Letter to the Editor| Volume 34, ISSUE 3, P577-578, March 2009

In Reply

      Thank you for the opportunity to reply to the letter by Dr. Freshwater. Dr. Freshwater takes exception to the phrase “standard of care” in the following passage: While closed reduction with percutaneous pinning and immobilization may have been previously recommended for definitive treatment, better results have been achieved with open reduction, ligament repair and internal fixation, which is now the current standard of care.
      This passage from my review was taken from: Grabow RJ, Catalano L III. Carpal dislocations. Hand Clin 2006;22:485–500. The referenced quote read: This [closed reduction and percutaneous pinning combined with immobilization] was previously the recommended treatment; however, recent literature has shown a high rate of recurrent instability, carpal incongruity, and arthritis. For most injuries, better results have been achieved with open reduction, ligament repair, and internal fixation than with closed methods, and open reduction is now the standard of care. [Emphasis mine]
      I sincerely appreciate Dr. Freshwater's comments about inflammatory comments in this (overly) litigious society, but it does not change the fact that certain treatment standards do exist and have already been published in peer-reviewed journals. According to the literature, open reduction and fixation of acute lunate and perilunate dislocations is the current standard of care. All of the articles reviewed unanimously recommended open reduction and internal fixation for treating lunate and perilunate dislocations. The scapholunate articulation cannot be reduced closed because of the paradox of Mayfield and Johnson. Accurate carpal alignment needs to be confirmed; this can only be done under direct visualization. According to Weil, Slade, and Trumble, a strong scapholunate interosseous ligament repair is the key to a successful long-term result; obviously, this cannot be performed without an open exposure. Treating these injuries with closed reduction, percutaneous fixation, and immobilization leads to suboptimal results compared with that of open treatment and, according to the literature reviewed, cannot be recommended.

      Linked Article

      • Standards of Care, Evidence-Based Medicine, and the Emperor's New Clothes
        Journal of Hand SurgeryVol. 34Issue 3
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          Commendably, the Journal of Hand Surgery continues to evolve and improve the quality of its articles. Recent enhancements include the designation of clinical studies by levels of evidence ranging from the highest (ie, high-quality randomized control trials) to the lowest (ie, expert opinion) (see ). Even the Review Section has sought improvement with articles on Current Concepts, Surgical Technique, and Evidence-Based Medicine.
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