The Journal of hand surgery, European volume最新文献

Introduction: We review the role of neuroplasticity in functional recovery after peripheral nerve transfers, with a focus on its contribution beyond simple restoration of muscle strength.

Methods: A narrative review of the literature from the past three decades was conducted. Peripheral nerve transfer techniques were examined with emphasis on adaptive changes within the central nervous system. Key clinical and experimental evidence was synthesized to highlight the mechanisms, advantages, and limitations of neuroplasticity.

Results: Functional recovery following nerve transfer depends not only on peripheral reconstruction but also on central adaptations. Although outcomes are often reported using muscle strength grading, this approach neglects critical aspects of coordination, selective control, and integration into complex motor tasks. Neuroplasticity facilitates meaningful function by enabling cortical and subcortical reorganization, but it also presents limitations related to variability, incomplete adaptation, and dependence on donor motor programmes. Review of the available evidence indicates that while neuroplasticity is indispensable to successful nerve transfer outcomes, it cannot fully overcome the intrinsic constraints of the donor-recipient mismatch.

Conclusions: Peripheral nerve transfers must be assessed within the broader framework of neuroplasticity. A balanced understanding of this mechanism - its reliability, benefits, and inherent limitations - provides an up-to-date perspective for clinicians and researchers. Such knowledge is essential to refine reconstructive strategies, optimize rehabilitation and align patient expectations with achievable functional outcomes.

Level of evidence: IV.

Purpose: Achieving balance in tendon repair is essential for restoring optimal function after tendon injuries, particularly in the hand and upper limb. We review and discuss key steps of 'balanced' flexor and extensor tendon repair and rehabilitation.Flexor tendon repair:To achieve optimal outcomes of tendon repair, the surgeon needs to consider the balance between mechanical strength and tendon nutrition. Strong multi-strand repairs provide security against gapping and rupture, but overly tight or running epitenon sutures may impair synovial and blood supply to epitenon. Pulley venting in zone 2 is another balance: too little venting risks the repair catching or rupturing, while too much venting risks bowstringing. In the wide-awake setting, intraoperative excursion testing shows the ideal venting length that allows a solid repair to glide freely without clinically significant bowstringing.In contaminated wounds, delayed repair avoids the risk of infection. Primary repairs are possible 1-2 weeks after injury, and even very late repairs can succeed if strong multi-strand core sutures are used and tension is carefully balanced. Repair tension should be sufficient to ensure that tendon ends are in close contact with slight bulkiness at the repair site to ensure a solid repair that allows early active digital motion.Extensor tendon repair and rehabilitation:Extensor tendon injuries proximal to the fingers also require balance between protection and movement. Immobilization risks stiffness, while early relative motion splinting with strong repairs allows safer functional use or early active motion exercise. Pain-guided active mobilization and patient education further help maintain glide without rupture.

Conclusion: Successful treatment requires a balance of various aspects of the repair process, including anatomical prerequisites, surgical techniques and rehabilitation strategies, through a multifaceted approach that encompasses careful surgical planning, accurate surgical repairs, optimal therapy protocol design and patient engagement.

The complex function of the wrist is difficult to replace with an arthroplasty. Although the first arthroplasty was implanted in 1890, it took more than 100 years to develop implants with good long-term results. The Motec wrist arthroplasty, introduced 20 years ago, replicates wrist function with a ball-and-socket articulation with a wide modularity of uncemented implants to allow tuning for patient anatomy and an optimal balance between mobility and stability. Achieving predictable, long-term function in the majority of patients demands dedicated long-term commitment by the surgeon in a continuous process to optimize the result. This paper summarizes the authors' collective experience and research using the Motec wrist arthroplasty. We discuss biomechanics, tribology, patient selection, surgeons'prerequisites, pearls and pitfalls as well as necessary follow-up and awareness to avoid problems and identify complications to obtain pain relief, preserve motion and improve quality of life for the patients.Level of evidence: V.

Introduction: Artificial intelligence (AI) is becoming increasingly integrated into clinical care in hand surgery. Its applications extend across diagnosis, planning, intraoperative assistance, postoperative monitoring, rehabilitation, prosthetics and education.

Applications: In diagnostic imaging, AI improves the detection of distal radius and scaphoid fractures, estimates osteoporosis from hand radiographs, identifies triangular fibrocartilage complex injuries on magnetic resonance imaging, segments bones and cartilage, and supports dynamic wrist analysis; ultrasound- and neurophysiological-based models aid carpal tunnel syndrome diagnosis. Prognostic models predict outcomes after carpal tunnel release and thumb carpometacarpal osteoarthritis with mixed performance. Pre- and intraoperative applications include large language model-based triage and coding, navigation and phase/gesture recognition from surgical video, autonomous microsurgical prototypes and telemanipulator platforms for supermicrosurgery. Artificial intelligence-enabled telemonitoring (e.g. remote photoplethysmography) and video-based mobility tracking support postoperative care and rehabilitation. Vision-guided and multimodal sensing enhance myoelectric prosthesis control.

Risks: Risks include data privacy and security, algorithmic bias (data, transposition, normative, annotation) and opacity, overreliance with automation bias and skill erosion, and unresolved legal and ethical questions (liability, conflicts of interest, compassion in care).

Conclusion: Balanced adoption requires diversified datasets, privacy-preserving strategies (pseudonymization, differential privacy, federated learning), transparent reporting, AI literacy and ethics in medical education and interfaces that expose uncertainty and employ cognitive forcing functions. Post-deployment surveillance should track data drift, out-of-distribution inputs and performance using automated alerts and multidisciplinary review. Artificial intelligence should augment, never replace, clinical judgment, with explicit role delineation and continuous monitoring to safeguard equity and patient-centred outcomes.

This study measured the difference in waste generated for the same procedure performed in a local procedure room and in an operating theatre. The equipment costs, sterilization costs and waste produced were less for the local procedure room.Level of Evidence: IV.

Introduction: Volar locking plate fixation with cancellous bone grafting is an effective treatment for scaphoid non-union. However, the plate can impinge on the volar rim of the radius, causing pain or restricted movement that often necessitates plate removal. The primary aim of this study was to evaluate the effect of hardware removal on wrist function and patient-reported outcomes after plate fixation for scaphoid non-union.

Methods: This prospective study assessed 49 of 113 patients who underwent plate fixation for scaphoid non-union and later required plate removal due to functional impairment. Range of flexion and extension, grip strength and Patient-Rated Wrist and Hand Evaluation (PRWHE) scores were measured before non-union surgery, after bone union but before plate removal, and at 3 months after plate removal.

Results: A decrease in wrist flexion after the initial non-union surgery (60-48°) was reversed by plate removal (48-65°). Extension and grip strength increased significantly compared with pre-operative values (54-65° and 66-88%). Patient-reported outcomes also showed marked improvement, with PRWHE scores improving from 36 preoperatively to 23 after union, and finally to 4 after plate removal. No complications related to plate removal were observed.

Conclusion: Plate removal in patients with functional impairment after scaphoid non-union surgery produces clinically meaningful improvements in wrist movement and patient-reported outcomes.

Level of evidence: Level III.

Introduction: Trapeziometacarpal joint osteoarthritis is common and can lead to pain, loss of pinch strength, and progressive deformity, including the classic Z-deformity. Understanding the pathomechanics of the disease progression can help surgeons effectively balance trapeziometacarpal joint arthroplasty.Biomechanics:The disease process begins with resorption of the anterior beak of the thumb metacarpal, weakening the anterior oblique ligament. This alters joint contact mechanics, leading to thumb metacarpal flexion and dorsoradial subluxation. As deformity progresses, the effective excursion of the thenar muscles shortens, reducing grip efficiency. Compensation by the flexor pollicis longus produces distal phalanx flexion, which shifts load dorsally across the metacarpophalangeal joint and promotes hyperextension, culminating in the classic Z-deformity.Arthroplasty:Trapeziometacarpal joint arthroplasty aims to restore thumb column balance by correcting basal joint deformity. Correct component selection and alignment are critical to stability and function. Cup orientation within the trapezium should approximate the flexion-extension axis to reduce dislocation risk. Dual-mobility designs have lowered dislocation rates compared with single-mobility implants. Careful resection of osteophytes, particularly between the thumb and index metacarpals, is essential to prevent bony impingement. Metacarpophalangeal joint hyperextension often improves following TMC arthroplasty through secondary soft-tissue stabilization, reducing the need for adjunctive metacarpophalangeal procedures. Arthrodesis remains an option in selected cases with significant instability or degenerative change.

Conclusion: Modern arthroplasty, particularly with dual-mobility prostheses, provides reliable correction of deformity, improved stability, and durable outcomes in patients with advanced TMC osteoarthritis.

Level of evidence: V.

Introduction: Focal fibrocartilaginous dysplasia is a rare, benign bone lesion that causes lateral angulation deformity of long bones in children, predominantly affecting the proximal tibia and distal femur. This study aims to present a case series of clinodactyly caused by focal fibrocartilaginous dysplasia in the phalanges and summarize its clinical and imaging features.

Methods: Twenty cases (29 phalanges) were retrospectively reviewed. The diagnosis was confirmed radiographically in all patients. Clinical and imaging data, including age at presentation, gender, clinical presentation, affected site, clinical course and deformity angle were collected.

Results: The cohort comprised 15 boys and five girls, with lateral angulation deformity as the predominant clinical manifestation. The mean age at presentation was 61 (range 6-132) months. Both hands were involved in seven patients. The involved phalanges included seven proximal and 22 middle phalanges. The median follow-up was 24 (range 12-60) months. Sixteen patients were followed up without intervention, with a deformity angle of 21° (SD 8°) at first presentation and 21° (SD 8°) at the last follow-up. Four patients received corrective osteotomy for aesthetic concerns, reducing the deformity from 30° (SD 14°) preoperatively to 5° (SD 2°) at the latest follow-up. No recurrence or progression was observed.

Conclusion: Phalangeal focal fibrocartilaginous dysplasia is an important cause of clinodactyly. The deformity remains stable without functional impairment. Surgical intervention is considered when patients' parents seek to address aesthetic concerns.

Level of evidence: IV.

The aims of this study were to establish the radiographic features of distal radial fracture malrotation on bone models and then assess the prevalence of distal radial malalignment in a series of extra-articular fractures in adults. We cut distal radial bone models and simulated pronation and supination malrotation in different positions of dorsal angulation. We also reviewed 160 displaced distal radial fractures in 158 adults assessing any malrotation immediately following fracture and after closed reduction. Malrotation was more obvious on lateral than posteroanterior radiographic images. Following a distal radial fracture, we noted malrotation in 58 (36%); 47 (33%) were either into supination or pronation, six definitely into supination and five clearly in pronation. Eleven were not manipulated. Of the remainder, 44 (of 149) (30%) were malrotated, 35 were into pronation or supination and 10 were into pronation. Malrotation was not associated with an ulnar styloid fracture. Distal radial fracture malrotation appears common but underappreciated. Future studies would be needed to determine if malrotation would affect clinical outcome.Level of evidence: V.

Compressive ulnar neuropathy at the wrist is usually caused by lesions within Guyon's canal. We present a rare case of compressive ulnar neuropathy owing to a tortuous ulnar artery proximal to Guyon's canal.Level of evidence: V.