The Journal of Hand Surgery (Asian-Pacific Volume)

Forearm deformities are often seen in children with severe birth brachial plexus palsy (BBPP). They may be either a supination or a pronation deformity and both hinder normal use of the hand and parents often request for corrective surgery. However, the correction of these deformities can be challenging due to a paucity of options. Also, there is less information in literature on the management of forearm deformities in BBPP compared to the information with regard to nerve surgery or correction of shoulder deformities. This article presents a synopsis of incidence, pathogenesis, clinical presentation and parental concerns related to these deformities. The decision-making considerations, management strategies and outcome expectations are also discussed. Patient selection is very crucial, and the treatment plan must be individualised depending on the disability, parental expectations and existing motor power in the involved limb. Correction of both the deformities have different considerations; however, effective correction of these deformities is immensely satisfactory to the patient/parents in terms of improved function and appearance of the limb.

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 flexion contracture (FC) of the proximal interphalangeal (PIP) joint can have a profound negative influence on daily activity. The outcomes of surgical release of the PIP joint in literature are based on small sample size studies done several decades ago. The aim of this study is to report the outcomes of surgical treatment for post-traumatic FC of the PIP joint and to identify factors that affect these outcomes.

Methods: This single institute retrospective study included patients from 2000 to 2020. We only included patients with post-traumatic FC of the PIP joint. We evaluated the demographic characteristics, cause of FC, surgical approaches and the various procedures conducted. We surveyed postoperative complications. During the study period, we asked about their current symptoms and evaluated their operative outcomes as excellent, good, fair or poor through the phone.

Results: The average FC recovery angle was 37.3°. The small finger was the most affected, and the most common cause of FC was a tendon laceration. The volar plate complex release was the most frequently conducted procedure. The FC improvement was positively correlated to the degree of preoperative FC. The more severe preoperative flexion–extension arc was presented, the more FC recovery was achieved after operation. Patients who underwent multiple procedures had a higher degree of preoperative FC, and better correction was achieved with multiple procedures than with a single procedure. The most critical complication was recurrence.

Conclusions: We were able to obtain average 37.3° of extension by surgical treatment. The more severe the FC presented before surgery, the greater the need for multiple procedures, however, this resulted in a significant increase in joint extension. Nevertheless, caution should be exercised regarding recurrence and could occur even with an experienced surgeon.

Level of Evidence: Level IV (Therapeutic)

Background: The stent technique of microvascular anastomosis, in which a stent is placed in the vessel before creating the anastomosis, is useful for accurate anastomosis formation, but the manipulation involved in stent insertion into the vessel and withdrawal from the anastomosis still poses problems. In this study, a silastic stent containing a copper wire-bent in an L-shape was designed and its utility in microvascular anastomosis was investigated in rats.

Methods: Eighty end-to-end anastomosis procedures of the right femoral artery and vein were performed in rats. Anastomoses were conducted either by the conventional method (Method C) or using L-shaped silastic stents (Method L), with anastomosis condition assessed after one side had been sutured, at the completion of vascular anastomosis and on postoperative day 7.

Results: After one side had been sutured, suture errors were observed in three veins with Method C. At the completion of vascular anastomosis, impaired blood flow was observed in two arteries and two veins with Method C, and in one artery with Method L. On postoperative day 7, impaired blood flow was observed in one artery and one vein with Method C and in one vein with Method L.

Conclusions: The use of L-shaped silastic stents preserved the advantages of the stent technique while simplifying stent manipulation. This technique may help reduce the risk of intimal trauma.

Background: Total wrist replacement (TWR) is rarely done in the Asia–Pacific region. The aim of this study is to report the surgical outcomes and experience of TWR in patients with advanced arthritis.

Methods: This is a retrospective review of all TWR patients in the Department of Orthopaedics and Traumatology, Prince of Wales Hospital, Hong Kong, which is a university tertiary centre, from January 2004 to March 2023. Recorded demographic parameters include gender, age upon surgery, pathology, types of implants and follow-up period. The surgical outcome parameters include range of motion, grip strength, wrist function assessment, radiological and clinical complications and any related secondary operations. Postoperative X-ray and clinical notes were reviewed. All wrist function assessments were performed by specialised occupational therapists according to protocol.

Results: The study included a total of 12 wrists of 10 patients, all Chinese–Asian, with a mean age of 61.4 years at surgery. Larsen grade V arthritis constituted 50% and grade IV 16.7% of the patients, amongst which 33% had volar subluxation. The mean follow-up period was 97.4 months (21–205 months). The mean grip strength was 64.2% of the unaffected side. The mean postoperative Disabilities of Arm, Shoulder and Hand (DASH) score was 41.12% and patient-rated wrist/hand evaluation (PRWE) score 18.0. Complication incidence was 16.67% for loosening, 8.3% for metallosis and 8.3% for infection. One patient required conversion to total wrist arthrodesis due to metallosis. No patient suffered from dislocation, periprosthetic fracture and infection.

Conclusions: TWR is an effective and safe alternative to total wrist arthrodesis with comparable outcomes. Our series outcomes are satisfactory and in line with literature. With meticulous soft tissue release and balancing, volar subluxation can also be corrected and may not be a contraindication.

Level of Evidence: Level IV (Therapeutic)

Background: Replantation of digital tip amputations, especially Allen III and IV, is challenging for hand surgeons as it requires a high level of microsurgical expertise and fine instruments. The graft repositioning over flap (GRF) technique is a simple and reliable procedure that provides length, sensation and nail growth and GRF has become popular in the last few years. The aim of this study is to report the short-term outcomes of the GRF technique.

Methods: This is a prospective study of all patients who underwent a GRF reconstruction for Allen III and IV digital amputations at our hospital over a 12-month period. In addition to demographic data and injury details, we collected outcomes data with regard to flap and nailbed graft survival, capillary refill time, nail growth, sensation (2-point discrimination), bone union and gain in length of digit compared to length at injury.

Results: Twenty patients underwent GRF reconstruction of digital amputation. They included 18 men and 2 women with an average age of 29 years. The thumb was the most frequently injured digit (n = 7). Electric saws (n = 5) and industrial machines (n = 5) accounted for 50% of injuries. Twelve amputations were Allen IV. Five patients were lost to follow-up and outcomes data was available for 15 patients. There was loss of flap and nail bed in three patients. There was no growth of nail in three patients. The distal phalanx graft was lost in six patients and united in the remaining nine patients.

Conclusions: The GRF technique is a simple and reliable option in patients in whom replantation is not possible. It restores length, provides sensation and nail growth in the reconstructed fingers.

Level of Evidence: Level IV (Therapeutic)

Background: This study aimed to evaluate our preliminary results and experience with the arthroscopic dorsal ligamentocapsulodesis in managing occult dorsal wrist ganglion cysts (ODGCs) associated with scapholunate (SL) instability.

Methods: All patients who underwent arthroscopic dorsal ligamentocapsulodesis due to an ODGC with concomitant SL ligament tear were retrospectively reviewed. In addition to demographic data and length of follow-up, outcomes data that included range of motion, grip strength, modified Mayo wrist score (MMWS), complications and radiographs were collected.

Results: The study included 18 patients (18 wrists; 10 female and 8 male). The mean age was 32 years (range: 19–48) and the mean follow-up was 34 months (range: 24–48). The mean preoperative extension deficit decreased from 5.5° (range: 0°–20°) to 2.7° (range: 0°–15°) at the final follow-up (p = 0.004). The mean preoperative flexion deficits decreased from 4.4° (range: 0°–15°) to 2.2° (range: 0°–10°) postoperatively (p = 0.003). The mean hand grip strength significantly increased from 27.7 kg (range: 22–36) to 38.3 kg (range: 31–46) at the final follow-up assessment (p < 0.001). The mean MMWS improved from 46 (range: 25–65) pre-operatively to 91 (range: 70–100) at the final follow-up (p = 0.0002). No major intra- or postoperative complications were observed.

Conclusions: SL instability may have an important role in the aetiology of ODGCs, and arthroscopic dorsal ligamentocapsulodesis can provide pain relief and functional improvement without recurrence at the short- to mid-term follow-up in the treatment of ODGCs.

Level of Evidence: Level IV (Therapeutic)

Background: This study introduces a novel method for the management of closed metacarpal neck fractures. Kirschner wires (K-wire) are introduced in a retrograde and the wires withdrawn through skin proximally at the base of the metacarpal. The fracture is reduced using traction and the reduction is maintained by antegrade advancement of the K-wires. The aim of this study is to report the outcomes of this technique.

Methods: A total of 36 patients with severely angulated closed metacarpal neck fractures underwent reduction and fixation using this novel method from January 2017 to December 2020 in centres in Ireland and Saudi Arabia. We performed a retrospective review of these patients’ clinical data examining their outcomes.

Results: Six months postoperatively, all fractures demonstrated bony union and correction of angulation. All patients exhibited excellent range of motion (ROM) with no significant impairment of hand function.

Conclusions: The method detailed here is a simple, minimally invasive and reliable technique that has not previously been described. It is suitable for use in the management of closed metacarpal neck fractures of the fourth and fifth metacarpal, with dorsal angulation greater than 60°.

Level of Evidence: Level IV (Therapeutic)

Introduction: Dorsal fracture dislocations (DFD) of the proximal interphalangeal joint (PIPJ) are challenging fractures. A palmar surgical approach and plate fixation has a high complication rate, including flexor contractions, reduction of range of motion (ROM) and secondary need for plate removal.

Methods: We use the flexor tendon pulleys to cover the mini plate with the assumption that it may reduce the adhesion between the mini plates and the tendons and reduce postoperative complications. We present the outcomes of using this technique in eight patients.

Results: All patients had an excellent outcome at a mean follow-up of 17 months, and none required removal of the implants.

Conclusions: This study presents a surgical technique that may potentially reduce the high complication rate found after ORIF for treatment of DFD of the PIPJ. Therefore, improving the clinical outcomes after this type of surgery.

Level of Evidence: Level IV (Therapeutic)

Background: In brachial plexus surgery, a key focus is restoring shoulder abduction through spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer using either the anterior or posterior approach. However, no published randomised control trials have directly compared their outcomes to date. Therefore, our study aims to assess motor outcomes for both approaches.

Methods: This study comprises two groups of patients. Group A: anterior approach (29 patients), Group B: Posterior approach (29 patients). Patients were allocated to both groups using selective randomisation with the sealed envelope technique. Functional outcome was assessed by grading the muscle power of shoulder abductors using the British Medical Research Council (MRC) scale.

Results: Five patients who were operated on by posterior approach had ossified superior transverse suprascapular ligament. In these cases, the approach was changed from posterior to anterior to avoid injury to SSN. Due to this reason, the treatment analysis was done considering the distribution as: Group A: 34, Group B: 24. The mean duration of appearance of first clinical sign of shoulder abduction was 8.16 months in Group A, whereas in Group B, it was 6.85 months, which was significantly earlier (p < 0.05). At the 18-month follow-up, both intention-to-treat analysis and as-treated analysis were performed, and there was no statistical difference in the outcome of shoulder abduction between the approaches for SAN to SSN nerve transfer.

Conclusions: Our study found no significant difference in the restoration of shoulder abduction power between both approaches; therefore, either approach can be used for patients presenting early for surgery. Since the appearance of first clinical sign of recovery is earlier in posterior approach, therefore, it can be preferred for cases presenting at a later stage. Also, the choice of approach is guided on a case to case basis depending on clavicular fractures and surgeon preference to the approach.

Level of Evidence: Level II (Therapeutic)

Background: We treated distal radius fractures (DRFs) beyond the watershed line without fracture of the lunate volar rim using a volar locking plate (VLP) and report the radiological and clinical outcomes at least 3 years after surgery.

Methods: In 41 consecutive patients between January 2012 and August 2017, the fragment was composed of the radial styloid process (distal to the watershed line) and the lunate volar rim was intact. We evaluated demographic factors, radiological features and radiological/clinical outcomes at the final follow-up.

Results: Twenty-nine patients were followed and evaluated. The mean follow-up period was 5.7 years. The mean patient age was 52.7 years and 24 patients had intracapsular intra-articular fractures. The fracture line was present in the lunate fossa in all patients. Twenty patients were classified as Soong grade 2, and five and four patients were grades 1 and 0, respectively. No radiological parameter (volar tilt, radial inclination, step-off and ulnar variance) was significantly different between the affected and contralateral normal sides. The mean visual analogue scale pain score and Disabilities of the Arm, Shoulder and Hand score, as well as the range of movement of the wrist, were not different between the affected and contralateral normal wrists. Finally, the grip strength on the affected side was 92% of the contralateral value. Major complications, such as nonunion, malunion and tendon rupture, were absent.

Conclusions: DRFs distal to the watershed line with an intact lunate volar rim are rare and easy to miss. Careful inspection of 3D-CT images is necessary to determine these injuries, and the optimal choice for proper fixation of the fragment amongst the commercial VLPs would result in satisfactory radiological and clinical outcomes.

Level of Evidence: Level IV (Therapeutic)

Thoracic outlet syndrome (TOS) caused by a primary brachial plexus tumour is very rare. A male politician in his 40s presented with numbness, left limb pain and positive Wright and Roos test results. Magnetic resonance imaging (MRI) revealed a tumour located just below the clavicle, compressing the subclavian artery during left arm elevation. Despite concerns regarding postoperative nerve deficits, surgery was performed because of worsening symptoms during the election campaigns. The pathology report revealed a schwannoma. Few reports have described TOS caused by primary tumours of the brachial plexus. While the decision to perform surgery for primary tumours of the brachial plexus requires careful consideration, surgery may be indicated in cases where the tumour location causes such symptoms.

Level of Evidence: Level V (Therapeutic)

Dupuytren disease is a common benign fibromatosis of the palmar and finger fascia caused by pathological cord formation. As both the retrovascular and lateral cords are jointly responsible for the flexion contracture of the distal interphalangeal (DIP) joint, isolated DIP joint contracture caused by Dupuytren disease is rare. We present a 34-year-old right-hand-dominant male patient with a 6-month history of an isolated DIP joint flexion contracture in the right ring finger due to Dupuytren disease. Surgical fasciotomy of the retrovascular cord improved the contracture without adverse events. It is important to pay attention to the anatomical relationships between the pathological cord and neurovascular bundle to avoid neurovascular injury during fasciotomy in patients with Dupuytren disease, especially in isolated DIP joint contracture cases.

Level of Evidence: Level V (Therapeutic)

A 60-year-old woman presented functional deficit of the index finger flexor digitorum profundus (FDP) tendon after shoulder arthroscopic rotator cuff repair. As no recovery was observed for 10 months, we conducted an operative exploration of the median nerve and the anterior interosseous nerve, followed by an external neurolysis. The patient recovered FDP function 4.5 months after the second operation. In a patient with persistent isolated FDP dysfunction after shoulder arthroscopy, operative exploration and external neurolysis could facilitate functional recovery.

Level of Evidence: Level V (Therapeutic)