Hand Swelling after Hand and Wrist Surgery: An Evaluation of its Effects and Assessment of Feasibility of a Double Blinded, Randomized Controlled, Pilot Study: Tranexamic Acid in Hand And Wrist Surgery (THAW) Study
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.