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Socket-shield technique expands the indications for immediate implant placement and effectively maintains the contour of the labial bone. However, due to its relatively high incidence of complications, the technique has not become routine. Understanding the biomechanical characteristics among different structures in socket-shield technique has clinical significance. In this study, finite element analysis was conducted to investigate the biomechanical correlations with the exposure, migration and fracture of the root shield. Seven three-dimensional finite element models were constructed with jumping gaps of 0mm, 0.5mm, 1mm, 1.5mm, 2mm, 2.5mm and 3mm, respectively. The results illustrate deep overbite loading induces unfavorable biomechanical reactions in various structures in socket-shield technique. For normal occlusion, the jumping gap that is too small leads to stress exceeding the yield strength of the root shield and comparatively large displacement in the root shield, possibly causing fracture and migration of the root shield. The jumping gap that is too large causes micro-damages to the cortical bone around the implant, potentially leading to cortical bone resorption and exposure of the root shield. Therefore, the technique should be avoided in patients with deep overbite loading, and the jumping gap of 1.5–2mm may be a suitable choice.

The surgeon may, on occasion, wish to perform a relatively minor procedure on a single finger with some types of tourniquet at the base of the finger. A potential complication of a digital tourniquet is neurovascular damage due to excessive tissue pressure and prolonged application time. We presented a case where a hand surgery and digital tourniquet was forgotten on the finger for one and a half days. Although neurovascular compromise had occurred, the left index finger was successfully saved after extensive medical treatment and leech therapy.

To compare the radioscapholunate (RSL) arthrodesis and radiolunate (RL) arthrodesis as a treatment for radiocarpal osteoarthritis following fractures of the distal radius, nine patients, 23 to 70 years old (average 41) at the time of surgery, were assessed two to 33 years after surgery. The periods between injury and surgery ranged from four months to 30 years. RSL arthrodesis was performed in three cases and RL arthrodesis in six. Post-operative wrist pain disappeared in six and was decreased in the other three. In the RSL group, the total arc of wrist flexion and extension was reduced from 50° pre-operatively to 35° post-operatively. In the RL group, it was increased from 72° to 76° after surgery. Grip strength improved in most patients, from 7 to 18 kg in the RSL group, and from 16 to 27 kg in the RL group. On roentogenogram, three patients showed arthritic changes in the adjacent joints, but there were no symptoms in two of the three patients. We concluded that partial radiocarpal arthrodesis (preferably RL arthrodesis) is a reliable procedure for radiocarpal osteoarthritis following fractures of the distal radius.

Of 875 idiopathic carpal tunnel syndrome (CTS) cases, 101 (11.5%) required trigger digit release operations within three years before and/or after carpal tunnel release (CTR); these 101 cases were investigated, retrospectively. Trigger digit release (TDR) was performed most often after the CTR, especially within three months. Next most common was at the same time as the CTR. The TDR performance rate after CTR was 5.9%. The nerve conduction study (NCS) comparison between trigger digits-associated CTS and isolated CTS showed that pre-operative distal motor latency was significantly more delayed in trigger digits-associated CTS, while there was no evidence of any difference due to age or gender. The difference of operative method (open or endoscopic procedure) did not influence the incidence rate of trigger digits after the CTR. This study suggested that trigger digits-associated CTS has a previously developed wide-ranging narrowing of the flexor tendon sheath.

Suspensionplasty was performed using the abductor pollicis longus tendon for osteoarthritis at the carpometacarpal joint of the thumb. The operated wrist had a full range of motion four months after operation; however, there was swelling on the dorsoradial aspect of the wrist and, upon terminal wrist extension, pain was present at the maximum dorsiflexion. Suddenly, one year after operation the patient could not extend the interphalangeal joint of the thumb. Surgical exploration revealed rupture of the extensor pollicis longus tendon. Tenosynovitis at the extensor carpi radialis brevis tendon, where the abductor pollicis longus tendon is sutured, might cause extensor pollicis longus tendon rupture. Late postoperative complications such as this extensor pollicis longus tendon rupture after suspensionplasty using the abductor pollicis longus tendon are extremely rare and this is the first case in the literature.

Background: To investigate asymptomatic flexor tendon damages after volar locking plate fixation of distal radius fractures in 32 wrists of 32 patients with distal radius fractures fixed using two plate types. Sixteen patients received the Acu-Loc volar distal radius plate, and the remaining 16 patients received the Aptus distal radius correction plate.

Methods: The flexor pollicis longus (FPL) tendon and flexor digitorum profundus were evaluated according to intraoperative findings at plate removal. Ultrasonography was used to measure the distance between the FPL tendon and distal edge of the plates (FPL plate distance) before plate removal, the distance between the FPL tendon and distal edge of the radius (FPL radius distance) after plate removal, in the contralateral wrist, and the angle between an extension line of a volar surface line on the proximal FPL tendon and a second volar surface line on the distal FPL tendon (FPL angles).

Results: Erosion of the FPL tendon was identified in four wrists, and erosion of the flexor digitorum profundus of the index finger was identified in one wrist. All five cases of wrists with flexor tendon damage had Acu-Loc plates installed. The average FPL angle before plate removal was 15.4° in the wrists with tendon damage, which was statistically significantly larger than the average FPL angle in the wrists without erosion.

Conclusions: The type of plate and larger FPL angle on ultrasonography may be the risk factors for flexor tendon damage.

Hardware-related complications are rare in patients with distal radius fractures who were surgically fixed with volar-locking plates. In this report, we present a case of locking screw loosening and migration to the palm four years following the treatment of type 23-C1 distal radius fracture with a volar locking-plate. This complication occurred without evidence of trauma, infection, non-union or plate breakage. Orthopaedic surgeons should be aware of such rare complication and add it to the list of potential postoperative complications when counseling their patients preoperatively.

There is a report that 60% of patients suffer from neck and shoulder symptoms following unilateral open type laminoplasty. As for French-window-open type cervical laminoplasty, however, postoperative nuchal pain has not been fully investigated. The purpose of this study is to describe the prevalence and severity of nuchal pain following French-window-open type cervical laminoplasty, and to investigate the pain's influencing factor. Eighty-three cases with spastic tetraparesis due to cervical spondylotic myelopathy or ossification of posterior longitudinal ligament were followed. We interviewed these patients, at three months after surgery and again at one year after surgery, about the existence of nuchal pain, its laterality, and whether treatment was needed. Nuchal complaints remained in 56 out of 83 patients at three months and in 37 out of 78 patients at one year following surgery. There was no correlation between the complaint and disease, age, sex, blood loss, or method of muscle reconstruction. The side for which the patient complained of pain coincided with the approached side, and the magnitude of the complaint correlated with operation time. The results suggest that the cause of the nuchal pain is damage to the posterior neck muscles by retractor.

Tendon transfer with extensor indicis proprius (EIP) has been performed widely for reconstructing ruptures of the extensor pollicis longus because of its simplicity and clinical outcome. We experienced a rerupture of the extensor pollicis longus restored by incorrect tendon transfer because of a major unrecognized variation in the anatomy of the EIP. Surgeons should perform such transfer with a detailed knowledge of the possible anatomical variations to avoid such serious complications.

The Sauve-Kapandji (SK) procedure for distal radioulnar joint osteoarthritis have complications including pain over the proximal ulnar stump, nonunion of the fused distal radioulnar joint, and less frequently, insufficiency fracture of the distal radius. We report a case of insufficiency fracture of the radial diaphysis as a rare complication of the SK procedure.

Background: Local flaps are widely used to cover fingertip defects. Errors in design or technical execution of the flap may lead to morbidity and additional surgical procedure. The purpose of this study was to review flap related complications requiring unplanned secondary surgery to characterize preventable issues.

Methods: 851 local flaps were used to reconstruct fingertip defects during a 9-year period. Patients requiring unplanned secondary surgery to address flap related complications were subjected to analysis.

Results: 31 of 851 flaps (3.6%) required unplanned secondary surgery because of flap related complications. The most reliable flap was VY advancement flap with only one (0.3%) re-operation. The reverse vascular island flap, cross finger flap, and neurovascular island flap were associated with the comparable number of complications (8.0%; 6.3%; and 3.8% respectively). Total or partial necrosis was the cause for re-operation in 6 patients (0.7%). The typical reason for secondary surgery was inadequate soft tissue cover of the tip with homodigital neurovascular island flap and flexion contracture with reverse vascular island flap. Cross finger flaps were revised because of poor graft take at the donor site, bulky flap or flap necrosis.

Conclusions: Local flaps are reliable operations to cover fingertip defects. Each flap has potential pitfalls, which may be avoided if the surgeon is aware of them.

Background: Flexor tendon repair carries a significant risk for complications, which often leads to revision surgery. The purpose of this study was to assess the effect of different factors on the risk for major complications patients undergoing a primary end-to-end flexor tendon repair and early passive mobilization regimen (Kleinert protocol).

Methods: Between January 2000 and September 2009, a total of 312 patients underwent a flexor tendon repair at out institution. We excluded patients whose injury was self-inflicted or secondary to a rheumatic disease or a fall leaving 187 patients with 325 injured tendons for the study.

Results: 152 (81.7%) patients were male and 34 (18.3%) females. Mean age of the patients was 32.7 years (SD 14.4, range 11 to 73). The fifth ray was most commonly affected. The majority of the injuries were located in zone II. Median delay to surgery was 3 days. Complications were observed in 34 patients (18.2%). Univariable analysis showed that patient age, mechanism of injury, injured ray, delay to surgery between three and seven days, and greater suture thickness were associated with increased risk of complications. In the subsequent multivariable analysis, only the mechanism of injury and delay to surgery remained as significant risk factors for major complications.

Conclusions: We conclude that complications after flexor tendon repair may be reduced by appropriate timing of the surgery. Delay to surgery lasting between three and seven days seems to be associated with increased risk for major complications.

Background: Volar locking plates have provided the capability to repair both simple and complex fractures. However, complications related to the inability to fix or to maintain the fixation of some fracture patterns have been reported with volar locking plates. The purpose of this study was to evaluate the results of dorsal plating treatment for specific pattern of fractures.

Methods: Patients with distal radius fractures were retrospectively evaluated. Inclusion criteria for this study were those related to the patient and treatment (adult patients, internal fixation with dorsal plating, a minimum follow-up of 12 months), and those related to the fracture pattern (displaced central articular fragment, volar distal fracture line not enough to allow volar fixation, displaced dorsal-ulnar fragment, dorsal partial fractures, combination of these patterns). Clinical outcome information including active range of motion, radiographs, PRWE and DASH questionnaires were collected. Complications were recorded.

Results: During a 6-year period, 679 distal radius fractures were treated with open reduction and internal fixation. Of these, 27 patients fulfilled the inclusion criteria. Patients were examined at a median of 34 months’ follow-up. All but pronation, supination, and radial deviation had a statistically significant difference compared to the opposite side. The median score on the DASH was 4.5 and 3.2 on the PRWE. No patient suffered loss of reduction during the follow-up nor were tendon ruptures recorded.

Conclusions: Although most of the distal radius fractures can be treated with volar locking plates, almost 5% of them present specific patterns that are amenable to treatment with dorsal fixation, without postoperative loss of reduction. These specific patterns are: (1) displaced central articular fragment, (2) volar distal fracture with less of 1cm distance from the distal volar edge of the radius, (3) displaced dorso-ulnar fragment, (4) Barton’s fracture, (5) combination of these patterns.

Background: Collagenase clostridium histolyticum has become a widely used treatment in the management of Dupuytren disease. The aims of this study are to assess the immediate success of treatment of Dupuytren contracture with collagenase injection, to measure long-term patient-rated outcomes, to determine whether the risk factors for the disease impacted outcomes and to report complications of collagenase treatment.

Methods: A prospective study was performed in a tertiary referral centre. Measurements were recorded pre-treatment, day 1 and day 90. Patient-rated outcome scores were measured using Disability of the Arm, Shoulder and Hand questionnaire (DASH) and the Michigan Hand Questionnaire (MHQ) at minimum 36 months post-injection.

Results: The study included 45 patients with 53 hands with a mean age of 65.7 years. The treatment was successful in 62% of patients with the greatest improvement in the metacarpal-phalangeal joint of the little finger. Diabetes, epilepsy, gender, alcohol intake and positive family history had no statistically significant predictive value on successful outcomes. Patient satisfaction at 41 months was high with mean MHQ score of 97.3.

Conclusions: Collagenase is effective in the treatment of Dupuytren contracture, with disease involving the little finger showing the greatest benefit. Risk factors for development of Dupuytren disease had no effect on successful outcome and long-term satisfaction rates are high.

Level of Evidence: Level III (Therapeutic)

Hook of hamate fracture occurs in baseball players during bat swing. These fractures are usually treated by excision of the fracture fragment and the players can return to the game without delay. We report a professional baseball player who presented with a hook of hamate fracture. He gave history of undergoing excision of the hook 4 years earlier for a fracture of the hook. He underwent re-excision of the regenerated hook and was asymptomatic at his final follow-up.

Level of Evidence: Level V (Therapeutic)

Background: Endoscopic carpal tunnel release (ECTR) is a less invasive procedure but has a higher risk of complications. We analysed ECTR cases dividing them into three periods according to a single surgeon’s experience when the ECTR was performed: the initial, midterm and late period. Cases of iatrogenically induced median nerve injuries that occurred after ECTR were then noted and evaluated.

Methods: We reviewed 195 ECTRs done with the 2-portal technique and divided the patients into three groups according to periods of when ECTR was done. The indications for ECTR surgery were limited to severe CTS cases. These groups of patients were similar in terms of age, duration of disease, electrophysiological study results and severity of the disease. The patients were evaluated for median neuropathy pre- and postoperatively using Semmes–Weinstein monofilament test (SWT), Disabilities of the arm, shoulder and hand (DASH) Score, Coin-flip test (CFT), postoperative paraesthesias and complications, such as pillar pain, and so on. Electrophysiological evaluation was performed only preoperatively.

Results: Postoperative median nerve recovery was overall good. Normal recovery was noted in 181 cases (93%). SWT, DASH and CFT were all significantly improved upon follow-up in all three groups. In terms of iatrogenic neuropathy, median nerve palsy worsened (including those transiently worsened) after ECTR in 11 cases (5.6%), even in the later period. The sensory disturbance was equally worsening from the radial to the ulnar side.

Conclusions: The fact that there were neurologically worsened cases even in the later period, when the operator is higher skilled in the technique, suggests that the surgical technique itself may be the one posing higher risk than the level of surgical skill. The most likely causes of aggravated nerve palsy were a direct injury by cannula insertion at the proximal portal, or additional median nerve compression during cannula insertion into the carpal tunnel.

Level of Evidence: Level IV (Therapeutic)

Background: A high incidence of ulnar nerve-related complications has been reported in open reduction and internal fixation for distal humerus fractures (DHFs). To minimise ulnar nerve damage, we used a percutaneous medial screw combined with a posterolateral plate in the elderly. The aim of this study was to evaluate the postoperative complications and functional outcomes of this method.

Methods: Data from patients aged over 65 who underwent this surgical procedure for DHFs at a single Level I trauma centre from 2013 to 2021 were extracted. Postoperative complications, reoperations, mean range of motion, Mayo Elbow Performance Index (MEPI) scores and Hand20 scores were retrospectively evaluated. All patients in this study received postoperative rehabilitation by hand therapists at our hospital.

Results: We identified 28 patients treated with this method. The mean follow-up period was 8.6 ± 3.7 months. The median intraoperative time was 125 minutes (interquartile range: 105–157 minutes). None of the patients developed ulnar nerve neuropathy, but one patient (3.7%) experienced radial nerve dysfunction. Two patients (7.4%) had nonunion. Implant failure occurred in three patients (11.1%) due to migration of the medial screw. One patient (3.7%) amongst them underwent reoperation. The mean flexion to extension arc was 97 ± 18°, 116 ± 19°, and 116 ± 19° at 1-, 3- and 6-month follow-ups, respectively. According to the MEPI, 20 patients achieved excellent results, seven patients achieved good results and one patient achieved a fair result at the last follow-up. The median Hand20 score was 4.3 (interquartile range: 2.1–14.0) at the 6-month follow-up.

Conclusions: The posterolateral plate and medial screw method showed good functional outcomes and few nerve-related complications. This modified method might be a better option for DHFs in elderly patients.

Level of Evidence: Level IV (Therapeutic)

Neurologic deterioration after surgery is one of the most serious complications of surgery for cervical compression myelopathy. It is divided into two subgroups depending on the time of onset; early onset (i.e. regressions of onset within the first year after surgery) and late onset (more than one year after surgery). Early onset deterioration, of course, includes an accidental damage on neural tissue during surgery which can be prevented by meticulous operation or applying a procedure offering a wider visual field, such as subtotal corpectomy with strut bone graft (SCS). Use of a surgical microscope also provides superior illumination and magnification in a small surgical field. Management of direct complications are discussed in the other chapters, and here we describe the detection and treatment of unpreventable neurological complications.