Electronic Thesis and Dissertation Repository

Thesis Format

Integrated Article

Degree

Master of Science

Program

Surgery

Supervisor

Grewal, Ruby

2nd Supervisor

Ross, Douglas

3rd Supervisor

MacDermid, Joy

Abstract

Hand and wrist edema after surgery is a common side effect. It is often first identified visually by the treating physician or therapist. Once recognized, conventional edema treatment is typically partially successful. However, there are a subset of patients that continue to have significant postoperative hand and wrist edema following surgery despite these therapies. This can be devastating to the patient and may lead to pain, stiffness and a reduced quality of life. Surprisingly, there is limited research providing objective reference values for hand and wrist edema acutely after surgery. The first objective of this thesis was to objectively assess hand and wrist edema after commonly performed hand and wrist procedures. The second objective was to relate these data to commonly evaluated outcome metrics including pain, function and range of motion. The final objective was to evaluate the feasibility of a randomized controlled trial assessing the effects of tranexamic acid in hand and wrist surgery; a novel use of a medication that has shown promise in postoperative edema reduction.

Patients undergoing limited fasciectomy for Dupuytren’s disease or open reduction and fixation for distal radius fractures were recruited over a three-month period. They were randomized to receive either a two-dose regimen of tranexamic acid or a placebo during the perioperative phase. Hand edema, patient reported outcomes, pain scores and range of motion data were assessed at multiple time points after surgery. Data analysis first assessed the entire cohort and then unblinded to assess for treatment differences. The limited fasciectomy cohort as a whole did not incur clinically significant hand and wrist edema throughout the postoperative phase. There were no correlations between edema and outcome measures in this group. Despite this, on average, patients had not recovered their full digit flexion by final follow up. The distal radius cohort had progressive decline of edema beginning at the first follow up. By the final follow up at three months, hand edema in this cohort had returned to near comparable values to the contralateral hand. This group showed a strong correlation between water displacement evaluation of hand edema and postoperative pain at multiple follow ups. The protocol used for this study proved to be feasible in obtaining the outlined objectives. A larger clinical trial will be necessary to assess the effects of tranexamic acid in hand and wrist surgery.

Summary for Lay Audience

Hand and wrist swelling (“edema”) are common after hand and wrist surgery. Although many of the current available therapies are successful in preventing or reducing swelling, there are still a number of patients that suffer with swelling long after their surgery. If this happens, it can lead to pain and stiffness of the hand, which can often delay or prevent patients from returning to work and normal activities. Surprisingly, there is very little evidence that explains how the hand and wrist swells early after surgery. Our study first looked at the current evidence available and reviewed how hand and wrist edema forms, how it is tested in the clinical setting and how it is typically treated. From there, we investigated and unveiled new data that describes the normal course of hand and wrist edema after some common hand and wrist procedures. We also looked at the connection between the amount of swelling and other factors such as pain, stiffness and satisfaction.

After we studied how the hand and wrist normally swells after surgery, we investigated the effects of a drug called Tranexamic Acid (TXA) on hand swelling after hand and wrist surgery. This drug has been shown to decrease swelling in other areas of the body but has not been studied in hand and wrist surgery. In our study, patient's undergoing hand or wrist surgery were recruited to participate. The patients that qualified for the study were randomly assigned to either receive TXA or a placebo. A patient's hand volume was measured and compared to values obtained before and after surgery. This was a small study that collected data to evaluate if a larger study with more patients is possible. Therefore, the goal was to make sure the process of the study does not need modifications before starting a larger trial. It also helped identify any trends that deserve more attention in future studies.

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