AAHS News Summer Draft.pmd

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500 Cummings CenterSuite 4550Beverly, MA 01915(978) 927-8330www.handsurgery.org

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MESSAGE FROM THE PRESIDENT

A publication of theAmerican Association for Hand Surgery

Summer2011

Steve McCabe, MD

INSIDETHIS ISSUE

From the Editor’s

Desk....................

Hand Therapist’s Profile:

Donna Breger Stanton...

Coding Corner .........

HAND Highlights .......

Panel Discussion:Pediatric Hand Surgery..

Hand Surgery ReviewCourse CD ...............

Recruit a Member.....

Hand Surgery Endowment ......

AAHS Calendar.........

2012 Keynote

Speaker.................

Board of Directors.....

AAHS Website............

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Hello.We have some exciting

things to report. With regardto the upcoming meeting weanticipate good participationfrom the Brazilian Surgeonsand are lining up an interest-ing group of guest speakers.Randy Bindra is sortingthrough the InstructionalCourses and the abstracts toput together a great pro-gram. Every member who

VARGAS INTERNATIONAL HAND THERAPY TEACHING AWARD

sent an abstract will be ableto present their work. Whenhe contacts you pleaseanswer in the affirmativeand plan to go to Red Rockfor the meeting. Handsurgeons want to hear whatyou are thinking and doing.

We have asked RonPalmer, the President of theEndowment Fund, to speakto the members. The endow-

(continued on page 18)


mentis notanab-stractcon-ceptbut isourgenerously donated moneybeing used to extend thereach of our organization.

Paula Galaviz MS,OTR, CHT

Armenia is a very smallmountainous country ofapproximately 3 millionpeople, nestled betweenTurkey, Iran, Azerbaijan, andGeorgia. Armenia, with aculture enriched by manylegends and folklore, is oneof the world’s oldest civiliza-tions. It was the first coun-try in the world to officiallyembrace Christianity as itsreligion (c. 300 A.D.)

The territory of Armeniahas changed often during itsdifficult history, as theArmenians have sufferedthrough invasions by manydifferent empires, and mostrecently was part of theSoviet Union. With thedissolution of the Soviet

Union, the Armenianeconomy deteriorated,as the Soviet factoriesclosed, and utilitieswere only minimallyfunctional. Althoughtheir economy hasmade some im-provements inrecent years,Armenia still relies

http://handsurgery.org/

HandSurgeryQuarterly

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Summer2011

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2

FROM THE EDITOR’S DESK

HAND SURGERY Quarterly

PresidentSteve McCabe, MD, FACSEditorThomas Hughes, MDManaging EditorLorraine M. O’Grady

Hand Surgery Quarterly is a publication ofthe American Association for Hand Surgeryand is published strictly for the membersof AAHS. This publication is designed as aforum for open discussion and debateamong the AAHS membership. Opinionsdiscussed are those of the authors or speak-ers and are not necessarily the position,posture or stance of the Association.Copyright ©2011, American Association forHand Surgery. All rights reserved. No por-tion of this newsletter may be printed with-out express written permission from thepublisher, 500 Cummings Center, Suite 4550,

Beverly, MA 01915, 978-927-8330.

Thomas Hughes,MD

This past June the AmericanAcademy of Orthopaedic Surgeryheld a summit in Rosemont, Illinoisto discuss the developing role of the“PIM” and “PI CME”. If you’re likeme, this series of letters held verylittle meaning. To those plasticsurgeons in our association, thoseletters may have a higher level ofrecognition, as the plastics boardhas begun using PIM’s already.PIM stands for PerformanceImprovement Module and PI CMErefers to Performance ImprovementContinuing Medical Education.

There are fourcomponents to theorthopaedicMaintenance ofCertification (MOC)process. Part I is“Evidence ofprofessionalStanding”. Part IIis “evidence of life-long learning andself-assessment”.Part III is “evidenceof cognitive exper-tise”. Finally PartIV is “evaluation ofperformance inpractice”. These are based on theguidelines from the AmericanBoard of Medical Specialties(ABMS), and are therefore identicalto the four parts of MOC for PlasticSurgery.

The ABMS addresses thesecomponents as follows (taken fromthe ABMS web-site):

· Evidence of ProfessionalStanding will require that thediplomat maintain a full andunrestricted license to practicemedicine in the United States orCanada.· Evidence of Life-Long Learningand Self-Assessment will be

addressed through on-going three-year cycles of 120 credits of Cat-egory 1 Orthopaedic or relevantContinuing Medical Education(CME) that include a minimum of20 CME credits of Self-AssessmentExaminations (SAE).· Evidence of Cognitive Expertisewill occur through a secure exami-nation, as is currently in place forrecertification.· Evaluation of Performance inPractice will include a stringentpeer review process and a fewperformance indicators: sign your

site, preoperativeantibiotics, in-formed consent andpostoperative anti-coagulation.

The purpose ofMOC Part IV is toimprove patientcare by measuringperformance andchanging thesystem based on theresults of thosemeasurements. It isthis component ofthe MOC processthat PIM’s and PI

CME is designed to address. Todate, no specific role for PIM’s andPI CME has been developed fororthopaedic surgery.

That being said, one of theearliest PIM’s developed was forCarpal Tunnel Syndrome (CTS).Through a web-based program,surgeons collected data on 10patients that had undergone carpaltunnel surgery. The results arecollected and compared to thedatabase of all the surgeons com-pleting the PIM. Then the surgeonsare given feedback on how theirresults differ from the groupcompleting the PIM. The eventualgoal is for surgeons to change their

practice basedon these resultsand thenreassess howtheir outcomeshave beenaffected by theperformanceimprovementactivity.

ABOS and ABPS have joinedforces to make the PIM in Carpaltunnel, and the PAPS in carpaltunnel, the same through the effortsof Dr. John Seiler and Dr. DonLalonde.

The MOC process is welldeveloped in Plastic Surgery. It is a10 year cycle. Every 3 years, diplo-mates provide evidence of profes-sional standing Part I (license, peerreview, etc). Also every 3 years, theyprovide evidence of life long learn-ing with CME records for Part II.

For practice evaluation ofperformance in practice, Part IV,they undergo an MOC practiceassessment module in PlasticSurgery (PAPS) every 3 years aswell. To do this, they select one of

Practice Improvement


The AAHS sees

itself in a leader-

ship role in this

process in regard

to hand surgery

Performance Im-

provement Mod-

ules (PIMs).


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Summer2011

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3

President’s Message (continued from page one)

The endowment has graduallychanged its focus over the years butthe important issue is that we needto be sure the money is used in amanner that reflects and amplifiesour will. Please talk to Ron Palmerabout the Endowment. We are notputting money into a black hole.We are paying for things that reflectpositively on our organization andmembers. Please donate and we canall bask in the synergistic glow.

HAND is doing well under theguidance of our editor, MichaelNeumeister. He is working on adigital application that hopefullywill be rolled out in the future. Wellwritten review papers are welcomealong with submissions reportingyour research. Submit your manu-scripts to our journal.

We are in a privileged positionto participate in Maintenance ofCompetence. Bridging both Ortho-paedic and Plastic Surgery, we have

board members inexcellent posi-tions in bothdisciplines to putus at the forefrontof the MOCprocess. At thisyear’s meeting wewill have someinstructionalcourses that are certified. As MOCbecomes prominent the HandAssociation will provide its mem-bership with the best opportunitiesto participate in this process.

VuMedi is a growing entity inour educational environment. Theremay be other similar sites out thereand others may be developed. Ihave reached out to the ASSH toorganize the Upper Extremitycontent under a common silo. Howthis particular site will fit into theeducational framework for HandSurgeons in the future is yet to bedetermined but I encourage you to

register and seewhat is there andto sign on to thewebinars. There isclearly a hugeopportunity fordelivery of thismaterial over theweb and at thispoint it is sitting

there free for us to use.

Finally I want to encourage youto continue your membership in theAssociation and to bring on newmembers. We have a lot of goodthings happening and we welcomethe participation of every member.If you want to participate more,please send me an email. If youhave a special skill, please volun-teer. We have a lot of work to doand we welcome any member whowants to be more involved.

Steve [email protected]

Every memberwho sent an ab-stract will be ableto present theirwork.


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Summer2011

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4

HAND THERAPISTS PROFILE: Donna Breger Stanton, MA, OTR/L, CHT, FAOTA

Personal:I became an occupational

therapist in the ‘60’s. I really hadno idea what I was getting into, butit turned out to be right for me. Iworked in neuro rehab, pediatrics,mental health, and orthopedicsuntil I found hand therapy workingat a hospital in Denver in the 70’s;we had so many hand patients wewere busy!

I eventually took a job in the USPublic Health Service Hospital inSan Francisco, joined the Commis-sioned Corp of the US PublicHealth Service and developed anOT program there. I attended theweekly hand clinic even though thehand surgeon was not interested insending his patients to handtherapy. After about a year hebegan to notice me, and at the sametime I received referrals from theresidents. The program began togrow. I became involved withpatients with Hansen’s disease thatwere seen in the SF clinic. I visitedthe Gillis W Long Center inCarville, LA and met Dr. PaulBrand and Judy Bell Krotoski. Judyand I continued our communicationabout care and treatment of HDand I was hooked. I eventually wasinvited to work at Carville withJudy Bell and moved to Louisianafor 5 years. It is a time that wasmost important to my professionalgrowth and development.

I accepted a position at theUniversity of California, DavisMedical Center, Sacramento,California where I worked as thesupervisor of hand therapy, devel-oped and upgraded the programand its presence there, whileworking with Robert Szabo, MD,MPH. This, too, was an importantpart of my professional growth anddevelopment. During this time Ibecame quite involved with Ameri-can Society of Hand Therapists andeventually served as ASHT presi-dent in 2005. During my presi-

Donna Breger Stanton, MA, OTR/L, CHT, FAOTA

dency I met Lynn Bassini when Icame to my first AAHS meeting.She invited me to my first missionwith Guatemala Healing Handswhich I did for three years in a row.Those experiences changed my lifeagain. I became a member ofAAHS in 2005 and have enjoyedmy experiences and opportunitieswith AAHS.

I moved from UC Davis to aposition as faculty in the OTprogram at Samuel Merritt Univer-sity in Oakland, CA. I have beenthe Academic Fieldwork Coordina-tor along with teaching classesrelated to modalities, assistivetechnology, splinting, complemen-tary healthcare systems in OT, andmentoring research groups as myprimary class, for the past 5 years.

Education:I graduated from San Jose State

University in Occupational Therapyin 1965 and was certified in 1966. Iattended University of SouthernCalifornia, having received a fullgrant from Health and HumanServices, 1970-71. I completed mythesis and education in 1979. I amnow enrolled in the OTD programat Jefferson University and amabout a third of the way through. Iam truly enjoying this experience.

Employer:I work as Associate Professor,

Academic Fieldwork Coordinator,Samuel Merritt University, OTProgram, Oakland, California.

AAHS Involvement:For the past 3 years, I have

served on the Membership Com-mittee and have attended severalmeetings since becoming a memberin 2005.

Best Part of My Job:I have so much flexibility and

am able to continue my interest andinvestment in clinical research at

the same time I work with mystudents to complete the final stageof their education.

Major Accomplishments:Becoming a hand therapist,

before certification exam, alongwith completing the first HTCCcertification examination, success-fully. I have several publications ofwhich I am very proud, particularlyresearch I completed with mycolleague at Carville, Bill Bufordwhen we studied the properties ofthermoplastic materials, which wassubsequently published in HandClinics with articles also in theJournal of Hand Therapy. I haveserved on the ERB of JHT for about10 years.

I was honored to receive theVargas traveling fellowship awardfrom AAHS. It was unfortunatecircumstance that shortly afterreceipt of this award I suffered aninjury that made it impossible forme to make the trip to Thailandwith Dr. Song. This has truly beena disappointment I still think about.

Clinical Specialties:I have focused on peripheral

neuropathies associated withHansen’s disease, sensibility testing,



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5

CODING CORNER

Eon K. Shin, MD

Sincethe roundtablediscussionfor thisissue ofHandSurgeryQuarterlyis focusedon pediat-ric handsurgery,this

column will provide coding guide-lines for the management of variouspediatric disorders. Given therather broad scope of this topic, Iwill focus on some of the morecommon congenital disorders thatmay be encountered by the practic-ing hand surgeon.

In correcting simple syndactyly,the most commonly used codesinclude 26560 and 26561. To repairincomplete syndactylies, theoperating surgeon may be able toobtain a complete correction withskin flaps only and should utilizecode 26560. For complete syndac-tylies, skin flaps and concomitantskin grafts are generally necessaryto separate the fingers fully. In thesecases, code 26561 should be used.

For complex syndactylies, code26562 is used to reflect the addi-tional work required to divide thebony, cartilaginous, and soft tissuestructures.

For the treatment of polydac-tyly, the surgical treatments can beas varied as the patients them-selves. For most polydactylysurgeries, code 26587 may besufficient and reflects reconstruc-tion of a supernumerary digit.However, codes 14040 and 14041can be used to record skin flaprearrangements depending on thesize of the defect. Codes for fullthickness skin grafting should alsobe used when appropriate. Formore extensive reconstructiveprocedures, codes to reflect exten-sor tendon realignment (26437),corrective osteotomies (26565 and26567), and collateral ligamentrepair/reconstruction (26540, 26541,and 26542) should be applied.

For thumb hypoplasia recon-struction, a variety of codes may beappropriate. Digit pollicizationutilizes code 26550. To augment thedeficient thenar muscles in thumbhypoplasia, an opponensplastyprocedure and the use of code

26494 (opponensplasty; hypothenarmuscle transfer) are generallyrecommended. With type II or IIIahypoplastic thumbs, the ulnarcollateral ligament may requirerepair or reconstruction. As men-tioned previously for managementof polydactyly, codes 26540, 26541,or 26542 should be applied toreflect repair of the collateralligament at the metacarpopha-langeal joint. Finally, codes 14040 or14041 should be used for patientsrequiring first web space release.

For camptodactyly, non-surgical treatments are generallyrecommended to resolve or de-crease any fixed flexion deformity.When surgical treatment is under-taken, local skin rearrangement(codes 14040 and 14041) is requiredto allow for complete proximalinterphalangeal joint extension. Fullthickness skin grafts (code 15240)may also be necessary for particu-larly severe contractures. Release ofthe proximal interphalangeal jointis described by code 26525. Ifrelease of the flexor digitorumsuperficialis to the finger is deemednecessary, code 26478 should beused to record this procedure.


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6

Highlights from HAND

Asif Ilyas, MD

In the second issue of HANDfor 2011 (Volume 6, Issue 2) anumber of provocative originalarticles, important case reports, andinsightful review articles arepresented. Original article topicsinclude:

Quality measures for carpaltunnel surgery.

Preferred sleep positionassociated with carpaltunnel syndrome.

Aberrant anatomy and safelimited-open carpal tunnelsurgery.

Anabolic steroid use inreversing denervationatrophy.

Population-based study ofDupuytren’s disease.

Epicondylectomy versusdenervation for lateralepicondylitis.

Total scaphoid titaniumarthroplasty

Complications followingvolar plating of distalradius fractures.

Cadaveric study of theextensor digiti minimi.

Originalstudy excerptsfrom this issueinclude:

Isaacs et alwho examinedthe role ofanabolic ste-roids in therecovery ofmotor function following majornerve repair. They studied forty-five Sprague-Dawley rats who wererandomized to three groups: twogroups with tibial nerve transectionfollowed by autograft nerve repairafter three months of active dener-vation, and one control group withno nerve transection. A nandroloneinfusion pump was placed 30 dayslater in one of the transectiongroups. At final testing, musclecontraction in the steroid-treatedrepair group was 72% relative tothe control group and compared to57% in the non-steroid repairgroup, indicating a potential rolefor anabolic steroid use in therecovery of atrophic musclesfollowing delayed reinnervation.

In addition, Berry et al studiedthe role of denervation of theposterior cutaneous nerve in themanagement of lateral epicondylitisthat is recalcitrant to traditionalnon-operative modalities. Theyretrospectively reviewed surgicalmanagement and outcomes oflateral epicondylitis and dividedthem into three groups: (1) lateralepicondylectomy alone, (2) dener-vation alone, and (3) denervationand lateral epicondylectomytogether. They identified that thedenervation group alone identifiedstatistically significant improve-ment in pain relief and faster returnto work then epicondylectomyalone. Furthermore, the denerva-tion plus epicondylectomy pro-vided the same results than dener-vation alone.

HAND is the official peer-reviewed Journal of AAHS, featuring

articles written by clinicians worldwide presenting current

research and clinical work in the field of hand surgery.

AAHS Members have complimentary access to HAND via

the Members’ Only webpage.

http://handsurgery.org/Hand/


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7

Around the Hand Table

(continued on next page)

PANEL DISCUSSION:PEDIATRIC HAND SURGERY

Chuck Goldfarb, MDAssociate Professor, WashingtonUniversity, Saint Louis

Scott Kozin, MDClinical Professor, Temple University andDirector of the Upper Extremity Division,Shriners Hospital, Philadelphia

Terry Light, MDDr. William M. Scholl Professor, andChairman, Department of OrthopedicSurgery and Rehabilitation, LoyolaUniversity, Maywood, IL

Alex Mih, MDAssociate Professor, Indiana UniversitySchool of Medicine, Department ofOrthopedic Surgery, Indianapolis, Indiana.

Let’s start our discussion oncamptodactyly. Chuck, could yougive us your thoughts on ourcurrent knowledge of the patho-physiology of camptodactyly?

Dr. Goldfarb: The hardest topicfirst, perfect. I think that ourknowledge is still lacking oncamptodactyly. It is a difficultdiagnosis with a variety of patho-logic etiologies that are confusingand limit treatment. Every ana-tomical structure in the finger hasbeen implicated in causingcamptodactyly.

Dr. Goitz: Are there some struc-tures that you think are moreimportant in this situation?

Dr Goldfarb: I think that aberrantinsertions of normal tendinousanatomy, such as the lumbricals arepart of the etiology. A tight FDStendon is often part of the etiologyand I think a lack of good extensorpower is also part of the etiology.

Dr. Goitz: Scott, how effective doyou feel is splinting, and what areyour typical instructions to thefamily?

Dr. Kozin: We always try splintinginitially. Splinting at least preventsprogression of the disease. I don’tthink it’s terribly efficacious during

I would like to welcome our four accomplished panelists in pediatric hand

surgery. They include: Chuck Goldfarb, MD, Associate Professor,

Washington University, Saint Louis; Scott Kozin, MD, Clinical Profes-

sor, Temple University and Director of the Upper Extremity Division,

Shriners Hospital, Philadelphia; Terry Light, MD, Dr. William M. Scholl

Professor, and Chairman, Department of Orthopedic Surgery and

Rehabilitation, Loyola University, Maywood, IL; and Alex Mih, MD,

Associate Professor, Indiana University School of Medicine, Department

of Orthopedic Surgery, Indianapolis, Indiana.Robert J. Goitz, MD

periods of rapid growth whenwhatever is tight further tightensand the contracture progresses. Westill always try splinting as atreatment before surgery. To lessenthe contraction, we have had thebest results with serial casting thatapplies a low continuous load.

Dr. Goitz: How long do youtypically go with splinting, andwhat are your typical instructionsto the family when you do providesplinting?

Dr. Kozin: Well, we’re open andhonest with the family and tellthem we just don’t know the timingor duration of splinting that leadsto improvement. We recommendthat the child wear the splints atleast when they’re sleeping andnapping but spend some time outof the splint to facilitate normalhand development. We don’t reallyhave a set algorithm for length orduration of splinting.

Dr. Goitz: Terry, what are yourindications for surgery, yourtiming, and the ideal age?

Dr. Light: We see two differentgroups of patients withcamptodactyly. Very youngchildren have a form of

- Robert J. Goitz, MD

What makes the IIIacomplicated in [hypo-plastic thumb] recon-struction is not onlythe MCP instabilitybut that the FPL maybe malpositioned andhave some intercon-nections with theextensor.


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8


Hand Table(continued from previous page)

camptodactyly involving multipledigits. Many of these digits re-spond to splinting in extension anddo not require surgery.

The second group, adolescents, areoften troublesome because theextent of their flexion contracturetends to progress as they are gothrough a rapid growth period.The younger kids’ fingers tend toimprove as they get older while theadolescents’ fingers tend to becomemore severely flexed over time. Iagree that the flexor digitorumsublimis is often a pathologicelement. If tenodesis exam con-vinces me that the sublimis iscontributing to the deformity, I willsimply release the sublimis andthen continue splinting postoperatively to further straighten thePIP joint.

Dr. Goitz: Terry, do you feel thatthere is an optimal age that patientsare compliant with post-optherapy?

Dr. Light: I splint every digit at thetime of presentation. Very youngchildren will wear splints but it isdifficult to construct a splint for ababy that provides sufficientconstraint. It is easier to makesplints for older children but theyare increasingly capable of remov-ing the splint if they find it annoy-ing. Preoperatively, compliancewith splinting gives me a sense asto whether the child or adolescentis likely to comply with postopera-tive splinting. Inevitably, adoles-cents will require splinting aftersurgery.

Dr. Goldfarb: There was a study inthe Journal of Hand Surgery last yearby Dr. Baek from Korea, and itreported excellent results in youngkids with stretching alone. Let’sjust say that I’ve not been able toreplicate those results with stretch-ing. It may be a lack of diligence in

stretching in my patient populationcompared to those in South Korea.I don’t know if anyone in the grouphas had a better experience.

Dr. Goitz: Alex, take us throughthe steps that you take once you doconsider surgery for these patients.

Dr. Mih: Well, I probably reservesurgery for patients that have a PIPjoint contracture that approaches 90degrees, so unless they’re prettyclose to that, I actually don’trecommend surgery. I would tellthe parents that I’m not sure we canactually improve the total arc ofmotion much but perhaps, wecould change the start and finishpoint of that arc of motion.

It does seem like camptodactyly hassomewhat of a spectrum in terms ofits tightness and in some patients, Ithink they actually have some levelof skin tightness that could benefitfrom Z-plasty. So in those patientswho would outline the skin incisionto include a Z-plasty at the PIPjoint, then inspect the flexor tendonsheath for any aberrant insertionsbecause occasionally, we havefound FDS on the outside of thesheath or having some insertioninto the sheath. I would agree withTerry that releasing the FDS isprobably an important part of thisand depending on the level of jointinvolvement, whether they havedeformity of the bony elements.There may be some role of releasingthe volar plate as well and thenpinning them so I do some tempo-rary pinning of the joint and in asmuch extension as possible. So tosummarize, it would be Z-plasty ofskin, inspection and release of FDS,evaluation for any other aberrantanatomy, volar plate release, andpinning.

Dr. Goitz: Any consideration fortendon transfer?

Dr. Mih: You know, I think there isa set of patients that we probablyend up putting in camptodactylygroup that is quite a bit more

supple in terms of their PIP contrac-ture that are more likely to have abit of an extensor deficiency. I thinkFrank Burke from Darby, Englandhas presented this a few times witha group of patients that seem tohave more of an extensor mecha-nism problem than a palmar sidejoint contracture and they probablyare completely different patho-physiology than what we think ofas camptodactyly but I think in thepatients that have problem withany kind of active extension that Iwould do in most cases an FDStransfer.

Dr. Goitz: Terry, Alex indicatedthat 90 degrees would be hisconsideration for surgical interven-tion. I find that the small fingergets out of the way pretty well withthe MP joint hyperextension andthe more radial fingers have aharder time getting out of the way.

Do you have a different opinion forsurgical indications for the radialdigits or would it be a similaramount of contracture?

Dr. Light: I am a bit more aggres-sive in the radial digits. If the skin

- Terry R. Light, MD

As I have followed youngpatients on whom I’ve per-formed Huber transfers, I’veseen that [they] may proveinadequate over time. Be-cause of this… I have shiftedto using the ring sublimusopposition transfer.


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9



is very taut, I will make a trans-verse incision from midaxial tomidaxial line at the flexion crease ofthe PIP and insert a diamondshaped full-thickness skin graft. Iplace a K-wire across the joint for 3weeks. This is particularly helpfulin digits that have a contracture of80 or 90 degrees.

Dr. Goldfarb: When we see radial-sided camptodactyly, patients aresent to a geneticist to rule out otherconditions and one of the thingsthat you’ll see are weird trisomymosaicism. Some of these trisomieshave facial issues that are moreobvious, but the mosaicism issomething that often goes undiag-nosed even though there are othermedical issues.

Dr. Kozin: With reference to theapproach to camptodactyly, we’vebeen using a spectrum approachthat was published by Foucher in2006. Similar to Alex’s comments,you go through this algorithm ofsteps that ultimately dictateswhether or not the structures needto be released sequentially andwhether a tendon transfer isrequired. If a tendon transfer is

required, we certainly make sureit’s not too tight because anytransfer that’s too tight will impairgrasp.

Guy Foucher F, Lorea P, Khouri RK,Medina J, Pivato G. Camptodactyly asa Spectrum of Congenital Deficiencies:A Treatment Algorithm Based onClinical Examination Plast. Reconstr.Surg. 2006;117: 1897-1905.

Dr. Goitz: Let’s move our discus-sion to syndactyly. Now, theprinciples and treatment of syndac-tyly have been outlined for decadesbut there continues to be numerousarticles related to minimizing skingraft.

Scott, how do you minimize skingraft and is this a desired interven-tion?

Dr. Kozin: Some of the articlesdiscuss excessive defatting to tryand minimize skin graft. I do notexcessively defat. I think you’reasking for trouble if you defat toomuch and the fingers can look kindof scrawny. We will defat before weinsert our flaps and we have usedthat dorsal advancement flap todecrease the amount of skin graftnecessary in incomplete syndactyly.We almost always use skin graft incomplete syndactyly.

Hsu VM, Smartt JM, Chang B, TheModified V-Y Dorsal Metacarpal Flapfor Repair of Syndactyly without SkinGraft Plast. Reconstr. Surg. 125: 225,2010.

Dr. Goldfarb: I have tried toavoid using skin grafts not becauseI dislike skin grafts but because Ithink that over time discolorationcan be an issue no matter theharvest site, and I think avoidanceof grafts will make the operation abit more straightforward whenappropriate. I use a graftlesstechnique a majority of the timeand I’ve been pretty satisfied withthe results over the last five toseven years and the families seemto be happy as well.

Dr. Goitz: How have you been ableto minimize skin grafting?

Dr. Goldfarb: So I agree withexactly what Scott said. We defat abit before insetting flaps but I don’toverly defat. We try to limit thenumber of sutures we place and thesomewhat loose closure has beenhelpful. Lastly, we bring new skininto the area by using the firstmetacarpal artery flap as describedby Sherif 1 an accessible source ofskin. It provides a nice commis-sural skin coverage and it’s beensatisfying for us.

Dr. Goitz: Alex, what are youroptimal donor sites for skin graft-ing?

Dr. Mih: You know it reallydepends. I think as we’ve all seenthere are syndactylys where there issignificantly more skin than othertimes, but I think that in most cases,we would use either for a smallamount of graft, the hypothenarregion, probably for larger graftsstill the full-thickness skin graftfrom the groin. We’ve occasionallyused upper extremity grafts fromeither the distal forearm or proxi-mal forearm but I think that is stillthe more common site of graft forour location has been the groinipsilateral site.

Dr. Light: I used the groin as adonor site for many years. As Ihave followed these children for 10to 15 years I have been disap-pointed to see that the grafted skintends to discolor and darken. Ihave shifted to using the dorso-lateral foot as a donor site. Thecolor match is much better. Forchildren who need a large amountof skin in multiple stages, such as achild with Apert syndrome, I use aPfannenstiel abdominal incision torepeatedly harvest skin graft.

Dr. Kozin: I agree with Terry. Ishifted away from the groin overthe years and primarily use a distalwrist crease via an elliptical inci-

- Chuck Goldfarb, MD

I have tried to avoidusing skin grafts [insyndactyly]...because Ithink that over timediscoloration can be anissue.


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10

A A H S 2 0 1 1 C O M P R E H E N S I V E H A N D S U R G E R Y R E V I E W C O U R S E

Tumors of the Hand and WristEdward Athanasian, MD

Compressive Neuropathies & CRPSWilliam Pederson, MD

Thumb Basal Joint Arthritis and Infl ammatory ArthritisSteven Moran, MD

Distal Radius FracturesDavid Bozentka, MD

Distal Radioulnar Joint (DRUJ)Peter Murray, MD

Scaphoid Fractures and Non-Unions, Kienbocks DiseaseRobert Goitz, MD

Carpal Instability, Wrist ArthritisJose Ortiz, Jr., MD

Fractures of the Metacarpals and PhalangesJerome Chao, MD

Flexor & Extensor Tendon InjuriesLoree Kalliainen, MD

Infections of the HandE. Gene Deune, MD

Congenital Hand DifferencesRobert Havlik, MD

Tendonopathies and Dupuytren’s ContractureMiguel Pirela-Cruz, MD

A must-have resource.Purchase this special limited edition DVD and put the entire2011 Comprehensive Hand Surgery Review Course at your fi ngertips. This invaluable resource includes faculty presentations of 12 topics covered on board examinations, the hand surgery certifi cation examination and resident in-training examinations. Recorded during the AAHS 2011 Annual Meeting, it’s a resource you’ll turn to over and over again.

$175 per copy, includes shipping.

*This DVD will operate only in a computer’s DVD drive.

Order by Phone: 978-927-8330

Order by Fax: 978-524-0498

Payment Options:

Check (made payable to American Association for Hand Surgery)

American Express Mastercard Visa

Quantities are limited.For additional information, please contact the AAHS Offi ce at 978-927-8330.

AAHSAmerican Association for Hand Surgery

Comprehensive Hand Surgery

Review Course

www.handsurgery.org

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11

Hand Table(continued from page 10)


sion. I will use a Pfannenstiel inAperts because of the fiberblastdeficiency that limits the skin’sability to stretch. I have used theantecubital crease for skin graftwhen I need it. I find the colormatch to be good, and it healsnicely.

Dr. Light: I am concerned thatattempts to only use local flapswithout skin graft may not improvethe long-term appearance of thehand. I find that incisions on thedorsal hand for advancement flapsare more objectionable to the familythan skin graft. I avoid using thedorsum of the hand proximal to theweb floor as a donor site for theweb floor I continue to rely uponlocal flaps that are harvestedprimarily from the dorsum of thefingers.

Dr. Goldfarb: The Sherif techniquerelies on having sufficient addi-tional skin, so I only use this dorsaladvancement flap if I’m convincedthere’s adequate other skin to allowfor primary closure without skingrafts. It makes no sense to use, Ithink, that flap in addition to skingraft since they’re already having adonor site. Our families have notobjected to dorsal scars from thistechnique.

The other thing is that I think we’veall learned that our closures don’tneed to be quite as precise and thatin the pediatric hand or finger thatwe can leave small areas open toheal in, in fact very quickly withminimal scarring so that thetroublesome area is usually in theproximal portion of the fingers ifyou need graft, that’s going to bethe area where you’ll need graft.

Dr. Goitz: Alex, if a skin graft fails,how large of a defect would youallow to heal by secondary inten-tion versus taken back to theoperating room for a reskin graft?

Dr. Mih: I would – relatively rarelyhave we ever done a re-grafting. Iwas trying to think of that. It mightdepend on where the defect oc-curred, whether it was out distal inthe digit whereas most of the graftswere more at the proximal junctureat the site of the finger and thedorsal rectangular flap. I thinkprobably if it we had lost a graftthere, I’m not sure I would re-graftit. I may let it go ahead and heal bysecondary intention and see if itwere a problem later on. I haven’thad to do that to my memory atleast.

Dr. Mih: So I only re-graft for acatastrophe; meaning either aninfection or the child somehowwiggled out of their postoperativemobilization but small deficits justlike Terry said heal in nicely. Wemake sure the cast fits snugly and Ido not even look at their woundsfor two and a half or three weeks.

Dr. Goitz: Scott, when do you firstcheck the wound?

Dr. Kozin: Three weeks. Again,the longer I’ve done congenitalhand surgery, the more I immobi-lize. We use the Marybeth Ezakiconcept of “punitive plaster”, usinga soft cast that can be more easilyremoved.

Dr Mih: I would agree with that. Ithink that the grafts always lookbad at ten days or anytime if youlook at it before three weeks and soI would agree with Scott, weactually don’t splint them. It seemslike the weight of the plaster orfiberglass just makes the dressingfall off easier so a large soft dress-ing removed at three weeks, I thinkallows the skin graft to take so ithas a good appearance and theparents are happy. Probably theonly times when it’s a problem iswhen it falls off and they have itrewrapped in the local emergencyroom or something where nothingis put in between the digits andthat’s always a problem.

Dr. Mih: Probably the one thingthat we’ve changed a bit just istiming and I’d be interested toknow what other people think of asideal timing for syndactyly separa-tion. We started a study some yearsago and actually looking at variousmethods of separation in terms oftype of flap, amount of skin graft,etc, and the interesting thing thatcame from that study was that theincidence of web creep was quitehigh in patients under the age of 16months. In fact, one out of four ofthose patients required secondarysurgery at some time in their life foraddressing the web creep and sonow, except in maybe border digitsthat have severe angulation, Iroutinely do not address thesyndactyly until they’re at least 16months of age.

Dr. Kozin: We agree 100%. Theolder articles are from Dupont andwe try and wait until the child is ayear and a half. It’s hard sometimesbecause the parents are underpressure to have their child’sfingers separated and I always tellthem there’s a one-third chanceyour child will need some kind of“touchup” as they age whether it becommissure creep, nail fold recon-struction, etc.

Dr. Light: I agree as well. Essen-tially, we’re doing our border digitsearlier, four to six months, for thecomplex thumb/index especiallywith the hope that if you separatethese digits of differing lengthearly, the affected fingers have abetter opportunity to grow straight.There still may be some deformityof these digits even with earlysyndactyly. I usually try to delaysimple long – ring finger syndac-tyly releases until 18 months of age.

Dr. Goitz: Terry, when you have achild with acrosyndactyly from anamniotic band and then concomi-tant syndactyly more proximal, doyou release them at the same timeor just release the tips and comeback?


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12



Dr. Light: I often release the tips at9 months of age. Then once thefingers are freed from one anotherdistally they may stretch out someof the skin proximally diminishingthe need for skin graft. I initiallyseparate the fingers apart down tothe level of the dorsal to palmarsinuses. I will fully release one webspace at the first procedure andthen selectively deepen the otherweb spaces three to six month later.

Dr. Goitz: Let’s move our discus-sion to duplicate thumbs. It seemsthere has been varying enthusiasmfor the Bilhaut-Cloquet procedure.Scott, do you find this procedureuseful in your armamentarium andwhen do you use it?

Dr. Kozin: I only use the Bilhautwhen I have to use the Bilhaut. Inother words, when resecting theradial thumb would lead to toosmall thumb that would be unac-ceptable, from a functional andcosmetic standpoint. I also use thetechnique described by Baeck in theJBJS in 2007.

Baeck GH, Goug HS, Chung MS, et al:Modified Bilhaut-Cloquet procedure forWassel type-II and III polydactyly ofthe thumb, J Bone Joint Surg Am89:534-541, 2007.

Dr. Goitz: Chuck, when do youconsider osteotomizing the residualthumb?

Dr. Goldfarb: I’m of the school ofthought that correcting bony align-ment is more important than realign-ing tendinous insertions. Therefore,if after excision of the extra thumb,usually the radial thumb, we don’thave a well-aligned thumb, I wouldrather at the first surgery go aheadand perform an osteotomy to obtaina straight thumb. I don’t think thethumb deformity, if there is any, willcorrect over time. I use bony tech-niques to correct any mal-alignment.

Dr. Mih: I would. I find it difficultto do an osteotomy in thoseangulated digits that have anoblique physis. Sometimes in atype I where you have two distalphalanges that are diverging, you’llfind that the physis is actuallyoblique and then I’m interested inwhether people would do anosteotomy below that to try andalign the digit even though you’remaking the joint crooked.

Dr. Kozin: That’s exactly what wedo. I think Howard Steel taught usa long time ago that you can’t treatthe x-ray. You treat the bone andmake the limb alignment straight.I think duplicate thumb surgery isone of those entities that you haveto be more aggressive rather thanless aggressive or you end up witha zigzag deformity.

Dr. Goitz: Alex, when is optimaltiming for surgical intervention forthese patients?

Dr. Mih: I think that it’s probablysomething we do at a younger ageand may be dependent on if thereare any other medical problems butgenerally, it’s probably donebetween 10 and some time beyond10 months. I don’t know that wepush to do it any sooner than thatbut I think it is something good tohave done possibly before too muchbeyond one year of age. I think ourpediatric anesthesiologist like us todelay elective surgery like this untilaround six months of age or beyond.

Dr. Goitz: Okay. Let’s talk aboutthumb hypoplasia, specifically, typeIIIa or better. Terry, can you reviewfor us the pertinent typical findingsin type IIIa hypoplasia?

Dr. Light: The critical finding thatdistinguishes the IIIa from the IIIbhypoplastic thumb is a stablethumb basilar joint. I first considerthe bony anatomy. Then, I evaluatethe degree of abduction of thethumb metacarpal relative to theindex metacarpal.Often, the resident who has exam-ined the patient will tell me, “This

child has good abduction” when,they have a very lax ulnar collateralligament of the metacarpal pha-langeal joint giving rise a pseudo-abduction in a thumb with limitedmetacarpal abduction. The stabilityof the ulnar and radial collateralligament at the metacarpal pha-langeal joint is evaluated, as are thethenar muscles and the extrinsicflexors and extensors.

Dr. Goitz: In my experience, whatmakes the IIIa complicated inreconstruction is not only the MCPinstability but the FPL may bemalpositioned and have someinterconnections with the extensor.Then there is the need to not onlyperform a tenolysis of the FPL, butto centralize the FPL as well asstabilize the MP joint.

Scott, how do you manage thesesomewhat divergent issues? Doyou address them all at the samesetting?

Dr. Kozin: I try to address all at thesame setting. The thumb indexwebspace is often underestimatedand we’ll address that by release ofthe fascia and some type of Z-plastyor a dorsal rotation flap.

- Scott Kozin, MD

I don’t reconstruct IIIbhypoplastic thumbs…[the] results ofpollicization [are] farbetter than reconstruc-tion for a type IIIbthumb.


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13



For the MCP joint instability, if ittends to be just the ulnar collateralligament, we’ll reconstruct thatdeficiency with our FDS oppositiontransfer. If it both collaterals aredeficient, we’ll perform a MPcontrodesis rather than try andreconstruct both ligaments at thesame setting.

Then for the FPL, we will releaseany abnormal connections, but wehave not had success with recon-structing the FPL tendon sheath orFPL tendon.

Dr. Goldfarb: That’s been ourexperience as well. If there’s noskin creases upon examination ofthe thumb preoperatively, it sug-gests that there is either scarring orinterconnections and a lack oftendon glide causing a lacking ofjoint motion. I’ve not had successin trying to tenolyse the FPL andregain motion. Tom Graham andDean Louis describe finding theinterconnections along the thumbin a pollicis abductus situation andI’ve not had their degree of successin separating these interconnectionsin the thumb and forearm.2

Dr. Goitz: Let’s take the samepatient who now presents to you at4 years old and has had his initialsurgery at one year old to attemptto stabilize the MP joint with acollateral ligament repair and nowstill has instability of the MP joint,no apparent function of the FPL tomove the DIP joint and they areunstable at the MCP joint whichappears to be where most of theirmotion comes.

Alex, how do you address thissituation?Dr. Mih: Well, I would agree it’svery difficult, if not impossible torestore an FPL function in thepatient because they don’t have anysheath and we’ve tried a few andhave had pretty much a failure ofany kind of tendon transfer in that

setting but I think as far as the MPinstability, we sometimes see this Ithink, in patients who have had anopponensplasty that has reallydeviated their MP joint as opposedto opposing their thumb.

Dr. Kozin: So I think if there’s aproblem of the opponensplastyinsertion, that may need to beaddressed in terms of some ad-vancement into the extensormechanism or beyond the extensormechanism but I think we recom-mend reconstructing the ulnarcollateral ligament either with alocal tissue or perhaps, a freetendon graft and temporary pin-ning of the joint, but I think most ofthe patients that I’ve seen that havehad MP deviation have had that, Ithink, due to some problems withtheir insertion of theiropponensplasty.

Dr. Light: I’d agree. As I havefollowed young patients on whomI’ve performed Huber transfers, I’veseen that their chondrodesis andcollateral plication stabilizationmay prove inadequate over time.Some of these thumbs have devel-oped excessive abduction across theMP joint. Because of this phenom-ena I have shifted to using the ringsublimus opposition transfer,pulling the tendon through bone toreinforce the radial collateralligament as Scott Kozin has de-scribed. I think that this provides amore stable long-term construct.

Dr. Goitz: Chuck, any consider-ations for pollicization for the IIIahypoplasia thumb?

Dr. Goldfarb: We have not becauseif our goal is to create a radial-sidedpost, I think that goal can beaccomplished well even if it’s athumb that doesn’t move particu-larly well. If we can achieve a well-positioned, stable thumb, I believethat we can achieve success bothfunctionally and aesthetically.Therefore, I’ve not donepollicizations in this situation andhaven’t regretted not doing

pollicizations. I’ve been happywith the results of reconstructionsand I agree with Scott earlier thatchondrodesis has been a helpfultool for us even in the youngerpatient. Perhaps I’ll look for themalpositioned insertions as Scottmentions in future revisionstabilizations but, my typicalapproach is chondrodesis orepiphyseal arthrodesis in the olderchild.

Dr. Kozin: We’ll use an AdrianFlatt tenet that if the thumb issmaller than the small finger, thenwe’ll discuss pollicization as aprimary procedure. Often thosethumbs are just too small and tooproximal to function as a good unitin grasp or prehension. I do think ittakes a fairly educated parent tounderstand why you’re going toremove a type IIIa thumb andpollicize the index.

Dr. Light: In one child that had areconstruction of a Type IIIIa thumbon one side and pollicization on theother side the parent asked me,“Why didn’t you do a pollicizationon both sides”, since the pollicizeddigit was clearly superior to the

- Alex Mih, MD

[In syndactyly] the inci-dence of web creep wasquite high in patients un-der the age of 16 months.So now…I routinely donot address the syndac-tyly until they’re at least16 months of age.


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14


reconstructed thumb. Clearly thepollicized normal index fingerfunctions very well in the thumbposition while the reconstructedIIIa thumb is a less sophisticateddigit.

Dr. Goitz: Alex, any considerationfor reconstruction in the IIIbhypoplastic thumb?

Dr. Mih: I think it does come upperiodically where families are notinterested in ablating that digit andI know we’ve all seen reports, orcases, or presentations from theOrient where some very exhaustiveefforts have been made to try tocreate a joint or create some stabil-ity. So I think taking some of thoseprinciples to heart, I actually havedone some stabilizations usingeither bone graft or some othermethod of creating a somewhatstable CMC joint for the family thatabsolutely did not want to have anablation and a pollicization. I thinkthere are now some reports, encour-aging reports of using a split-second metatarsal as an intercalarygraft to create a stable proximaljoint and that looks intriguing.

Dr. Kozin: I don’t reconstruct IIIbhypoplastic thumb and I give themthe article by Guy Foucher. Hisresults of pollicization were far betterthan reconstruction for a type IIIbthumb. I’ve actually never recon-structed a type IIIb or IV thumb.

Foucher G, Medina J, Navarro R:Microsurgical reconstruction of thehypoplastic thumb, type IIIB, JReconstr Microsurg 17:9-15, 2001

Dr. Goldfarb: I don’t think thequestion is whether we think it’sbetter, but I agree that there areparents who simply are adamantthat this is not an option and ingeneral, I say, well, then I don’t thinkI have a solution that addresses yourconcern but there may be solutionsthat are worth exploring.

Dr. Mih: Well, I think the few timesI’ve done this, the parents are a lothappier with the result of that than Ihave been so I think they’ve been gladthat they went through it. I think theother interesting thing as we’ve seensome of those patients long term,they’re high school seniors or so bynow and you look at the thumb andyou just can’t stand the way it looksbut they’re happy with it so I thinkobviously, it’s, as we all know, thepatient and family expectations reallyinfluence the reception of the result.

Dr. Kozin: I don’t think there’s any-thing wrong with having the patientjust maintain their type IIIb. They canlive with it and that is their preroga-tive. I’m just not sure that reconstruc-tion really improves its function.

Dr. Goitz: So it sounds that mostwould agree that a IIIb would be anindication for pollicization andmany times, it would be patientand family influences that wouldmove us to not pollicize. Chuck, isthere any findings that you would,regardless of the family desires,consider a IIIa for pollicization?

Dr. Goldfarb: I have onlypollicized IIIb thumbs, never theIIIa thumb. Whenever there issome type of substantial thumbpresent, it requires a great deal ofdiscussion with the family and I’dmuch rather see a floating thumb, atype IV, or an absent, a type Vbecause it’s more straightforward toassure the family that we’re doingthe right thing by pollicizing theindex finger. When there’s a smallthumb, and when the thumb lookssubstantial even though the proxi-mal metacarpal may be absent, ittakes a lot of work to assure thefamily they’re making the rightchoice for their child.

Dr. Goitz: Let’s move our discus-sion to radial longitudinal defi-ciency. Alex, a patient presents toyou within the first week of lifewith a complete radial deficiency.Do you immediately cast, splint,and is it affected by whether it’sunilateral or bilateral?

Dr. Mih: You know, probably weend up using splints for the mostpart and also evaluate them forelbow motion to see whether or notthey have an elbow extensioncontracture going along with it so Ithink in the newborn or first weekor two of life, I tend to instruct theparents on passive stretch and thenhave a splint made that they put on.

Dr. Goldfarb: We’ve gotten awayfrom casting entirely, in large partbecause of the use ofprecentralization distraction as apart of our approach to radialdeficiency. We did not have verygood success using casts and we’vegone to a minimalist approach withstretching alone in the newbornsetting.

Dr. Goitz: Chuck, give us yourthoughts about your considerationfor centralization versus distractionlengthening versus nothing.

Dr. Goldfarb: I believe that avoid-ing intervention is an interesting andreasonable recommendation becausethe results of centralization remaindifficult and less than ideal; however,we’ve been happy with a kind of two-stage centralization process wherestage one is applying an externalfixator and distracting the soft tissuesand then stage two is more of the for-mal centralization. The benefit of thepre-centralization distraction is thatit makes the centralization procedureitself more straightforward. It mini-mizes trauma to the growth plate ofthe distal ulna and provides, and atleast in the short term, a more satis-fying outcome.

Dr. Goitz: Chuck, what age areyou putting the external fixator on?

Dr. Goldfarb: The earliest we’vedone it is 12 months. It tends to bea little tricky because we use a ringfixer which is large and the child isso small. I would say average ageis probably 18 months.



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15


Dr. Light: I tend to put a fixator onwhen children are 10 to 12 months.I still occasionally will do a singlestage in children whose wrist isvery supple. Typically, I’ll put asmall uni-planer fixator on theulnar side and do a volar radialrelease at the same time. I find thatthe release tight volar radial fascialtissue removes soft tissue impedi-ments to distraction.

Dr. Goitz: What percent Terry, doyou find that you’re doing singleintervention for centralizationversus the distraction lengthening?

Dr. Light: Probably about 20% aredone in a single stage, the othersare treated with a preliminaryfixator.

Dr. Kozin: We will do a singlestage only if we see the carpus onthe end of the ulna in the AP andlateral x-ray planes. A lot of times,it looks okay in the AP planes but isvery volar and need distraction. Ido think it’s a real heart to heartdiscussion with the parents becausewe know that the recurrence rate isuniform with or without thedistraction. Furthermore, in thosekids that truly favor their ulnarhand, they’re doomed to recurbecause that’s the way they interactwith their world.

Dr. Goitz: Alex is the concern forphyseal arrest as much a concernwith now the application of exter-nal fixator first followed by central-ization?

Dr. Mih: I think it is, and I thinkthat a lot of the longer term longitu-dinal studies of forearm length areinstructive in that it’s pretty uni-form that we are unable to avoidsome damage to the physis or someeffect of its growth. So I think wemay be too optimistic in our abilityto avoid physeal damage or slow itsgrowth so I think it’s probably in

almost every case we have somelevel of epiphyseal effect withcentralization.

Dr. Light: I think it’s difficult toknow in specific cases. If you lookat some of the work from [Heikel]the un-operated ulna in radialdysplasia will grow to 50% to 60%of the length of the contralateralnormal ulna. So the baseline is thatwe call it radial dysplasia but thereis a substantial degree of ulnardysplasia in these limbs. I think youcan create further injury to thedistal ulnar physis so that theydon’t grow to their potential but thepotential of these limbs in terms ofgrowth, if we never operate onthem, is substantially less thannormal.

Dr. Light: Tony Sestero andVanHeest3 had an excellent studybuilding on Heikel’s work whichfurther quantifies the length of theulna in the un-operated limb,versus the limb treated withnotching of the distal ulna, versusthe limb treated without notching.It showed that the more invasivewe are and the more we do opera-tively to the end of the ulna, themore likely we are to affect growthof the ulna. I believe that theexternal fixator has decreased thelikelihood of physeal issues but Iagree with Alex that it certainlyhasn’t eliminated that risk.

Dr. Goitz: That said Scott, what doyou do at the time of centralizationin addition to soft tissue balancingto minimize the chance for recur-rence?

Dr. Kozin: We’ll take off the fixatorand centralize at the same setting.We no longer take off the fixatorand wait for some time. We willperform an ulnar approach to act asa dermodesis, perform a capsularplication, and then we’ll imbricatethe ECU.

Dr. Goitz: Terry, when do youconsider radial lengthening in thelongitudinal radial deficiency?

Dr. Light: Rarely. I am concernedthat if I lengthen the short radius ina young child, the subsequentgrowth won’t be proportionate andwe will need to repeat the proce-dure in once or twice prior toskeletal maturity.

Dr. Goldfarb: I share Terry’sconcern that you may lengthenonce and then have to lengthen itagain but we’ve had reasonablesuccess balancing a type I or type IIshort radius and it helps balancethe carpus on the end of the fore-arm a bit better and it seems tomaintain over time. I think one ofthe experiences we had that was alittle bit negative was that weachieved excellent length of theradius but you have to be careful,as Scott mentioned, and watch atthe lateral view radiograph becausethe carpus can slide underneath thelengthened radius during thelengthening. We have to be carefulto balance lengthening the radiuswhile maintaining carpal alignmenton all radiographic views, and Inow will pin the carpus and handto either the ulnar or radius duringthe lengthening process to makesure we maintain alignment.

Dr. Goitz: Chuck, you’ve pub-lished on fusion and the outcome inthe radial deficient limb. What areyour indications at this point forconsideration of fusion in the olderpatient?

Dr. Goldfarb: When Paul Manskewould talk to families he would tellthem that centralization was thefirst stage of a two-part treatmentfor radial deficiency and the secondstage was fusion of the ulnocarpaljoint. This is reflective of the factthat there is such a high failure ratefor the centralization procedure, orat least recurrence rate of thedeformity. When there’s an 8 yearold or more likely a 10 or 12 yearold, with marked recurrence ofradial angulation and flexion, Ibelieve fusion is a great option forthe family. It creates a well aligned



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16


forearm. It adds length to theforearm and the patient doesn’tloose significant motion in that theydon’t usually have a lot of helpfulmotion anyway. The families thathave had ulnocarpal fusion aftercentralization at our center havebeen very happy with it.

Dr. Kozin: I concur. I think thatchildren who have had failedcentralization and ultimately have afusion, appear to be pretty contentwith the overall alignment of theirlimb especially if they’ve had apollicization that works well.

Dr. Goitz: Chuck, can you give ussome indication of how muchdeformity you would considerfusion for?

Dr. Goldfarb: It’s such a toughquestion to answer because itdepends so much on the child andthe family and what activitiesthey’re struggling with and howmuch the appearance is an issue- Idon’t think there’s a rigid number.In the study we published, we useda combination of both radialangulation and wrist flexionbecause both issues are problematicfor the families. For radial devia-tion, we used a minimum of 45degrees with a flexion posture4 of atleast 25 degrees.

Dr. Light: As we’ve tended tobalance our centralizations betterby posturing the hand in ulnardeviation, recurrence of radialdeviation is less common than itused to be. Unfortunately, thepersistence of flexion is almostuniversal and the arc of motion isusually from neutral to somedegree of flexion. When the wrist isfixed in both flexion and radialdeviation I may suggest fusion.

Dr. Kozin: I think this is a primeopportunity to enlist your therapist.Our therapist will spend ampletime with the child figuring out theappropriate positions to maintaintheir ADLs. In some cases, the wristis fused in some degree of flexion toenhance functional and to augmentdigital extension.

Dr. Goitz: Alex, are there anydifferent considerations in a patientwith bilateral radial longitudinaldeficiencies?

Dr. Mih: You know, probably thething that comes up most often inthose patients is in their preadoles-cent years when they have diffi-culty with perineal care that’s thetime when we’ll do a lengthening ofthe forearm bone that is there. If it’sjust the ulna or if they had someamount of radius because of theirdifficulty in hygiene. So I thinkprobably the bilateral patient ismore likely to come in when they’re

10 or 11 years of age with thatcomplaint of inability to performpersonal hygiene and that’s whenwe do distraction, lengthening ofthe limb. I think otherwise, thetreatment has probably been fairlysimilar to a unilateral presentationat a young age.

Dr. Goitz: I want to thank each ofyou for sharing your expertiseduring this panel discussion. It’sbeen very enlightening for me, andthank you all for participating.

1.Plast Reconstr Surg. 1998Jun;101(7):1861-6. V-Y dorsalmetacarpal flap: a new technique forthe correction of syndactyly withoutskin graft. Sherif MM.2. J Hand Surg Am. 1998Jan;23(1):3-13. A comprehensiveapproach to surgical management ofthe type IIIA hypoplastic thumb. Gra-ham TJ, Louis DS.3. J Hand Surg Am. 2006 Jul-Aug;31(6):960-7. Ulnar growth pat-terns in radial longitudinal defi-ciency. Sestero AM, Van Heest A,Agel J.4. Ulnocarpal epiphyseal arthrodesisfor recurrent deformity after central-ization for radial longitudinal defi-ciency. Pike JM, Manske PR, SteffenJA, Goldfarb CA. J Hand Surg Am.2010 Nov; 35(11):1755-61. Epub2010 Oct 8.

use and effectiveness of contrastbaths, provocative testing of carpaltunnel syndrome.

Greatest Professional

Challenge:My greatest professional

challenge was becoming an excel-lent hand therapist and under-standing the biomechanics that was

Hand Therapist Profile (continued from page 4)

a part of my job when working atthe Gillis W. Long Hansen’s diseaseCenter, Carville, Louisiana. Dr.Paul Brand essentially mandatedthat we know and understand howto incorporate objective measures inour work, and employ biomechan-ics to optimal advantage in oursplinting and care of our patients.At the time it was new for handtherapists to become more educated

in this specialty within a specialty,and now it is a requirement just tobe a hand therapist, thanks to thework of Dr. Paul Brand and hisinspiration to us hand therapiststhat I hope is never lost.

Three Words that

Describe Me:Honest. Hard worker. Caring


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17

O

F

F

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E

T

W

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E

R

Strategies for Success in

Hand and Upper Extremity Care

A. Lee Osterman, MD

Randall W. Culp, MD

Sidney M. Jacoby, MD

Alejandro Badia, MD

Charles J. Eaton, MD

Joseph E. Imbriglia, MD

Donald H. Lalonde, MD

»»HONORED

PROFESSORS

CHAIRMEN

CONTACT INFORMATION

URL: www.handfoundation.org

EMAIL: [email protected]

PHONE: 610.768.5958

CME Credits available

E d d bS d b S t d b


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18

Vargas Mission to Armenia (continued from page one)

heavily on foreign aid, and directsupport provided from Armeniansliving in other parts of the world.

Health care in Armenia isslowly changing from its Sovietinfluences, which from a therapystandpoint, mainly involvedmassage and mobilization as theprimary treatment methods.Following a massive earthquake in1988, The Red Cross establishedArmenia’s first post-traumaticrehabilitation center, with trainedOccupational and Physical Thera-pists. Gradually formal educationalprograms for Kinesio-Therapistsand Occupational Therapists weredeveloped, with the main areas ofpractice being pediatric rehabilita-tion, and rehabilitation followingCVA’s and spinal cord injuries foradults. There currently are noformal therapist training programswhich are specific to upper extrem-ity pathologies or splinting.

My affiliation with Armeniabegan several years ago, when Iwas contacted through the IFSHT(International Federation of Societiesfor Hand Therapy) web site by anArmenian therapist named, HovikPiranyan. Initially we made plansfor Hovik to come to our clinic for ahand therapy educational experi-ence. When Hovik was not able toobtain a United States visitor’s visa,I had the idea to submit YerevanArmenia as a possible location for aVargas Mission. The preparationfor this mission spanned over two

years as we secured Armenianphysician support, and obtainedinvitations from several facilities inArmenia. I received the awardfrom the American Association forHand surgery in 2010, however wasnot able to complete the missionthat year, due to various schedulingdelays.

Meanwhile, in Chicago, Dr.Robert Schenck was being encour-aged by an Armenian friend, toconduct a medical mission toArmenia. Through the magic ofGoogle, Dr. Schenck discovered thatI would be going to Armenia as aVargas Award recipient. Even moreincredible was the fact that I used towork for Dr.Schenck about 20years ago. Wearranged tocomplete themission together,spanning fromMay 2nd throughMay 12th, 2011.Unfortunately,Hovik who hasbeen in Francefor the past fewyears completingtherapy trainingwas not available during ourmission. Our host for the missionwas Dr. Davit Abrahamyan, aplastic surgeon.

My initial three days werespent providing therapy consulta-tions during Dr. Abrahamyan’s

physician clinics. Although thera-pists were present during many ofthese appointments, there was littletime available for hand therapytraining. I learned that Dr.Abrahamyan, very skillfully hasbeen fabricating his own splints forpatients when needed, and essen-tially did not refer patients to thetherapists. He also was hoping thatI would teach his new employee,with no medical background, theessentials of splinting.

It was following much pressurefrom me and Dr. Schenck togetherthat I was finally allowed to spendmore time working directly withthe therapists. I found that as the

days passed,more thera-pists andstudents wereeagerlyshowing up atclinics where Iwas at, withsome comingall the wayfrom thecountry ofGeorgia. Iutilized everyopportunity to

provide splinting demonstrations,education regarding diagnoses,discussions on hand therapytreatment techniques, and toprovide educational presentationsfrom my laptop. Language was abarrier as many of the therapistsdid not speak English, necessitatingadditional time for interpretation. Iwas very impressed with theknowledge of the therapists forbasic therapy techniques, and fortheir eagerness to learn more.

The majority of the patientsseen were children, and quite a fewof them had birth-related brachialplexus palsy. There were someadult patients with various forearmor digit lacerations, now presenting

(continued on next page)Davit Abrahamyan, MD, Paula Galaviz MS, OTR, CHT, and Robert Schenck, MD.


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19

with contractures for splinting. Mymost interesting case involvedspotting a factitious disorder in a 15year old boy. In the evenings of ourfinal three days, Dr. Schenck and Ipresented a seminar to over 100physicians and therapists. Ourtopics included tendon repair andrehabilitation, compression disor-ders, brachial plexus palsy, and apresentation about hand therapy inthe USA. Throughout these presen-tations, the skills, knowledge andimportant contributions of handtherapists were highlighted,especially stressing the therapist/physician team approach.

Armenia’s Health Care Ministryprovides free services for children,handicapped individuals, andveterans. Hospital’s will completerequired surgeries in an emergencyfor adult trauma patients, butfollow-up care, elective surgery,diagnostic tests, and therapy mustbe paid for out of pocket. Insuranceis available for adults, at a cost,which most cannot afford. As aresult, medical services are unat-tainable for the majority of Arme-nians. The concept of a multi-disciplinary team caring for pa-tients is for the most part, absent.Most physicians manage casesindependently of rehabilitation,and do not yet seem to recognize itsimportance.

I think there are many obstaclesto overcome for a first hand therapyclinic to be established, includingthe following:1. Improved physician recogni-

tion of the importance oftherapy, improved physiciancommunication with therapists,and improved physicianutilization of therapy.

2. Improved therapy educationand skill development in theschools, and through profes-sional development methods(courses, written materials).

3. Establish an affordable methodof payment for adult therapyservices, so that provision oftherapy can be a viable service.

4. Obtaining equipment andsupplies (i.e. goniometers,splinting materials, modalities,etc.) – which currently arepractically non-existent.

I think additional exposure tothe successful models of handsurgery and therapy in the U.S. andperhaps other European countriesis needed to promote the continuedgrowth of therapy in Armenia. Thiscould happen through futuremission trips by U.S. therapist/physician teams to Armenia, orthrough Armenian physician/therapist visits to the U.S.

Armenians seem to be of themindset that they can only accom-plish things through foreignmonetary investments. I believethat they could work through manyof their procedural difficultiesusing the resources that they have,perhaps with some outside guid-ance. Consulting with profession-als in organizations such as AAHSwho have faced similar issues inother countries, could be verybeneficial.

I have been working on a fewissues since my return home. Ihave asked Scott Kozin, M.D. fromShriner’s Hospital in Philadelphia,if he would be willing to host a visitfrom Dr. Abrahamyan, and provide

training in surgeries for birth-related brachial plexus palsy. Hegraciously accepted, and Dr.Abrahamyan was very excitedwhen he learned of this opportu-nity. I have been communicatingwith a large service organizationfor people with developmentaldisabilities, regarding their poten-tial interest in arranging a serviceproject in Armenia to educate careproviders about program servicesfor people with developmentaldisabilities. I spent a portion of aday touring an Armenian residen-tial institution, and feel that en-hanced programming could im-prove the residents’ quality of life. Ihave also provided treatmentadvice via the internet to Dr.Abrahamyan while encouraginghim to refer the patient for therapy.

I am very thankful to AAHS forthis fantastic opportunity. I hopemy visit results in some positiveopportunities for growth fortherapists, physicians and residen-tial care programming services.

Vargas Mission to Armenia (continued from previous page)


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20

From the Editor’s Desk (continued from page 2)

Online AAHS membership applications are now available on the AAHS Website:

www.handsurgery.org

All AAHS members should consider sponsoring an associate, colleague, protégé, trainee, or fellow formembership in the American Association for Hand Surgery. Over the last several years the AAHS hasincreased its membership and continues outreach in this area. Because an application for membershiprequires support by an AAHS member, you are likely to be asked by a prospective applicant to serve as hisor her sponsor. We know that there are a number of hand surgeons, hand therapists, and allied healthprofessionals who have much to offer the Association. Please help us identify them.

To apply for AAHS Membership, applicants can begin the online application process themselves atwww.handsurgery.org or AAHS members may initiate an application for a new applicant in the MembersOnly area of the AAHS website.

Please feel free to contact the Membership Committee chairs if you have any questions regarding apotential candidate or the application process.

Jeffrey B. Friedrich, MD, Active Membership Committee ChairRebecca von der Heyde, PhD, OTR/L, CHT

Affiliate Membership Committee Chair

Recruit an AAHS Member

20 procedures such as carpaltunnel, basal joint surgery, flexortendon repair, Dupuytren’s contrac-ture, or metacarpal fracture.Theyenter data on-line from 10 consecu-tive cases of their chosen proceduresuch as carpal tunnel. They reviewa benchmarking report to see howthe rest of the diplomates managecarpal tunnel surgery. They com-plete an MOC-approved educa-tional activity in carpal tunnelsurgery such as the one beingoffered at AAHS 2012 in Red Rock.Finally, they complete the onlineAction Plan for Improvement.

In year 8, 9 OR 10 of the cycle,they take the 200-question com-puter based exam (part III). Theexam questions are based on theMOC Study Guide from ASPS toprepare for the examination.

Plastic Surgery has alreadyincorporated PIM’s and PI CMEinto their recertification process.They are required to obtain PI CME

and complete a PIM as part of thisprocess. In an effort to make thisprocess easier for our members, theAAHS will offer plastic surgerycertified PI CME at the annualmeeting this January in Nevada.

For orthopaedists whosecertificates expire in 2010-2012, therequirements will not involve anyPIM’s or PI CME. They will berequired to be licensed, have CMEthat includes a scored self-assess-ment exam, and provide a case list.It can be expected that over the nextseveral years, there will be arequirement to complete PIM’s andPI CME, but the exact method isstill being determined.

The goal of the PIM/PI CMEsummit in Rosemont was to 1.Develop PIM’s and PI CME that areuseful in promoting practiceimprovement, 2. Develop workingrelationships between the stake-holders (the board, AAOS, AAHS,etc), and to 3. Create standardiza-

tion among PIM modules. TheAAHS sees itself in a leadershiprole in this process in regard tohand surgery PIM’s. Given that wehave already developed these PIM’sfor our plastic surgery members,we feel that, with the help of theASSH, we can provide the PIM’sthat will best suit our members’needs.

If it isn’t clear from the proceed-ing paragraphs, Part IV of the MOCprocess is still evolving for handsurgeons. MOC is confusing and issignificantly different from our pastmethods of recertification. How-ever, it is critical that we shape theprocess. As with every aspect ofmedicine, if we don’t shape it forourselves, someone else will do itfor us. There is opportunity forinvolvement in this process forthose that are interested. If youhave an interest in developing aPIM or becoming involved in thisprocess please contact me and I willhelp you towards that end.


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21

NEW ADDRESS AND CONTACT INFORMATION

The American Association for Hand Surgery has moved.Please note the new address and phone numbers:

500 CUMMINGS CENTER, SUITE 4550BEVERLY, MA 01915

PHONE: (978) 927-8330FAX: (978) 524-8890

EMAIL: [email protected]

The mission of the Hand Surgery Endow-

ment is to foster and promote the highest

quality of hand care through development

and sponsorship of educational programs

related to the hand and the upper extrem-

ity, through communications with health

care professionals and the public, and

through the endowment of research.

The Hand Surgery Endowment depends greatly upon thegenerosity of AAHS members and affiliates for support.Contributions support current and future initiatives:

Guatemala Healing Hands Foundation

Health Volunteers Overseas Missions

Partnerships with International Federation ofSocietiesfor Surgery of the Hand (IFSSH), OrthopaedicResearch & Education Foundation (OREF), and manyother organizations for international outreach andvolunteer missions to improve global hand care

Vargas International Hand Therapist Teaching Award*

Research Grants, including the AAHS Annual ResearchGrant* and the HSE/AAHS/PSF Combined Pilot ResearchGrant*

* Applications for the AAHS Research Grant and Vargas Awardwill be available on the AAHS website in September.

DONADONADONADONADONATE TO HSETE TO HSETE TO HSETE TO HSETE TO HSE

Calendar2011September 8-10, 2011ASSH Annual MeetingLas Vegas, NV

September 22-25, 2011ASHT Annual MeetingNashville, TN

September 23-28, 2011ASPS Annual MeetingDenver, CO

2012January 11-14, 2012AAHS 42nd Annual MeetingRed Rock Casino Resort & SpaLas Vegas, NV

March 3-5, 2012 (Surgery)Hand Rehabilitation Founda-tion 2012 Surgery and TherapySymposiaLoews PhiladelphiaPhiladelphia, PA

March 3-6, 2012 (Therapy)Hand Rehabilitation Founda-tion 2012 Surgery and TherapySymposiaSheraton City Center HotelPhiladelphia, PA

2013January 9-12, 2013AAHS 43rd Annual MeetingNaples Grande Resort & ClubNaples, FL

2014January 8-11, 2014AAHS 44th Annual MeetingGrand Hyatt KauaiResort & SpaKauai, HI

https://impak.prri.com/hse_members_online/donate/index.asp


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Summer2011

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22

2012 Annual MeetingKeynote SpeakerProfessor Steven Levitt hasagreed to be our distinguishedkeynote speaker at the 2012Annual Meeting. ProfessorSteven Levitt is the author of thebestselling book, Freakonomics,and Superfreakonomics and isthe William Ogden Professor ofEconomics at the University ofChicago. He is also a contribut-ing author to the NY Times withhis weekly blog, Freakonomicswhich has also been turned intoa movie.

Saturday, January 14, 201210am – 11am

Red Rock Casino and ResortLas Vegas, NV

Professor Steven Levitt

Members Only Website Access:http://handsurgery.org/members/

AAHS Members have exclusive access to the Members Only area of the AAHS website. To access,simply log-in with your individual Username and Password. Contact the AAHS AdministrativeOffice if you need your login information.

Access HAND, the official Journal of the AAHS - This is the best way to gain full access.

Go Green and receive electronic-only access to HAND Search the AAHS Membership database by name,

geographic area, or specialty to find your colleagues. Sign up to receive Table of Contents alerts from

HAND. Update and verify your Member Record for efficient

and effective communication. Please be sure to noteyour specialty so your colleagues can find you!

2011-2012 Board of Directors

President: Steven McCabe, MD

President-Elect: Jesse B. Jupiter, MD

Vice President: Donald H. Lalonde, MD

Secretary: Brian D. Adams, MD

Treasurer: Michael W. Neumeister, MD

Treasurer-Elect: Peter Murray, MD

Past President: A. Lee Osterman, MD

Penultimate Past President: Nicholas B. Vedder, MD, FACS

Historian: Miguel A. Pirela-Cruz, MD

Parliamentarian: Jaiyoung Ryu, MD

Senior Directors at Large: Randip R. Bindra, MD, FRCS

Steven L. Moran, MD

Junior Directors at Large: Thomas B. Hughes, MD

Jeffrey B. Friedrich, MD

Past Sr. Affiliate Director: Susan Michlovitz, PT, PhD, CHT

Sr. Affiliate Director at Large: Georgette A. Fogg, OTR/L, CHT

Jr. Affiliate Director at Large: Sharon Andruskiwec, PT, CHT

www.handsurgery.org

http://handsurgery.org/meeting/

Documents

AAHS News Summer Draft.pmd