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

Background: Percutaneous screw placement can treat nondisplaced or scaphoid waist fractures. Screws positioned in areas of highest trabecular density improve fracture stability and bone healing. This study aims to compare the density of six segments of the intact scaphoid bone to facilitate optimal screw positioning. Methods: This study compared the density of six segments of the scaphoid bone in 214 intact scans using the 3D Quantitative Imaging (3DQI) Platform. The scaphoid was divided into proximal, middle and distal regions, each with radial and ulnar segments. Densities were measured in Hounsfield units (HU) and compared using a mixed effects model. Results: The proximal pole had the highest density (proximal radial 551 ± 115 HU; proximal ulnar 546 ± 116 HU), followed by the middle, with the distal pole having the lowest density. The proximal segments were significantly denser than the middle and distal segments. Conclusion: Our study suggests a more ulnar starting point in the distal pole for retrograde percutaneous screw placement, to maximise engagement of the highest trabecular bone density. For the antegrade approach, the proximal pole demonstrates consistently uniform density, permitting screw placement based on fracture plane; however, if possible, the ulnar segment of the distal pole should be engaged.

Dupuytren disease (DD) has been described since the 17th century, but its true aetiology remains a mystery. The treatment of DD largely involves addressing the end stage of a complex fibroproliferative pathway, specifically, the cords. In recent years, there has been a shift to less radical approaches, with an increased adoption of percutaneous needle aponeurotomy (PNA) or collagenase. However, the difficulty in comparing outcomes across various treatments is likely to persist due to limitations in evaluating the effectiveness of those treatments. Patient-reported outcome measures may not accurately reflect disease severity or treatment success; objective measures might not correlate well with subjective improvements and treating all joints with equal weight is unrealistic. Additionally, the inherent difficulties of blinding in studies comparing surgical and percutaneous techniques, along with heterogeneity of the affected population, further complicate outcome assessment. There are interesting developments in the basic science arena resulting in a deeper understanding of the signalling pathways driving DD. Targeting molecular targets early in the signalling pathway may hold the key to preventing pathological contractures in Dupuytren patients. Level of Evidence: Level V (Therapeutic).

Background: The prognosis of Kienböck disease (KD) depends upon the extent of damage to the articular surface of the lunate and its adjacent articulations. Arthroscopy offers valuable information for management and decision-making by revealing the status of the articular surface, which radiographs cannot visualise. Methods: This study on KD assessed 10 patients, correlating radiographic and arthroscopic evaluations to enhance diagnostic accuracy and determine the decision-making, which may result in improved functional outcomes for patients. Results: Findings have shown that arthroscopy often reveals critical details not visible by imaging, influencing surgical planning. Notably, the management plan changed in 50% of the cases following arthroscopic assessment in our series. The radiological evaluations indicated changes in the lunate, carpal collapse and instability angles, while wrist arthroscopy offered further insights into cartilage damage, lunate fracture and ligament integrity. Additionally, wrist arthroscopic evaluations facilitated minimally invasive procedures, such as scapho-capitate fusion through a mini-incision, potentially resulting in a shorter recovery time and a decreased risk of complications relative to the conventional dorsal approach, thereby providing a much more satisfactory functional outcome. Conclusion: The study concludes that combining radiographic and arthroscopic data enhances comprehensive diagnostic accuracy and guides precise surgical intervention in KD. Level of Evidence: Level IV (Therapeutic).

The clenched fist deformity (CFD) in adult patients with upper motor neuron syndrome (UMNS), typically due to a brain or spinal cord injury, can develop from an imbalance of the extrinsic finger flexors relative to the extensors. This brings the fingers into a flexed posture across the metacarpophalangeal (MCP) and interphalangeal (IP) joints and places the fingertips close to or in contact with the palm. The intrinsic musculature of the hand also plays a contributing role to the flexion deformity across the MCP joints whose contribution to the deformity can be masked by the extrinsic flexors. Severity of the CFD is patient specific and ranges over a spectrum dependent upon the involved muscle groups and underlying spasticity, myostatic contracture and/or joint contractures. In addition to markedly decreasing function, patients and caretakers may struggle with hygiene in the hand and even develop wounds within the palm. Surgical correction of the CFD can be classified as procedures implemented for muscles with (functional) or without (non-functional) volitional motor control. Techniques encompass muscle-tendon lengthening, tenotomies, tendon transfers, muscle origin release (slides), joint capsule and/or ligament releases. A comprehensive review of the surgical approach to correcting the CFD for the hand with and without volitional motor control in the fingers will be presented. Level of Evidence: Level V (Therapeutic).

Background: In mutilated hand reconstruction, the choice between index or little finger as the sole ulnar post to oppose a functional thumb remains controversial. This study objectively compares functional outcomes between these two configurations in basic two-digit hand. Methods: This retrospective study (2013-2020) evaluated 11 patients with a functional two-digit hand. Inclusion criteria included an uninjured thumb and the presence of only one uninjured digit serving as an ulnar post, either little finger (group 1) or index (group 2), characterised by good web space, sensate perception, painlessness and the ability to oppose each other in movement. Assessments included pinch and grip strength measurements, Jebsen-Taylor Hand Function Test (JHFT) and disabilities of arm, shoulder and hand (DASH) score. Non-parametric tests (Mann-Whitney U) compared continuous variables with significance at p < 0.05. Results: Objective testing revealed superior function in group 2 patients (index finger ulnar post) patients versus group 1 patients (JHFT: 1.39 vs. 1.91 minutes; grip: 4 vs. 1.2 kg; pinch: 2.5 vs. 0.4 kg). DASH scores favoured group 2 patients (25.2 vs. 37.4), though not statistically significant (p = 0.144). Conclusions: Our findings challenge traditional ulnar-digit preference, demonstrating the index finger provides significantly better strength and functional outcomes as the ulnar post in basic two-digit hands. These results support prioritising radial-digit reconstruction when the first web space is uncompromised, though individual patient factors and occupational demands should be considered. Level of Evidence: Level III (Therapeutic).

Background: Fingers are highly susceptible to injuries, leading to functional impairment, particularly in the thumb and index finger. While traditional reconstructive methods exist, they often involve multiple surgeries and complications. Distraction lengthening, a minimally invasive technique, promotes bone and soft tissue regeneration, making it a promising alternative for digital lengthening. This study aims to assess the efficacy and functional results of distraction lengthening in patients with traumatic shortening of digits. Methods: This was a prospective observational cohort study conducted at a tertiary care centre. This study evaluated distraction histogenesis in 11 trauma patients with digital shortening. A unilateral mini external fixator was used for gradual distraction following osteotomy. Distraction began 5-7 days post-surgery at 1 mm/day, with healing monitored via radiographs. Functional recovery, length gained, healing index and patient satisfaction were assessed over a 1-year follow-up. Results: Patients (73% male, aged 16-30) primarily sustained machinery-related injuries. The mean preoperative shortness was 20.4 mm, with an average length gain of 20.2 mm. The mean external fixation and consolidation times were 111.3 and 91.36 days, respectively. The healing index averaged 47.5 days/cm. Functional grip, thumb web space and hand utility improved significantly, with success influenced by stable fixator use, surgical technique and patient adherence. Conclusions: Distraction lengthening is a reliable and effective method, offering functional restoration with minimal invasiveness. Despite prolonged treatment, it preserves sensitivity, prevents stiffness and eliminates the need for bone grafting. Level of Evidence: Level IV (Therapeutic).

Background: Peripheral nerve stimulation (PNS) has emerged as a promising treatment for refractory neuropathic pain in the upper extremities, particularly for patients unresponsive to conventional therapies. This systematic review and meta-analysis aims specifically to evaluate the effectiveness and safety of nerve stimulation of the brachial plexus (BP) for managing chronic neuropathic pain in the upper extremities. Methods: A comprehensive literature search was conducted following PRISMA guidelines across major databases, including PubMed, Scopus and Embase. Five studies met the inclusion criteria, encompassing a total of 157 patients with BP or other peripheral nerve injuries. The primary outcome measures included pain reduction and quality of life improvement, assessed through validated pain scales such as the Numerical Rating Scale (NRS) and patient-reported outcomes. Results: This meta-analysis demonstrated significant reductions in pain scores following BP nerve stimulation (MD: -4.88, 95% CI: -5.80 to -3.96, p < 0.05). Additionally, improvements in quality of life were observed, with over 30% enhancement in Short Form (SF)-36 scores. The overall complication rate was low, with only 9.2% of patients experiencing adverse events, such as lead migration or postoperative infection. Conclusions: These findings suggest that PNS at the level of the BP is both a safe and effective intervention for the management of refractory neuropathic pain in the upper extremities. Level of Evidence: Level IV (Therapeutic).

Background: Trigger finger occurs primarily at the A1 pulley. However, triggering of the flexor tendon can also occur at the A2 pulley. The full release of the A2 pulley should be avoided because it may cause bowstringing and flexion weakness. To reduce the incidence of postoperative complications, we have performed a complete release of the A1 pulley via a volar approach and a complete release of the A2 pulley at the radial edge via a radial mid-lateral approach. This study aimed to investigate the outcome of our procedure. Methods: Seventeen fingers underwent A2 pulley release at the radial edge via a mid-lateral approach after complete release of the A1 pulley via a volar approach. The mean age of patients was 68 years. Regarding the Quinnell classification, 15 fingers were grade IV, 1 finger was grade II with triggering at the A2 pulley level and 1 finger was grade I with a ganglion on the A1 pulley. Results: The mean extension loss of the PIP joint was 23° preoperatively and 2° at the final examination, and the respective mean tip-palmar distances were 19 mm and 3 mm. No symptoms or signs suggested the bowstring of the flexor tendon during the observation period (mean: 99 weeks; range: 19-180 weeks). Conclusions: Our procedure is preferable for managing the tenosynovitis at the A1 and A2 pulleys. The release of the A2 pulley at the radial edge via a radial mid-lateral approach yielded a favourable result without bowstringing. Level of Evidence: Level IV (Therapeutic).

Background: While functional and patient-reported outcomes are similar for closed reduction percutaneous pinning (CRPP) and open reduction internal fixation (ORIF) of phalanx fractures, controversy exists regarding optimal fixation choice. In this study, we tested the null hypotheses that there is no difference in (1) percentage of patients undergoing secondary procedures within 2 years, (2) therapy utilisation and (3) total costs following CRPP and ORIF of phalanx fractures. Methods: Using an administrative claims database, we identified patients undergoing CRPP or ORIF of phalanx fractures from 2011 to 2020. Secondary procedures assessed within 2 years after CRPP or ORIF included phalanx osteotomy, tenolysis, irrigation and debridement, metacarpophalangeal joint arthrodesis and interphalangeal joint arthrodesis or arthroplasty. We calculated therapy utilisation at 6-month intervals after surgery and total cost of care at 90 days post-procedure. Multivariable logistic regression models were used to evaluate the association between choice of surgical fixation and incidence of secondary procedures, adjusting for age, sex, region, insurance and Elixhauser comorbidity index. Results: The composite incidence of secondary procedures was 3.1% after CRPP and 4.7% after ORIF (p < 0.001). Within 2 years after CRPP, fewer patients had tenolysis (odds ratio [OR] = 0.57 [95% confidence interval (CI): 0.52-0.63]), interphalangeal joint arthrodesis (OR = 0.51 [95% CI: 0.41-0.62]) or interphalangeal joint arthroplasty procedures (OR = 0.58 [95% CI: 0.38-0.87]). Patients who underwent CRPP had increased therapy utilisation, but similar 90-day total cost of care. Conclusions: CRPP for phalanx fractures is associated with a lower incidence of subsequent procedures compared to ORIF. Further studies are needed to compare CRPP with ORIF for phalanx fractures while accounting for specific fracture patterns as confounders, which was a limitation of this study. Level of Evidence: Level III (Therapeutic).

Background: Palmar midcarpal instability (PMCI) is often neglected in diagnosis and lacks a gold standard treatment. It is primarily associated with dorsal radiocarpal (DRC) ligament insufficiency. We used a combined approach of arthroscopic thermal capsular shrinkage and open DRC ligament suture tensioning for symptomatic PMCI and present our outcomes. Methods: From 2018 to 2022, nine PMCI patients (mean age: 32 years) underwent this treatment. The mean symptom duration was 15.3 months, with a mean follow-up of 16.8 months. Outcomes were measured by wrist ROM, grip strength, VAS for pain, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and modified Mayo Wrist scores. Results: All patients showed significant improvement in pain, grip strength and function, with maintained radiocarpal stability at final follow-up. Although wrist ROM showed mild limitation after surgery, all patients returned to their previous work and activities. Conclusions: This approach may provide an effective and less aggressive treatment for PMCI. Level of Evidence: Level IV (Therapeutic).