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

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).

Background: In patients with a zone 1 flexor digitorum profundus (FDP) avulsion fracture, we suture the FDP tendon to the A5 or A4 pulley using an absorbable suture as an adjunct to standard surgical fixation. This minimises the proximal retraction force of the tendon during the early postoperative period. The aim of this study is to report the clinical outcomes of this approach. Methods: This is a retrospective study of all patients who underwent this technique over a 2-year period between January 2020 and December 2022. Patients aged 18-65 with isolated zone 1 FDP avulsion fracture and who complied with physical therapy and follow-up protocols were included. Demographic information, injury details, surgical methods and postoperative outcomes, including range of motion (ROM), Strickland score, grip strength and Quick disabilities of hand, shoulder and arm (Quick-DASH) score were measured. Results: Eight patients (three females, five males; average age 45.75) were included. Injuries occurred in the ring finger (3) and little finger (5), with sports-related injuries being the most common cause (4). Surgical methods varied, including K-wire, pull-out techniques and combinations of these techniques. At 1-year follow-up, the average active ROM was 87.5° ± 10.9° in the proximal interphalangeal (PIP) joint and 46.9° ± 11.5° in the distal interphalangeal (DIP) joint. Strickland score was excellent in two patients, good in four and fair in two. Grip strength averaged 78.12% of the contralateral side. Quick-DASH scores averaged 14.6 ± 6.8. No tendon ruptures or implant failures were observed. Conclusions: The absence of rupture and satisfactory functional outcomes suggest that this technique is a viable option for treating zone 1 FDP avulsion fracture. Further studies with larger sample sizes and longer follow-up periods are warranted. Level of Evidence: Level IV (Therapeutic).

Distal radioulnar joint (DRUJ) instability following distal radius fracture (DRF) is an increasingly recognised entity, particularly with recent advances in the management of DRF. This review aims to provide a comprehensive appraisal of DRUJ anatomy, methods of assessing instability and current treatment strategies. Both non-operative and operative modalities are considered. In the acute setting, surgical management primarily involves open reduction and internal fixation (ORIF) of the distal radius, which can restore DRUJ stability through correction of translation and distraction of the distal fragment. Management of concomitant injuries, such as ulnar styloid fractures and triangular fibrocartilage complex (TFCC) tears, are also addressed, particularly in cases where instability persists following DRF fixation. In the chronic setting, DRUJ instability is categorised according to underlying pathology: bony abnormalities (including distal radius malunion and ulnar styloid nonunion) and soft-tissue insufficiency (notably TFCC tears). Finally, attention is drawn to associated conditions - such as DRUJ subluxation and stiffness - which may complicate management or remain underrecognised in clinical practice. Level of Evidence: Level V (Therapeutic).

Acquired digital fibrokeratoma (ADFK) is a rare benign tumour that can be difficult to diagnose when unusually large or atypical in presentation. We report a man in his 50s with a slowly enlarging lesion on the fifth toe that reached 30 mm over 2 years. MRI revealed a well-circumscribed soft tissue mass with homogeneous, low-signal intensity internally on T1- and T2-weighted images, without features of malignancy. Excisional biopsy confirmed ADFK, and the postoperative defect was reconstructed with a reverse digitolateral flap. After a year, there was no recurrence and both functional and cosmetic outcomes were favourable. This case represents an exceptionally rare presentation of giant ADFK and highlights the importance of preoperative imaging for accurate diagnosis and systematic treatment planning. Level of Evidence: Level V (Therapeutic).

Background: Malunions of the distal radius are the commonest complication of distal radius fractures and can be debilitating. A corrective osteotomy seeks to restore the patient's anatomy, with advances in technology permitting the use of patient-specific technology to accurately achieve this goal. This study compares the biomechanical properties of these systems, against standard implants, with the hypothesis that improved biomechanical properties may translate into improved functional and clinical outcomes for these patients. Methods: Ten artificial, identical, 3D-printed right distal radii were randomised. Five samples were fixed using a standard distal radial locking plate, with a pre-determined osteotomy site using planning software (control group). The remaining five samples were prepared using a 3D-printed jig, prior to fixation with a patient-specific distal radius locking plate (intervention group). A further five general distal radius sawbones were prepared and fixed using standard techniques, using the same pre-determined osteotomy level and degree of correction as the other groups (baseline group). The specimens were cyclically loaded for 2,000 cycles. Primary outcome was interfragmentary motion at the osteotomy site, with secondary outcome measures of stiffness of the construct and failure. Results: We found a statistically significant difference in motion when comparing the intervention and control groups, at both 80 N and 250 N of load (80 N: 88 µm, p < 0.001; 250 N: 316 µm, p < 0.001). The difference between the control and baseline groups was not found to be statistically significant (80 N: p = 0.13; 250 N: p = 0.088). The patient-specific implant was found to be the stiffest construct of the three specimens, and this difference was statistically significant. Conclusions: Our study shows increased mechanical stability in patient-specific implants, which may support earlier rehabilitation of patients. However, this study has highlighted a need for high-quality clinical research, to investigate how this data translates into the clinical, functional and union outcomes for these patients.

Background: Camitz opponensplasty is a widely used reconstruction procedure for severe carpal tunnel syndrome. However, it has several drawbacks, including poor pronation during thumb opposition and a tendency for flexion at the thumb metacarpophalangeal (MP) joint. We developed a novel procedure to overcome these issues while preserving its advantages. Methods: Our procedure involves mini open carpal tunnel release (KnifeLight) and the transfer of the palmaris longus (PL) tendon to the rerouted extensor pollicis brevis (EPB) tendon using the distal part of the PL tendon as a pulley. We assessed sensory and motor function recovery up to 12 weeks postoperatively, and changes in subjective symptoms, satisfaction with surgery and presence of pulley loosening after 1 year. Results: In 47 hands, palmar abduction of the thumb improved from an average of 32° preoperatively to 45° at 4 weeks postoperatively, and tip pinching between the thumb and index finger recovered in all patients by 8 weeks postoperatively. Furthermore, within 4-8 weeks postoperatively, all patients showed improvement in pinching and grasping, enhancing hand function in activities of daily living (ADL). Self-evaluation of surgery in patients followed for more than 1 year was generally favorable. None of the patients who were directly evaluated showed any deviation of the EPB tendon at the pulley. Conclusions: Our technique is a potential alternative to the Camitz procedure as it retains the advantages of the Camitz procedure while overcoming its drawbacks. Level of Evidence: Level IV (Therapeutic).

Background: Distal radius fractures are the most common fractures in the upper extremity. Volar plate fixation is a commonly performed surgical procedure for this fracture. Flexor tendon rupture is a serious postoperative complication due to attrition between the plate and tendon. This study aimed to analyse the factors associated with the time from surgery to tendon rupture, classify plate position and determine the incidence of flexor tendon rupture in relation to plate position. Methods: This multicentre retrospective study included 28 patients (24 women) with flexor tendon rupture following volar plate surgery for distal radius fractures. Plate positions were classified into four types based on plain radiographs. They were distal position (DP), dorsal angulation (DA), screw protrusion (SP) and proximal position (PP). The associations between the time to rupture and factors, including patient backgrounds and radiological parameters, were examined. Results: Thirty-five flexor tendons ruptured. All cases included Soong grade 1 or 2 plate prominence. The average time to tendon rupture was 101.5 months (SD 60.2, range: 1.1-202.1). No factors were significantly associated with time to rupture. Flexor tendon ruptures were associated with DA in 17 ruptures, DP in 11, SP in 6 and PP in 2. SP was observed in the non-locking system only. Conclusions: Attention must be paid to the possibility of tendon rupture in patients with Soong grade 1 or 2. The risk of flexor tendon rupture was highest in patients with prominent plates due to DA. Level of Evidence: Level IV (Therapeutic).

Enchondromatosis secondary to Ollier disease (OD) is rare, with secondary chondrosarcomas (CS) accounting for only 1% of malignant osseous tumours. This is one of only two reports documenting four enchondromas of different bones of the same hand developing malignant transformation, with long-term follow-up. This is a 72-year-old female with histologically proven CS from multiple enchondromas of the index finger metacarpal and proximal phalanx, and middle finger proximal and middle phalanges. Six years following curettage and bone grafting, she showed no recurrence or metastases from CS. While CS of the hand behaves aggressively, they rarely metastasise and show good 5-year survival rates. Due to good prognosis, function-sparing surgical options are acceptable over amputation, accompanied by close surveillance. Level of Evidence: Level V (Therapeutic).

Background: While early research identified features of volar locking plate design and placement as risk factors for flexor tendinopathy, temporal trends in rates of flexor tendinopathy have not been characterised despite the use of newer generations of volar plates and increased awareness of these risk factors. In this study, we tested the null hypothesis that there is no temporal trend in the incidence of flexor tendinopathy after surgical fixation of distal radius fractures. Methods: Using a national administrative claims database, we identified adults undergoing surgical fixation of isolated, closed distal radius fractures from 2011 to 2020. Patients were grouped by the quarter of the year they underwent surgery. We measured the incidence of flexor tendinopathy, malunion, nonunion and hardware removal at 1 and 2 years after the index procedure. We used a linear regression model to evaluate the association between time (per quarter) and the incidence of each complication. Results: We included 196,194 patients who underwent surgical fixation of distal radius fractures. With respect to 1-year outcomes, the incidence of flexor tendinopathy decreased by 0.6% per quarter, malunion increased by 0.8% per quarter, nonunion decreased by 2.1% per quarter and hardware removal increased by 0.5% per quarter. With respect to 2-year outcomes, the incidence of flexor tendinopathy decreased by 0.6% per quarter, malunion increased by 0.5% per quarter, nonunion decreased by 2.6% per quarter and hardware removal increased by 0.4% per quarter. Conclusions: The incidence of flexor tendinopathy after distal radius fracture fixation decreased from 2011 to 2020, which may reflect developments in volar plate design, improvements in implant selection and/or increased surgeon awareness of the risk of flexor tendinopathy. Further studies are needed to evaluate the aetiology of this trend. Level of Evidence: Level III (Therapeutic).