Journal of Hand and Microsurgery最新文献

Wide awake local anaesthesia no tourniquet (WALANT) surgery has gained increasing popularity in recent years for hand surgery fast-tracked by the COVID pandemic. It involves infiltration of lidocaine with adrenaline to the operative region ensuring a good visual field owing to the vasoconstrictive effects of epinephrine. It has numerous advantages over traditional anaesthetic (TA) for flexor tendon repairs including testing of tendon strength on table as well as immediate revision of the repair if needed. Currently there are a number of studies in the literature evaluating WALANT versus TA in flexor tendon injuries with continuing debate on the optimal modality but no amalgamated synthesis of data. The authors report the first systematic review and meta-analysis on the topic. The authors conducted the review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards (PRISMA) guidelines. All studies comparing flexor tendon repairs under WALANT versus TA were included. The primary outcome measure was range of movement (ROM) with secondary outcomes including adhesions/tenolysis, rupture as well as re-operation rates. OpenMeta[Analyst] software was utilised for data synthesis. Five studies in total met the inclusion criteria with an overall assessment of 624 fingers. There was no significant difference observed between WALANT and TA for tendon rupture; odds ratio 1.027 (0.450, 2.342) p-value = 0.950, the incidence of adhesions/tenolysis; odds ratio 0.601 (0.172, 2.093) p-value = 0.424 or re-operation rates; odds ratio 1.193 (0.544, 2.618) p-value = 0.659. ROM was reported to be better in the WALANT cohort; odds ratio: 1.641 (1.010, 2.669) p-value = 0.046. WALANT offers a safe and effective mode of anaesthetic over traditional modalities with comparable outcomes for flexor tendon repairs. Although ROM appears superior, the number of randomised control trials are currently low and more high quality studies are necessitated to enhance the current evidence base.

This article introduces a surgical technique for cross-intrinsic transfers (CIT) to correct ulnar drift in rheumatoid hands performed under wide-awake local anesthesia no tourniquet (WALANT). This approach allows real-time adjustment of tendon transfer tension and active patient participation in hand movements and deformity correction during the procedure. It can be combined with other surgeries such as prosthetic replacement arthroplasties of the MCP joints. The technique was applied to six patients, resulting in a significant reduction of ulnar deviation from an average of 70° preoperatively to 8° postoperatively. All patients reported high satisfaction with good outcomes.

Background: Trapeziectomy and abductor pollicis longus hammock ligamentoplasty may be performed in the surgical management of trapeziometacarpal joint osteoarthritis (TMC OA). Several anaesthesia techniques are available for TMC joint surgery, including wide-awake local anaesthesia no tourniquet (WALANT), regional anaesthesia, and general anaesthesia (GA). The aim of this study was to compare the clinical outcomes of trapeziectomy and abductor pollicis longus hammock ligamentoplasty performed under WALANT versus GA.

Methods: This retrospective study included 22 patients who underwent surgery for TMC OA between 2017 and 2019. Patients' pre- and post-operative pain intensity, grip and pinch strength, and functional scores were compared. Pain intensity was assessed 1 h after surgery, while overall outcome measures were evaluated one year post-operatively.

Results: The results showed that patients who underwent WALANT had significantly lower pain intensity 1 h postoperatively compared to those who received GA. Both groups experienced a reduction in pain, improvement in grip strength, and functional scores after at one year, with no significant differences between them. No significant differences were found between the GA and WALANT groups in terms of postoperative VAS scores, grip strength, and functional scores.

Conclusions: We recommend WALANT for trapeziectomy and APL hammock ligamentoplasty due to its effectiveness in reducing early post-operative pain and achieving functional outcomes comparable to those of GA.

Introduction: Injuries to the flexor tendons of the hand pose significant challenges in both surgical repair and postoperative rehabilitation. Despite advancements in techniques, there remains uncertainty about the most effective postoperative rehabilitation protocol/strategy. This study aims to address this debatable issue by evaluating different rehabilitation protocols following surgical repair in zone II flexor tendon repair.

Methods: A systematic review and meta-analysis followed PRISMA guidelines, searching databases up to December 2023. Inclusion criteria covered studies on zone II flexor tendon repair in adults, with various rehabilitation strategies and hand function as primary outcomes. Data extraction and bias assessment employed predefined tools.

Results: Among 916 initial articles, 28 met the inclusion criteria. Published from 1980 to 2023, these studies involved 1414 patients, predominantly affecting the little, index, and middle fingers. Various suture techniques and materials were used, with early active and passive motion as primary rehabilitation protocols.

Conclusion: This review highlights early active and passive motion as common postoperative rehabilitation strategies for zone II flexor tendon repair. While active motion showed greater range of motion improvement, both protocols had comparable reoperation rates and grip strength outcomes. Future research should focus on refining protocols and assessing long-term outcomes to optimize patient care.

Purpose: The completely degloving injury of multiple fingers is a challenging clinical problem. Based on our technical experience, a novel two-stage surgery of abdominal hypodermal pocket followed by separation and full thickness skin grafting was conducted.

Methods: From January 2017 to August 2020, 7 cases (17 fingers) of degloving injury of multiple whole fingers who were treated in a two-stage fashion; an emergency first stage surgery of abdominal hypodermal pocket embedding and a second stage surgery (4 weeks later) of full thickness skin grafting, were retrospectively studied. The results were evaluated according to the patient subjective evaluation, static two-point discrimination and disabilities of the arm, shoulder and hand (DASH) scores and active range of motion (ROM) of metacarpophalangeal (MP) and proximal interphalangeal (PIP) joints.

Results: All seven cases healed successfully, although two cases experienced distal phalanx necrosis. The affected fingers recovered with a good appearance and soft texture and the results were either satisfying or acceptable for all participants. The active ROM of MP joint ranged from 55° to 64° with an average of 59.5° three months postoperatively and ranged from 70° to 81° with an average of 77.2° six months postoperatively, while the active ROM of PIP joint ranged from 58° to 69° with an average of 64.1° three months postoperatively and from 76° to 86° with an average of 81° six months postoperatively. One year postoperatively, the static two-point discrimination ranged from 7 to 10 mm with an average of 8.6 mm and DASH scores ranged from 25 to 42 with an average of 37.

Conclusion: A novel two-stage surgery of abdominal hypodermal separated pockets followed by full thickness is an effective and worthwhile option for treating the completely degloving injury of multiple fingers.

Endoscopic technique of carpal tunnel release is widely accepted as successful and safe as long as the surgeon is well-trained. Compared to the traditional open technique, there exists a steep learning curve for familiarisation of equipment, training of hand-eye coordination and appreciating tactile feedback. The available literature and manuals do not illustrate the practical challenges encountered during the procedure. We describe a guide for single-portal technique under local anesthesia, including surgical planning, cautions, and troubleshooting processes based on our experience with 136 cases in Asian hands which is known to be smaller.

Introduction: The simultaneous bilateral release of carpal tunnels still remains a non-unanimous practice. We prospectively studied the contribution of ultrasound-guided surgery coupled with Walant anaesthesia in the simultaneous release of both carpal tunnels.

Materials and methods: Patients who presented bilateral clinical involvement confirmed by electromyogram were operated on in the operating room under Walant anaesthesia by minimally invasive knife section under ultrasound guidance. The follow-up focused on pain immediately after local anaesthesia, when leaving the operating room, on day 1 and then on day 7. Satisfaction on day 0, day 7 and at 3 months, complications as well as the resumption of daily activities, light manual activities then heavy manual activities were reported.

Results: 10 patients were operated on. The median average pain score was less than 1 after anaesthesia, on day 0 in the immediate postoperative period on day 1 and on day 7. Mean satisfaction was above 9 ​at day 0, day 7 and month 3. There were 2 minor postoperative complications, one spontaneously resolved after 45 days, the other requiring additional intervention on another site of compression of the median nerve upstream. Resumption of light manual activities was 3 days and heavy manual activities 31 days.

Discussion: The release of the bilateral carpal tunnel remains a rare surgical practice due to fear of pain and postoperative disability particularly during the initial postoperative period. However, the release of the carpal tunnel in ultrasound-guided surgery under Walant anaesthesia has proven painless and fast function recovery.

Conclusion: The release under Walant anaesthesia with ultrasound assistance of simultaneous bilateral carpal tunnel is safe for the patient. Patient satisfaction is high. We recommend this technique in selected patients.

Introduction: Animal bones have been used as a model to mimic human bones for investigation of fracture patterns and fixation techniques. This study aims to investigate the effects of torsional forces of varying speeds on the spiral fracture in human metacarpal using a chicken humerus model.

Materials and methods: Thirty fresh-frozen chicken humerus bones were dissected and equally divided into three groups. The bones were mounted onto a customized jig and subjected to different torsional loading rate at 22.5°/s, 30°/s and 45°/s, respectively. The fracture pattern, angle and length were analysed.

Results: Our results concurred with other studies that used mature animal long bones which showed no correlation between spiral fracture morphology and torsional rate. We also noticed differences between mature and immature long bones at various torsional speeds.

Conclusion: The chicken humerus model demonstrated a promising alternative to investigate the effect of bone material properties on the spiral fracture pattern. The intent of this study was to expand it as a suitable bone model for resident teaching and research purpose.

Purpose: The purpose of this study was to identify and characterize factors that may contribute to revision surgery following primary cubital tunnel release (CuTR) surgery.

Methods: A retrospective study was performed by reviewing all patients who underwent CuTR at a single institution between 2014 and 2021. Only primary in situ CuTR surgeries were included. Exclusion criteria were any case of primary ulnar nerve transpositions or ulnar nerve decompression surgery related to pathology other than isolated ulnar neuropathy (ie. elbow fracture repair, medial epicondylitis debridement, etc.). Revision surgery was defined as return to the operating room by the index surgeon or another surgeon within the same practice for repeat ulnar nerve decompression and/or transposition. Patient demographics and surgical information was analyzed to determine factors that may be associated with revision surgery following primary in situ ulnar nerve decompression.

Results: A total of 1367 patients met inclusion criteria. Revision rate following primary CuTR was 1.2 ​% (n ​= ​16). Of the factors evaluated, younger age (46.6 vs 57.0 years) and a history of cervical stenosis had a higher correlation with undergoing a revision. Patients who had revision surgery were more likely to have negative electrodiagnostic studies versus those who did not. Otherwise, there was no association between sex, race, tobacco use, medical comorbidities, symptom severity, bilateral symptoms, or concurrent surgery and the subsequent need for revision ulnar nerve decompression.

Conclusions: Following primary in situ CuTR, younger age or a history of cervical stenosis may be at higher risk of undergoing revision surgery. Additionally, patients without electrodiagnostic evidence of ulnar neuropathy may have less reliable outcomes versus those who have a positive nerve study. Given the unpredictable nature of ulnar nerve surgery, further prospective data including diagnostic imaging and biomechanical evaluation of patients following ulnar nerve release may help provide a deeper understanding of this unique patient population.

Level of evidence: Prognostic, level IV.

Introduction: Low-caliber gunshot wounds (GSW) to the hand are common and their incidence is increasing. Most low-caliber GSW's are treated in the emergency department (ED) with washout, intravenous antibiotics and any further follow-up treatment usually performed in an outpatient capacity. Treatment of these injuries specifically to the hand may be controversial in terms of timing and extent of washout, debridement, and fixation. Currently, the literature lacks a concise treatment algorithm, and this report aims to provide clinical scenarios that may educate management decision-making for patients with these injuries.

Methods: We discuss three cases that failed this initial treatment presenting as an infected nonunion. Each patient underwent irrigation, stabilization, and received antibiotics, yet showed no evidence of interval healing at follow-up. One of the patients demonstrated evidence of infection only one week following the injury.

Results: Cultures were positive in all cases and a surgery for debridement, fixation as well as antibiotic treatment was necessary. Only one patient followed up as recommended by the treating surgeon, yet two of three of the patients demonstrated clinical improvement after surgical intervention.

Conclusions: Despite being low caliber, this type of GSW to the hand likely causes more damage than to a larger part of the upper or lower extremity given the proximity of vital anatomic structures in the hand. We suggest considering a more aggressive initial treatment in the emergency room, especially for fracture patterns that could otherwise be treated non-operatively and in a particularly nonadherent population.