Journal of the American Society for Surgery of the Hand最新文献

Several severe types of injuries are not amenable to traditional techniques of peripheral nerve repair. In these cases, the distal nerve branching and contact points in the end muscles are avulsed, essentially removing the neural portion of the muscle. Direct muscular neurotization often can reconstitute some muscle contraction and function by implanting a nerve graft, divided into several slips, directly into the muscle. This article describes the indications, contraindications, and technical issues associated with direct muscular neurotization.

Silastic metacarpophalangeal joint replacement has been used successfully to treat patients with inflammatory arthritis, particularly rheumatoid arthritis of the hand, for many years. Initially, patients can expect satisfactory relief of pain, improved alignment, movement between 30° to 60° of active flexion, and, as a consequence, improved function. The implants themselves can survive in situ for many years with a published overall survival rate of greater than 60% at 15 years or more. There are, however, a number of complications, these complications and their management are discussed further.

Elbow stiffness is a common problem after trauma to the elbow. The goal of treatment should be to achieve a functional range of motion (30°–130°). Nonsurgical options are physical therapy and splinting. Surgical options depend on the degree of degenerative change in the elbow joint. With mild to moderate degenerative changes, procedures such as soft-tissue releases, debridement, and Outerbridge-Kashiwagi arthroplasties may be performed either open or arthroscopically. With more severe degenerative changes, the options are more limited depending on the age and activity level of the patient.

Resection of the distal ulna for posttraumatic arthritis and treatment of arthritis and instability of the distal radioulnar joint can be improved with distal ulna prosthetic replacement. In this review, the anatomy, mechanics (kinematics and kinetics), rationale, and indications for surgical replacement of the distal ulna are presented. The surgical technique is precise and the important tenets of proper ulnar head implant insertion provides a guide for use of the implant. Preliminary results after 2 years of clinical experience are most encouraging.

Lymphedema, infection, and healing delay are among feared complications in patients undergoing upper extremity surgery after prior mastectomy and axillary dissection with or without radiation therapy. Most of these cancer patients are advised to avoid any procedure on their ipsilateral upper extremity including blood pressure monitoring, intravenous punctures, and surgery. As a result, many of these patients hesitate to undergo necessary upper extremity surgery such as arthritis surgery and even carpal tunnel release. Many hand and upper extremity surgeons believe that these precautions are unnecessarily stringent and believe that indicated upper extremity surgeries could be performed safely in these patients. We surveyed 1,200 members of The American Society for Surgery of the Hand and the 606 returned questionnaires were analyzed. More than 95% of the hand surgeons surveyed do not hesitate to perform surgery on an upper extremity in a patient after ipsilateral lymphadenectomy and/or irradiation, decreasing to 85% if there is pre-existing chronic lymphedema; 94% use a tourniquet in a routine fashion (74% use a tourniquet in the presence of existing lymphedema); 46% use a Bier block when clinically indicated (only 21% would use a Bier block in a patient with lymphedema); and 36% are comfortable using an axillary block (25% in the case of lymphedema). Thus, most of the polled surgeons would prefer to perform surgery on these patients under a general anesthetic, but still would use an extremity tourniquet for a bloodless surgical field in their routine manner. The rate of reported complications in these patients was 23% in patients with pre-existing chronic lymphedema and only 3% in patients with no lymphedema. After surgery, 46.2% of the surgeons do not undertake any additional precautions than in their routine practice with all upper extremity surgery patients. However, 53.8% would change their routine practice for such patients and these changes range from placing the surgical tourniquet on the forearm instead of the upper arm, use of perioperative prophylactic antibiotics in all patients irrespective of the type of surgery, use of postoperative compression garments, and specific postoperative hand therapy aimed at the prevention of postoperative edema.