What’s New in Hand and Wrist Surgeries

How technology and patient-centered care are enhancing outcomes.

Two months ago, a patient visited the surgical experts at NYU Langone Health. After being diagnosed with necrosis of his entire forearm due to complications from COVID-19, the 76-year-old faced an extreme case that led doctors to consider a twofold approach — one that not only would improve his quality of life, but ultimately save it.

Doctors from several clinical departments came together to plan a surgery that would amputate the least amount of tissue and bone, work with the latest prosthetics and allow the patient to function in the best possible way for many years to come.

According to Jacques Hacquebord, MD, chief of hand and wrist surgery for NYU Langone Orthopedics in New York City and a surgeon on this case, a holistic approach that accounted for the patient’s overall physical and emotional issues was important. “We prioritize mental health in patients’ treatment plans because it’s one of the most overlooked factors, yet it’s just as important as their physical therapy and recovery,” he says.

This case was more complex than most hand and wrist surgeries, especially those performed on an outpatient basis. But it illustrates how the performance of hand and wrist surgeries is being reconsidered across all sectors of today’s surgical landscape.

Advances in common arthroscopic wrist cases are enabling more of these surgeries to be performed in outpatient facilities thanks to increasingly minimally invasive techniques. These procedures include distal radius fractures, ulnar-shortening wafer osteotomies, bony arthritic spur removals, percutaneous fracture treatments and an array of percutaneous soft tissue procedures such as trigger finger release surgeries.

Some advances quicker than others

Beyond minimally invasive techniques, recent advances in hand and wrist also include robotic assistance, advancements in diagnostic imaging, regenerative medicine and 3D printing.

For example, the growing adoption of arthroscopy in the subspecialty is enabling surgeons to more easily visualize and treat patients with common conditions such as wrist arthritis and carpal tunnel syndrome through small incisions. As a result, these surgeries are increasingly occurring in outpatient centers, as patients experience quicker recoveries and far fewer painful side effects.

Dr. Hacquebord says advances in hand and wrist surgeries have been rapid in some areas while slower in others.

“One thing that is ripe for change is more arthroscopic procedures for the wrists and hands,” says Dr. Hacquebord. While these procedures are pretty much the norm in Europe, he says the U.S. has been slower in adopting methods that can reduce recovery times.

The reasons for this are complex. Fewer surgeons have been trained in minimally invasive techniques, which come with a learning curve. Finances and operations at surgery centers are sometimes an issue, as some don’t have the staff and equipment to perform these procedures. There are also reimbursement considerations, as some methods of payment depend on financial incentives for adopting minimally invasive techniques compared to more traditional surgeries.

"One thing that is ripe for change is more arthroscopic procedures for the wrists and hands."
—Jacques Hacquebord, MD

In addition, the effective management of hand and wrist issues in the outpatient setting still often depends on the specific medical issue at hand. An example: “We are still treating someone with an arthritic condition very similarly to the way we did 50 years ago,” says Dr. Hacquebord.

Remedies for carpal tunnel, on the other hand, are slowly improving as procedures such as endoscopic carpal tunnel release are taking hold, allowing for smaller incisions that minimize stiffness and pain, as compared with the more traditional open surgery technique.

Dr. Hacquebord also notes the emergence of improved surgical treatments for issues such as arthritic thumbs and wrists, where a growing number of surgeons are removing partial bone and even nerves to enhance strength and mobility. These techniques, he says, often produce better results and far less downtime for patients, particularly those who are younger and more active.

Also being studied and tested are joint replacements of the thumb. Dr. Hacquebord foresees this as a logical next step to decrease pain and increase mobility in patients of all ages when other surgical options have failed.

The use of local anesthesia in outpatient settings during ultrasound-guided release of carpal tunnels and trigger fingers is an improvement and a big change from just a few years ago, he adds.

Although some patients may still struggle with recovery depending on their age and other factors, the trend toward minimal invasiveness is generally providing many of them quicker returns to normal life and activities compared to traditional techniques and open surgeries.

“You want the patients to recover quicker and easier,” says Dr. Hacquebord. “You don’t want patients to come back weeks later still stiff and sore.”

For example, with a small surgery such as a trigger finger procedure, the goal is for the patient to be back to relative normal in about a week or two. Ultrasound guidance helps achieve this in a much less invasive manner than traditionally by releasing the A1 pulley, a tight band of tissue that surrounds the tendon, so the finger can glide more freely.

Other advances that are reshaping hand and wrist surgery include:

• Robotic-assisted surgeries that enhance precision and reduce tissue damage;
• 3D printing of custom implants and surgical guides that are personalized for each patient;
• Augmented reality and virtual reality tools that a growing number of surgeons are using for surgical planning, education and rehabilitation;
• Wearable postoperative rehabilitation monitoring devices that are showing promise as a valuable connection between the health network and patient, enabling enhancements in the originally prescribed regimen based on the information provided through real-time metrics;
• Advances in AI that aid in surgical planning.

The psychology of rehabilitation

At NYU, some of the most common hand and wrist cases are due to accidents, not aging, including many partial hand and finger amputations from work-related injuries.

Although these cases are generally more acute than those treated in outpatient settings, there’s a general movement toward the holistic approach that Dr. Hacquebord and his team employ for all of their hand and wrist cases, no matter the setting. “The goal is always for a patient to regain function and sense of self,” he says. “Our approach to handling these cases is changing and needs to change.

“Life is all about expectations. We as surgeons are not the patient, and often we forget or never realize the patients’ understanding or inexperience.” He says pre-op counseling must improve not only by setting realistic expectations for recovery, but also by addressing patients’ fears and anxieties.

The impact of sports medicine

WHOLE PERSON Dr. Jacques Hacquebord, chief of hand and wrist surgery at NYU Langone Health, says holistic care is essential for patients to fully recover.

At Rothman Orthopaedics in Philadelphia, emerging technologies play an important role in how patients are treated for hand and wrist issues.

“I most frequently perform arthroscopic procedures of the wrist for TFCC (triangular fibrocartilage complex) injuries whether they are traumatic or degenerative,” says Justin Kistler, MD, a Rothman hand and wrist surgeon. “These are common sources of wrist pain. This area of the wrist is more easily visualized and treated through arthroscopy rather than traditional open surgery using a large incision.”

These outpatient surgeries can often be completed in less than an hour, and often with the patient under sedation rather than general anesthesia, adds Dr. Kistler.

“We typically perform these surgeries through two or three small incisions, each less than one centimeter,” he says.

“Outpatient surgery centers generally offer a more efficient patient-centered experience. It is not uncommon for arthroscopic procedures to be performed such that the patient can be in and out of the surgery center in three hours or less. Outpatient surgery also allows the patient to recover at home where they are more comfortable rather than requiring a hospital stay.”

Because Rothman is well known for treating professional sports figures, much of the research that goes into treating first-class athletes is applied to all of its surgical patients.

When treating hands, Dr. Kistler focuses not only on everything a patient uses them to do today, but well into the future. “People rely on the use of their hands every day,” he says. “It’s what connects us to the world, both literally and figuratively. Pain in the hand or wrist can disrupt our lives at work and at home. I see a variety of causes of hand and wrist pain — young patients with sports or traumatic injuries, older patients with degenerative conditions and anyone in between. No one is immune to injuries of the hand and wrist.”

Dr. Kistler says arthroscopic techniques are seeing the greatest advances, particularly in conjunction with the growing use of hand and wrist implants. “The implants are generally small and provide ease of use for the surgeon,” he says.

Dr. Kistler agrees that every case and every patient should be evaluated individually.

“I always stress to my patients and the surgical centers that I can perform a lot of procedures under just local anesthesia,” he says. “Wide awake surgery does not restrict anyone from having outpatient surgery in a surgical center.”

Minimally invasive hand and wrist surgery can offer reduced pain and inflammation, faster recovery, less or no rehabilitation, improved functional outcomes and generally more satisfied patients. Surgery is not always the appropriate option, however.

“I attempt non-surgical treatment in just about all of my patients,” says Dr. Kistler. “Most people can be treated successfully without surgery. If surgery is deemed necessary, then pain relief can usually be achieved, but certainly no guarantees can ever be made for complete surgical success in everyone.” OSM