Hand surgery & rehabilitation最新文献

Introduction: Distal radius malunions in older patients represent a therapeutic challenge due to osteoporotic bone quality and the need to preserve autonomy. Spanning plates, which are widely used in complex distal radius fractures, allow immediate weight-bearing, but their use in corrective osteotomies has not been reported.

Case report: We report the case of a 77-year-old right-handed female patient, dependent on a cane, who presented with a distal radius malunion 3 months after conservative management of a displaced fracture. The deformity resulted in severe functional impairment and loss of independence. Considering her frailty and scheduled tibiotalar arthrodesis, a corrective osteotomy of the distal radius with an autologous bone graft and fixation using a dorsal spanning plate was performed during the same procedure. This strategy allowed for the patients to use a cane immediately after the procedure. Rehabilitation was initiated early, leading to full recovery of finger flexion within 11 days. Five months after plate removal, the patient presented 50 ° flexion, 50 ° extension, and a grip strength of 12 kg; showed complete pain resolution; and had a QuickDASH score of 18.18.

Conclusion: This case highlights the potential use of spanning plates as a temporary fixation method for distal radius corrective osteotomy in frail older patients. This technique allows weight-bearing immediately after surgery, thus preserving autonomy while providing satisfactory functional and radiological outcomes.

Level of evidence: 4:

Background: Several opponensplasty techniques have been employed to address thenar muscle atrophy associated with severe carpal tunnel syndrome (CTS). Although modified Camitz opponensplasty (MCO) using the palmaris longus (PL) tendon is widely used by hand surgeons, alternative tendon transfer donors have been proposed, such as opponensplasty using the flexor digitorum superficialis of the ring finger (OF4). However, it is unclear which surgical technique provides superior outcomes. Hence, this systematic review aims to examine the difference in functional outcomes between MCO and OF4 for restoring thumb opposition in advanced CTS.

Methods: A systematic search using PubMed, MEDLINE, Embase, and Scopus was performed. English-language articles reporting outcomes of opponensplasty for carpal tunnel syndrome were only included. The Mann-Whitney U test was used to compare differences in clinical outcomes.

Results: 301 studies were identified and only 8 eligible studies were collected and reviewed. In both groups, the postoperative outcomes were better than the preoperative ones. Among the outcomes that could be directly compared between groups, no clear differences were found.

Conclusion: Although both surgeries can provide good thumb opposition, the choice of opponensplasty technique should be based on the surgeon's experience and preference unless being performed on a patient with congenital PL tendon deficiency.

Background: Chondrosarcomas are primary bone malignancies, with most lesions of the hand representing low grade chondral tumours (LGCT). Low grade (grade one) chondrosarcomas are defined as Atypical Cartilaginous Tumours by the 2020 World Health Organisation Classification. Grades two and three are termed high-grade chondral tumours (HGCT).

Aim: To establish whether low-grade chondral tumours of the hand can be safely treated with simple curettage and assess recurrence rates.

Methods: Retrospective data was analysed from a tertiary referral hospital for bone tumours in the UK over a 13-year period. 158 patients with histological proven chondral tumours of the hand, requiring curettage, resection or amputation were included.

Results: 13 (8.2%) had HGCT and 145 (91.8%) had LGCT. 136 LGCTs underwent intralesional curettage (98.5%). 8 (5.1%) underwent wide local resection (6 LGCT and 2 HGCT). 14 (8.9%) underwent amputation (5 LGCT and 9 HGCT). All HGCT patients were free from recurrence at a median of 81.7 months. Patients expressing GD2/3 tumour marker antigens were more likely to be HGCT on histology compared with those not expressing GD2/3 and more likely to require extensive surgery.

Conclusion: In contrast to chondrosarcoma occurring in long bones, there is often discordance between histological and radiological appearance in lesions occurring in the small bones of the hand. These lesions may appear aggressive radiologically but prove to be low-grade on histology. We concluded that intralesional curettage was an effective method for managing LGCT of the hand, whilst more extensive surgery can be reserved for higher grade tumours. GD2/3 expression was associated with high-grade lesions.

Evidence level: III.

Purpose: Peripheral nerve stretch injuries are highly challenging to treat due to a poor understanding of the differences between injuries that recover naturally and those requiring surgical intervention. The rat median nerve exhibits two levels of mechanical and structural failure, epineuroclasis and endoneuroclasis, and this study investigated their long-term structural and functional outcomes. An investigation into the outcomes of distinct degrees of nerve stretch injury could help in accurately assessing the prognosis for recovery and the need for surgical treatment.

Methods: Left median nerves of 17 rats were stretched to an epineuroclasis (n = 8) and endoneuroclasis injury (n = 9), right nerves served as sham-control. Nerves were stretched using a hook attached to a load-cell, generating load-deformation curves in real-time. Epineuroclasis injury was induced with a first, endoneuroclasis injury with a second rapid force reduction. Handheld electrical stimulators were used to assess function before, immediately after and 12 weeks after injury. Tissue was harvested for histology and rats were euthanized.

Results: Epineuroclasis showed persistent epineurial disruption at 12 weeks, similar to an acute injury, while nerve function improved over time. Endoneuroclasis resulted in a traumatic neuroma in 8/9 nerves, in a neuroma-in-continuity in 5/6 intact nerves, and a chronic loss of function at 12 weeks.

Conclusions: The prognosis for recovery and the likelihood of neuroma formation after stretch injury worsens along an outside-in sequence of connective tissue failure in the rat median nerve.

Clinical relevance: The neuroclasis classification might be helpful in developing novel diagnostic tools and evaluating the prognosis for recovery and need for surgical treatment. This study further highlights a potential need for different classification systems for nerve stretch and crush injuries.

Purpose: Distal radius fractures (DRFs) are common orthopaedic injuries often requiring surgical intervention. While opioids are frequently prescribed for postoperative pain, concerns regarding new persistent opioid use have emerged, particularly in opioid-naïve patients. This study examines whether early postoperative opioid prescribing increases the risk of new persistent opioid use following DRF surgery.

Methods: A retrospective cohort analysis was conducted using the TriNetX database. Opioid-naïve patients undergoing DRF surgery were stratified into opioid and no-opioid cohorts based on prescription within 30 days postoperatively. Propensity score matching was applied to adjust for confounding variables. The primary outcome was new persistent opioid use, while secondary outcomes included mortality, new mental health disorders, and persistent upper extremity pain from 90 days through one year postoperatively.

Results: Early opioid prescription was associated with a significantly higher risk of new persistent opioid use (4.2% vs. 1.4%), an increased rate of persistent forearm, hand, or finger pain (1.0% vs. 0.6%), and a higher incidence of wrist pain (5.8% vs. 3.8%) (all p < 0.01). No significant differences in mortality or new mental health disorders were observed.

Conclusions: Early opioid prescribing following DRF surgery is significantly associated with new persistent opioid use and persistent upper extremity pain. These findings may highlight the need for judicious opioid use and alternative pain management strategies to reduce the risk of prolonged opioid utilization.

Level of evidence: Therapeutic, Level III.

Introduction: Total wrist arthrodesis (TWA) is a definitive treatment for advanced wrist pathology. This study aimed to evaluate patient-reported outcomes (PROMs), persistent complaints, and quality of life after TWA at a minimal one year of follow-up.

Methods: A multicenter retrospective cohort of 28 patients who underwent dorsal plate TWA between 2009 and 2022 was analyzed. The primary outcome was the Overall Subjective Self-Assessment (OSSA) including a specific analysis of patients' complaints. Secondary outcomes included QuickDASH, PRWE, VAS, SF-36, grip strength, and satisfaction.

Results: Mean follow-up was 116 months. OSSA averaged 5/10, with reduced mobility as the main complaint. Patients reported low pain levels (mean VAS 2). Grip strength was 55% of the contralateral side. Despite functional limitations (mean QuickDASH and PRWE: 42), satisfaction was high (mean 8/10). The SF-36 physical score was lower than the general population, but mental health was preserved, regardless of the etiology for TWA.

Conclusion: While OSSA revealed moderate score due to immobility, overall acceptance and adaptation post-TWA were high. Preoperative counseling is essential to align expectations with outcomes.

Level of evidence: IV.

Aims/hypothesis: Beta cells within the pancreatic islet represent a heterogenous population wherein individual sub-groups of cells make distinct contributions to the overall control of insulin secretion. These include a subpopulation of highly-connected 'hub' cells, important for the propagation of intercellular Ca²⁺ waves. Functional subpopulations have also been demonstrated in human beta cells, with an altered subtype distribution apparent in type 2 diabetes. At present, the molecular mechanisms through which beta cell hierarchy is established are poorly understood. Changes at the level of the epigenome provide one such possibility which we explore here by focussing on the imprinted gene neuronatin (Nnat), which is required for normal insulin synthesis and secretion.

Methods: Single cell RNA-seq datasets were examined using Seurat 4.0 and ClusterProfiler running under R. Transgenic mice expressing eGFP under the control of the Nnat enhancer/promoter regions were generated for fluorescence-activated cell (FAC) sorting of beta cells and downstream analysis of CpG methylation by bisulphite and RNA sequencing, respectively. Animals deleted for the de novo methyltransferase, DNMT3A from the pancreatic progenitor stage were used to explore control of promoter methylation. Proteomics was performed using affinity purification mass spectrometry and Ca²⁺ dynamics explored by rapid confocal imaging of Cal-520 and Cal-590. Insulin secretion was measured using Homogeneous Time Resolved Fluorescence Imaging.

Results: Nnat mRNA was differentially expressed in a discrete beta cell population in a developmental stage- and DNA methylation (DNMT3A)-dependent manner. Thus, pseudo-time analysis of embryonic data sets demonstrated the early establishment of Nnat-positive and negative subpopulations during embryogenesis. NNAT expression is also restricted to a subset of beta cells across the human islet that is maintained throughout adult life. NNAT⁺ beta cells also displayed a discrete transcriptome at adult stages, representing a sub-population specialised for insulin production, reminiscent of recently-described "β_HI" cells and were diminished in db/db mice. 'Hub' cells were less abundant in the NNAT⁺ population, consistent with epigenetic control of this functional specialization.

Conclusions/interpretation: These findings demonstrate that differential DNA methylation at Nnat represents a novel means through which beta cell heterogeneity is established during development. We therefore hypothesise that changes in methylation at this locus may thus contribute to a loss of beta cell hierarchy and connectivity, potentially contributing to defective insulin secretion in some forms of diabetes.