Techniques in Hand and Upper Extremity Surgery最新文献

There is currently no consensus on which existing treatment for chronic Boutonniere deformity is most effective. We describe a method of central slip reconstruction with an autologous "V" shaped tendon graft folded on itself through a bone tunnel for the treatment of Boutonniere deformity. All 3 patients healed well with an average active range of motion of the distal interphalangeal joint 10 to 70 degrees, proximal interphalangeal joint 15 to 90 degrees, and metacarpophalangeal joint 0 to 90 degrees with a follow-up duration between 4 years and 5 years. This is a straightforward technique that can be performed in patients with chronic, post-traumatic and flexible Boutonniere deformity.

Isolated management of metacarpophalangeal (MCP) joint injuries or sagittal band disruptions often leads to incomplete symptom resolution and suboptimal functional outcomes, particularly in complex trauma. We present a combined surgical technique integrating MCP joint arthroscopy with open sagittal hood repair for traumatic extensor mechanism instability and intra-articular pathology. This paper describes a stepwise approach to address both intra-articular and soft tissue components of MCP joint injuries. Arthroscopy facilitates direct visualization, synovectomy, debridement, and capsular shrinkage, while open sagittal band repair allows for tendon centralization, repair of a hood rupture, and occasional definitive realignment. This dual approach provides a comprehensive treatment option, ensuring the stabilization of both the joint capsule and the extensor mechanism. An illustrative case demonstrates restored tendon alignment and joint stability with no intraoperative complications, highlighting how this combined technique enhances diagnostic precision and therapeutic outcomes in complex MCP joint injuries.

Technical note-2 illustrative cases. Suturing delicate structures risks iatrogenic damage from excessive exposure. Traditional methods, such as incisions and tissue retraction, can lead to adhesion, scarring, and impairment. We describe the reverse exposure-limiting suture (RELS) as a suture-burying maneuver facilitating controlled approximation while minimizing tissue exposure. RELS was applied to a proximal nail-bed laceration and a Zone 2 flexor tendon injury. The needle is first passed through the defect, then reversed beneath the overlying structure with the swage leading, allowing approximation without elevating protective tissues (such as eponychium) or releasing pulleys. As reversing the needle via the swage may theoretically increase tissue trauma, the technique should be applied cautiously in delicate regions. Both cases healed uneventfully: normal nail regrowth at 6 weeks (case 1) and excellent early function without pulley compromise at 3 months (case 2). Initial experience suggests that RELS is feasible in anatomically constrained regions; further study is needed to define its efficacy and stiffness, which may potentially compromise indications, safety, and outcomes.

Fifth metacarpal neck and distal diaphyseal fractures with severe angulation, displacement, or malrotation may benefit from surgery. Fixation approaches include antegrade and retrograde intramedullary fixation, transmetacarpal Kirschner wires (K-wire), and plate fixation. K-wires are a particularly promising option due to their simple, non-invasive, and cost-efficient nature. This study describes a novel K-wire technique for fracture fixation and presents early outcomes and complications. 21 patients with fifth metacarpal neck or distal shaft fractures were retrospectively reviewed after treatment with an antegrade intramedullary K-wire with a "T-handle" bend proximally, a gentle bend distally, and a transosseous wire transfixing the fourth and fifth metacarpal heads to control rotation. Patient characteristics, radiographic data, and postoperative outcomes were collected. Patients were immobilized in a cast or splint for an average of 5 weeks (range: 3.7 to 9.3 weeks). Mean follow-up was 8.4 weeks (range: 3.7 to 27.7 weeks). Mean preoperative angulation was 49.7 degrees (SD: 13.7 degrees, range: 19 to 71 degrees) and mean postoperative angulation was 17.5 degrees (SD: 4.2 degrees, range: 11 to 26 degrees). The operative small finger metacarpal phalangeal joint achieved an average flexion of 72.1 degrees compared with 89.6 degrees on the nonoperative side ( P =0.001). Four patients developed cellulitis around a K-wire and were successfully treated with pin removal and oral antibiotics. Two patients developed numbness over the dorsal small finger. There were no nonunions. In conclusion, severely angulated, displaced, or malrotated fifth metacarpal neck and distal shaft fractures can be effectively treated with this novel, simple, inexpensive, and minimally invasive K-wire technique.

Digital extensor tendon instability or subluxation occurs in the setting of a sagittal band injury, which allows the extensor to subluxate off the metacarpal head upon flexion at the metacarpophalangeal joint. This can cause painful snapping of the tendon and limit the initiation of active extension. Surgical tendon stabilization is appropriate for patients who fail initial nonoperative splint immobilization after acute injury or those with chronic tendon subluxation. Existing surgical techniques are limited by bulky subcutaneous repairs, reliance upon compromised tissues, and/or the need for postoperative immobilization. We describe a technically simple and repeatable extensor stabilization technique using a free tendon graft secured with the Arthrex SwiveLock Anchor. This novel approach is sutureless, low-profile, technically simple, and robust enough for immediate active motion. This technique was safely utilized in 8 patients by 3 different surgeons, with resolution of extensor instability without recurrence.

Delayed tendon injury has been historically treated with several techniques, including staged tendon graft and flexor digitorum profundus (FDP) transfers from neighboring rays. Nevertheless, the use of the flexor digitorum superficialis (FDS) hemi-tendon from neighboring fingers may provide the same results with less donor site morbidity. This article aims to present the safety and effectiveness of the fourth FDS hemi-tendon transfer technique to treat zone I-5th FDP injuries on cadaver specimens, and to describe its in vivo application. In 4 fresh-frozen forearms, the fifth FDP was cut at zone I. All the fourth and fifth finger pulleys, except for A2 and A4, were incised. The fourth FDS ulnar hemi-tendon was harvested, passed through the A2 and A4 pulleys of the fifth finger, and sutured to the distal fifth FDP stump. To test finger flexion after tenorrhaphy, FDS and FDP tendons were pulled at wrist level, along the forearm axis, with a dynamometer. In all specimens, a complete flexion of fingers was obtained after FDS and combined FDS-FDP traction. The technique was applied in vivo for a staged reconstruction in a 35-year-old patient, resulting in good active and passive finger range of motion, a tip-to-palm distance of 0 mm, and no complications, bowstringing, or quadriga effect at 1-year follow-up. These cadaveric study and case report confirm that the fourth FDS ulnar hemi-tendon transfer is safe and effective in treating zone I fifth FDP delayed injuries, both during single and staged reconstructions.

Percutaneous headless screw fixation is an effective, minimally invasive treatment option for select individuals with nondisplaced or minimally displaced scaphoid waist fractures. While both volar and dorsal approaches have been described, fixation rigidity is optimized by screw placement down the center axis of the scaphoid. This is crucial, as the central axis placement of the screw allows for more stable fracture fixation. Intraoperative fluoroscopic confirmation is critical to ensure optimal center axis or near-central axis placement of both the guide pin and ultimately the final headess screw within the scaphoid. Traditionally, intraoperative guide pin and screw position is assessed utilizing live fluoroscopy by rotating the wrist to obtain AP, PA, oblique and lateral views. We present unique, intraoperative "perfect dot" and "bullseye" fluoroscopic views that allow for more accurate confirmation of central axis or near-central axis guide pin and headless screw placement-views that are applicable for both percutaneous and open scaphoid fixation.

Benign tumors of the carpal bones are uncommon, and their optimal treatment is still a topic of debate due to the condition's rarity. While there is consensus on treating enchondromas with pathological fractures to alleviate symptoms, the best approach for removing these benign tumors remains uncertain. With the growing popularity of wrist arthroscopy for various wrist pathologies, we present our technique of arthroscopic enucleation, bone grafting, and fixation of scaphoid enchondroma. Our method showed favorable outcomes at the one-year follow-up. We aim to describe our technique, including video, Supplemental Digital Content 1, http://links.lww.com/BTH/A241 illustration, to encourage consideration of arthroscopic alternatives. The clinical, radiological, and therapeutic aspects of this rare benign tumor of the carpal bone are also briefly discussed.

Trigger finger is a common hand condition, with surgical treatment primarily based on the release of the A1 pulley. While open surgery remains the gold standard, ultrasound-guided percutaneous techniques have demonstrated their advantages due to their minimally invasive nature and their positive impact on recovery. However, in the case of trigger thumb, these techniques present specific challenges, particularly due to the proximity of neurovascular structures and constraints related to instrument orientation. The objective of this paper is to describe a novel axial and antegrade ultrasound-guided percutaneous approach for the release of the A1 pulley in trigger thumb, aiming to enhance procedural accuracy while minimizing iatrogenic risks. This technique is based on an antegrade minimally invasive release with an axial orientation under real-time ultrasound guidance, without reliance on theoretical bony landmarks. This approach enables optimized visualization of anatomical structures and precise control of the instrument's trajectory. It could serve as an additional alternative to existing strategies for the treatment of trigger thumb. The axial and antegrade ultrasound-guided percutaneous approach appears to be a promising technique for trigger thumb release. Further studies are required to evaluate its clinical efficacy, feasibility, postoperative recovery, and safety on a larger scale.