Journal of Hand Surgery-Asian-Pacific Volume最新文献

Background: Patients with wrist injuries presenting to the emergency department (ED) are commonly managed as suspected scaphoid fractures. Resources for timely standard wrist magnetic resonance imaging (MRI) scans can be insufficient. This study aimed to evaluate the effectiveness of limited sequence wrist MRI scans in diagnosing suspected scaphoid fractures in patients with negative initial radiographs. Methods: A prospective, single-centre study comprising 279 consecutive wrists with suspected scaphoid fractures with initially negative radiographic findings. Patients were reviewed in fracture clinic 10-14 days post injury. If anatomical snuffbox, scaphoid tubercle tenderness or pain on axial loading of the thumb were present, a limited sequence wrist MRI scan was requested. Results: Median time from injury to ED presentation was 1 day, injury to MRI scan was 15 days and a follow-up appointment with scan result was 21 days. The MRI scans showed 47 (17%) scaphoid fractures, 66 (24%) fractures of another bone and 150 (54%) soft tissue injuries. A total of 73 (26%) scans reported no abnormalities. The sensitivity for tenderness at the anatomical snuff box was 91%, at the scaphoid tubercle was 81% and pain on the thumb axial grind test was 49%. Following their MRI scan, 41% of patients were discharged from the clinic. Six (2%) patients had operations, with four percutaneous scaphoid fixations, one EPL tendon reconstruction and one scapholunate ligament repair. Conclusions: Early limited sequence wrist MRI scans facilitate timely and effective management of suspected scaphoid fractures, thus reducing patient morbidity from missed fractures or unnecessary prolonged immobilisation. Level of Evidence: Level II (Diagnostic).

Background: The Krukenberg procedure involves surgically separating the radius and ulnar to create a pincer-like grasp, providing an alternative for upper limb amputees in resource-limited settings where advanced myoelectric prosthetics are inaccessible. It restores prehension and potentially offers patients' autonomy in daily tasks. This review explores the patient demographics; indications; surgical techniques and outcomes of published reports of the Krukenberg procedure. Methods: A scoping review was conducted following PRISMA guidelines across PubMed, MEDLINE, Cochrane, Web of Science, EMBASE, Scopus, Ovid and Google Scholar. Studies that were peer-reviewed and published outcomes following a Krukenberg procedure were eligible for inclusion. Data on demographics, surgical methods and postoperative results were extracted. Results: Twenty-two studies (1937-2024) were included. Trauma was the primary indication (83.4%), followed by burns (10.4%) and congenital anomalies (5.5%). The Bunnell incision was most frequently employed, with nerve and muscle preservation critical for function. Interosseous membrane dissection and selective muscle resection, preserving vascular integrity, minimised bulk while maintaining function. Most patients regained independence, with a mean pincer strength of 7 kg. Complications were minimal, and were primarily skin necrosis, scarring and rare osseous sequelae, i.e. osteomyelitis, malalignment or bony overgrowth, managed via stump shortening or osteotomy. Conclusions: The Krukenberg procedure improves functional independence and socio-economic reintegration, especially in bilateral amputees. It remains a viable option in resource-limited settings where advanced prosthetics are unavailable. However, the evidence is limited by study heterogeneity. Success depends on vascular and neural preservation and early rehabilitation. Level of Evidence: Level III (Therapeutic).

Background: Carpal tunnel syndrome (CTS) is a common neuropathy of the upper limb, with carpal tunnel release (CTR) being a widely performed surgical intervention when conservative treatments fail. However, up to 20% of patients experience persistent or recurrent symptoms, and up to 12% may require revision surgery. This study aims to evaluate the outcomes of revision CTR with external neurolysis compared to primary CTR using propensity score matching (PSM). Methods: This retrospective single-centre cohort study included patients who underwent primary and revision CTR between March 2021 and February 2024. A total of 38 patients were analysed, with 19 patients undergoing revision CTR (Group 1) and 19 patients undergoing primary CTR (Group 2). PSM (1:1 nearest-neighbour, calliper 0.2) was used to ensure comparability between the groups based on age, weight, height, body mass index (BMI), comorbidities and the operated arm. Clinical outcomes were assessed using the Visual Analogue Scale (VAS) for pain and the Boston Carpal Tunnel Questionnaire (BCTQ) for symptom severity and functional status. Results: Patients in Group 1 initially presented with significantly higher VAS scores compared to Group 2 (8.1 vs. 6.5, p = 0.001). At an average follow-up of 13.9 months, the BCTQ scores for symptom severity scale (SSS) and functional status scale (FSS) in Group 1 were comparable to those in Group 2 (SSS: 16.0 vs. 17.4, p = 0.393; FSS: 12.2 vs. 14.9, p = 0.101). No significant differences in CTS severity grades on electrodiagnostic studies were observed between the groups preoperatively. One patient in Group 1 experienced symptom recurrence 18 months postoperatively, but no other complications were reported. Conclusions: Revision CTR with external neurolysis can effectively manage persistent or recurrent CTS, though patients may require a longer recovery period to achieve outcomes similar to those undergoing primary CTR. Level of Evidence: Level IV (Therapeutic).

Until now, we were able to find 38 reports of Vater-Pacini corpuscles (VPC) neuromas of the digital nerve. We reported our first case in 2023. In this article, we present our subsequent three cases of VPC neuromas and discuss their clinical presentations and anatomical origin. Interestingly, the hyperplastic VPC neuromas were found within the epineurium of the digital nerve in two cases. Anatomically, the VPCs extend, like a kite on a string, from the digital nerve and should not exist within the peripheral nerve. The regeneration and remodelling of VPCs over time have been entirely unknown. There may be stem tissue, like seeds of VPCs, in the peripheral nerves. When they receive some stimulation, they may form new VPCs. Moreover, with hyperstimulation, they may excessively form and become a VPC neuroma. Level of Evidence: Level V (Therapeutic).

Background: Diaphyseal ulna shortening osteotomy (USO) is an accepted treatment for multiple ulnar sided wrist pathologies. Recently, a number of specifically designed compression plates for USO have become available. The purpose of the study was to assess the outcomes of an ulnar osteotomy compression plate system for USO across multiple centres. Methods: A multicentre cohort study was conducted on USO performed for a variety of ulnar-sided wrist pathologies using a USO compression system. Radiographic, clinical and subjective outcomes were assessed postoperatively and compared between aetiologies. Results: A total of 174 USOs were performed with union achieved in 170 osteotomies. Overall satisfaction was high and 83.2% returned to work. And 31.6% of patients required plate removal. Conclusions: The use of a specific USO compression plate provides a reasonable option for USO with similar results across multiple sites. High union rates can be achieved. However, the incidence of plate removal was high and remains a potential concern warranting further study. Level of Evidence: Level IV (Therapeutic).

Surgical treatment of Kienböck disease remains controversial and depends on patient age, activity and disease stage. We report an 18-year-old female badminton player who presented with wrist pain, limited motion and decreased grip strength. Imaging revealed a displaced coronal lunate fracture, with the palmar fragment locked against the volar rim of the radius, consistent with Lichtman Stage IIIC and Bain grade 2b. MRI showed low signal intensity, suggesting compromised vascularity. Arthroscopy confirmed intact cartilage except at the fracture site. Lunate reconstruction using the Kuhlmann technique with a vascularised bone graft was performed, and the scaphoid was temporarily fixed to the radius to offload the lunate. At 2-year follow-up, despite the development of radiolunate osteoarthritis, the patient showed significant improvement in pain, grip strength and wrist motion. This case highlights that although disease progression may continue, joint-preserving reconstruction can achieve favourable functional outcomes in young, active patients. Level of Evidence: Level V (Therapeutic).

Background: Scaphoid non-union is a challenging condition that can lead to chronic wrist pain, decreased range of motion (ROM) and functional impairment. One promising approach involves the use of costo-osteochondral rib autografts, offering a non-vascularised and structurally supportive environment for bone regeneration. This systematic review aims to evaluate the current evidence regarding the management of non-salvageable scaphoid proximal poles and non-union using rib costo-osteochondral autografts. Methods: A comprehensive search of electronic databases was conducted. Data extraction was performed independently by two authors. The primary outcomes were ROM, grip strength, pain, functional outcomes and complications. Results: A total of six studies were identified that met the inclusion criteria. A total of 101 patients had undergone scaphoid costo-osteochondral autografting with a rib donor. Postoperative active ROM arc had a mean of 112° (range: 78°-125°), with grip strength mean of 34 kg (range: 22-50 kg). Various functional outcome measures were reported, such as the QuickDASH, Patient Rated Wrist Evaluation (PRWE) and Visual Analogue Scale (VAS), with overall improvement noted for function and pain. Complications were reported in 10% of cases, including four donor site complications. Conclusions: The available literature supports the use of costo-osteochondral rib autografts to treat the non-salvageable proximal scaphoid, with short-term improvement in ROM and function. However, given the heterogeneity of the included studies and the limited number of high-quality randomised controlled trials, further research is needed to establish the optimal graft selection for scaphoid AVN or non-union. Level of Evidence: Level III (Therapeutic).

Background: Brachial plexus (BP) injuries are a known complication of shoulder dislocation, yet optimal management strategies remain unclear. This systematic review aims to evaluate the outcomes and treatment approaches for BP injuries following shoulder dislocation. Methods: A systematic review was conducted according to PRISMA guidelines across four databases: PubMed/MEDLINE, Embase, Scopus and Web of Science. Eligible studies included human subjects with BP injuries following shoulder dislocation. Data extraction and risk of bias (ROB) assessment were independently performed by two reviewers. Due to heterogeneity amongst the studies, a meta-analysis was not conducted. Results: Out of 2,060 initial studies, 9 met the inclusion criteria, encompassing a total of 255 patients (256 limbs) with a mean age of 55.9 ± 16.0 years. Of these, 193 (75.7%) had BP injuries post dislocation. Conservative management was the most common treatment (149 cases, 67.4%), followed by neurolysis ± nerve transfer (44 cases, 19.9%) and nerve repair (28 cases, 12.7%). Amongst 133 patients with reported BP injury patterns, the posterior cord was most frequently involved (38.3%). Sensory and motor recovery was observed in 51.6% and 45.2% of patients respectively, with 60.4% of patients achieving MRC grade ≥ 4 in studies that reported this metric. The mean follow-up period was 28.4 months. Conclusions: BP injuries following shoulder dislocation are uncommon but clinically significant. Conservative treatment remains the predominant approach, though surgical interventions may offer improved functional recovery in selected cases. Level of Evidence: Level III (Therapeutic).

Background: Patients with dorsal fracture dislocations of the proximal interphalangeal joint (PIPJ) may have significant functional impairment. This study aims to present the outcomes of open reduction and internal fixation (ORIF) in patients who presented late with dorsal fracture dislocations of the PIPJ and to evaluate factors affecting the outcomes. Methods: This retrospective study included patients who presented late with a dorsal PIPJ fracture dislocation and underwent ORIF. The outcome measures included active arc of motion (AAOM) of the PIPJ and distal interphalangeal joint (DIPJ), grip strength, Quick disabilities of the arm, shoulder and hand (Q-DASH), Ishida and Ikuta scores. The outcomes data was statistically analysed to determine association of outcomes with the finger involved, mechanism of injury, presence of concomitant injury, delay between injury and surgery, percentage of the articular surface involved, presence of comminution of the volar lip and involvement of proximal phalanx head. Results: The mean surgical delay was 58 days. The average articular surface involvement was 58%. The PIPJ AAOM improved by 72°, with a 10° mean flexion deformity, an average Q-DASH score of 4.8 and grip strength at 84% of the non-operated hand. Eleven patients achieved excellent Ishida and Ikuta scores, two good and four fair-to-poor. Surgical delay had no significant impact (p > 0.05), but less-comminuted fractures and non-cricket injuries showed better recovery (p < 0.05). Concomitant injuries and proximal phalanx head involvement correlated with higher disability scores, lower grip strength and poorer functional outcomes (p < 0.05). Conclusions: ORIF is a viable, joint-preserving surgical option that can be considered in delayed cases up to 2 months. This technique retains the native osteochondral fragments. The surgical approach allows one to convert to hemi-hamate arthroplasty (HHA) as an alternative procedure in the same setting when fracture is not amenable for reconstruction. Level of Evidence: Level IV (Therapeutic).

Background: Contralateral C7 (CC7) is an important donor nerve for reconstruction in global brachial plexus palsy. In 2013, Shu Feng Wang introduced the direct repair of lower trunk (LT) to CC7. The outcomes of hand recovery reported in the study was significantly better than the traditional techniques. We did a retrospective analysis of 11 consecutive adult patients who underwent reconstruction for pan-brachial plexus injury by repair of the CC7 to LT along with other extraplexal nerve transfers. Methods: Patients were evaluated for motor recovery of flexion and extension at elbow, wrist and digits (Modified medical research council [MRC] grading). They were also evaluated for cortical plasticity and complications, if any. Results: Eleven consecutive patients underwent CC7 to LT transfer during the study duration. The mean follow-up period was 85 ±11.39 months (range: 69-105 months). Two out of the eight patients with a CC7 transfer to MCN regained M4 elbow flexion, while one regained M3 function. The remaining five did not recover elbow flexion. Two patients who had an ICN to MCN transfer regained M4 elbow flexion. Four out of 11 patients regained >M3+ wrist and finger flexion. Out of the four patients with a CC7 to LT, none recovered any elbow extension. Out of the seven patients who underwent a phrenic to PDLT transfer, six regained M3+ elbow extension. Out of the seven patients with phrenic to PDLT transfer, none regained any wrist or finger extension. Conclusions: Outcome in terms of composite motor recovery of hand is better that other reconstructive techniques but falls short of qualifying as a functionally useful hand. Elbow flexion recovery is inferior when compared to other extraplexal nerve transfers. Neuropathic pain is reduced. There is restoration of protective sensation in both ulnar and median nerve territory. Level of Evidence: Level IV (Therapeutic).