Hand surgery & rehabilitation最新文献

Background and aim: Virtual reality offers new clinical assessment and rehabilitation options that can complement or, in some cases, replace traditional methods. However, the applicability of using virtual reality tools for assessment of upper limb functional capacity has not been fully explored. We therefore developed an immersive virtual reality adaptation of the 6-Minute Pegboard and Ring Test (6PBRT-VR). The aim of the study was to test the validity and reliability of the 6PBRT-VR for the assessment of upper extremity functional capacity, and to assess the performance and feasibility of the proposed tool.

Methods: Thirty healthy young adults were included in the study. The participants performed the classical 6-Minute Pegboard and Ring Test first and then the 6PBRT-VR. The test-retest reliability of the 6PBRT-VR was assessed on intraclass correlation coefficient. Concurrent validity was assessed on the correlation between the 6PBRT-VR test-retest scores (number of rings moved) and the correlation between the scores from the classical 6-Minute Pegboard and Ring Test and the 6PBRT-VR. Convergent validity was assessed on correlations with handgrip strength and the total Quick Disabilities of the Arm, Shoulder, and Hand score. Cardiorespiratory responses were also measured (at baseline and after each test). Perceived arm fatigue was assessed on the Modified Borg Scale.

Results: The 6PBRT-VR exhibited excellent test-retest reliability, with an intraclass correlation coefficient of 0.866 (95% confidence interval 0.737-0.934). Mean 6PBRT-VR score correlated strongly with the mean score of the classical 6-Minute Pegboard and Ring Test (r = 0.817, p < 0.001). A significant association was found between the 6PBRT-VR and the classical 6-Minute Pegboard and Ring Test in terms of variations in heart rate, systolic blood pressure, and Modified Borg Scale score (p < 0.001). Mean 6PBRT-VR score showed moderate correlations with right (r = 0.571, p = 0.001) and left handgrip strength (r = 0.550, p = 0.002).

Conclusion: The 6PBRT-VR is a reliable and valid virtual tool for assessing upper-extremity functional capacity in young adults.

Background: Carpal tunnel release can be performed as open or endoscopic surgery. In WALANT (wide awake local anesthesia no tourniquet) a tourniquet is not used, ensuring less discomfort for the patient. In locoregional distal nerve block, on the other hand, a tourniquet is needed and can be painful. This raises the question as to which method of anesthesia is actually preferred for the patient and the surgeon. Patients undergoing staged bilateral carpal tunnel release present a unique opportunity to study this question.

Methods: Fifteen patients were included in this prospective study. The primary endpoint was the preference for anesthesia type in patients and surgeons. Surgeon preference was based on the visibility and fluency of the procedure. Secondary endpoints for patients comprised pain scores for performing surgery and anesthesia and pain caused by the tourniquet.

Results: Baseline demographic and clinical information was collected. There was no significant difference in pain for performing local anesthesia or surgery. Surgeons may find that performing endoscopic release under WALANT is more challenging, as visibility tends to be significantly poorer. The mean pain caused by the tourniquet used during the wrist block procedure was rated as 3.6. In both surgeries, 77% (10/13) of the patients preferred the WALANT anesthesia.

Conclusion: In general, endoscopic carpal tunnel release was better tolerated under WALANT than locoregional distal nerve block. Although statistical analysis showed no significant difference in visibility and fluency for the surgeon between the two anesthesia techniques, we do not recommend endoscopic release under WALANT due to the consistent report of reduced visibility in the surgical field. This limitation, likely related to the presence of anesthetic fluid, may have failed to reach statistical significance due to small sample size, but is nevertheless a considerable challenge in practice.

Level of evidence: 1B.

Purpose: This study aimed to introduce a new high-frequency ultrasound classification of De Quervain tenosynovitis based on a large group of patients. Detailed characteristics of classification are also reported.

Methods: From January 2014 to February 2024, patients diagnosed with De Quervain tenosynovitis were retrospectively reviewed. High-frequency ultrasound (7-14 MHz) scanning was performed to identify the anatomy of the extensor pollicis brevis and abductor pollicis longus tendons, presence of intertendinous septa, and pathologic changes. The affected wrist was compared to the contralateral wrist.

Results: 453 patients were included: 65 male and 388 female; mean age, 46 ± 27 years (range, 24-65 years). Symptom duration was 14 ± 27 weeks. Disease types were type 0 (n = 5), type 1 (n = 195), type 2a (n = 72), type 2b (n = 18), type 2c (n = 50), type 3 (n = 59), type 4 (n = 45), and type 5 (n = 9). Mean retinacular thickness was 2.1 ± 0.5 mm in affected wrists and 0.4 ± 0.1 mm in contralateral wrists (p < 0.01). The intercompartmental septum was significantly thicker on the affected side (1.2 ± 0.7 mm) than on the asymptomatic side (0.1 ± 0.4 mm) (p < 0.01).

Conclusions: This novel classification provides detailed ultrasonographic characteristics of De Quervain tenosynovitis, based on a large population of patients. It may help in selecting treatment and predicting outcome. However, relevance and therapeutic significance remain to be demonstrated.

Level of evidence: Therapeutic study, Level IV.

Vascularized bone flaps from the hand and wrist are an alternative to free bone transfer. Their obvious advantages recommend them for routine use. Indications and techniques should be known by hand surgeons.

Purpose: Restoring shoulder function after axillary nerve injury is always a challenge. Transferring a branch of the radial nerve destined to the triceps onto the anterior division of the axillary nerve has become the preferred technique. However, this is not always possible, especially when the axillary nerve is severely injured around the posterior part of the humeral neck. The purpose of this cadaver study was to assess the feasibility of transferring the nerve of the long head of the triceps through an anterior and lateral humeral neck tunnel, directly onto the branch of the anterior division of the distal axillary nerve where it enters the deltoid fibers, by two surgical approaches.

Materials and methods: This anatomical study was performed using 6 fresh cadavers (12 shoulders). A medial brachial approach was used to locate the radial nerve and its first branch, innervating the long head of the triceps. Then a second, transdeltoid approach was made to locate the end of the anterior branch near where it enters the deltoid fibers. The long head of the triceps nerve was transected as close as possible to the muscle, to provide the longest length possible. Then an anterior and lateral subdeltoid tunnel was made to retrieve this branch through the transdeltoid approach.

Results: The long head of the triceps nerve could always be sutured to the anterior branch of the axillary nerve. Given the 7-12 mm surplus length (mean, 8.8 mm), tensionless suturing was possible in an anatomical region amenable to easier microsurgery.

Discussion: Transfer of the long head of the triceps to the anterior branch of the axillary nerve through an axillary or posterior approach remains the preferred method for reinnervating the deltoid. However, in some patients, the axillary nerve is injured at or beyond the typical microsurgical suturing zone, which means that transfer cannot be accomplished under optimal conditions. For this reason, we suggest making the transfer more distally, using a dual approach that allows direct suturing of the long head of the triceps nerve onto the anterior terminal branch, which shortens the distance between the sutured nerve and the deltoid, and should improve outcome.

Proximal interphalangeal joint stress fractures commonly occur as epiphyseal line injuries in teenage climbers; however, fractures with closed epiphyseal lines are rare. Poor outcomes are more common if treatment is delayed. We report the case of a 16-year-old climber who underwent delayed surgical treatment for a fracture with a closed epiphyseal line, with a favorable outcome. There was 20 ° extension lag at the proximal interphalangeal joint and a fracture on the dorsal aspect of the base of the metaphyseal bone, with osteosclerosis at the fracture site. The fracture site was refreshed and internal fixation was performed using the tension-band wiring technique. At 3 months postoperatively, there was no pain, extension had improved, and bone union was achieved. This case illustrates the effectiveness of surgery in achieving favorable outcomes for delayed proximal interphalangeal joint stress fractures in climbers with epiphyseal line closure. LEVEL OF EVIDENCE: V.

Radial nerve entrapment at the LIS is an aching pain in the distal, lateral upper arm and leads to weakness in wrist and thumb/index finger extension. Additionally, a positive scratch collapse test and localized pain on pressure at the entrapment site are observed. The described approach uses a minimally invasive percutaneous ultrasound-guided technique under local anesthesia.

Introduction: Carpal tunnel syndrome, especially when bilateral, may be associated with amyloid deposits, a precursor of systemic amyloidosis. Systemic amyloidosis affects various organs, cardiac involvement having the poorest prognosis. Diagnosis is often delayed. Current treatments are only effective in the early stages of the disease. The primary objective of our study was to evaluate the incidence of amyloidosis in patients with bilateral carpal tunnel syndrome; the secondary aim was to screen for cardiac forms.

Material and methods: Between 2019 and 2023, we conducted a single-center prospective observational and diagnostic study to investigate the anatomical pathology of amyloid deposits in tenosynovial samples taken during open nerve release surgery on the median nerve. The tenosynovial biopsy was sent to a specific laboratory for analysis, and typing if positive. If amyloidosis was detected, the patient was referred to a specialist for a specific work-up.

Results: We included 54 patients, with a mean age of 67 years (range, 51-89 years): 16 men and 38 women. Sixteen analyses were positive, 12 of which were transthyretin and 4 non-typed.

Discussion/conclusion: Bilateral carpal tunnel syndrome was predictive of amyloidosis. As synovial biopsy during surgery is simple and rapid, it should be implemented to identify amyloidosis at an early stage. This could change prognosis, by improving survival through screening and initiation of early specific treatment.

Level of evidence: IV.