The Journal of Hand Surgery (Asian-Pacific Volume)

Background: Antithrombotic therapy following replantation remains controversial, and the survival of replanted digits is affected by various other factors, such as the state of vascular damage and the surgeon’s level of skill. The present study’s aim is to obtain clinical evidence for postoperative antithrombotic therapy in replantation, with antithrombotic therapy being the only variable.

Methods: This was a single-center retrospective study of patients who underwent replantation of a completely amputated digit by the same surgeon. The subject sample included 17 patients/19 digits (group A) in whom heparin and prostaglandin E1 (PGE1) were used postoperatively during a 1-year period, 19 patients/22 digits (group B) in whom heparin was not used postoperatively but PGE1 was used for a 1-year period, and 16 patients/19 digits (group C) in whom neither heparin not PGE1 were used postoperatively for a 1-year period.

Results: Patient background and surgical procedure were not significantly different among groups, and only the postoperative use of heparin and/or PGE1 showed differences. Incidence of arterial occlusion, venous occlusion, or vascular spasm were not significantly different among groups (arterial occlusion: 1 digit in group A, 2 in group B, and two in group C, p = 1; venous occlusion: 1 digit in group A, 2 in group B, and three in group C, p = 0.67; vascular spasm: 1 digit in group A, 2 in group B, and one in group C, p = 1). Postoperative bleeding was significantly more common in the group using heparin (7 patients in group A, 0 in group B, and zero in group C, p < 0.001).

Conclusions: These results suggest that heparin and PGE1 administration do not improve impaired blood flow following replantation. Considering the potential complications, heparin and PGE1 following replantation do not seem necessary.

Background: Tooth knuckle injuries can be expensive to treat and may necessitate amputation in some cases. Several limitations exist in the literature regarding our knowledge around the factors predicting amputation and the need for multiple debridements in treating this injury.

Methods: A historic cohort study of 321 patients treated for tooth knuckle injuries was undertaken. Twenty-one demographic, clinical and laboratory variables were collected. Two outcome measurements were collected - the need for amputation and the need for more than one surgical debridement. A multivariate logistic regression was performed to determine the relationship between the predictor variables and the outcome measurements.

Results: Of the 321 patients examined, 1.6% required amputations and 25% required multiple debridements. Osteomyelitis was found to be a major predictor for amputation in these patients (OR = 35). Delayed presentation (OR = 1.1) and diabetes (OR = 2.6) were found to significantly increase the risk of requiring multiple debridements.

Conclusions: Our models were able to predict what patients were at the greatest risk for amputation and multiple debridement. Reducing rates of osteomyelitis and delays in presentation may help reduce the incidence of amputation and reoperation in this injury.

Background: Literature provides little and controversial evidence regarding the influence of ulnar variance (UV) on the incidence of scaphoid fractures. The aim of this retrospective study was to assess UV in a large number of patients with acute scaphoid fracture in comparison to a control group of the same population.

Methods: During a two year period, 182 patients with acute scaphoid fractures (fracture group) and 182 ethnicity-, gender- and age-matched patients with wrist contusions (control group) were treated in three non-university hospitals. Using standardized digital wrist radiographs, UV values were measured by means of the method of perpendiculars by two independent examiners. The UV values of the fracture group were then compared to the UV values of the control group.

Results: Analyses of the agreement between the two raters resulted in a good to excellent inter-item correlation of 0.89, with a high intra-class coefficient of 0.93 (95% confidence interval: 0.87–0.95). Mean (SD) UV value was -0.82 mm (1.77) in the fracture group and 0.27 mm (1.44) in the control group. Paired sample t-test showed a significant difference between the two groups (p < 0.0001).

Conclusions: According to this study, patients with scaphoid fractures are significantly more likely to show a negative UV than matched patients with wrist contusions.

Background: Patients with some thumb polydactyly subtypes are regarded as having a high risk of secondary deformities or poor treatment outcomes. Radially deviated type is one of these subtypes, but its characteristics and definitive treatment outcomes remain unclear. This study aimed to evaluate the pre- and intraoperative findings and surgical outcomes of this subtype.

Methods: We identified eight patients with unilateral and proximal phalanx-type polydactyly. The mean age at surgery was 14.6 months, and the mean follow-up period was 7.2 years. We investigated the patients’ initial radiograms, surgical procedures and findings, changes in alignment of the retained thumb, and postoperative outcomes using the Japanese Society for Surgery of the Hand scoring system.

Results: Although the gross appearance of the thumb was a radial deviation, there was an ulnar deviation at the metacarpophalangeal joint on radiography. The ulnar proximal phalanges were delta phalanges in three patients and were connected with the radial proximal phalanges by cartilage in five patients. We retained the ulnar thumbs in all patients and corrected the alignment in seven cases; open wedge osteotomy was performed for three patients with a delta phalanx, and tendon transfers from the radial to ulnar thumb were performed for the other four. The mean outcome score was 17.6/20, with one patient with excellent, six with good, one with fair, and none with poor scores. One patient experienced recurrent radial deviation around the interphalangeal joint five years after surgery and underwent corrective osteotomy, but the other patients maintained good alignment.

Conclusions: Radially deviated thumb polydactyly is not simply radially deviated; the shape of the proximal phalanx of the ulnar thumb is important to determine the surgical procedure. However, our results indicated that the alignment is almost manageable, and the surgical outcome was comparable to that of patients with a proximal phalanx-type thumb polydactyly.

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: This study aimed to identify the effect of the progression of postoperative wrist osteoarthritis on 5 years clinical and radiological outcomes after volar locking plate fixation of distal radius fractures.

Methods: Altogether, 56 patients with distal radius fractures were followed up 5 years after surgery. Clinical assessment was performed using the Mayo modified wrist score, a visual analogue scale of pain, the Japanese version of the Disabilities of the Arm, Shoulder, and Hand score, and Patient-related wrist evaluation. Standardized wrist radiographs were used to assess wrist morphology and the Knirk and Jupiter’s degree of osteoarthritis. Multivariate logistic regression was used to analyze postoperative morphological changes in the wrist and carpal alignment regarding their correlation with progression of wrist osteoarthritis.

Results: Progression of postoperative wrist osteoarthritis was recognized in 37 of the 56 cases (66.1%). Compared with the clinical outcomes at the time of the fracture union completion, almost clinical outcomes improved up to 5 years follow-up time as well as at 1 year after surgery. The range of wrist flexion at 5 years follow-up was significantly less in the progressive osteoarthritis group than in those with non-progressive osteoarthritis. The persistent step-off immediately after surgery significantly affected the postoperative progression of wrist osteoarthritis. Changes in the radial inclination, volar tilt, and radioscaphoid angle correlated with progression of wrist osteoarthritis. The highest correlation was with the change of radioscaphoid angle.

Conclusions: Good clinical results were maintained at 5 years after surgery, but progression of postoperative wrist osteoarthritis interfered with improvement of wrist flexion. Change in the radioscaphoid angle was the factor that was most highly correlated with progression of postoperative wrist osteoarthritis.

Background: To date, little is known about the characteristics of highly cited studies in hand surgery compared with other orthopaedic subspecialties. We aimed to assess the position of hand surgery within the orthopedic surgery literature.

Methods: We conducted a bibliographic analysis using the Web of Science database to review 1,568 articles published between January 2012 and December 2012 in 4 relevant general orthopedic and 2 hand surgery journals. We used the number of citations within 3 years of publication to measure the impact of each paper. To analyze prognostic factors using logistic regression analysis, we extracted data on orthopedic subspecialty, published journal, location of authorship, and type of study for all articles. For clinical studies, we also recorded details on study design and sample size.

Results: Of eligible hand surgery articles (n = 307), the majority (62%) were case reports/series. Only 19% were comparative studies, comprising a significantly smaller proportion of comparative studies from other subspecialties in general orthopedic journals. Systematic reviews/meta-analyses generated a significantly higher number of average citations, whereas educational reviews were consistently cited less frequently than other study types (14.9 and 6.1 average citations, respectively). Being published in the Journal of Bone and Joint Surgery, American volume, having authorship in North America or Europe and Australia, focusing on subspecialties like hip & knee, sports, or shoulder, utilizing a comparative or randomized clinical trial study design, and having a larger sample size increased the odds of receiving more citations.

Conclusions: Clinical studies related to hand surgery published in general orthopedic journals are most often of lower quality study design. Having a larger sample size or using a comparative study or randomized clinical trial design can improve the quality of study and may ultimately increase the impact factor of hand surgery journals.

Background: Primary malignant tumours of the hand are extremely rare, with chondrosarcoma being the most common. We describe six consecutive cases of chondrosarcoma (CS) of the hand, with a follow-up of 12 months to 10 years after surgical intervention.

Methods: Five cases were primary tumors and one was secondary to Ollier’s disease. Mean age at diagnosis was 67.5 years (range 46 to 85 years) and three patients were males. The bone most commonly affected was the proximal phalanx (in 4 patients), followed by the metacarpal bone (3 cases in the other 2 patients). The first symptom was an increase in volume in five cases and a pathological fracture in one. The x-ray study showed signs of malignancy in two cases only. In the other four cases, CT and MRI studies were necessary to complete the diagnosis.

Results: Primary amputation was performed in two cases and intralesional curettage and cancellous bone autograft in four. Primary amputation was performed in two cases and intralesional curettage and cancellous bone autograft in four. We found three grade I/III CS and three grade II/III CS in the histological study. Local recurrences occurred in three patients, two being grade II/III CS. One of the three had undergone an initial amputation and underwent re-amputation, another had had curettage of the lesion and was amputated, and the third patient decided not to undergo the procedure due to her age. A pulmonary nodule was suspected at the most recent follow up in a fourth patient, who had been diagnosed with a grade II/III CS.

Conclusions: Although CS of the hand bones behaves as a locally aggressive lesion, it rarely metastasizes. Intralesional curettage with a cancellous bone autograft appears to be a good option in low-grade CS to preserve the function, keeping in mind the high rate of recurrence. Wide excision or amputation is recommended when severe joint deformity or soft tissue involvement interferes with hand function.

Background: To evaluate the treatment of severe dorsal fracture dislocation (DFD) injuries of the proximal interphalangeal joint (PIPJ) by open reduction, bone grafting and fixation with mini-hook plates.

Methods: Fourteen patients with extensive dorsal fracture dislocation of the PIPJ were operatively treated to reconstruct the fractured middle phalanx volar lip using a fabricated hook plate in conjunction with elevation and bone grafting of depressed articular fragments where present.

Results: Restoration of PIPJ articular anatomy and congruence by hook plate fixation permitted full-range mobilization of the joint during fracture healing, with an average arc of motion of 81° and an average loss of extension of 12.9° at a minimum of 6 months follow up. Hook plate treatment of PIPJ fracture dislocation restores articular anatomy and joint congruence at a single sitting and permits post-operative mobilization without the need for extension block splinting.

Conclusions: Our results demonstrate a good range of motion following treatment, however hardware removal and tenolysis was necessary in 36% of cases.

Background: The trapeziometacarpal joint is the second most common site of osteoarthritis in the hand and the most frequent one to require surgery. Arthrodesis of the trapeziometacarpal joint is recognized as one of the valuable technique but unfortunately there has been wide variation in the union rate. The purpose of this study was to evaluate a new arthrodesis technique involving a cross-shaped bone graft and locking plate fixation.

Methods: Eleven male patients diagnosed as Eaton’s stage III osteoarthritis of the trapeziometacarpal join were treated in our institute. The mean patient age was 62 years (range 50 to 80 years). At the day after surgery, physical therapy was started and free use of the hand was permitted.

Results: Patients showed radiographic evidence of trapeziometacarpal joint union after an average postoperative period of 8.3 weeks (range 6–12 weeks). The VAS pain score significantly decreased from 7.2 points preoperatively to 0.4 points after surgery. Mean side pinch strength increased significantly from 3.8 kg (53% compared to unaffected side) prior to surgery to 6.2 kg (86%). The DASH score improved from 38.6 (range 34.1–43.2) preoperatively to 17.0 (6.8–22.7) postoperatively.

Conclusions: These data suggested that our technique is a successful procedure for the trapeziometacarpal joint arthrodesis. Cross-shaped bone grafts have the advantages of restoring thumb length and providing internal stabilization, especially for rotational force. No complications arose at the bone harvest site of the iliac crest. The procedure seems to be technically demanding, particularly for adapting the bone graft to perfectly match the shape of the defect.

Background: The increasingly fashionable sport of motocross is practiced worldwide by millions of people, but there is very little in the literature regarding its associated injuries and their prevention. We therefore present the first comprehensive, prospective study looking at hand and wrist injuries resulting from motocross injuries in the UK.

Methods: Data was prospectively collected over a 5-year period (from 2010 to 2015) at our regional trauma unit. We exclusively looked at motocross riders. Injuries sustained via motorcycle were excluded from our study.

Results: During the period studied (five years), 615 injuries were collected, including 240 patients with 265 hand and wrist injuries. Most of injuries were sustained in male patients. The patient’s age range was from 4–78 years with most injuries occurring during the spring and summer months. A total of 96 (40%) patients required operative treatment. The most common injury pattern was distal radius fractures (n = 53, 20%), followed by metacarpal fractures (n = 38, 14%) and phalangeal fractures (n = 36, 13.5%).

Conclusions: This study shows the impact and incidence of related hand and wrist injuries. Motocross is a globally fashionable sport. This study shows that the number of annual tournaments and racers have doubled in last 5 years. The number of hand and wrist related injuries and operative requirements have quadruples over the last five years. It is recognized as a high-risk sport despite the use of protective equipment and course adaptions. These injuries can have implications for nearby treating hospitals.

Background: Some cases treated with open palm technique need relatively long wound healing time. This study aims to clarify whether the preoperative lifestyle-related diseases or factors are associated with surgical results after the open palm technique for Dupuytren’s contracture.

Methods: The study included 122 fingers of 84 hands of 84 consecutive male patients with Dupuytren’s contracture who were treated with McCash’s open palm technique at our hospital from 1980 to 2016. The average age of the patients was 68.0 years (range, 39–86). The follow-up period was at least 6 months (average, 36.3 months). Using multiple regression analysis, we investigated preoperative factors associated with surgical results. The factors examined were age, affected side, contracture of the little finger, number of contracted fingers, contracture of the proximal interphalangeal (PIP) joint, Meyerding classification, diabetes mellitus, hypertension, alcohol intake, and smoking. Surgical results were judged at 6 months after surgery and wound healing time was evaluated.

Results: According to Tubiana’s criteria, there were 59 excellent hands (70.2%), 18 good hands (21.4%), 5 fair hands (6.0%), and 2 poor hands (2.4%) at the final physical examination after surgery. The average of the percentage of improvement in contracture was 86.1%. The average number of days needed until complete open wound closure was 22.9 days. Multiple regression analysis revealed that the significant preoperative factors associated with the percentage of improvement in contracture were multiple contracted fingers and involvement of PIP joint contracture, and that the factor associated with delayed wound healing was current smoking.

Conclusions: Multiple contracted fingers and involvement of PIP joint contracture are associated with insufficient improvement of joint contracture. Current smoking is associated with delayed wound healing, but not with improvement of joint contracture, after the open palm technique for Dupuytren’s disease in men.

The Journal of Hand Surgery Asian-Pacific Volume (JHS-AP) has retracted the above paper from its March 2019 issue (Volume 24, Number 1, pp. 72-75). The Editor-in-Chief of JHS-AP received a letter from the corresponding author asking for withdrawal of the above paper due to the violation of research ethics. Below are the contents of the letter sent by the corresponding author. The online version of the above paper (https://doi.org/10.1142/S2424835519500139) has been removed form the JHS-AP webpage and all hosting service providers have been informed of this move.

Background: Strong surgical repair is the mechanical basis of early mobilization and prerequisite for biological healing following tendon grafting. Side to side and pulvertaft repairs were developed to meets these demands. However, these techniques have later been modified to improve the strength of repair but their characteristics have not been compared.

Methods: We compared biomechanical strength of the modified side-to-side (SS) repair with the modified Pulvertaft (PT) repair technique in turkey tendons keeping overlap length, anchor points, type of suture, suture throw and amount of suture similar. Two investigators performed 34 repairs during one summer month to test the tensile strength of the repair using mechanical strength testing machine. Variables measured were maximum load, load to first failure, modulus, load at break, mode of failure, site of failure, tensile strain, tensile stress. The statistical comparison was carried by Levene’s test and T test for means.

Results: The mean maximum load for modified SS repair was 50.3 (SD 13.7) N and modified PT repair was 46.9 (SD 16.4) N. The tensile stress at maximum load for SS and modified PT repair was 4.7 (SD 4) MPa and 4.2 (SD 3) MPa respectively. The suture cut through was the commonest mode of failure.

Conclusions: We found no statistical difference between 2 repairs in load at which they started failing (p = 0.16), and maximum load repairs could withstand (p = 0.35). Our study uniquely compares two techniques under standard conditions, and contrary to existing evidence found no difference. However, in our opinion the number of anchor points may have a greater impact than number of weaves on the strength.

Background: The single looped suture modified Lim/Tsai technique is widely used for flexor tendon repairs. It has been shown to possess better biomechanical properties and require less repair time per tendon as compared to the double looped suture original Lim/Tsai technique. However, there is no clinical data on the modified technique.

Methods: The retrospective study included zone 2 flexor tendon repairs made using the modified Lim/Tsai technique from January 2008 to December 2014. Clinical outcome was assessed using the revised Strickland and Glogovac criteria, which categorises repairs based on the total active motion of the repaired digit.

Results: Sixty-two patients with 74 digits were included. The overall mean total active motion was 122°. The overall satisfactory outcome of the modified Lim/Tsai technique was 81.1%. The rupture rate of the modified Lim/Tsai technique was 2.7%. Using multivariate linear regression model, we found that outcomes were negatively influenced by subzone 2C and crush/saw injuries, but not by concomitant neurovascular injuries or post-operative follow-up duration.

Conclusions: Based on this retrospective study of patients with zone 2 flexor tendon injuries, the clinical outcomes of modified and original Lim/Tsai techniques are comparable. As such, there is no clinical evidence favouring one over the other.

Parkes Weber Syndrome (PWS) is a congenital disorder characterized by the presence of arteriovenous malformations (AVMs) in upper or lower extremities. We herein present a 35 year-old male with PWS with complex AVMs in the right upper extremity; he had been previously treated with multiple sessions of vessel embolization, sclerotherapy and AVM resections. The patient presented to our clinic with two month history of progressive hand ischemia, digit necrosis and infection. Angiography was performed demonstrating numerous AVMs and filiform flow through the ulnar artery with poor opacification of arterial structures in the hand. Because of advanced ischemia, soft tissue infection and osteomyelitis, a distal forearm amputation was indicated. Hand threatening ischemia secondary to steal phenomenon associated to AVMs in PWS is rarely encountered and reported. This case illustrates a complex clinical presentation with advanced disease that required limb amputation.

Acute compartment syndrome of the forearm secondary to hematoma without direct trauma has been reported rarely. We report a case of acute compartment syndrome of the forearm following a hematoma after playing golf. A 55-year-old man felt pain in his left forearm while playing golf that gradually worsened. He could not continue to play and visited the emergency department of our hospital. The radial side of his left forearm was markedly swollen on presentation, and he suffered severe pain that worsened with ulnar flexion of the wrist; no paralysis or hypesthesia was observed. A hematoma in the brachioradialis was seen on magnetic resonance imaging, and radial compartment pressure was 120 mmHg. A diagnosis of acute compartment syndrome was made, and urgent fasciotomy was performed. The patient recovered with no dysfunction of the arm.

We report a rare case of radial dislocation of the extensor tendon over the metacarpophalangeal (MCP) joint of the thumb. Ulnar dislocation has been reported, but previous reports have not mentioned radial dislocation of the extensor tendon in the thumb. Radial dislocation of the extensor tendon of the thumb gradually progressed after cerebral hemorrhage and the patient could not extend MCP joint of the thumb. To resolve difficulty in extending the MCP joint, surgical centralization of the extensor tendon and partial resection of the flexor pollicis brevis (FPB) and abductor pollicis brevis (APB) insertions was performed. The patient recovered function of thumb extensors.

Combined simultaneous radial wrist extensor injuries, namely ipsilateral extensor carpi radialis longus (ECRL) and brevis (ECRB) avulsion fractures, are rare. While non-operative management with cast immobilization has been described, most recommend operative intervention in the acute setting. Surgical repair of chronic injuries, however, has received little attention in the literature. This case describes a 50-year-old male who sustained combined ipsilateral ECRL and ECRB avulsion fractures from the bases of the index and middle metacarpals. Five months after the initial trauma, he underwent surgical repair with lengthening of the tendons using a novel technique and suture anchor fixation. This case demonstrates that successful repair of this rare injury can be achieved with retracted extensor tendons in the chronic setting.

Few cases of humeral medial epicondyle nonunion develop to symptomatic condition. We report a pediatric case of distally displaced nonunion. At first, the palliative repair surgery was chosen due to irreduciblity of the epicondyle fragment at 10 years old. After 2 years and 3 months wait for maturation of ossification at the trochlea, the definitive surgery consisting of epicondylectomy and ligament reconstruction was performed. This is the first pediatric case of humeral medial epicondyle nonunion with an unossified trochlea which needed a two-staged surgery. We highlight the surgical plan aimed at anatomical ligament reconstruction focusing an isometric point of MCL.

Giant cell tumour of tendon sheath (GCTTS) is considered benign, but well known for its high recurrence rate. Bone involvement of GCTTS is not uncommon and closely related to local recurrence after surgery. Radiologic findings of bone involvement are pressure erosion, circumscribed cortical destruction and degenerative arthritis. The treatment involves complete resection of tumor including bone lesion. This case presents GCTTS of young male patient with multiple bone destructions of different state, treated by complete excision of the tumor and curettage of bone lesion.

We present the case of a fit and well 62-year-old male with Dupuytren's disease in the right hand who underwent percutaneous needle fasciotomy (PNF) for a moderate flexion contracture of the right little finger. 18 months later he developed a pain-free soft tissue swelling at the distal previous needling site. A fasciectomy procedure identified a cyst within the pre-tendinous cord, which was confirmed as a dermoid inclusion cyst on histological analysis. Dermoid inclusion cysts may occur in the hands at the site of penetrating trauma but we are unaware of any report of an inclusion cyst at the site of PNF surgery. We present this unique case of a dermoid inclusion cyst following percutaneous needle fasciotomy as a novel complication.

A 25-year-old man sustained a right-sided brachial plexus injury from a high-velocity motocross accident. Physical examination and electromyography were consistent with a pan-brachial plexopathy with no evidence of axonal continuity. The patient underwent a spinal accessory to suprascapular nerve transfer and an intercostal to musculocutaneous nerve transfer with interpositional sural nerve grafts. He recovered MRC 4/5 elbow flexion and MRC 2/5 shoulder abduction and external rotation. Twenty-two months post-injury the patient displayed a flicker of flexion of his flexor pollicis longus and flexor digitorum profundus to his index finger – he went on to recover a functional pinch. Thirty-six months post-injury the patient displayed a flicker of contraction in brachioradialis with motor unit potentials on electromyography. This case demonstrates that some patients may have capacity for functional recovery after prolonged denervation and highlights the potential impact of anatomical anomalies in the assessment and treatment of peripheral nerve injuries.

We report a case of complete laceration of both flexor tendons in the dominant ring finger of a young male caused by a closed volar fracture fragment of the proximal phalanx. Careful clinical examination, reasonable index of suspicion and ultrasound confirmation play a pivotal role in the diagnosis and surgical planning of this rare yet consequential injury. Good outcomes can be achieved from the surgical management and rehabilitation of both soft tissue and bony injuries when planning of surgical approaches and fixation techniques are facilitated by an accurate pre-operative diagnosis.