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An MUSC blog
Keyword: orthopaedics

For three of the most common hand conditions, MUSC Health’s highly skilled surgical team offers specialized and minimally invasive solutions.

Milton B. Armstrong, M.D., professor of Surgery and Division Chief of Plastic, Reconstructive and Hand Surgery at MUSC Health, details the less invasive treatment options that exist for carpal tunnel syndrome, Dupuytren's contracture and Raynaud's disease. MUSC’s surgeons have the specialized training to consistently execute successful results.

Carpal Tunnel Syndrome: Endoscopic Treatment Approach

According to Dr. Armstrong, carpal tunnel syndrome is one of the most common conditions that bring patients into his office. This condition is caused by compression of the median nerve at the wrist, causing numbness and tingling in the fingers and weakness in the hand.

For the past century, open surgery has been the primary treatment for carpal tunnel syndrome. In this procedure, surgeons make an incision on the palm, cut the ligament that covers the nerve causing the problem and then close the skin.

Over time, surgeons have attempted this procedure using smaller and smaller incisions at the wrist. Today, Dr. Armstrong says he uses a very small incision about a centimeter in length and uses an endoscope to view the ligament from the underside. A knife attached to the endoscope then cuts the ligament and the surgeon closes the skin with one or two sutures—in a procedure that can be completed in 15 minutes or less.

For patients who are a good fit for this procedure, Dr. Armstrong says the less invasive nature can make for a quicker recovery. Often, patients can return to work 10 days to 2 weeks faster than if they had undergone the open technique.

“That helps people who have jobs that require significant use of their hands for activities as well as others, such as students, who have busy lives to return to. It's a very useful procedure,” he says.

Dupuytren's Contracture: Injection Treatment

A less common hand condition that Dr. Armstrong treats, Dupuytren's contracture is primarily seen in patients of Northern European ancestry. Patients develop contractures in the palm and the fingers, which pull the fingers down toward the palm over time. While not generally painful, the condition can cause stiffness and rigidity, making movement of the fingers difficult.

Dupuytren's contracture has traditionally been treated with an open technique. In the procedure, a hand surgeon opens the skin, then separates and takes out tissue that's fibrotic, which is otherwise normal tissue that becomes problematic in certain groups of people. This can be a lengthy procedure, lasting up to 2 hours in some cases, and requires meticulous dissection of important structures, such as digital nerves and flexor tendons.

Today, Dr. Armstrong and other MUSC Health surgeons can often bypass surgery entirely with an injection treatment. “We have an enzyme, called Xiaflex, that we can inject into the contracted cord to break it up,” he says. “In many cases, we can avoid open surgery.”

Patients receive the injection and then follow up with their doctor, anywhere from 24 hours to 7 days after the procedure. The doctor then breaks up the contracture manually—no operating room necessary.

“That's been a boon for these patients, especially people who may be older or have other medical problems that make them not ideal candidates to go under anesthesia,” explains Dr. Armstrong. “We can now treat this problem without having to put a patient under an anesthetic and open the skin with a scalpel.”

Raynaud's Disease: Botox® Offers Relief

Raynaud's disease, a type of vasospastic disorder, happens when a spasm of the arteries travels to the fingers. This can either be an isolated problem, more common in young women, or an issue related to other disease processes, such as lupus.

In severe cases, patients can develop ulcers and pain in their fingers due to lack of blood flow. “In some patients where it's very severe, to the point where the tissues have died off, we have to do amputations of some parts of the fingers,” says Dr. Armstrong.

Traditionally, doctors have performed an open operation that aims to release tissues around the arteries to allow for better blood flow.

“The smooth muscles within arterial walls are controlled by little nerves, the digital nerves, and so we separate the nerves from the arteries using magnification, sometimes with the microscope,” says Dr. Armstrong. “It’s a technically demanding operation and doesn’t guarantee success. Those patients have significant pain from the surgery, and then we have to wait for days or weeks to the results of the surgery.”

Hand surgeons treating Raynaud's disease now have another treatment option to consider: Botox®, or botulinum toxin A. Commonly used to treat a host of cosmetic problems, such as wrinkles of the face and forehead, Dr. Armstrong says Botox® can be a useful adjunct for this problem.

“What we have found is that the botulinum toxin, which relaxes smooth muscles, can be injected into some patients’ hands,” says Dr. Armstrong. “It breaks up the spasm and can have as good a result for some patients as doing the open surgery.”

Carpal Tunnel and Other Techniques Require Intensive Training

These three procedures illustrate how advanced, minimally invasive approaches can offer a multitude of benefits to patients, possibly limiting the need for surgery, often with a similar or better result. However, Dr. Armstrong emphasizes the need for specialized training in performing these hand procedures.

In the division of plastic surgery alone, MUSC Health has four physicians who are fellowship-trained hand surgeons, three of whom are also board certified in surgery of the hand. All of this additional training helps guide surgeons toward the best treatment results for patients.

“Physicians should ensure they’re referring patients to a surgeon who is trained and who understands the anatomy and pathophysiology of these problems,” says Dr. Armstrong, noting that an open procedure may be the next option if a less invasive technique doesn’t offer patients sufficient relief or isn’t recommended.

When patients discuss their treatment options with an expert in minimally invasive and open hand techniques, they can ensure they receive well-rounded recommendations and effective results.

For more information, contact Dr. Armstrong at armstrom@musc.edu.
 

The Musculoskeletal Institute at MUSC Health brings orthopaedics, rheumatology and endocrinology specialists under one roof to treat an array of bone and joint disorders as well as metabolic bone diseases and osteoporosis.

This multidisciplinary care model offers care and convenience benefits to patients: The team’s depth of expertise in musculoskeletal care makes the institute uniquely capable of coordinating the care of patients with complex conditions. And patients don’t have to travel to see the specialists they need—they can get all of their care in one place, saving them time and energy.

Treating Hip Pain: What Multidisciplinary Looks Like

The institute’s multi-specialty approach ensures a smooth process for both patients and doctors. Patients can easily get the services they need, and physicians can seamlessly coordinate that care.

“Our advantage as a functional unit for patient care is that the physicians within those three groups interchange and freely move patients among one another based upon the diagnoses and the needs of the patients,” says  Vincent Pellegrini, M.D., chief of the Musculoskeletal Institute and chair of the department of orthopaedics at MUSC.

Consider a patient with hip pain, who makes an appointment with Dr. Pellegrini. If he determines that a patient’s pain originates from the back, he can simply walk around the corner to a spine surgeon colleague.

“The spine surgeon would then see that patient,” explains Dr. Pellegrini. “And he may decide that day that the patient really doesn't need an operation but might benefit from injection therapy.”

The coordination continues from there: “The spine surgeon would then walk around the corner and take that patient to see a physiatrist or a physical medicine physician, who might then do a therapeutic and diagnostic injection.”

Diagnostic tests, evaluation by multiple specialists and treatment: All this could happen in the same space, on the same day, even though the patient came in for hip pain and it turned out to be a back condition. These are not “what-if” scenarios—stories like this happen daily at the Musculoskeletal Institute at MUSC Health.

Orthopaedics, Endocrinology and Rheumatology: A Triad of Care Focus

The Musculoskeletal Institute combines orthopaedics, endocrinology and rheumatology for a reason: These disciplines frequently cross over and require complex care decisions, such as physical rehabilitation.

Patients who benefit from this type of care can include:

  • An orthopaedic patient who thought he or she needed surgery but could benefit from a joint injection and a rehabilitative specialist consult
  • A patient with rheumatoid arthritis who is having severe hand pain, who could benefit from consulting with a hand surgeon and a hand therapist
  • A patient with osteoporosis who has been using Fosamax® for a long time and has unique fractures that require the collaboration of an endocrinologist (to adjust the medication and dosing) and an orthopaedic surgeon (to surgically treat the problem)
  • A patient with hip or knee arthritis who needs an orthopaedic surgeon to address inflammatory arthritis and a rheumatologist to help adjust the medication before surgery

At many centers, all of those appointments would need to be on separate days, with separate specialists. At the Musculoskeletal Institute, we bring together an extensive team to care for a wide swath of people—in a more effective, efficient way.

“With many of our patients, it can take a village to have all of the resources needed to take care of certain problems that are a little more unusual,” says Dr. Pellegrini.

Hip Pain, Osteoporosis and More: Patient and Physician Benefits

The Musculoskeletal Institute has a patient-centric focus, resulting in care that’s improved, coordinated and timely. Dr. Pellegrini says these benefits extend to referring physicians as well—particularly for complicated cases that could use an extra set of eyes from a different specialist.

“I believe most referring physicians are primarily interested in taking care of their patients in a way that’s efficient and expedient,” he says. “Because we put an array of resources under one roof, it allows us to take care of some of the more complicated patient needs that can overwhelm a smaller practice with fewer resources. Our team approach can be very beneficial in certain patient situations.”

For more information, contact Dr. Pellegrini at pellegvd@musc.edu.
 

MUSC Health Sports Medicine, a specialized group of orthopedic doctors and other medical providers within MUSC’s Musculoskeletal Institute, is passionate about providing comprehensive, personalized care to athletes. 

“We’re focused on the evaluation, diagnosis, treatment (both operative and nonoperative) and rehabilitation of injury or pain conditions in the muscles, bones and joints that impact athletes and active people,” says Shane Woolf, M.D., chief of orthopedic sports medicine at MUSC Health.

At MUSC Health Sports Medicine, patients have access to integrated care—from the time of injury until they’re back at play. Patients also benefit from the group’s concentration on education and research, which promotes best practices and novel techniques that demonstrate an expert level of sports medicine care.

Beyond Orthopedic Treatment for Athletes

What sets MUSC Health Sports Medicine apart from most orthopedic groups? According to Dr. Woolf, the answer is in the scope of what—and who—they treat. “I like to consider orthopedic sports medicine as primarily soft tissue orthopedic trauma, as opposed to general orthopedic trauma, which involves primarily treating fractures,” he says. “We all treat broken bones, but at MUSC Health Sports Medicine, our orthopedic sports medicine specialists are skilled in the repair or reconstruction of cartilage, muscle, ligament and tendon injuries and joint instability.”

MUSC Health’s sports medicine group is affiliated with numerous area sports teams, including local high schools as well as the Charleston River Dogs, a minor league baseball team, and the Charleston Battery, a USL pro soccer team. While the focus is on sports medicine, the team doesn’t discriminate based on athletic ability.

“We have experience in treating active and athletic people of all age ranges, activity levels and skill levels,” says Dr. Woolf.

Many athletes may require medical care outside of orthopedic injury issues. MUSC Health Sports Medicine coordinates that care, too. “When you’re playing a sport, even at a recreational level, many medical problems need to be managed differently compared to people who don’t engage in athletics or an active lifestyle,” explains Dr. Woolf.

Conditions such as exercise-induced asthma, diabetes and heart issues can benefit from a sports medicine focus. “Our primary care sports medicine colleague, Alec DeCastro, M.D., is skilled at helping patients with medical issues remain active,” says Dr. Woolf.

Importance of Coordinated Sports Medicine Care

At MUSC Health Sports Medicine, specialists take a big-picture approach to athlete care, coordinating among many specialties.

“We integrate with other specialists very closely,” says Dr. Woolf. “We work with referring primary care physicians as well as our colleagues in radiology, primary care sports medicine, neurology, cardiology and other divisions within our institution. We get athletes the evaluation they need, even if it’s not necessarily an orthopedic issue. We keep it personal, customizing treatment plans for each patient.

“We want to make sure that every patient is safe to play, and we use every resource within our disposal to find a way to allow them to participate in their chosen activity, safely,” adds Dr. Woolf.

Two examples of how patients benefit from this coordination:

  • Joint injuries: A patient receiving joint injections sees a radiologist for image-guided injections, to confirm treatments are reaching the area of concern. Physical therapy professionals can then assist the same patient with rehab of the joint.
  • Gastrointestinal issues: MUSC Health specialists work with the Women’s Tennis Association when athletes are in town for a tournament. When an athlete has a gastrointestinal issue, for example, she might be connected with an MUSC Health specialist for a quick evaluation. “Even though the condition isn’t a musculoskeletal problem, it still affects athletic performance, and we’re happy to coordinate that care,” says Dr. Woolf.

A Leader in Sports Medicine Research and Education

MUSC Health sports medicine specialists are also educating future sports medicine providers and promoting evidence-based care through evolving research.

“We are very much engaged in research and education for sports medicine. We’re not only evaluating and treating these problems, but we’re studying them as well to learn how to provide better care,” says Dr. Woolf.

Specialists teach a range of skills to sports medicine residents and students, from the intricacies of open and arthroscopic surgery techniques to education on the importance of rehabilitation after an injury.

Current research studies are delving into a range of sports medicine points of interest, such as:

  • Improving rehabilitation after ACL tears
  • How foot pain relates to weakness in an athlete’s core (the muscles and joints in the back, pelvis, abdomen and hips that make up the fundamental foundation of the body)
  • Identifying injuries and best treatment plans for cartilage problems in the shoulder and knee

Whatever an athlete’s medical concern, MUSC Health Sports Medicine can help coordinate care and ensure the best treatment, and the fastest recovery, for each individual.

For more information about the MUSC Health Sports Medicine program, contact 843-876-0111.

Dr. Vincent Pellegrini, Chair of the Department of Orthpaedics, leading a revision hip replacementFigure 1 Logo

Join Dr. Vincent Pellegrini, Chair of the Department of Orthopedics at MUSC Health, on April 26 at 8 pm as he leads a virtual grand rounds on revision hip replacement on the free case-sharing app Figure 1 (http://figure1.com, app available on iOS and Android). Annotated surgical photos highlighting key moments in this complex surgery will drop one by one, with Dr. Pellegrini available live online to answer questions and respond to comments. Follow @MUSChealth on the app to participate in this event and see photographs from other complex and innovative surgeries at MUSC Health.

leddy and surgery team preparing prosthesisIn May 2015, an 8-year-old boy from Columbia, SC became the second child in the state to receive an extendible implant that replaced the leg bone that osteosarcoma had destroyed.  Orthopaedic oncologist Lee Leddy, M.D., Associate Professor in the Department of Orthopaedics at MUSC Health, performed the surgery, removing the cancerous bone (and its growth plate) and replacing it with a device designed to be lengthened over time to ensure that both legs will be of equal length. During follow-up visits every four to six weeks, the boy will place his leg into a doughnut-shaped magnet that will drive a gearbox to extend the prosthesis nine centimeters, the remainder of the boy’s projected growth.

Prior to this technology, options for a child whose growth plate had to be removed due to cancer were amputation; rotationplasty, in which the child’s ankle is substituted for the knee joint; or implants that required repeated surgeries to lengthen the prosthesis.  With this device, future operations are not necessary. More than 100 procedures have been completed in the U.S. with this device, but only two in South Carolina, both by Leddy at MUSC Health.

Leddy says this prosthesis is a dramatic improvement over the ways doctors previously met the challenges of limb salvage surgery in the skeletally immature patient. “Being able to reliably lengthen the extremity without surgery is a major advantage,” he says. “However, it is important to realize how critical the team approach is when treating these complex problems.”

The team of specialists who collaborated on these complex cases included musculoskeletal radiologists who interpreted radiographs and magnetic resonance imaging reports,  pathologists who evaluated biopsy tissues, sarcoma-trained surgical oncologists who helped resect the cancer and reconstruct the extremity, operating room nurses, oncologists who made recommendations regarding chemotherapy, and physical therapists who worked with the patients to help return them  to their active lives.

Leddy says that assuming a good response to chemotherapy and physical therapy, these patients can expect a full recovery. 

Photo provided by Sarah A. Pack

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