias include insults to thebrain caused by certain kinds oftumors, infections, stroke, meta-bolic conditions, and toxins.
Dystonia-plus: Sometimesdystonia occurs along with symp-toms of other neurological disor-ders or has a particular quality thatresembles another disorder. Theseforms may be put in a categorycalled dystonia-plus.
THERAPEUTIC MANAGEMENT OFFOCAL DYSTONIA
Writing, playing music be-comes a challenge when dealingwith dystonia. In theory, patientswith focal dystonia could be treated
(continued on next page)
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5
by inhibiting the opposing musclesthus allowing function to occur.
This has been attempted in thepast with relaxation techniques oreven Botox, however, with limitedsuccess.
We at Hands-On-Care wereable to treat a patient of FocalDystonia (musician’s dystonia) byproviding a proprioceptive input tothe opposing muscles thus assistingit in providing inhibitory stimulusthereby controlling the movement.The cause of dystonia is not pre-cisely understood. Misfiring ofneurons in the sensorimotor cortex,a thin layer of neural tissue cover-ing the brain is thought to causeunwanted contractions. The sourceof this misfiring may be a result ofimpaired inhibitory mechanismsduring muscle contraction. Whenthe brain tells a given muscle tocontract, it simultaneously silencesmuscles that would oppose theintended movement. In dystonia, itappears that the ability of the brainto inhibit the surrounding musclesis impaired leading to loss ofselectivity.
Background:
Focal dystonia is a neurologicalcondition that affects a muscle orgroup of muscles in a specific partof the body causing involuntarymuscular contractions and abnor-mal postures such as twisting andrepetitive movements or abnormalpostures. For example, in focalhand dystonia, the fingers eithercurl into the palm or extend out-ward without control. In high levelmusicians, focal hand dystonia isreferred to as musician’s dystonia.When called upon to perform anintentional activity, the musclesfatigue very quickly and somemuscle groups do not respond(causing weakness) while othersover-respond or become rigid(causing micro-tears under load).The symptoms worsen significantlywith continued use, especially in
the case of focal dystoniaTreatment has been limited tominimizing the symptoms of thedisorder as there is no successfultreatment for its cause. Reducingthe types of movements that triggeror worsen dystonic symptomsprovides some relief, as doesreducing stress, getting plenty ofrest, moderate exercise, and relax-ation techniques. Various treat-ments focus on sedating brainfunctions or blocking nerve com-munications with the muscles viadrugs, neuro-suppression ordenervation. All current treatmentshave negative side effects and risks.
While research in the area ofeffectiveness of hand therapyintervention for dystonia remainsweak, there is reason to believe thatrehabilitation will benefit patientswith dystonia. Hand therapy can beutilized to manage changes inbalance, mobility and overallfunction that occur as a result of thedisorder. A variety of treatmentstrategies have been employed toaddress the unique needs of eachindividual. Potential treatmentinterventions included in the pasthave been splinting, therapeuticexercise, manual stretching, softtissue and joint mobilization,postural training, bracing, neuro-muscular electrical stimulation,constraint-induced movementtherapy, activity and environmentalmodification.
CASE STUDYThe case study we are present-
ing is of a musician patient with a20 year history of Focal Dystonia,diagnosed first as Lateral epi-condylitis due to pain in theforearm as a result of the inabilityof the extensor muscle to inhibitcontractions. He was eventuallydiagnosed with Focal Dystonia andtreated with a wide range oftreatments including Botox.He self referred himself to our clinicfor treatment. Treatment startedwith stretching of forearm, splint-ing and eccentric strengthening ofthe proximal shoulder/ posturalmuscles. While the shoulderstrength improved, we worked oncalming pain/ tenderness withmyofascial release/ US/ Estim. Thiswas then combined with taping ofthe volar wrist to provide theinhibitory feedback to the extensormuscles.
Taping was done by keepingthe wrist in slight flexion; tape wasapplied to volar wrist in flexionallowing movement to neutralposition only. This position allowedstretching of the extensors musclesas recommended hourly.
The patient was seen 1x weekfor 5 weeks. Taping was started inthe 3rd week, patient was providedwith cover roll and leuko tape andtrained to tape himself and allprecautions for skin care weregiven. Patient was instructed tostretch extensors every hour while
Hand Therapist Corner (continued from previous page)
(continued on page 22)
Hand
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6
From the President (continued from page 1)
Calendar of Events
We have started having ateaching roster for AAHS surgeonsand therapists in Kumasi Ghana,and we have openings for you to gothere to teach hand surgery andtherapy. If you are interested,please contact me [email protected].
Mission Statement for AAHS;Working Together to AdvanceGlobal Hand Care and Education
This is who we are and whatwe do. We have a great meeting inJanuary in a warm place where newideas and new speakers are wel-comed. Our mission works hand inglove with the mission of the HandSurgery Endowment which is “Topromote global hand health.”
New Opportunities for AAHSMembers to Speak at InternationalMeetings
Eighteen members of AAHStaught a precourse the day before
the Brazilian Hand Society meetingin Rio de Janeiro in April 2013. Asimilar event will occur with anAAHS precourse to be held Oct 15,2014 before the Argentinian Societyfor Surgery of the Hand meeting, inBuenos Aires. There is great interestand opportunity for our youngermembers to teach with the oldermembers at these internationalmeetings. Those of you who areinterested in speaking at futureprecourses please contact Dr. JulieAdams at [email protected] ;Dr.Don Lalonde [email protected];or Dr. Mark [email protected].
Want to volunteer overseas?AAHS is making it easier for
you than ever. All you need to do iscontact us and we will give you allthe information you need so youcan see your choices. We will alsoset you up with a mentor who hasbeen there and done that so you feelcomfortable if this is your first shotat it.
2014 AAHS ResearchGrant Recipient
Donald Lalonde, MD,Dalhousie University,
New Brunswick, Canada
“A Randomized, ControlledTrial Comparing Combination
Therapy of Ibuprofen + Acetami-nophen versus Hydrocodone +
Acetaminophen for theTreatment of Pain after Carpal
Tunnel Surgery”
CONGRATULATIONS
HAND SURGERY
Quarterly
President
Donald H. LaLonde, MD, FACS
Editor
Thomas Hughes, MD
Managing Editor
Lorraine M. O’Grady
Hand Surgery Quarterly is a publi-cation of the American Associationfor Hand Surgery and is publishedstrictly for the members of AAHS.This publication is designed as aforum for open discussion anddebate among the AAHS member-ship. Opinions discussed are thoseof the authors or speakers and arenot necessarily the position, pos-ture or stance of the Association.
Copyright ©2014, American Asso-ciation for Hand Surgery. All rightsreserved. No portion of this news-letter may be printed without ex-press written permission from thepublisher, 500 Cummings Center,Suite 4550, Beverly, MA 01915, 978-927-8330.
2014January 8-11, 2014
AAHS Annual Meeting
Grand Hyatt KauaiResort & Spa, KauaiHawaii
May 18-21, 2014XIX FESSH CongressParis, France
October 16-18, 2014Congress AsociacionArgentina de Cirugiade la ManoBuenos Aires, Argentina
2015January 21-24, 2015
AAHS Annual MeetingAtlantis Resort
Paradise Island, Bahamas
June 17-20, 2015
XX FESSH Congress
Milan, Italy
2016January 13-16, 2016
AAHS Annual Meeting
Westin Kierland Hotel
Scottsdale, Arizona
Hand
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7
This edition of the HandSurgery Quarterly features a roundtable discussion on finger arthritis.Most hand surgeons prefer to treatthis condition conservatively withsplint immobilization and corticos-teroid injections before consideringsurgical intervention. Reimburse-ment for corticosteroid injectionsincludes any type of local anesthe-sia and the Evaluation/Manage-ment (E/M) service as long as it isnot a significant, separate service.
For corticosteroid injections ofthe finger joints, CPT 20600 isreported. When an injection isperformed on the same day that anE/M service occurs, however,modifier -25 can be appended to theE/M code to reflect an unplannedcorticosteroid injection duringinitial visits or follow-up visits.However, an E/M visit cannot bebilled for planned injections.
According to the 2013 Com-plete Global Service Data forOrthopaedic Surgery, global days
CODING CORNER: FINGER ARTHRITIS
Eon K. Shin, MD
are not associated with corticoster-oid injections into the finger joints.However, a procedure note shouldbe included within the patient’smedical record for documentationof anatomic location, site prepara-tion, local anesthetic administra-tion, drug dosages, and patientreaction.
Coding for most finger arthritissurgeries is straightforward. Whenperforming an arthrodesis of themetacarpophalangeal joint, twocodes may be utilized: CPT 26850and CPT 26852. Both codes reflectthe work of a metacarpophalangealjoint arthrodesis, but CPT 26852 isappropriate when autograft fromanother body area is incorporated.
Arthrodesis of the proximaland distal interphalangeal jointsshares the same set of codes. Whenperforming an interphalangeal jointarthrodesis without autograft, useCPT 26860. This code includesservices such as the insertion ofsynthetic bone substitutes, arthro-tomy and capsular repair of the
interphalangeal joint, and release ofthe volar plate and collateralligaments. For each additional jointfused in the same operative setting,use CPT 26861.
When autografts are incorpo-rated into interphalangeal jointarthrodeses, CPT 26862 should beutilized. This code reflects theadditional work required to harvestbone graft from a separate anatomiclocation. Each additional joint fusedin the same setting is reported byusing CPT 26863.
Use CPT 26530 for metacar-pophalangeal joint arthroplasty.Synovectomy of the metacarpopha-langeal joint, release of the volarplate and collateral ligaments,insertion of a wire for joint fixation,and reconstruction of the extensormechanism are all included withinthis global service package. Mosthand surgeons, however, will likelyuse CPT 26531 for implant arthro-plasty of the metacarpophalangealjoint. This code reflects the addi-tional work required to insert ajoint prosthesis.
Similarly, CPT 26535 and CPT26536 should be used for proximalinterphalangeal joint arthroplasties.Since most hand surgeons insertsilicone or possibly pyrocarbonimplants for finger arthroplasties,CPT 26531 and CPT 26536 will mostfrequently be utilized for metacar-pophalangeal and proximal inter-phalangeal arthroplasties, respec-tively.
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8
AROUND THE HAND TABLE
(continued on next page)
Panel Discussion: Finger Arthritis
Marco: Thank you all for participat-ing. As moderator I thought I couldthrow out some statements andthoughts for discussion and wecould build off of those. As we’refocused primarily on finger arthritisI thought we could work our wayfrom proximal distal starting withthe MP joint. As you know, rheuma-toid arthritis is much more commonthan osteo. In terms of non-opera-tive intervention, I would like to seewhat people’s thoughts are. As Ilook at my own practice I find that Iuse Voltaren Gel more and more.John have you been using Voltarenmuch or no?
John: Yes. Particularly for.....maybea 50 year old construction workerwith an isolated middle or an indexfinger, MP joint that’s arthritic, sure.
Marco: My patients have reportedback to me that it works quite goodand.....Steve, Kristin have you had agood experience with it?
Steve: I haven’t tried it. I may havejust learned something new alreadyon this conference call. My nonoperative interventions for MCParthritis have essentially beensplinting for rest—all my patientswith any kind of mild to moderatehand arthritis get a good restingsplint, for evening or night timewear at least. I’ll also offer patientscorticosteroid injections; I’ve beenusing Dexamethasone lately. I’ll dothat occasionally if it providessubstantial relief, and if the patientis not yet ready for surgical inter-vention. I don’t really draw the lineat any particular number or intervalof injections.
Marco: Is it a 40mg dose?
As we’re focused pri-marily on finger ar-thritis I thought wecould work our wayfrom proximal distalstarting with the MPjoint.
-Marco Rizzo
Moderator: Marco Rizzo, MD, Mayo Clinic, Rochester, Minnesota
Participants: Steven Haase, MD, University of Michigan, Ann Arbor, Michigan
Jerry Huang, MD, University of Washington Medical Center, Seattle, Washington
John Lubahn, MD, Hand, Microsurgery & Reconstructive Orthoperdics, Erie Pennsylvania
Kristin Valdes, OTD, OTR, CH, Venice, Florida
John: That’s what I use.
Steve: I use 0.5 mL of 4 mg/mLdexamethasone, mixed with 1 mLof 1% plain lidocaine. I rarely injectthe entire amount. I think overall Itend to use a lower dose and asmaller amount for most things,having seen some problems withsteroids.
Marco: Yes. What kind of problemshave you seen? Skin changes?
Steve: It’s mostly been anecdotal,but when I talk to my partners andother colleagues that have usedhigher doses—things like Kenalog-40—they’ve seen more atrophy ofthe soft tissues and more of the so-called “flare reaction”, wherepatients get a worsening of the painfor a day or two after injection. Ihave almost never seen that; I thinka lower dose seems to keep meaway from that.
Marco: Kristin do you see flushingand things like that or skin changeswith some of the injections or no?
Kristin: Well, I’m the token thera-pist on the panel, so I am seeingpeople for splinting and, believe itor not, I also do recommend thatthey ask a physician for theVoltaren; because, again anecdot-ally, I am seeing people that reallyreport that they have good symp-tom relief from it. And in fact, somepeople tell me that that’s how theymake it through the day. I definitelydo a night splint, sometimes daysplinting as well to support thejoints if someone has flare and alsowork on joint protection, education,and symptom relief throughmodalities mainly.
Marco: Perfect.
Marco: Jerry, we’d welcome yourthoughts about the Voltaren. Haveyou used it much or are youpleased with it?
Jerry: Yes, I’ve used it a coupletimes. I have a few patients who areworried about the GI effects ofsystemic NSAIDs as well as longterm effects on their kidney. So Ihave used it for, in particular, onpatients with thumb CMC arthritis,who find it quite helpful. I willoften prescribe topical Voltaren, butthen defer to their PCPs for refillsor consideration of supplementingVoltaren with other oral NSAIDs.
Marco: Ok. You inject quite often?
Hand
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9
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Hand Table (continued from previous page)
Jerry: As far as injections, I mostlytell patients the injections are reallymeant to be a band-aide, if they arehere for a really bad flare up that’sabove their tolerable level of pain.Those are the times the injectionswill be helpful. I also usually tellthem once you get beyond three orfour injections, there is researchsupporting detrimental effects ofcorticosteroids on articular carti-lage. Beyond three or four injectionsyou can potentially accelerate theprocess side.
Marco: John do you have a differentapproach to rheumatoids andosteos with regard to injections andis your approach on that prettystandard?
John: Well no I probably injectrheumatoids as much or morebefore you leave topicals, occasion-ally people can’t afford full care andwhatever and we have a pharmacythat’ll compound ibuprofen oralmost anything you want as anonsteroidal and so for those thereis Aspercreme you can get over thecounter.
Just anecdotally lately I’ve hadsome patients say that Biofreezereally helps them. I don’t totallyunderstand that but it’s like DP or10’s or any sort of counter-irritant.
Helps a lot of people; but I’ll injectrheumatoids probably as much ormore than I would particularlywith an isolated joint.
Marco: Yeah our pharmacy ismixing ketoprofen now withdifferent types of Vanicream. It’samazing what they can mix to-gether now a days. Gabapentin andketamine.
John: I think they even put[phenamil].....Well if somebody’sreally got a horrible pain problem.
Marco: I think in my experienceBiofreeze doesn’t seem to work aswell as the Voltaren. I believe thegoing rate on Voltaren is $48 or $42for a tube. There is also Solarazewhich is a 3% concentration whichcan be very effective, but it’s veryexpensive.
John: Pharmacies here like topackage three of those large littletubes for about $75.
Marco: That’s a reasonable rate.
John: Which is not bad because itlasts quite a while.
Marco: I agree with you Johnregarding injections. Inrheumatoids I inject as much asnon-rheumatoids. I prefer a lowerdose steroid much like what youdescribe. I use 10mg/ml Kenalog.
Steve: That’s exactly what I used upuntil about 2 years ago when wehad a bad batch of Kenalog that Icouldn’t push through a 27-gaugeneedle. Of course, the pharmacydenied all knowledge of a problem,but then they did recall the drugabout 2 months after I stoppedusing it. I stuck with the dexam-ethasone, because I see that itactually works just as well in myhands.
Marco: Does anyone use celestone?
John: One of my partners does.
Marco: I know there was a shortagedue to the fact that they wereholding it for infants with lungproblems. But I’ve used that in thepast as well.
Jerry: Have you noticed the sameefficacy with Dex versus Kenalog?My partners will do Dexametha-sone only for trigger andDeQuervain injections, and onlyuse Kenalog for intra-articularinjections. In my experience,Kenalog appears to be moreeffective. I am wondering whatother’s experiences are with that.
Steve: Well, having switchedcompletely to dexamethasone forthe last couple years, I have found itto be just as effective as I recallKenalog-10 was, but I haven’tstudied my outcome rigorously.
Marco: Any additional commentson injections and Voltaren ortopicals at this point?
John: No but just that people comeback for more of it so it’s got to helpthem.
Marco: Yes. Absolutely.
Jerry: Are you putting patients whoare on Voltaren, on oral NSAIDs aswell or do you do the Voltaren onlyand worry about additive sideeffects?
Marco: I think you can mix and Idon’t have any restrictions. Voltarenis an adjunct to me. However, if youread the insert on the Voltaren it’squite scary about things like crossreactivity with other medicationsand side effects such as patients onCoumadin. But I haven’t seen anyproblems with compounding effect.
John: I had one patient tell me thatshe got an upset stomach with itbut in hindsight she was probablyusing more than she should have.
Marco: Moving on to the splinting.Kristin I appreciate your thoughts.What’s your preference, what doyou think, what kind of splintworks best for arthritis for the MPjoints?
Kristin: Probably a static nightsplint, made out of the plasticmaterial. Because it puts the joint atrest for the most part. But during
I stuck with the dex-amethasone, because Isee that it actuallyworks just as well inmy hands.
-Steve Haase
Hand
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10
Hand Table (continued from previous page)
the day I find that people don’t likethe harder orthotic material andthat they really prefer the neoprenedevice. Even though it doesn’tprovide as much support, I thinkagain it’s more the fact that hardmaterial gets in the way of dailyactivities.
Marco: For a single joint do youprefer hand-based or form-based?
Kristin: For a single joint I definitelyprefer hand-based. Then try to keepout as many joints that arenoninvolved, it keeps the rest of thehand free.
Marco: And for the rheumatoidsprimarily forearm based?
Kristin: Yes, for the rheumatoidspredominantly forearm based.Sometimes what I will also do is,even though I’m making it out ofthe hard plastic material, I willalign the digitals and make surethat they have almost “little gut-ters” that each lie in; and that way itkeeps the fingers from being in theulnar drift position and maintainbetter anatomical alignment.
Marco: Is there still a rule fordynamic splinting in rheumatoidsperioperatively?
Kristin: Not so much. I use staticnight splinting for pain relief anddeformity correction even perhapsif their digits have as much as a 20to 30 degree drift. And I’ve putthem in a static night splint for aperiod of at least a month if notlonger; and people have really goodrelief with that and actually havebetter alignment. Some patients aresorry that they haven’t had a trial ofsplinting earlier in their onset. But Iwill have to say that the other thingis I just don’t see as much of it as Iused to - just because of the oralmedication that’s so prevalent thesedays. I’ve been a therapist formany years and I just don’t see theamount of rheumatoid deformitiesthat I used to years ago.
Marco: You know the DMARDshave really changed a lot of the real
severe deformities that we used tosee. Even though at a center likeours we still see quite a bit ofrheumatoids, and some folks whoare just not responding to themedications, I think they’ve reallychanged the overall volume; wouldeveryone agree? John, Jerry, Steve?
John: 100%.
Steve: Very much so yes.
Jerry: I agree. I really don’t see alarge volume of rheumatoids in mypractice, since the rheumatologistdo such a great job managing thesepatients with DMARs. I still rou-tinely place patients following MParthroplasty, especially rheumatoidpatients with preoperative ulnardrift to help with coronal align-ment. I also find dynamic outriggersplints helpful in the first fewweeks to help patients with activeextension. For post-traumatic orosteoarthritis, I do mostly staticextension splinting.
Marco: In terms of splinting, againKristin do you recommend 6months of splinting? Indefiniteperiod of splinting, or do you say,“Ok try it for 6 months and de-pending on how things go. Whatare your formal recommendations?
Kristin: When I first give it to themI tell them - if it bothers them, theyshouldn’t wear it, but for the mostpart I tell them that they need towear it indefinitely. I say wear it astheir symptoms dictate. So if theyare having a bad day or a flare, thatwould be an evening they wouldneed to wear it. But if there is a daywhen they’re not having problemsand they feel like they want to gowithout it, they can do that. So it’salmost more as symptoms dictateand that is what I tell them when Igive directions for the splint.
There was actually just a study,which has never been done before,on the use of paraffin for peoplewith arthritis. And it found thatthey had greater relief of pain, aswell as range of motion. So againthat’s something that a lot of timesI’ll recommend. People can go toWalmart or to Target and buy ahome unit; so I always recommendthat. I usually do a trial in the clinicand if they like it, then I recom-mend they try it at home. Again,anything that they can do toimprove range of motion and getpain relief usually improves handfunction overall.
Marco: Once daily?
Kristin: As needed. Usually at leastonce a day but occasionally if I havesomebody who will tell me thattheir hands are really painful, theycan do it a few times during theday.
Marco: Ok. Interesting.
John: I had sore knuckles and havegone over to the therapy depart-ment and put my hand into paraffinand it feels great. I have had peoplesay that it didn’t do anything forthem. Like Kristin said, give them atrial first before they buy one.
Marco: Sure.
John: They’re only about $35. That’sabout what they cost here at Targetor Walmart or Kmart.
So it’s almost more assymptoms dictate andthat is what I tellthem when I givedirections for thesplint.
-Kristin Valdes
(continued on next page)
Hand
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11
Hand Table (continued from previous page)
Kristin: Right.
Marco: Do you think there’s adifferent between the paraffin andthe corn that folks are using?Kristin, is it the same idea in yourperspective?
Kristin: No I think the paraffin andthe theory behind it is that they cantolerate a higher degree of heatbecause it’s specific gravity. Theparaffin it’s actually set at about 132degrees; so I think that’s the benefitof the paraffin.
John: So when they mix it with themineral it only gets so hot right?They can’t burn themselves?
Marco: Yeah.
Kristin: Exactly. Even though thereare some people who still don’ttolerate it very well. If that’s thecase, I’ll put saran wrap on theirhand first and then dip it, and thatseems to work. I’ve never hadsomebody say it’s too hot after I dothat.
Marco: Well thank you. Is it safe forme to say that an arthrodesis for theMP joint of the fingers is not anideal plan A for arthritis?
Steve: I agree.
Marco: Yeah.
John: I think a construction workermakes sense.
Marco: One of the complaints I getare that patients are a little bitfrustrated with the lack of dexteritywith the abduction of the finger.
John: I’ve had one recently and theman didn’t really seem all thathappy with it although he’d had anarthroplasty and it would havebroken 3 or 4 years.
Marco: Well that’s the dilemma wecan all appreciate.
John: You wouldn’t have beenhappy either.
Marco: Now the arthroplasty forosteos, I think that the modularimplants do much better than theydo for the PIP’s from my experience.What do you think Jerry or Steve?
Jerry: We do have a skewed popu-lation at Harborview with the largemajority of MP arthritis from post-traumatic arthritis, with someosteoarthritis. In this population,we recommend arthrodesis for theIF MP joint, due to the enormousstresses on the joint for lateralpinch. Otherwise, I agree. Mostpatients would prefer surgery thatpreserves some motion. I do have adiscussion with patients aboutconcerns for progressive ulnardeviation deformity for the IF andMF MP joints though.
Marco: Yeah.
Jerry: My preference has alwaysbeen doing MP arthroplasty, eventhe ones that have developed ulnardeviation deformity over time,following their arthroplasty. Mostof those patients are quite happy,being able to maintain some degreeof MP arc of motion. In general,they are happier than patients whohave had MP arthrodesis. It’simportant to set patient expecta-tions though and have that discus-sion about potential coronal defor-mity and implant failure.
Steve: I think I’m right with you. Idon’t see a great volume of osteoar-thritis in the MP joint, but when Ido I’ve typically gone with asurface replacement arthroplasty. Ihave not ever done an MCP arthro-desis in the fingers. And I’ve seenpatients pretty universally satisfied,even in patients where the bonestock is not great. I did have onepatient with pretty remarkablesubsidence that required revision,but she is still content with themotion we were able to preserve,and with the pain relief. So I havenot had to go an arthrodesis.
Marco: John, additional thoughts?
John: I agree I guess and theyounger patient was really good[bone stuck] but in an older indi-vidual with osteopenia boy......feellike going ‘still works’.
Marco: You’re pretty happy that’s
what I was going to lead into.
John: If it breaks you can take it outand leave them with a receptionor....put a new one in.
Jerry: Agree.
Marco: Are you concerned aboutsilicone and border digits John atall or is that not an issue.
John: I’m concerned about anythingin a border digit.
Marco: Yes.
John: Again I think......I look at thebone [stock] and if there’sosteopenia I do silicone. If they’vegot healthy bone stock I’d probablygo with pyrocarbon or one of themetal on plastics.
Marco: Sure.
John: Plastic on metal I guess.
Marco: In terms of rehabbingfollowing MP arthroplasty, haveyou been fairly satisfied with themotion afterwards?
Kristin: I am definitely satisfiedwith the motion but again bearingwhat type of arthroplasty theyhave, is that one of the things thatI’ve learned as a younger therapistis the more motion they have, theless stability they have. So withworking on getting more motion atthe small finger and your ringfinger and if we would get 50degrees in motion that the MP jointof the index finger with the oldsilicone arthroplasty that was whatwe were hoping for, because withthem present too much then theywould have laxity and then thejoint would be unstable again. So Ithink the advancement of the newarthroplasties have allowed peopleto have better motion then theyused to years ago. I think that’s anadvantage of having the newerarthroplasty; I’m seeing peoplehave more motion and they arehappy with it.
Marco: What is your preference forthe surgical approach?
(continued on next page)
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Hand Table (continued from previous page)
Steve: When I’ve done pyrocarbonimplants, I’ve typically done atendon-splitting approach and I’vebeen happy with that.
Marco: John when you do a rheu-matoid what’s your approach? Doyou prefer to go ulnar to theextensor tendon or radial?
John: Almost always release theulnar intrinsics and reconstruct theradial side.
Marco: The soft tissue balancing isso critical in those cases. Jerry, yourthoughts? Does anyone in thepanel do intrinsic transfers? I don’tpersonally, I prefer just the release.
Jerry: In rheumatoid patients withsevere ulnar drift, I routinelyperform ulnar intrinsic releases andcentralize the extensor mechanism.If there is severe ulnar subluxationof the extensor mechanism, I prefergoing ulnar and releasing the ulnarsagittal bands and imbricate theradial sagittal band at the end of theprocedure. For post-traumatic MPjoints, I prefer tendon splitting. Ihave not done cross intrinsictransfers.
Marco: And I know John Stanleyreported his longer term outcomesof MP arthroplasty and one of thevariables that lead the long betterlongevity is the cross intrinsictransfer, but certainly it’s debatable.
John: You know every now and thenyou get a patient with Lupus orsomething like that where the jointsare way off - particular if the jointsurfaces are still pretty good, and themuscles still look pretty good. I’vedone them and anecdotally gotenough that I could probably pull afew and show them in a conference,but I wouldn’t do them on one ofthose stiff rheumatoids. I don’t thinkit’s going to accomplish anything.
Marco: Personally, I’m reticent to dothe modular implants on therheumatoids unless they have verygood bone stock and they’re verywell controlled disease. I’m moreinclined to do the silicones in those
patients; and we can talk moreabout that but in terms of rehab andrecovery, you place them in a post-op splint for how long and when doyou start motion, and how do youproceed?
Steve: Since I don’t see a largevolume of rheumatoid patients inmy practice, I’ll defer to the otherson this one.
John: Well long ago I did the oldtraditional dynamic splint with theoutrigger, but now I just do a staticsplint for about 3 weeks and thengradually start to move them with aremoval. I wouldn’t say I wouldnever use an outrigger. Maybesomebody who was only deviatingI might put something on todynamically hold them moreradially but for the most part astatic splint works pretty well.
Jerry: Yes. I have been placingpatients into a plaster splint in fullextension for about a week or so. Ihave still been writing referrals fora static splint as well as dynamicoutrigger. I think a lot of this is forcoronal soft tissue balance that’sreally helpful. I probably would doa short arc of motion 0 to 30 for thefirst 4 weeks. I agree with whatKristin mentioned. I really want tomake sure they’re quite stable andthere are no concerns of destabiliz-ing with too much motion. And I’mok not getting compete MP flexion.The goal is to achieve 50-60 degreesof MP flexion. The dynamicoutrigger is used in the daytime for4 weeks total. Static splinting for 4weeks except for therapy and thenanother 4 weeks of night-timesplinting and between activities.
Marco: I’m inclined to agree. Youknow I like the static splinting for3-4 weeks even, much like whatyou described John. I still do usedynamic splinting on occasion soit’s still an important considerationbut less and less utilized. I’ve goneand visited a few places now andthere’s such a wide variability onhow people do post-operative
management. I don’t know if I’mover treating some of these orunder treating. Most people don’timmobilize for more than 4 weeksthough. Some started moving veryearly; much like what you’redescribing as well Jerry. So withprotection of course. It’s hard toreally study this. Kristin, what doyou think works best for post-op?
Kristin: Again I think it dependssomewhat on the patient. I alwaysdo static splinting and if they havesome deviation then I will put adynamic component and maybe arotational component on it as well.It also depends on how much laxitythere is, but typically yes, I usuallystart with the dynamic day splintand then the static night splint. Butyou have to consider the cost factorand that requires 2 orthotic devicesand that can be expensive even forsomebody’s 20% that can be higherthan what a lot of people want to go.
Marco: Yes. That’s a good point. Interms of the risk in these patients asthe rheumatoids in particular. John,if they have a lot of radial devia-tion, but no pain at the wrist, whatwould you recommend? How doyou address?
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.. long ago I did the oldtraditional dynamicsplint with theoutrigger, but now Ijust do a static splintfor about 3 weeks ...
-John Lubahn
Hand
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13
John: Is it somebody that has MPproblems to and you’re going toaddress both?
Marco: Yes. They have a lot of radialdeviation and the traditional ulnardeviation of the hand that we see.
John: I think the real dilemma iswhen they’ve got radial deviationand a fairly painless functional wrist.
Marco: Exactly.
John: MP joints then.....that’s a realdilemma....gosh in an elderlyindividual who’s knuckle reallyhurts and their wrist doesn’t hurt atall and I know it’s going to be a,biomechanically, lousy construct I’llstill do the MP’s but in a youngerindividual, which you almost neversee anymore, I would do aradioscapholunate fusion.
John: I just put a couple of screwsacross, and I’ve had pretty goodsuccess with those. I don’t do a longpin down the middle. I don’t do aplate at the top. I just do a stablethe proximal role.
Marco: That’s such a good point.The ones who are symptom free, it’soften hard to convince them thatanything should be done. BobBeckenbaugh taught me a simple Z-lengthening of the ECRL that youcould do. In addition, you couldfrankly just release the ECRL and ofcourse there’s the well-knownClayton transfer where you take theECRL and try to bring it over to theECU. As a word of caution I’vetried to transfer at times, andsometimes the ECU tendon is prettyvolar so it’s not always so easy toreach it and feel like you’ve got asatisfying reconstruction and thosecases I’ve released the ECRL.Generally speaking it seems to beok although I’ve had some wherethe radial deviation persist. It’salways, to me, I think a little bitmore comforting when they havesymptoms at the wrist and you canmake a legitimate argument fordoing something like the partialwrist fusion like you said John.
John: The transfer makes a lot ofsense when balance is tough and Ialways worry about overcorrectingit.
Marco: That’s true and I think thatin some cases, revision cases I findthat the soft tissues for thecentralizations can be quite limitingin terms of what you have andquite dissatisfying. You tighten theligaments on the radial side and I’dbe interested in hearing what thepanel’s preferences are. Of courseyou can do it through drill holes orK-Wire holes, or you could justanchor it and then plicate on itselfyou know. Put a suture and anchorit at its insertion at the metacarpaland then grab a good bite of it andhog it down. But I think that one ofthings I sometimes will do, al-though this is almost the last resortis I’ll suture the central tendon atthe base of the index finger dorsallythrough a K-Wire hole and anchorit there so it doesn’t slide off somuch. You can plicate the tendontoo. You can tighten it so as to helpkeep the MP joint more extended aswell; but I say that with cautionbecause if you do too much you canobviously limit their MP flexion.
What I find to be the key to successwith some of these is, how diseasefree are they distally? You know, ifthey’re PIP’s and DIP’s are not sodiseased I think they clearly domuch better than if they haveconcomitant disease in those otherjoints as well.
Finally, I’m interested in everyone’sopinion but I don’t know that thearc of motion changes much inthese patients – it just shifts frommore flexed to extended. But thepatients seem to like that. They likethe ability to have their handsopened up, even though the truefunctional improvement is debat-able. They’re so frustrated with theflexed posture that they’ve had forso long, they seem to welcome theextended posture.
Steve: Well that’s certainly been our
experience in Michigan with therheumatoid population. And I’veseen that with the osteoarthritis aswell. They may not get outstandingrange of motion, but they have a lotless pain and are very satisfiedpatients.
Marco: Jerry what are yourthoughts on that?
Jerry: Well I agree with others thattheir total arc of motion is often nodifferent than preoperative totalmotion. The main benefits are thepain relief as well as more fingerextension. With regards to ADL’s Ithink it’s really made a big differ-ence for them. Cosmetically, theyalso like having their hand flat andextended. Sometimes, you can see asubstantial increase in range ofmotion post-operatively.
Marco: John what do you tellpatients about recurrence in termsof what to expect 5-10 years downthe line?
John: I tell them that depending onhow active they are, the implantswill fail and how well their diseaseis controlled - they may needrevision. I don’t know how accuratethat is with [dmarts] if they get itunder control.
Marco: Well certainly a point ofdiscussion. Any final thoughts onthe MP joint as we move distal?
Marco: Ok. Well let me put out astatement for the PIP joint to saythat the fusion is a good procedurefor the PIP joint, arthritis. Wouldeveryone agree or disagree?
John: Is it rheumatoid or in general?
Marco: In general.
John: I recently had a constructionworker who just would not let medo it and I did an implant on him. Ithink I agree with you from thesurgeon standpoint.
Steve: I would agree with that, too.However, I think it’s a hard sell formost patients to take away motionwhen they really want their finger
Hand Table (continued from previous page)
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14
Hand Table (continued from previous page)
to just be “normal” again. For theosteoarthritis patient, when I’vebeen able to talk someone into it,they’ve been happy. But it’s hard totalk them into it. When they hearabout all the arthroplasty possibili-ties, even though we try to paint thepicture as a little more uncertain,with questionable implant longev-ity, they like the idea of maintainingmotion; it’s very hard to conve-nience them otherwise.
Jerry: I think that osteoarthritispatients mostly a really goodfunctional arc of motion, so theirpresenting chief complaint isusually their pain. I think that’s thetoughest population to counsel. Ithink even if you paint a very grimpicture as Steve had mentioned, Ithink they still would prefer takethe chance. Because despite thecomplications in the literature, Ithink most patients will choose anarthroplasty knowing that there’s achance of failure and possibility ofa revision to a fusion.
Marco: I think you’re touchingexactly on an issue that I wrestlewith as well. Study after studyshows that it’s hard to prophesizehow much motion can be obtained.The PIP is such an unforgivingjoint. And so I tell the patients,“Look your pain reliefs prettypredictable but I can’t predict howmuch motion you’re going to have.You could argue some motionobviously is better than no motion,but the specter of failure down theroad and reoperation down theroad is pretty heavy with the PIPjoint.” And you’re right, it’s a toughsell to the patient. A fusion is quitescary to them. I don’t have a lot oftricks on how to optimize range ofmotion after PIP arthroplasty.We’ve tried a wide variety ofdifferent rehab protocols. John doyou have any thoughts. Obviouslythere’s a lot of variability and thepathologies that we see.
John: I think it’s got to be justcollagen and a lot of individual
biochemistry. It’s just anecdotally Ilet the father of the head nurse onthe orthopedic floor a few years agowho was in his 70’s. He’d had acouple of MI’s and he’d had a reallypainful arthritic small fingered PIPjoint. He had a total knee thatworked well and he just wanted animplant and I put a metal on plasticone in and that was really lucky I gota great result. He lived about 3 years.He had about 70 or 80 degrees offlexion and it didn’t hurt him. Heonly lived here 4 more years, but theaverage heavy laborer I’m convincedthat implant would have failedprobably at 5 years so. Was yourquestion more therapy?
Marco: Oh no I certainly haveappreciated that. You know I sawone back just this week, 6 years outand an index finger off. And thenthis is another topic of discussionwhich I’d like to open up, is theindex finger PIP. I did a PIP im-plant with pyrocarbon, and sheloves it. She’s got a stable implant,stable x-rays, excellent range ofmotion to 90 degrees.
John: The next patient’s got a 30degree fracture, plus it’s from 30-60
Marco: Exactly.
John: You’re sitting there thinking,well it used to be crooked, it used tobe off to the other side. Now it’snice and straight and it doesn’t hurtanymore. Why don’t you like it?
Marco: And I think that with apatient is critical for those because Ithink that just have to make surethey’re realistic. I’ve learned to tryto temper their expectations.Patients are not typically unhappybecause of pain. They hate itbecause we didn’t achieve theirdesired expectations with regard tomotion. What do you think Steve?
Steve: I think you’re correct. I’ll justput in a plug for silicone with thePIP as well. I’ve done that mostrecently in an elderly lady with afair bit of dementia who reallydidn’t want a fusion. She’s doinggreat; I’ve replaced 3 or 4 PIP’s, atleast a couple on each hand. Sheoften would forget to wear hersplint, and forget to observe herpostoperative restrictions, butended up doing well anyway. Herpain relief is excellent. So I thinkthat in the patient with poor bonestock, who’s got terrible pain anddoesn’t want to live with it any-more, even in a fairly unhealthypatient or a very elderly patient, Ithink it can give them several yearsof pain reduction and pretty goodfunction.
Jerry: For the index finger, I amcurrently recommending PIP jointfusion. In the other digits I havebeen pretty happy with arthro-plasty but I think it really comesdown to patient expectations. I hada patient that was in her 60s withsevere osteoarthritis in her IF PIPjoint with ulnar deviation defor-mity. After discussion of PIParthroplasty vs. fusion, she wantedto proceed with arthroplasty as shewanted to preserve motion. She did
(continued on next page)
For the index finger, Iam currently recom-mending PIP jointfusion. In the otherdigits I have beenpretty happy witharthroplasty but Ithink it really comesdown to patient expec-tations.
-Jerry Huang
Hand
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Quarterly
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Hand Table (continued from previous page)
great for 2 years with no pain andexcellent functional arc of motion.But at 2 year follow up, it was aroutine follow up with no com-plaints of pain. She did noteincreased swelling for a fewmonths. Her radiographs showedcomplete subsidence of the implanton the proximal phalanx as well asa periprosthetic fracture withpistoning of the implant. We endedup converting to a index PIP fusion.Interestingly enough she came backfor her middle finger and despitethe index MP failure ,really left itup to me as what I thought wasideal for her. She was not unhappyor upset with the fact that indexfinger had failed, but I think it wasthe initial expectation that there ispotential for failure.
Marco: That’s encouraging.Oftentimes when I discuss withpatients I say, you know I alwayswant to try to figure out what’s theanswer to the question if it fails,what are my options and revisionversus fusion? We looked up aserious of fusions after failedarthroplasty and we found thateven though we couldn’t getpredictably as good a fusion rate aswe would with primaries as youwould expect, that a good percent-age patients who did not healremained quite satisfied. Even asthey developed a pseudarthrosis,we serendipitously backed into aresult where there was a jog ofmotion and pretty good pain relief.I don’t know if everyone’s experi-ence has been similar with that.
John: Sometimes they just resetthem and leave them.
Marco: Jerry? What’s your prefer-ence? Kwires?
Jerry: I frequently use 90-90wiring....part of the reason I likedoing that because I feel like forrotational alignment, it is mucheasier for me; I can do fine adjust-ments even after placement of thehardware. For a patient with poorbone quality where I’m worried
about the wire actually cuttingthrough or for revisions, I’ve beendoing tension band wiring.
Marco: John do you have a pre-ferred method for fusion?
John: My fellowship wrote aboutinterosseous wires where you do aloop around in a kwire to hold itand......I think I’ve involved PeterSterns and do tension band. It’sprobably my preferred technique.Occasionally I’ll put a screw across.Has everyone taken the self assess-ment exam? How did they answerthe question on how much flexiondefused the PIP joint in the index?
Marco: Yes. 40 to 60, was 40 one ofthe answers?
John: Yeah it was.
Marco: Yeah I used 40.
Marco: I noticed Peter’s article. Hefuses them pretty straight.
John: I would have said 0 to 20.
Marco: That’s a good point.
John: Cut it down to 40, I’ve gotpeople....I think they individualizeit. What do they do for a living?
Marco: That’s a good point. Stevewhat do you think?
Steve: I’ll have to recuse myselfsince I wrote that question. I wasgoing for the textbook answer, but Iagree. I think you have to individu-alize it for the patient; and I thinkthe correct answer was 40. But itmay get thrown out if all the smartpeople didn’t agree that was a goodanswer.
John: I forget it. If you take it thisyear it tells you right away how youdid.
Marco: That’s a good point.
Jerry: I’m thinking individual.Patients want to go back and playgolf or racquet sports, a little bitmore flexion is preferred. But I hada patient with post traumatic smallfinger PIP joint, fixed at 80 degreesand she wanted an almost com-pletely straight even though it’s hersmall finger.
John: Somebody plays the piano orsomething.
Jerry: Yes. She’s a classic pianistand that’s what she wanted to beable to do is to play the pianoagain.
Marco: I’ve seen a handful of thesepatients who come back with afixed swan neck deformity follow-ing arthroplasty. And when I firstsaw one, maybe 8 years ago, I waslooking at the possibility of fusingthese in a better more functionalposition because these patients arequite frustrated. But the caveat isthat most of them are pain free, andan implant, especially one that’sbeen previously cemented ischallenging to remove. A reason-able alternative to fusion that BobBeckenbaugh taught me is asuperficialis hemi-endesis on thesepatients and maybe V-Y lengthen-ing of the extensor. And thiseffectively functions like a softtissue fusion where you can putthem in a more functional position.We’ve looked at a series of theseand we’ve been pleased. Thepatients are pretty happy and it’s amuch simpler solution for anotherwise potentially complicatedsurgical problem. I don’t know ifanyone has any experience withthings like that.
Steve: I’ve had no experience withthat. I guess now I know where tosend them, if I see that.
Jerry: Yeah I’ll be sending themover to Rochester as well!
Marco: I just threw it out as a lessonthat I’ve learned and something I’vebeen encouraged about. Finally, Ithink we could touch briefly on theDIP joint. You know one of thethings that, obviously I think in myopinion motivates patients forsurgery is the deformities. They’renot in as much pain as they arefrustrated with the deformity. Howdo you talk a patient through thatSteve in terms of their proposedtreatment options?
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16
Hand Table (continued from previous page)
Steve: I would agree it’s not usuallya big focus of pain; althoughcertainly pain enters into it. Usuallywhen I approach these patients Iadvise them that pain is really themain indication for wanting tointervene unless the deformity issevere, because it’s difficult todeliver a perfect result. My ap-proach has varied a little bit overthe years. My partner’s a minimalistand from him I’ve learned that youcould just use a couple of K-wires.More recently I’ve gone to a head-less screw, despite the fact that itdoesn’t usually allow me to getmuch flexion at the joint. Most ofmy patients really want it to bealmost completely straight so thatdoesn’t seem to be a problem.They’re tired of having crookedfingertips; they’d rather have itstraight. So I think that sometimes aheadless screw can deliver that. Inmy experience I’ve used more ofthose in the last couple years than Ihave before.
Marco: Do you have preference onthem? Do you like the Acutrak minifusion screw?
Steve: I’ve been using the Acutrakfusion despite some of my frustra-tions with it not truly being acannulated set, and being a littleconcerned when I take the K-wireout and try to get the screw in thesame spot. It’s always that momentof panic where the finger is kind offlopping around, and you feel likeyou’ve lost your alignment. But Ifind that once it starts to compress alittle bit you can make minoradjustments and then compress it alittle more, and it really does dowell in my limited experience.
Marco: You know Kevin Runfreepresented at the academy a coupleyears back a technique that in-volved just percutaneously placingthe screw (retrograde) across thejoints. And not doing any carpentryat the DIP joint; I haven’t had thecourage to do that. I tend to stilldenude the cartilage Has anybody
had any experience with just thepercutaneous, the compressionscrew?
John: I had a couple where it kindof gabbed and I might as well havejust done that and it worked out ok.
Marco: It seems like the non-unionsdon’t invite so much trouble as youwould expect.
John: If you’ve got a good solidscrew they don’t but if you had acouple of kwires.
Marco: Jerry what’s your preferenceabout managing surgically in termsof technique.
Jerry: For technique, I think it reallyis patient preference. For the mostpart I do feel fusion in full DIPextension with a single screw givesstable fixation. In our hospital, wedo have approved SBI 2.0 and 2.5mm headless cannulated compres-sion screws. More and moreimplant device companies aremaking smaller and smaller com-pression screws. I believe Syntheshas a 2.4 mm screw as well. That’smy preference. If a patient wants 20degrees of flexion or very smallbones, then I’ll use K-wires. I keepit pretty simple.
John: You can get 20 degrees with acannulated screw
Marco: That’s a good point John. Doyou have any problems with thenail? I haven’t knock on wood but Iworry about some of the screwsirritating the nail.
John: You have to use the small one.
Marco: Yes.
Jerry: I have also seen patientswhere the 2.0 mm screw is biggerthan their medullar canal, so forsome of those I use Kwires to besafe.
Steve: Yes. Before the smallerscrews were out, several years ago,I tried it with just a mini-Acutrak,and I got scared away from thescrews for a while until smallerones were available.
Marco: Yes. But for the thumb Ithink sometimes Kwires workbetter. It allows more variability inposition and have a long talk aheadof time with them. We hash outwhat’s better. And the nice thingabout Kwires is that they’re moreforgiving. If you’re not happy withthe position you can redo it andtweak it. Screws are less forgivingand it’s hard to make some changes.Although I’ve had success withboth, and it’s a pretty darn predict-able outcome for IP fusions. I thinkmost patients are quite happy
One last thing about hemi-arthroplasty’s for the PIP. I don’tknow if anyone has.....I’ve done afew now. I went to the IFSSHmeeting in 2010 and saw there wasa presentation from a fellow inSwitzerland who presented hemi-arthroplasty’s with pyrocarbon as ameans to obviate some of thefrustrations with the distal compo-nent and also preserved bone stock,and hopefully minimize some of thecatastrophic loosening that we see.
John: I’ve done a couple in MPjoints.
Marco: Have you been pleased withthat?
John: Yes I have. Worked out ok.Haven’t done any MP PIP joints.
Marco: I’ve done a handful. I’vebeen pleased so far. One patient Idid a year and a half ago on her leftside asked me to do her index andlong on the right. And she’s recov-ering now, just recently two monthsout. But she’s got a little bit morepain on the right now. Maybebecause I did both fingersbut....anecdotally I am hopeful thatshe’ll be fine. She loves her left side.Now again the same business withno real improvement with inmotion, and it’s more of a painrelieving endeavor. Makes thesurgery much more simple and itdoes preserve bone stock for futuresurgeries if need be.
Steve: It was a good discussion.Thank you Marco.
Hand
Surgery
Quarterly
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17
2014 AAOS Clinician Scholar Program
From the 2012 AAHSSponsored AAOS Scholar
Participation in AAHSsponsored events greatly helpedshape my career so far. I vividlyremember when I first met Dr.Steve McCabe during one of themeetings and how approachable hewas, and motivated me to be aclinician scientist. Participatingin the Clinician Scholar Develop-ment Program as an AAHSsponsored candidate was yetanother one of the wonderfuleducational opportunities Icherish. It was great to learn fromestablished clinician-scientistswho had many tips and pearls ofbeing productive as scientists, butalso successful as clinicians.Meeting residents and fellowswho shared similar interests andsharing our struggles and successcertainly made me feel that I wason the right track. The connec-tions I made by participating inthe program has been invaluablepart of my research and clinicalcareer so far, and I wish thatresidents and fellows consider thisprogram to enrich their experienceas clinician-scientists.
- Min Park
The AAHS will again sponsor a participant for the 2014 AAOS Clini-cian Scholar Program.
The AAOS/OREF/ORS Clinician Scholar Development Program(CSDP) is an annual program seeking applicants in their PGY2-PGY 5residency years, in fellowships, and Junior Faculty through year three whohave the potential/desire to become orthopaedic clinician scientists. Up to15 participants are selected to participate in the 1.5 day CSDP trainingworkshop. CSDP topics include the following:
Overview of the Clinician Scientist (Scholar) Timeline
Peer Review Process
Grant Writing 101
Navigating the National Institutes of Health
Resources of the NIH Intramural Research Program
Collaborating with Scientists
Career Training for Basic Scientists and Clinical Scientists
Establishing a Mentor
New Initiatives and Alternate Approaches
The Orthopaedic Research Society (ORS) in the Development ofthe Clinician Scientist
The Orthopaedic Research and Education Foundation (OREF) inthe Development of the Clinician Scientist
OREF from an MD Perspective
Role of the Department of Defense (DoD)/Defense AdvancedResearch Projects Agency (DARPA)
The Surgeon Scientist: A Chairman’s Perspective
A Personal Perspective: Balancing it All
Notice of applications will be sent to AAHS members as soon as theyare available.
Visit the AAHS Website: http://handsurgery.org
Hand
Surgery
Quarterly
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18
NEWTo include your job posting on the AAHS websiteand in the next issue of Hand Surgery Quarterly,please visit http://handsurgery.org/job-board.cgi.
AAHS Job Board
Orthopaedic Hand Surgeon inWestchester County, New YorkDate Available: ImmediateDescription: Specialty Orthopaedics isa five surgeon and two PA orthopedicgroup with specialists in joint replace-ment, sports medicine, foot andankle, and spine surgery. We are auniversity affiliated private practice25 minutes north of New York city.Our offices are state of the art andhave full EMR and imaging capabili-ties. We are recruiting a hand surgeonto join our practice and serve asDirector of Hand Surgery at aregional university affiliated hospital.Contact:Mary GroganSpecialty Orthopaedics, PLLC600 Mamaroneck Avenue, Suite 101Harrison, New York 10528office (914) 686-0111fax (914)[email protected]
Orthopedic Hand Surgeon Opportu-nity in Indianapolis, IndianaDate Available: OpenLocation: Franciscan PhysicianNetworkDescription: Franciscan Physician Net-work (FPN) - Central Indiana is seek-ing a Board Certified/Board EligibleOrthopedic Hand Surgeon to join itsgrowing orthopedic group.The ideal candidate will be fellowshiptrained in hand surgery. This positionis a blend of General Orthopedic and
Orthopedic Hand Surgery.Franciscan Physician Network, CentralIndiana Region, is based in Indianapo-lis and is a partnership of over 225 phy-sicians and advanced-practice provid-ers work Franciscan St. Francis Health.A career with the Franciscan PhysicianNetwork offers work-life balance andthe following:Competitive compensation plan in-cluding income guarantee, with bonusincentives; Generous start-up bonus;Relocation allowance; CME stipendplus 5 paid days; Full benefits package,including health, life, dental and vision;Retirement options.Franciscan Physician Network hasmore than 750 physicians at 260 prac-tice locations, who care for more thanthree million patients annually. Thisorganization brings together, under onename, the many physician groups as-sociated with Franciscan Alliance’s hos-pitals and various access points allacross the system.Franciscan Alliance is one of the larg-est Catholic Health care systems in theMidwest and has a number of nation-ally recognized Centers of Health CareExcellence.As the nation’s 13th largest city, India-napolis offers everything you couldwant in a large, metropolitan city, to-gether with the friendly environmentexpected from a small community. Lo-cals, as well as visitors from around theworld, flock to Indianapolis to see:The host of the 2012 Super Bowl; Theworld-famous Indianapolis 500 and the
Allstate 400 at the Brickyard NASCARrace; The Children’s Museum of India-napolis - the largest children’s museumin the world; Indianapolis Zoo andWhite River Gardens - the only accred-ited combined zoo, aquarium and bo-tanical gardens; Indianapolis Museumof Art - one of the largest general artmuseums in the nation; IndianapolisSymphony Orchestra at the HilbertCircle Theatre; Countless national andlocal theaters and dance troupes, suchas Indiana Repertory Theatre, Ameri-can Cabaret Theatre, American Caba-ret Theatre, Indianapolis Civic Theatre,Dance Kaleidoscope and moreContact: Jamaul RileyPhysician Recruitment SpecialistFranciscan Physician [email protected] Sierra Drive,Suite 1200Greenwood,Indiana317-528-8776
Orthopaedic Hand SurgeonDate Available: ImmediateLocation: The University of TexasHealth Science Center, San AntonioDescription: The nationally recognizedDepartment of Orthopaedic Surgery isseeking an individual for a full-timefaculty position at the Assistant or As-sociate Professor level. Academic rankwill be commensurate with past expe-rience. Responsibilities will include in-volvement in clinical service, teachingand research activities. Employmentwithin the Department of Orthopaedicsat UTHSCSA offers a competitive sal-ary and an attractive benefits package.The applicant must be board certified/board eligible with fellowship training.A Texas License will be required. TheUniversity of Texas Health Science Cen-ter at San Antonio is an equal employ-ment opportunity/affirmative actionemployer. All faculty appointments aredesignated as security sensitive posi-tions.Contact: Robert H. Quinn, MDChair and Residency Program DirectorDepartment of Orthopaedics – MC 77747703 Floyd Curl DriveSan Antonio, Texas [email protected] ONLINE
The Hand Surgery Endowment has adopted a primary mission to promoteglobal hand health. The Endowment’s initiatives to support this missioninclude providing research grants, supporting international volunteerismactivities in collaboration with Guatemala Healing Hands Foundation andHealth Volunteers Overseas, and granting the AAHS Vargas InternationalHand Therapy Teaching Award. The HSE Board of Governors hopes toexpand on its offering in the years ahead.
Please consider making a contribution to HSE and its primary mission topromote global hand health at http://handsurgery.org/endowment. Contribu-tions are tax deductible and donors are acknowledged annually for theirgenerosity at the AAHS Annual Meeting.
HAND SURGERY ENDOWMENT
Hand
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Quarterly
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19
HAND is the official journal of the American Association for Hand Surgery.HAND is an international peer reviewed journal which combinesmultidisciplinary expertise from surgical, medical, hand therapy and otherspecialties to advance the quality of care and health of patients with handand upper extremity pathologies.
Download the HAND journal mobile app! The app is available to AAHSmembers for download on Apple devices in the App Store by searching for“HAND Journal” or “AAHS Journal”, or by scanning the QR code below,and provides instant access to allcurrent and past issues of the journal.
Once the app has downloaded to yourdevice, you will need to login withyour personal AAHS username andpassword once for authentication(contact the AAHS administrativeoffice to obtain your personalusername and password).
Members can use the app functions tobrowse volumes and full text articles,search for work by specific authors,and more.
Download HAND on Your Mobile Device
“A surgeon may not always beright, but a surgeon is alwayscertain,” or so one of my mentorswas fond of saying. By that mea-sure, my decision to head to Ghanaas part of the Health VolunteersOverseas Program was incrediblyunsurgeon-like. I knew that thedecision felt “right”; here was aprogram at a teaching hospital withfledgling residencies in orthopedicsand plastic surgery. My partners atthe University of Wisconsin are,without exception, regular partici-pants in international collaborativesurgical programs. My parentorganization, the American Asso-ciation for handy Surgery (AAHS)declared last winter that one of ourfocuses would be on Global handHealth. Despite this, doubt morethan certainty crept into my mon-
key mind whenever Icontemplated makingthis trip. I wonderedwhether I could bringany useful knowledge(would my experienceand skillset be tooesoteric and technol-ogy-driven); I doubtedI could teach anythingbeyond what theirprofessors alreadyknew (they are fully trained inEuropean models); lastly, despitehaving travelled a bit internation-ally, I feared the unknown of a newcountry. Blame too many adven-ture stories as a youth.
Nevermind that Kumasi is acity of roughly 2 million, that theteaching hospital (Komfo AnokyeTeaching Hospital, or KATH)
houses 1000 beds, and that a recentreport on internet connectivitysuggested that Africa (and it seemsGhana) will “leapfrong” ahead inconnectivity since it relies heavilyon unwired, mobile broadband.Experience would soon provewhich pre-conceived beliefs heldtrue and which I would need tochange.
The following is an excerpt from the September 2013 issue of KATH HVO Hand Surgery from Dr. Salyapongse on histrip to Ghana. To read the full report please visit the AAHS website: http://handsurgery.org/multimedia/files/2013/KATH-Report-2013.pdf
A Report from GhanaNeil Salyapongse, MD
Hand
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Quarterly
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JONATHAN ISAACS, MDJonathan Isaacs, appointed
this year as Junior Member atLarge on the AAHS Board ofDirectors, has been an activemember in the Hand Associa-tion since completing his handand microsurgery fellowship atDuke University. After beingintroduced to the AAHS by Dr.
Wyndell Merritt, Jonathan recalls being immediatelydrawn to the diversity and creativity that distinguishedthe AAHS from other organizations. His involvementsoon evolved to serving on the editorial board forHAND and participating on the membership andannual meeting program committees. Most recently hewas asked to serve as Vice-President on the Board ofGovernors for the Hand Surgery Endowment.
Jonathan’s interest in education and researchextend beyond the Hand Association. He has been onfaculty of the Department of Orthopaedics within theVirginia Commonwealth University Medical Center inRichmond, Virginia since 2002 and now serves as Chiefof the Division of Hand Surgery. He runs the Ortho-paedic Microsurgery Lab and has published multiplescientific and clinical papers primarily on nerveregeneration. These efforts were honored with theHerman M. and Vera H. Nachman DistinguishedResearch Professorship which he holds. Though nerveis his primary interest, he has published multiplemanuscripts and chapters on other hand and wristtopics most notably as Co-Editor of the text Arthritisand Arthroplasty: The Hand, Wrist, and Elbow. He isinvolved in several other medical societies includingthe ASPN, ASSH, and the Virginia Orthopaedic Societywhere he just completed a term as president.
Though active in medical organizations, teaching,and research, Jonathan maintains a full time clinicalpractice within the VCU Health System. He enjoys all
hand and wrist surgerybut has specificallyfocused on microsurgicalreconstruction andperipheral nerve surgeryincluding brachial plexus.He recently establishedthe Upper Extremity andPeripheral Nerve Centerat VCU. His efforts havebeen recognized by hispeers within the Univer-sity and Richmondcommunity with several
LEADERSHIP PROFILESROBERT J. SPINNER, MD
Dr. Robert Spinner is thecurrent secretary of the Ameri-can Association for HandSurgery. He has been a memberof the AAHS since 2008. Hisfather, Morton, was a handsurgeon. Rob was born andraised in North Woodmere,New York. He was graduated
from Woodmere Academy in Long Island. He receivedan undergraduate degree in Humanities & Sciencefrom MIT, a Master’s degree in Greek and LatinLiterature from Christ Church College, University ofOxford, and his medical degree at the Mayo Clinic.
Rob completed two residencies: first in orthopedicsat Duke and then in neurosurgery at Mayo. As part ofhis training, he completed a 1 year peripheral nervefellowship with David Kline in New Orleans. Hereceived the Congress of Neurological Surgeons (CNS)Cushing Fellowship to visit several sites of excellencein peripheral nerve surgery. He stayed at Mayo wherehis practice is limited toperipheral nerve surgery.He is board certified inboth Neurologic Surgeryand Orthopedics. AtMayo, he is the Burton M.Onofrio Professor ofNeurologic Surgery and aProfessor of Orthopedicsand Anatomy. He servesas Chair of Research inthe Department ofNeurologic Surgery. Heis Chair of Mayo’sAcademic Appointmentand Promotions Commit-tee as well as the VisitingMedical Student Clerk-ship Program. He hasenjoyed the many opportunities to mentor students,residents, fellows and young faculty.
Rob has a close working relationship with AllenBishop and Alex Shin as part of a busy,multidisciplinary Brachial Plexus Clinic. Rob’s mainacademic interests are related to peripheral nervetumors and tumor-like conditions. Major interestsinclude the mechanisms of tumor formation andpropagation whether related to benign conditions suchas intraneural ganglia; or perineural spread of malig-nant lesions. He has active intramural and extramuralfunding related to basic science research in nerve
(continued on next page)(continued on next page)
Major interestsinclude the mecha-nisms of tumorformation andpropagationwhether related tobenign conditionssuch as intraneu-ral ganglia; orperineural spreadof malignantlesions.
He enjoys allhand and wristsurgery but hasspecifically fo-cused on micro-surgical recon-struction andperipheral nervesurgery includingbrachial plexus.
Hand
Surgery
Quarterly
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21
2013-2014 Board of Directors
PRESIDENT
Donald H. Lalonde, M.D.
Dalhousie University
Saint John, New Brunswick
PRESIDENT-ELECT
Mark E. Baratz, M.D.
University of Pittsburgh
Pittsburgh, Pennsylvania
VICE PRESIDENT
Michael W. Neumeister, M.D.
SIU - Plastic Surgery
Springfield, Illinois
SECRETARY
Robert Spinner, M.D.
Mayo Clinic
Rochester, Minnesota
TREASURER
Peter Murray, M.D.
Mayo Clinic
Jacksonville, Florida
TREASURER-ELECT
John D. Lubahn, M.D.
Hand Microsurgery &
Reconstructive Orthopedics
Erie, Pennsylvania
PAST PRESIDENTJesse B. Jupiter, M.D.
Massachusetts General Hospital
Boston, Massachusetts
PENULTIMATE PAST PRESIDENTSteven McCabe, M.D.Toronto Western HospitalToronto, Ontario
HISTORIANA. Lee Osterman, M.D.Philadelphia Hand CenterKing of Prussia, Pennsylvania
PARLIAMENTARIANWilliam W. Dwierzynski, M.D.MCW Clinic at Froedtert HospitalMilwaukee, Wisconsin
SENIOR DIRECTOR AT LARGELoree K. Kalliainen, M.D.Regions HospitalSt. Paul, Minnesota
SENIOR DIRECTOR AT LARGEWilliam C. Pederson, M.D.The Hand Center of San AntonioSan Antonio, Texas
JUNIOR DIRECTOR AT LARGE
Jeffrey Greenberg, M.D.
Indiana Hand to Shoulder Center
Indianapolis, Indiana
JUNIOR DIRECTOR AT LARGE
Jonathan Isaacs, M.D.
Virginia Commonwealth University
Richmond, Virginia
SENIOR AFFILIATE
DIRECTOR AT LARGE
Joy MacDermid, BScPT, PhD
London, Ontario
PAST SENIOR
AFFILIATE DIRECTOR
Sharon Andruskiwec, PT, CHT
Milford, Connecticut
JUNIOR AFFILIATE
DIRECTOR AT LARGE
Kristin A. Valdes, OTD, OTR, CH
Venice, Florida
awards including the VCU Physi-cian Champion award and multiplelistings as one of the “Top Docs” inHand Surgery by RichmondMagazine.
Jonathan’s wife, Christine, is theChief of the Division of Generalistwithin the Obstetrics and Gynecol-ogy Department at VCU. Theyhave two beautiful daughters,Sophia (8) and Olivia (6) that keepthem plenty busy when not atwork. When not “enjoying being aDaddy”, Jonathan enjoys bikingalong the James River which runsthru Richmond.
regeneration. His classical back-ground has facilitated research inthe history of medicine.
He is a clinical councilor for theAmerican Association of ClinicalAnatomists and the liaison for theAmerican Association of Neuro-logical Surgeons (AANS) to theAmerican College of Surgeons. Hewas President of the AmericanSociety of Peripheral Nerve in 2012-2013 and the Sunderland Society in2008; Chair of the Peripheral NerveTask Force of the joint sections ofAANS/CNS from 2009-2011; and a
member of the Mayo Clinic AlumniAssociation Board of Directors from2003-2009.
Rob enjoys reading, travelingand quiet time with his family. Hiswife Alex, a French Canadian, is ahematologist and Associate Dean ofStudent Affairs at Mayo. Their twoboys Max (9) and Noah (7) are bigbaseball enthusiasts.
ISAACS SPINNER
LEADERSHIP PROFILES (continued from previous page)
working on shoulder/posturalstrengthening 2 time / day andtaping 23/7 to the wrist.
Results: By the 4th visit patientwas able to report progress withdecreased pain in the forearm.By 5th visit patient was able towrite legibly and sign himself in,and play the guitar some withoutcontractions which he had not beenable to do in 20+ years.
CONCLUSION
In this case study, Leuko tapingproved to be an effective treatmentmodality for focal dystonia.Leukotape provided proprioceptivefeedback (the sense of the orienta-tion of one’s limbs in space) toallow function.
The position-movement sensationwas originally described in 1557 byJulius Caesar Scaliger as a “sense oflocomotion”. Much later, in 1826,Charles Bell expounded the idea ofa “muscle sense” and this is cred-ited with being one of the firstdescribed physiologic feedbackmechanisms. Bell’s idea was thatcommands are carried from thebrain to the muscles, and thatreports on the muscle’s conditionwould be sent in the reversedirection.With Leuko taping input is used toinhibit function while maintainingflexibility and the ability to performfunctional activities. We concludedwith this case study that someforms of focal dystonia may be
treated by providing such inhibi-tory proprioceptive sensation viaLeuko taping due to its rigid yetflexible properties. Further studiesare indicated at this time as to thelong term efficacy of this treatmentmethod.
REFERENCES
Current and Future Medical Treatment inPrimary Dystonia, Cathérine C.S. Delnooz,Bart P.C. van de Warrenburg DMRF
Botulinum Toxin Benefits Many PSPPatients With Dystonia, Daniel M. Keller,PhD
The Functional Neuroimaging Correlates ofPsychogenic versus Organic Dystonia,Anette E. Schrag, Arpan R. Mehta, Kailash P.Bhatia, Richard J. Brown, Richard S. J.Frackowiak, Michael R. Trimble, Nicholas S.
Ward, James B. Rowe
Hand Therapist Corner (continued from page 5)
