The Journal of hand surgery, European volume最新文献

Background: Metacarpophalangeal joint destruction in rheumatoid arthritis leads to pain, deformity, impaired function and poor cosmesis. Arthroplasty remains a principal reconstructive option for restoring alignment and improving function.

Methods: This narrative review summarizes the current concepts of metacarpophalangeal joint arthroplasty in patients with rheumatoid arthritis. The historical evolution of surgical techniques and implant designs is outlined, with particular emphasis on flexible silicone implants, which remain the most widely used option. Indications, contraindications, implant alternatives and key aspects of surgical technique and rehabilitation are discussed. Reported clinical outcomes, complications, and long-term implant survival are reviewed.

Results: Flexible silicone implants remain the most widely used prostheses and remain the best performing. They offer reproducible correction of ulnar drift and volar subluxation, with consistent improvements in hand alignment, function and appearance. Alternative implants, including surface-replacement and pyrocarbon prostheses, aim to replicate joint anatomy but have shown less predictable results in the rheumatoid setting, largely due to soft-tissue insufficiency. Across all implant types, outcomes are closely linked to surgical technique, particularly soft-tissue balancing, tendon realignment and management of associated deformities. Complications include recurrent deformity, limited motion, implant fracture and infection, although long-term patient satisfaction is generally high.

Conclusions: Metacarpophalangeal joint arthroplasty continues to play a central role in the management of the rheumatoid hand. Despite advances in implant technology, flexible silicone arthroplasty provides reliable functional and cosmetic improvement in appropriately selected patients. Durable outcomes depend on reconstruction of the soft tissues, correction of associated deformities and rehabilitation, rather than implant design alone.

Level of evidence: V.

Background: The balance of the finger is maintained through a complex interaction of intrinsic and extrinsic mechanisms that coordinate motion, stability and force transmission across the metacarpophalangeal and interphalangeal joints. Although flexor muscle mass exceeds that of the extensors, equilibrium is achieved through precisely calibrated tendon positioning, lever arms and passive restraints. This balance permits efficient motion with minimal energy expenditure and allows rapid transition between power and precision function.Physiological balance:Active balance is generated by coordinated action of extrinsic flexors and extensors with intrinsic modulators, including the interossei and lumbricals, which regulate tendon tension and joint sequencing. Passive stabilizers including the palmar plate, collateral ligaments, sagittal bands, annular pulleys and retinacular ligaments maintain tendon alignment, optimize lever arms and prevent subluxation. Balance modulation is provided by Landsmeer's ligament and Winslow's diamond, and the camshaft and hypomochlion effects further refine interphalangeal coordination and stability. Disruption of any component alters tendon vectors and joint moments, producing predictable deformity patterns including clawing, boutonnière, swan-neck deformity and bowstringing.Restoration of balance:Restoration of balance requires more than structural repair. Successful management depends on correcting bony alignment, restoring joint mobility and reconstructing soft-tissue relationships to re-establish physiological force distribution. Surgical options include tendon transfer, intrinsic release, pulley reconstruction, centralization procedures and nerve reconstruction, dependent on underlying pathology.

Conclusion: Finger function depends on finely tuned balance of intrinsics and extrinsics. Understanding the dynamic and passive stabilizing mechanisms is essential for diagnosing imbalance and for planning reconstructive strategies that restore movement.

Level of evidence: V. Narrative review.

Introduction: The biomechanical role of the dorsal scaphotriquetral ligament (DSTL) ligament in scapholunate (SL) stability remains debated. We assessed DSTL contribution using a cadaveric sectioning model.

Methods: Twenty-four wrists underwent sequential sectioning: none (phase 0), palmar/proximal scapholunate interosseous ligament (SLIOL) (phase 1), dorsal SLIOL (phase 2), superficial dorsal intercarpal ligament (DICL) (phase 3) and DSTL (phase 4). Under axial loading (60 N; cyclic 60-200 N) and wrist motion, the SL gap and carpal angles, and a CT-derived dorsal instability scaphoid angle (DISA) were measured.

Results: Phase 1 produced no significant instability. Dorsal SLIOL sectioning (phase 2) initiated dynamic instability, with increased SL gap and angles under load and dorsal scaphoid translation, but no resting dorsal intercalated segment instability (DISI). Sectioning the superficial DICL fascicle (phase 3) did not add instability. DSTL sectioning (phase 4) produced the largest changes, with marked SL diastasis, increased angles and DISA, and DISI at rest and under load.

Conclusion: Dorsal SLIOL sectioning produced load-dependent (dynamic) SL instability, whereas subsequent DSTL sectioning was associated with progression to static instability, supporting the DSTL as an important dorsal restraint. The DISA may provide an additional CT-based measure of dorsal scaphoid subluxation; however, clinical validation is required.

Most hand fractures can be treated non-operatively, encouraging early mobilization once stable (typically after 2-3 weeks). The authors emphasize the tremendous powers of recovery of the hand from injury and that a mobile malaligned hand is much better than a stiff, normally aligned hand. In deciding upon the best treatment for any injury it is important to consider the patient as a whole, local resources and skills, as well as the specific injury. For most hand fractures non-operative treatment reliably gives good outcomes (which we have classified as Group A injuries) and typically cannot be improved upon with surgery. In some, surgery is clearly the best option (which we have classified as Group B injuries). The challenging group is where there is uncertainty (which we have classified as Group C injuries), especially where there is little or no good published evidence; for these we give our opinions based upon experience.Level of evidence: V.

Introduction: Digital mucous cysts (DMCs) are common benign lesions of the distal interphalangeal joint that may cause pain, nail deformity or aesthetic dissatisfaction. Surgical treatment consists of cyst excision with local flap coverage to achieve satisfactory soft-tissue reconstruction. However, limited data are available comparing the aesthetic outcomes between flap techniques.

Methods: We conducted a retrospective study of patients who underwent surgical treatment for a DMC at our University Hospital between January 2019 and July 2024, with a minimum follow-up of 1 year. Two local flap techniques were used for skin coverage: the biquadrangular flap and the Hueston flap. Aesthetic outcomes were assessed using the Patient and Observer Scar Assessment Scale (POSAS). Secondary outcomes included nail dystrophy, cyst recurrence, joint stiffness and postoperative infection.

Results: Fifty patients were included: 27 treated with a biquadrangular flap and 23 with a Hueston flap. No statistically significant differences were observed between the two groups in patient or observer POSAS scores. Likewise, there were no significant differences regarding secondary outcomes, including nail dystrophy, recurrence, joint stiffness or infection.

Conclusion: Both biquadrangular and Hueston flaps yield comparable aesthetic satisfaction and clinical outcomes after surgical excision of digital mucous cysts. Flap selection does not appear to influence scar quality or postoperative complications and may therefore be guided by surgeon preference, anatomical considerations and patient expectations.

Introduction: The lunocapitate angle is a radiological parameter that can be used to identify midcarpal malalignment. This study aimed to determine the reproducibility of a measurement method for the lunocapitate angle on plain lateral wrist radiographs and to determine the normal values.

Methods: The lunocapitate angle was measured in a standardized manner by three observers. Inter- and intra-observer variabilities were first tested on 18 radiographs. The lunocapitate angle was measured on lateral wrist radiographs of 172 patients with a mean age of 30 years (range, 20-40). Forty-nine percent of the patients were men and in 56% the left wrist was involved.

Results: The interobserver variability was good with an intraclass correlation coefficient (ICC) of 0.89. The intraobserver reliability was excellent for all three investigators, with ICCs of 0.93, 0.93 and 0.91, respectively. The mean lunocapitate angle was 15° (SD 10; range, -18 to 43°) 95% CI -3 to 34°. The mean lunocapitate angle was 17° in women and 13° in men (p = 0.005).

Conclusion: In this study, a reproducible method is presented to measure the lunocapitate angle on plain radiographs and normal values were established that can be used as a reference.

Level of evidence: IV.

Introduction: This study aimed to identify predictors of early and late postoperative complications following syndactyly release. We analysed a series of 684 webspace releases at a paediatric tertiary care referral centre. We hypothesized that patient demographics and presentations would resemble the findings of previous reports. In addition, we hypothesized that complete or complex syndactyly would be predictive of early and late postoperative complications regardless of other demographic and presentation factors, as compared to simple or incomplete syndactyly.

Methods: Patients 0-17 years of age at presentation with congenital hand syndactyly who underwent surgical correction were included. Outcomes of interest included early (less than 30 days) postoperative complications and late (greater than 30 days) postoperative complications, including pathologic scar formation and/or web creep.

Results: In total, 684 web spaces from 318 patients were included. The average follow-up time was 2.2 years. The early 30 day complication rate was 12%, while the incidence of late postoperative complications was 26% with a web creep incidence of 8.8%. On regression analysis, complete syndactyly and bony involvement were predictors of early 30 day complications. Male sex and complete syndactyly were predictors of developing late postoperative complications. In a subgroup analysis of simple syndactyly cases, web creep and hypertrophic scarring were significantly higher in cases reconstructed with skin grafts compared to cases that utilized a graftless dorsal metacarpal VY island flap technique.

Conclusions: While early postoperative complications are infrequent, one quarter of cases will develop a late postoperative complication. Complete syndactyly is a predictor of early and late postoperative complications. Reconstructing simple syndactyly with a graftless dorsal metacarpal VY island technique may lead to fewer postoperative complications.

Level of evidence: IV.

Introduction: The main aim of this study was to compare functional, pain and clinical outcomes between patients who underwent implant removal combined with total wrist denervation and patients who underwent implant removal alone for painful intra-articular malunion of fracture of the distal radius that was not amenable to osteotomy.

Methods: This single-centre, prospective study included adult patients with painful intra-articular distal radial malunion non-amenable to osteotomy between 2022 and 2025. Patients were offered either implant removal combined with total wrist denervation (combined group) or isolated implant removal (isolated group). The primary endpoint was a comparison between groups of the postoperative Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and visual analogue scale (VAS) pain scores at 1 year. The secondary outcomes were the comparison of the postoperative range of motion (ROM), grip strength and complications.

Results: Overall, 35 patients were included. In the combined group, the QuickDASH and VAS scores were significantly improved at 1 year from 45.5 (IQR: 38.6 to 50.0) to 18.2 (IQR: 13.6 to 27.3) and from 4.8 (SD 1.1) to 1.6 (SD 1.4), respectively. In the isolated group, no significant improvement in the QuickDASH nor in VAS was found. At 1 year, patients in the combined group had a significantly lower QuickDASH score, lower VAS scores and improved grip strength compared with patients in the isolated group. There was no difference between the groups regarding ROM and number of complications.

Conclusion: The addition of total wrist denervation during implant removal appears to offer substantial symptom relief and improved function in this population.

Level of evidence: III.

Introduction: Traumatic brachial plexus injuries (TBPI) are life-changing and can lead to permanent changes in function and pain within the arm and hand. Historically, TBPI research has reflected the priorities of researchers and clinicians rather than those with personal experience of living with a TBPI. The James Lind Alliance (JLA), supported by the National Institute for Health Research, has developed a rigorous methodology for increasing public engagement in research by giving an equal voice to patients, carers, and healthcare providers to ensure that their concerns are represented in future health research programmes. These projects are called priority setting partnerships (PSPs).

Methods: A JLA PSP, comprising patients, carers and clinicians, was created and completed to agree future research priorities in adult TBPI. The JLA PSP methodology was followed throughout.

Results: One-hundred and fifty-four respondents replied to an initial survey generating 704 questions. These were assessed, grouped and combined to create 68 summary questions or 'uncertainties'. Three were excluded after literature review suggested they had already been answered by research. Seventy-nine respondents answered an interim prioritization survey, choosing their top ten from the summary questions. In a workshop, nine patients, two carers and 11 clinicians met, discussed and ranked the top 22 questions from the interim survey to identify the top 10 research priorities. Psychology, physical therapy treatments and management pathways were among the top ranked priorities.

Conclusion: These results will inform researchers and funding bodies about research priorities for patients, carers and clinicians to direct future research on TBPI.

Level of evidence: V.

Introduction: The internationally recommended reference-standard treatment for cutaneous squamous cell carcinoma is surgical excision. International guidelines recommend excision margins based on the risk of recurrence, which is determined by several features including the anatomical site. The lip and ear are universally recognized as high-risk sites, although there are discrepancies in the guidelines regarding the risk stratification of hand squamous cell carcinoma. This systematic review examines the evidence for the local recurrence rate of invasive squamous cell carcinoma of the hand following surgical excision.

Methods: On 4 February 2024, we searched MEDLINE, Embase, CENTRAL and ClinicalTrials.gov. A supplementary search was performed on 23 January 2025. All study types reporting recurrence data following excision of more than five primary invasive squamous cell carcinomas of the hand were included. Cases of in-situ squamous cell carcinoma were excluded.

Results: Sixteen case series reporting 1437 lesions and 3752 lesion-years of follow-up were included. Eight studies reported no recurrences, although they lacked sufficient data or follow-up. Six studies reported high incidences of recurrence ranging from 7 to 31%. The two largest studies reported recurrence incidences of 1 and 2%, respectively. Of the included studies, only one commented on adherence to international guidelines within their results.

Conclusion: Owing to the heterogeneous nature of lesion types and management, as well as follow-up and potential study bias, the incidence of recurrence of squamous cell carcinoma in the hand varies in this review. The uncertainty in the evidence is reflected by discrepancies in international guidelines. Further research is needed to establish recurrence risk and inform management decisions.