The Journal of Hand Surgery (Asian-Pacific Volume)

Artificial intelligence (AI) has witnessed significant advancements, reshaping various industries, including healthcare. The introduction of ChatGPT by OpenAI in November 2022 marked a pivotal moment, showcasing the potential of generative AI in revolutionising patient care, diagnosis and treatment. Generative AI, unlike traditional AI systems, possesses the ability to generate new content by understanding patterns within datasets. This article explores the evolution of AI in healthcare, tracing its roots to the term coined by John McCarthy in 1955 and the contributions of pioneers like John Von Neumann and Alan Turing. Currently, generative AI, particularly Large Language Models, holds promise across three broad categories in healthcare: patient care, education and research. In patient care, it offers solutions in clinical document management, diagnostic support and operative planning. Notable advancements include Microsoft’s collaboration with Epic for integrating AI into electronic medical records (EMRs), enhancing clinical data management and patient care. Furthermore, generative AI aids in surgical decision-making, as demonstrated in plastic, orthopaedic and hepatobiliary surgeries. However, challenges such as bias, hallucination and integration with EMR systems necessitate caution and ongoing evaluation. The article also presents insights from the implementation of NUHS Russell-GPT, a generative AI chatbot, in a hand surgery department, showcasing its utility in administrative tasks but highlighting challenges in surgical planning and EMR integration. The survey showed unanimous support for incorporating AI into clinical settings, with all respondents being open to its use. In conclusion, generative AI is poised to enhance patient care and ease physician workloads, starting with automating administrative tasks and evolving to inform diagnoses, tailored treatment plans, as well as aid in surgical planning. As healthcare systems navigate the complexities of integrating AI, the potential benefits for both physicians and patients remain significant, offering a glimpse into a future where AI transforms healthcare delivery.

Level of Evidence: Level V (Diagnostic)

Background: We aimed to evaluate the effectiveness of our novel operation technique that included radial shaft shortening plus supination producing osteotomy and transfer of the biceps brachii tendon to the brachialis tendon in patients with chronic radial head dislocation secondary to brachial plexus birth injury (BPBI).

Methods: Fourteen patients with chronic radial head dislocation resulting from BPBI were included in this study, with a minimum 1-year postoperative follow-up period. All patients underwent the same surgical procedure. The range of motion of affected elbow was measured with a standard goniometer. The Mayo Elbow Performance Score (MEPS) was used to measure for evaluation of functional result of these patients. The affected elbow radiograph also obtained in the last visit for evaluation of compatibility of the radiocapitellar joint.

Results: Fourteen patients (10 males and 4 females) were included in the study. The average age at the time of surgery was 7.2 (5–8) years and average follow-up was 73.2 ± 19 (36–131) months. Although the forearm active–passive pronation decreased, active–passive supination significantly improved postoperatively (p < 0.001). Ten patients had excellent MEPS results (90 and above), two patients with good results (75 and 80), one patient with fair (65) and one patient with poor result (55). Radiocapitellar reduction was achieved in 78.5% (11/14) of the patients.

Conclusions: The novel surgical techniques that included radial shaft shortening plus supination producing osteotomy and transfer of the biceps brachii tendon to the brachialis tendon improved the functional outcomes of patients with chronic radial head dislocation secondary to BPBI.

Level of Evidence: Level IV (Therapeutic)

Background: Various studies have examined occlusive dressings in fingertip amputations and reported good outcomes. Occlusive dressing preserves appropriate pH, cell accumulation and moisture for healing, thereby limiting scar formation and deformity. To our knowledge, no study was performed in tropical Asia. This study aims to demonstrate the viability of healing fingertip amputations through secondary intention using an effective dressing technique, even in warm tropical climates.

Methods: All patients who presented to our institution with fingertip amputations from 1 July 2020 to 31 July 2022 were analysed retrospectively. Seventeen patients (15 male, 2 female) of mean age 37.2 ± 9.4 years old with 18 injured digits were retrospectively analysed. Twelve (66.7%) were Allen Type III injuries, and one patient required distal phalangeal K-wire fixation. During the patient’s final review, static 2-point discrimination, pulp sensation, fingertip contour and nail deformities alongside the last measured range of motion (ROM) of the injured finger was recorded. Treatment duration and days of leave taken were also summed and assessed.

Results: Patients were dressed with semi-occlusive dressing for an average of 20.1 ± 6.83 days. The average total duration of dressing is 36.78 ± 18.88 days over an average of 7.18 ± 4.03 dressing visits. Mean duration of follow-up was 108 ± 63.46 days. Good outcome measures in sensation, pulp contour, nail deformity and ROM similar to existing literature were reported.

Conclusions: Occlusive dressing remains a viable and feasible treatment option for fingertip amputation even in a tropical climate. While this simple treatment method may require more effort from patient, wound healing was attained after 36.8 ± 18.9 days of dressing.

Level of Evidence: Level IV (Therapeutic)

Background: Presence of available healthy nerve roots on the injured side determines the outcome after nerve reconstruction. Paucity of nerve roots warrants contralateral C7 harvest for optimal results. We aim to study the risks and benefits of retro oesophageal transfer of contralateral C7 root in infants with birth brachial plexus injury.

Methods: Study was carried out from 2017 to 2022 in 13 children who have undergone retro oesophageal transfer of contralateral C7 root to affected side. Follow-up period ranged from 8 to 60 months after the surgery. Motor power assessment was done using by active movement scale.

Results: Average active movement score for abduction was found to be 6, elbow flexion 5.7, elbow extension 5.8, wrist extension 3, wrist flexion 4, finger flexion 4.8 and finger extension 3.8, respectively. No neurological deficits, limb length anomaly noted in the normal upper limb after contralateral C7 harvest.

Conclusions: Retro oesophageal transfer of contralateral C7 is a safe technique in birth brachial plexus injury. The advantage of retro oesophageal transfer is reduction in the length of nerve grafts, thus helping in early neurotisation of distal forearm and hand muscles. The large axonal output from contralateral C7 can be used to reconstruct different nerves without any residual deficits on the normal side.

Level of Evidence: Level IV (Therapeutic)

Background: External neurolysis is an important approach to treating symptomatic peripheral nerve entrapment. In cases of recurrent neurolysis or particularly extensive neurolysis, a paucity of overlying soft tissue for closure over the freshly liberated nerve presents a challenge to long-term surgical success as primary closure of this tissue may predispose the patient to recalcitrant epineural scarring. We report the intermediate term outcomes of the use of adipofascial perforator flaps as a means of vascularised tissue resurfacing of nerves in these difficult scenarios.

Methods: We retrospectively reviewed patients undergoing external neurolysis for painful peripheral nerve lesions who subsequently had soft tissue reconstruction with local adipofascial flaps. Data with regard to age, gender, limb involved, duration of symptoms, number of prior surgeries, operative time, type of flap, vascular basis of flap, duration of follow-up, visual analogue pain score, monofilament sensory testing and complications were collected.

Results: We included six patients (four women) with a minimum follow-up period of 17 months (range: 17–25 months). Age ranged from 39 to 60 years of age. Four cases involved the upper extremity and two the lower extremity. Symptoms had been present between 1 and 10 years. All operations utilised a local adipofascial flap perfused by a named perforating vessel emanating from an adjacent axial vessel. Operative time for flap creation and inset was 74 minutes, on average. There was one minor complication owing to superficial wound dehiscence. All patients reported substantial pain relief (≥five-point reduction on visual analogue scale; scores 0–3 at last follow-up) and objective sensory testing demonstrated improvement.

Conclusions: Our report pays particular attention to surgical technique that is applicable to both upper and lower extremities in addition to intermediate term safety and pain outcomes.

Level of Evidence: Level IV (Therapeutic)

Background: Supracondylar humerus fractures (SHFs) are common paediatric injuries, with high risk of vascular compromise. Some patients present with a ‘pink, pulseless hand’, caused by occlusion of brachial artery flow but with collateral circulation preserving distal perfusion. Management of these patients remains controversial, especially when resources may be limited for prolonged hospitalisation and serial monitoring by skilled staff. The aim of this study is to present the intraoperative findings, surgical procedures done and outcomes at 6 weeks for patients with paediatric supracondylar fractures with a pink pulseless hand.

Methods: We retrospectively identified 13 patients who presented to a public hospital between January 2019 and May 2023 with a displaced SHF and pink, pulseless hand. All patients underwent an open reduction with an anterior approach allowing for exploration, protection and repair of neurovascular structures. Distal flow was restored in the brachial artery either with topical lidocaine application, thrombectomy or artery reconstruction.

Results: Out of 13 patients, all had intact median nerves and 10 had intact arteries (69%), of which seven were interposed at the fracture site and four were in vasospasm. Of the three patients with true arterial injury (23%), two had a crushed artery and one had thrombosis of the artery. Peripheral pulses were restored within an hour of fracture open reduction in all patients. At final follow-up, a mean 6 weeks postoperatively, all patients had recovered without neurovascular deficit, compartment syndrome or Volkmann ischemic contracture.

Conclusions: In resource-limited settings, we recommend performing open exploration and reduction for patients with SHFs with pink, pulseless hand. This approach prevents iatrogenic neurovascular injury during closed reduction attempts, allows for immediate repair of a brachial artery injury and avoids unnecessary hospitalisation and serial monitoring.

Level of Evidence: Level IV (Therapeutic)

Background: We aim to evaluate the impact of advanced age and sex on postoperative complications and radiographic outcomes after open reduction with internal fixation of distal radius fractures (DRF).

Methods: We conducted a retrospective chart review, including all patients who underwent open reduction with internal fixation of a DRF between 2012 and 2018 at a single level 1 trauma centre. We recorded patient age, sex, fracture classification (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association [AO/OTA]), time from injury to surgical date, surgical duration, diabetes status, tobacco use, illicit drug use, history of osteoporosis, use of adjuvants, fixation type, postoperative radiographic restoration of normal parameters and early complications including loss of reduction within 30 days postoperatively. Advanced age was defined as age greater than 60 years.

Results: A total of 521 patients underwent operative treatment – 264 males and 257 females. Males were twice as likely (23.5% vs. 10.1%; p < 0.0001) to sustain a type C3 fracture and be treated with a wrist spanning plate (5.3% vs. 0; p < 0.0001). A larger percentage of elderly patients undergoing operative treatment of DRF were female (20.2% vs. 5.7%; p < 0.0001) and females were more likely to carry a pre-injury diagnosis of osteoporosis (9.3% vs. 0%; p < 0.0001). And 100% of the elderly patients received were treated with a volar plate. The overall early loss of reduction was 7.5%. The overall complication rate was 8.2%. No differences in early postoperative complications were identified between sexes or age groups. Neither female sex nor advanced age was found to have increased risk of postoperative complications or early loss of reduction. Similar postoperative radiographic parameter measurements were obtained across groups as well.

Conclusions: Our results support the idea that operative treatment of unstable DRF in elderly patients and women is a reasonable treatment option without significant increases in early postoperative complications.

Level of Evidence: Level III (Therapeutic III)

Background: The most common types of wrist dislocation are trans-scaphoid lunate dislocation (TLD) and trans-scaphoid perilunate dislocation, in which the lunate and proximal scaphoid are dislocated through the midcarpal joint. There is another rare type of dislocation in which the proximal carpi are dislocated through the radiocarpal joint. The purpose of this study is to examine the clinical features of this type of dislocation.

Methods: Six cases of the proximal carpal fracture dislocation via the radiocarpal joint were retrospectively reviewed. All patients underwent open reduction and internal fixation with the ligament reconstruction. A Mayo wrist score was assigned to each patient based on the assessment of pain, functional status, range of motion and grip strength at the last follow-up. Clinical subjective evaluation of function and pain was assessed using the patient-rated wrist evaluation (PRWE) method.

Results: All patients were male and injured with a median age of 33.5 years. The median follow-up period was 10 months. There were three types of dislocations: Scaphoid fracture dislocation, TLD and scaphoid-lunate dislocation. All patients had satisfactory results with an average PRWE of 7.2 ± 4.7. The preoperative VAS was 6.7 ± 1.0 and the postoperative VAS was 0.7 ± 0.7 (p < 0.01). Postoperative grip strength accounted for 89.2% ± 9.8% of the contralateral side; the Mayo wrist score averaged 90.0 ± 6.5, with four patients obtaining excellent and two good results.

Conclusions: Fracture dislocation of the proximal carpal bones through the radiocarpal joint is an independent type of wrist dislocation that tends to occur in young men with high-energy impact. The wrist is most often injured in a pronation hyperextension position. If treatment is timely and appropriate, the prognosis is quite good.

Level of Evidence: Level IV (Therapeutic)

Background: The long axis of the radius is a standard reference for measuring radiological parameters in distal radius fractures. However, in patients with severe comminution and anatomical variation with distal radius bowing, it is challenging to assess using the long axis of the radius. The long axis of the ulna can be used as an alternative reference. The aim of this study is to assess the reliability and level of agreement using the long axis of the ulna as an alternative reference in comparison to the long axis of the radius.

Methods: Posteroanterior (PA) radiography of the wrist in patients with acute distal radius fractures was evaluated in two rounds by four observers. Radial height, radial inclination and ulnar variance were measured using radial and ulnar long axis as references. The intraobserver and interobserver reliability of the measurements with two reference axes was assessed using intraclass correlation coefficient (ICC). The level of agreement was determined using the Bland–Altman plot.

Results: In total, 59 patients who underwent PA radiography of the wrist were included in this study. All parameters exhibited good agreement between the two methods, with a mean difference of nearly zero (radial height = −0.03 mm, radial inclination = −0.14° and ulnar variance = 0.03 mm). The limits of agreement in radial height (−2.87, 2.82 mm) and ulnar variance (−0.81, 0.87 mm) were narrow. However, for the radial inclination, it was wider (−6.21, 5.94°). Intraobserver reliability between the long axis of radius and ulna (ICC = 0.85–0.99 and 0.84–0.98, respectively) was good to excellent. The interobserver reliability of each parameter was excellent (ICC = 0.94–0.97).

Conclusions: The ulnar long axis can be used as an alternative reference for measuring radial height, radial inclination and ulnar variance in PA radiography of the wrist in acute distal radius fracture, particularly if the radial long axis is distorted.

Level of Evidence: Level III (Diagnostic)

A 15-year-old girl with humeroradial synostosis since birth underwent a resection arthroplasty. A trapezoidal resection osteotomy of approximately 2 cm was performed at the anterior part of the bone flexure. This resulted at 18 months in an elbow arc of motion of 60°–110° and forearm pronation/supination of 40° and 60° without postoperative complications and improved disabilities of the arm, shoulder and hand and Hand 20 scores. Radiographic analysis revealed a humeroradial joint with a maintained pseudarthrosis and hinged motion at the humeroulnar joint. When performed by an experienced surgeon, resection arthroplasty corrects humeroradial synostosis, resulting in improvement in range of motion and quality of life.

Level of Evidence: Level V (Therapeutic)

Juxta-articular myxoma (JAM) is a rare soft tissue tumour predominantly composed of mucinous tissue and usually found around large joints. We report a 73-year-old woman with a 5-year history of a soft tissue mass in the thenar eminence of the right wrist who presented to our department. An initial diagnosis of a ganglion cyst was made using magnetic resonance imaging (MRI) and the jellied content of the mass by aspiration. Two years after presentation, surgical treatment with tumour resection and carpal tunnel release via the radial approach was performed because the symptoms of carpal tunnel syndrome worsened, and the tumour invaded the carpal tunnel. Histopathological examination revealed a JAM. At the 1-year follow-up, the symptoms of carpal tunnel syndrome had resolved, and no recurrence was confirmed by MRI.

Level of Evidence: Level V (Therapeutic)

Congenital dorsal curvature of the distal phalanx has been previously described as ‘reverse Kirner’ or ‘ski-jump’ deformity. This report describes bilateral occurrence in the thumbs. A 13-year-old male presented with difficulty caring for his thumbnails and in picking up small objects. Examination showed dorsal curvature of the distal phalanges of both thumbs, with greater curvature of the right side. Radiographs showed wedge-shaped epiphyses and dorsal curvature without coronal plane deviation of the distal phalanges. There was objective and subjective decrease in function associated with lateral pinch and tripod grasp. The reported aetiopathogenesis for Kirner deformity cannot explain the observed dorsal curvature. The bilateral nature makes a secondary physeal cause unlikely and suggests an embryologic basis. Due to the noticeable deficits in function, operative intervention may be warranted.

Level of Evidence: Level V (Therapeutic)