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

Degenerative changes of the distal interphalangeal (DIP) joint are often managed surgically with arthrodesis or silicone implant arthroplasty when conservative treatments fail. Conventional approaches for silicone implant arthroplasty require division of the extensor tendon, leading to prolonged immobilisation and potential extension lag. We introduce a novel palmar flexor tendon splitting approach. This approach allows silicone implant arthroplasty while preserving the extensor mechanism, eliminating the need for post-surgical immobilisation and permitting early range of motion exercise. We performed silicone implant arthroplasty using this approach on 16 fingers in 12 patients and followed up for more than 3 months. There was no flexor tendon rupture or nerve injury, and the mean DIP range of motion was 28.3°, with an extension lag of 11°. Postoperative wound healing was excellent in this approach, with no delayed healing or maceration. This approach is simple and eliminates postoperative immobilisation and has the potential to reduce extension lag. Level of Evidence: Level V (Therapeutic).

Background: Patients with end-stage renal failure (ESRF) are prone to vascular complications that may result in limb ischaemia and gangrene. While lower limb amputation (LLA) outcomes in this population are well-documented, data on upper limb involvement remain limited. This study aimed to characterise the types of hand conditions leading to hand specialist referrals amongst ESRF patients, identify risk factors associated with upper limb amputation (ULA) and assess post-amputation survival outcomes. Methods: ESRF patients referred to a single hand surgery unit were recruited over 5 years. Data on demographics, comorbidities, referral diagnosis and treatment were obtained. Univariate analysis and Kaplan-Meier survival analysis were performed using STATA. Results: Of the 76 included patients, 50% were referred for infection and the rest for trauma, digit ischaemia and gout in decreasing order of incidence. A total of 22 patients, accounting for 29% of the cohort, required ULA. All but one patient (96%) underwent a ULA due to an infection. Significant risk factors identified are having an ipsilateral arteriovenous fistula (p = 0.024), peripheral neuropathy (p = 0.031), peripheral arterial disease (PAD; p = 0.00010), hyperlipidaemia (p = 0.013), the history of previous surgery for a soft tissue infection (p < 0.0001) and previous amputation in any limb (p = 0.013). Survival rates at 1, 2 and 5 years post-ULA were 82%, 59% and 14%, respectively. The time to mortality after index amputation was 2.42 years. Conclusions: Infections were the most common referral diagnosis and the primary indication for ULA in ESRF patients. Identified risk factors - including PAD, previous soft tissue infection, prior LLA and the presence of an ipsilateral AV fistula - put patients at increased risk for ULA. Post-amputation survival was poor, with high mortality within 5 years. Level of Evidence: Level IV (Therapeutic).

Background: Instability of the second and third carpometacarpal joints (CMCJs) is a rare disorder. This study aimed to present treatment outcomes of CMCJ instability in elite boxers. Methods: Combat-sport athletes with second and third CMCJ instability treated at our hospital between 2011 and 2023 were included. Diagnosis and severity were assessed using lateral stress radiographs (Iijima-Kusunose [IK] classification). Treatment was based on the IK classification. Patients requiring surgery underwent arthrodesis using a single headless compression screw. Data collected included age, sex, symptom duration, type and level of sport, hand involved, number of CMCJs involved, IK grade, treatment type and follow-up period. The lead and rear hands were defined by boxing stance, independent of hand dominance. Outcome measures were pain (visual analogue score [VAS]), postoperative stability and complications. Results: Twenty athletes (19 male, 1 female; mean age: 24.7 years) were included. All had unilateral injuries, involving the lead hand in 2 and the rear hand in 18. There were 5 patients with grade 1, 3 with grade 2 and 12 with grade 3. Seven were treated conservatively and 13 surgically. Mean symptom duration was 15.8 weeks in conservatively treated and 1.7 years in surgically treated patients. All returned to their pre-injury competition level and were pain-free without residual instability. The mean follow-up was 6.7 years (range: 1.8-11.7 years). Three surgical patients had complications (one screw fracture, one metacarpal base fracture and one loosening), all resolving without sequelae. Conclusions: The IK classification-based strategy and a simplified single-screw arthrodesis provide an effective framework for diagnosing and treating CMCJ instability in elite combat-sport athletes. Level of Evidence: Level IV (Therapeutic).

Scapholunate instability (SLI) is the most frequent cause of carpal instability. There is a plethora of repair methods with a trend towards minimally invasive techniques, with the general principles aimed at restoring the integrity of the ligament and physiological carpal kinematics. We introduce a novel, all-arthroscopic one-needle-one-suture repair technique as a potential repair technique for SLI. Utilising a single 0 FiberWire suture threaded through an 18-gauge (18-G) needle, this technique allows for precise suture placement within the scapholunate ligament complex. The suture is secured with an arthroscopic gliding knot. This method reduces the need for multiple punctures and complex suture manoeuvres, thereby streamlining the surgical procedure and providing a simpler, minimally invasive alternative for certain patients with SLI. Level of Evidence: Level V (Therapeutic).

Background: Triangular fibrocartilage complex (TFCC) disruption and extensor carpi ulnaris (ECU) instability are common concomitant injuries. This study presents outcomes of simultaneous open TFCC repairs with ECU stabilisation. Methods: This retrospective cohort study reviewed patients with symptomatic distal radio-ulnar joint (DRUJ) instability and ECU subluxation who underwent simultaneous open repair of the TFCC and ECU stabilisation between 2014 and 2016. Patients were diagnosed clinically, and TFCC tear and ECU subluxation were confirmed using magnetic resonance imaging (MRI) and ultrasound (US), respectively. All patients initially underwent therapy, and surgery was offered to those with persistent symptoms. Open foveal repair of the TFCC was performed using suture anchors, while ECU stabilisation was done by deepening of the ECU groove and subsheath reconstruction. Data collected included demographics, injury details, pre- and post-surgical symptoms, range of motion, grip strength and the modified Mayo wrist score (MMWS). Results: Eleven patients were included in the study. They presented with ulnar-sided wrist pain that limited their activities of daily living. All could recall a specific injury prior to the onset of symptoms. All patients had improvement in measured outcomes after surgery. The preoperative difference in mean arc of motion between the injured and uninjured wrist improved after surgery. The mean grip strength of the injured wrist compared to the uninjured wrist improved from 72% to 93%. The mean MMWS improved from 66.4 before surgery to 92.7 after surgery. Ten of eleven patients were pain-free at the last review, and all could carry out daily activities comfortably. The follow-up duration averaged 18 months (range: 3 months-4 years). Conclusions: The outcomes of simultaneous open repair of the TFCC and stabilisation of the ECU are excellent. Patients with DRUJ instability should be screened for ECU instability, and both pathologies should be addressed simultaneously. Level of Evidence: Level IV (Therapeutic).

Background: Carpal tunnel syndrome (CTS) is the most common nerve entrapment syndrome, caused by median nerve compression at the wrist. Its aetiology remains unclear, with idiopathic and diabetic-related forms. Diabetic patients (type 1 and 2) have a higher CTS risk, likely due to oedema, neo-angiogenesis and increased non-inflammatory fibrosis in the sub-synovial connective tissue (SSCT). Vascular endothelial growth factor (VEGF) A plays a key role in vascular permeability and angiogenesis, particularly in diabetic CTS. This study compared histopathological differences and VEGF expression in idiopathic and diabetic CTS. Methods: A total of 45 CTS patients were divided into three groups: idiopathic CTS (CTS-I, n = 15), type 1 diabetic CTS (CTS-DM1, n = 15) and type 2 diabetic CTS (CTS-DM2, n = 15). Biopsy specimens from the transverse ligament, tenosynovium and epineurium were analysed for fibrosis, oedema, vascular proliferation and vascular thickness. Immunohistochemistry assessed VEGF-A and its receptors VEGFR-1 and VEGFR-2. Results: Vascular proliferation and thickness were higher in CTS-DM1 than in CTS-I (p < 0.01) and CTS-DM2 (p < 0.05). Tenosynovium in CTS-DM1 and CTS-DM2 showed increased oedema, vascular proliferation and thickness compared to CTS-I (p < 0.001). Epineurium showed no significant oedema differences but had increased vascular proliferation and thickness in diabetic CTS (p < 0.001). VEGF and its receptors were significantly overexpressed in fibroblasts, endothelial and synovial cells in diabetic CTS. Conclusions: Our study evidenced an increased expression of VEGF and its receptors 1 and 2 in endothelial cells, fibroblasts and synovial cells of the transverse ligament, tenosynovium and epineurium in patients with diabetic CTS compared to idiopathic CTS. We also observed increased oedema, vascular proliferation, vascular wall thickness and tenosynovial fibrosis in diabetic patients. These histological findings are known to be promoted by VEGF and may provide a potential pathophysiological basis for CTS. These findings suggest a therapeutic rationale for anti-VEGF therapy as an adjunct or alternative to surgery in diabetic CTS patients. Level of Evidence: Level III (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: 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: 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).