AAHS-Newsletter-Winter-2011

Hand surgery is a smallworld. That size offers us theability to personally discuss dif-ficult cases and share concernsover patient care, the business ofhand surgery, and other perti-nent issues. The AAHS meetingprovides the perfect forum forsuch conversations. Sotake the opportunity toshare a margarita andyour thoughts.

Also take advantageof the offshore meetingsite to explore theMayan Riviera. WhileCancun is the heart ofthe meeting, an after-noon boat ride to IslaMujeres is a worthwhileexcursion. In Mayan times, theisland served as the sanctuaryfor the goddess Ixchel, theGoddess of fertility, medicine,happiness and the moon. In1517, when the Spanish expedi-tion under Cordova landed, they

found many female shaped idolsrepresenting the goddess Ixchel,thus Isla Mujeres got its name,the island of the women.

For the more adventuresome,rent a car or take a tour to Playadel Carmen, the bustling city ofthe Riviera Maya. Then onward

to the Mayan ruins atTulum and Coba. At theheight of the Mayancivilization, Coba hadover 50,000 inhabitants.Amble down a milelong path to NohochMul, which at 140 feet isthe tallest pyramid onthe Yucatan. It’s theonly one left in Mexicothat you can still climb.

So despite the heat and theincline, that’s what you do. Atthe top you’ll see the altar—like-ly the site of human sacrifice—and a view of verdant jungle asfar as the eye can see, patrolledfrom above by awooping hawksand quetzals. In that serenityyou can contemplate and digestthe teachings of the IC youattended or the musings of theadventurer, Aron Ralston, ourguest speaker.

Finally, cool off with a swimin a cenote. The entire Yucatan isa honeycomb of undergroundrivers and caverns calledcenotes. The most profound isthe legendary Dos Ojos Cenote.A local guide equips you withsnorkel, mask, and flippers andleads you into the chilly, crystalclear water. Water temperature

Welcome toCancun!

Hopefully the weather hascooperated and we areenjoying tropical breezesand warm sands. One ofthe advantages of the of

the AAHS meeting is that it bal-ances a superb educational pro-gram (this year mastermindedby Jesse Jupiter and SueMichlovitz) and time for social-izing and relaxing with col-leagues. The importance of suchtime spent in conversation andshared experiences highlightsthe theme of the Cancun meet-ing: collegiality. We have a num-ber of Latin and South Americancolleagues attending and weacknowledge their friendshipand importance in the dialog ofhand surgery.

Winter

2011

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2 From the Editor’s Desk

AAHS Calendar ofMeetings

3 Hand Therapist &Affiliates’ Corner

5 Coding Corner

6 Around the HandTable: Treatment ofDupuytren’sDisease

11 Hand TherapyTechniques forStages ofDupuytren’s

15 Hand TherapyProfile: CharleenStennett, OTR/L,CHT

17 2011 AnnualMeeting Program at a Glance

20 Mentor Program

A Publ ica t ion of the Amer ican Assoc ia t ion for Hand Surgery

www.handsurgery.org

900 Cummings Center

Suite 221U

Beverly, MA 01915

M E S S A G E F R O M T H E P R E S I D E N T

A. LEE OSTERMAN, MD, FACS

Nohoch Mul is the tallest pyramid on the Yucatan.

The Rules ofEngagement

Scott Kozin served as thepresident of the AAHS from2008-2009. In the year prior,he had approached me toserve as a representative

from the AAHS to the AAOS(American Academy of Ortho-paedic Surgery). Prior to that, I hadvery little involvement in “orga-nized medicine.” I had attended themeetings, obtained my CME, madea few presentations, but that wasabout all. This was my first oppor-tunity to see how these organiza-tions functioned to serve theirmembers.

The AAOS has several boardsthat guide their society. One ofthese had been recently reorganizedinto the Board of Specialty Societies(BOS). Each specialty society has aset number of representatives tothat board who then make recom-mendations about how the AAOScan better serve and work with thevarious specialty societies. This wasthe role I was give by Scott in 2007.Apparently the structure that hadbeen in place prior to my joiningthe BOS was ineffective and theBOS was an attempt by the AAOSto better interact with the variousspecialty societies. As a result, theleaders of this group were chargedwith an openness and flexibility towork with the specialty societiestoward a more productive relationship.

As a resident and as a youngattending I had looked at theAAOS, the ASSH and the AAHS asorganizations that I would join.They were run by people whosenames I had read in journals andtexts, or after whom a procedure orpiece of surgical equipment hadbeen named. They were, I thought,designed to give me the informa-tion I would need to develop in mypractice as a hand and upper-

extremity surgeon. At my first fall meeting of the

BOS, however, I realized that theseorganizations are dynamic and inconstant need of innovation andinterested volunteers. For the firsttime I recognized that these werenot associations that I would join,but rather that they were myfriends and colleagues associatedtoward common goals. The AAOSwas not a society that was tellingme what to do, but instead was ask-ing me what should be done. It wasreally very enlightening to think ofthe AAHS and the AAOS as myorganizations working for me.

Since that time, I have been elect-ed to serve as the junior-member-at-large on the board of the AAHS. Atmy first board meeting I was askedto take over as editor of thisnewsletter. This demonstrates, Ithink, the willingness of the AAHSto have member input and involve-ment. It also demonstrates the needfor more member participation.There are countless opportunities toget involved.

So, I encourage each member ofthe AAHS to become engaged.

Becoming involved in our associa-tion allows you to mold it to yourneeds. One of the most difficulttasks a professional society faces isaccurately assessing its member’sneeds and responding to them.There is no better way to do thisthan to have greater memberinvolvement. So plan to attend thebusiness meeting in Cancun or lookto join a committee.

Finally, as I assume therole of the editor of thisnewsletter, I will encouragemember participation here aswell. I encourage any feed-back on the form or contentof our newsletter. I alsoencourage contributions orsuggestions for topics by ourmembers. If there are mem-bers who wish to becomeinvolved in a routine column or toparticipate in a round-table discus-sion, I would invite your input. It isyour newsletter and your associa-tion. Become engaged in order tomake them a success! H

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F R O M T H E E D I T O R ’ S D E S K

THOMAS HUGHES, MD

Hand SurgeryQuarterly.....

Winter

2011

2011January 12-15, 2011AAHS 41st Annual MeetingRitz Carlton CancunCancún, Mexico

February 16-20, 2011AAOS Annual MeetingSan Diego, CA

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

September 23-28, 2011ASPS Annual MeetingDenver, CO

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

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

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

AAHS Calendar

For information contact: AAHS Central Office at 978-927-8330or www.handsurgery.org

Let’s See theResults!

It is thought that a picture speaksa thousand words. Then it isplausible that a video can tell awhole story. In this time, videotechnology is all the rage. It is

time to get out the video cameraand capture our results and innova-tions in hand therapy rehabilitation.

The invention of the Internet hasbecome an essential tool for evalua-tors, researchers, and educators. Itis used for communication, onlinedata collection, retrieving data andresearch, online learning, andforum chats. And now with socialnetworking programs such asFacebook and YouTube, the internetis fundamentally altering how peo-ple (young and old) consume infor-mation, particularly in the form ofvideo content.

It is fascinating to go to a sitesuch as YouTube and search handrehabilitation or splinting. You seecompanies advertising products,hand professionals showing offskills or inventions, even handrehabilitation patients becomingvideo stars themselves. Hours ofvideos where our patients areshowing functional gains in rangeof motion and occupation becauseof the exercises prescribed, thedynamic splint worn, and the ther-aputty used.

Incorporating videos into ourpresentations is an excellent tool tomarket new ideas and hand reha-bilitation practices. When speakingto a group, video clips can helpfocus an audience, wake up theaudience, and connect with theaudience. This is the power ofvideo. A short video clip can illus-trate a principle, it can demonstratehow a splint works, it can demon-strate live results in hand functionthat is being achieved, it allows fortestimonials of satisfied patients.Adding video to a slide presenta-

tion allows information to beshared, that offers a personal touchthat is not available with still pic-tures alone.

Using video does not need to beexpensive; it can be done with thevideo mode of a digital camera or acamcorder. Of course willingpatient participation and consent isabsolutely necessary. Once videoshave been taken they can be storedas files on computer harddrives or memory sticks.Most computers areequipped with adequatevideo editing programs onthe operating system. Forexample on Windows, thereis Windows Movie Makerand on Mac there is iMovie.Use these programs to cutout a section of video, splitvideo and/or mash two clipstogether. To make the use of a videoappear seamless in your presenta-tion, save the video clip in a folderand then insert the video clip on aslide within the presentation. (Forexample power point presentationslides). This is referred to as embed-ding the video clip into a slide.

Most information sharing outletsare resorting to internet access.Even this newsletter is availableonline if preferred, rather thanreceiving a paper copy. Online sub-missions are being used for journalapplications. Why not includevideo clips along with an onlinepaper submission to capture theintended audience and demonstrateresults. Including video clips in ourpresentations and other educationalapplications will give audiencesclear, concise and QUICK informa-tion. H

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H A N D T H E R A P I S T A N D A F F I L I AT E S ’ C O R N E R

AMANDA HIGGINS,OT


Winter

2011

is 77° Fahrenheit throughout theyear and the maximum depth isapproximately 30 feet. The water isexceptionally clear as a result ofbeing rainwater filtered throughlimestone; for an hour you are onanother planet. Renewed andrefreshed, you are ready for theFriday evening gala salsa party.

Cancun and its environs are anexciting venue in keeping with theAAHS mission of providing a spe-cial personal, social, and education-al experience for our members. AsPresident this year, I have beenlucky to have a dynamic board thathas worked diligently to augmentthe Associations’ education,research, and service goals, whilemaintaining our fiscal solvency inthese tumultuous economic times.Your association is in good hands.So celebrate the passion that ishand surgery today and in thefuture. Best wishes for the holidaysand a prosperous New Year. H

F R O M T H E P R E S I D E N Tcontinued from page 1

PresidentA. Lee Osterman, MD, FACS

EditorThomas Hughes, MD

Managing EditorAnne Behrens

Hand Surgery Quarterly is a publicationof The American Association for HandSurgery and is published strictly for themembers of AAHS. This publication isdesigned as a forum for open discussionand debate among the AAHS member-ship. Opinions discussed are those ofthe authors or speakers and are not nec-essarily the position, posture or stanceof the Association.

Copyright ©2010, The AmericanAssociation for Hand Surgery. All rightsreserved. No portion of this newslettermay be printed without express writtenpermission from the publisher, 900Cummings Center, Suite 221U, Beverly,MA 01915, 978-927-8330.

Coding andDupuytren’s

It is my privilege to step into aposition vacated by Dr. Leon S.Benson, who had providedAAHS Hand Surgery Quarterlyreaders with coding pearls since

2003. Since the focus of this issue ison treatment of Dupuytren’sDisease, we will look at relatedtreatment codes in this inauguraledition.

For those of us who utilize more‘traditional’ surgical techniques fortreatment of Dupuytren’s contrac-ture, CPT coding is a relativelystraightforward affair. Code 26121refers to a palmar fasciectomy pro-cedure but is not routinely used tocode for surgical correction ofDupuytren’s deformity. Code 26123is explicitly used for ‘release of asingle digit’ and includes all surgi-cal techniques for correction includ-ing Z-plasties, skin grafting, andproximal interphalangeal jointrelease. Code 26125 is applied foreach additional finger treated and

should be used in conjunction with26123. Though neuroplasties of thedigital nerves would certainly beperformed during any correctivesurgery for Dupuytren’s contrac-ture, code 64702 is essentially bun-dled into the above CPT codes andcannot be used separately.

When the small finger isinvolved, the insertion of theabductor digiti quinti muscle is typ-ically identified and excised inorder to fully release the digit. Inthese cases, utilizing code 26593(release, intrinsic muscles of hand)is reasonable.

Needle aponeurotomy, alsocalled percutaneous needle fascioto-my, is a minimally invasive tech-nique that can be performed in theoffice. For these cases, code 26040 isused. Open partial fasciotomy is asimilar procedure to needle aponeu-rotomy but is performed in theoperating room and employs code26045.

Effective February 2, 2010, theFood and Drug Administrationapproved Auxilium PharmaceuticalInc.’s biologics license applicationfor clostridium histolyticum colla-genase (Xiaflex®) to treat

Dupuytren’s patients with a palpa-ble cord. According to Medicare,providers could bill for the collage-nase injection (code 20550) in addi-tion to the drug (HCPCS codeJ3590) as of November 15, 2010.Incidentally, code 20550 is the sameone commonly used for corticos-teroid injections in treating stenos-ing tenosynovitis. For accurate pay-ment, these codes should be sub-mitted on the same claim.Prior to November 15,providers were instructed tobill for code 26989 (unlistedprocedure, hands or fingers).

Some insurance providersrequire very specific docu-mentation of a positive ‘tabletop test,’ contracture of atleast 30 degrees at themetacarpophalangeal joint orproximal interphalangeal joint, andfunctional limitations secondary tothe flexion deformity. To ensureappropriate payment, it is essentialthat these findings be spelled outprior to treatment.

Since the use of Xiaflex® requiresa manipulation procedure the dayafter injection, providers can billcode 99213, which pays for evalua-tion and management of an estab-lished patient. Bundled with this feeis manipulation of the finger underlocal anesthesia or analgesia. Code29130 can also be utilized for splintapplication. Most insuranceproviders will approve Xiaflex®

injections if performed by anorthopaedic or plastic surgeon. Upto three injections per cord are typi-cally allowed as indicated at 4 weekintervals. Only one cord should beinjected at a time. Stay tuned tonew developments with Xiaflex®

coding, as reimbursement for theprocedure under a dedicated CPTcode is expected in January, 2012.

H

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C O D I N G C O R N E R

EON K. SHIN, MD


Winter

2011

Fasciotomy/Fasciectomy Procedure Codes

26040 Fasciotomy, palmar (eg, Dupuytren’s contracture); percutaneous

26045 Fasciotomy, palmar (eg, Dupuytren’s contracture); open partial

26121 Fasciectomy, palm only, with or without Z-plasty, other local tissue rearrangement, or skingrafting (includes obtaining graft)

26123 Fasciectomy, partial palmar with release of single digit including proximal interphalangealjoint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includesobtaining graft)

26125 Same as 26123, each additional digit

26593 Release, intrinsic muscles of hand, each muscle

Clostridial Collagenase Injection Codes

20550 Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar ‘fascia’)Accepted after November 15, 2010

26989 Unlisted procedure, hands or fingersAccepted before November 15, 2010

J3590 Unclassified biologics

29130 Application of finger splint; static

99213 Office or other outpatient visit; evaluation and management of an established patient

Dr. Benhaim: I think this is a veryexciting time for Dupuytren’s dis-ease and its treatment. There hasbeen a lot of national attentionfocused on this recently, with manynew surgical nuances and differ-ences in technique, especially withthe gaining acceptance of needleaponeurotomy, the issue of collage-nase and how they both are impact-ing our treatment options. There isstill controversy as to what is thebest type of open surgery—is it aclassic dermatafasciectomy, palmarfasciectomy, or limited incisiontypes of procedures? And, as youall know, patients have becomemuch more savvy with the Internetand are much more informed thanever before. They come in with cer-tain biases and we have to try tonavigate our way through thosebiases.

I want to start off with Dr. Eaton,who put on a fantastic Dupuytren’ssymposium in May of this year. Alot of that symposium was based onsome exciting research and somenew developments in the basic sci-ence aspects of Dupuytren’s dis-ease. Charlie perhaps could give usan update.

Dr. Eaton: Sure. It’s a very excitingtime and there’s quite a bit of basicscience research that’s going onglobally. One of the fun things thatcame out of the symposium wasgetting people together who areworking on similar topics but did-n’t know that the others were.

Basic science is screaming formore work in three areas: the first is

genetics. We have new genetic toolsand very interesting research allaround the world, but we're hin-dered by the lack of an animalmodel, and lack of a good startingpoint. We haven't yet clearly identi-fied the problem chromosome,much less a specific gene. CouldDupuytren’s be a retroviral infec-tion or a spontaneous mutation?Dupuytren’s is disproportionatelycommon in European Americanscompared to African Americans, somuch so that it begs the question: isit a European gene, or is it theopposite, or maybe there’s a genefrom Africa which confers a specialresistance to the causative factor ofDupuytren's? There’s so much wedon't know.

The second area is cell biology.TGF beta one is clearly a key player.Robson and others have shown invitro that tamoxifen blocks theeffect of TGF beta on Dupuytrenmyofibroblasts, and Degreef hasshown that perioperative oraltamoxifen improves the results offasciectomy. Should we be injectingpalms with a depot version ofTamoxifen? TGF beta works byblocking nitric oxide inducedmyofibroblast dedifferentiation.Should we be studying the effect ofputting nitropaste on the palms?The metabolic precursor to nitricoxide is arginine. Should we do tri-als of arginine supplementation?And Botox is not just the botulini-um toxin, it also contains C3 trans-ferase exonzyme, which blocks sev-eral steps in the pathway of fibrosis.

Botox is beingreported as a treat-ment for keloidscars and botox hasbeen shown toreduce contracture,adhesions andfibrosis after experi-mental surgicalwounds. We shouldbe looking at this.

The third area isdemographics. Wedon't even knowwhetherDupuytren's is onecondition or sever-al, like diabetes.Maybe it's notunpredictable asmuch as it is hetero-geneous. Abe in Japan, Bayat in theUK and Degreef in Belgium haveextended the concept of diathesis toinclude risk factors of bilaterality,radial hand involvement, male gen-der, more than two fingersinvolved, age of onset under 50—allthese are independently associatedwith higher risk of early recurrence.Studies which don't take these fac-tors into account are comparingapples and oranges—in the dark.We need to use these in all futurestudies. Also, the fastest way to getmeaningful results of treatment is tostudy patients with aggressiveDupuytren's, because they have ahigh likelihood of early recurrencewhich reduces the sample variation,compresses the time needed for

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Treatment of Dupuytren’s DiseaseThe moderator for this discussion is Prosper Benhaim, MD, FACS, Associate Professor and Chief of Hand Surgery, UCLA Hand Center, UCLA Department of Orthopaedic Surgery, Los Angeles, CA. Joining him are hand surgeons Charles Eaton, MD, President, Dupuytren Foundation, Hand Surgeon, Jupiter, FL; Vincent Rod Hentz, MD, EmeritusProfessor of Surgery, Stanford University, Stanford, CA. Chief, Hand Surgery Section, VA Palo Alto Health Care System,Palo Alto, CA; Neil F. Jones, MD, Professor and Chief of Hand Surgery, Department of Orthopedic Surgery and Division ofPlastic and Reconstructive Surgery, UCI Medical Center, University of California Irvine, CA; and hand thera-pist Saba Kamal, OTR, CHT, Director Hands-On-Care, President American Society of HandTherapists–California Chapter, Partner in Advanced Rehab Seminars, San Jose, CA

PROSPER BENHAIM, MD, FACS

THIS IS A VERYEXCITING TIME FOR

DUPUYTREN’S DISEASEAND ITS TREATMENT.

THERE HAS BEEN A LOTOF NATIONAL

ATTENTION FOCUSEDON THIS RECENTLY.

results and magnifies the effects oftreatment. We need to all get on thesame page. We need to set up aglobal Dupuytren’s registry.

Dr. Benhaim: I think those are excit-ing new insights into our under-standing of Dupuytren’s diseaseand they do spark some veryimportant and interesting ques-tions, especially with regard to thegenetic and demographic features. Ithink we have all seen that, in fact,Dupuytren’s is a very heteroge-neous disease in its presentations.

Okay, Dr. Jones, at this point,what are your thoughts on conven-tional open fasciectomy? I knowthat you have done some work withlimited palmar fasciectomy-types ofincisions to try to reduce theamount of inflammation and post-operative recovery time, with someexcellent results in your populationof patients. Can you put into con-text for us what the role of conven-tional open fasciectomy is, and per-haps a little bit of a discussion onthe advantages and disadvantages;and any pearls that you may impartto the audience with regard to mini-mizing the risk of complicationsassociated with open fasciectomy?

Dr. Jones: Certainly. There are prob-ably 3 basic types of fasciectomy—total, segmental and limited. Totalor radical palmar fasciectomy—removing all the palmar fascia—hasprobably become obsolete. Mostsurgeons perform a segmentalfasciectomy, only addressing one ortwo fingers. There are 3 types ofincision: either you can do a longi-tudinal incision and convert it atthe end with Z-plasties, or you cando Bruner incisions, or you can dothe McCash technique, a transverseincision in the palm and occasional-ly transverse incisions in the fin-gers. Usually these are left openand allowed to granulate, but occa-sionally they can be skin grafted,usually with a full thickness skingraft. If I’m going to use theMcCash incision, then I graft thedefect, because they will contract if

you leave it open. I personally don’tuse the longitudinal incision—youend up with tiny Z-plasties and thetips of those flaps usually don’t sur-vive, and result in dehiscence orinfection. So I use large Bruner inci-sions both in the palm and in thefingers. At the end of the contrac-ture release, I gain increased lengthin the skin by using V-to-Y plasties.

I’ve been experimenting withfasciectomy through limited inci-sions for the past 7 years. It hasbeen done in Europe and inEngland using small semi-circularflaps over the cord, and then excis-ing small segmental portions of thecord through these small incisions. Iuse 2 or 3 small 1 centimeter longtransverse incisions: usually one inthe palm, one at the MP joint leveland one at the PIP joint level. It’s avery technically demanding opera-tion, but I think it’s safer than nee-dle aponeurotomy because you canidentify and protect the digitalnerves. Rather than just dividingthe cord with the needle and leav-ing behind remnants of the cord toreform, you can excise a complete 1cm segmental defect in the cord.Sometimes you can work fromtransverse incision to transverseincision and completely excise theentire cord, but you need a verygood assistant.

The problem with Dupuytren’ssurgery is that you can get most ofthese fingers fully straight, but indoing so, they may lose full flexion.So the basic concept of the limitedincision technique is that you wantto regain finger flexion as fast aspossible, hopefully within 3 daysand certainly by 10 days to 2 weeksso that patients require minimalpost-operative hand therapy. Dr.Eon Shin has submitted our seriesof patients who underwentDupuytren’s release through limit-ed incisions with a 2-year follow upand these results are very gratify-ing.

Dr. Benhaim: Do any of the memberson this panel modify the conven-tional Bruner incisions, or perhapsprefer to use a longitudinal incisionwith multiple Z-plasties in theseverely contracted finger, wherethere may not be enough skin—at

least theoretically—to go fromseverely flexed to fully extended?

Dr. Hentz: I will frequently use astraight-line incision and do Z-plas-ties, although usually larger Z-plas-ties. I’m quick to use full-thicknessgrafts in the severely contractedindividuals because they’re so shortof skin that the manipulation thatyou have to do at suturing the skincreates the background for that stiff-ness. So I’m quickto use full-thicknessgrafts even in anunoperated, first-time procedure ifthey are severelycontracted.

Dr. Benhaim: If youdo use a skin graft,how does thatmodify your reha-bilitation? Do youkeep the handimmobilized for 10days or longer?How do patients dowhen they’ve had askin graft and hada 10 or 14 day delayin mobilization toallow the skin graftto take?

Dr. Hentz: I immobi-lize. I use a bol-ster—like most ofus do—and removethe bolster aboutday 4, and start themmoving. And by day4 the grafts are vascularized enoughto allow motion. I start them mov-ing real early.

Dr. Eaton: I don’t start them quite assoon as that—a week is more mypreference. I know some surgeonswill completely immobilize for 3weeks after dermofasciectomy andskin graft, and I’ve seen some goodresults of other patients who havehad that type of protocol. But I stillthink that early mobilization is keybecause lack of flexion is a signifi-cant long term problem.

Dr. Jones: I definitely use full thick-ness skin grafts, although I am not

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Winter

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NEIL F. JONES, MD

THE BASIC CONCEPT OF THE LIMITED

INCISION TECHNIQUE IS THAT YOU WANT TOREGAIN FINGER FLEXIONAS FAST AS POSSIBLE

SO THAT PATIENTSREQUIRE MINIMAL

POST-OPERATIVE HANDTHERAPY.

as aggressive in moving them as Dr.Hentz. I splint them in full exten-sion for a week and then let themstart moving. However if I’m doinga primary Dupuytren’s releasewithout any skin grafting, I movethem very quickly, usually by thesecond or the third day.

Dr. Benhaim: Saba, can you address,in a more global fashion, your con-cept of when patients who havehad open fasciectomies, with orwithout a skin graft, should starttherapy? Do you think there is a bigdifference in the outcome if youstart therapy on day 1 versus 3, oreven day 7 or 10, if you have had toprotect the skin graft for perhaps aweek or so?

Ms. Kamal: The way we normallytreat Dupuytren’s patients is forearly range of motion. If it’s justopen fasciectomy without a skingraft, the patient is splinted on thesecond day in a hand-based splint.If the patient had multiple fingersworked on resulting in a swollenhand, then we let them rest for acouple of days, to allow for theinflammation to subside, and thenget them moving. If the patient hada skin graft, in order for the skingraft to take, the patient is usuallyreferred a little late, at 3 days ratherthan the day or two after surgery.So we keep them in the splint forthat week, and then start movingthem. Some patients I’ve known atother places have had a forearmincluded in the splint. We usuallydon’t do that because it causes a lotof wrist stiffness later down theroad. But light range of motionearly on and then slowly progress-ing them through the differentstages of therapy allows for thatearly range and prevents that flex-ion stiffness that a lot of peoplecomplain about as we go on.

Dr. Benhaim: Two of the panelistshave already suggested that one ofthe main problems with these typesof surgical procedures is not somuch that the patients can’t neces-sarily get all the way straight, but

they have trouble making a tightfist afterward. In my practice, oneof the most frustrating aspects ofDupuytren’s surgery is the frustra-tion that the patient feels with theinability to make a tight fist. Haveyou noticed any specific type ofpatient or condition that would pre-dispose a patient to that type ofoutcome? Do you have any tips forus as to how to prevent that, from atherapy perspective?

Ms. Kamal: Sure. Usually patientswho have had a volar plate releasetend to develop adhesions at theZone II level. We try to address thisearly: first, we address this by gen-tle early passive and then activeROM, which includes tendon glid-ing and especially differential glid-ing. Edema management is donewith 3/4 finger gloves to allowthem the tactile feedback to encour-age use of the hand yet providecompression for the swelling. Oncethe sutures are healed, we thera-pists remove the sutures for the sur-geon so that we can start the scarmassage early on rather than wait-ing for the sutures to be removedlater or too early and construct ascar mold. One of the things thatreally tends to help is flexion wrap-ping, that is wrapping the finger inflexion to get full passive range ofmotion. If they don’t have that,obviously they’re not going to getthe full glide, the differential glid-ing and thus the active motion thatseems to frustrate these patients. Ifwe do notice an adhesion develop-ing around Stage 2 or 3 ofDupuytren’s healing stages, we addneuro muscular electrical stimula-tion (NMES) to get those tendons topull through the scar adhesions(something we use in flexor tendonmanagement) and that seems tohelp with maximizing the activerange of motion limitation thatsome of these patients may presentwith.

Dr. Benhaim: Dr. Eaton, you havebeen injecting patients with steroidafter a needle aponeurotomy. Doesanyone here also inject steroid afterconventional surgery?

Dr. Hentz: I’ve not done that.

Dr. Jones: I haven’t used a steroidinjection after segmental fasciecto-my but I have used it after a needleapeneurotomy. However, I’m notsure it does any good.

Dr. Eaton: The data on it is still lack-ing. I routinely infiltrate the needleaponeurotomy portals with a fewmilligrams of Kenalog at each site.The basis of this is that we knowthat local steroid injection modu-lates theDupuytren’s biolo-gy, and that it’s fol-lowed fairly quicklyby loss of myofi-broblasts in the areaand to a certainextent turning offthe main biology.Long term effectsI’m not sure of, andthe other thing thatmakes it hard toassess—and a studyneeds to be done tolook at this—is thatafter a fasciotomy,over a few weeks,adjacent noduleswill soften up andbecome less promi-nent. That’s proba-bly just the effect oftaking the tensionoff of the tissuesthat are attached tothe nodule, andtraction and tensionon the Dupuytren’stissue. Laboratorywork very clearlyshows that tissue tension provokesthe whole biology, so it may be thatthe softening that you get after asteroid injection is from the steroidbut it also may be a mechanicaleffect.

Another other thing to throw inthe mix is Lynn Ketchum’s experi-ence with injecting steroids intonodules. A refinement of that is ifyou inject steroid into a nodulewithout an associated cord, a nod-ule in the palm, it’s fairly pre-dictable that the nodule will goaway, at least temporarily, and thatcan be very impressive. However, if

H A N D TA B L E


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2011


...COLLAGENASE IS ALITTLE TOO GOOD. ITWORKS TOO WELL INTHESE NICE CASES

THAT YOU LOVE TO SEEWALK INTO YOUR

OFFICE BECAUSE YOUKNOW YOU CAN DO

YOUR SURGERY AND THEY’RE GOING TOBE HAPPY, AND YOU’LL

BE HAPPY.

VINCENT ROD HENTZ, MD

you inject a nodule in the palm thatis associated with a contracture anda palpable cord, it doesn’t respondas predictably.

The third thing is that if youinject nodules in the fingers associ-ated with some contracture, it mayactually provoke or accelerate theongoing contracture. So all of thatneeds to be made more clear withadditional studies. In the meantimeI inject after doing a release just tohelp smooth the post-operativerecovery.

Dr. Jones: There’s a detrimental sideeffect of steroids if you’re doing asegmental fasciectomy. You may getdelayed skin healing and potentialdehiscence of the incision if youmove them too early. I have notused steroids in conventionalDupuytren’s surgery for this reason.

Dr. Benhaim: The traditional treat-ment after doing a palmar fasciecto-my, or even a needle aponeurotomy,is to place the hand into an exten-sion splint with the fingers in fullextension. Others have suggestedthat this perhaps places the tissuesunder some tension, which canincrease the inflammatory responseafter surgery. What is your currentsplinting protocol after an openfasciectomy for a patient who hashad a couple of fingers released?Do you place the fingers in fullextension, or are you putting just apartial extension split to try to takethe tension off the incisions/skinflaps and try to minimize theinflammatory response? Do youworry at all that not placing the fin-gers in full extension may lead tolosing some ground rather quickly,even just a few days after surgery?

Dr. Hentz: Probably everyone has adifferent approach. I will do thefasciectomy and make sure that Ican get the fingers as extended as Ihoped—that may not always befully extended, but at least I try toachieve my and the patient’s goals.But once I’ve done my closure,whether it’s with Z-plasties or with

zigzag incisions—and as Dr. Joneshas said, a V to Y advancement togain a little soft tissue length.splint them in a comfortable posi-tion. My feeling is that if you arestressing your skin flaps then youare creating some ischemia andthat’s going to initiate an ischemiccascade and potentially affect thehealing. We get into problems if wemake these patients uncomfortable.So I splint them in a comfortableposition and then they start movingrelatively early, say 3 or 4 days. Weknow from our biological studiesthat it takes a few days for scar toform, so I’m not worried about a lotof scar forming in 2 or 3 days. Idon’t feel that you need to splintthese people in extremes of posi-tions.

Dr. Eaton: I would agree with that: Ithink people have less inflamma-tion afterward. I only splint after adermofasciectomy and skin graft,and then only in the resting postureof that hand. The whole issue ofsplinting has lacked evidence untilfairly recently, and what is startingto come out goes against a lot oftradition. Roslyn Evans comparedtraditional passive extension splint-ing with only active extension andfound that avoiding passive exten-sion gave fewer post-op woundhealing problems, lower instance offlare and a better final range ofmotion. The Norwich Dupuytren’sgroup in England has taken this onestep further and I don’t thinkthey’ve published this yet, but theylooked at routine night-time splint-ing versus splinting only if patientsstarted losing extension post-op.They looked at patients who werecompliant verses non-compliantwearing their splints, and theyfound at a year post-op that bothpatient satisfaction and total activeextension were better in those whodid not wear night-time splints.That turns some things on theirhead, but there’s another area thatwe need to look at. It may be thatcommon sense of splinting in exten-sion may not be that sensible.

Dr. Jones: I’ll play the devil’s advo-cate. Obviously, there are somepatients that you can’t achieve full

extension, especially at the PIP jointbut you should be able to get themajority of patients fully extendedwith meticulous surgery. Even ifthey have a 90 degree contracture atthe MP joint, you should be able toachieve full extension, but fullextension at the PIP joint may belimited by secondary changes in thevolar plate, collateral ligaments andthe flexor tendon sheath. If I can’tget the finger fully extended at thePIP joint, thenthere’s obviouslysomething secon-darily affectingthose other struc-tures and I may notbe able to get thefinger fully straight.But I splint all fin-gers as straight as Ican achieve surgi-cally. If you don’tsplint them asstraight as you can,I think you loseground right fromthe start. Similarly, Idisagree with theNorwich group,because many ofmy patients tell methat they start to seetheir finger flexdown more if theystop using a nightsplint in the firstfew months. If theystart night splintingagain, they canregain that lost exten-sion quite quickly.The only time I do not splint a fin-ger completely straight is if there’sany compromised circulation to thefinger. Then I usually flex the fingerjust a little bit for the first day or soand consequently relax any tensionon the incisions and the digitalarteries.

Dr. Benhaim: Saba, do you have anyinput on this?

Ms. Kamal: We normally splint ourpatients in complete extension.However, we provide enoughpadding for the patients to workthrough that extension rather than

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2011


THERE’S QUITE A BIT OF BASIC

SCIENCE RESEARCHTHAT’S GOING ONGLOBALLY [..ONDUPUYTREN'S

DISEASE]. WE HAVETO PUSH TO HAVEMORE WORK DONE

TO FIND BIOLOGICALTREATMENTS.

CHARLES EATON, MD

forcing them in extension so thatthey are able to do it at their com-fort level. This prevents a CRPSresponse and the sutures frompulling out. However, we’re seeingthat if the patients don’t wear thesplint they actually do start to loseground. And the patients are alsoeducated that if during the day theydo see that the finger starts todroop, they’re just supposed to putit on for an hour or so—that waythey regain the function but not loseextension and yet continue to gainflexion. The intricacies are in thepadding: how the padding and thesplinting is done to gain the exten-sion at the right joint, providing asubtle 3-point pressure with thefoam padding with the amount ofpadding that’s placed in, and allow-ing the patients to do it at their ownpace. Also, we do instruct thepatients to continue to wear thenight splint for 6 months regardlessof family history/recurrence, andthe patients are more than happy tocomply.

It’s the principle of stretched relax-ation, that as the tissues relax theyautomatically extend out ratherthan forcing them through aggres-sive stretching, because that willjust increase swelling and furtherthe contracture.

Dr. Benhaim: I think one of the mostdifficult patients that we see is theyoung patient who has very exten-sive disease at early onset, withassociated ectopic disease sites,such as Ledderhose Disease,Peyronie’s Disease, or knuckle padformation on the dorsal aspects ofthe PIP joints. What is the panel’sthought on how you treat thesepatients? Is anyone doing an initialminimal approach with needleaponeurotomy? Do you go straightto palmar fasciectomy because youknow that the recurrence rate isgoing to be extremely high? Do yougo extreme and do something like adermatofasciectomy with skingraft? What is the general thoughton how to approach these patients?

Dr. Eaton: I have an unusual demo-graphic of patients—most of thefolks who I see with Dupuytren’sdon’t want open surgery. And that’seven if these folks have a lot of riskfactors for early recurrence. Andafter explaining options to themand even knowing that they mayget fairly short improvement, manyof these folks will request needlerelease. Interestingly, not all of themhave dramatic early recurrences,which shows that even with knownrisk factors you can’t always predictoutcome. But I think for someonewho looks like they have very bio-logically aggressive disease thatplaces them at high risk for earlyrecurrence, you could do a minimalapproach with a needle release, orcollagenase. If their biology doesn’tturn out to be as bad as you think itis, great. However, if they show thatthey have very aggressive biology,they are probably going to flunkfasciectomy as well. And you couldmake the case to make their firstopen operation dermofasciectomyand skin graft. And I think that hasan advantage of not having dermo-fasciectomy and skin graft being the2nd or 3rd operation. That’s wherepeople run into trouble. They’reoperating in very scarred terrain onthe final operation.

Dr. Jones: Patients are much moreeducated now and they may evenknow what Dupuytren’s diathesis isand they obviously know aboutneedle aponeurotomy. So I have noproblem doing a needle aponeuro-tomy as the initial operation insomebody with Dupuytren’sdiathesis, but I tell them what theymay probably develop in the future.My own opinion about the diathesisis that you need to operate on thesepatients sooner rather than later.That means I will operate on anyfinger with a 30 degree contractureat the MP joint or the PIP joint. Iwill do a segmental fasciectomy intwo or even three or four digits—but I don’t usually skin graft themif I operate on them early. However,if they then recur again, usually thesecond time around, then I will usea full-thickness skin graft based onHueston’s “fire-break“ concept.

Dr. Hentz: I’ve found it hard to con-vince somebody that has these riskfactors associated with the diathe-sis, a young patient with disease inseveral fingers who’s never had anytreatment, to accept having a goodbit of his palmar skin removed andfull thickness skin grafts. Eventhough it may be the best in thelong run for them, it’s hard gettingthem to agree to it. So my approach,like Dr. Jones’, has been to do amore standardoperation.However, I encour-age them to have itdone earlier asopposed to waitinguntil it bothersthem a lot because Ithink that the oper-ation certainly iseasier.

If they do recur,which many ofthem do, I’ll do alimited fasciectomy,excise all damagedand scarred skin ofthe proximal pha-lanx and place a bigskin graft asopposed to anotherbig fasciectomy. I’venot seen so manyfolks who I thoughtwere great candidates for needleaponeurotomy because they fre-quently have these big, thick nod-ules—many of them have PIP con-tractures, and their disease is in theform of a big nodule that’s occupy-ing a lot of the proximal phalanx. Ihave a hard time conceptualizinghow I’m going to affect that with aneedle or with a collagenase. It’slike trying to melt a glacier by pour-ing a teacup of hot water—it’s justnot going to happen. So for thosefolks my initial procedure is afasciectomy. Maybe a little bit moreextensive, but still a fasciectomy.

Dr. Benhaim: Dr. Eaton, do you havea response to that?

Dr. Eaton: The difficulty with fasciec-tomy on people with aggressiveDupuytren’s is a lot of them don’tcome back even when they have a

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THERAPISTS SHOULDASSIST WITH REMOVALOF SUTURES TO START

PROMPT SCARMANAGEMENT AND

PREVENT ADHESIONS OFTHE FLEXOR TENDON.

SABA KAMAL, OTR, CHT


recurrence. So it’s hard to sort outthe long-term results. I think thelong-term results of dermofasciec-tomy and skin graft are more pre-dictable in these folks than simplefasciectomy, but I would agree thatif they’ve had a fasciectomy thatfirst time, the second operationshouldn’t be a repeat of a radicalkind of fasciectomy but rather aSWAT mission to replace wholezones of skin and not trying to filetout all the fascia. The business of afirebreak skin graft is also interest-ing. Dias has shown that small fire-break skin grafts are no more effec-tive than fasciectomy alone. So Ithink the key, as has been said, is to

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have a big skin graft if you’re goingto use one.

Dr. Benhaim: Great. The patient withthe fairly significant contracture ofa PIP joint may have had that con-tracture for many years, and mayhave developed a secondary PIPjoint volar capsule contracture thatis independent of the Dupuytren’sdisease itself. I think we have allbeen in the situation where wehave done a very thorough andextensive release of theDupuytren’s disease, either by nee-dle aponeurotomy or by conven-tional open technique, but find thatthere is still a 20 or 30 degree PIPjoint contracture that is really notdue to either Dupuytren’s cord orretrovascular disease, or even dis-ease immediately underneath the

skin. We have released everythingthat we can possibly release, yetthere is still this residual PIP con-tracture. What is your approach tothat patient? Do you ignore it? Doyou do a PIP joint closed capsuloto-my? Do you actually open the flex-or tendon sheath and do a formalopen PIP joint capsulotomy? Whatis your approach?

Dr. Hentz: There are lots of differentways to do this. First off, for thosepeople I spend a little more timecounseling them basically to deter-mine what their risk factors are andwhat their expectation is. So I gointo the operation with some senseof how aggressive to be in that cir-cumstance where they have a PIPcontracture. Usually these are going


Hand Therapy Techniques for Stages of Dupuytren’sSaba Kamal, OTR, CHT

Stage I: Immediate post op Day One after surgerySplinting: A hand based splintshould be fabricated with openfoam padding to increase gentlePIP extension, i.e. a dorsalpadding is applied on P1 on thesplint and volar padding isapplied on the straps.

Splinting is done for night timeonly if a single digit is involvedthat does not have muchswelling, however, if the patientpresents with a multi-digitinvolvement and a balloon hand,the splint is left on for 3 days, dayand night to allow for the reduc-tion in swelling. Pt. removes thesplint only for exercise. If skingraft is done the splinting is lefton for 1week to protect the graftthen ROM is started. No aggres-sive extension should be done tominimize the risk excessiveswelling, incision opening up orCRPS. If the nerve is involved, thejoint involved is kept on slack.However, if volar plate release isdone then PIP joint issues need tobe taken into account.

Edema: If pitting edema is pre-sent, heat with elevation needs tobe done, followed with retrogrademassage and gentle passive ROM.

In this stage wound care, heat-ing the hand in gentle flexion,gentle ROM, tendon glides, man-agement of swelling should bedone.

Stage II: 10-14 days after suture removalIn addition to the above, thera-pists should offer to remove thesutures as the incision heals, thisaccelerates the scar managementprocess. Once sutures are removedadding paraffin/heat with stretchin flexion, gentle exercises like pegrolls (graded large to small),extension exercises (putty roll),last exercise must be an extensionexercise. Along with this provid-ing scar mold, scar massage,edema glove etc. is helpful. Patientis instructed in wearing the splintduring the day, if they notice anydrooping of the finger, for at leastan hour to restore the extension.

Stage III: Decrease in swelling,presence of full passive ROMAdd more aggressive strengthen-ing with putty gripping and

extension exercises, Velcro boardsetc, use LMB for PIP joint manage-ment if it has a soft end feel andNMES if active ROM deficit is pre-sent in flexion. End ROM isachieved with static progressivesplinting.Principles of stress relaxation withsplinting should be taken into accountin the initial stages and principles ofcreep in the later stages of splinting.

Stage IV: Full active and passive ROMHeavy gripping exercises dynamicgripping with pro hand gripper(graded gripper), (grip–move–place–release) with different sizedpegs, end range extension withstatic progressive splinting duringthe day and continue with nightextension splinting for 6 months.Emphasis should be placed oneducating the patient at everyvisit, on the importance to wearthe splint at night for 6 monthsafter the surgery to prevent recur-rences.Tip: Conservative management:Adding scar mold in the night splintprovides a gentle stretch to the tissueswhen managing very early stages ofDupuytren’s disease.

to be the folks that have 45 to 60 to70 degrees, it’s been there for awhile and you’ve searched every-where for those cords. Since I start-ed rereading McFarlane’s articles,I’ve searched in areas that I didn’tsearch before and have found cordsthat I’ve removed and had betterresults. But if you have made agood search and now you’re facedwith what to do, how aggressive tobe with the rest of the peri-articularstructures, I usually will start outwith gentle manipulation which iskind of a closed capsulotomy,because sometimes that’s all theyneed. You’ll feel a little stretch and alittle semi-tearing, but the jointcomes much straighter and youdon’t have to go do a lot of incising.If that doesn’t work and the patientand I have agreed on the level ofaggression, then I will systematical-ly start releasing things until I’veachieved what I think the patientwants me to achieve. Now if they’rein a 60 to 70 degree range and it’s

been there a long time, I have coun-seled them ahead of time—particu-larly if it’s the 4th and particularlythe little finger—more than likelytheir extensor mechanism is now sostretched that they’re not going tokeep the correction that I might getat the operating table. I may getthem nearly straight, but if it’s a 5thfinger and it’s been at 60 or 70degrees for a good while, they’renever going to keep that extensionbecause their extensor mechanismis now overstretched. I modify mydiscussions with the patients basedupon those factors.

Dr. Jones: I agree almost completelywith Dr. Hentz. It is very importantto look very carefully for retrovas-cular cords and in the little fingerfor cords arising from thehypothenar muscles. If the patientstill has a residual contracture at thePIP joint after you have released thecords, then I incise the flexor ten-don sheath between the distal endof the A2 pulley and the proximalend of the A4 pulley, because manytimes there’s a contracture in theflexor tendon sheath itself ratherthan in the collateral ligaments or

the volar plate. Just like Dr. Hentz, Iperform a gentle manipulation ofthe PIP joint into extension and ifnecessary a closed capsulotomy, butI no longer do an open capsulotomyreleasing the volar plate and collat-eral ligaments with a scalpel. Anopen capsulotomy tends to result ina dramatic loss of flexion of the fin-ger. It’s very much like campto-dactyly in which you can get thefinger straight, but they then loseflexion. I counsel these patientsbefore surgery, so that if their fingercan be improved from let’s say a 60degree PIP joint contracture to 20 or30 degrees and they maintain goodflexion, that’s a much better func-tional finger than if we hadachieved full extension but nowthey lack touching the distal palmarcrease by 2 centimeters.

The final very important pointthat Dr. Hentz made, which wasinitially described by Paul Smith inEngland, is that if the patient has along standing PIP joint flexion con-tracture, the central slip may havebecome attenuated, just like anulnar nerve palsy. Even if you get

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2011


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13


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2011

the finger straight, the central slipwill not be able to maintain that.Paul Smith has shortened the cen-tral slip, but I’ve not done thatmyself. I would be very cautious ofdoing it because even if it achieveda fully straight extended finger, thepatient may then not be able tofully flex their finger.

Dr. Eaton: I agree with all of that. Ithink that a closed manipulationcan be very helpful. I think that theflexor sheath is often part of theproblem of a secondary forceresulting in contracture. I think theliterature is clear on the long-termineffectiveness of open PIP releaseat the time of fasciectomy. Separatestudies by Weinzweig, by Richieand by Byerman all showed intra-operative gains from PIP capsuloto-my are lost at one year post-op.Buck-Gramko showed that PIParthrolysis and pinning led to flex-ion loss but not extension gain.Long term, you can make thingsworse, but not better with opencapsulotomy.

Dr. Benhaim: I’d like to move ontoneedle aponeurotomy. As you allknow, this has become an increas-ingly popular technique as a lessinvasive alternative to conventionalopen palmar fasciectomy. It hasnot, however, been widely adoptedas a mainstream technique by per-haps the majority of hand surgeonsstill in 2010. I guess the area ofinterest for me is why do you thinkthere has been such resistance touniversal adoption of needleaponeurotomy? Are there somebasic simple ideas that you mighthave as to why surgeons have beena little bit resistant to adopting thisas a mainstream technique for agood proportion of our hand sur-geons?

Dr. Hentz: Charlie should answerthis question, but I will make thisone comment. I think that theremay be many closet needleaponuerotomers.

Dr. Eaton: I think that’s true. I thinkthere are a couple reasons. The sim-plest one is there’s inertia in newtechniques. Unless surgeons arereally compelled by a great financialincentive or by a legal incentive,change is often slower than wewould expect. I think another issueis that it sounds like it’s stupid anddangerous, and the idea of doing ablind procedure in the palm issomething which most hand sur-geons’ initial reaction—includingmine when I first heard of this—was “…well, that’s just a bad idea,that’s just asking for trouble…”,and then they don’t think about itagain. I think that’s the reason whythe interest in needle release ispatient driven, because the patientsknow all these horror stories offasciectomy and people they knowthat have had problems and they’relooking for their treatment optionsreally almost more than the sur-geons. But I think the main issue isjust inertia, plus a lot of hand sur-geons have postponed looking intoneedle release because it looked asthough the next step was going tobe collagenase.

Dr. Benhaim: So Charlie, perhaps youcould give us a brief primer for thesurgeon who may be contemplatingneedle aponeurotomy as a tech-nique in his or her armamentarium.What are your general indicationsand contraindications to needleaponeurotomy? Are there any sim-ple basic technical pearls that youthink are important before someonestarts performing this technique?

Dr. Eaton: The first is to read aboutor observe the basic technique fromsomebody who has experience. Thebig concerns that people have areavoiding nerve and tendon injury.This really requires the proper intra-dermal anesthetic technique. Themantra is if the fingertip is notnumb, and if there aren’t any pares-thesias, and if active finger range ofmotion doesn’t catch the tip of theneedle, then you’re doing no harm.The technique description andvideos of this technique are avail-able online, and coming up in printpublication. But the minimumrequirement is contracture from a

palpable cord, in an area wherethere’s some skin reserve, andcooperative patient. The idealstarter patients would be folks whodon’t have big beefy hands, buthave relatively soft skin, isolatedMCP contracture, with a clear MCPcord. And there is a learning curve,as with any technical skill it takes alittle while to get the feel of theneedle and the feel of how thewhole thing proceeds. But in gener-al, starting out on relatively safecases with isolated MP contracturenot terribly severe is a fairly pre-dictable way to get an improve-ment, the patients are happy, andyou can advance from there.

Dr. Benhaim: Dr. Jones, you havedone both a lot of open surgeryand some needle aponeurotomy.How do you make the decision touse an open versus needle tech-nique in a particular patient?

Dr. Jones: Dr. Hentz and Dr. Eatonhave talked about this beingpatient driven, and I think thesepatients come to you already hav-ing decided that they want a nee-dle aponeurotomy and I can under-stand that, but there are somepatients that I don’t personallythink are suitable candidates for it.So I will tell them that in my expe-rience their particular anatomydoes not lend itself to a needleaponeurotomy and I also tell themthat this is not a panacea. If youlook at the few long-term follow-up studies of needle aponeurotomyand if you follow your ownpatients, and maybe Dr Eaton willcounter this, there is a significantlyhigh recurrence rate around 65% at2 years. It obviously depends onhow you define recurrence. OnceI’ve explained this, then I let themmake their decision. To me theideal candidate for needle aponeu-rotomy is someone with relativelythin skin; somebody who has whatI call a very central cord – I don’twant a cord that is situated in anarea where I know the digitalnerves are likely to be. Certainly anisolated MP joint contracture isgoing to be much easier than com-bined MP and PIP joint contrac-

H A N D TA B L E



tures. Finally, I don’t want a patientwith a very large nodule sittingover the palmar aspect of their PIPor DIP joints. So those are some ofmy indications and contraindica-tions for doing needle aponeuroto-my, and I just let the patient maketheir decision. If they don’t take myadvice that they’re not a candidatefor a needle aponeurotomy, maybethey go off and have it done bysomebody else anyway.

I will also just make two otherpoints. One is when you askedabout why surgeons are loathe totake it up, I think it’s just like a lotof other minimally invasive surgerylike endoscopic carpal tunnelrelease. If you can’t see the anato-my, then I think many surgeons arereticent or fear damaging a struc-ture and being exposed to the legalsystem. And I would counter thatby suggesting the next time you doa Dupuytren’s that you’re going todo open, just try needling the cordin the palm, and then incorporatethe needle portal in your incisionand see just how much of the cordyou’ve released and see how closeyou were to the digital nerve andthe flexor tendon sheath.

My final point is that I use nee-dles a lot in the very severely con-tracted finger that I’m going to doan open fasciectomy on. If you usea needle right at the start, you maybe able to extend the finger a littlebit more and be able to get the fin-ger into the lead hand. So that’sanother very useful trick for usingneedle apeneurotomy.

Dr. Benhaim: One of the main criti-cisms of needle aponeurotomy isthe higher recurrence rate reportedin the literature. Are there any tech-niques that you use, Dr. Eaton, tominimize the risk of recurrenceafter needle aponeurotomy?

Dr. Eaton: In theory, more thoroughreleases to relieve cord tensionshould result in slower recurrences,but this really has to be studied.The one study that is the mostrecently reported is from Paul

Werker’s group. He reported an85% recurrence rate at 5 years; andthe problem that I have in compar-ing that is because of the demo-graphic of my patients it makes itdifficult for me to have follow upssince so many come from a dis-tance. I don’t have the numbers toeither confirm or refute that. I doknow that the technique that wasused was more similar to the tech-nique that was developed in Paris,which is to use one or two portalsor levels of release, give a strongpull, and get as much improvementfrom that as can be. I suspect andI’m hoping that the numbers willultimately show that by releasing atmore levels and resulting in a morediffuse release of tension along allof the diseased tissue, that the affectwill last longer. But ultimately itcomes down to the fact thatDupuytren’s is not a surgical dis-ease, it’s a medical condition thatdoes not yet have a medicine; andtrying to come up with the bestoperation for Dupuytren’s is kindof like trying to figure out which isthe best hammer to sweep waterout of your driveway in the rain.It’s just the wrong tool. It works toa degree, but we have to push tohave more work done to find bio-logical treatments.

Dr. Benhaim: So that brings us to thenext question, which is the closestthat we have to a biological treat-ment, which is the recent approvalby the FDA of collagenase for treat-ment of Dupuytren’s disease.Clearly, this does not address theunderlying cause, but it does allowus to attack the collagen in a non-surgical fashion. Dr. Hentz, youhave been involved in some of theinitial studies and I know that youhave a lot of experience with colla-genase. What are your currentthoughts on the role of collagenasein your treatment of these patients?Is there a particular set of indica-tions or contraindications that youuse in your current practice inpatients who have not had anyprior treatment?

Dr. Hentz: My comments when I’masked that by my colleagues hasrecently been that collagenase is a

little too good. It works too well inthese nice cases that have in myexperience been the cases that youlove to see walk into your officebecause you know you can do yoursurgery and they’re going to behappy, and you’ll be happy. Thecurrent indications for collagenasein my practice is almost anybodythat has a palpable cord—asopposed to that big nodule that Italked about that occupied most ofthe proximal phalanx. And I’m try-ing collagenase in essentially allcomers who first receive informedconsent about the various treat-ments. If they still want to try colla-genase I am using it in almost anylocation where I definitely have atarget that’s not adjacent to the flex-or tendon. And so I think the indi-cations are still being developedand our success rate in the patientsthat we’ve done since the drug wasreleased by the FDA—has been sig-nificantly better than our resultsduring the clinical trials. I thinkthat’s due to the fact that we cananesthetize these individuals whenit comes time to do the 24 hour or48 hour post injection manipulation.That lets us be a little bit moreaggressive, and my results are bet-ter in these 18 or 20 folks that I’veinjected so far outside the clinicaltrials, than in the 30 or 38 or 40folks that we had in the clinicaltrial.

Dr. Benhaim: Dr. Jones, have you hadany experience with collagenase? Ifnot, what are your concerns aboutits use?

Dr. Jones: I’ve just started to playwith collagenase, but maybe I’m alittle more skeptical and have con-cerns regarding the recurrence rateand injury, similar concerns relatedto needle aponeurotomy.Collagenase does not distinguishbetween a Dupuytren’s cord andthe flexor tendon and 2 flexor ten-dons ruptured in the original colla-genase trial and all those injectionswere performed by hand surgeons.If you look on the Auxilium web-site, there are far more “other physi-cians” as opposed to hand surgeons

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“accredited” to use collagenase. So Ihave great concerns that in thefuture, some patients may end upwith a far worse problem with aflexor tendon rupture due to colla-genase being injected into the flexortendon sheath or into a tendon. Ifyou have collagenase injections

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being done by physicians (otherthan hand surgeons) who do nothave a specialist’s knowledge ofhand anatomy, then I think there’sgoing to be a greater propensity forthe collagenase to end up in areasother than the cord itself.

The second issue is the rate ofrecurrence. Dr. Hentz recently pub-lished a very small series andreported that 60% of MP joint con-tractures recurred at 8 years, to

about half of what the original con-tracture had been, but the recur-rence rate of PIP joint contractureswas literally 100%.

I believe both collagenase andneedle aponeurotomy are not adefinitive cure for Dupuytren’s, buthave a role in the initial treatmentof Dupuytren’s. The risk of needleaponeurotomy is injury to the digi-tal nerves; the risk of collagenase is


H A N D T H E R A P Y P R O F I L E

Charleen Stennett,OTR/L, CHTPersonal: Originally from Jamaica,and upon moving to the UnitedStates, Miami became my home.When not working at the office, Ilove to play tennis, run, spin,rollerblade, watch movies, shopand travel. I especially enjoycreating and sharing new andwonderful memories with familyand friends.

Education: Attained an A.S. fromMiami Dade Community Collegein 1991 and then graduated fromFlorida International Universitywith a B.S. in OccupationalTherapy in 1994. I received mycertification in Hand Therapy in2003.

Employment: Currently workingfor The Hand Institute in Miami,Florida with renowned handsurgeon Dr. Jorge Orbay. I have hadthe pleasure of working by his sidefor 15 years. I am privileged toserve as both full time handtherapist and director ofrehabilitation services for the handand upper extremity practice.

AAHS Involvement: Associatemember since 1999. I have had thepleasure of attending numerousconferences at exquisite locations.Exceptional educational andnetworking opportunities areafforded consistently.

Best Part of My Job:There is a culture atmy work place that iscomplementary.Having a physicianreadily availableobserving andchallenging is a greatsupport and show oftrust. Watching himlisten as patients sharetheir gratitude of metgoals. Working with aknowledgeable,efficient and congenialstaff is heartening. Witnessing awide spectrum of patient injuries,keeps me grounded and challengedto strive to continue to provide themost innovative care.

Major Accomplishments: Thereare three milestones that I cherishdearly. The first one being my over-twenty years military service in theUnited States Army. The second isthe privilege of conducting lecturesin my field within the US andSouth America, and being able tooffer the South American lecturesin Spanish , a long held wish. Thethird is having become a CertifiedHand Therapist in 2003. I continueto strive for the ultimate pinnacleof personal achievement.

Clinical Specialties: I truly enjoythe wide spectrum of patients thatarrive at our facility. I especiallylike acute trauma injuries that forcecreativity and critical thinking outof the norm. I treasure splintingand wound care.

Greatest ProfessionalChallenge: Providing the highestlevel of quality patient care to mypatients has always been mymantra. Of late, it has been abalancing act of the most extremekind. This due to reimbursementand number of visit curtailments asimposed by insurance companies.The situation is further exacerbatedby increased copayments for thealready cash-strapped patients. Forthe institution, the impact has ledto forced adjustments and in itswake has left meager financialresources for salaries, supplies andthe like. On the part of our patients,we have experienced less time withthem again caused by theaffordability gap. It is not quite yeta crisis, but the emerging realitiesappear very undesirable.

Three Words That DescribeMe: Independent, empathetic,adventurous. H

rupture of a flexor tendon, but Isuspect the rate of recurrence afterboth techniques will be very similar.

Dr. Benhaim: I would love to get Dr.Hentz’s thoughts on recurrencerates, but before I do that, I wouldlike to hear Dr. Eaton’s input on col-lagenase, given his very busyDupuytren’s practice.

Dr. Eaton: I am intrigued, but havenot yet used it for two reasons. Oneis that I haven’t yet seen a situationfor which I thought that it offered areal advantage over doing a needlerelease. The other is that I see peo-ple from a distance, and to organizea several day visit and the followup afterward, logistically is a littlebit of a problem. I agree with Dr.Jones that I don’t think that it’s ulti-mately going to be a biologicallysuperior intervention because youdo get recurrences afterward. I amintrigued by the reports of doingfasciectomy following collagenase,and fasciectomy following needlerelease. You do get some scar tissuein the subcutaneous and deeper tis-sues after doing a needle release inmy experience and others. The peo-ple that I’ve talked to have donefasciectomy following a recurrenceafter collagenase have described thetissues as actually being in fairlygood shape, and concerns aboutgross architectural derangementfrom the effect of collagenase havenot borne out. The tissue planesseemed to be pretty well preserved,and so that may actually be anadvantage.

Dr. Benhaim: Dr. Hentz, yourthoughts on recurrence rates aftercollagenase treatment?

Dr. Hentz: Well, we don’t know. Andthat’s both the long and the shortanswer. The paper that Dr. Jonesalluded to was our follow up of thePhase II dose response trial thatwas done in 1999. We tried to get asmany folks back at about 8 yearsafter the treatment as we could, andof the few we did get back, wefound that folks that had MP con-

tractures that had a good responsefrom the dose response study—inother words they came essentiallystraight—maintained themselvespretty well. Some of them had newdisease, but not to the point whereyou would even consider offeringsurgery for them. The PIP wasanother matter, and because manyof those folks didn’t respond verywell during the dose responsetrial—they didn’t come all the wayout straight—they had residual con-tracture at the end of the doseresponse trial. When they cameback they had fairly significantworsening of their PIP contractures.

For the most recent trial, there isan extension study going on to lookat what happens over 5 years, andwe’re coming on the year 3 anniver-sary for that. The year 2 anniver-sary data was put out and itshowed that of all of the people inthe Phase III trial—there were 200+subjects who got the collagenase—19% now have some evidence ofdisease. They didn’t have a contrac-ture necessarily, but you could feelthat there was something there thatwasn’t there a year before. So at 2years they were not recurring to thepoint where you would treat them,but 19% had something that youcould feel. And I suspect that num-ber will go up at the 3rd year andthe 4th year and the 5th year. And Ican’t agree more that collagenase isnot a cure. It’s just a different tool. Ithink it has some safety advantages,at least from my perspective, out inthe finger – even though that iswhere the tendon rupturesoccurred, but of the tendon rup-tures in the studies all incurred ininjections in the same area, and thatis in the 5th finger out close to thePIP joint. And that’s now sort of theno-man’s land for collagenase. Butfor me, because collagenase doesn’taffect the nerves, it doesn’t digestthe basement membranes, they’re adifferent collagen—I think the safe-ty factor in my hands at least forPIP cords for a minimally invasivetechnique is in favor of collagenase.Others who are more skillful with aneedle and have greater experience,I suspect that they can do this justas safely.

Dr. Benhaim: One last question, if Icould. I think we have all had expe-rience with patients who come intoour offices with early disease andask us if there is anything they cando to prevent further progression oftheir Dupuytren’s contracture. Arethere any things that you can rec-ommend to your patients eithernow or perhaps in the future thatmay be able to prevent further con-tracture? Is there any particular rolefor prophylactic splinting? Saba,can you address this initially andthen maybe some of the other pan-elists can chime in?

Ms. Kamal: Usually when a patientis referred to us for early manage-ment of Dupuytren’s and there isn’tany contracture/cording, just aminimal stiffness, puckering in theskin where they’re lacking somefunction; our response used to be tojust educate them and tell them asto when to approach the surgeon.But some patients who have beeninsistent on us doing somethinghave actually surprised me becausein addition to educating them onthings to avoid—activities, andthings to do—when I splinted them,in fact this has happened on severaloccasions where we splinted them,showed them gentle massage tech-niques, used modalities—within 3or 4 visits they’ve actually been ableto resume the activity the way theywanted to. And that was a surpriseto me that I was able to make achange where I didn’t think it waspossible. So that was pretty interest-ing. So just with night splinting,gentle massage techniques andusing modalities, I was able to helpthem.

Dr. Benhaim: Dr. Hentz, anythoughts on that?

Dr. Hentz: I don’t. I know LynnKetchem still is an advocate and ina recent presentation he talkedabout what he was doing and firm-ly believes that if you stay afterthese people and inject them regu-larly with fairly large doses ofsteroids, that you can alter the pro-gression of their disease. But as faras I know, he’s the lone voice.

Dr. Benhaim: Dr. Eaton?

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Dr. Eaton: The experience that I havehad with steroid injections for nod-ules I’ve talked about earlier, and Ido think that there’s a place for thepatient that has a nodule or nodulesin the palm not associated with con-tractures. And I have had theopportunity to follow up with somefolks that I’ve treated this way whohad complete resolution of theirnodules lasting for a couple ofyears. It’s something to think about.I don’t think that it’s a predictablething when someone has a contrac-ture, or when the nodules are out inthe fingers. As far as splinting,there’s a very interesting presenta-tion by Meinel from Germany,using a silicone rubber surface onthe splint. He took the cue from thebeneficial effect of topical siliconeon hypertrophic burn scars, ofwhich there’s a fair bit of literature.

He used silicone elastomer to con-struct the entire palmar surface of aresting night-time extension splint.His protocol was to have folks weara splint every night that was fash-ioned in their position of maximumactive extension. Each month, if theactive extension had improved,they would be fitted with a newsplint in maximum active extension.Some of these folks would continueto have some improvement inextension over the course ofmonths. This is after doing a needlerelease. Based on that experience,there may be a role of looking atthis type of splint early on as main-tenance, and I think that would bean interesting study to do—particu-larly in people who show up earlybut have a high diathesis score.

Dr. Benhaim: Dr. Jones, the last word.

Dr. Jones: I have tried injectingDupuytren’s nodules, but I onlyinject very painful nodules. I’veseen modest resolution in their size,

but I’ve never seen them melt awaycompletely. The only nodules I’veever seen melt away have beenones that have probably been relat-ed to some traumatic incident, butI’ve never seen true Dupuytren’snodules resolve completely.

There is, however, a subset ofpatients who are incredibly hyper-anxious about Dupuytren’s disease.They’ve been on the Internet andthey come in demanding your rec-ommendation to prevent their con-dition progressing. For thesepatients, I’ve been using a siliconepad for many years, which I alsouse on other hand incisions. Thepatient just tapes it onto the surfaceof the nodule at night beneath asmall resting extension splint. Idon’t think it does anything interms of preventing the progressionof the disease, but it certainly psy-cho-treats their anxiety!

Dr. Benhaim: Thank you all so muchfor participating in this panel. H

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A A H S 2 011 A N N U A L M E E T I N G P R O G R A M AT A G L A N C E

Wednesday, January 12, 2011Specialty Day Program 6:30–7:00 am Continental Breakfast

7:00–8:00 am Instructional Courses

101 Fingertip and NailbedInjuries Chair: Mark Belsky, MD Instructors: Kodi Azari, MD;

Jennifer Green, MD; EricS. Wroten, MD; JeffreyYao, MD; Georgette Fogg,OTR/L CHT

102 Rheumatoid HandReconstructions Chair: Asif Ilyas, MD Instructors: Brian Adams,

MD; Michael Baumholtz,MD; Marco Rizzo, MD;Peter Stern, MD

103 How to Make anIntraoperative Video Chair: Eric Hofmeister, MD

Instructors: MatthewBernstein, MD; MattConcannon, MD

104 Update on Kienböck’sDisease Chair: Steve McCabe, MD Instructors: John Stanley,

MBChB; Roberta Morris,OT CHT

105 Dupuytren’s DiseaseUpdate Chair: Jaiyoung Ryu, MD Instructors: Kyle Bickel, MD,

FACS; Philip Blazar, MD;Rod Hentz, MD; EduardoZancolli, MD

106 Reconstruction of PostTraumatic Deformities ofthe Finger Chair: Randip Bindra, MD

FRCS Instructors: Gunter

Germann, MD; DouglasSammer, MD; Tsu-MinTsai, MD; SharonAndruskiwec, PT CHT

8:10–8:30 am President and ProgramChairs Welcome A. Lee Osterman, MD FACS,

AAHS President Jesse Jupiter MD, Program

Chair Susan Michlovitz, PT PhD

CHT, Specialty Day Chair

8:30–9:30 am Panel: Should I HaveSurgery? Will TherapyHelp? What is theEvidence? Moderator: Mark Baratz,

MD; Gretchen Kaiser,OTD OTR/L MBA CHT

Panelists: Warren Hammert,MD DDS; Steven McCabe,MD; Stephanie Sweet,MD; Sue Blackmore, MSOTR/L CHT

9:30–10:30 am Panel: New Technologiesin Upper ExtremityMedical and SurgicalCare–CurrentPerspectives Moderators: Brian Adams,

MD; Gretchen Kaiser,OTD OTR/L MBA CHT

Panelists: John Lubahn, MD;John Taras, MD; JeffreyYao, MD; Rebecca von derHeyde, PhD OTR/L CHT

10:30–10:50 am Coffee Break

10:50–11:30 am Panel: TroublesomeFractures in the Hand Moderator: Jesse Jupiter, MD Panelists: Peter Tang, MD;

Georgette Fogg, OTR/LCHT; Jennifer Thompson,MPT CHT; Aviva Wolff,OTR CHT


AAHS 41st AnnualMeetingJanuary 12–15, 2011Ritz Carlton–Cancún, Cancún, Mexico

11:30 am–12:00 pm Invited Guest Lecture

(not offered for credit) Stephen Sullivan, MD “Surgical ExperiencesWhile In Haiti”

12:00–1:00 pm Panel: Cosmetic(Rejuvenation) HandSurgery: Form versusFunction Moderator: Laurence

Glickman, MD FRCSCFACS

Panelists: Gunter Germann,MD; Randy Miller, MD;Cynthia Cooper, PT

5:00–6:00 pm “Margaritas withMentors” Reception

6:30–8:30 pm Welcome Reception

Thursday, January 13 6:30–7:00 am Continental Breakfast

7:00–8:00 am Instructional Courses (6 options)

107 Management of Injuries tothe PIP Joint Chair: Peter Stern, MD Instructors: Steven Haase,

MD; Thomas Hunt III,MD; David Netcher, MD;Jorge Orbay, MD; KristinValdes, OTD OTR CHT

108 La Federacion De La Mano:Hand Study Groups Chair: Carlos Fernandes, MD Instructors: Scott Kozin, MD;

Lynn Festa, OTR/L CHT;Joy MacDermid, BscPTPhD; Susan Michlovitz,PT PhD CHT

109 Principles of TendonTransfer Chair: John Lubahn, MD Instructors: Neal Chen, MD;

David Zelouf, MD; TimCooney; Terri Wolfe,OTR/L CHT

110 Wide Awake Hand Surgery Chair: Donald Lalonde, MD Instructors: Sean Bidic, MD;

Eric Hofmeister, MD; A.Lee Osterman, MD FACS;Susan Kean, PT CHT

111 Fractures of the Scaphoid:Pitfalls and Pearls Chair: Stephanie Sweet, MD Instructors: Sanjay Desai,

MD; John Drewniany,MD; William Geissler,MD; Hervey Kimball,

MD; Peter Murray, MD;Paul Brach, MS PT CHT

112 Fracture Dislocations aboutthe Elbow Chair: David Ring, MD Instructors: Brent Bamberger,

MD; Jose Ortiz, MD;Jaiyoung Ryu, MD;Lawrence Weiss, MD;Carol Page, PT DPT CHT

8:00–8:15 am Presidential Welcome A. Lee Osterman, MD FACS

8:15–8:45 am Obama in the OR Moderator: Mark Rekant,

MD Speaker: Andrew Gurman,

MD

8:45–9:30 am Panel A: New Flaps forHand Surgery (NewWorkhorse Flaps for theHand) Moderator: James Chang,

MD Panelists: Allan Bishop, MD;

Jeff Friedrich, MD;William Pederson, MD;Paula Galaviz, OT

Panel B: Flexor TendonInjuries–MasterTechniques Moderator: TBD Panelists: Donald Lalonde,

MD; John Taras, MD;Rebecca von der Heyde,PhD OTR/L CHT

9:30–10:30 am Scientific Paper SessionsA & B Session A Moderators: David

Bozentka, MD; W.P.Andrew Lee, MD

Session B Moderator: MichaelNeumeister, MD

10:30–10:55 am Coffee Break

11:00–11:30 am Presidential Address “Collegiality: The Art ofthe Handshake”A. Lee Osterman, MD FACS

11:40 am–12:30 pm Invited Guest Lecture

Aron RalstonAdventurer and author of Between a Rock and aHard Place(not offered for credit)

12:30–1:30 pm Lunch with Exhibitors

Friday, January 14 6:30–7:00 am Continental Breakfast

7:00–8:00 am Instructional Courses (6options)

113 Update on CongenitalDeformities - Controversies Chair: Scott Kozin, MD Instructors: William Cooney,

MD; Neil Ford Jones, MD;Terry Light, MD

114 Reconstruction ofMalunion of the DistalRadius Chair: David Bozentka, MD Instructors: Philip Blazar,

MD; Jesse Jupiter, MD;Andrew Koman, MD;Kristin Valdes, OTD OTR CHT

115 CMC Arthritis Open andArthroscopic Treatment Chair: Mark Rekant, MD Instructors: Alejandro Badia,

MD; Eduardo Zancolli,MD; Tambra Marik, OTDOTR/L CHT

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116 Complex Hand Fracturesand Dislocations in ContactAthletes Chair: Michael Hayton, MD Instructors: Thomas Graham,

MD; Steven Margles, MD;Chaitanya Mudgal, MD;Aviva Wolff, OTR CHT

117 Reconstruction of theBurned Hand Chair: Keith Brandt, MD Instructors: Michael

Neumeister, MD; RogerSimpson, MD; JonathanWinograd, MD; Ted Chapman, MIL USA,MEDCOM, CRDAMC

118 Challenges of OrthoticSelection Chair: Rebecca von der Hyde,

PhD OTR/L CHT Instructors: Mark Rekant,

MD; Jerry Coverdale, OT,CHT; Lynn Festa, OTR/LCHT

8:00–8:10 am Welcome

8:10–8:40 am Panel: Innovative HandSurgery–AnInternational Perspective Moderators: A. Lee

Osterman, MD FACS;Aviva Wolff, OTR CHT

Panelists: Carlos Fernandes,MD; AlexandruGeorgescu, MD; PakCheong Ho, MD; John

Stanley, MBChB;Eduardo Zancolli, MD

8:40–8:55 am Debate: Is the NegativePressure WoundDressing a Panacea orDevice of the Devil? Moderator: Randip Bindra,

MD FRCS Debaters: Andrew Koman,

MD; Jonathan Winograd,MD

8:55–9:15 am Debate: Locked DistalRadius Plate–Holy Grailor Fool’s Gold? Moderator: Daniel Nagle,

MD Debaters: Michael Bednar,

MD; Jorge Orbay, MD

9:15–10:15 am Scientific Paper Sessions A & B Session A Moderators: David

Ring, MD; JonathanWinograd, MD

Session B Moderators:Warren Hammert, MD;Gretchen Kaiser, OTDOTR/L MBA CHT

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continued from page 18 10:15–10:30 am Break

10:30–11 am Scientific Paper Sessions A & B Session A Moderators: Renata

Weber, MD; SueMichlovitz, PT PhD CHT

Session B Moderators: PeterMurray, MD; JoyMacDermid, BScPT PhD

11–11:45 am Joint ConcurrentAAHS/ASPN Panel:Assessment andManagement of theMangled Hand Moderator: Jesse Jupiter, MD Panelists: Neil Ford Jones,

MD; Rajan Gupta, MD; L.Scott Levin, MD; WilliamPederson, MD; LuisScheker, MD

Joint Concurrent AAHS/ASPN Panel:Failed NerveDecompression–NowWhat? Moderator: Allen Van Beek,

MD Panelists: Allan Belzberg,

MD; Tsu-Min Tsai, MD 11:45 am–12:30 pm Danyo Lecture

Moderator: A. Lee Osterman,MD FACS

12:30–1:30 pm Annual BusinessMeeting (AAHSMembers Only)

1:30–5:50 pm Comprehensive HandSurgery Review Course Chair: Peter Murray, MD

For information on HRCsessions, titles, instructors,and the presentation details,go towww.handsurgery.org.

3:30–3:50 pm Break

7:00–10:00 pm AAHS Salsa DinnerDance

Saturday, January 15AAHS/ASPN/ASRM Combined Day 6:30-8:00 am Breakfast with Exhibitors

7:00–8:00 am AAHS/ASPN/ASRMInstructional Courses

201 Controversies in theManagement of NerveCompression in the UpperExtremity Chair: Thomas Hughes, MD Instructors: Tyson Cobb, MD;

Neil Ford Jones, MD; JohnLubahn, MD; MaryNordlie, MS OTR CHT

202 Reconstruction of Acute andChronic ScapholunateLigament Injuries–How ITreat Chair: Mark Rekant, MD Instructors: Steven Moran,

MD; Peter Stern, MD;Jennifer Thompson, MPTCHT

203 Cortical Plasticity andChanges with Nerve Injury Chair: Dimitri Anastakis, MD Instructors: Martijn Malessy,

MD PhD

204 Adult Brachial PlexusLesions Chair: Allan Belzberg, MD Instructors: Michael Dorsi,

MD; Thomas Tung, MD;Justin Brown, MD

205 Monitoring Technologies forFlaps and Replants Chair: William Swartz, MD Instructors: Darrell Brooks,

MD; Alex Keller, MD;Hakim Said, MD

206 Innovation in Free FlapSurgery Chair: Geoff Gurtner, MD Instructors: David Brown,

MD; Paul Cederna MD

8:15–8:30 am AAHS/ASPN/ASRMPresidents’ Welcome A. Lee Osterman, MD FACS,

AAHS President Paul S. Cederna, MD,

ASPN President Peter C. Neligan, MD, ASRM

President

8:30–9:30 am AAHS/ASPN/ASRMPanel: Robotic Surgery Moderators: Jesse Selber, MD Panelists: Michael Bednar,

MD; Philippe Liverneaux,MD; Sijo Parekattil, MD

9:30–10:00 am Coffee Break withExhibitors

10:00–11:00am Joint PresidentialKeynote Lecture Bob Woodruff (not offered for credit)

11:00 am–12:00 pm AAHS/ASPN/ASRM

Joint Outstanding PapersH


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Below is a list of AAHS members who have generouslyoffered to teach their expertise in specific areas, lettingour members continue to learn the way we weretaught, as residents and fellows, in the clinic and oper-

ating room with a surgical mentor. For more informa-tion, please contact the AAHS Central Office. H

AAHS Mentoring Program Volunteers

NAME EMAIL PROCEDURE(S)

R. D. Beckenbaugh, MD [email protected] Technique of pyrocarbon arthroplasty of the thumb carpometacarpal; and metacarpophalangeal andPIP joints of the digits

Richard Berger, MD, PhD [email protected] Wrist surgery

Kyle Bickel, MD [email protected] Vascularized bone graft reconstruction for carpal pathology; complex fracture management in thehand and wrist; and arthroscopic wrist ganlion excision

Allen Bishop, MD [email protected] Brachial plexus reconstruction; carpal vascularized bone grafts; and microvascular free tissuetransfers

James Chang, MD [email protected] Dupuytren's Contracture; thumb reconstruction; flexor tendon surgery; trapezial excisionarthroplasty; and medial epicondylectomy

Kevin Chung, MD [email protected] Rheumatoid and congenital

Tyson Cobb, MD [email protected] Endoscopic Cubital Tunnel Release

E. Gene Deune, MD [email protected] Congenital hand anomalies; upper and lower extremity reconstruction for deficits due to trauma;cancer resecation; and neurological disorders (i.e. brachial plexus)

Scott H. Kozin, MD [email protected] Pediatrics

Don Lalonde, MD [email protected] Wide awake approach to hand surgery

W. P. Andrew Lee, MD [email protected] Post traumatic hand reconstruction; mini incision carpal tunnel release

Susan Mackinnon, MD [email protected] Ulnar nerve surgery

Nash Naam, MD [email protected] SLAC wrist reconstruction; vascularized bone graft in treating scaphoid nonunions; ulnar shortening& radial shortening; PIP & MP joint arthroplasty; LRTI; arthroscopy of the CMC joint of the thumb

Daniel J. Nagle, MD [email protected] Wrist arthroscopy; endoscopic carpal tunnel release

Michael Neumeister, MD [email protected] Basilar joint arthroplasty; peripheral nerve decompression

Jorge Orbay, MD [email protected] Wrist fractures

A. Lee Osterman, MD [email protected] Advanced wrist arthroscopy and small joint arthroscopy. Can also mentor a topic such as DRUJproblems, or wrist fracture.

Julian J. Pribaz, MD [email protected] Soft tissue reconstruction; microsurgical reconstruction; spare parts surgery and extremityreconstruction

Michael Raab, MD [email protected] Corrective osteotomy (volar or dorsal) of distal radius malunion with iliac crest bone grafting

Jaiyoung Ryu [email protected] Wrist reconstruction; distal radius fracture; and scaphoid fracture/nonunion

David Slutsky, MD [email protected] Use of volar wrist portals for wrist arthroscopy and arthroscopic repair of dorsal radiocarpalligament tears; nonbridging external fixation of intra-articular distal radius fractures; nerveconduction studies for hand surgeons; and comparison of NCS and PSSD for the diagnosis of CTS

William Swartz, MD [email protected] Tendon transfer and ulnar nerve

Thomas Tung, MD [email protected] Brachial plexus and nerve transfers

Joseph Upton, MD [email protected] Congenital hand surgery

Elvin Zook, MD [email protected] Fingertip reconstruction

AAHS-Newsletter-Winter-2011

Documents

ofthe aahs meeting

hand surgerywww

ofthe advantages

aahs meetingprovides

aahs from2008

t h e p r e s i d e

heart ofthe meeting

g e f r o