I would also like to mention that the AAHS was privileged to be a guest society and an integral participant in the annual meeting of the German Society for Surgery of the Hand, Frankfort, Germany; held in late September. The meeting chairman was Michael Sauerbier, an AAHS member, who put together a fantastic program. Members of AAHS were very well represented in the various symposia and scientific sessions. Our guest nation partnerships continue to grow and we look forward to future collaborations with other guest societies around the globe.

Thanks for your help. Happy Holidays to everyone. Pete

$15K total in research funding was awarded in 2016. Grants helped fund Dr. Ryan Schmucker, MD, from the SIU School of Medicine. His project entitled "Investigations of Fat Grafting as a Treatment Modality for Skin Fibrosis in Scleroderma" was the recipient of the 2016 AAHS Annual Research Grant. The Endowment also funded Dr. Amanda Ross, MD, also from the SIU School of Medicine. Her project entitled “LGR6+ Epithelial Stem Cell Augmentation of Fracture Healing” was supported by an AAHS/PSF Combined Pilot Research Grant.

During the annual meeting held in Scottsdale we hosted another HSE/GHHF Silent Auction. There will be another combined auction at the upcoming Hawaii meeting and the Endowment looks forward to continuing this charitable tradition. In Scottsdale the HSE also hosted its 1st Golf Tournament fundraiser. The golf tournament in Hawaii will be held in conjunction with ASRM.

As we move into the New Year the Endowment will continue with its fundraising and begin to expand upon its programs.

The HSE will fund 8 Volunteer Scholarships in 2017 for sites in Honduras, Bolivia, Vietnam, Ghana and various sites through HVO for trainees, junior surgeons and hand therapists. The application deadline is December 31, 2016, so be sure to apply by then if interested.

At the meeting in Waikoloa, HI the HSE will honor the recipients of the Vargas Award, the Humanitarian Award and the Lean and Green Award. We will co-host the HSE Fundraising Golf Tournament along with ASRM and encourage participation in this event at the meeting. $15K in research grants will be awarded as part of the Annual Research Grant and PSF Matching Grant Programs.

It has been a privilege to serve as the Endowment President these last 3 years. The success of the Endowment has been built on the generosity of our members, the support of the Board and the great support staff that administers our organization. Jonathan Isaacs, our current Vice-President, will be taking over the leadership role at the end of the Hawaii meeting and I am confident that his leadership coupled with continued Board support will take the Endowment to new heights for the future. The efforts of the Endowment are directly linked to our mission statement and I strongly encourage all of you to seriously consider supporting its efforts.

Jeffery Greenberg, MD
President, HSE

With chronic central slip injuries and loss of central slip substance, an extensor mechanism turndown or free tendon graft may be necessary. The work of a central slip turndown is best described by CPT 26426 (extensor tendon repair using local tissues), while the additional work of harvesting free tendon graft is best reflected with CPT 26428. Alternatively, an extensor tenotomy may be performed in boutonniere deformities that are passively correctable. This would help to relieve the hyperextension at the distal interphalangeal joint while permitting increased finger flexion. CPT 26060 can be employed in these situations and describes a subcutaneous extensor tenotomy.

For more moderate deformities, lateral band release or reconstruction is a useful tool. The lateral bands can be step-cut over the middle phalanx and the lengthened proximal and distal portions then sutured to one another. This may help to reestablish the balance of the lengthened central slip while avoiding complications associated with mallet deformity. Another approach may include excision of the triangular ligament and transverse retinacular ligaments, thereby allowing the lateral bands to be repositioned dorsally. The bands are then sutured distal to the PIP joint. Regardless of the approach, CPT 26476 (tendon lengthening, extensor) would be appropriate coding for these surgeries.

With more severe or fixed boutonniere deformities, surgical treatment would focus mostly on regaining finger extension. A volar plate release with possible collateral ligament release should be reported using CPT 26525 (capsulotomy for contracture). Finally, in cases with associated degenerative changes at the PIP joint, arthrodesis or arthroplasty surgeries would be reasonable. CPT codes 26860-26863 should be used for PIP joint arthrodesis, while CPT codes 26535-26536 describe PIP joint arthroplasty, depending upon the approaches used.

For peri-articular fractures about the PIP joint, conservative surgical treatment may include percutaneous fixation using Kirschner wires or dorsal block pinning with associated PIP joint instability. For pinning of either the proximal phalanx or middle phalanx, CPT 26727 is used. If there is associated PIP joint instability, then CPT 26776 is used to describe pinning across the PIP joint. Any kind of open approach to the fracture would require use of CPT 26746 (open treatment of articular fracture), while an open approach used specifically to treat a PIP joint dislocation would need CPT 26785 (open treatment of joint dislocation). These codes are often combined with one another, depending upon the severity of the fracture and any associated joint instability.

For significant PIP fracturedislocations, open reduction with internal fixation may not be possible. Hemihamate arthroplasty has become a popular alternative to volar plate arthroplasty in the treatment of these injuries. The work of a hemihamate arthroplasty can best be described with the following codes: (1) CPT 26567 to describe the corrective osteotomy and bony contouring at the base of the middle phalanx, (2) CPT 20900 for harvest of the bone graft from the hamate, and (3) CPT 26746 for open fixation and stabilization of the bone graft.

Finally, PIP arthrodesis or arthroplasty surgeries are appropriate for injuries that are chronic or non-salvageable. These codes have been discussed for central slip injuries.

With chronic central slip injuries and loss of central slip substance, an extensor mechanism turndown or free tendon graft may be necessary. The work of a central slip turndown is best described by CPT 26426 (extensor tendon repair using local tissues), while the additional work of harvesting free tendon graft is best reflected with CPT 26428. Alternatively, an extensor tenotomy may be performed in boutonniere deformities that are passively correctable. This would help to relieve the hyperextension at the distal interphalangeal joint while permitting increased finger flexion. CPT 26060 can be employed in these situations and describes a subcutaneous extensor tenotomy.

For more moderate deformities, lateral band release or reconstruction is a useful tool. The lateral bands can be step-cut over the middle phalanx and the lengthened proximal and distal portions then sutured to one another. This may help to reestablish the balance of the lengthened central slip while avoiding complications associated with mallet deformity. Another approach may include excision of the triangular ligament and transverse retinacular ligaments, thereby allowing the lateral bands to be repositioned dorsally. The bands are then sutured distal to the PIP joint. Regardless of the approach, CPT 26476 (tendon lengthening, extensor) would be appropriate coding for these surgeries.

With more severe or fixed boutonniere deformities, surgical treatment would focus mostly on regaining finger extension. A volar plate release with possible collateral ligament release should be reported using CPT 26525 (capsulotomy for contracture). Finally, in cases with associated degenerative changes at the PIP joint, arthrodesis or arthroplasty surgeries would be reasonable. CPT codes 26860-26863 should be used for PIP joint arthrodesis, while CPT codes 26535-26536 describe PIP joint arthroplasty, depending upon the approaches used.

For peri-articular fractures about the PIP joint, conservative surgical treatment may include percutaneous fixation using Kirschner wires or dorsal block pinning with associated PIP joint instability. For pinning of either the proximal phalanx or middle phalanx, CPT 26727 is used. If there is associated PIP joint instability, then CPT 26776 is used to describe pinning across the PIP joint. Any kind of open approach to the fracture would require use of CPT 26746 (open treatment of articular fracture), while an open approach used specifically to treat a PIP joint dislocation would need CPT 26785 (open treatment of joint dislocation). These codes are often combined with one another, depending upon the severity of the fracture and any associated joint instability.

For significant PIP fracturedislocations, open reduction with internal fixation may not be possible. Hemihamate arthroplasty has become a popular alternative to volar plate arthroplasty in the treatment of these injuries. The work of a hemihamate arthroplasty can best be described with the following codes: (1) CPT 26567 to describe the corrective osteotomy and bony contouring at the base of the middle phalanx, (2) CPT 20900 for harvest of the bone graft from the hamate, and (3) CPT 26746 for open fixation and stabilization of the bone graft.

Finally, PIP arthrodesis or arthroplasty surgeries are appropriate for injuries that are chronic or non-salvageable. These codes have been discussed for central slip injuries.

The election has certainly been a highlight of the year (or low-point, depending on your political leanings). Regardless of party affiliation, there is no doubt that this year’s election outcome will affect physicians more than just about any other group in the country. The ACA has been in force for several years now, and with this election we are certain to see changes in its shape and form, if not its complete elimination. The Trump administration is nothing if not “dynamic” and where we will be a year from now is very unclear.

It is clear that in uncertain times such as these, our medical organizations provide value to practitioning physicians across the country. They will help us to navigate the uncertain times ahead. We hope that these new times will be favorable to physicians.

Certainly the appointment of an orthopaedic surgeon as the director of the department of Health and Human Services (Tom Price) suggests a move in the right direction. At the same time, we know that there will be change, and change is hard to plan for. We at the AAHS will stay alert to changes that can affect our members and will work with the larger orthopaedic, plastic, and general surgical organizations that can affect influence over those changes in the coming years.

So I hope you will all have a productive year, happy holidays, and a wonderful new year. Most importantly, I hope to see you on “The Big Island” in January.

Rationale in Figure 3 outlines why RMF works to restore the balance of forces within the extensor apparatus, unload a repaired central slip and shuttle lumbrical and interossei forces to correct a boutonniere deformity. Balance is further restored as RMF imposes flexor tendon quadriga and resets the lumbrical tensiometer to reduce the force and angle of interphalangeal joint flexion.^{3, 4}

When to consider RMF

• Acute and chronic boutonniere deformities with passive PIPJ extension to at least 20° and isolated DIP flexion of at least 30°.
• Central slip repairs with full passive PIPJ extension and mobile DIPJ flexion
• Fracture/crush of the proximal phalanx to prevent a PIPJ extension lag or remodel a developed lag.

How to decide if RMF is an option
If uncertain about the continuity of the extensor apparatus after injury, before using Elson’s test 5, 6 try Lalonde’s “Pencil test”! 7 (Figure 4) Elson himself states that his test does not make evident a partial central slip injury and can be unreliable due to the patient’s pain or lack of cooperation.5 In my opinion if the Elson’s or modified test is done before the Pencil test, the continuity of any remaining fragile fibers may be further damaged. So if the Pencil test is applied first and balance is restored, rehabilitation using RMF is appropriate.

Most proximal phalanx fractures or crush injuries can be stabilized and moved safely in a modified RMF orthosis. Without doubt the position of RMF is a great tool for early controlled motion exercises. If adhesions have already formed, wearing a RMF orthosis during life activities serves dual-purpose; scar remodeling and extensor apparatus rebalancing.

Specific rehabilitation techniques for use of RMF will be presented as an instructional course at the 2017 AAHS annual meeting in Hawaii. I hope to see you there!

Julianne W Howell, PT, MS, CHT
Samaritan Health Services
Corvallis, Oregon (USA)

Figure 1: RMF orthosis for the long finger.

Figure 2: The fabric of the extensor apparatus. Illustration ©Katie Wright 2016 Wright.design.illustration@gmail.com

Figure 3: RMF-dispersal of tension rationale matrix

Figure 4: For any boutonniere deformity, try Lalonde’s Pencil test before Elson’s or modified Elson’s tests to observe if a RMF orthosis can corrected it.

Figure 4a-b: Lalonde’s Pencil test⁷

Figure 4c: Elson’s test ⁵

Figure 4d: Ton’s modified Elson’s test⁶

References

1. Merritt WH. Relative motion splint: Active motion after extensor injury and repair. JHS Am 2014; 39(6):1187-94.
2. Brand PW. Clinical mechanics of the hand. 1985. The CV Mosby Company.
3. Savage R, Pritchard MG, Thomas M, Newcombe RG. Differential splintage for flexor tendon rehabilitation: An experimental study of its effect on finger flexion strength. Journal of Hand Surgery (British and European) 2005; 30B (2):168-74.
4. Chung B, Thanik V, Chiu DTW. Relative motion splinting for flexor tendon repairs: Proof of concept. Abstract Annual Meeting American Association for Hand Surgery Bahamas, January 22, 2015.
5. Elson RA. Rupture of the central slip of the extensor hood of the finger: A test for early diagnosis. The Journal of Bone and Joint Surgery 1986; 68B (2): 229-31.
6. Ton AR, Soeters JNM, Hovius SER, Stam HJ. A modification of Elson’s test for the diagnosis of an acute extensor central slip injury. The British Journal of Hand Therapy 2006; 11(4):111-12.
7. Hirth MJ, Howell JW, O’Brien L. Relative motion orthoses in the management of various hand conditions: A scoping review. Journal of Hand Therapy (2016); (in press):1-27.

The Registration Desk will be located in the Grand Promenade at the Hilton Waikoloa Village. Registration hours are as follows:

Tuesday, January 10	7:00am – 5:00pm
Wednesday, January 11	5:30am – 5:00pm
Thursday, January 12	6:00am – 5:00pm
Friday, January 13	6:00am – 6:00pm
Saturday, January 14	6:00am – 5:00pm

You will receive a Name Badge and abbreviated Program Guide upon check-in at the Registration Desk. Name Badges must be worn at all social functions, meals and scientific sessions.

Scientific Sessions will take place during the following times:

Tuesday, January 10
Ultrasound Course	8:00am – 12:00pm
Wide Awake Hand Surgery Course	1:00pm – 6:00pm
Wednesday, January 11	6:00am – 5:00pm
Thursday, January 12	6:00am – 12:30pm
Friday, January 13	6:00am – 4:00pm
Saturday, January 14	6:00am – 12:00pm

The Exhibit Hall will be located in the Grand Promenade. Exhibit Hall hours are as follows:

Wednesday, January 11 Welcome Reception	6:30pm – 8:00pm
Thursday, January 12	6:00am – 12:30pm
Friday, January 13	6:00am – 1:00pm
Saturday, January 14	6:00am – 12:00pm

Industry Lunch Symposia:

Thursday January 12, 2017

Industry Lunch Symposia: AxoGen, Inc. (Not for Credit)	12:30 – 2:00pm Kohala 1-3
Industry Lunch Symposia: Skeletal Dynamics (Not for Credit)	12:30 – 2:00pm Kona 4/5

These events are neither supported by nor endorsed by ASPS or AAHS.

Social Events:

Wednesday, January 11
6:30 – 8:30pm	Welcome reception	Grand Promenade/Lagoon
Friday, January 13
12:00 – 5:00pm	HSE/ASRM Endowment Golf Tournament	Francis H. I'I Brown Golf Course
7:00 – 10:00pm	*Annual Meeting Dinner Dance (Outside venue, please dress accordingly.)	Palace Lawn

*Badges are required to enter all Scientific Sessions, Social Events and the Exhibit Hall.

Silent Auction: Items will be available for view and bid in the foyer directly outside the meeting room. Bidding will open Wednesday the 11th, and will close during the AAHS Banquet on Friday, January 13th. All contributions go towards the HSE and Guatemala Healing Hands Foundation.

Transportation: Kona International Airport (KOA) is approximately 30 miles from the Hilton Waikoloa Village. Please visit the official website of KOA to review different ground transportation options. hawaii.gov/koa/ground-transportation

Wi-Fi Access: A special code will be provided when you check in at the Registration and Meeting Services Desk when you pick up your badge that will allow you access to the meeting space Wi-Fi.

I had the privilege to meet clinician-scientists who have excelled in their careers by effectively balancing their clinical, research, and personal responsibilities. We discussed critical elements of being a successful clinician-scientist, including methods for securing funding and strategies for preventing burnout. They personalized my experience at the program by giving me advice that is relevant to my career path. Additionally, I had the opportunity to meet several like-minded residents and fellows who I hope to collaborate with in the future. I strongly recommend that residents or fellows who are interested in an academic career in orthopaedic surgery should consider participating in this program.

Joseph A. Gil

2017 Humanitarian Award
Scott Kozin, MD

2017 Lean & Green Award
Robert E. Van Demark, Jr., MD

2017 HAND Journal Award
Daniel E. Mckee, MD

In developing Hand Surgery Update VI, we had 3 goals: select authors who are preeminent subject matter experts in the areas covered by each chapter; provide a true update of published literature over the last 5 years while linking it to the past with a summary of a “classic” article; and emphasize the most recent impactful information— not create an exhaustive text— thereby complimenting the previously published ASSH Textbook of Hand & Upper Extremity Surgery. It was a privilege for us to review each of these chapters. We learned a tremendous amount and were constantly reminded of the vastness of our specialty

The practice of hand surgery is truly a global one and we are indebted to our international colleagues for their great contributions to the field; this sentiment is reflected in the cover design of the book. We also recognize all of our authors who donated countless hours of hard work to provide outstanding and provocative chapters that we hope you will enjoy reading. In the years to come, we hope you will enjoy and rely on Hand Surgery Update VI. It was an honor to serve our ever-changing specialty, through the publishing of this edition. The book is available as an e-book or hard copy on the ASSH website.
Peter M. Murray, MD
Warren C. Hammert, MD