The Journal of Hand Surgery (Asian-Pacific Volume)

Carpal tunnel syndrome (CTS) is the most common upper extremity compressive neuropathy. The reference standard for the diagnosis of CTS remains an area of controversy. The diagnosis can be established clinically, but options for confirmatory testing include electrodiagnostic studies, ultrasound and diagnostic aids such as the CTS-6 score. This review article summarises the current evidence for each confirmatory testing modality, contrasts their advantages and disadvantages and discusses future directions for investigation.

Level of Evidence: Level V (Diagnostic)

Background: Currently, large-sample epidemiological studies on congenital upper limb differences (CULD) in China are relatively rare. This report presents our centre’s experience on the spectrum of diseases and related factors.

Methods: Information was collected from patients with CULD who underwent surgical treatment at our centre from September 2018 to October 2023. Data collection included patient name, gender, age, clinical features and diagnosis, family history, parents’ age, parents’ medical history, pregnancy history and family income. Bivariate relationships between these variables were examined.

Results: The average age of the patients was 4 years; 1,398 patients (99%) were aged 9 months to 18 years, and 17 patients (1%) were adults. There were 848 males (60%) and 567 females (40%), with a statistically significant gender distribution (p < 0.05). The most common differences were polydactyly and syndactyly, accounting for 47% and 14%, respectively. Syndromic patients accounted for 14%, and cardiac conditions were the most prevalent non-musculoskeletal issue (55%). First-born patients accounted for 54% of patients, and the average age of parents for first-born patients was 30 ± 5 years for fathers and 29 ± 2 years for mothers. For non-first-born patients, the average age of parents was 33 ± 6 years for fathers and 32 ± 5 years for mothers, with a statistically significant difference between the two groups (p < 0.001).

Conclusions: In China, congenital limb differences are still dominated by polydactyly and syndactyly. Heart conditions occur most frequently in patients with syndromes.

Level of Evidence: Level IV (Epidemiological)

Background: Surgery is often offered to patients with mallet fractures that have a large, displaced fragment and/or joint subluxation. However, the surgical approach remains a subject of debate, and surgery is frequently associated with unsatisfactory outcomes. We felt that the angle formed by the fracture line and the long axis of the distal phalanx on a lateral view radiograph (fracture line angle [FLA]) could be useful in determining the appropriate treatment strategy. The aim of this study was to assess the FLA and its distribution in mallet fractures.

Methods: Three researchers measured the mallet FLA and the percentage of articular surface (PAS) involved in the lateral radiographs of 103 patients with a mallet fracture.

Results: There was a strong correlation between the mallet FLA and the percentage of joint surface involvement between the three researchers. The mean FLA was 42.59° (±11.54) and it ranged from −1 to +1 standard deviation in 73 individuals (70.87%). The FLA varied over a wide range, while clustering near the average value. The average PAS involvement was 46.5% (±8.7%). There was no correlation between FLA and PAS involvement (p > 0.05).

Conclusions: It is possible to quantify the mallet FLA accurately and consistently. It varies widely, regardless of the PAS involvement. When choosing the type of treatment and making prognostic predictions, the mallet FLA may be a helpful guide.

Level of Evidence: Level IV (Diagnostic)

Background: With ageing of the population, there is an increasing likelihood that elderly people will seek employment, with a resultant increase in the incidence of hand injuries, including digital amputations. However, the surgical indication for replantation of an amputated digit in elderly patients is controversial. The purpose of this study was to compare functional outcomes after single-digit replantation of the thumb to long finger in older (≥65 years old) and younger (<65 years old) patients to assess the feasibility of digit replantation in the elderly population.

Methods: A retrospective cohort study was performed in 25 patients (12 elderly and 13 younger) with successful replantation of the thumb, index or long finger at our hospital. All patients were followed up for more than 1 year. Key pinch strength, Semmes–Weinstein (S–W) test, % total active motion (TAM), Purdue Pegboard Test score (hand dexterity) and Disabilities of the Arm, Shoulder and Hand (DASH) score were investigated.

Results: Elderly patients showed significantly worse results for the S–W test and Purdue Pegboard Test score. The % TAM, key-pinch strength and DASH scores were similar in the two groups.

Conclusions: Replantation surgery in elderly patients results in similar postoperative hand function (finger mobility and pinch strength) and activities of daily living to those in younger patients.

Level of Evidence: Level III (Therapeutic)

Background: Flexor sheath infections require prompt diagnosis, and management with intravenous antibiotics and/or surgical washout followed by hand therapy. Complication rates as high as 38% have been reported. Our unit takes a relatively conservative approach to the management of flexor sheath infections and select patients are managed non-surgically via our outpatient antibiotic service where they are clinically reviewed and receive a once daily dose of intravenous antibiotics. The aim of this study is to determine if outpatient management of flexor sheath infections was associated with an increased risk of complications compared to those admitted as an inpatient.

Methods: A retrospective review was carried out with all patients clinically diagnosed with flexor sheath infection who were seen at our unit between January 2014 and December 2020. Age, gender, co-morbidities, cause of infection, management and subsequent complications were recorded.

Results: A total of 128 patients with flexor sheath infections were treated. And 68% were male. Mean age was 50.4 years. A trend towards fewer presentations each year with animal bites, foreign bodies and penetrating trauma as the main cause of infection was noted. And 89% (n = 114) required admission with the other 11% (n = 14) treated as an outpatient. And 77% (n = 98) underwent surgical washout. And 6% (n = 8) suffered a complication.

Conclusions: While flexor sheath washout continues to be standard practice, 23% of patients were safely managed with intravenous antibiotics and 11% purely via an outpatient service.

Level of Evidence: Level IV (Therapeutic)

Background: Triphasic bone scintigraphy (TPBS) is often used to diagnose complex regional pain syndrome (CRPS). The primary aim of this study is to determine if the diagnosis of CRPS in patients with a positive TPBS (TPBS +ve) is accurate. A secondary aim is to determine if there was delay in treatment of patients who underwent TPBS compared to those who did not have a TPBS.

Methods: Of 225 consecutive patients presenting to the first author’s practice with a diagnosis of CRPS, 65 had TPBS performed before referral with 62 having TPBS +ve. The remaining 160 were clinically diagnosed and a TPBS was not done (TPBS-ND). Patients were classified into five categories – wrong diagnosis, dystonic-psychogenic hand, causalgia, flare reaction and irritative carpal tunnel syndrome (ICTS). Patients with flare reaction and ICTS were considered as having true CRPS and the rest were considered as misdiagnosis. The patients’ demographics, duration of symptoms, pre- and postoperative pain, functional score and patient satisfaction were compared.

Results: Of the 62 TPBS +ve, there were 38 (61%) misdiagnosis. The proportion of misdiagnoses was fewer in the TPBS-ND group (45%; p = 0.036). Thirty-two of the 62 TPBS group (52%) and 92/160 (56%) of the TPBS-ND group had surgical treatment. At a mean follow-up of 19 months, pain dropped 6.5 ± 2.5 points in the TPBS +ve group. Disabilities of the arm, shoulder and hand (DASH) score fell by 56 ± 27. The mean single assessment numeric evaluation (SANE) score was 8.6 ± 2.3. These results did not differ substantially from those of the TPBS-ND group.

Conclusions: A significant number of patients in this study who had TPBS +ve were misdiagnosed in this study. Outcomes after treatment of CRPS were consistently good despite the results of the TPBS. Patients with TPBS +ve had a significant delay to diagnosis. We conclude that TPBS is not useful in the management of CRPS.

Level of Evidence: Level III (Therapeutic)

Background: Carpal tunnel syndrome (CTS) can be treated surgically. Although the minimally invasive open surgical method is widely used, it is not possible to directly visualise the entire length of the carpal tunnel, especially the proximal end, which is on the side away from the skin incision. In this study, we performed a mini-open carpal tunnel release with endoscopic assistance to release the entire length of the carpal tunnel under direct vision and investigated the treatment outcomes.

Methods: The surgical method included an incision of ≤2 cm in the palm, cutting of the transverse carpal ligament under direct vision and cutting of the forearm fascia under endoscopic vision. A uniquely designed sheath was used for the endoscopic resection. We investigated the sex, age, medical history, symptoms, examination findings, anaesthesia method, operation time, thenar motor branch variation, postoperative complications, presence or absence of pillar pain and final examination findings of the target patients.

Results: A total of 100 hands (85 patients) were included. Anatomical variations of the thenar motor branches were observed in 19 hands. At the final follow-up, hand numbness improved in all patients, while mild numbness was observed in 25 hands. The abductor pollicis brevis muscle improved in all patients with paresis, but 8 of the 27 hands remained completely paralysed. Pillar pain was observed in 36 hands at 8 weeks postoperative, but the condition improved in all patients. The clinical outcomes of this study were good with no cases of major complications or reoperation.

Conclusions: The minimally invasive open surgical method described here can be reliably used to release the forearm fascia proximal to the carpal tunnel. The thenar motor branch can also be confirmed under direct visualisation, making it a relatively safe and useful approach.

Level of Evidence: Level Ⅳ (Therapeutic)

Background: Advances in treatment philosophies and microsurgical techniques for peripheral nerve injuries (PNI) have led to improved outcomes. However, lack of standardisation in the evaluation of clinical outcomes after PNI treatment precludes the ability to compare reconstruction methods, such as nerve transfer, nerve grafting, free functioning muscle transfers and tendon transfers. To this end, our goal is to work collaboratively to establish a core outcome set to evaluate outcomes after PNI.

Methods: The protocol for this arc of work, delineated in this manuscript, consists of two phases: (1) conducting a systematic review of how outcomes are currently reported following PNI and (2) a Delphi process to gain consensus on the measures to include in the core outcome set for PNI. In the Delphi process, two online rounds will be used to gather consensus on the importance of each outcome measure. A final round will be conducted in person to discuss and resolve measures for which there is not yet consensus and to finalise the core outcomes set.

Conclusions: Through this process, a common standard for reporting outcomes after PNI will be created, facilitating collaboration and future research.

Background: The transfer of latissimus dorsi (LD) and teres major (TM) have been described for restoration of external rotation (ER) and shoulder abduction in neonatal brachial plexus palsy (NBPP). The aim of this prospective randomised study is to compare the outcomes of LD versus TM transfer in the treatment of internal rotation contracture of the shoulder in children with NBPP.

Methods: The study was conducted from February 2014 to January 2018 and included NBPP patients with internal rotation contracture of the shoulder. Patients were randomised to either LD (Group 1) or TM (Group 2) tendon transfer. Patients were followed up for at least 38 months and assessed for improvements in the arc of shoulder abduction and ER.

Results: The study included 30 patients with 15 patients randomised to each group respectively. Group 1 (n = 15) included 4 boys and 11 girls with a mean age of 2 years and 8 months (range: 1.5–5) and a mean follow-up of 62 months (range: 38–68). Group 2 (n = 15) included 6 boys and 9 girls with a mean age of 2 years and 6 months (range: 1.5–4.8) and a mean follow-up of 58 months (range: 38–68). All patients showed improvement in shoulder abduction and active and passive ER. There were no differences in shoulder abduction (p = 0.467), active ER (p = 0.124) and passive ER (p = 0.756) between both groups.

Conclusions: Both LD and TM tendon transfers improved shoulder function in NBPP patients with internal rotation contracture of the shoulder.

Level of Evidence: Level II (Therapeutic)

Background: The purpose of this study was to conduct an updated survey of American Society for Surgery of the Hand (ASSH) membership to evaluate current preferences for surgical management of thumb CMC arthritis. Past surveys have demonstrated LRTI to be the most preferred surgical technique. We hypothesised that current surgical preferences for thumb CMC arthritis have changed over the last several years due to rising popularity of high-strength suture implants.

Methods: A 22-question survey inquired about the preferences for the surgical management of basal joint arthritis and was sent to the ASSH membership. Descriptive statistics were calculated on all survey questions. Chi-squared analysis was used to compare differences in thumb CMC arthroplasty preferences across respondents.

Results: A total of 1,499 responses were available for analysis, yielding a response rate of 29.9%. For surgical management of basal joint arthritis in the primary setting, the largest percentage of respondents preferred open trapeziectomy with suture suspension arthroplasty (39.2%); amongst them, over half (56%) used a high-strength suture implant. This was followed by open trapeziectomy with LRTI (38.3%). In the revision setting, most respondents preferred open trapeziectomy with suture suspension arthroplasty (53.5%), followed by LRTI (24.6%). In determining the choice of procedure, respondents felt some form of metacarpal suspension and implant cost to be more important factors than ligament reconstruction and interposition. A higher proportion of international members (16.2%) utilised implant arthroplasty than US/Canadian members (1.1%; p < 0.01).

Conclusions: Past surveys have demonstrated LRTI to be the most preferred surgical technique. The current survey demonstrates open trapeziectomy and suture suspension arthroplasty, especially using high-strength suture implants, gaining popularity amongst surgeons, while open trapeziectomy and LRTI decreasing in preference. Suture suspension arthroplasty is now the preferred surgical technique in both the primary and revision setting.

Level of Evidence: Level IV (Therapeutic)

Background: Thumb carpometacarpal (CMC) arthritis is a painful and debilitating condition, which in severe cases may be treated by surgery. Previous studies have emphasised the importance of rehabilitation following surgery to achieve optimal results. This study aimed to investigate whether intensive hand therapy is effective in improving hand functions after arthroscopic partial trapeziectomy with suture-button (SB) suspensionplasty in patients with thumb CMC arthritis.

Methods: This was a retrospective observational study that used non-randomised historical controls. Patients who underwent arthroscopic partial trapeziectomy with SB suspensionplasty were divided into two groups according to whether they had postoperative hand therapy or not (hand therapy group, n = 12; no hand therapy group, n = 11). CMC joint pain, range of motion (ROM), grip and pinch strength in the operative side and Quick Disability of the Arm, Shoulder and Hand (QuickDASH) score were compared before surgery and at the final follow-up for each group.

Results: CMC joint pain, ROM and QuickDASH scores significantly improved following surgery, in both groups. Conversely, postoperative grip and pinch strength only increased significantly in the hand therapy group (grip strength: effect size = 0.36, pinch strength: effect size = 0.44).

Conclusions: This study demonstrates that early-stage intensive hand therapy is an effective intervention after arthroscopic partial trapeziectomy with SB suspensionplasty, specifically for improving grip and pinch strength.

Level of Evidence: Level III (Therapeutic)

Background: Several studies have described pathology in relation to transverse sigmoid notch morphology, using the Tolat transverse sigmoid notch classification. It is believed that the entire shape of a sigmoid notch can be described using Tolat sigmoid types. We hypothesised that the determination of the sigmoid notch shape (SNS) depends on the level of the transverse CT plane on the axial axis of the distal radius. The aim of this study was to determine and compare the transverse SNS on different axial CT levels in the same wrist.

Methods: The transverse SNS of 53 participants were independently qualitatively classified by two researchers in accordance with the four morphologies described by Tolat et al. The SNS was determined at two levels on the axial axis of the distal radius; at the level of the most prominent part of Lister tubercle, determined on the sagittal plane and at the level of the ‘smallest distance between the ulnar head and sigmoid notch’ (SDUS).

Results: Forty-seven percent of the wrists demonstrated different SNS types according to Tolat classification, depending on the axial level of the CT scan. Interobserver agreement on the transverse sigmoid shape was 87% at Lister tubercle and 85% at SDUS, which can both be interpreted as ‘excellent’.

Conclusions: Despite an excellent interobserver agreement, 47% of the study population had different transverse sigmoid notch types within the same wrist. We, therefore, conclude that Tolat transverse sigmoid classification may not be useful for the description of potential pathology in relation to the sigmoid notch morphology.

Background: Diagnosis of ligamentous wrist injuries can be challenging with the absence of dynamic instability on radiographs. Our aim was to evaluate the accuracy of cone-beam computed tomography (CBCT) arthrography in diagnosing scapholunate ligament (SLL), lunotriquetral ligament (LTL) and triangular fibrocartilage complex (TFCC) injuries.

Methods: A systematic review and literature search were conducted in compliance with Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) and registered at the International Prospective Register of Systematic Reviews, PROSPERO (CRD42024517655). A mixed-effects logistic regression bivariate model was used to estimate summary sensitivity and specificity, and hierarchical summary receiver operating characteristic (HSROC) curves were constructed to determine diagnostic accuracy of CBCT arthrography.

Results: We identified five studies assessing the accuracy of CBCT arthrography against wrist arthrography or intraoperative findings as reference standard. The pooled estimates for sensitivity and specificity of CBCT arthrography was 93% (95% CI 40–100) and 91% (95% CI 81–96) for SLL injuries, 83% (95% CI 37–98) and 64% (95% CI 42–81) for LTL injuries and 78% (95% CI 57–91) and 80% (95% CI 54–93) for TFCC injuries. The area under the curve was 0.91 (95% CI 0.89–0.94), showing an excellent diagnostic accuracy of CBCT arthrography in SLL injuries. CBCT arthrography had an estimated mean effective dose of 3.2 mSv (2.0–4.8).

Conclusions: Our study confirms that CBCT arthrography has an excellent diagnostic accuracy for wrist ligamentous injuries with comparably high sensitivity to conventional arthrography and a better specificity. While further studies with more robust methodology are required to support its implementation in clinical practice, our analysis shows that it is a reliable option and has a promising future.

Level of Evidence: Level III (Diagnostic)

Background: Flexor pollicis longus (FPL) tendon injury is a significant complication following distal radius fractures treated with volar locking plate fixation. We were unable to find any studies investigating the FPL tendon in relation to the distal radius in various functional hand positions. The aim of this study is to comprehensively evaluate FPL tendon location in essential functional hand positions commonly encountered in daily life, including pulp pinch, key pinch, chuck grip, power grip, cylindrical grasp and spherical grasp.

Methods: We assess the position of the FPL tendon and finger flexor tendons concerning the radius in various functional hand positions. Sixty-two wrists in 31 healthy volunteers were examined using transverse ultrasonography at the watershed area of the radius in six different functional hand positions, including pulp pinch, key pinch, chuck grip, power grip, cylindrical grasp and spherical grasp.

Results: The shortest distance between the FPL tendon and radius was observed in the key pinch position with a mean of 3.37 mm, while the cylindrical grasp position showed the farthest distance with a mean of 4.21 mm.

Conclusions: The location of the FPL tendon and finger flexor tendons varies across different functional hand positions. Our study shows that these tendons are closest to the radius when the hand is in the key pinch position.

Level of Evidence: Level IV (Diagnostic)

Background: This study evaluated operating room (OR) space required for various hand surgical procedures. We analysed the size requirements for hand surgical cases divided into four settings: (1) large OR setting requiring fluoroscopy and microsurgical equipment, (2) medium-sized OR setting for cases requiring fluoroscopy, (3) smaller OR setting and (4) minor procedural room without anaesthesia with the aim to describe room size requirements for hand surgery practices.

Methods: A variety of hand surgical cases were selected: large cases (microvascular digit replantation), medium-sized cases (closed reduction percutaneous pinning [CRPP] of phalangeal fractures) and smaller cases (carpal tunnel release [CTR]) with and without anaesthesia. Space requirements were compared to general surgery cases (laparoscopic appendectomy) and general orthopaedic surgery cases (cephalomedullary nail [CMN]). Necessary operative equipment was measured (ft²) to calculate requirements for each procedure.

Results: Large hand cases such as digit replantation necessitated the most OR space (125 ft²), followed by general orthopaedic cases (CMN; 118 ft²), medium-sized hand cases (CRPP phalanx; 107 ft²), general surgery laparoscopic appendectomy (68 ft²), small hand cases (CTR; 85 ft²) and minor procedures (49 ft²).

Conclusions: Hand procedures can be divided into major procedures requiring significant OR space (125 ft²), medium procedures in standard OR suites (107 ft²), procedures in small ORs with anaesthesia (81 ft²) or office-based setting without anaesthesia (49 ft²). These findings help define space utilisation for hand procedures and may have practical implications related to efficiency, cost and patient safety in the hospital and outpatient setting.

Level of Evidence: Level IV (Economic and Decision Analyses)

Poncet disease (PD) is a rare form of reactive polyarthritis associated with acute tuberculosis (TB). Multiple TB foci are rare in PD, particularly on the hands. Herein, we describe a case of PD with foci in the trapezium and spine of a 76-year-old man. His medical history included knee arthritis as well as hand and lumbar pain. Radiography and magnetic resonance imaging revealed lytic lesions in the trapezium and spine, which were suspected to be caused by TB infection. An open biopsy of the trapezium and spine was performed. The biopsy results revealed dry necrosis and epithelioid granulation. The diagnosis of PD was made, and the patient was referred to a TB specialty hospital. Our results highlight the importance of considering PD in older patients with multiple TB foci, especially on the hands.

Level of Evidence: Level V (Therapeutic)