Hand Surgery

This report outlines my experience with 20 patients who underwent bilateral endoscopic carpal tunnel releases: one side by a uni-portal (Unit-Cut) release, the other by a two portal (modified Chow) technique at the same time. All patients were treated as out-patients, the operations being performed under local anaesthesia with light sedation, no tourniquet inflated, and with pressure bandage applied for twelve hours only. The patients underwent an accelerated rehabilitation programme beginning the same day, and were encouraged to use their hands as soon as possible. Grip and pinch strength return was similar for both techniques, the single portal being slightly quicker. Return to work averaged 8.5 days (range 3–25 days) and full activities returned by 14.3 days (range 1–40 days). When asked, the patient strongly preferred the single portal technique, i.e., 18 out of 20 patients.

Carpal tunnel syndrome (CTS) and trigger finger (TF) are two related disorders which involve alterations in the normal mechanical loading of tendon sheath pulleys. This study examines the presence of Type II collagen in the carpal ligament and A-1 pulley by Western blotting to determine the extent of cartilage metaplasia that may occur in these tissues. Cyanogen bromide peptides generated from tissue supplied from 77 patients were separated by SDS-PAGE and transferred to nitrocellulose. The membranes were stained with the E1E5 monoclonal antibody and collagen levels were quantified. All specimens were found to contain at least small amounts of Type II collagen. Approximately 15 percent of the samples from patients with carpal tunnel syndrome and trigger finger were found to contain significantly elevated levels of Type II collagen. All specimens with high levels of Type II collagen were found in female patients. These increases may indicate the presence of cartilage metaplasia enabling the tissue to counteract compressive loads. With further study, tissue staining techniques using monoclonal antibodies may provide useful clinical information on severity or long-term outcome prognosis.

Thirty-six adult patients with 44 trigger fingers of less than four months' duration entered a prospective study on the efficiency of treatment with local injections of a combination of corticosteroids and lidocaine. From this study it may be concluded that the short-term success rate (93%) of one to three injections of methylprednisolone and lidocaine 2% (Depo-Medrol®) is comparable to that achieved by surgical or percutaneous tenolysis. At one year of follow-up, this success rate still amounted to 86%. In our hands, this therapy is without complications or side effects.

Sixteen patients were operated on consecutively for palsy of the posterior interosseous nerve. The aetiologies were traumatic in 12 patients and non-traumatic in four. Operative neurolysis was done in six cases. Neurorrhaphy with sural nerve grafting was performed in two cases. Tendon transfer was done in eight cases. Relief of compression has the best result followed by nerve repair. Iatrogenic nerve injury after radial plating carried the worst prognosis. Although motor power was not normal after surgery, tendon transfer still provided a useful hand with residual extension lag of the fingers. The prognosis of operative treatment of posterior interosseous nerve syndrome depends mainly on its aetiology.

The accessory nerve and the motor branch of the cervical plexus have been used as donor nerves in neurotisation procedures for brachial plexus palsy. However, there are few reports in the literature that describe their anatomy in detail. The aim of this study is to delineate the applied anatomy of these nerves. We emphasise their course in the posterior triangle of the neck as well as within the trapezius muscle. Fourteen cadavers were dissected. We identified nerves not reported before and they are the lateral cutaneous branches of C3 and C4. The deep branch of C4 is present in all the cases; it supplies the trapezius muscle and we believe it contains motor fibres. The accessory nerve gives a branch in the neck in only one case. The accessory nerve joins the deep branch of C4 in 93.3% of the cases. Clinical implications of the findings would be discussed.

The purpose of this study was to evaluate and compare peripheral nerve regeneration following the use of alternative non neural materials to traditional direct repair techniques and autologous nerve graft. Autologous vein and synthetic polytetrafluoroethylene (PTFE) segments were used to repair standardized defects of the tibial nerve in rabbits. The materials served as sheaths for direct primary repairs and as conduits to bridge a gap in the nerve. Evaluations performed at five months revealed that direct primary repairs ensheathed by vein segments produced a significantly greater number of axons regenerating across the repair site, whereas PTFE, either as a sheath or conduit, failed to improve axonal regeneration. Also, vein conduits used to bridge nerve gaps was less effective than traditional nerve grafts.

This paper is a retrospective clinical review of flexor tenolysis performed on 23 digits for restricted active flexion following open and closed hand injuries. Based on Strickland’s¹³ grading scale, over 90% of digits had an excellent or good result at three months. No digits lost range of motion and there were no tendon ruptures. Importantly the active range of motion was much improved at three months compared with the initial postoperative assessment. This review reinforces the benefits of continuing dedicated hand therapy for at least three months and confirms the usefulness of flexor tenolysis as a salvage procedure in a carefully selected patient population.

The author’s 30 years experience with long grafting procedure is presented and the essentials of the technique are outlined. When both flexor tendons are cut in Zone 2, secondary repair using long graft gives the possibility of better results than the conventional tendon grafting, when scarring exists in the palm.

Ulnar Median Claw following trauma or Hansen’s disease is a fairly common problem in developing countries. The methods for correction of this deformity use a relatively arbitrary method for estimation and application of tension to the transferred tendon. The present paper outlines an objective and simple method of judging the tension required in these transferred tendon slips.

From April 1987 to February 1995, 188 amputated fingertips in 156 cases were replanted. 177 fingertips survived (94.3%). The follow-up time ranged from 12 to 36 months. The cosmesis and functions of the replanted fingertips were excellent.

Six cases of greater arc injury, defined as a perilunate dislocation of the carpus with a fracture of at least both the scaphoid and the capitate, were treated by open reposition and both internal and external fixation. Revascularisation of the capitate by implantation of the first dorsal intermetacarpal artery was attempted in three cases. At a mean follow-up of six years and four months, all patients complained of residual pain in the wrist. Carpal mobility and grip strength were reduced, and all patients showed mild or moderate arthritic changes. Progressive cartilage damage over the proximal pole of the capitate seems to be a determining factor in the outcome. Open reposition and both internal and external fixation are recommended in order to possibly diminish the incidence of arthritis and minimise secondary carpal instability.

Because the distal radioulnar joint (DRUJ) is a weight-bearing joint, surgical procedures treating DRUJ instability must be evaluated accordingly. Biomechanically, such procedures can be viewed from two approaches: One that preserves DRUJ biomechanics, which includes Groups A (intracapsular anatomical reconstruction) and B (ulnar shortening alone); and another that radically alters DRUJ biomechanics, which includes Groups C (tendon sling) and D (resection of ulnar head). This study compared the results of these two approaches.

Sixty-four patients having DRUJ surgery between 1984 and 1993 met the inclusion criteria of painful dorsal dynamic DRUJ instability, no DRUJ arthrosis, and no ulnocarpal impingement. However, only 25 returned for follow-up examination (Group A, 14 patients; B, 3; C, 2; D, 6). Grip strength, instability, pain, ROM, and satisfaction were scored.

The total scores of Groups A and B combined were significantly better than those of Groups C and D combined. Scores for pain with lifting weight and for instability in the combined Groups A and B were significantly better than those in the combined Groups C and D.

Although the number of patients who returned for follow-up was small, the significantly better scores achieved by the groups whose procedures preserved DRUJ biomechanics (anatomical reconstruction or ulnar shortening), indicate that these procedures may be the treatment of choice over the techniques that radically alter the DRUJ biomechanics (tendon slings or ulnar head resection).

A patient with bilateral absence of flexor pollicis longus received 2 stage tendon transfers with pulley construction strengthening both thumbs and obtaining adequate IP joint motion with improved dexterity.

This paper reviews the various techniques and procedures available for reconstruction of the digits to restore form and function in the aplastic hand. The author presents his own experience and discusses future trends in the management of missing digits.

This paper presents an operative technique of syndactyly release (syndactylysis) without skin grafting. A series of 31 cases, of simple, complex and complicated syndactylies are presented with a mean follow-up of 4.4 years. The results demonstrate that a good outcome can be reliably obtained by syndactylysis without the use of skin grafts.

In most places the surgical and rehabilitative management of tetraplegic patients is done on an ad hoc basis. We believe that the best interests of these unfortunate patients can only be served by a comprehensive surgical and rehabilitative management protocol through a dedicated team of professionals.

The surgical protocol should be a basic standard programme known to the whole team. Depending on the patient's basic needs, variations to this basic surgical programme could be worked out.

We propose a basic surgical programme for the mid-cervical tetraplegic patient in order to get rid of cumbersome external splints during the rehabilitative period. Substituting surgical procedures for external splints has become known as “internalisation of splints”. These include:

1. Motorising elbow extension using an improved bone-to-bone posterior deltoid to triceps tendon transfer.

2. Motorising forearm pronation by rerouting biceps tendon around radius.

3. Motorising thumb and finger extension, using M. brachioradialis.

4. Metacarpophalangcal finger flexion, using flexor digitorum superficialis tendon Zancolli lasso procedure (tenodesis effect).

5. Motorising distal interphalangeal finger joint flexion, using extensor carpi radialis longus transfer.

6. Thumb pinch/adduction against the fingers, rerouting flexor pollicis longus tendon to extensor carpi radialis brevis tendon, end-to-side.

7. Thumb stabilisation procedures on any one or two thumb joints.

The above procedures contribute greatly to the independent function of the patient. Careful preoperative assessment and prerequisites include the patient’s needs, patient’s motivation, muscle power and endurance and important “trick movements”.

This paper first describes the usual sequence of the structural changes affecting the wrist and the matacarpal arch in rheumatoid arthritis. Acccording to this sequence, four different types of wrist deformities and two different types of metacarpal arch deformities are determined and their specific features are presented. Treatment options are mentioned for each type, and the author’s preferred treatment is discussed in more detail.