Q&A:

How did you become interested in the field of hand surgery?
I have a fairly non-traditional arrival into medicine. My parents were artists, stay-at-home potters, and I was homeschooled during my early years. My parents would go into their studio and my mom would set me down to do my homework while they worked. It was this early exposure to artistry and sculpture that had a lot of influence in my entering into surgery. I entered public school and discovered an aptitude for science, and it was the marrying of artistry and math and science that then set me on my course. As a child, I was influenced also by a local physician who cared for family and me and who consistently gave us a gift of service and generosity. That affected my decision to pursue a career in medicine. In college, I did veer away from medicine for a while, focusing on microbiology, and had instead decided to pursue a career in vaccine development. I worked in a smallpox lab and then participated in an infectious disease internship for four months in Zimbabwe. However, it was while I was there in the hospital in Zimbabwe that I met a visiting surgeon participating in mission work. That was my “aha” moment. It really clicked for me that medicine, and surgery specifically, was what I wanted to do. Plastic surgery was an early decision for me in medical school because it combined artistry and surgery—I wanted to do reconstructive surgery.

I went to Johns Hopkins for medical school and then returned to my West coast roots and matched at Loma Linda for plastic surgery residency. There were two women that I worked with there—Drs. Sharon Kalina and Frances Sharpe—and those two women changed my life. They showed me how hand surgery is this wonderful blend of art and science, and they helped teach me, guide me, and support me throughout my residency. They helped nurture and influence my career in ways that were very generous and are still impacting me and shaping how I grow in my practice. I then went to USC for my hand fellowship, which was an amazing experience and was incredibly trauma-heavy and brachial-plexus heavy. Now, I’m very blessed to have a job that allows me to do those things in my career. That’s the somewhat long answer of how I came to hand surgery.

Did you have any struggles or set-backs growing up that you had to overcome to reach these goals?
I’d say the limitation I had to overcome would be the lack of resources early on. Coming from a non-professional, low-income family in a rural area, there were not many opportunities available to me. When I wasn’t in class, I had to work to support myself and didn’t have the time to engage in extracurricular activities to advance my career. I also didn’t know what I didn’t know back then: I didn’t know that shadowing a physician was even an option or that I could reach out to those in the fields I was interested in for mentorship. That’s one of the reasons I feel that social media is a good platform to reach out to a wider audience. It’s a way to educate people about the field and provide mentorship to those who may not have access otherwise, like my younger self.
(editor’s note: you can follow Dr. Leis on Instagram at @dramberleis)

You now practice at UC Irvine and have been there since 2015. How did you end up in Southern California? What’s made you feel that this program is a good fit for you, at this point in your professional career?
I met my husband two days before residency started. He’s in the film industry, and he’s been there for all of it—residency, fellowship, everything with me. So, when it was time to look for a job, the compromise was that we would stay in the general region to accommodate both of our careers and allow him to engage with his community as well. It happened that UC Irvine had a position open in their department of plastic surgery, affiliated with a children’s hospital (CHOC) that needed a plexus surgeon. I couldn’t have found a better job; it was a dream position. My role there has since evolved a lot. When I started, I was the first hand surgeon on faculty. I came in with new ideas and perspectives about how to structure the curriculum and hand education and asked if I could make these changes. This led to my current role.

It sounds like you took the initiative and really put yourself out there, looking for ways to improve things, rather than it just being a role you were handed.
Yes, it definitely takes effort and work. That’s an important distinction. So, the initial role of changing and updating the curriculum then evolved into me becoming the assistant program director, then program director once I was eligible, after completing my boards. I’m also the director for the division of hand surgery, which is one of the largest divisions in our department. Within the division, I try and help nurture the careers of my junior faculty and help encourage them to grow their practices.

In your professional career, how have you navigated your rise as a female surgeon? Have you experienced any setbacks or challenges along your path related to your gender—whether they be external or internal expectations or limitations?
Well, there has been the chronic annoyance of being treated differently than my male colleagues. It chafes at a point, and there have been times when it has really been frustrating to me. However, there have also been times where my role is to figure out how to power through it and figure out a way to make enough space for those who come behind us, until we reach a place where the world has changed. I know I’ve certainly become more assertive about introducing myself and all my trainees as “doctor” right away, to patients and to peers and co-workers in the OR setting. For example, during timeout, residents will often introduce themselves by their first name. I have instead started leading the time-out, and I make sure to introduce myself and all my residents by “doctor-insert-last-name” to make that distinction, because it is a title that we have all earned.

For our trainees, I think it’s also important to highlight the positives when we find them. For example, I had a patient with an osteoid osteoma of her middle phalanx of a finger, and she and her family didn’t speak English and were scared and overwhelmed. One of my female residents spoke their language, and I asked her to help translate, reviewing the condition, answering their questions, and discussing their surgery. During this interaction, she was present with me and another male resident. When it was time for surgery, the little girl wanted to know where “the boss” was, because the female resident who spoke her language was who she and her family associated with being the leader. This made me so excited because, to this little girl, there was no question about who was in charge—it was the woman communicating with them. I try to encourage the residents with these victories. I point out that these examples are trending towards a better and more equal future.

I’ve also recognized that I deal with a combination of imposter syndrome, that sense of not feeling as recognized as my male colleagues, and also that drive to reach this internal idea of perfection that may not be feasible. These things, coupled together, can lead to burnout and it’s something that I’m working on trying to recognize and proactively address even better. It’s important to me to be a good role model for my trainees.

What have you done to combat burnout (for you and your residents)?
Traveling has been great for me. I didn’t give myself enough time off during the first couple years of practice. After my boards I was so exhausted. Shortly after that, I finally took time to go with my husband to Ireland for two weeks. At the end of that trip, I felt so restored. Now, I try to recognize when it is getting to be too much, and then adjust course so that I can reset to a place of internal harmony. I’m still working on finding the balance—it’s a constant process.

How have you had to modify your practice and your life with the rise and persistent of covid?
In our residency, we’ve utilized Zoom, limited in person interactions, and have been communicative with our residents. We’ve worked to be really open and honest with our residents and let them know that we’re all in this together. Telemedicine wasn’t really feasible for many of our hand patients and although elective cases decreased, trauma volume increased. We were profoundly busy surgically.

What are your goals/next steps for the future?
I want to start building a cerebral palsy spasticity clinic for our Children’s hospital. It took several years to put all the pieces together for our brachial plexus clinic, and I’m ready to tackle the next challenge and start bringing that clinic on board. I love the idea of pushing myself and helping care for a patient population that is often overlooked. This clinic is still in its nascent stage.

And for our final question, what’s your favorite procedure in hand surgery?
I love pediatric plexus surgery. It is my absolute favorite group of procedures. I have a weekly pediatric hand surgery clinic and twice a month, it is brachial plexus. I still remember the first case that I did as an attending. Hands-down, it was the most terrifying operation in which I’d ever engaged. I spent so much time preparing, that I ended up dreaming about the operation for several nights leading up to the case. There are so many opportunities to improve and grow as a surgeon in pediatric plexus surgery. In this specialty, I love that it keeps me engaged and thinking. I’m always pushing myself and am being pushed by the work of others to improve, and I just love it.

Ask the Expert Query: Coding for CMC arthroplasty. What codes do you use for LRTI, suspensionplasty, tightrope, endobutton, etc. Can you bill for a deQuervain release? Is dorsal capsulodesis a code you should use? Is there an added code for suture suspension other than just trapeziectomy? And any other general thoughts on it.

Expert Response: Coding for CMC Arthroplasty, like the surgery itself, should be straightforward. The CPT manual describes CPT 25447 Arthroplasty, interposition, intercarpal or carpometacarpal joints, but further details come from the Global Service Data (GSD) provided by the American Medical Association (AMA) and the American Academy of Orthopaedic Surgeons (AAOS) as well as the AMA CPT Assistant.

The GSD suggests that synovectomy, arthrotomy, osteophytectomy, joint debridement, excision of the trapezium and internal fixation would all be considered bundled into the surgical procedure for 25447. The placement of an initial cast or splint is also included in the procedure. As with every surgery, local and regional anaesthesia (ie “median nerve block” “radial nerve block”) are bundled into the procedure when performed by the operating surgeon, and all aspects of the surgical approach and closure are considered bundled as well. Thus, it would generally be inappropriate to code 25000 for release of the first dorsal compartment, or any separate closure code, including dorsal capsulodesis. Unbundling typically leads to denials and delays in reimbursement, but, more importantly, it is considered fraudulent and may subject the surgeon to penalties, clawbacks and potential litigation.

Generally, any interposition into the scaphometacarpal space, or into the trapeziometacarpal space in the case of a hemiresection, whether it be a portion of the flexor carpi radialis or a graft, would be included in 25447. This would include suture, tendon, local tissue graft, or other spacer. If a piece of tendon from a distant site is excised through a separate incision and placed in the trapezial space, this could be coded with 20924 - Tendon graft, from a distance (eg, palmaris longus, toe extensor, plantaris).

When a tendon is formally transferred, the GSD suggest that this is a separate service, and the National Correct Coding Initiative (NCCI) edits, which identify code pairs which should not be coded together, allows both 25447 and 26480, and 25447 and 25310. Either 26480, transfer or transplant of tendon, carpometacarpal area or dorsum of hand; without free graft, each tendon or 25310, tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendon would be considered reasonable choices for the classic transfer of the FCR to the first metacarpal, as in the Ligament Reconstruction and Tendon Interposition described by Burton and Pellegrini. This is specifically covered by the January 2005 CPT Assistant article, and any payor attempting to deny reimbursement for this service should be referred to that document.

Simple excision of all or part of the trapezium without associated procedures (i.e hematoma distraction arthroplasty) should be reported using 25210 Carpectomy; 1 bone. Internal fixation/pinning is included and should not be coded separately.

The rarely used 25445 (Arthroplasty with prosthetic replacement; trapezium) is meant for a complete and anatomic replacement of the trapezium and should not be used for suspension, graft interposition, hemiarthroplasty or endobutton type reconstructions.

Suspensionplasty, when performed using a suture button/endobutton/TightRope or suture between the FCR and APL tendons, does not involve the same degree of work as a formal tendon transfer and the 25447 + 26480/25310 should not be billed for these procedures unless a local tendon (FCR or APL) is transferred and secured to the first metacarpal and an interposition is placed. Any additional procedure performed by the surgeon to suspend the first metacarpal, if deemed sufficiently difficult and separate from 25447 to warrant separate reimbursement, should be coded with an unlisted procedure (CPT 25999) with documentation comparing it to a code similar in scope and work.

Several additional procedures are often performed at the same time as CMC arthroplasty. If the trapezoid is partially resected for STT/pantrapezial arthritis, 25210 Carpectomy; 1 bone may be coded separately. If the extensor pollicis brevis is transferred/tenodesed to the first metacarpal to prevent MP hyperextension, 25310 Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendon may be used. Treatment of MCP hyperextension with a volar capsulodesis should be reported using 26516 Capsulodesis, metacarpophalangeal joint; single digit, while MCP hyperextension treated with MCP fusion should be reported with 26850 arthrodesis, metacarpophalangeal joint, with or without internal fixation. As always, a separate ICD-10 code would need to be linked to these procedures to justify the additional codes, and the codes would typically be coded with a -51 (Multiple Procedures) modifier.

Overall, most CMC arthroplasties will be coded as 25447 with no more than one or two additional codes, most often 26480. This classic code pair has come under fire by unscrupulous payors, but it is clearly spelled out in the CPT Assistant, which is considered canonical by coding experts, that these two codes should be separately reimbursed and do not represent bundled services.

Ask the Expert Query: Hello, We have a scenario that I was wondering if you would weigh in on. 26356 and 26502 were both performed. 26502 is a "separate procedure" and should not be billed when done with another procedure on the same anatomical location. The tendon pully was not cut to repair the tendon flexor, it was torn due to the injury. Thank you!

Expert Response: The AAOS/AMA-published Global Servjce Data specifically note that 26356 does NOT include repair of any flexor pulleys, and that code should be coded separately. You shouldn’t even need to use a 59 modifier. If that is getting kicked back, the coder is incorrect and should refer to the GSD for guidance.

Happy Coding!

Noah Raizman, MD MFA
Chair, ASPN Coding Committee
Vice-Chair, ASSH Physician Reimbursement and Coding Committee
AMA Relative Value Update Committee Alternate Advisor

Do you have a burning question for one of our experts?
Is there a tough case you just need some advice with?
Not sure how to properly code a case?
Has there been a topic that you have been looking for clarity on?
If you have a question for us please send it in to contact@handsurgery.org. Make sure to include your question, and if it is a case any pertinent information or imaging. Once we have your responses we'll pick a few each newsletter and present it here. Looking forward to all the great questions!

Why use an Early Active Motion (EAM) protocol?
Several studies found that patients treated with an EAM program had greater total active range of motion than with the use of EPM protocols (3, 4). The rate of rupture was slightly higher in the active group 5% vs 4% in passive group. (5) Proximal tendon excursion is necessary to prevent peritendinous adhesions. This may not occur with passive movement due to the frictional forces that are present between the tendon, subcutaneous structures, and the wound bed following the repair. The tendon, instead of gliding, may buckle, roll or fold up with very little to no proximal migration (6,7). Early active flexion involves using a light muscle contraction to move tendon proximally (8). Nonetheless, poor excursion may also be evident with an EAM regime. The tendon, especially in zone 2, may be prevented from moving proximally through the flexor tendon sheath if it presents with a) a bulky repair in which the A2 or A4 pulleys have not been vented, or b) with an increase in the work of flexion (WOF), such as, moderate to severe edema, joint stiffness, or resistance to flexion from extensor tendon tethering (9). Active distal interphalangeal (DIP) joint flexion should be observed for true proximal excursion of the flexor tendons (10). Lalonde (7) recommends actively flexing to “half a fist” with 45° at the DIP, PIP and MCP joints, respectively. This allows for 5—15 mm of proximal excursion of the flexor digitorum profundus tendon (FDP). Figure 1.

Currently, there are 2 types EAM: partial active flexion (11, 12,13) and “place and hold” (14) with the combination of synergistic wrist motion (15) all beginning within 3-7 days following the repair. These types of regimes require a stronger repair using 4- to 6-strand core sutures (16) which have the strength of approximately 43N to 60N to withstand light active motion of approximately 15N (17), in addition to a minimal increase in the WOF post-operatively. Ideally, EAM should be utilized with patients who are therapy compliant with non-complicated or clean flexor tendon repair (18) Figure 2. Complex tendon injuries can result in an increase in the WOF or resistance to tendon gliding thereby increasing the risk for poor gliding, gapping or rupture.

Early active motion uses partial active flexion or the initial 1/3 of a full fist to glide the flexor tendon proximally, within the first post-operative week. It is supported by studies from Wu and Tang (7) who have demonstrated that an active full fist, prior to 3 weeks post-surgery can gap or rupture a tendon due to the increase of forces that the tendon is subjected to in composite flexion, such as, pulley impingement, dorsal capsule tightening, and compression from edema. The partial active motion protocols focus on stimulating IP joint motion, particularly DIP joint, and passive flexion is crucial prior to active in order to decrease the WOF. They also incorporate less metacarpal (MCP) flexion (30°-45°) and add wrist extension with partial digital flexion. The rational being that 45° of wrist extension significantly decreases flexor force by decreasing the passive resistance of the extensors (19). Moreover, FDP flexion force is significantly reduced with less MCP flexion (< 30°) (20) which also favors DIP flexion by inhibiting the lumbricals, assists in avoiding a full fist, and promotes differential glide between the FDP and the flexor digitorum superficialis tendon (FDS).

Another type of EAM is “place and hold” with a full fist (13) along with synergistic wrist motion (20). This regime first uses passive motion to place the digits in flexion and then has the patient actively hold or maintain the position with an isometric contraction. Despite excellent to good outcomes using this regime, some concerns have arisen regarding the safety of this protocol. The first is that the protocol uses an active contraction of the flexors at end-range or full fist where the flexor force increases dramatically and can lead to gapping or rupture (8). Secondly, the amount of force that the patient uses to maintain full digital flexion is difficult to dose and may overload the repair (22). Indeed, at the 2017 EFSHT conference, in Budapest, Van Strien (23), and Lalonde in 2019 (7) presented live intraoperative wide-awake videos demonstrating how repaired FDP tendons behave in zone 2 with a “place and hold regime” using a full fist: with passive flexion the FDP buckles and with active hold it glides proximally by forcefully “jerking” the repair. If a repair is not tensioned correctly or the WOF increases, this movement can gap or rupture a tendon. Lalonde (7) suggests using a half-fist with “place and hold” regime.

In the 2014 IFSHT Flexor tendon committee report all the surgeons recommended a controlled EAM regime following flexor tendon repair (24). A purely passive regime such as the Duran or Kleinert is indicated: 1) in with patients who are not able to follow EAM precautions, 2) when the core suture of the repair is less than 4-strands, 3) in severe, untidy wounds or when an increase in edema or the WOF prohibits active motion despite a 4 to 6-strand clean-cut repair (Figure 3). When digital edema is moderate or severe (9) active DIP flexion will be absent or difficult to achieve; therefore, a passive regime is safer. The therapist should switch to a passive or an immobilization regime when there is an increase in the WOF that is not responding to therapy or when the patient is non-compliant as a tenolysis is better than a rupture.

Conclusion
From the workings of Lalonde, Wu, Tang et al, it is recommended that stronger surgical techniques (i.e., 4- to 6-strands crossing the repair site), along with intraoperative testing of the tension of the core suture and tendon glide, using the flex and extension test (12) or active flexion with wide awake (25), before closing the wound, to prevent post-operative gapping and rupture is crucial. In addition, the greater understanding of tendon forces during active movement and the factors that contribute to the WOF allow the therapist to confidently apply an EAM protocol to an injury that has been is repaired with a robust suture and minor complications. An optimal outcome is also dependent on patient compliance and close communication between the hand therapist and surgeon.

For therapists, managing the factors that increase WOF, prior to applying an EAM regime, is essential in preventing ruptures and improving outcomes. PIP flexion contractures can be managed with digital night extension splint (22) inside the dorsal blocking splint. This maintains extension of the PIP joint thus preventing flexion contracture and uses the lumbricals in case of inadvertent flexion (Figure 4). When using an EAM regime always “warm up” (9) by acquiring first full passive flexion prior to active motion.

Additional information and tips:

- Edema control with compressive wrapping (e.g, coban) (Figure 1)
- International Federation of Societies of Hand Surgeon (IFSSH) 2014 Report on Flexor Tendon Management

1. 4-6 strand repair – the gold standard
   1. Splinting - All use dorsal a blocking splint with wrist in neutral or slightly extended 0-30°, MP’s 0-45°—70°, IP’s extended
2. Early Active Motion
   1. Lalonde (Canada): Starts active motion 2-4 days post op
      1. Wide Awake repair: assesses gaps in repair during surgery
      2. Active Motion of MP: 0-45°, PIP: 0-45°, DIP: 0-45°
   2. Chang (USA): Place and hold within the 1st week, Active flexion at day 23
   3. Elliott (Europe): Gentle Active motion 1 day after repair
      1. Wrist in slight extension
   4. Sandow (Australia): Active motion immediately
      1. Goal of full active motion in 1 week
   5. Tang (Singapore): Active Motion between day 3-10
      1. Allow 1/3 range to of AROM, enough to get glide
   6. Vogelin (Germany): Active motion in week 1
3. Klinert: Out of favor due to
   1. Flexion contractures and
   2. Lack of differential glide

Declaration of patient consent. The author certifies that she has obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be published in the newsletter.

A.

B.

C.

Figure 1. A. EAM protocol: passive IP flexion of clean cut (glass) zone 2 Primary repair with 4-the strand core suture of the FDP tendon 4th digit. B. PIP and DIP flexion 45°, notice good FDP flexion even with compressive wrap. C. Important to measure DIP flexion - essential for verifying true proximal glide.

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Figure 2. A. Clean cut primary repair with 4-strand core suture of FDP tendon 3rd digit. Communication with hand surgeon: Intraoperative passive flexion and extension test performed with no gapping and full tendon excursion. Patient referred for EAM (partial flexion). B. Full passive flexion prior to active flexion. C. Note that DIP joint, FDP flexor tone is present following passive motion. EAM protocol initiated with compliant patient.

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B.

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Figure 3. A. Primary repair of FDP with 4-strand core suture in zone 2 of the index and middle from a saw injury. Intraoperative report stated no gapping observed following the passive flexion and extension test. Patient referred for EAM “place and hold”. Observation: Severe edema is present and digital skin creases and flexor tone are absent. B. Following edema treatment still no flexor tone. C. PIP flexor tone is evident; however, DIP flexor tone is absent despite full passive motion and continued WOF treatment. Edema is moderate and still impeding DIP flexion. To prevent gapping or tendon rupture this patient’s protocol was switched to a EPM regime after communicating with hand surgeon.

A.

B.

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Figure 4. A. Same patient from Figure 1. Any finger that has undergone surgery will have a tendency to flex. B. It is essential to control flexion contracture early on with digital splint that blocks inadvertent FDP flexion by using lumbrical flexion instead. C. In addition assists in edema control at night and in between exercises.

Bibliography

1. Strickland J.W. Glogovac SV. Digital function following flexor tendon repair in zone 2: a comparison study of immobilization and controlled passive motion. J. Hand Sug. 1980; 5A (6):537-43)
2. Evans, R.B. Managing the injured tendon: current concepts. J of Hand Ther 2012; 25: 173-190.
3. Trumble TE, Vedder NB, Seiler JG 3rd, Hanel DP, Diao E, Pettrone S. Zone-II flexor tendon repair: a randomized prospective trail of active place-and-hold therapy compared with passive motion therapy. J Bone Joint Surg Am 2010 Jun;92(6):1381-9.
4. Neiduski RL and Powell RK. Flexor tendon rehabilitation in the 21st century: A systematic review. J Hand Therapy Apr-Jun 2019;32(2):165-174.
5. Starr HM, Snoddy M, Hammond KE, Seiler 3rd. Flexor tendon repair rehabilitation protcols: a systematic review. J Hand Surg Am 2013 Sep;38(9):1712-7.e1-14
6. Manske PR. Flexor tendon healing. J Hand Surg [Br] 1988; 13:237-245.
7. Meals C, Lalonde D and Gilles C. Repaired flexor tendon excursion with half of fist of true active movement versus full fist place and hold in the awake patient. Pastic and Recostructive Surgery Global Open 2019.
8. Horii E, Lin G, Cooney W, Linscheid R, An K. Comparative flexor tendon excursion after passive mobilization: an in-vitro study. J Hand Surg 1992:17A:559-66
9. Wu YF, Tang JB. Tendon Healing, edema, and resistance to flexor tendon gliding: clinical implications. Hand Clin 2013:173—174.
10. Horibe S, Woo SL-Y, Spiegelman JJ, Marcin JP, Gelberman RH. Excursion of the flexor digitorum profundus tendon: a kinematic study of the human and canine digits. J Orthop Res 1990 Mar;8(2):167-75
11. Peck FH, Roe AE, Ng CY, et al. The Manchester short splint: A change to splinting practice in the rehabilitation of Zone II flexor tendon repairs. Hand Ther 2014; 19:47-53
12. Higgins A, Lalonde D. Flexor tendon repair postoperative rehabilitation: The Saint John protocol. Plast Reconstr Surg Glob Open 2016;4: e 1134.
13. Tang JB, Xiang Z, Zhang JP, Qing J, Gong KT, Chen J. Strong Digital Flexor Tendon Repair, Extension-Flexion Test, and Early Active Flexion: Experience in 300 Tendons 2017 Hand Clin 33:455-463
14. Strickland JW, Cannon NM. Flexor tendon repair-Indiana method. Indiana Hand Cent Newsl. 1993; 1:1-18
15. Amadio PC. Friction of the gliding surface. Implications for tendon surgery and rehabilitation. J Hand Ther Apr-Jun 2005.
16. Strickland J. The scientific basis for advances in flexor tendon surgery. J Hand Ther 2005; 18:94-109
17. Strickland J, Gettle K, Flexor tendon repair – the Indianapolis method. In Hunter JM, Schneider LH, Mackin EJ eds. Tendon and nerve Surgery in the Hand – A Third Decade, St. Louis: CV Mosby; 1997:353-61
18. Cullen KW, Tolhurst P, Land D and Page E. Flexor tendon repair in zone 2 followed by controlled active mobilization.
19. Savage R., The influence of wrist position on the minimum force required for active movement of the interphalangeal joints. J of Hand Surg August 13-B;3: 262-268
20. Kursa K, Lattanza L, Diao E, Rempel D. In vivo flexor tendon forces with finger and wrist flexion during active finger flexion and extension. J of Ortho Res April 2006:763-769
21. Amadio PC, Friction of the gliding surface: Implications for tendon surgery and rehabilitation. J Hand Ther Apr-Jun 2005;18(2):112-9
22. Peck F, van Strien G, Invited presentation IFSHT 9th triennial congress in New Delhi, India March 2013. Tips and tricks in the rehabilitation of flexor tendon injuries.
23. van Strien G. Early active flexor tendon treatment – why we do it and how we do it. EFSHT 2017 congress: June 22, 2017 Budapest Hungary
24. Tang JB, Chang J, Ellliot D, Lalonde DH, Sandow M and Vogelin E. IFSSH flexor tendon committee report 2014 J of Hand Surg [European Volume] 2014;39 E(1) 10-115.
25. Lalonde DH and Martin AL. Wide-awake flexor tendon repair and early tendon mobilization in zones 1 and 2. Hand Clin 2013;207-213

Towards validating opioid prescribing guidelines to assist hand surgeons reign in their role in opioid abuse and divergence. Less prescribed opioids beget efficacy and satisfaction with minimal refill requests.

An Article Review of Adalbert JR, Ilyas AM. Implementing prescribing guidelines for upper extremity orthopedic procedures:
a prospective analysis of postoperative opioid consumption and satisfaction. Hand 2021;16:491-7

Jonathan B. Lundy, MD, FACS

By Jonathan B. Lundy, MD, FACS
Hand Surgeon, US Army Institute of Surgical Research

Our goal with this and the previous issue’s article review has been to focus on potential solutions that hand surgeons can implement to curb the abuse and diversion of opioids. This issue’s review discusses the recent report by Adalbert and Ilyas on implementing opioid prescribing guidelines for outpatient hand surgical procedures. (1) There is a lack of awareness on the appropriate number of opioids to prescribe and of the amount patients actually take (2). The purpose of the authors’ study was to prospectively evaluate postoperative opioid consumption for upper extremity outpatient procedures. Prescribing was based on a more concise modification of general guidelines developed by the authors’ institution. These guidelines were a product of a previous evaluation of opioid prescription and consumption (Table 1). (3)

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Upcoming Webinars and Online Video Resources from AAHS

AAHS/AAOS CME Webinar: Peripheral Nerve Injuries - Management of Nerve Gaps
Monday, September 13, 2021, 8:00 PM Eastern (7:00 PM Central, 6:00 PM Mountain, 5:00 PM Pacific)

Nerve injuries are common upper extremity injuries facing Orthopaedic Surgeons, Hand Surgeons, and Plastic Surgeons. However, these injuries can be particularly challenging and controversial in the setting of a nerve injury with a gap not amenable to primary repair. Fortunately, a number of surgical options exist to manage nerve gaps but various patient, anatomic, and clinical variables need to be considered in deciding the optimal surgical strategy and post-surgical therapy. Our expert faculty will review the various surgical options including nerve autografts, allografts, conduits, and nerve transfers – with a particular focus on evidenced-based indications, surgical techniques, pearls and pitfalls, and post-surgical rehabilitation strategies. Moreover, strategies for nerve gaps for both digital nerves and mixed peripheral nerve will be discussed. Faculty: Moderator and Chair Asif Ilyas, MD, MBA; Kyle Eberlin, MD; Amy Moore, MD; Michael Rivlin, MD; Peter Tang, MD, MPH

This webinar is being hosted by the AAHS and the American Academy of Orthopaedic Surgeons (AAOS). All AAHS members, including orthopedic, general, and plastic surgeons, hand therapists, advanced practice providers, and trainees, are able to register for this webinar for free through the Academy platform. To ensure your complimentary rate as an AAHS member, please contact AAOS Customer Service at 1-800-626-6726 or +1-847-823-7186.

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Learn About a Nonsurgical Treatment Option and Review Case Studies with Dupuytren’s Contracture Expert, Dr. Glenn Gaston
Tuesday, October 19, 2021, 8:00 to 9:30 PM Eastern Time

Join Endo Pharmaceuticals for a virtual clinical overview of Dupuytren’s contracture, including experienced perspective on the treatment procedure, patient consultation, and case studies. Attendees will also learn about Endo’s new Injection Simulator, developed to help you practice and improve your technique.
Presented by: Dr. Glenn Gaston

Registration will be available soon.

Visit the AAHS website for complimentary access to 18 outstanding webinar recordings for replay.

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Local Flavor: What to do and see in Carlsbad, California in January 2022

Jesse Kaplan, MD, MBA

Welcome to San Diego! Feel free to insert your favorite Ron Burgundy quote from Weatherman. San Diego has the honor of hosting the AAHS Annual Meeting in January 2022. As a nearby Southern California native, I am excited to welcome you to Carlsbad, California.

Carlsbad is 1.5 hours south of Los Angeles and 30 minutes north of Downtown San Diego. Uniquely situated in Northern San Diego County, you get some of the best California has to offer without the crowds and congestion of the city. I hope you have a chance to enjoy the beach, sun, great food and amazing beer.

The Omni La Costa Hotel is located between Carlsbad and neighboring city Encinitas. Whether you want to enjoy the local spots or take a trip down to downtown San Diego, there is lots to do and see between courses or after we finish up for the day. Here are some fun activities to consider in the near-by area:

Beaches: San Diego has great beaches. The nearby Carlsbad state is a fun 5 mile stretch of beach with wide sand and fun waves. Nearby beaches are Terramar and South Ponto Beach which are a short drive from the hotel. For the surfers who would like to score a few winter waves or anyone looking like to give surfing a try, the closest surf breaks are Cardiff and Swami’s. You can also take a drive and a hike down to the famous Black’s Beach. There are fun breaks in Encinitas, Del Mar and La Jolla. If you drive north of Camp Pendleton and you can check out San Clemente and Trestles.

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Receive a 15% Discount on 2022 Annual Meeting Registration

The Hand Association’s leadership and Program Chairs are working to put together a stellar event to reunite the hand care community in January! How can you receive a 15% discount on 2022 Annual Meeting registration?

Recruit a friend or colleague to join AAHS this year! New members elected in 2021 and existing AAHS members who recruit a friend or colleague to join the Hand Association as a member will receive a 15% discount off 2022 Annual Meeting registration fees!

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