· reflex sympathetic dystrophy (rsd)/crps/sudeck … · 2019-08-03 · (rsd)/crps/sudeck does not...

ifsshezine

CONNECTING OUR GLOBAL HAND SURGERY FAMILY

www.ifssh.info VOLUME 9 | ISSUE 3 | NUMBER 35 | August 2019

UPCOMING EVENTS RESEARCH ROUND-UP

SPECIAL FEATURES · REFLEX SYMPATHETIC DYSTROPHY

(RSD)/CRPS/SUDECK DOES NOT EXIST · OUTCOME MEASUREMENT IN

HAND SURGERY

SUDECK / RSD / CRPS1

1

August 2019

3 EDITORIAL • IFSSH/IFSHT Congress, Berlin 2019 • Points to Ponder - Ulrich Mennen

4 EXECUTIVE NEWS President: Acceptance Speech - Marc Garcia-Elias

5 SECRETARY-GENERAL REPORT 14th IFSSH Congress Berlin, 2019 - Goo Hyun Baek - Daniel J. Nagle

8 PIONEER PROFILES • Stewart H. Harrison • Hanno Millesi

10 COMMITTEE REPORT • Asian-PacificFederationofSocietiesfor

SurgeryoftheHand(APFSSH)2019Report • Hand and Wrist Biomechanics International

(HWBI) • IFSHT report to IFSSH executive committee

meeting

14 SPECIAL FEATURES • Outcome measurement in hand surgery - Miriam Marks, - Daniel B. Herren • ReflexSympatheticDystrophy(RSD)/CRPS SUDECK does not exist. - F. del Piñal

21 ART "Together Strong"

34 RESEARCH ROUND-UP OutcomesFollowingReplantation RevascularizationintheHand - Hoyune Esther Cho, - Sandra V. Kotsis - Kevin C. Chung

36 MEMBER SOCIETY NEWS • TheBelgianSocietyforSurgeryoftheHand • AssociationofChinese-speakingHand

Surgeons United • Ecuadorian Hand Surgery Society

(ECUMANO) • BrazilianSocietyforSurgeryoftheHand

(SBCM) • AustrianSocietyforSurgeryoftheHand • ChileanSocietyforSurgeryoftheHand

42 SHARE SECTION ImagesfromtheIFSSH/IFSHTCongressin Berlin June 2019

57 UPCOMING EVENTS Listofgloballearningeventsandconferences

forHandSurgeonsandTherapists

www.ifssh.info VOLUME 9 | ISSUE 3 | NUMBER 35 | AUGUST 2019

contents

ThisAugustEzineissuefeaturestwothoughtprovokingpresentations. Both challenge conventual thinking. Both examine long held “truths”. Bothdemandarethinkofconceptswhichwehavepropagatedfromone generation to the next. Bothaskforaparadigmshiftinourclinicalpractice. Theremaybe(andprobablyare)morelonghelddiagnoses,concepts,didactic dogmas, surgical techniques, diagnostic methods, customs, and mannerisms which need “updating”. The challenge is on! With sincere regards,Ulrich

The14thtriennialIFSSHCongresshasbeenahugesuccess.Notonly“biggerandbetter”insize,attendanceandorganization,butalsoacademically the choice was outstanding. ThisagainemphasizestheimportanceoftheIFSSHfunction:tocreateaplatformforHandSurgeonsandHandTherapistsfromallovertheworld to share their experience, ideas and expertise. Andtointeract:buildingbridges Well done Berlin!

IFSSH/IFSHT Congress, Berlin 2019

EDITORIAL

IFSSH DISCLAIMER:The IFSSH ezine is the official mouthpiece of the International Federation of Societies for Surgery of the Hand. The IFSSH does not endorse the commercial advertising in this publication, nor the content or views of the contributors to the publication. Subscription to the IFSSH ezine is free of charge and the ezine is distributed on a quarterly basis. Should you be interested to advertise in this publication, please contact the Editor: [email protected]

IFSSH EZINE EDITORIAL TEAM:EDITOR:Professor Ulrich Mennen Past President: IFSSH

DEPUTY EDITOR: Professor Michael Tonkin Past President: IFSSH

GRAPHIC DESIGNER: Tamrin [email protected]

TO SUBSCRIBE GO TO: [email protected]

ifsshezine

CONNECTING OUR GLOBAL HAND SURGERY FAMILY

Points to Ponder

Prof. Ulrich Mennen

Editor: IFSSH Ezine

Past President: IFSSH

EDITORIAL

2 3

August 2019www.ifssh.info

EXECUTIVE NEWS

President: Acceptance SpeechMy dear colleagues:Iwishtothankyou,membersoftheMemberSocietiesofthisFederation,forhavingplacedyourtrustandconfidenceinme.Beingaskedtoserveasthe19thPresidentoftheInternationalFederationofSocietiesforSurgeryoftheHandisanhonour,andanundeservedprivilegewhichIwilltreasureallmylife.

Asyouprobablyknow,Iamawristsurgeon,andabasicscienceenthusiast,fascinatedbytheanatomyandmechanicsofthewrist.Maybebecauseofthis,Iknowthateventhemostsimplestructurebecomescomplexwhenyoulookatitcarefullyenough.Yet,weshouldnotregardcomplexityasathreat,butasanopportunitytoseefurther,achallengetoovercome.Complexityisonlyaproblemifoneisafraidoffacingit.ThisishowIthinkwe should work in this Federation. Let us not see “the different”asathreat,butasanotherindispensablefaceofthe polyhedron,we live in. In the IFSSH there is no place forqualifyingadjectivesthatsetborders,butonlyforthose that erase them.

Asidefromananti-supremacist,Iamalsoacompulsoryoptimist,apositivethinkingtypeofpersonwhoisnotafraidoffacingproblemsasapartoflife.Ilikeseeingtheglasshalffullratherthanhalfempty.Ibelieveinfindingsolutionswhereothersonlyseeproblems,andI wish I could contaminate you all with this attitude. To me that is the only way to do things. This does not mean thatIdisregardhowsignificantthiscommitmentis.Iknowitwillbehard,butIamreadytobuilduponthesuccessesofthepastanddowhateverIcantofulfillourmission, which is no other than to promote hand surgery throughout the world, to protect your interests worldwide, andtolookafterthewidercommunityofhandpatients.

Let’snotfinishthiswithoutexpressingourgratitudetothe outgoing Immediate Past President Michael Tonkin. Alwayskind,alwayshumble,heprovidedtheIFSSHwithdirectionandleadershipoverthelastfewyears.Hehandledmanydifficultissueseffectively.Ilearnedfromhim what “keep calm” means, despite my pronunciation wasneverbeingright.Butaboveall,hewaseffectiveatkeepingnon-essentialissuesoutoftheboardroom.Thesetraits I intend to continue during my term.

Thank you, Michael, and thank you all so much again.

Best wishes!

MarcKind regards,

Marc Garcia-EliasPresident: IFSSH.

SECRETARY-GENERAL REPORT

ItisagreathonourformetohavetheopportunitytoservetheIFSSHasSecretary-General.DuringthepreviousthreeyearsasSecretary-GeneralElect,ItriedtolearntheheritagesandlegaciesoftheFederationasmuchaspossible.

TheIFSSHnowhas60MemberSocietiesfromallovertheworldwhosecultures,languages,andwaysofthinkingdifferfromeachother.AlthoughIdonotunderstandallthedifferencesofthevariouscountries,Ifoundthatwecanfindagreementamongstourselvesthroughharmonyandteamwork.

TheBylawsoftheFederationstatethatitsmissionistocoordinatetheactivitiesofalltheSocietiesforSurgeryoftheHandthroughouttheworld,andinthiswaytopromoteknowledgeofsurgeryofthehand.

UndertheguidanceofMarcGarcia-Elias,ournewPresident,andwiththehelpoftheExecutiveCommitteemembersandtheMemberSocieties,IwilldomybesttocoordinatetheactivitiesoftheMemberSocietiesandtoincreaseandspreadthisknowledge,especiallytothedisadvantagedmembersandyounghandsurgeons. Future Meetings Adetailedlistofnationalandregionalhandsurgerymeetingsisavailableonthe IFSSHwebsite.ThetriennialIFSSHCongressesareasfollows:

XVth IFSSH – XIIth IFSHT Congress London, United Kingdrom 27th June - 1st July, 2022

XVIth IFSSH – XIIIth IFSHT Congress Washington D.C., USA 29th March - 3rd April, 2025

Goo Hyun Baek

Secretary-General, IFSSH

Email: [email protected]

Welcome from the incoming Secretary-General

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The14thTriennialCongressoftheInternationalFederationofSocietiesforSurgeryoftheHandandthe11thTriennialCongressoftheInternationalFederationofSocietiesforHandTherapywereheldintheBerlinCityCubefromJune17throughJune21.ThiswasthefirstCongresstoincludemanyactivitiesoftheFederationofEuropeanSocietiesforSurgeryoftheHand(FESSH).TheorganizingcommitteechairedbyProfessorJörgvanSchoonhoven,ProfessorMaxHaerle,ProfessorAndreasEisenschenk,NataschaWeihs&BeateJungorchestrated an extraordinary Congress. Over 4000 physicians and therapists participated in this meeting representing 92 countries. The Congress theme was “Building Bridges Hand in Hand” and given the massive international attendance it is clear the Congress did indeed accomplish that goal.

Themeetingfeaturedapre-CongressMondayeducationdaywhichfeaturedmanyindustrysponsoredcoursesandlectures.TheCongressofficiallyopenedMondayafternoonwiththeOpeningCeremonythatfeaturedtherecognitionofnewlynominatedPioneersofHandSurgery.Thirty-sevenPioneersfrom19societieswerehonored.ThesePioneersalongwiththeirfamiliestravelledfromallovertheworldtoparticipateinthisceremonythatwasindeedmonumentalandinspiring.TheOpeningCeremonywasfollowedbyacocktailpartywithanentertainingperformancefrom“TheCarpalBossandLooseBodies”band,featuringmanyhandsurgeonsandtherapistsfromaroundtheworld.

Thescientificprogramwasimpressive.TherewasanoverwhelmingresponsetotheCallforAbstracts,with1800submissionsassessedby242reviewers.TheCongressOrganizingCommitteethenappointed45Germancolleaguestolead27subgroupsandworkwith27internationalhandexpertstobuildthescientificprogramme.Thefinalprogramincluded357invitedlecturesand1123freepapersoverseenby347chairpersons.

TheIFSSHDelegatesmetonWednesday,June19,2019.ThefirstorderofbusinesswastowelcomeanewmembertotheIFSSHfamily,theEcuadorianSocietyforSurgeryoftheHand.TheEcuadoriansocietyisthe60thsocietytojointheIFSSH!

ThenextorderofbusinesswastheelectionofthenewExecutiveCommittee(ExCo):ImmediatePastPresident: Dr.ZsoltSzaboofHungaryPresident: Dr.MarcGarciaEliasofSpainPresidentElect: Dr.DanielNagleoftheUnitedStatesSecretary-General: Dr.GooHyunBaekofSouthKoreaSecretary-GeneralElect: Dr.RajaSabapathyofIndiaHistorian: Dr.DavidWarwickofEnglandMemberatLarge: Dr.JinBoTangofAssociationofChinese-speakingHandSurgeonsUnited

TheExCo,duringthecomingmonths,willbeworkingwiththeDelegatesonmuchneededbylawschangesaswell as structural changes to increase Society participation in the ExCo.


TheDelegateswerethenchargedwiththeselectionofthe2025IFSSHtriennialmeetingsite.Dr.ScottLevin,thecurrentPresidentoftheASSH,presentedthewell-preparedbidbyTheAmericanSocietyforSurgeryoftheHandandtheAmericanAssociationofHandSurgerytohostthe2025IFSSHTriennialCongressinWashingtonDC.Dr.MarcelloRosadeRezende,PresidentoftheBrazilianSocietyforSurgeryoftheHand,providedtheDelegateswithanexcellentpresentationpromotingRiodeJaneiroforthe2025IFSSHCongress.Finally,Dr.LuisNaquira,PresidentoftheColombianAssociationofHandSurgery,gavearousingpresentationurgingtheDelegatestosupporttheColombianbidtotakethe2025IFSSHCongresstoCartagenadeIndias.InspiteofexcellentpresentationsbyDr.RezendeandDr.Naquira,theAmericanbidprevailed.The202515thTriennialIFSSHCongresswillbeheldinWashingtonDC,USAfromMarch29toApril3.TheIFSSHisveryindebtedtotheAmerican,BrazilianandColombianSocietiesfortheirdedicationtothecreationofextraordinarybidsandsuperbpresentations.

Thisyear’sinvitedSwansonLecturerwasDr.StevenHoviuswhoprovidedaninsightfulandthought-provokingdiscussionofthechallengesfacinghandsurgeonsaroundtheworldastheytrytoprovidethebestcaretotheirpatients.ThePresidentialGuestLecturewasdeliveredbyProfessorDr.KlausLeisinger,raisingtheinterestofparticipantswithhisthoughtson“Criticalissuesforaworldwewant:Whatdoweknow?Whatshallwedo?Whatmaywehope?”

Ofcourse,everyIFSSHCongressprovidesopportunitiesforsocialinteractionbetweenthemembersofourmembersocieties.TheGermansocietyorganizeda“BerlinNight”atarenovatedcoldstoragefacility(TheKühlhaus)datingbacktotheearly20thcentury.HighpoweredmusicfilledtheairwhileattendeesdancedandenjoyediconicGermanfoodanddrink.TheGaladinnerwasheldonThursdaynightattheRitz-Carltonandfeaturedgreatfoodanddrinkaswellasanoutstandingbandthatkepthandsurgeonsandtherapistsdancingintotheweehoursofthemorning.

Onceagain,manythankstotheGermanSocietyforHandSurgery,GermanSocietyforHandTherapy,FederationofEuropeanSocietiesforSurgeryoftheHandandtheInternationalFederationofSocietiesforHandTherapyforputtingonatrulyextraordinaryCongress,Bravo!

Best wishes to all. Dan

Daniel Nagle

President Elect, IFSSH


MESSAGE FROM OUTGOING SECRETARY-GENERAL: DANIEL NAGLE

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PIONEER PROFILES

StewartH.Harrisonwasbornon 15 July 1912 in Highgate, London, UK. Both parents died when he was still a pre-schooler.Hewasbroughtupbyhismaternalgrandparentsin Dunblane, Scotland, andattended Stanley House SchoolinBridgeofAllan.

In1934hequalifiedinDentistryandin1935inMedicineattheEdinburghUniversity,Scotland.HeobtainedhisFRCSfromEdinburghin1938.

During the SecondWorldWar, he served asMajor inthe Royal Army Medical Corps, stationed in Nigeriaand later in north-west Europe. Following the war, he worked at the Birmingham Accident Hospital, training under Sir Harold Gillies. In 1958 he worked with RainsfordMowlemattheMountVernonHospitalwherehedevelopedanumberofoperations,amongstothersthe techniqueofdelayedprimaryflexor tendongraftsforflexortendoninjuries.Hisplasticandreconstructivesurgery background saw him promoting the novelconceptofprimaryflapcoverofopenlowerleginjuriesby cross leg flaps. This new technique drasticallyreduced the infection rate.Thesecross legflapshavenowbeenreplacedbymicro-vascularfreeflaps,buttheprinciple stays the same.

Another of his pioneering contributions waspollicisation for the Thalidomide cases, tendontransfers as a prophylactic procedure to prevent thedeformingcycleoftherheumatoidwrist,andearlyPIP

joint fusion with his newly developed polypropyleneintramedullary pegs. In 1979 Harrison was appointed the Hunterian Professor for his contribution to thetreatmentoftherheumatoidhand.Healsowrotearticleson thesurgicalmanagementofburninjuries,cranio-facialreconstructionandchronicinfectionoftheaxilla.

In1956StewartHarrison,AdrianFlatt,RobertRobbins,Douglas Reid and Graham Stack started the SecondHandClub,whichunlike the FirstHandClub, had anopenmembership!ThetwoHandClubsjoinedtogetherin1968tobecometheBritishSocietyforSurgeryoftheHand. He served as President in 1972. In 1976 he was electedPresident of theBritishAssociationofPlasticSurgeons.

Hislast5yearsofretirementwasspentinSpainwherehediedon12May2011attheageof98years.Stewart Harrison was married to Phyllis Eustace in 1942, and they have one son.

AtTheEighthCongressoftheInternationalFederationofSocietiesforSurgeryoftheHandinIstanbul,Turkey,10 June 2001, Stewart H. Harrison was honoured as “PioneerofHandSurgery”.

PIONEER PROFILES

Hanno Millesi was born on24 March 1927, the son of ageneral practioner in Villach, Carinthia, Austria. In 1951, he received his medical degree from the Universityof InnsbruckMedicalSchool.He then trained in pathology and internal medicine at the Wilhelminen Hospital in

Vienna, and in general surgery and plastic surgery at the 1stSurgicalClinic,UniversityofViennaMedicalSchool.He studied with Dr. Alan Ragnell at the StockholmSurgical Hospital, Sweden. In 1967 he obtained hispostdoctoral qualification based on extensive researchonthepathogenesesofDupuytren’scontracture. Millesi was appointed Head of the Section of PlasticSurgery,1stSurgicalClinic,UniversityofViennaMedicalSchool and Associate Professor of Plastic Surgery in1972.HewasProfessorofPlasticSurgeryattheViennaUniversityMedicalSchoolfrom1982until1995,whenhebecameProfessorEmeritus.In1974hefoundedthefirst24-hour replantation service in Europe with colleagues frombothSurgicalUniversityClinicsinVienna.HewasappointedDirectoroftheLudwig-BoltzmannInstituteforExperimentalPlasticSurgery,Vienna(1975),andHeadofthenewPlasticandReconstructiveSurgeryClinicoftheUniversityofVienna(1993).InJanuary1996,hebecameMedicalDirectoroftheViennaPrivateHospital. He authored or edited 20 textbooks and over 320scientific publications on his areas of study, includingthepathogenesisofDupuytren’scontracture;mechanicalpropertiesofpalmaraponeurosis,tendon,skin,andscartissue; biomechanical properties of elastase; healingof nerves; gliding apparatus of peripheral nerves;

microsurgery of peripheral nerves; interfasiculargraftingofmedianandulnarnerves,andnervegraftingofthebrachialplexus. He was a member of 21 scientific societies includingthe Austrian Society for Surgery of the Hand, and theAmerican,British,French,Italian,Spanish,Venezuelan,and Turkish Hand Societies, and the International College of Surgeons. He was FoundingMember and Presidentof the Austrian Society of Plastic Surgery (1971-75),International Society of Reconstructive Microsurgery(1972-73), GermanSpeakingStudyGroup onPeripheralNervesandVessels (1978-82), and theAustrianSocietyforSurgeryof theHand(1989-96). HewasPresidentofthe Sunderland Society (1985-86) and the InternationalCollege of Surgeons-Austrian Section (1985-1998), andmember of the Executive Council of the InternationalConfederationforPlastic,ReconstructiveandAestheticSurgery(1987-95). Prof.Millesihasreceivednumeroushonoursandawards,amongst others: Hoechst (1967), Eiselsberg (1972) andGerman Society of Surgery Jubilee (1974) prizes. GoldMedals from the Italian Club of Microsurgery (1980)andthecitiesofVienna(1987)andMilan(1988),DoctorHonoris Causa University of Breslau, Poland (1980),Commandant of the Italian Republic (1982), AustrianGoldenAwardforScienceandResearch(1995).HegavetheMoberg (1973),Kazanjian (1975) andASSHFounder(1987)Lectures. Attheageof90years,HannoMillesipassedawayon28April 2017 in Viena, Austria. In May1998, Prof.Dr.HannoMillesiwashonouredas”Pioneer ofHandSurgery” by the IFSSHat its SeventhInternational Congress in Vancouver, B.C., Canada

STEWART H. HARRISON LDS, RCS (Edinburgh), FRCS (England)United Kingdom (1912 - 2011)

HANNO MILLESI MDAustria (1927 - 2017)

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COMMITTEE REPORTS

Reports from IFSSH affiliated OrganisationsASIAN-PACIFIC FEDERATION OF SOCIETIES FOR SURGERY OF THE HAND (APFSSH) 2019 REPORT

19th June 2019, Goo Hyun Baek

Current Member Societies (13)Australian Hand Surgery SocietyBangladeshSocietyforSurgeryoftheHandHongKongSocietyforSurgeryoftheHandIndianSocietyforSurgeryoftheHandIndonesianSocietyforSurgeryoftheHandJapaneseSocietyforSurgeryoftheHandKoreanSocietyforSurgeryoftheHandMalaysianSocietyforSurgeryoftheHandNewZealandSocietyforSurgeryoftheHandAssociationofHandSurgeonsforthePhilippinesSingaporeSocietyforHandSurgeryTaiwanSocietyforSurgeryoftheHandThaiSocietyforSurgeryoftheHand Observer Societies (5)ChinaSocietyforSurgeryoftheHandMyanmarSocietyforSurgeryoftheHandPakistanSocietyforSurgeryoftheHandVietnamSocietyforSurgeryoftheHandSriLankaSocietyforSurgeryoftheHand APFSSH Executive CommitteePresident:GooHyunBaek(Korea)President-Elect:RajaSabapathy(India)GeneralSecretary:TonyBerger(Australia)GeneralSecretary-Elect:FuminoriKanaya(Japan)ImmediatePastPresident:Yuan-KunTu(Taiwan)

Official Journal of APFSSH‘TheJournalofHandSurgeryAsian-PacificVolume’since 1996Published4issues(Mar,June,Sep,Dec) APFSSH Congresses11thAPFSSHMeeting:CebuCity,Philippines(7th-10thOctober,2017)12thAPFSSHMeeting,Melbourne,Australia(9th-11thMarch,2020)13thAPFSSHMeeting,Singapore(May,2023)

This past year has seen many developments in the activitiesoftheAPFSSH.ManyoftheoriginalaimsofthefirstCharteroftheAPFSSHbeingtopromoteHandSurgeryandEducationintheRegionandtosupportaTravellingFellowshiphavebeensomewhathamperedbyalackoffundsanddifficultiesincoordinatingactivitiesthroughouttheregionundertheumbrellaoftheAPFSSH.Allthemembersocietiesareveryactiveintheirowncountriesandhavefrequentcombinedscientificmeetings.TheFederationhassomefundsbutthesearebeingheldbymembersocietiesfromdonationsandfromtherunningofourscientificmeetings.InordertoincreasetheactivityoftheFederationtheexecutivehasoverthepast2yearsbeenworkingtowardsestablishinganofficeandabankaccountwherefundscanbecollectedandthenusedtoachievetheaimsoftheFederation.WithsomanydifferingcountriesandlawsintheregionthisprovedtobealittledifficultbutwiththeworkofourSingaporeancolleaguesweareonthethresholdof

opening an account and having an administrative baseinSingapore.InordertosatisfythefinancialrequirementsofSingaporeithasalsobeennecessarytoestablishaproperConstitution.ThishasbeenamonumentaltaskwithusefulcontributionsfrommanymembersofourFederation.TheConstitutionwasvotedonandadoptedbytheexecutiveandmemberdelegatesat a Council meeting in Taiwan last month. With a fewdetailstocompleteoverthenextfewmonthstheFederationwillsoonbeabletoachieveitsaimsintheregion. TheJournalofHandSurgeryAsianPacificVolume,istheofficialjournaloftheAPFSSHwhichispublished4timesayear.181articlesaresubmittedin2018,andacceptance rate was 36%. TheFederationwebsiteisalsoundergoingaredevelopmentandwiththeincreasedactivityoftheFederationwehopetoencouragemorecontributionstothewebsitewithmeetingannouncementsandothereducational activities. With the Constitutional work completed the attention oftheFederationisnowdirectedtowardsthenextAPFSSHmeetingtobeheldinMelbourneAustraliainMarch2020.Thisisco-convenedbytheAustralianand New Zealand Hand Surgery Societies and the AsianPacificWristAssociation.ItisagainheldinconjunctionwiththeAPFSHTwithmanycombinedsessions. We are also trying to support registrations fromhandsurgerysocietiesfromdevelopingnationsinourregionbyofferingreducedregistrationratesandraisingfundsfromotherregistrationstofurthersupportattendeesfromthesemembersocieties. WhilstMelbournemaybefartotravelforsomeMembers,Iwouldliketoencourageasmanyofyouaspossibletoattend.Iamsurethetripwillbeworthwhile.

HAND AND WRIST BIOMECHANICS INTERNATIONAL (HWBI)

www.hwbi.org

Thehandandwristrepresentoneofthemostchallengingstructuresinthestudyofbiomechanics,aswellasintheevaluationofmanybiomechanicalprinciples.Handandwristbiomechanicshasbeensomewhatunderdevelopedincomparisontomainstreambiomechanicsresearchoverthepastcentury.Whilenumerousbiomechanicalstudieshavebeeninitiatedbysurgeonsandengineers,collaborativeeffortsamongscientistsandcliniciansarerequiredinorderforcontinuingprogressioninresearchandfurtherimprovementoftreatmentmodalitiesandoutcomes.

For over 25 years, the International Symposia on Hand and Wrist Biomechanics have provided the opportunityforglobalscientificexchangeandmutualencouragementamongbasicscienceandclinicalinvestigators. In 2012, the International Advisory BoarddecidedtoformHandandWristBiomechanicsInternational(HWBI)tofurtherenhancethedevelopmentofhandandwristbiomechanicsanditsclinical applications. It is our hope that through the structuredorganizationofHWBI,researchactivitiesrelatedtohandandwristbiomechanicswillbeelevatedandclinicaltranslationwillbeimproved.

HWBIisaffiliatedwithInternationalFederationofSocietiesforSurgeryoftheHand(IFSSH)andtheInternationalSocietyofBiomechanics(ISB).Withtheseaffiliations,theHWBIbenefitsfromIFSSH’sandISB’sestablishedexcellenceaspremierinternationalorganizationsandtheirvastumbrellanetworksinpromotingbasicscienceandclinicalapplications.Inturn,theHWBIcontributesitsspecialtyknowledgetothebroadfieldsofhandsurgeryandbiomechanics.HWBIregularlyorganizessymposiainconjunctionwith IFSSH and ISB congresses.

COMMITTEE REPORTS

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COMMITTEE REPORTS COMMITTEE REPORTS

IFSHT REPORT TO IFSSH EXECUTIVE COMMITTEE MEETING

17JUNE2019.AnneWajon,PresidentIFSHTCityCube,Berlin

IFSHT PRESIDENT ACTIVITIES 2016-2019• Hosted IFSHT EXCO interim meeting in Hong Kong,

2017topreparegoalsforcurrentterm• Approved and appointed an administrative

assistant• FinalisedadjustmentofIFSHTmembershipfeesto

bemoreequitableandsustainable,effective• January 2020• DeletedtheCommercialmembershipcategory(to

bevotedonatCouncilmeeting)• RewrotetheIFSHTcontracttemplateforfuture

congresses,andupdatedsignedagreementsfor• Berlin 2019 and London 2022• RepresentedIFSHTatEurohand2017,ASHT2017

and 2018, APFSHT 2017, EFSHT 2018• Attended site visit in Berlin, 17-19 June 2018, in

preparationfor2019Congress• Continuetoupdatewebsitecontent,including

offeringonlineapplicationsformembership,awardsandgrants,aswellasinformingmembersofonlineresourcesandeducationalopportunities.

IFSHT TRIENNIAL MEETINGS11th IFSHT Triennial Congress / 14th IFSSH Triennial Congress, 2019 Berlin, Germany• 30-year IFSHT anniversary – goniometers

purchasedascelebratorykeep-sake• InauguralpresentationofLifetimeAchievement

award• WorkedwithourinternationalCo-chairsof

theScientificProgramtoensurehighqualityworkshops and papers at Congress

12th IFSHT Triennial Congress / 15th IFSSH Triennial Congress, 2022 London, UK• Websiteaddressupdatedtoifssh-ifsht2022.com.• NicolaGoldsmith(President-elect)workingwith

BAHTandIFSSHaftercompletionofBerlin2019.

13th IFSHT Triennial Congress / 16th IFSSH Triennial Congress, 2025• Receivedbids:Delegateswillbevotingon

combinedASSH/AAHS/ASHTinWashington• DC, ASOCIMANO/ASCOTEMA in Cartagena,

ColumbiaandfromSBCM/SBTMRiode• Janeiro,Brazil.

IFSHT MEMBERSHIP• Fullmembers:37,representingmorethan9500

hand therapists worldwide. Greece reinstated• Associatemembers:Bangladesh,Mexico,Nepal,

Philippines, Qatar, Singapore, Thailand, and United ArabEmirates.

• Correspondingmembers:Bahrain,Barbados,Gaza,Ghana,Iran,Malta,Romania,SaudiArabia,SriLankaandZimbabwe.

Regional Liaison Organisations: American Association forHandSurgery(AAHS),AsiaPacificFederationofSocietiesforHandTherapy(APFSHT),EuropeanFederationofSocietiesforHandTherapy(EFSSH),InternationalFederationofSocietiesforSurgeryoftheHAND(IFSSH)andInternationalSocietyforSportTraumatologyoftheHand(ISSPORTH)andSouthAmericanSocietyHandTherapy(SSTM).

COMMUNICATIONWithin IFSHT:- Executive committee:• Continue to chair regular Skype-call meetings, and

useTeamworksasourvirtualoffice• Havebeenworkingcloselywithsecretarygeneral

to ensure goals achieved and queries addressed.• Preparedthebudgetfor2019-2022,allocatingfunds

formajorwebsiteupdate

- Committee activity:• Educationcommittee:hascompletedasurveyof

fullmembersinvestigatingsocietyactivities,andalsoaskedassociate/correspondingmembersfortheir needs to aid development

• Ad Hoc Social Media Committee has posted updatesaboutIFSHTandtheCongressinBerlin

• By-laws Committee has made some updates, especiallytoreflectdeletionofcommercialmembershipcategory

• Translation committee: now translating IFSHT Update into Japanese and Spanish.

- Delegate communication:• Delegatescontinuetoreceiveregularupdatesfrom

the IFSHT Secretary General and vote electronically in IFSHT elections.

With Hand Therapists around the world:• IFSHTUpdate:published4xannuallyintheUS

andtheBritishJournalsofHandTherapyanddistributedtoallmembercountries.NowincludedintheIFSSHEzine.

• IFSHTwebsite(www.ifsht.org):Continuetoregularlyupdatewebsitewithnewfeaturesandcontent.Over300requestsforhandtherapyinformation,education,internationalreferralforpatient care received over last three years.

• IFSHT Hand Therapy Connections E-Newsletter: 2x peryear.Currently,1937subscribers.

• IFSHTFacebook:remainsactiveIFSHTcontributiontoIFSSHE-zine:IFSHThascontinued to source and prepare a short clinically relevantarticlefortheIFSSHEzine.RecenttopicsincludesplintingforthumbMPjointhypermobility.

IFSHT AWARDS AND SPONSORSHIP ACTIVITY

-EvelynMackinAward:sponsorshipofatherapist(s)fromadevelopingcountrytoattendtriennialcongress.In2019,IFSHTfullysupportedfourtherapiststoattendthecongress.TherapistswerefromBhutan,Zimbabwe,EstoniaandPoland.IFSHThas

bookedandpaidforflights,accommodationandregistrationinfull.

- IFSSH/IFSHT Triennial Congress Travel Grant: Eighteenapplicantsreceivedfundstosupport,registration, accommodation and/or travel. Funds were distributedbasedonguidelines,specificallyforcountrieswithlowGDP,forassociatememberswhohadnotattendedtheCongresspreviously,withfundsfromthe2016SilentAuctionspecificallyusedtosupport speakers and poster presenters.

- IFSHT-IFSSH International Hand Therapy Teaching Awards. During this term, grants madeavailabletosupporttherapiststeachinghandtherapyin less-developed countries have increased to$US1500. Four applications were received and support offeredto:• JaneFedorczyk(USA)travelledtoRwandainApril

2018(fundsnotrequired)• JennyBall(Australia)travelledtoNepalinMay

2018• MerylGlover(UK)travelledtoMalawiinOctober

2018• ShrikantChinchalkar(Canada)travelledtoSri

LankainFebruary2019

-CristinaAlegriAwardforInnovationinHandTherapywillbeawardedatcloseofinnovationsessionon Friday. Eight worthy nominations were received.

-TheinauguralIFSHTLifetimeAchievementAwardwillbeawardedin2019tohonorthosewhohavemadeaglobalimpactonprofessionofhandtherapy. 13 recipients will receive award at IFSHTopening ceremony on Tuesday 18 June.

-Dynamometers:~15available.SinceJune2018,deliveredtoNepal,Bolivia,Tanzania,Rwanda,Zimbabwe,India,Vietnam,Malawi,Argentina,Kathmandubyvisitingtherapists.

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SPECIAL FEATURE

Outcome measurement in hand surgery

This article provides an overview on why and how data can help to improve high-quality patient care inhandsurgery.Itsummarizesthemostcommonpatient-reportedoutcomemeasures(PROMs)thatcanbeusedindailypracticeandforstudies.Furthermore,itfocusesonhowtointerpretPROMsdataandshowsthat several clinically relevant interpretation methods areavailable,regardlessofthestatisticalp-value.

Why outcome measures? Without measuring treatment outcome, we can neither improve our hand surgical interventions nordemonstratetheireffectiveness.Althoughsomeinterventionshavebeenproveneffectiveandsafefora certain patient population, this does not necessarily

meantheycanbeappliedtopatientsinanotherclinicalsetting.Therefore,standardizeddocumentationofoutcomesisessentialnotonlyinstudies,butalsoin clinical routine. For the latter, documentation is bestrealizedusingregistries.Largeregistriesinhandsurgery are rare. Unlike in orthopedics, where such registries have a long tradition, hand surgical data are onlynowbeingcollectedonlargerscalesinasmallnumberofcountries.

Thesebigdatabasesarerequiredtogainmoreevidenceaboutinterventionsthatisstatisticallysoundandrepresentsareal-worldsetting.Registrydatamaybeconsideredadvantageousoverresultsstemmingfromindividual and somewhat restricted clinical trials.

SPECIAL FEATURE

Table 1: Most common and validated PROMs for patients with hand conditions

Name Target population No of items Domains Pros / Cons

MHQ3-10 All hand conditions 37 items Six subscales: overall hand function, activities of Pros: Good measurement properties, scores both hands separately, subscales can be scored individually

daily living, pain, work performance, aesthetics, Cons: Quite long

satisfaction

Brief MHQ8,11-13 All hand conditions 12 items Six domains: overall hand function, activities of Pros: Good measurement properties, short

daily living, pain, work performance, aesthetics, Cons: Subscales cannot be scored individually

satisfaction

URAM14-16 Dupuytren’s disease 9 items One domain measuring functional disability of Pros: Good measurement properties, specific for patients with Dupuytren’s disease, short

patients with Dupuytren’s disease Cons: Not suitable for other hand conditions

BCTQ / Levine Carpal tunnel 19 items Two subscales: symptom severity scale, functional Pros: Specific for CTS, good measurement properties

Scale17-19 syndrome (CTS) status scale Cons: Not suitable for other hand disorders, potential item redundancy

Overall,outcomemeasurementshelptoquantifypatientbenefitandtheeffectofanewinterventioncomparedtoestablishedprocedures.Theycanalsohelpinidentifyingremainingdeficitsafterinterventions as well as the associated socio-economic consequences. In the modern world with its increasing healthcosts,outcomemeasuredatacanformthebasisfornegotiationswithhealthauthorities.Ultimately,wewouldalsoliketoknowjusthowourpatientsarereallydoing.

Most commonly used patient-reported outcome measures (PROMs) Awidevarietyofoutcomemeasuresareavailableforassessinghandconditions.Aliteraturereviewanalyzingaseriesofstudiesfocusedontreatmentfortrapeziometacarpalosteoarthritis,forexample,revealedthattherewere21differentquestionnairesinuse.1SimilarfindingshavebeenreportedforDupuytrenstudies,wherebyonly14%usedvalidatedPROMs2. The diversityinreportingoutcomesmakesitdifficulttocompareresultsbetweenstudies.Table1highlightsthemostcommonandvalidatedPROMsforpatientswithdifferenthandconditions.

TheDisabilitiesoftheArm,ShoulderandHandquestionnaire(DASH)oritsshortenedform,thequickDASH24,25ismissinghere.Why?TheDASHisstillthe

most commonly used questionnaire in hand surgery, and several studies attest to its good measurement properties26-29. BUT: The DASH is intended to measure functionoftheentireupperextremityandnotjustthe hand. The questionnaire contains items relevant toshoulderandelbowfunctionthatsignificantlyinfluencethetotalscore.Therefore,itisrecommendedtouseahand-specificquestionnairefortheprimaryevaluationofhandsurgicalprocedures.TheDASHmightstillhaveitsplace,forexample,inmorecomplexdisease patterns such as rheumatoid arthritis, where thewholeupperextremityisinvolvedandtheeffectofasingleinterventiononglobalfunctionrequiresevaluation.

Core setsOutcomemeasuresshouldcoveralldomainsofinteresttocomprehensivelyassessthehealthstatusofapatient.Forexample,thedimensionsofobjectivedata(clinicalmeasures,radiologicalcriteria),functionaloutcome(handandextremityspecific)andpatient-ratedsubjectivedata(qualityoflife,functionandpain)togetherwithsocio-economicdataandcomorbiditiesareofinterest.Thisimpliestheuseofmanydifferentoutcomemeasuretools,whichmaycontributetoahighadministrativeburdenforboththehealth-careproviderandpatient.Ifavailable,coresetsassessingthe clinical and patient-reported outcomes as well

MHQ=MichiganHandOutcomesQuestionnaire;URAM=UnitéRhumatologiquedesAffectionsdelaMain(URAM)scale;BCTQ=BostonCarpalTunnelQuestionnaire;PRWE=PatientRatedWristEvaluation

“If you can’t measure it, you can’t improve it” - P. Drucker

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SPECIAL FEATURE SPECIAL FEATURE

ascomplicationsshouldbeused,suchasthealreadyestablishedcoresetsforassessingpatientswithdistalradiusfractures30orhandosteoarthritis(OA)31.

Somerecentprojectsareconcentratingontheestablishmentofaminimaldatasettoevaluatesubjectiveoutcomewithonlyasmallnumberofrelevantquestions.Inthefieldsofthelowerandupperextremity as well as spine surgery, this approach has provensuccessful.A6-item“CoreOutcomeMeasuresIndex”questionnairedevelopedforpatientswithspine, hip and knee disorders32-34 and the 1-item “Single AssessmentNumericEvaluation”toolforpatientswithshoulder disorders35bothcompriseaminimaldatasetthatdeliversusefulinformationonthetreatmentoutcomes. Such a short, multidimensional tool could alsobeappliedinhandsurgery.Itcouldevenserveasapreoperative evaluation tool to determine the patient’s needs and expectations, which may in turn help to improvetheindicationqualityfordifferenttherapyoptions.

Statistical versus clinical significance Theinterpretationofstudyresultsistraditionallybasedonstatisticalsignificance.However,astatisticallysignificanttreatmenteffectdoesnotnecessarilyequatetoameaningfuloutcomeforthepatient36,37.Thepatient’sperceptionofatreatmenteffectisimportantandshouldbeconsideredineveryinstanceofclinicalcare.

“Basedonthep-value≤0.05,weconcludethatourtreatmentwaseffective”.Inresearcharticles,weoftenencounterthiskindofstatement.However,isthisstatisticaleffectivenessdirectlyrelatedtothatperceivedbythepatientsthemselves?Toanswerthis question, one should take a closer look at the characteristicsofp-values.TheAmericanStatisticalAssociation(ASA)highlightsthecommonissueswithp-value.Asmallp-valueofteninducesaninappropriateconclusionthatalargetreatmenteffectwasachieved36. However,ap-valueprovidesneitheradirectmeasureofthemagnitudeofatreatmenteffectnordescribesthe

importanceoftheresults.Thecalculationofap-valueisbasedonthesamplesize.Thelargerthesamplesize,the more likely a statistical analysis will result in a “significant”p-valueregardlessofwhethertherewasonlyasmalltreatmenteffect.Incontrast,“significance”mayprobablynotbeattainedwithasmallsamplesize,althoughalargetreatmenteffectisapparent36.Therefore,alternativeinterpretationsoftreatmenteffectsbasedonclinicalrelevancehavebecomeincreasingly popular38,39. There are three underlying concepts that measure this aspect:

1. Minimal Important Change (MIC) Theminimalimportantchange(MIC)isthesmallestchange in a score, which patients perceive as important. This outcome considers any change within a single group or patient40,41, and changes exceeding theMICcanbeconsideredrelevantforthepatient42.A related term known as the minimal clinically importantdifference(MCID)isalsowidelydescribedintheliterature.SeveralstudiesdefinedtheMICforvarious outcome measures in hand surgery13,43-48;forexample,theMICfortheMichiganHandOutcomesQuestionnaire(MHQ)is11points47.

2. Minimal Important Difference (MID) Theminimalimportantdifference(MID)isthesmallestdifferencebetweenpatientsorpatientgroupsthatisconsidered important40,41. In hand surgery, the MID has onlybeencharacterizedfortheUnitéRhumatologiquedesAffectionsdelaMain(URAM)scaleinpatientswith Dupuytren’s disease and is 8 points44.

3. Patient acceptable symptom state (PASS) Thepatientacceptablesymptomstate(PASS)isthevaluebeyondwhichpatientsconsiderthemselveswell49.ThisvaluehasbeendeterminedforthequickDASHinpatientsaftercarpaltunneldecompression(PASS≤34)27. In patients with hand osteoarthritis, PASSvaluesaredefinedfortheAustralian/Canadian(AUSCAN)HandOsteoarthritisIndex(PASS≤43)50, pain numericratingscale(PASS≤1-5-4.1)12,51andthebriefMHQ(PASS≥64)12.

Example: Interpretation of study results Toillustratethedifferencebetweenstatisticalandclinical relevance, we simulated two studies with thebriefMHQscoreasarepresentativeoutcomeparametertoassessatreatmenteffect.Thescorerangesfrom0to100pointswith100denotingthebesthandperformance.Inthefirstsimulationwithdatafrom10patients,themeanbaselinescoreof53(standarddeviation[SD]6)increasedto64(SD11)atthepost-treatmentfollow-upexamination(Figure1a).Theresultantp-valueof0.07impliesthatthereisnosignificanttreatmenteffect.However,themeanscorechangeof11pointscorrespondstotheestablishedMICperceivedbypatients.Asaresult,wecanconcludethatthetreatmentisindeedeffectivefromthepatient’sperception.

Incontrast,thebaselinebriefMHQscoreof53(SD1)wassimilaraftertreatment(55[SD1])forthesecondstudysimulationincluding100patients(Figure1b).Althoughthecalculatedp-valueoflessthan0.001

indicatesahighlysignificantimprovement,themeanchangeofonly2pointssuggeststhelackofaclinicallyrelevanttreatmenteffect.

Despite the patient-centered approach, MIC/MID/PASS values cannot stand alone. Statistical tests should undoubtedlybeperformedtoprovetheeffectivenessinadequately powered studies. In addition to these tests, informationaboutthemagnitudeofchangebasedoneffectsizesandconfidenceintervalsshouldbeprovided.

Summary and Outlook Insummary,measuringtheoutcomeofaspecifictreatment is crucial to improve patient care. Patient-reportedoutcomesareindispensableand,ifpossible,jointanddiseasespecificquestionnairesshouldbeappliedtoavoidresponsebiasduetotheapplicationofglobalquestionnaires.Furthermore,theuseofcoresetsorminimaldatasetsisfavorabletoprovidedatathatarecomparableinsystematicreviewsandmeta-analyses.

Theinterpretationofstudyresultsshouldnotonlyrelyonp-values,butalsoconsidertheeffectthatisrelevanttothepatient.TheMICandPASSareusefultoolstointerprettheoutcomeofindividualpatientsduring clinical routine, to appraise study results and forsamplesizecalculation.

Duringclinicalroutine,thesurgeoncanjudgeiftreatmenthadasubjectivelyimportanteffectforthepatientandifthepatientissatisfieddespitepotentialresidualsymptoms.Fortheinterpretationofstudyresults,knowledgeoftheMICandPASSiscrucialtolookbeyondthep-values,whichdonotconsiderthemagnitudeofatreatmenteffectandaredependentonthesamplesize.

Figure 1a: Brief MHQ score in a simulated study including 10 patients. The mean change between baseline and follow-up is 11 (SD 3) points with p = 0.07 (Wilcoxon signed-rank test).

Figure 1b: Brief MHQ score in a simulated study including 100 patients. The mean change between baseline and follow-up is 2 (SD 0.4) points with p < 0.001 (Wilcoxon signed-rank test).

Figure 1a Figure 1b

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Goldhahn J, Vliet Vlieland TPM. Outcome measuresandtheirmeasurementpropertiesfortrapeziometacarpalosteoarthritis:asystematicliteraturereview.JHandSurgEurVol.2013;38:822- 838.

2. BallC,PrattAL,NanchahalJ.OptimalfunctionaloutcomemeasuresforassessingtreatmentforDupuytren’s disease: a systematic review and recommendationsforfuturepractice.BMCMusculoskeletDisord.2013;14:131.

3. ChungKC,PillsburyMS,WaltersMR,HaywardRA.ReliabilityandvaliditytestingoftheMichiganHand Outcomes Questionnaire. J Hand Surg Am. 1998;23:575-587.

4. MarksM,AudigéL,HerrenDB,SchindeleS,NelissenRG,VlietVlielandTP.MeasurementpropertiesoftheGermanMichiganHandOutcomesQuestionnaireinpatientswithtrapeziometacarpalosteoarthritis.ArthritisCareRes(Hoboken).2014;66:245-252.

5. KroonFPB,BoersmaA,BoonenAetal.PerformanceoftheMichiganHandOutcomesQuestionnairein hand osteoarthritis. Osteoarthritis Cartilage. 2018;26:1627-1635.

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7. Shauver MJ, Chung KC. The Michigan Hand OutcomesQuestionnaireafter15yearsoffieldtrial.PlastReconstrSurg.2013;131:779e-787e.

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10. Nolte MT, Shauver MJ, Chung KC. Normative Values oftheMichiganHandOutcomesQuestionnaireforPatients with and without Hand Conditions. Plast ReconstrSurg.2017;140:425e-433e.

11. WaljeeJF,KimHM,BurnsPB,ChungKC.Developmentofabrief,12-itemversionoftheMichiganHandQuestionnaire.PlastReconstrSurg.2011;128:208-220.

12. Marks M, Hensler S, Wehrli M, Schindele S, Herren DB. Minimal important change and patient acceptablesymptomstateforpatientsafterproximalinterphalangealjointarthroplasty.JHandSurgEurVol.2019;44:175-180.

13. Wehrli M, Hensler S, Schindele S, Herren DB, Marks M.MeasurementPropertiesoftheBriefMichiganHand Outcomes Questionnaire in Patients With Dupuytren Contracture. J Hand Surg Am. 2016;41:896-902.

14. BeaudreuilJ,AllardA,ZerkakDetal.UnitéRhumatologiquedesAffectionsdelaMain(URAM)scale:developmentandvalidationofatooltoassessDupuytren’sdisease-specificdisability.ArthritisCareRes(Hoboken).2011;63:1448-1455.

15. BernabéB,LasbleizS,GerberRAetal.URAMscaleforfunctionalassessmentinDupuytren’sdisease:acomparativestudyofitsproperties.JointBone

Spine.2014;81:441-444.16. 16.RodriguesJN,ZhangW,ScammellBE,Davis

TR.WhatpatientswantfromthetreatmentofDupuytren’sdisease--istheUniteRhumatologiquedesAffectionsdelaMain(URAM)scalerelevant?JHandSurgEurVol.2015;40:150-154.

17. Leite JC, Jerosch-Herold C, Song F. A systematic reviewofthepsychometricpropertiesoftheBostonCarpal Tunnel Questionnaire. BMC Musculoskelet Disord.2006;7:78.

18. LevineDW,SimmonsBP,KorisMJetal.Aself-administeredquestionnairefortheassessmentofseverityofsymptomsandfunctionalstatusincarpal tunnel syndrome. J Bone Joint Surg Am. 1993;75:1585-1592.

19. De Kleermaeker FGCM, Boogaarts HD, Meulstee J, Verhagen WIM. Minimal clinically important differencefortheBostonCarpalTunnelQuestionnaire:newinsightsandreviewofliterature.JHandSurgEurVol.2019;44:283-289.

20. MacDermidJC.ThePRWE/PRWHEupdate.JHandTher. 2019.

21. MehtaSP,MacDermidJC,RichardsonJ,MacIntyreNJ,GrewalR.Asystematicreviewofthemeasurementpropertiesofthepatient-ratedwristevaluation.JOrthopSportsPhysTher.2015;45:289-298.

22. Mulders MAM, Kleipool SC, Dingemans SA et al.NormativedataforthePatient-RatedWristEvaluationquestionnaire.JHandTher.2018;31:287-294.

23. MacDermidJC.Developmentofascaleforpatientratingofwristpainanddisability.JHandTher.1996;9:178-183.

24. HudakPL,AmadioPC,BombardierC.Developmentofanupperextremityoutcomemeasure:theDASH(disabilitiesofthearm,shoulderandhand)[corrected].TheUpperExtremityCollaborativeGroup(UECG).AmJIndMed.1996;29:602-608.

25. BeatonDE,WrightJG,KatzJN,UpperExtremityCollaborativeG.DevelopmentoftheQuickDASH:comparisonofthreeitem-reductionapproaches.JBoneJointSurgAm.2005;87:1038-1046.

26. RodriguesJ,ZhangW,ScammellBetal.ValidityoftheDisabilitiesoftheArm,ShoulderandHandpatient-reportedoutcomemeasure(DASH)andtheQuickdash when used in Dupuytren’s disease. J HandSurgEurVol.2016;41:589-599.

27. Clement ND, Duckworth AD, Jenkins PJ, McEachan JE.InterpretationoftheQuickDASHscoreafteropen carpal tunnel decompression: threshold valuesassociatedwithpatientsatisfaction.JHandSurgEurVol.2016;41:624-631.

28. Forget NJ, Jerosch-Herold C, Shepstone L, Higgins J.PsychometricevaluationoftheDisabilitiesoftheArm,ShoulderandHand(DASH)withDupuytren’scontracture:validityevidenceusingRaschmodeling.BMCMusculoskeletDisord.2014;15:361.

29. Kennedy CA, Beaton DE, Smith P et al. MeasurementpropertiesoftheQuickDASH(disabilitiesofthearm,shoulderandhand)outcomemeasureandcross-culturaladaptationsoftheQuickDASH:asystematicreview.QualLifeRes.2013;22:2509-2547.

30. Goldhahn J, Beaton D, Ladd A et al. Recommendationformeasuringclinicaloutcomeindistalradiusfractures:acoresetofdomainsforstandardizedreportinginclinicalpracticeandresearch.ArchOrthopTraumaSurg.2014;134:197-205.

31. KloppenburgM,BoyesenP,SmeetsWetal.ReportfromtheOMERACTHandOsteoarthritisSpecialInterestGroup:advancesandfutureresearchpriorities.JRheumatol.2014;41:810-818.

32. ImpellizzeriFM,MannionAF,NaalFD,LeunigM.ACoreOutcomeMeasuresIndex(COMI)forpatientsundergoing hip arthroplasty. J Arthroplasty. 2013;28:1681-1686.

33. ImpellizzeriFM,LeunigM,PreissS,GuggiT,MannionAF.TheuseoftheCoreOutcomeMeasuresIndex(COMI)inpatientsundergoingtotalkneereplacement.TheKnee.2017;24:372-379.

34. MannionAF,ElferingA,StaerkleRetal.Outcomeassessmentinlowbackpain:howlowcanyougo?EurSpineJ.2005;14:1014-1026.

35. WilliamsGN,GangelTJ,ArcieroRA,UhorchakJM,

Daniel Herren MD MHAChief of Hand Surgery

Schulthess Klinik

Zurich/ Switzerland

[email protected]

Miriam Marks, PhDResearch Associate

Department of Teaching, Research and

Development

Schulthess Klinik, Zurich, Switzerland

[email protected]

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TaylorDC.ComparisonoftheSingleAssessmentNumeric Evaluation method and two shoulder ratingscales.Outcomesmeasuresaftershouldersurgery.AmJSportsMed.1999;27:214-221.

36. WassersteinRL,LazarNA.TheASA’sStatementon p-Values: Context, Process, and Purpose. The AmericanStatistician.2016;70:129-133.

37. GreenlandS,SennSJ,RothmanKJetal.Statisticaltests,Pvalues,confidenceintervals,andpower:a guide to misinterpretations. Eur J Epidemiol. 2016;31:337-350.

38. Harris JD, Brand JC, Cote MP, Faucett SC, Dhawan A. ResearchPearls:TheSignificanceofStatisticsandPerilsofPooling.Part1:ClinicalVersusStatisticalSignificance.Arthroscopy.2017;33:1102-1112.

39. MarksM,RodriguesJN.Correctreportingandinterpretationofclinicaldata.JHandSurgEurVol.2017;42:977-979.

40. Mokkink LB, Terwee CB, Knol DL et al. The COSMIN checklistforevaluatingthemethodologicalqualityofstudiesonmeasurementproperties:aclarificationofitscontent.BMCMedResMethodol.2010;10:22.

41. de Vet HC, Beckerman H, Terwee CB, Terluin B, BouterLM.Definitionofclinicaldifferences.JRheumatol.2006;33:434.

42. Engel L, Beaton DE, Touma Z. Minimal Clinically ImportantDifference:AReviewofOutcomeMeasureScoreInterpretation.RheumDisClinNorthAm.2018;44:177-188.

43. RodriguesJN,MabvuureNT,NikkhahD,ShariffZ,DavisTR.Minimalimportantchangesanddifferencesinelectivehandsurgery.JHandSurgEurVol.2015;40:900-912.

44. RodriguesJN,ZhangW,ScammellBEetal.Recovery,responsivenessandinterpretabilityofpatient-reportedoutcomemeasuresaftersurgeryforDupuytren’sdisease.JHandSurgEurVol.2017;42:301-309.

45. Marti C, Hensler S, Herren DB, Niedermann K, MarksM.MeasurementpropertiesoftheEuroQoLEQ-5D-5Ltoassessqualityoflifeinpatientsundergoing carpal tunnel release. J Hand Surg Eur

Vol.2016;41:957-962.46. MaiaMV,deMoraesVY,DosSantosJB,FaloppaF,

BellotiJC.Minimalimportantdifferenceafterhandsurgery:aprospectiveassessmentforDASH,MHQ,andSF-12.SICOTJ.2016;2:32.

47. LondonDA,StepanJG,CalfeeRP.DeterminingtheMichigan Hand Outcomes Questionnaire minimal clinicallyimportantdifferencebymeansofthreemethods.PlastReconstrSurg.2014;133:616-625.

48. Shauver MJ, Chung KC. The minimal clinically importantdifferenceoftheMichiganhandoutcomes questionnaire. J Hand Surg Am. 2009;34:509-514.

49. TubachF,RavaudP,BaronGetal.Evaluationofclinicallyrelevantstatesinpatientreportedoutcomes in knee and hip osteoarthritis: the patientacceptablesymptomstate.AnnRheumDis.2005;64:34-37.

50. BellamyN,HochbergM,TubachFetal.Developmentofmultinationaldefinitionsofminimal clinically important improvement andpatientacceptablesymptomaticstateinosteoarthritis.ArthritisCareRes(Hoboken).2015;67:972-980.

51. TubachF,RavaudP,Martin-MolaEetal.Minimumclinically important improvement and patient acceptablesymptomstateinpainandfunctionin rheumatoid arthritis, ankylosing spondylitis, chronicbackpain,handosteoarthritis,andhipandkneeosteoarthritis:Resultsfromaprospectivemultinationalstudy.ArthritisCareRes(Hoboken).2012;64:1699-1707.

SPECIAL FEATURE ART

TOGETHER STRONG | Artist: Norma MacDonald | 1992 Australia Oil on Watercolour

Art Exibit #8

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alreadybeenburntonastake,asIwillhavedeliveredmyInvitedKeynoteSpeechbeforetheAmericanSocietyforSurgeryoftheHandonmyfindingsonRSD.However,likeGalileo,whowhenbeforetheInquisitionTribunalandpressedtorenouncehisthoughtspublicly,mumbled““Eppursimuove”(yetitmoves)”,Itoowillstandandsayoutloud:RSD/CRPS1doesnotexist.

THE BEGINNING OF THE END:

PreliminariesIconsiderthewholeconditionnamedRSD-CRPS1-Sudeck,tobeacompletefabrication.Inmyview,itis a very convenient “trashcan” diagnosis, where all paincomplaintsthatwedonotunderstandcanbeplaced. The patient with this “syndrome” is sent away fromthesurgeontoPhysicalTherapy(andlatertothePainClinic).Inthismanner,wesurgeons,getridoftheproblem,ofthepatient,andwecancontinuesleepinghappilyfeelingwecouldnothavepreventedtheproblem.Inotherwords,thesourceofchronicpost-operativepaincanbeblamedonRSD,and,ofcourse,onthepatient,whoistheultimatepersonresponsibleforbeingsosicklythattheydevelopthiscondition.Let’sstressfromthebeginningthatmanyofusthinkthatthereissomethingverysuspiciousaboutthewholeconcept.However,sinceeverybodyacceptsit,weplaywhatinpsychologyiscalledthebystandereffect:“ifnobodyiswillingtodoanything,whyshouldI?”5

TheoriginofCRPSisconfusing,butitbegan150yearsagowhenSilasMitchell,aneurologist,describedtheburningpainandvasomotorchangessoldiershadintheirlimbsaftersustainingmajornervetrunkinjuries.The condition was named causalgia and it had an evidentincitingpathology-anerveinjury.ThisinitialconceptwasdistortedbyPaulSudeckin1900,whoextended the condition to cases with similar clinical picturebutcausedbyminororevenanon-traumaticevent(minorcausalgia).Later,LericheandPolicardwouldattributeoveractivationofthesympatheticnervoussystemasforthepathologyresultinginthe

unusualclinicalpicture.Itisdifficulttodeterminewhen and how this totúm revolutum ended up in what weknowtodayasRSD/CRPS1/Sudeck.Butevenwithtoday’s medical advances,6,7 this “condition” has no consistentclinicalpicture,nospecificdiagnostictests,an unknown pathophysiology, and lacks pragmatic curative treatment. Surprisingly, with such a meagre pedigree,itcommandsamajorplaceinthemedicalliterature.Itisbackedbynofewerthan6000papersinasimplePubMedsearchandhundredsofchaptersinreferencebooks.

Indeed,itisremarkablethatnow,inthecurrenttrendofprecisescientificvirtuosity,whenthereisadorationforstatisticsversusobservation;now,whenanythingpublishedinanyofthe“reputed”journalshastobeproved,doublytested,doublyblinded,anddoublywrappedinnumbers;preciselyNOW,itsohappensthat this condition survives, as concocted more than 100yearsago,purelythankstoourblindadherencetolong-establishedtenets,withnoscientificfoottostandon.Isthisnotconcerning?

Tobefair,theconditionhasbeennottotallystaticsinceitsinceptionbyMitchell,SudeckandLeriche.Someyearsago,theterminologyandtaxonomyofreflexsympatheticdystrophywererevisedinordertododgethelackofsympatheticsysteminvolvement.8 The new terms are complex regional pain syndrome type1(CRPStype1)andCRPStype2.9BothCRPS1and2sharedsymptomsandsigns,butwhileintype2thereisaninjurednerve,inCRPS1nonerveinjurycanberecognized.Thus,reflexsympatheticdystrophy(RSD)andSudeckisparentheticallyretainedforCRPStype1andcausalgiaisinturnmaintainedforCRPStype2.

AlthoughinthispaperIwillrefermoretoCRPS1,Iwillunavoidablydiscussboth,asCRPS1and2areoftenmixedintheliterature,sharecorediagnosticfeatures,and hence, make the distinction quite elusive at times.10,11 FromthebeginningIshouldremarkthattrueCRPS2(causalgia)isadifferentanimalfromCRPS1:ithasanunderlyingpathology(adamagednerve),

SPECIAL FEATURE

Reflex Sympathetic Dystrophy (RSD)/CRPS/SUDECK does not existIntroduction The beginning of the end:

- Preliminaries - The literature.- The recognition that Pain Clinics are graveyards.-Thelackofknowledge/CRPSratio.- The Budapest criteria

• The importance of “Irritative CTS”.• The series: 100 patients diagnosed with RSD• The aftermath.• Conclusions.

ThisessaywaspromptedbyaletterfromProfessorMennen,EditorofEzine,askingmetoupdatetheEditorialIwroteintheJournalofHandSurgeryEuropean Volume.

ThispaperisaboutmyextremescepticismintheexistenceoftheSudeckatrophy,alsoknownasreflexsympatheticdystrophy(RSD)orcomplexregionalpainsyndrome(CRPS).Thenameforthisdiagnosisvariesdependingontheageofthesurgeon,theirbackground,andtheircountry,buttheyalldescribethesame:anabnormalpainfulresponseaftertraumaorsurgery,accompaniedbyvasomotorchanges,atleastintheearlystages,andthelackofaplausiblecauseforitsdevelopment.

Iwasemotionallymoved,whenProfessorMennenwrote:“Your“message”isveryimportantbecausesomanypatientsareunfairlylabelled[withthediagnosisofCRPS1]oftenbecauseofdoctors’slapdashdiagnosis-making,ignoranceorincompetence”(seealso:IFSSHEzine,Volume29,February2018,Editorial,“ChecklistforHolisticManagement”).Icannotagreemorewiththisstatementandtheimportanttruthsitbearsonourprofession.InmanycasesdiagnosingapatientwithCRPSistantamounttolabellingthemasapariah.Itisknownthatsomedoctorswillrefusetoseeanypatientwith this diagnosis. Even worse, are the iatrogenic and psychologicalconsequencesofthisdiagnosistothepatient: 2-4noceboeffect,medicalization,addictiontoopioids and psychotropic drugs, personality changes, lowself-esteem,catastrophicthoughts,etc.Manyofthese medications and therapies make it increasingly difficulttoreversetheprocess.Mysecondconcernaboutthisdiagnosisisthatitoftenistheendresultofpoordoctoring;inmostcasesrigorousphysicalexamand listening to the patient will elucidate the true mechanicalorphysicalsourceoftheirpain.

InthisreportIwilldescribetheprocesswhichdrovemeintoplayingthisQuixotesqueroleofplacingmyreputationonthelineateverymeetingforthesakeofdebunkingthisdiagnosisonceandforall.Asamatteroffact,bythetimethiswritingcomesoutImayhave

“Eppur si muove” G. Galilei.

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SPECIAL FEATURE

The recognition that the Pain Clinics are graveyardsAgain,manycluescomebychance.Ihadapatientwho,havingbeeninthePainClinicwiththediagnosisofRSDfor10yearsfollowingaminorcrushtohisthumb,cameforanotheropinion.Ifoundhehadaglomus tumor, which I treated and cured. As I used to liveinasmalltownwhereeverybodybumpsintoeachother, when I ran into the pain doctor whom I told, quite excitedly,thatIhadsuccessfullytreatedapatientofhiswhohadbeendiagnosedwithCRPS.Hereplied,somewhatoffended:“Myroleisnottoknowwhatthepatientshavebuttoeasetheirpain”….andhewasright,buthealsogavemeamostimportantclueformyfuture:onceyouareinthePainClinicnobodyisgoingtohelpyoutogetoutofthere.

The lack of knowledge/CRPS ratioAfterthisveryfirstpatientIbegantoseemoreandmorepatientsdiagnosedwithRSDand,inmost,Iwasabletofindthecauseandtreatthemsuccessfully.

ThiswasastonishingasbydefinitionapatientwhohasbeenlabelledasCRPShasnotreatablecausefortheirpain.IalsonoticedthatmostcasescamefromsurgeonswhomIknewnottobethemostknowledgeable(Figure2).Withoutdoubt,behindthesealarmingnumberstherewasaneedtogetridof“annoying”patientswhowouldbecondemnedtothePain Clinic - to the graveyard- with no hope in sight.

Figure 2. Exponential increase of CRPS cases as related to ignorance

Table 1. Budapest Criteria for CRPS (Harden at al., 2010)

AT THE TIME OF EXAMINATION THE PATIENT MUST REPORT:

1. Continuing pain disproportionate to inciting event

2. Symptoms at least 1 in 3 of the following 4 categories:

Sensory hyperaesthesia/allodynia

Vasomotor temperature/ colour changes - assymetry

Sudomotor oedema/sweating changes - assymetry

Motor / Trophic deceased ROM. weakness tremor/dystonia

trophic changes in skin, hair or nails

3. Signs at least 1 in 2 of the following categories:

Sensory hyperaesthesia to pin prick

Allodynia to light touch

Vasomotor evidence of temperature/colour assymetry

Sudomotor evidence of oedema/sweating assymetry

Motor / Trophic evidence of deceased ROM, weakness

tremor/dystonia, trophic changes to skin,

hair or nails

4. No other diagnosis explaining symptoms and signs

SPECIAL FEATURE

surgicaltreatment,andoftenacure.12,13 Conversely, CRPS1,whichis(still)mainlyconsideredasympatheticmediatedproblem,hasamedicalapproachwithvariablesuccessandlow-qualityevidencetosupportanyoftherecommendedtreatments:14 stellate ganglionblocks(repeatedasneeded),15 sympatholytic drugs,opioidsanddrugsforneuropathicpain(anticonvulsants/antidepressants),bisphosphonates,steroids,free-radicalscavengers,amongmanyothers.6,7,15-20

Ishouldstress,thatdespitethefactthattheconditionhas a main place in medicine, prominent surgeons and neurologists had already expressed their concerns on theoveruseofCRPSasadiagnosis.8,21-24 Championed byDrKasdan,somerealizedthatbehindmanyCRPScases were the so-called psychogenic-hand.25,26 Zhu, Jupiter, and Jones12,13,27pointedoutthatsomeformsofcausalgia(presentlyknownasCRPS2)couldbetreatedsurgicallyofferingasolutiontopatientswithexcruciatingpainwhereanervehadbeeninsulted.10,28

As early as 1962, Stein29linkedsomeformsofSudecktocompressionofthemediannerveinthewrist.Lateron,severalstudiesfavorthesameapproachforpatientswho have positive neurophysiological studies.11,30-32 Finally, Dr. Dellon deserves a main seat among these pioneers,andalthoughhisbodyofworkhasbeendevotedtothelowerlimb,24,33 hisfocusonthenerveastherootcauseofthisconditionhasalsobeenappliedintheupperlimb.34

Is the literature always right?Weareallinfluencedbytheliteratureandwhathasbeenwrittenweighsheavilyonanychange.Noonewants a rumpus in their Journal. Not surprisingly in my Editorial in JHSE,1theEditor-in-chiefaddedanotesayingthatthejournalviewwastoacceptCRPSasacondition.35However,oneofmymentors,IanJackson(atopcraniofacialsurgeonattheMayowho,tomysurpriseandfortune,pupiledmeveryearlyoninmycareer),tookmeabackbysaying:“Onlystupidpeoplebelieveeverythingthathasbeenwritten”.Hewasso

right!Thereareplentyofexampleseveninrecentmedicalhistory.Let’srememberthatthehighestimpactjournals,i.e.NewEnglandJournalofMedicine,Lancet,JAMA,AnnalsofSurgeryandmanyothers,havesupportedthebenefitsofvagotomyforpepticulcersforgenerations,yetweallknowthatthewholeideawas“fakenews”.

ForCRPStheliteraturehasundergoneconstantadaptation to the results which demonstrated that aprevioustheoryexplainingandjustifyingCRPSwaswrong.JustthinkforamomentthattheroleofsympatheticsysteminRSDwasdismissed,oncewell-performedrandomizedstudiesprovedthataplacebowasjustasgoodasthesympatholyticdrugs.8,21

Aggressive treatments such as phenol, were met with atbestnoeffectoratworstthepainfulsympathalgia.36 The promising spinal cord stimulation37 could not standthetestoftime,38and,soon,forthesteroids,oranydrugyoucanimagine.EveninrecentreviewsofthetopiconRSD:6,7,15,16,18,20,39 ”could”, “should”, “perhaps”, “attimes”,“often”,“frequently”,“seems”,“may”,“guess”,“suppose”,“theorize”,“surely”,“accept”,“classically”,“commonly”,“probably”,“suggest”,“speculate”…”oftenare,butalsomay”arethestrongestscientifictermsthedifferentauthorsusetosupporttheirconclusions.Couldthediagnosisbeafabrication?(Figure1).

24 25


SPECIAL FEATURE

Asalways,mostresponsescouldbefoundintheliterature.Ithasbeenlongknownthatbrachialgiaorevenmoreproximalpain,canbeoriginatedbycompressionofthemediannerveinthecarpaltunnel,andthatbyreleasingtheligamentthepaindisappears.41,42SwellinghasnotbeenconsideredaprominentfeatureinCTS,yetBurkeetal.haveprovedittobeamostprevalentsymptominidiopathicCTS.43 TheworksofOchoaandothersopenedmyeyesandhelped me to understand that the median nerve could cause pain in the ulnar nerve territory, proximally or even simulate an acute myocardial attack.10,44

Furthermore, Bennett and Xie45 demonstrated in rats that nerve compression triggered a clinical picture similartoaCRPS1.ThisassuredmeIwasverymuchon the right track: the median nerve. Nevertheless, I still needed more evidence.

Currently,anyground-breakingchangeinourpractices, or any new condition, is accepted only ifaccompaniedbyobjectivedata,statisticsand“evidence”.Albeitgood,weshouldnotforgetthatobservationhascontributedenormouslytotheprogressofMedicine.Throughobservation,Flemingrealizedthatpenicilliumhadabactericidaleffect.Throughobservation,syndromessuchas“partialthenaratrophy”and“acroparesthesia”(derogativelyknown,asitaffectedmostlywomen,as“hystericalnocturnal paresthesias” – these were certainly pre #metoodays)werelinkedtogether,givingbirthtoanewcondition:theultrafamouscarpaltunnelsyndrome(CTS).46Itisastonishingtorealizethatthemostcommonoperationahandsurgeonperformstoday,carpaltunnelrelease(CTR),wasunknownuntil1950.Thousandsofpatientshavebenefitedfromthisimportantunderstanding-simplybasedonobservation.47,48 Beforethislinkageseveral“treatments”foridiopathicCTSpatientshadbeenrecommended:quinine,iron,arsenic,morphine,strychnine,henbane,galvanizationofthehandswithinterruptedandcontinuouscurrent,PhenobarbitalandBromidecombinedwithavasodilator,andribresection,amongmany others.46 To sum up, all these advances, and so

manymoreintheHistoryofMedicine,werethankstoobservation,presentlyreviledbythescientificmethodology.

Throughobservationwenoticedthatagroupofpatientswhohad“compression”ofthemediannerve,did not display the typical CTS signs and symptoms. Chiefcomplaintswerepainandtinglinginthemediannervedistribution(butoftennotlimitedtoit),worseningofthesymptomsatnight,swelling,and,aboveall,inabilitytomakeafullfist(Figure4).Thosewere exactly the same signs and symptoms a very differentgroupofpatientsdisplayed.Thelatterwereall patients with previous trauma to their hands and whohadbeenlabelledandtreatedforCRPSpriortoreferral.Bothgroupswereindistinguishableclinicallyandbothweretreatedwithcarpaltunnelrelease(CTR).Innocasewerecontinuousaxillaryblocks,sympatholyticmedication,orstellateganglionblocksgivenafterthesurgery.Lightpainkillers(paracetamolorally)wasprescribedasperourusualprotocolforpatientswhohaveidiopathicCTR.Theresponseandoutcometosurgerywasindistinguishable.Wenamedthis new condition irritative carpal tunnel syndrome, asthemediannerveseemedtobeirritatedratherthan

Figure 4.

SPECIAL FEATURE

Weaknesses of the Budapest criteriaButwhywasitpossibleforasurgeontolabelaconditionasbeingCRPSifithadatreatablecause?How could we make a diagnosis that has such anenormousimpactonapatient’swell-beingsofrivolously?Thereasonwas,withoutadoubt,thatthecriteriaappliedtodiagnoseCRPSwereextremelyindistinctandbiased:anythingwouldfit(Table1).40 Specifically,pain(criteria1)wassubjective,andcriteria2and3weresharedbytrauma,inflammatoryconditions, ischemia, etc, and were thus quite unspecific.However,themostunfairofalldiagnosticcriteria,andtheonewhichlaterprovedtobethemain“sinkhole”,wasitem4.Criteria4lefttoadoctor’sdiscretionwhichpatienttheyfelthadanunknowncondition.AsIalreadypointedoutinmyformereditorial,“Theonlypersonwhoshouldreliablystatethatthereisnotanovertorganiccauseforapatient’spainshouldbethespecialistinthefieldi.e.aHandSurgeon”. The rest do not have the knowledge and understandingtolabelapatientwithCRPS.Butevenintherealmofhandsurgery,doweallknowthesame?

THE IMPORTANCE OF IRRITATIVE CTSTherecognitionthatIcouldsuccessfullytreatpatientslabelledashavingRSDbyfellowsurgeons/doctors, and the direct relationship to their lack ofknowledge,triggeredinmymindthefollowing“anti-establishment”thought:“Ifonlyweallknewallthefacts,RSD/CRPS/Sudeckwouldnotexist”.I,hence,becameobsessedtryingtounderstandwhatthese patients really had. It was clear that some had factitiousissues,othershadsustainedanervetrauma(Causalgia/CRPS2),andalargegrouphadsufferedfrombad-doctoring.But,whatabouttherest?

IamnotsureexactlyhowandwhenIrealizedthatthecomplaintofworseningofsymptomsatnightreportedbysomeCRPSpatientswastheclueintheremainingcases. The only condition that I knew to produce this wascompressionofthemediannerveinthecarpaltunnel.However,thesepatientslabelledasCRPShadaverydifferentpicturefromaclassiccarpaltunnel

syndrome(CTS):painandnumbnessawayfromthemediannerveterritory,swelling,stiffness,burningpain,etc(Figure3).

Figure 3. Asampleofchartsofmyongoingstudy,showingtheareaofallodynia-dysesthesiasinthehandreportedbythepatients(marked).Notethatmosthad more symptoms in the ulnar nerve territory, some inaglovedistributionandfewinthemediannerveterritory.

26 27


SPECIAL FEATURE

CTscanshowsthestatusofthewristathisveryfirstvisit,3monthsaftertheaccident.ThemalunionwasaggravatedbyaconcurrentVolkmannandintrinsicmusclescontracture.Surgerywasadvisedbutthepatient declined, arguing that his treating doctor had stressed to him that any surgery in a Sudeck patient wouldharmhim.Instead,a4-monthcourseofPTandpsychotropic medication were recommended. He was losttofollowupafterthis“confrontation”.

Thosewhohadsurgeryhadtheirproblemsolvedallbarone.Thisspecificpatientremainedunhappyduetostiffness.Herpainwasratedduringphysicaltherapyas8over10inaVAS(0-10).Nevertheless,herpainatnightanddaytimedroppedfrom10to0atthesixmonthfollowup.Thisparticularpatienthad a metastatic lung cancer and was undergoing chemotherapy. She developed shoulder and wrist pain afterhavingbeenoperatedonforawristfracture.Itis worth stressing that those with Irritative CTS were operated on disregarding their nerve conduction studieswhichwerenegativeinasignificantnumberofthose whom were asked.

Tosummarize,bykeepingthecategorizationchartinmind,nopatientsweretobelabelledasRSD/CRPS1/Sudeck.

THE AFTERMATHTThebirth,orthedeath,ofanyconditionorassumedtreatmentis,inevitably,surroundedbycontroversy.Recently,wehavewitnessedthedeathofvagotomyinpepticulcermanagement,despiteawealthofsupportiveliteratureinhigh-rankingjournals.

In my Quixotesque role to kill this condition, I am notalone-Iamstandingontheshoulderofgiants,surgeons and neurologists,8,10-13,21-34 whose keen eyes havebeencorneringthecondition:psychogenichand,causalgia(CRPS2)werebutapartofthepicture.But this was not enough, there were some patients leftoutwhohadsymptomsandsignsthatcouldbeassignedtoCRPS.Mybackgroundasawristand

microsurgeonallowedmetospotstructuralbad-doctoringastherootcauseofmanyCRPScases.Thefinalpiecetothejigsawwasnotingthatthemediannervecouldbeirritatedwithoutbeingcompressed,thusfrequentlythestandardneurologicalstudieswerenon-contributory.Morethan40patientshavebeenoperatedonforirritativeCTS(Figure7)andallexceptone,aforementioned,responded.Whethershehad an “unknown condition”, a psychogenic hand, or a grievancebecauseofherunderlyingmedicalcondition,requiresfurtherstudy.Inthisrespect,patientswhodonotimproveafterarigoroussearchforthecauseorafterfailedsurgery,mightneedtogotothePainClinic.Thismustalwaysbeunderthesupervisionofthe treating surgeon. For sure, the Pain Clinic should notbeagraveyardofdiscardedpatients,buttheplacewherepatientsaretobetreatedtemporarily,whiletherootcauseoftheproblemissoughtoutandsolved.

Figure7.Thispatientwasseen8monthsaftersustainingaDRFtreatedinacast.Nomalalignmentexisted on the X-rays. Nevertheless, she developed pain and swelling that required intensive PT and treatmentinthePainClinic(seepatient’spictureontheleftat5monthswithpersistingswelling).Onherfirstvisit,despitebeingongabapentin,lidocainepatches/opioidssheratedherpainas8(onaVAS:0-10)andcouldnotmakeafist.FiveweeksafterCTRunder local her pain was 0. She returned to work as a housekeeper in a hotel.

Butdonotgetmewrong,theproblemisnotsolvedbysimplyreleasingthecarpalligament.Infact,doingso,canevenbedetrimental:therearemany

Figure 7

SPECIAL FEATURE

compressed. I should stress that these patients were operated disregarding their nerve conduction studies whichwerenegativein2/3ofthosewhomwereasked.

Figure4.Severeformofbilateralirritativecarpaltunnelsyndrome.Inbothpictures,thepatientisbeingaskedtomakeatightfist.Ontheleft,heisshownpreoperatively,ontherightheisshownintheORafterbilateralCTRunderlocalanesthesia.Noantecedenttraumacouldberecalled.

THE SERIES: 100 patients with the diagnosis of RSDIrritative carpal tunnel syndrome was the missing link Iwaslookingfortobeabletocomefullcircle!!!

ToconfirmthatIwasright,Istudiedacohortof100consecutivepatientswhohadcometotheofficewiththediagnosisofRSD.(Ittookmemorethan4yearstogatherthefirst25patients,butonceIhadappeared on the national news dealing with this topic,Igatheredtheremaining75inlessthanayear).Briefly,thepreliminarydatashowsthatninety-fivepercenthadbeendiagnosedwithRSDbyaphysician(surgeonorrehabilitationdoctor)andtherestbyatherapist.Ninetypercenthadbeentreatedinapainclinic. Ninety-three percent were on opioids and/or psychotropicmedication,oneformorethan15years.The remaining were on painkillers and steroids. All hadpain,senseofstiffnessand/orlimitedrangeofmotion.

Thegeneralresultscanbesummarizedinthechartbelow(Figure5).Notethaninnearlyhalf,baddoctoringwasbehindthescenes:ignoranceorovertmalpracticemaskedbytheCRPS/RSDacronyms!!

The psychogenic-hand patients were advised to go to a psychiatric consultation with little success. Five patientsdidnotrequireanysurgicaltreatment,butsupportinPTandwereweanedoffdrugs.Iopenhereaparenthesistostressthatitisnotuncommonforsomepatientstodevelop,aftersurgeryortrauma,whatIwastaughttobea“flarereaction”.Theclinicalpictureappearedsomeweeksafterthetrauma/surgeryandsharedthesamesymptomsandsignsasaCRPS1.TheproblemclearedupwithPTandreassurance.Now,duetoabuseofthediagnosisofCRPSandthelaxityofthecriteria,18,40someflarereactionscanbemisinterpretedasCRPS-draggingthepatientintotheperniciouseffectsofsuchamisdiagnosis.2-4

Nearlyhalfdismissedanyoperationonthegrounds:“my doctor advised me against surgery”, “my doctor told me you are only interested in operating on me to make money” and “the literature is against surgery”, yettheyhadtreatableconditions.Theoversightedpathologywasattimesembarrassing(Figure6).

Figure 6. This 34-year-old male diagnosed with Sudeck had neuropathic pain, anesthesia in the mediannerveterritory,andafrozenhand.HehadsustainedamotorbikeaccidentwhichrequiredaweekofICUadmissionforabdominalandheadtrauma.Thewristwasplacedina(tight?)cast.The

Figure 5: True allocation of the patients diagnosed with Sudeck’s in this study.

Figure 6.

28 29


incontradictionofthecurrenttrendofrocketingnumbersofCRPS1cases(50,000newcasesperyearintheUSA),55 removing the niche will reduce the incidenceoftheproblemdrasticallyinfewyears,ashasalreadyoccurredinotherunsubstantiatedepidemicsinourfield.56,57

Inclosing,IbeseechyoutohelpmetowipeoutthisfabricationthatleavesoursufferingpatientsstrandedinPainClinicsaroundtheglobe.Ourendeavorispavedwithresistance,notonlyhastheexistenceofRSDbeenengravedinstoneinourminds,butstubbornoppositiontonewideasispartofthehumannature.IconfessedinmyEditorial1thatIdreamedabouttheeradicationofthispseudo-condition.Nowthattheenlightenmentissoclose,IadmitthattoooftenIawakeninthemiddleofthenightandittakesmehourstofallsleepagainbecauseoftheexcitementofknowingthatifIsucceedIwillhavedonemoregoodthananythingelseIhaveproducedinmylife.PleasehelptheprogressofsciencebyplacingallyourmedicalknowledgeattheserviceofyournextCRPSpatient.

Asafinalcaveat:Ittakesasmallleapofimagination,thatifIcandebunkthewholeCRPSconceptinmyterrain,therestofthebodywillbeopenforotherstodeliverthefinalblow(ajobalreadystartedbyprominentgiants).13,33,58

References 1. delPiñalF.Editorial.Ihaveadream...reflex

sympatheticdystrophy(RSDorComplexRegionalPainSyndrome-CRPSI)doesnotexist.JHandSurgEurVol.2013Jul;38(6):595-7.

2. RingD,BarthR,BarskyA.Evidence-basedmedicine:disproportionatepainanddisability.JHandSurgAm.2010Aug;35(8):1345-7.

3. Hayes PJ, Louis DS, Kasdan ML. Additional considerations in complex regional pain syndrome. JHandSurgAm.2012Mar;37(3):625.

4. Bass C. Complex regional pain syndrome medicaliseslimbpain.BMJ.2014Apr28;348:g2631

5. RosenbaumL.TheNot-My-ProblemProblem.NEnglJMed.2019Feb28;380(9):881-885

6. MarinusJ,MoseleyGL,BirkleinF,BaronR,MaihöfnerC,KingeryWS,vanHiltenJJ.Clinicalfeaturesandpathophysiologyofcomplexregionalpainsyndrome.LancetNeurol.2011Jul;10(7):637-648.

7. Bruehl S. Complex regional pain syndrome. BMJ. 2015Jul29;351:h2730.

8. OchoaJL.Truths,errors,andliesaround“reflexsympathetic dystrophy” and “complex regional pain syndrome.”JNeurol1999;246:875–879

9. Stanton-HicksM,JänigW,HassebuschSJ,HaddoxJD,BoasR,WilsonP.Reflexsympatheticdystrophy:changingconceptsandtaxonomy.Pain.1995;63:127-133.

10. ThimineurMA,SaberskiL.ComplexregionalpainsyndrometypeI(RSD)orperipheralmononeuropathy?Adiscussionofthreecases.ClinJPain1996;12:145–150.

11. PlaczekJD,BoyerMI,GelbermanRH,SoppB,GoldfarbCA.NervedecompressionforcomplexregionalpainsyndrometypeIIfollowingupperextremitysurgery.JHandSurgAm.2005;30(1):69-74.

12. ZhuSX,LuSB,YaoJX,LiuZS,SunYW,WangXL,LiZY,FuZG,LiuZX.Intrafasciculardecompressioninthetreatmentofcausalgiawithspecialreferencetothemechanism.AnnPlastSurg.1985Dec;15(6):460-4.

SPECIAL FEATURE

Dr. F. del Piñal Serrano 58-1B.

28001- Madrid

Ph:+34-914310051.

Paseo de Pereda 20-1

39004-Santander. Spain

Ph:+34-942364696

Email: [email protected]

Personal: [email protected]

SPECIAL FEATURE

factorsinplay.Justaswhenrecognizingafactitiousinjuryyougettoknowallpossibleanswers,25,26,49,50 the sameappliesforbad-doctoring.Inabout40%ofthecasestherewasamajormedicalerrorbehindthem(includinginadequatecarpaltunnelreleasein15%).Co-existentshoulderpainandestablishedstiffnessinterfereintherecoveryandhastobeaddressed.Besides this, surely the percentages and root causes ofCRPScasesvaryineachsurgeon’spractice.Asanexample,thismaybemoreanerveprobleminDr.Dellon’soffice,moreamechanicalcauseinmine,andamixedetiologyinothers’.Wearecurrentlylookingfora test that could help everyone to spot a patient with atreatablecondition.Wearestudyingthesmallfiberswhicharetheafferentsforpain,burningsensation,andwhichdominatevasomotoreffectors(A∂fibers-smallmyelinated-andCfibers-unmyelinated).Thesefiberscannotberecordedbythestandardneurophysiologicaltests(whichstudylarge–fast-conducting-myelinatedfibers).Perhapstheso-calledSympatheticSkinResponsetestmayproveuseful.51-52 Another avenue isfunctionalbrainMRI.Withthelatter,wewanttosortoutwhohasrealpain,andhowdifferentthisisin irritative carpal tunnel syndrome versus idiopathic carpal tunnel syndrome.

Myfinalwordsgotothesufferingpatientswhoneedourloveandcompassion.Theyhavebeenwanderingfromonedoctortoanotherandresemblezombiesmorethannormalpeople.Veryfewarelookingfora secondary gain, and indeed most are under the effectofmultipledrugsandreceivingnoempathy.(Irecently had, as a patient, an ICU doctor, who could notstopcursingtheincomprehensionshehadbeenthroughbeforewetackledherproblem).Icannotdenythat there are patients whose characteristics may makeusrepudiatethemfromtheveryoutset.Butlet’sberational.Firstofall,astheyhavealreadybeensubjectedtoafailedtreatment,theywillregardthenewsurgeonwithsuspicionandlackofconfidence.Furthermore,thosewhohavebeeninthePainClinicforalongperiod,havebecomeaddictedtoseveral

drugs,withpersonalityimplications(lowself-esteem,passive-aggressiveness, uncoordinated discourse, amongothers).Typically,allofthemhaveaverylowthresholdforpainand,becauseoftheirlonguse-andabuse-ofdrugs,theyself-medicatesettingtheirownrulesmuchtoourdespair.However,afterseveraldaysorweeks,oncetheystarttofeelbetter,theyplacetheirregainedtrustintheirtreatingdoctorandbecomethemostcooperative,thankfulandwillingtohelpothersthat you have ever had. Love them, they need our love and care.

CONCLUSIONS: The amplifier effect.IfIweretocondenseallmyresearchintoaverysimpletheory,Ishouldnameitthe“Amplifiereffect”.Thetermstressesthat,muchliketheamplifierofamusicsystemwhichmultipliesthesoundpickedupbytheneedleoftheturntable,the“damaged/irritated”nervewilllikewisemultiplythefinalpainreadinginourcortextothepowerof“n”(Figure9).Thistheorymayappear as unproven as others that have attempted toexplainthephysiopathologyofCRPS.However,thereisanimportantdifference-thisapproachhaspragmaticallyprovedsuccessful.

AnotherconclusionofthisstudyisthatCRPS1and2arethesamecondition,theformerwithan“irritated”nerve(RSD,Sudeck),andthelatterwithastructurallydamagednerve(causalgia).Nevertheless,botharenervemediatedpathologies.Therefore,amoreappropriatetermforthewholeclinicalpicturecouldbe“Neuralamplifiedpain”.Patientswithoutanerveissue,havetobecategorizedaspsychogenichand,malingerers,victimsofbaddoctoring,andsomeearlycasescouldfallintotheso-called“flarereaction”pigeonhole.Finally,aminoritymaybeascribedtounknownconditions(1in100inmyseries).Ifoneadherestotheseunderstandings,therewillbenomoremysteryhiddeninCRPS.Moreimportantly,thepatientwillbeproperlyallocatedtoarealcondition,nottoCRPS.Consequently,thiswillpreventunnecessarysufferingandmedicalizationinallpatients,2-4 and aboveallinthosemostvulnerable.53,54Iforeseethat

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36. StraubeS,DerryS,MooreRA,etal.Cervico-thoracicorlumbarsympathectomyforneuropathicpainand complex regional pain syndrome. Cochrane DatabaseSystRev2013;9:CD002918.

37. KemlerMA,BarendseGA,vanKleefM,deVetHC,RijksCP,FurnéeCA,vandenWildenbergFA.Spinalcordstimulationinpatientswithchronicreflexsympathetic dystrophy. N Engl J Med. 2000 Aug 31;343(9):618-24.

38. Kemler MA, de Vet HC, Barendse GA, van den WildenbergFA,vanKleefM.EffectofspinalcordstimulationforchroniccomplexregionalpainsyndromeTypeI:five-yearfinalfollow-upofpatientsinarandomizedcontrolledtrial.JNeurosurg.2008Feb;108(2):292-8.

39. Field J. Complex regional pain syndrome: a review. JHandSurgEurVol.2013Jul;38(6):616-26.

40. HardenN,BruehlS,PerezRetal.Validationofproposeddiagnosticcriteria(the‘BudapestCriteria’)forcomplexregionalpainsyndrome.Pain.2010,150:268–74.

41. CrymbleB.Brachialneuralgiaandthecarpaltunnelsyndrome.BrMedJ1968;3:4701.

42. Cherington M. Proximal pain in carpal tunnel syndrome.ArchSurg.1974Jan;108(1):69.

43. BurkeDT,BurkeMA,BellR,StewartGW,MehdiRS,KimHJ.Subjectiveswelling:anewsignforcarpaltunnelsyndrome.AmJPhysMedRehabil.1999;78(6):504-508.

44. TorebjörkHE,OchoaJL,SchadyW.Referredpainfromintraneuralstimulationofmusclefasciclesinthemediannerve.Pain.1984Feb;18(2):145-56.

45. Bennett,C.J.,andXie,Y.-K.:Aperipheralmononeuropathyinratthatproducesdisordersofpain sensation like those seen in man. Pain, 33: 87-107. 1988.

46. Boskovski MT, Thomson JG. Acroparesthesia and carpal tunnel syndrome: a historical perspective. J HandSurgAm.2014Sep;39(9):1813-1821.

47. BrainWR,WrightAD,WilkinsonM.Spontaneouscompressionofbothmediannervesinthecarpaltunnel;sixcasestreatedsurgically.Lancet.1947Mar8;1(6443-6445):277-82.

48. PhalenGS,GardnerWJ,LaLondeAA.Neuropathyofthemediannerveduetocompressionbeneaththetransverse carpal ligament. J Bone Joint Surg Am. 1950Jan;32A(1):109-12.

49. ReadingG.Secretan’ssyndrome:hardedemaofthedorsumofthehand.PlastReconstrSurg.1980Feb;65(2):182-187.

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51. Santiago S, Ferrer T, Espinosa ML. Neurophysiologicalstudiesofthinmyelinated(Adelta)andunmyelinated(C)fibers:applicationtoperipheral neuropathies. Neurophysiol Clin. 2000 Feb;30(1):27-42.

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SPECIAL FEATURE

13. JupiterJB,SeilerJG3rd,ZienowiczR.Sympatheticmaintainedpain(causalgia)associatedwithademonstrableperipheral-nervelesion.Operativetreatment.JBoneJointSurgAm.1994;76(9):1376-1384.

14. O’Connell NE, Wand BM, McAuley J, et al. Interventionsfortreatingpainanddisabilityinadults with complex regional pain syndrome. CochraneDatabaseSystRev2013;4:CD009416

15. PattersonRW,LiZ,SmithBP,SmithTL,KomanLA.Complexregionalpainsyndromeoftheupperextremity.JHandSurgAm.2011Sep;36(9):1553-62

16. GayAM,BéréniN,LegréR.TypeIcomplexregionalpainsyndrome.ChirMain.2013Oct;32(5):269-80

17. VarennaM,AdamiS,RossiniM,GattiD,IdolazziL, Zucchi F, Malavolta N, Sinigaglia L. Treatment ofcomplexregionalpainsyndrometypeIwithneridronate:arandomized,double-blind,placebo-controlledstudy.Rheumatology(Oxford).2013Mar;52(3):534-42.

18. ŻylukA,PuchalskiP.Complexregionalpainsyndrome:observationsondiagnosis,treatmentanddefinitionofanewsubgroup.JHandSurgEurVol.2013Jul;38(6):599-606.

19. ChevreauM,RomandX,GaudinP,JuvinR,BailletA.BisphosphonatesfortreatmentofComplexRegionalPain Syndrome type 1: A systematic literature reviewandmeta-analysisofrandomizedcontrolledtrialsversusplacebo.JointBoneSpine.2017Jul;84(4):393-399.

20. KomanAL,SmithBP,SmithTL.Apracticalguideforcomplex regional pain syndrome in the acute stage andlatestage.In:WolfeSW,HotchkissRN,PedersonWC, et al, editors. Green’s operative hand surgery. 7thedition.Philadelphia:ChurchillLivingstone;2017. p.1797-1827.

21. SchottGD.Interruptingthesympatheticoutflowincausalgiaandreflexsympatheticdystrophy.BMJ.1998Mar14;316(7134):792-3.

22. BarthRJ,HaralsonR.Differentialdiagnosisforcomplex regional pain syndrome. The Guides Newsletter,September/October2007.AmericanMedical Association:1– 4, 12–16.

23. BarthRJ.ComplexRegionalPainSyndrome.ChapterKin:MelhornJM,Eskay-AuerbachM,eds.20thAnnualAmericanAcademyofOrthopaedic Surgeons Workers Compensation and MusculoskeletalInjuries:ImprovingOutcomeswithBack-To-Work, Legal, and Administrative Strategies. AmericanAcademyofOrthopaedicSurgeons;2018.

24. DellonAL.RSD,Chapter7,3rdEd.,Painsolutions.LightningSourceInternetPublications,2013,pp205-230.

25. KasdanML,StuttsJT.Factitiousinjuriesoftheupperextremity.JHandSurgAm.1995May;20(3Pt2):S57-60.

26. StuttsJT,KasdanML,HickeySE,BrunerA.Reflexsympathetic dystrophy: misdiagnosis in patients withdysfunctionalposturesoftheupperextremity.JHandSurgAm.2000Nov;25(6):1152-6.

27. JonesNF,ShawWW,KatzRG,AngelesL.Circumferentialwrappingofaflaparoundascarredperipheralnerveforsalvageofend-stagetractionneuritis.JHandSurgAm.1997May;22(3):527-35

28. AdaniR,TosP,TaralloL,CorainM.Treatmentofpainfulmediannerveneuromaswithradialandulnararteryperforatoradipofascialflaps.JHandSurgAm.2014Apr;39(4):721-7.

29. Stein,AHJr.Therelationofmediannervecompression to Sudeck’s syndrome. Surg Gynec Obstet.1962;115:713-720.

30. GrundbergAB,ReaganDS.Compressionsyndromesinreflexsympatheticdystrophy.JHandSurgAm.1991;16(4):731-736.

31. Monsivais JJ, Baker J, Monsivais D. The associationofperipheralnervecompressionandreflexsympatheticdystrophy.JHandSurgBr.1993;18(3):337-338.

32. Koh SM, Moate F, Grinsell D. Co-existing carpal tunnel syndrome in complex regional pain syndromeafterhandtrauma.JHandSurgEurVol.2010;35(3):228-231.

33. DellonAL,AndonianE,RossonGD.CRPSoftheupper or lower extremity: surgical treatment outcomes.JBrachialPlexPeripherNerveInj.2009Feb20;4:1.

SPECIAL FEATURE

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RESEARCH ROUND-UP

1. What were your main reasons for writing this article?Theassessmentofoutcomesofreplantationhasnotbeenstandardizedandhasnotappliedsophisticatedoutcomes tools. We wanted to evaluate the evidence incurrenthandsurgeryliteratureandadvocateforincreaseduniformityintheoutcomesassessments,thetypeofoutcomesmeasured,instrumentsusedtomeasure, and the way they are reported.

2. What are the most interesting/important results and conclusions of your article?Themostinterestingfindingofourresearchishowthereissomuchheterogeneityinpublishedarticles,spanningfromthetypeofamputationinjuriesincludedinthestudycohort(digittypeandlevelofinjury,typeofinjury,severityofinjury,etc)andoutcomesreported(success/failureofinitialrevascularization,longtermsurvival,functionaloutcomesassessedatdifferentfollowupperiods,typesofoutcomesassessed,etc).Theimportantconclusionisthattheapparentvariabilityofdatamakesitdifficultforsurgeonstodrawanymeaningfulconclusions.Weshouldstrivetoevaluate and report outcomes in a standard way.

1. What should all hand surgeons (and/or hand therapists) reading your article understand about the findings of your research?We have provided in our article our recommendationsfortheessentialcomponentsof

outcomesevaluationfollowingreplantationinthehand(seetablebelow).Weneedmorestudiestofollowtheguidelineandproducecomparableresults,tosynthesizeaccuratetreatmentguidelines.Then,hand surgeons can devise treatment plans that willbestsuitpatients’needsandproducedesiredoutcomes.

4. Will you be conducting further research/publishing further work on this topic? If so, what will it entail??Our team at Michigan CenterforHand Outcomes and Innovation Research(M-CHOIR)hasconductedmanystudiesinvestigatingoutcomesafterreplantation in the hand. We are striving to generate high-quality evidence to help surgeons provide bettercare.

At this time, we have two large-scale studies ongoing. “Finger Replantation and AmputatioN CHallenges in assessing Impairment, Satisfaction,and Effectiveness(FRANCHISE)”isaninternational,multicenter retrospective cohort study evaluating patients treated with revision amputation or replantation,withfunctionalandpatient-reportedoutcomesassessedatleastoneyearaftertreatment.“FingerReplantationandAmputationMulticenterstudy(FRAM)”isalsobeingplannedatmultiplesitesbothinternationallyanddomesticallyintheU.S.,withprospectivecollectionofoutcomesupto1yearafterrevisionamputationorreplantation.

OUTCOMES FOLLOWING REPLANTATION/REVASCULARIZATION IN THE HAND

Research Roundup

RESEARCH ROUND-UP

Hoyune E Cho, Sandra V Kotsis, Kevin C Chung “Hand Clinics” May 2019, Volume 35, Issue 2, Pages 207-219

Hoyune Esther Cho, MD

NIH T32 Postdoctoral Research

Fellow, Section of Plastic Surgery

Department of Surgery

University of Michigan Medical

School

[email protected]

Outcome Domain Parameters/ Recommended Method Measuring Instrument to Assess and Report

Digit survival Vascularity and digit Assessed after 21 days postoperatively

viability

Arc of motion Total active motion Sum of active range of motion at MCP, PIP, and DIP joints

for each digit, measured with a goniometer

Sensation 2-point discrimination Shortest distance measured between 2 distinct points of

test touch by calipers

Sensation Semmes-Weinstein Smallest monofilament size detected by patient. Fibers

Monofilament test must be perpendicularly placed and pressed onto the skin

just to bend slightly.

Grip strength Jamar hydraulic hand Handle position 2, patients sitting straight back, feet

dynamometer flat, shoulder adducted, elbow flexed at 90 degrees with

forearm and wrist in neutral position. Strength should be

measured in weight (kgs or lbs), and report should include

the ratio between injured and uninjured side.

Return to work Patient-reported Capture patients’ return to same job, different job, or

unable to work

Complications Cold intolerance, pulp Present or absent, provider assessed with patient

atrophy, nail deformity reports

Patient-reported Patients’ subjective Michigan Hand Outcomes Questionnaire (MHQ) and

outcomes evaluation of overall Disabilities of the Arm and Shoulder (DASH) questionnaire.

hand function, activities Total and subsection scores, administered at multiple

of daily living, pain, work time points during follow-up

performance, aesthetics,

and satisfaction

Tableoftheessentialcomponentsofoutcomesevaluationfollowingreplantationinthehand

Sandra V. Kotsis, MPH

Research Coordinator,

Section of Plastic Surgery

Department of Surgery

University of Michigan Medical

School

[email protected]

Kevin C. Chung, MD, MS

Charles B.G. de Nancrede Professor

of Surgery, Chief of Hand Surgery

Director, University of Michigan

Comprehensive Hand Center

Michigan Medicine

[email protected]

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MEMBER SOCIETY NEWS

Member Society NewsTHE BELGIAN SOCIETY FOR SURGERY OF THE HAND

TheBelgianSocietyforSurgeryoftheHandintroducedtheBelgianHandSurgeryCertificate(BHSC)inOctober2018.ThisContinuingEducationalProgram(PVG)withaCertificate,isan inter-university training program supported byallsevenBelgianUniversities.Theaimistostandardizethecompetencyinsurgeryofthehandand peripheral nerves.

The BHSC course runs over two years, consists of4modulesperyear,eachmodulerunover2days(FridayandSaturday,8hoursperday).Theprogramentailsamixoftheory,casediscussionand cadaveric training. At least 80% attendance is obligatory.

Themodulesareorganizedinturnbytheuniversitiesandtheteachersarefromtheparticipating universities to ensure an optimal standardoftraining.

The training program is open to all Orthopaedic , General and Plastic Surgeons , as well as residents intheirlasttwoyearsoftrainingfromEuropeandbeyond.

ThestandardoftheprogramisbasicandcanpreparethemfortheEuropeanDiplomainHandSurgeryExaminationaftertherequiredfellowshiptraining.AdmissiontotheprogramissubjecttoreviewbytheBHSCSteeringCommitteeandtheuniversities internal regulations.

Afterthe2yearprogram,twooralexamsareconductedbytwointer-universitypanels,each

havingtwoexaminers,atleastoneofthemwhohasto have a PhD. The student may choose to have the examination conducted in Dutch, French or English.

Theresultoftheexamissimplyapassorfail.ApassearnsthecandidateaCertificate.Astudentwhofails,mayrequestaperformancereport.Onere-exammaybeattemptedwithin3months.

Feedbackbystudentsforqualityimprovementisdoneonthetopics,sessionsandspeakersaftereach session.

Thefirstcyclerunsfrom2018-2020.Moreinformationcanbehadfrom:https://www.bhsc.be/

MEMBER SOCIETY NEWS

ASSOCIATION OF CHINESE-SPEAKING HAND SURGEONS UNITED

The annual event, The Jixia Hand Surgery Forum, washeldinTianjin,June13-16,2019,co-or-ganisedbyTianjinHospital,togetherwithNantongUniversity, Shandong Provincial Hospital and BeijingJishuitanHospital.TheForumwaspairedwithPre-IFSSHmeetingorganisedbytheAssociationofChinese-speakingHandSurgeonsUnitedinTianjin.

The Forum and pre-IFSSH meeting were attended bymorethan500handsurgeonsfrommain-land China and other countries. The entire events werelivebroadcastedthroughWechatalloverChina, with over 2,000 hand surgeons online watchingnationwide.Theyearlyforumisfeaturedwithsystematicpresentationsandlivelydebates.Inthisyear’sevent,thedebatesincludedfingertiprepair,positionofhandimmobilisation,insitucubitaltunnelreleaseversusanteriortranspositionoftheulnarnerve,treatmentofKienbock’sdisease,nervetransfer,nervesuper-chargingprocedures,selectionsoffreeflapsforsofttissuedefects,andtreatmentofcongenitalanomaliesofthehand.International attendees presented techniquesonfreeflaptransfers,biomechanicsofdistalradiusfractures,anddiagnosisofmediannervecompressionintheforearm.NightsessionsfeaturedlecturesfromDrs.DonLalondeandElisabetHagertontendonrepairandnervecompressionoftheupperextremities.Thenightsessions lasted until 10:20 in the evening.

Thepre-IFSSHmeetingfocusedonwide-awakesurgery in China, where wide-awake surgery isverypopular.InTianjinHospital,thehostofthemeeting, more than 20,000 patients underwentwide-awake surgery in the past 3 years. This is perhaps the largest case series in a single unit inthe past 3 years. Other hospitals in China, including

Nantong University, Shandong ProvincialHospital,QiluHospitalofShandongUniversity,and Jiangyin People’s Hospital, popularly use this approach.ThepresentationsfromoutsidemainlandChinaincludedaseriesoftalksfromDrs.DonLalonde,ElisabetHagert,GregoryBain,andSang-HyunWooontheirusesofthisapproach.

Drs. Carlos Henrique Fernandes and Shanshan Jing introducedhandsurgeryinBrazilandUK.Freepapersontreatmentofdistalradialfracture,wristarthroscopy,digitalsensateflaptransfers,fingerjointreplacement,andhandfractures.Thepre-meetingconcludedwithanightboattourinHaihe,withastonishingviewsoftheTianjinskyline and historic area along the Haihe.

TheForumwillbeheldnextyearinBeijing,andwillbeorganisedbyBeijingJishuitanHospitalin April, 2020.

ThephotosarefromtheForumandpre-IFSSHmeeting

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JOURNAL HIGHLIGHTSMEMBER SOCIETY NEWS MEMBER SOCIETY NEWS

ECUADORIAN HAND SURGERY SOCIETY (ECUMANO)

AbriefhistoryHand surgery in Ecuador has an interesting beginning.In1964thefirsthandtransplantintheworldwasdoneinthecityofGuayaquil,performedbyDrRobertoGilbertElizaldeandhissurgicalteam.Thiscausedinternationalinterest.AteamfromBoston, USA visited to study the case.

Despitethisfactandforsomeotherreasons,thedevelopmentofhandsurgeryasaspecialtyinEcuador was very slow. It was not until 5 years ago thatagroupofspecialistsinhandsurgerysawthe need to have an entity which would unite the EcuadorianHandSurgeons.Beforethen,itwasonly the Ecuadorian Orthopedics and Traumatology Society which had chapter dedicated to hand pathology.

During the 2016 IFSSH Congress in Buenos Aires, this steering group met in a restaurant and signedadocumenttoestablishtheEcuadorianSocietyforSurgeryoftheHand(ECUMANO).ThisdocumentisseenasthecharterofECUMANO(ActofFoundation).LegalstatusoftheSocietytooksometimeandwasofficiallyrecognizedon17May2019bytheEcuadorianPublicHealthMinistry(MinisterialAgreement360-2019).

SinceECUMANOShasbeenmeetingandbeeninexistenceactivelypromotinghandsurgeryforthe

last 3 years in Ecuador, the current IFSSH President MarcGarcia-EliasencouragedourSocietytojointheIFSSHasafullMemberSociety.TheEcuadorianSocietywasvotedthe60thMemberoftheIFSSHinBerlin in June 2019.

DuringtheshortexistenceofourSociety,wehaveorganizedseveralnationalcourses,WebinarswithforeigncolleaguesfromMemberSocieties,andhaveparticipated in international congresses, such as theBi-nationalColombo-VenezuelanCongressandthe 2018 FESSH Congress in Copenhagen.

CurrentlyECUMANOhas5foundingmembers,10associatemembersand4aspiringmembers.WeexpectakeengrowthofmembershipnowthatourSocietyhasbecomeaMemberoftheinternationalhandsurgeryfamily.Thiswillcertainlyboostourefforttoimprovethegeneralstandardofhandsurgery in our country.

BRAZILIAN SOCIETY FOR SURGERY OF THE HAND (SBCM)

1. The 39th Brazilian Congress for Surgery of the Hand

The39thBrazilianCongressforSurgeryoftheHandwillbeheldfrom1-3AugustinthecityofGramado,inthesouthernregionofBrazil.Thisyeartherewillbealargenumberofinternationalspeakers:FranciscoSoldado(Spain),JamesCalandruccio(USA),JeffreyGreenberg(USA),JorgeClifton(Mexico),MichaelHousman(USA),andRonaldo

Carneiro,aBrazilianfromNaples–USA,whowillbeourHonoredGuest.

TheinvitednationalMemberSocietywillbeIsrael. With an impressive delegation, the Israeli colleagues will share their experiences on various waystotreatinjuries.

Thisyear’sprogramfocusesonnewtreatmentsanddebates.Wewantparticipantstosharetheirideas,clarifydoubts,andsharestories.“Thelecturesaregreattoolsforgettingtoknowsomethingnew,butthediscussionsaretheonestostrengthenlearning,” says SBCM’s Vice President and the 39th CBCM’s President Milton Pignataro.

Formoreinformation,refertothesite:www.mao2019.com.br.

2. The Brazilian Society for Surgery of the Hand actively participated in the 14th IFSSH Congress in Berlin, June 2019

From 17-21 June, during the 14th IFSSH Congress inBerlin(InternationalFederationofSocietiesforSurgeryoftheHand),about120membersoftheBrazilianSocietyforSurgeryoftheHandactivelyparticipatedinthescientificprogram.Itwasoneofthe largest delegations among the 92 participating countries.

TheBrazilianSociety(SBCM)presentedRiodeJaneirotohostthe2025IFSSHCongressandforthat purpose it developed certain actions such asthepresentationofawell-structuredbiddingprocess,withinformationaboutthecityofRioandtheinfrastructureavailablefortheevents,aswellasabookaboutthe60yearsofexistenceoftheBrazilianSocietyforSurgeryoftheHandwhichiscelebratedthisyear.ThismaterialwassenttoallthedelegatesoftheIFSSHMemberSocietiesbeforehand.

Unfortunately,Brazilwasnotthecountrychosen,butthefeelingremains:“WearesurethatwehavedoneourbestfortheSociety.Wearealsosurethatalotstillhastobedone,especiallybythenewgenerationofhandsurgeonsinBrazil.“TopresentBrazilandSBCMtointernationalcolleagueswasaunique experience”, says SBCM’s President Marcelo RosadeRezende.

3. Brazilian surgeons are honored as “Pioneers of Hand Surgery”

Every three years, during the IFSSH Congress, surgeonsfromallovertheworldarehonoredas“PioneersofHandSurgery”.AttheIFSSHCongressinBerlin,theBraziliansClaudioHenriqueBarbieri,and Edie Benedito Caetano, were among the other Pioneers honored.

ClaudioHenriqueBarbieriwasinGermanytoreceive his award while Edie Benedito Caetano could not attend the ceremony and was represented bytheSBCM’ssecretary,SamuelRibak.

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JOURNAL HIGHLIGHTSMEMBER SOCIETY NEWS MEMBER SOCIETY NEWS

AUSTRIAN SOCIETY FOR SURGERY OF THE HAND

TheAnnualCongressoftheAustrianSocietyforSurgeryoftheHand(OEGH)inco-operationwiththeAustrianSocietyforHandTherapy(OEGHT)tookplaceinthewestofAustriainMontforthaus,Feldkirchfrom1-2March2019.Dr.ChristophMittler hosted 153 participants and organised an interesting programme under the topic “Hand -Injuriesandtendondiseases”.DuringtheseCongresses the Board and other Committee Meetings take place.

The Society’s work includes several working-groups and various committees, amongst others ‘HandTherapy’,‘FutureofHandMalformationsinAustria’ and ‘Hand Surgery Specialisation. We are pleasedthata“YoungHandSurgeonsForum”wasestablished.TheforumhasitsownCommitteeandreportstotheBoardoftheSociety.Thisnewgrouppresentlyhas35members.

WecompletedtheAustrianRegisterontheuseofXIAPEXforDupuytren’sdisease.TheRegisterhas788 patients with 814 interventions.The results will bepublishedsoon.

WearelookingforwardtoournextAnnualCongresswhichwillbeheldinMurau(Styria)undertheleadershipofDr.WalpurgaSchiffer.Thetopicfortheeventis“Rheumatology&Prosthetics”andwilltakeplacefrom6-7March2020.

Photo 1: Annual Congress at Montforthaus in Feldkirch.

Photo 2: 153 participants took part at the annual Congress 2019.

CHILEAN SOCIETY FOR SURGERY OF THE HAND

SincethelasttimewepublishedintheIFSSHEzinemany interesting things happened.

Juan Manuel Breyer completed his term as presidentandReneJorqueraassumedasnewpresident,SebastianvonUngerasvice-presidentandMiguelSanhuezaassecretaryoftheChileanHand and Microsurgery Society.Lorena Parra is still our IFSSH delegate doing a greatjob.

Last year, another EWAS Wrist Arthroscopy course was completed in Santiago de Chile with internationalguestparticipationofPedroDelgado,Gustavo Mantovani and Martin Caloia.

TheChileanOrthopedicSociety(SCHOT)meetingheldinSantiagoinNovember2018waswellattended, and we were pleased to welcome Julie Adams, Alex Shin and Alton Barron in Chile. They gaveexcellentlecturesandenjoyedourChileanhospitality.

The triennial IFSSH Congress in Berlin was an amazingexperience.Itwasacomprehensivemeetingwithawiderangeoftopicsandmanyfriends.Chileactivelyparticipatedwithlectures,paper presentations and panel discussions. The Chileansurgeondelegationwasoneofthebiggestyet(Photo)

We are now preparing to participate in the South American Congress in Cartagena de Indias in August, then the ASSH meeting and our own meetinginNovemberinSantiago.TheinvitedguestsareAndreaAtzeiandBaubackSafa.

Chile is the 2020 invited Society to the AAOS meeting in Orlando, Florida.

WeareproudoftheworkwearedoingandthevisibilitythatourSocietyishavingaroundtheglobe.ThisisinpartthankstotheIFSSH.

HopetoseeourHandSurgeryfriendsagainsoon.

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JOURNAL HIGHLIGHTSSHARE SECTION JOURNAL HIGHLIGHTS SHARE SECTION

Images from the IFSSH/IFSHT Congress in Berlin June 2019

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UPCOMING EVENTS

CRISTINA ALEGRI INNOVATION AWARDA blinded IFSHT international evaluation committee chose Judy Bell-Krotoski posthumously for her contribution to the development and standardization of the Semmes Weinstein monofilaments for sensory testing. She was chosen from eight nominees.

IFSHT LIFETIME ACHIEVEMENT AWARD The NEW Lifetime Achievement Award has been devel-oped to recognise therapists who have made outstand-ing contributions to hand therapy internationally. Their contributions will influence many generations to come.

IFSSH EZINEThe IFSHT contribution to the May 2019 IFSSH EZINE is a valuable resource for hand therapist clinicians: “Improving thumb MCP joint stability with a simple lightweight splint” by Sarah Ewald (CH).

IFSHT is keen to have interesting, clinically relevant articles to con-tribute to the IFSSH Ezine. Contact [email protected] to contribute or if you have a suggested

For hand therapy educational events, go to “National/International Education Events” under “Education” at www.ifsht.org.

11TH IFSHT TRIENNIAL CONGRESS: BERLIN, GERMANY The 11th IFSHT and the 14th IFSSH Triennial Con-gresses June 2019 in Berlin saw THE BIGGEST GATH-ERING EVER IN THE WORLD OF HAND THERAPISTS AND HAND SURGEONS. Of the 4,001 attendees from 92 countries, more than 700 were hand therapists !!!

The four-day programme was packed with instructional lectures, scientific paper presentations, workshops and more than 150 e-posters. Special thanks to Natascha Weihs & Beate Jung who co-chaired the IFSHT Congress and many thanks to Ms. Jung and Dorit Aaron who co-chaired the scientific committee, and Lisa O’Brien, who chaired the abstract review committee, for developing such an educationally stimulating program.

2019-2022 IFSHT EXECUTIVE Six therapists have volunteered to lead IFSHT in the coming three years. Contact details for all EXCO members can be found at www.ifsht.org.

L to R: Anne Wajon (AU), Past-President; Nicola Goldsmith (UK), President; Peggy Boineau (USA), President-Elect; Maureen Hardy (USA), Secretary General; Susan de Klerk (SA), Information Officer and Stacey Doyon (USA), Treasurer.

L to R: D Thomas (FR), J-C Rouzaud (FR), C van Velze (SA), R Prosser (AU), M Persson (SE) (rear), V Frampton (UK) L Feehan (CA) (rear), P McKee (CA), A Estrada (CO), S Chinchalkar (CA), J Colditz, (US) and A Wajon (AU), IFSHT President. E Mackin (US) and A Leveridge (UK) were unable to attend to receive their awards.

Anne Wajon, IFSHT President, (at podium) recognizes the German Organizing Committee: L to R are Katja Karasev, Natascha Weihs, Beate Jung, Johanna Ismaier, Christine Popp, and Dominik Simon

1 2 t h Tr i e n n i a l I F S H T C o n g r e s s | L o n d o n , E n g l a n d | J u n e 2 7 -J u l y 1 , 2 0 2 2 | w w w. i f s s h - i f s h t 2 0 2 2 . c o . u k

VOL 13 NO 3 | JULY 2019

UPCOMING EVENTS

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November 7~9, 2019

Seoul St. Mary's Hospital, Seoul, South Korea

Abstract Submission Deadline: July 31, 2019

Abstract Acceptance Announcement: August 31, 2019

Early Bird Registration Deadline: September 30, 2019

Website: http://www.APWA2019.com

Secretariat of APWA 2019124, Bukbyeonjung-ro, Gimpo-si, Gyeonggi-do, Republic of Korea 10098Phone : +82-31-987-5963 Fax : +82-31-987-5967E-mail : [email protected]

UPCOMING EVENTS UPCOMING EVENTS

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Foundation for Hand Surgery

Campus Biotech Innovation Park, Bâtiment F2/F3, Avenue de Sécheron 15, CH-1202 Geneva, Switzerland Tel: +41 225 45 12 92 - [email protected]

www.foundation-handsurgery.org nonprofit organization

To European Societies for Surgery of the Hand

We set up the Hand Surgery Foundation dedicated to Education and Research in Hand Surgery.

The Foundation for Hand Surgery is a non-profit European organization, independent, without industrial support or conflict of interest. The status of the foundation based in Geneva can be consulted on the website www.foundation-handsurgery.org.

Its aim is to offer additional training opportunities for hand surgeons at all stages of their professional training, from the early years to the final stages of perfecting their already acquired technical skills.

Education program includes both junior sessions for surgeons-in-training and senior sessions. The "senior" sessions are intended primarily for surgeons wanting to benefit from the experience of expert surgeons with a reputation on a particular issue. Many invited experts from Europa are part of the education training program.

The sessions are organized in Geneva (Swiss Foundation for innovation and training surgery- SFITS- Geneva University Hospital) and at the School of Surgery in the microsurgery laboratory (Nancy, Fr).

The program of the next training modules over a period of three months, is below.

Applicants participating in the training will be able to register on the dedicated site www.foundation-handsurgery.org. We hope to see you and share our experiences.

The Foundation does not belong to anyone; its aim is to be there for everyone.

Best regards,

Gregoire Chick, Gilles Dautel, Philippe Bellemère, Bruno Lussiez, Alain Tchurukdichian

Scientific Board G. Chick (CH) G. Dautel (FR) P. Bellemère (FR) B. Lussiez (MC) A. Tchurukdichian (FR) Scientific Commitee M. Ceruso (IT) A. Ferreres (SP) M. Garcia-Elias (SP) E. Hagert (SE) M. I. Winge (NO) Contact [email protected]

EWAS ISTANBUL, TURKEY

SEPTEMBER 20-21, 2019

5th WRIST ARTHROSCOPY COURSE

UNIVERSITY OF HEALTH SCIENCESBALTALIMANI BONE DISEASES

TEACHING AND RESEARCH HOSPITAL

CHAIRPERSONS

Prof. Dr. Kahraman OZTURK & Prof. Dr. Tufan KALELI

SCIENTIFIC SECRETARIATProf. Dr. I. Bulent OZCELIK

Asst. Prof. Dr. Ayse SENCAN

(with International Participation)http://www.wristarthroscopyturkey.org/

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3rd ‘Overseas Day’ SymposiumEffective Teaching across Cultures in Global Surgery

13 September 2019 | 09:00 - 17:00

LocationRoyal College of Surgeons of Edinburgh

A one-day symposium for anyone interested in overseas work in developing countries, particularly in the fields of plastic or hand surgery.

Topics for Discussion:• How to Get Involved in Surgical Work Overseas• Cultural Factors in Global Surgical Training Expert speaker Local surgeons from across the globe give personal insights• Making use of Technology in Global Surgical Teaching• Designing Surgical Curriculum for the Local Environment

Intended Audience:• Consultant Volunteers• Therapists• Trainees

Places are limited and are secured by giving your credit card details to the BSSH office - no money will be taken but non-attendance will cost £50. Please complete and return the form overleaf if you wish to attend

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12APFSSH/8APFSHT12th Asian Pacific Federation of Societies for Surgery of the Hand &

the 8th Asian Pacific Federation of Societies of Hand Therapists Triennial Meeting 11-14 March 2020 | Melbourne Convention and Exhibition Centre

apfssh2020.org

We look forward to seeing you in Melbourne from the 11th - 14th March 2020, to learn, be inspired, network with colleagues and enjoy everything Melbourne has to offer.

WEB apfssh2020.org • CONTACT US [email protected]

UPCOMING EVENTS

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· reflex sympathetic dystrophy (rsd)/crps/sudeck … · 2019-08-03 · (rsd)/crps/sudeck does not...

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