The Journal of Hand Surgery (Asian-Pacific Volume)

Background: Different techniques are used to release simple and complex congenital syndactyly in order to create an adequate web space, and to separate the fingers to allow independent function.

Methods: This article is a systematic review of the literature, aiming to evaluate the evidence for the different techniques and outcome measures utilised.

Results: The studies consisted mainly of retrospective, non-controlled descriptive series and a few retrospective cohort studies. The level of evidence is predominantly poor.

Conclusions: Although recommendations in favour of any particular surgical technique cannot be given based on evidence, a number of conclusions can be drawn out of the existing literature with regards to the design of the incisions for finger separation, use of pulp flaps and grafts.

Background: There are many options to treat post osteomyelitic gaps in forearm bones. We report a pediatric series with postosteomyelitic forearm segmental defects reconstructed with fibular only graft: the non vascular fibular intramedullary bridging bone and additional grafting (FIBBAG) and the results thereof.

Methods: Outcomes in 8 patients treated with fibular strut and overlay matchstick grafts were retrospectively assessed. The clinical results were expressed as forearm shortening, range of motion at elbow and wrist joint. The radiological evaluation included time to union, presence of fractures and recurrence of infection, if any.

Results: The average patient age was 6 years (range, 3–12 years). The radius was involved in 6 and ulna in 2. Union occurred in all patients. The average intraoperative gap to be spanned was 5.86 cm (range, 3–14 cm). The average time for union was 6.63 months (range, 2–14 months). Two patients required additional bone grafting procedures. No graft fatigues/fractures were noted in available follow up. There was no recurrence of infection in any case. A positive ulnar variance was seen in 3 patients at follow up. Forearm shortening was a major cosmetic limitation following the procedure.

Conclusions: Fibular strut and additional bone grafting (FIBBAG) is one of the viable options for reconstruction of post osteomyelitic forearm defects in children with low procedural complication rate.

Background: A hypothenar perforator free flap, which is harvested from the palm, is suitable for reconstruction of a finger pulp skin defect, but this flap has rarely been reported, and most of these flaps in previous published reports were designed on the proximal zone of the hypothenar area. In the present report, hypothenar perforator free flaps on the distal zone, namely distal hypothenar perforator free flaps, including two sensate flaps, were used for four cases with pulp defects.

Methods: Four distal hypothenar perforator free flaps were used for four patients with skin defects of the finger pulp, including one thumb, two index fingers, and one little finger. The average period from the injury to reconstruction was 30.3 days (range 21 to 47 days). The age of the patients ranged from 49 to 68 years, and the flap size ranged from 18 × 30 to 25 × 45 mm². Two cutaneous branches of the ulnar palmar digital nerve of the little finger were harvested for the sensate flaps. At final follow-up, sensory restoration of the flap was measured using the Semmes-Weinstein monofilament test and the static two-point discrimination test.

Results: All donor sites were closed directly, and all flaps survived totally. The average postoperative period was 12 months (range 5 to 15 months). The Semmes-Weinstein monofilament test was all blue (3.61, 3.22, 3.61) for the three flaps followed-up for more than 12 months, including two sensate flaps and one insensate flap. The surgical scars were inconspicuous, and there were no donor site complications.

Conclusions: We consider that a distal hypothenar perforator free flap has a high degree of usability for a medium-sized defect such as the whole finger pulp. In the future, whether sensory nerve branches of this flap should be sutured will need to be clarified.

Background: Superelderly patients (defined as 80 years old and older) account for 18% of all distal radius fractures in our institution and this number is increasing with the ageing population. When faced with the option of surgery, patients in this age group have concerns with regards to the long term outcomes including functional outcomes and the time to fracture union. Therefore, the aim of this study was to evaluate the functional outcomes in this specific population.

Methods: Patient selection for surgery was determined by the fracture stability, the patient’s premorbid function and underlying comorbidities. Post operatively, the time to fracture union after surgical fixation, surgical complications and patients’ functional outcome scores were recorded. The method of anaesthesia and any anaesthesia-related complications were also included.

Results: There were 76 superelderly patients who underwent surgical fixation of their distal radius fractures identified from our institution’s prospective database from 2009 to 2016. Overall there were good functional outcome scores. The DASH scores at 3 months and 6 months were 17 and 10 respectively. Furthermore, the mean time to fracture union in our population was 47 days (approximately 7 weeks). There were only 2 post-operative surgical complications but no anaesthesia-related complications.

Conclusions: Surgical fixation of distal radius fractures in appropriately selected patients in the superelderly population yields good functional outcomes.

Background: The purpose of this study is to describe our technique of thumb ulnar collateral ligament (UCL) repair with suture tape augmentation and to evaluate the short-term outcomes in our initial series of patients treated with this method of repair.

Methods: Patients with minimum one-year follow up after isolated UCL repair with suture tape augmentation were contacted for clinical evaluation, radiographs, and postoperative outcome questionnaires, including the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire and study-specific questions. Thirteen of 15 (87%) consecutive patients who were treated using this method of repair were available for follow-up, 9 with acute tears and 4 with chronic tears.

Results: Average post-operative thumb metacarpophalangeal (MCP) and interphalangeal (IP) joint range-of-motion (ROM) was 0–57.5° and 0–71°, respectively, for chronic tears and 2.2–53.9° and 0–71°, respectively, for acute tears. Average grip and pinch strength relative to the unaffected hand was 102% and 84%, respectively, among patients with chronic tears and 103.3% and 88.7%, respectively, among those with acute tears. All patients demonstrated stability with a firm endpoint, relative to the unaffected thumb. The average QuickDASH score among all patients was 11.9 for the disability/symptom module, 0 for the sport module and 16.5 for the work module. Stiffness was reported among 4 patients and no patient suffered wound-related issues or other complications.

Conclusions: Thumb UCL repair with suture tape augmentation demonstrates short-term outcomes comparable to what has been reported for other methods of repair. It may potentially allow for an expedited recovery and rehabilitation process.

Background: Arthritis can have profound debilitating effects on the hand secondary to finger deformities and pain. Arthroplasty of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) can be performed to reduce pain while maintaining joint range of motion.

Methods: We used outpatient surgery registries from the states of California and Florida to assess the trends of arthroplasty across several recent years and to determine if the outcomes differ based on disease etiology.

Results: We found that there has been a steady decline in number of MCP arthroplasty procedures performed annually between 2005 and 2011 while PIP arthroplasty procedures peaked in 2007 and have since also declined. There was an overall complication rate of 2.4% and no difference in cardiac, respiratory, deep venous thrombosis and infection between patients with osteoarthritis and other arthritic etiologies. However, the risk of device failure in patients with rheumatoid arthritis is found to be significantly higher than for patients with osteoarthritis (p < 0.01).

Conclusions: PIP and MCP arthroplasty are safe procedures with an overall low complication rate. The increased risk of device related complications observed in patients with rheumatoid arthritis can be used to appropriately counsel this patient population regarding post-operative expectations and prognosis.

Background: Self-inflicted wrist lacerations have the potential to lead to crippling sequelae and repeated suicidal attempt. To obtain good results, we have treated self-inflicted wrist lacerations using a multidisciplinary team - emergency, hand surgery, psychiatry, and rehabilitation. This study aims to review features of this type of injuries and suggest multidisciplinary team approach as an optimal treatment.

Methods: Our multidisciplinary approach can be summarized as follows: initial evaluation, psychological interview, surgery, and rehabilitation. The medical records including wound features, injured structures and psychological data were reviewed retrospectively. Assessment of functional outcomes, and comparative analysis of various psychological parameters were conducted.

Results: Most patients resulted in excellent or good functional outcomes. Five patients reattempted wrist cutting with suicidal intent during follow-up. Only 21.3% patients had a suicidal intent and it was not associated with injury severity and functional recovery. Alcohol ingestion and presence of associated injuries was significant different between severity groups. Presence of suicidal intent was irrelevant to injury severity and functional recovery, but relevant to alcohol ingestion, presence of associated injuries and presence of psychiatric diagnosis.

Conclusions: In order to minimize catastrophic disability and repeated suicide attempts, a balanced multidisciplinary approach is one of the best methods to obtain excellent functional outcomes and prevent repeated injuries in patients with self-inflicted wrist lacerations.

Background: Postoperative results of ulnar shortening osteotomy for ulnar abutment syndrome were compared between groups of patients in whom the plate was placed on the volar side and those in whom the plate was placed on the dorsal side.

Methods: A total of 35 wrists of 14 males and 21 females were evaluated. The average age of patients at surgery was 44.3 years, and the average follow-up period was 66.2 months. After transverse osteotomy was performed, the ulna was fixed using a 6-hole LC-LCP or a LC-DCP on the dorsal (group D) or the volar (group V) side, respectively. Imaging and clinical results, rates and reasons for implant removal were evaluated.

Results: There were 27 patients in group D and 8 in group V. A significant difference was observed only in the postoperative grip strength compared with that of the unaffected side between groups V and D (102% and 87%, respectively). Implant removal was performed in 18 (64%) patients in group D and in 7 (88%) in group V, and the main reasons for this were pain in group V and discomfort in group D. Re-fracture occurred after implant removal in one patient in group D.

Conclusions: There were no differences in the imaging and clinical results depending on the plate position. It is preferable to avoid implant removal by placing the lower profile plate on the dorsal side.

Background: A new beta-tricalcium phosphate with unidirectional pore structure (UDPTCP), Affinos^® (Kurray, Okayama, Japan), has been in clinical use since 2015. To date, there have been only a few clinical studies using this material. We report here the first clinical study for distal radial fracture in the elderly population treated with UDPTCP.

Methods: Consecutive patients aged 65 years or older with dorsally displaced unstable fracture of the distal radius (n = 36) were treated operatively in our department. Following reduction of the fracture site, a 7 mm size cube of UDPTCP was placed in the gap of the bony defect and the fracture stabilized with mono-axial or poly-axial type locking plates and screws. Remodeling of the UDPTCP was evaluated by plain radiograph and clinical outcomes were also assessed.

Results: UDPTCP was significantly resorbed at 2 months after surgery, both at the center and periphery of the material. Complications were only observed in the post-operative period. Significant correction loss of radial alignment was seen in patients stabilized with poly-axial locking plate. The clinical outcome in all cases was excellent.

Conclusions: Block UDPTCP is a safe and convenient material for the treatment of distal radius fracture and is replaced within a suitable time period after grafting into the fracture site. UDPTCP and stable internal fixation is therefore a reliable strategy for restoring and preserving anatomical position, especially in the elderly population.

Background: This study aimed to describe a novel surgical technique in which a bridge plate was used for the treatment of hamatometacarpal fracture-dislocations and to assess its radiologic and clinical outcomes.

Methods: A retrospective review of 16 patients treated with the bridge plate technique for hamatometacarpal fracture-dislocations was performed between 2010 and 2015. Clinical and radiographic evaluations were performed at months 3, 6, and 12 postoperatively. Active wrist and metacarpophalangeal joint ranges of motion and Quick Disabilities of Arm, Shoulder, and Hand (DASH) scores were recorded for the injured hands. Grip strength data were collected for both the injured hands and the contralateral uninjured hands.

Results: All patients included in our study were male (mean age 31 years). The average Quick DASH score was 24.3 ± 9.1 at 3 months, 12.3 ± 7.3 at 6 months, and 6.2 ± 6.6 at 12 months. All patients returned to their original jobs within 5 weeks of the procedure. Grip strength eventually recovered to 90% of that of the uninjured hand, and none of the patients complained of finger or wrist joint stiffness.

Conclusions: The use of the bridge plate technique may be an effective alternative treatment for patients with comminuted hamatometacarpal fracture-dislocations.

Background: Although the current nonsurgical treatment for trigger digits is corticosteroid (CS) injection, it often comes with adverse effects that may cause some limitations. Currently, Hyaluronic acid (HA) has been successfully used in tendinopathy and may be used in stenosing tenosynovitis. The aim of this study is to compare the efficacy of ultrasound-guided injection between the HA and CS in trigger digits treatment.

Methods: Double-blind randomized controlled trial was conducted. Fifty patients with 66 trigger digits were randomly assigned into an intervention group (1 ml of low-molecular weight HA) and a control group (1 ml of 10mg/ml triamcinolone acetate). The ultrasound-guided injection and local anesthesia (0.5 ml of 1% lidocaine without adrenaline) were used. The Quinnell grading, Visual Analog Scale (VAS) score of pain, Disabilities of the Arm, Shoulder and Hand (DASH) score and complications were collected at 1-, 3-and 6-month follow-up.

Results: The mean age of HA group (33 digits) and CS group (33 digits) were 58.3 years and 54.7 years respectively. Nine patients were loss of follow-up (7 in HA group and 2 in CS group). The Quinnell grades have shown an improvement in both group. The CS group had a significant better improvement at 1-month (p-value < 0.001) and there was no significant difference at 3-and 6-month follow-up between the two groups. The median of VAS and DASH score were significantly improved by time in both groups (p-value < 0.01). The CS group showed a better significant improvement in early period of follow-up (p-value < 0.05). However, there was no significant difference between the two groups in the last follow-up.

Conclusions: HA and CS injection has a comparable therapeutic effect in treatment of trigger digits. However, CS injection has higher efficacy of pain and inflammation reduction in the early phase of the disease.

Background: In a small series, it has been postulated that delayed release of complex syndactyly of the 3rd web in Apert syndrome patients causes compression on epiphyses, with early epiphyseal closure, leading to symphalangism and reduced capitate ossification. We wished to see whether this remains true in a larger series.

Methods: We reviewed radiographs of 48 patients (86 hands) with Apert syndrome seen in the department of Plastic and Reconstructive Surgery, Great Ormond Street Hospital, between the years 2001–2012. Patients underwent surgical release of syndactyly in a staged fashion with the 3rd web release left until last. We measured the size of the capitate ossification center relative to that of the hamate and determined the relative position of the middle finger metacarpal relative to the ring finger metacarpal.

Results: We found agreement with many findings, however we weren’t able to demonstrate the catch-up growth of the capitate after release of the third web. The failure of normal distal migration of the 3rd metacarpal appeared to occur until the 3rd web release is performed.

Conclusions: Consistent findings of delayed ossification of the capitate and failure of normal distal migration of the third metacarpal add support to the initial hypothesis, however, we cannot fully conclude that an earlier release of the third web is recommended, further research is still needed.

Background: The aim of this study is to determine the prevalence of Martin-Gruber Anastomosis (MGA) in healthy Egyptian subjects, and to discuss the available literature regarding MGA subtypes and their clinical implications.

Methods: An electrophysiological study was conducted in both forearms of 140 healthy subjects. This included the ulnar and median nerves. Compound muscle action potentials were recorded from abductor pollicis brevis, abductor digiti minimi, and first dorsal interosseous muscles. Other measurements included the compound motor action potential amplitude and its innervation ratio.

Results: MGA was found in 56 of the 280 forearms. This included 20 men and 36 women. Type II MGA subtype was the most frequent in both genders. The MGA was bilateral in 6 subjects and more frequent on the right side. The highest mean amplitude and innervation ratio were recorded at first dorsal interosseus muscle.

Conclusions: The prevalence of MGA in the studied sample of the Egyptian population is 20%. It is important for Hand, Orthopaedic and Neurosurgeons to be aware of this anatomic variation in order to explain paradoxical motor and sensory loss in patients.

Background: Palmar tilt and ulnar variance are crucial parameters for evaluating the distal radius. Identifying suitable reference points for these parameters on lateral wrist radiographs remains challenging. The purpose of this study was to establish reference points for measuring palmar tilt and ulnar variance on lateral wrist radiographs and to evaluate the reliability of these two parameters using the newly defined reference points.

Methods: The distal articular surfaces of 25 cadaver radii were marked at four different locations using thin wires. These bones were radiographed and constant landmarks were recorded. The reliability of the palmar tilt and ulnar variance measurements was assessed using the new reference points and two serial measurements recorded by three observers on 27 standardized lateral wrist radiographs.

Results: The reference points for palmar tilt on lateral radiograph were the dorsal and volar end points of the subchondral line. The subchondral line was connected to two of five metaphyseal cortical lines. The reference point for lateral ulnar variance was easily defined on the midpoint of the proximal aspect of the subchondral line. The corresponding posteroanterior central reference point for ulnar variance was at the ulnar corner of the subchondral line. Inter- and intra-observer reliabilities were overall good for the palmar tilt measurements, and excellent for the ulnar variance measurements.

Conclusions: Palmar tilt can be determined accurately with a good understanding of the radiographic landmarks on lateral radiographs, and by addressing the problems caused by ulnar inclination of the articular surface of the distal radius. Lateral wrist radiographs can provide a complete picture of the ulnar border of the radius for measuring ulnar variance.

Background: Traumatic digital amputations require early replantation, and proper surgical technique is a critical factor for a successful digital replantation. Non-surgical factors can also effect the digital survival rate. Previous studies have used univariate analysis and logistic regression which could not identify the various complex associations of patient-related and digit-related factors. This study aimed to identify the determinants of digital survival after replantation, using multi-level analysis.

Methods: A retrospective analysis of 209 patients with 272 finger revascularizations and replantations performed from the metacarpophalangeal joint to the end of the finger. Demographic data, place of injury, mechanism of injury, level of amputation, and success rate were examined.

Results: The overall survival rate of digital replantation during the study period January 2004–December 2017 was 64%. Surgeon’s experience 3–5 years (OR 13.04), type of injury as guillotine (OR 6.79) and number of venous anastomoses for two veins (OR 6.83) were the most important pre-operative and intra-operative factors affecting the survival rate as clarified by a multi-level hierarchical model.

Conclusions: Although successful replantation involved many factors, the most important factors that directly affected the survival of the amputated digit were surgeon’s experience, venous anastomosis and type of injury.

Traumatic fractures involving an ununited olecranon apophysis in adults have been rarely documented in the literature. We present the case of a 21-year-old male wrestler with an elbow injury after a fall. Imaging revealed an acute fracture of the olecranon with sclerotic rounded edges indicating an injury through a persistent olecranon apophysis. Open reduction and internal fixation was performed with plate fixation and bone grafting with radiographic and clinical healing at 6 weeks. Review of the literature revealed 5 case reports showing high rates of non-union with tension band constructs while plate and screw fixation had no incidence of nonunion. Fractures through an ununited olecranon apophysis are successfully treated with plate and screw fixation with bone grafting.

Aneurysmal bone cysts associated with tubular bones of the hand are rare and even rarer in the paediatric age-group. They are rapidly growing, destructive benign bone tumors. Multiple treatment modalities for aneurysmal bone cyst have been reported in the literature, but controversy exists regarding optimal treatment. We report a case of aneurysmal bone cyst of proximal phalanx of middle finger in a 2 year old child treated at our tertiary care hospital. The diagnosis was confirmed with pre-operative MRI, FNAC and post-operative histopathology. Curettage of the lesion and autologous bone grafting was performed. The hand was immobilized in a short below elbow slab for 4 weeks followed by physiotherapy. Excellent radiological and functional outcomes were obtained with no recurrence at a 5 year of follow up.

This case report presents a very rare fracture combination in a perilunate dislocation including the scaphoid, capitate, hamate and triquetrum and the cornu anterior of the lunate, with an intact scapholunate ligament in a left wrist. An open reduction and internal fixation of the scaphoid, capitate, hamate and triquetrum was performed.

Extensor tendon rupture of the finger is a very rare complication of Kienböck’s disease. However, advanced Kienböck’s disease can cause an attritional rupture of extensor tendons due to displaced lunate fragment. An extensor tendon of the thumb is frequently damaged in the distal radial fracture, and an extensor tendon of the fifth finger is mainly ruptured in arthritis of distal radio-ulnar joint. On the other hand, the extensor tendons of the 2^nd, 3^rd and 4^th fingers are usually ruptured in advanced Kienböck’s disease. We report two elderly patients diagnosed with advanced Kienböck’s disease after non-traumatic rupture of extensor tendon of the fingers. Since the extensor tendon rupture in Kienböck’s disease present as a loss of active extension of metacarpophalangeal joint in the central fingers, these patients should undergo imaging of the wrist joints to ascertain concomitant Kienböck’s disease.

Eosinophilic fasciitis (EF) is a rare form of fibrosing disorder associated with peripheral eosinophilia with scleroderma-like skin induration and fasciitis in the extremities resulting in painful swelling, erythema and progressive contracture. We present a case report of EF and a literature review to raise awareness of this unusual condition and also highlight key features in its management.