MDNews - Cleveland-Akron-Canton

January/February 2018

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IT'S NO SECRET that patients today seek the best possible outcomes with the least invasive procedures in order to minimize downtime in their daily lives. Improving these minima lly invasive procedures and quickly returning patients to their full potential has also been the goal of orthopaedic surgeons. This is most evident in qua lity-of- life-restoring surgeries such as tota l joint arthroplasties and arthroscopic approaches to tota l shoulder, hip and knee, as well as minimally invasive spine surgeries. While the majority of the atten- tion has focused on these large joints, it's important to note that minimally invasive techniques have also been developed in many areas of hand surgery. They include surger y for common neuropathies, treatment of arthritic con- ditions, fracture care and athletic injuries. The most common compressive neuropa- thy in the upper extremity is carpal tunnel syndrome. It is successfully treated via open carpa l tunnel release. However, endoscopic carpal tunnel surgery has been shown to decrease pain, restore grip strength and allow patients to return to work and other routine activities faster. This minimally invasive approach is also utilized in cubital tunnel syndrome. Severe neuropathy of the ulnar nerve can contribute to a significant dysfunction of the hand. Traditionally, a 15–20cm incision was made on the medial aspect of the arm in order to fully decompress the ulnar nerve. In the past, it was favored to perform a transposition. The more recent trend is endoscopic in situ decompression, which requires only a 1–2cm incision. T h is is not on ly cosmet ica l ly more appealing, but also 2009 Watts showed lower complication rates a nd higher patient satisfaction using endoscopic cubita l tunnel release versus open in situ decompression. While joint replacements in the hand are not as prolific as they are in the hip, knee and shoulder, there is hope for the millions who su‚er from arthritis of the hand. After non-operative treatments fail, options for arthritis in the hand include bone excision a nd f usion . A lt houg h e‚ective, these restrict function in an attempt to relieve pain when there are limited indications for joint replacement arthroplasty. Arthroscopic minimally invasive treatments for debridement, synovectomies and loose body removal can successfully prolong the longevity of the joint with pain-free function. In my practice, I o‚er arthroscopic minimally invasive approaches for arthritis of the elbow, wrist, metacarpophalangeal and thumb carpometacarpal joints. Acute traumatic and athletic injuries ca n be ma naged a r throscopica lly a s well. The main areas for arthroscopy in ha nd surger y a re in the wrist a nd elbow. Numerous fracture reductions and treatments have been described via arthroscopic or arthroscopic assisted procedures. These include surgery of the radial head, coronoid, distal radius and scaphoid (the most commonly fractured carpal bone in the wrist). Wrist arthros- copy can a‚ord an anatomic reduction of the fracture and then fixation of the scaphoid is accomplished percutaneously. Alnaeem, in his 2016 systematic review and meta-analysis, showed percutaneous scaphoid fixation versus non-operative cast immobilization achieved a faster return to work and time to union with no di‚erence in morbidity. This method further minimizes scarring as compared to traditional approaches to scaphoid. Finally, Dupuytren's disease, which has been widely treated via open procedure, has been trending towards less invasive procedures such as needle aponeurotomy ( NA) a nd Col la gena se Clos t r id iu m Histolyticum (CCH) injection since 2010. CCH a‚ords a return to normal func- tion within a week or two, as compared to open surgical interventions, which would take months to regain a similar level of function. Minima lly inva sive a r throscopic/ endoscopic hand surgery is an impor- tant, evolving approach that needs to be presented to patients as an option amongst traditional interventions. These tech- niques can translate to a patient's quicker recovery, less pain after surgery, minimal scarring and faster return of function. D r. R afa l S ta ch o w i c z i s a b o a rd- certified, fellowship-trained orthopedic surgeon specializing in hand and upper extremity surgery at Crystal Clinic in Montrose and Green OH. ■ RAFAL Z. STACHOWICZ, MD A Minimally Invasive Approach HAND SURGERY — 1 2 1 2S P E C I A L S E C T I O N : O R T H O P E D I C S

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