The Journal of Hand Surgery (Asian-Pacific Volume)

Background: Wide Awake Local Anesthesia No Tourniquet (WALANT) uses a mixture of lidocaine and epinephrine for anesthesia and has found great success in hand surgery. At the Philippine Orthopedic Center (POC), we still use local anesthesia along with a tourniquet which gives the patient pain and discomfort at the tourniquet site. This study aims to determine perioperative and post-operative pain, intraoperative bleeding and immediate clinical outcomes of patients using WALANT for surgical anesthesia for carpal tunnel release.

Methods: A case series of all patients who underwent carpal tunnel release under WALANT from April 2016 to September 2016 is presented. Those with concomitant trigger finger and de quervain disease which required release on the affected hand were also included. A tourniquet was on standby in case of uncontrollable bleeding. Intraoperative bleeding, pain NRS scores, and return to daily activity were noted.

Results: Thirteen patients were included in the study; 3 were male, 10 were female. Mean age was 58 years, Mean surgical time was 15 minutes. Twelve were reported to have “some bleeding” and one was reported to have “bleeding but was still manageable”. None of the surgeries were totally bloodless or had too much bleeding that necessitated a tourniquet. Pain NRS scores during injection of local anesthesia had a mean of 2. None of the patients felt pain during and immediately after the surgery. Average time return to daily activity was 6 days. No complications were noted.

Conclusions: Patients included in the study who underwent carpal tunnel release under WALANT did not experience pain associated with a tourniquet. Visualization of the field was adequate enough for the surgeons to do the surgery without the need for a tourniquet and with no associated complications.

Background: The aim of this study was to identify the risk factors for median nerve dysfunctions after volar locking plate (VLP) fixation for distal radius fracture (DRF).

Methods: We prospectively assessed the incidence of median nerve symptoms (MNS) such as numbness, pain, paresthesia, or hypesthesia in the area innervated by the median nerve and evaluated post-operative nerve conduction (NC) in 91 hands of 121 patients after VLP fixation for DRF. Multivariate logistic regression analysis was conducted to identify factors independently associated with MNS and abnormal NC in the injured wrist.

Results: There were 18 cases (20%) of MNS on the injured side, 9 hands (10%) of both MNS and abnormal NC, 11 hands (12%) with only abnormal NC, and 9 hands with only MNS. Sensitivity, specificity, and diagnostic accuracy of abnormal NC for diagnosing MNS were 50%, 86%, and 78%, respectively. Four cases did not respond to conservative treatment and received carpal tunnel release concomitantly with plate removal. Logistic regression examination revealed that volar placement of the plate and short stature were significant independent predictors of MNS, while patient age was the sole independent predictor of abnormal NC.

Conclusions: Our study demonstrated that plate prominence, short stature, and age were significant independent risk factors for median nerve dysfunctions after VLP fixation for DRF.

Background: This study investigated the functional outcomes of intramuscular ulnar nerve transposition (IMUNT) in young adults with cubital tunnel syndrome (CuTS).

Methods: This retrospective study enrolled 37 military soldiers on active duty diagnosed with and treated for CuTS to determine the compression sites, complication rate, and postoperative results. Patient outcomes were analyzed using the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and the Bishop–Kleinman rating scales.

Results: Patient outcomes were analyzed after a mean follow-up duration of 26.1 (22–29) months for 37 extremities. DASH scores improved from 38.7 (range, 13–63 points) preoperatively to 5.8 (range, 0–18 points) postoperatively. Patient improvement was statistically significant (p < 0.05). Based on the 12-point Bishop–Kleinman rating system, 30 (82.1%) patients were graded as excellent; five (13.5%) as good, and two (5.4%) as failed outcomes. Statistically significant improvements in both key pinch and grip strength were noted. Complications included one case of transient neuroparaxias of the medial antebrachial cutaneous nerve and one case of hematoma formation.

Conclusions: We consider intramuscular ulnar nerve transposition to be a satisfactory procedure for CuTS. The procedure enhances upper limb function, thus allowing the patients to resume their physically demanding work with minimal complications.

Background: The objective was to study the hypotheses that an advanced zone II flexor tendon rehabilitation protocol would avoid rupture, achieve a high range of excursion, and minimize interphalangeal contracture during both the early phases and at the conclusion of healing. We also proposed the null hypothesis of no difference between any two of the zone II subdivisions.

Methods: Fifty-one consecutive adult patients with zone II flexor tendon repairs of a single finger were retrospectively evaluated on an active contraction rehabilitation protocol with no splint, no tenodesis protection, and immediate full composite extension. There were 38 males and 13 females with a mean age of 39 years (range 18–69) involving 15 index, 7 long, 6 ring, and 23 small fingers. Repairs were located in flexor subzone IIA for 8 fingers; subzone IIB, 14; subzone IIC, 19; and subzone IID, 10. Differences in outcome between any two subzones were compared by T-test with p < 0.05.

Results: Mean active arcs of motion in degrees at 3 weeks post repair were PIP 1-93; DIP 0-44; and total active motion (TAM) 221. At 6 weeks PIP 2–98; DIP 1–51; and TAM 236. At 10–12 weeks PIP 1–101; DIP 1–56; and TAM 246. Final TAM by flexor subzone IIA was 243; IIB, 251; IIC, 246; and IID, 246. There were no significant differences between any two subzones. Mean final DASH score was 5. There were no ruptures.

Conclusions: The results support the hypotheses. Outcomes of the therapy protocol demonstrated the lack of interphalangeal joint flexion contractures, high range of total active motion achieved early and sustained, and no ruptures. No differences were identified between and two of the flexor subzones.

Background: Distal radius fractures are among the most common fractures encountered in orthopedic practices. If treated operatively, most implants are retained after the fracture heals unless there is hardware failure, limitation of wrist motion, pain, infection, tendon rupture, or tenosynovitis. Complications have been reported during hardware removal, including not knowing the exact implant prior to its removal. If a patient presents for plate removal to a surgeon who did not perform the initial fracture fixation, having a preoperative visual aid can help the treating surgeon choose the right instruments for their removal.

Methods: To identify many of the available distal radius fixation devices, we searched the Internet and contacted local industry representatives. We also approached industry personnel at the commercial exhibit of a national hand society meeting to provide us with implants they manufacture. The implants were placed on the volar and dorsal aspects of sawbone models of the distal radius and in one case the radial styloid, using the screws, screwdrivers and accessories in the standard implant set and then posteroanterior and lateral x-rays of the implants were obtained. We created an atlas and a list of the screwdriver(s) used for each.

Results: We obtained radiographs and photographs for 28 implants that were manufactured by 14 different companies. Two companies sent us radiographs and photographs placed on either a sawbone or cadaveric model. We found that 7 of the implants were outliers and could be identified easily on the x-rays, whereas 21 implants had similar design of shaft and distal components.

Conclusions: To aid the orthopedic surgeon in their removal, we compiled a comprehensive list of most distal radius fixation devices on the market including plates and their corresponding screws and screwdrivers. The goal was to help the surgeon when removing the plate to identify the implant on radiographs.

Background: Patients with ulnar-sided wrist pain and positive ulnar fovea sign are usually treated nonsurgically before surgical options are considered. However, the outcomes of nonsurgical management are unknown. Many of these patients also have unstable distal radioulnar joint, but there has been no comparison between the outcomes of these patients with stable and unstable distal radioulnar joint. The objectives of this study are to (1) determine the outcomes of nonsurgical and surgical treatment of patients with positive ulnar fovea sign, and (2) compare the outcomes of patients with stable and unstable distal radioulnar joint.

Methods: A retrospective analysis of the outcomes of patients with ulnar sided wrist pain and positive fovea sign was performed from March 2009 to December 2014. Outcomes were measured based on patient-reported pain improvement, grip strength and range of motion of the affected wrist before and after treatment. A total of 100 wrists in 98 patients were reviewed.

Results: 54% of wrists managed nonsurgically experienced pain improvement. 83% of wrists managed surgically experienced pain improvement. The mean grip strength increased by 2.8 kg and 2.7 kg, while the range of motion decreased by 14° and 5° after nonsurgical and surgical treatment respectively. When comparing patients with stable and unstable distal radioulnar joint, there were statistically more wrists with unstable distal radioulnar joint that experienced pain improvement after treatment.

Conclusions: The study showed that there is a role for nonsurgical treatment for wrists with positive ulnar fovea sign with more than half of the patients experiencing pain improvement. We also found that positive ulnar fovea sign patients with unstable distal radioulnar joint had better pain outcomes compared to those with stable distal radioulnar joint.

Background: Although there have been many studies of the vascularized bone graft (VBG) or unloading procedures alone for the treatment of Kienböck disease, little information has been reported about patients treated with VBG combined with unloading procedures. The purpose of this study is to 1) describe the outcomes in patients treated with VBG combined with unloading procedures, 2) compare the outcomes according to the unloading procedures and 3) find any radiologic parameters affecting revascularization in Kienböck disease.

Methods: A retrospective review was performed involving in 20 patients undergoing 4^th and 5^th extensor compartmental VBG with unloading procedures for Kienböck disease from 2010–2015. After VBG in all patients, unloading procedures were additionally performed depending on the ulnar variance. These additional operations included joint leveling procedures (radial and capitate shortening osteotomy) or temporary scaphocapitate pinning. Radiologic outcome was evaluated according to Lichtman stage and presence of revascularization evidence. Clinical evaluations included wrist range of motion, grip strength, visual analogue scale (VAS), and Mayo wrist score.

Results: VBG with joint leveling procedures was performed in 11 patients (5 radial shortening and 6 capitate shortening) and VBG with temporary scaphocapitate pinning was performed in 9 patients. Although clinical outcomes were not significantly different according to the unloading procedures, there were significantly more patients with evidence of healing of osteonecrosis on radiographs in joint leveling procedure group than temporary scaphocapitate pinning group. Overall, evidence of healing of osteonecrosis was found on plain radiographs in 11 patients and was not found in 9 patients. However, there were no significant preoperative radiological parameters affecting revascularization on radiographs.

Conclusions: Not all patients had evidence of revascularization on radiography after VBG combined with unloading procedures for Kienböck disease. However, among the unloading procedures, joint-leveling procedures positively influenced the revascularization process.

Background: The role of early radiographic imaging in the management of distal radius fractures (DRFs) is unclear. The aim of this study was to assess whether early post-operative radiographs for DRFs influences the ongoing management of this patient group. We hypothesize that routine early radiographs do not influence the management of DRFs.

Methods: This was a retrospective review of patients undergoing open reduction and internal fixation using a volar locking plate between 2012 and 2017 at our institution. Patients were identified using hospital electronic databases. Clinical information was gathered from the electronic health records and PACS systems and analysed on a spreadsheet. An early post-operative radiograph was defined by the authors as imaging on a patient’s first postoperative visit.

Results: 237 patients were identified. The median number of days patients were reviewed post-operatively was 13 (interquartile range 9–16). 172 (73.1%) patients had early post-operative radiographs, with 100 (58.1%) intra-articular and 72 (41.9%) extra-articular fractures. Of patients who underwent imaging, 7 (4.0%) had their post-operative fracture management altered (7 intra-articular, 0 extra-articular) with 1 (0.58%) requiring immediate surgical revision as indicated by imaging.

Conclusions: Our study questions the value of routine early post-operative radiographs in the management of distal radius fracture fixations, in particular if the fracture is extra-articular. This is of importance in the setting of constrained resources and represents a poor use of limited healthcare facilities, as well as unnecessary radiation exposure.

Background: Scapholunate dissociation (SLD) is a common and sometimes disabling ligamentous injury of the wrist. The aim of the treatment is to restore carpal alignment and to prevent joint degeneration. In the current study, we reported mid-term results of our technique using suture anchor fixation within the SL interface.

Methods: Nine male patients with an average age of 35 years underwent scapholunate suture anchor fixation (SLAF) for chronic and symptomatic dynamic or reducible static SLD from 2011 to 2016 with a mean follow-up of 36 months. After dorsal wrist exposure, a 2.8 mm suture anchor was inserted in the dorsoproximal lateral articular surface of the lunate bone. The two ends of the sutures were passed through the two divergent canals in the scaphoid. The sutures were tied over the tuberosity after reducing the SL alignment. Two K-wires supported SL and scaphocapitate (SC) alignment for 8 weeks. Radiographic parameters, wrist range of motion and grip strength were measured. Quick-DASH and Modified Mayo Wrist Score (MMWS) were used to assess the functional outcome.

Results: The grip strength and passive motion reached to 75% and 88% of the other side, respectively. The SL gap was 5.4 mm, 2.6 mm and 3.4 mm before surgery, after pin removal, and on the follow-up stress radiographs, respectively. The SL angle was 82, 52 and 65 degrees at any time point, respectively. Average Quick-DASH score was improved from 60 to 25. According to MMWS score, one patient was excellent, one was good, five were fair, and two were poor.

Conclusions: SLAF is a simple technique with minimal soft tissue manipulation that enables correction and maintaining of the carpal alignment with favorable mid-term results.

Background: The objective of this retrospective study was to evaluate the outcomes of ulnar stump stabilization after ulna head resection using the FCU tendon by investigating the rate of postoperative extensor tendon rupture and click on forearm rotation.

Methods: Wrist synovectomy (distal radioulnar joint (DRUJ), radiocarpal and midcarpal joints) and ulnar head resection combined with ulnar stump stabilizing procedure were performed in 58 wrists of 53 patients with RA in our hospital. Before operation, the dorsal subluxation ratio (DSR) of the ulnar head was measured with a multi-slice computed tomography (CT) images. The stabilization of ulnar stump after head resection was performed by the value of the DSR or the instability before the operation.

Results: There was neither extensor tendon rupture nor click on forearm rotation in all the patients. Smooth forearm rotation was achieved by ulnar head resection and stabilizing procedure for the ulnar stump. The active range of forearm supination and pronation increased significantly from 68° ± 23° (mean ± SD) to 80° ± 10°, and from 69° ± 17° to 74° ± 13°. The grip power increased from 117 ± 62 mmHg to 185 ± 55 mmHg. In the assessment using 3DCT, the preoperative DSR of 54% improved to 8% on the whole (n = 58). In the wrists with extensor tendon rupture (n = 36), the preoperative DSR of 58% improved to 12%. In the wrists without tendon rupture (n = 22), the preoperative DSR of 46% improved to 2%.

Conclusions: The operative technique of ulnar stump stabilization using the FCU tendon was one of the suitable procedure to prevent complications after ulnar head resection.

Background: The purpose of this study was to develop a reproducible upper limb swelling model and quantify the efficacy of changing elevation posture in swelling reduction using this model.

Methods: A manual sphygmomanometer was applied to healthy volunteers’ upper arms while in a dependent position for 25 minutes to create venous congestion and swelling. Seven different levels of pressure (250, 120, 100, 80, 50, 40 and 30 mmHg) were tested. Every 5 minutes, the level of swelling was measured using the volumetric method. Any complications were recorded. We then compared the swelling reduction potential among 3 limb postures (arm on head, elevation brace, and simple sling). The significance level was set at p < .05.

Results: Thirty to forty milliliters of swelling was created for all pressure levels except the 250 and 30 mmHg. All complications including transient nerve palsy, pain and petechiae were severe at 250 and 120 mmHg, less severe at 100 mmHg, mild at 80 mmHg, and absent below 40 mmHg. Both the on head and elevated brace limb postures markedly and significantly decreased swelling greater than the simple sling posture.

Conclusions: We found that 20 ml or greater swelling can be reliably created with a blood pressure cuff inflated to 40 mmHg on the upper limb. The on head and elevated brace postures demonstrated a greater degree of swelling reduction than the simple sling posture.

Background: The objective of this paper was to determine the validity, reliability and internal consistency of the translated FILIPINO DASH (FIL-DASH) questionnaire in patients with traumatic brachial plexus injuries.

Methods: Thirty-five adult patients with traumatic brachial plexus injury were enrolled in the validation stage. The same questionnaire was given to the patient between 7 to 14 days for the test-retest reliability. The validated Filipino version of the SF-36 was used as the gold standard to determine the construct validity of the translated DASH. We also compared the DASH score with the SF-36 total and subscale, validated Brief Pain Inventory Severity and Interference Scale and the Visual Acuity Scale (VAS) for Pain.

Results: The internal consistency was adequate, with Cronbach’s Alpha for the 30 items of 0.93 and an average inter-item covariance of 0.399. The test-retest reliability was 0.87 (p < 0.001). There was no significant difference in establising the validity of the translated DASH against SF-36 total and Subscale, validated Brief Pain Inventory Severity and Interference Scale and the Visual Analogue Scale (VAS).

Conclusions: The translated DASH (FIL-DASH) questionnaire was internally consistent and showed no difference in testing for test-retest reliability and validity against functional outcome measures and pain scales validated for adult Filipinos.

Background: The purpose of this study was to determine whether baseline characteristics predict outcomes twelve weeks after open reduction and internal fixation of proximal phalangeal fracture.

Methods: A cohort of patients (n = 48, mean 35 years; SD 11) commencing outpatient rehabilitation within one week of surgery were reviewed. Outcomes of interest were active PIP extension; active total range of motion; pain at rest; comprehensive pain; strength; and hand use (reported difficulty performing specific activities such as turning a door handle, as well as usual activities including housework and recreation) at twelve weeks. Possible predictors included which finger is injured, whether the fracture is intra or extra-articular, whether the dominant or non-dominant hand is injured and/or how much pain is experienced in the first post-operative week. Multiple linear regression was performed to produce a model of the prediction for each outcome of interest at Week 1 (baseline).

Results: Results from multivariate linear regression analyses suggest that pain at rest at baseline was significantly predictive of pain at rest (OR = 1.25, 95% CI = 1.06–1.47), p = 0.01), comprehensive pain (OR = 3.18, 95% CI = 1.47–6.84, p = 0.01), and hand use (OR = 2.38, 95% CI = 1.18–4.80, p = 0.02) twelve weeks after open reduction and internal fixation of proximal phalangeal fracture. The turning point on the receiver-operator characteristic curve of false versus true risk (AUC = 0.94, p = 0.04) indicated that at least a score of 4.5 on the 10 cm visual analogue scale for baseline resting pain was needed for significant likelihood of reduced hand use. Which finger was injured, location of fracture and side of injury were not predictive of any outcomes.

Conclusions: Moderate to high levels of resting pain in the week following surgery for proximal phalangeal fracture is predictive of pain and hand use at twelve weeks. Moderate to high levels of resting pain should be recognised as unusual, and could be targeted in rehabilitation. Further prospective studies are needed to determine whether early identification and targeted intervention to reduce pain improves outcomes at 12 weeks.

Background: To compare outcomes of atraumatic hand surgeries using the WALANT technique versus intravenous regional anesthesia or local anesthesia with tourniquet.

Methods: We conducted a comprehensive literature search using PubMed, MEDLINE, Embase, and Cochrane Library from inception to October 2018. All randomized or quasi-randomized trials and cohort studies comparing WALANT procedure versus local anesthesia or intravenous regional anesthesia with tourniquet among atraumatic hand surgeries were included. Methodological quality and risk of bias of eligible studies were assessed by three independent reviewers. The random effects model was used due to both statistical and clinical heterogeneity among studies.

Results: The search yielded 496 records, of which 9 studies were included in the systematic review. We were able to pool findings for operative time, post-operative pain scores, patient satisfaction, and complication rates. On the average, the WALANT group had longer operative times by 2.06 minutes (pooled mean difference, random effects, 95% confidence interval 0.46 to 3.67 minutes, p = 0.01, I² 0%, p = 0.66). The post-operative pain scores were lower in the WALANT group by an average of two VAS points (random effects, pooled mean difference −2.40, 95% confidence interval −3.41 to −1.38, p < 0.00001; I² 0% p = 0.99). We had insufficient evidence to demonstrate a difference in terms of patient satisfaction (random effects, pooled risk ratio 0.98, 95% confidence interval 0.93 to 1.03, p = 0.36, I² 0%, p = 0.64) and complication rates (random effects, pooled risk ratio 0.40, 95% confidence interval 0.07 to 2.18, p = 0.29, I² 60% p = 0.08) between WALANT versus conventional methods.

Conclusions: The WALANT group reported lower post-operative pain scores, but had slightly longer operative times. There are no significant differences between WALANT and conventional methods in terms of patient satisfaction and complication rates.

We report a case of a symptomatic forearm deformity due to a premature distal ulnar fracture solved by 3D custom made cutting guides. Our patient is a sixteen years old girl referred to us due to a forearm deformity and a dysplasic ulnar head associated to pain at the dorsum of the distal ulna and at the radial head at the elbow. Using custom-made cutting guides on a 3D model, a both bone forearm osteotomy was performed. At 18 months of follow up, the range of motion did not improve significantly but our patient referred no pain and she was satisfied with the procedure. The accuracy of single cut osteotomies, utilizing three-dimensional planning and custom patient guides has been previously established. This technique helped with the pain in our case.

One of the serious complications of Seymour fractures is infection. A 24-year-old male presented with the open infected distal phalanx fracture of the middle finger. Wound debridement, irrigation, use of antibiotics and external fixation with the aid of mini-Ilizarov provided a resolution to the infectious process and enabled us to achieve a stable osseous union in correct position.

We present a case of compartment syndrome of the forearm following harvesting of a full thickness skin graft from the medial forearm for a double digit dermofasciectomy. The patient underwent forearm fasciectomy followed by multiple surgical debridements. At 18 months, despite intensive physiotherapy, the patient was left with a very significant residual functional deficit. This case highlights a previously undescribed but devastating complication of closure of a forearm skin graft donor site.

A 49-year-old female patient with carpal tunnel syndrome at both hands was performed open carpal tunnel release. 4 months later, on the left hand, severance of the thenar branch was found by electromyography. On the 138th day, re-exploration was performed for direct nerve repair. During exploration, we identified the transligamentous variation of recurrent motor branch. Direct nerve repair was successful. At 6 months after direct repair, the nerve function began to return. At 2 years after direct repair, the nerve function has almost returned. There are some variations on the recurrent motor branch. And we overlooked transligamentous variation when we perform more decompression around the median nerve. It is important that recognize variations of thenar branch when we perform carpal tunnel release for not occurrence of severance of thenar branch.