Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the Asia-Pacific Federation of Societies for Surgery of the Hand最新文献

The objective of this report is to present a case of hand burn linear contracture release performed under local anesthesia. It also introduces the one-per-mil tumescent solution consisted of 0.2% lidocaine and 1:1.000.000 epinephrine as a local anesthesia formula, which has the potential of providing adequate anesthesia as well as hemostatic effect during surgery of the hand without tourniquet. The surgery was performed on a 19 year-old male patient with multiple thumb and fingers flexion linear contracture for 105 minutes without any obstacle. The patient did not complain any pain and discomfort during the procedure; while bloodless operative field was successfully achieved. At four-month follow up, the patient could fully extend his thumb, middle and ring finger, while the index was limited by 10° at the DIP joint. Overall, the patient was satisfied with the outcome.

Soft tissue sarcomas in the thumb are rare, but often require amputation to ensure tumour clearance. This can severely impair the use of the entire upper limb and negatively impact quality of life. We describe a 63-year-old male patient with a large malignant fibrous histiocytoma affecting the base of his dominant right thumb. A wide resection of this tumour was performed, followed immediately by index finger pollicization and first web space reconstruction with a reverse pedicled posterior interosseous artery flap. The patient was able to continue using his right hand for functions of daily living and was free from local recurrence until he died from distant metastases 2 years later. Primary thumb reconstruction following amputation for sarcoma can allow a patient to retain useful hand function postoperatively. Provided that strict principles of tumour clearance are adhered to, this need not compromise local recurrence rates.

Background: This study investigated the exact failure mechanisms of the most commonly used conventional tendon repair techniques. A new method, radiographing repair constructs in antero-posterior and lateral projections before and after tensioning was used. This allowed to precisely analyse failure mechanisms in regards to geometrical changes in all three dimensions. Additionally the biomechanical stability focusing on gapping was tested.

Methods: Sheep fore limb deep flexor tendons were harvested and divided in eight groups of ten tendons. Three common variants of the Kessler repair method and four common 4-strand repair techniques were tested. Additionally a new modification of the Adelaide repair was tested.

Results: Biomechanical testing showed no significant differences in gapping for the three tested 2-strand Kessler repair groups. Once a double Kessler or 4-strand Kessler repair was performed the stability of the repair improved significantly. Further significant improvements in biomechanical stability could be achieved by using cross locks in the repair like in the Adelaide repair method. Qualitative analysis using radiographs showed that all Kessler repair variants unfolded via rotations around the transverse suturing component, no matter which variant was used.

Conclusions: Additional to the commonly described constriction of the repair construct, the rotating deformation is the main reason for repair site gapping in Kessler tendon repair methods. The term "locking" in a Kessler repair is misleading. The cruciate repairs tended to loose grip and drag (cheese-wire) through the tendon and therefore lead to gapping. The most stable repair constructs in all three dimensions were the Adelaide repair and its interlocking modification. This is due to the superior anchoring qualities of its cross locks and three dimensional stability.

Background: To present the efficacy of 1:1,000,000 tumescent solution for resection of vascular malformation in hand and upper extremity without tourniquet application.

Methods: Four patients with five slow flow vascular malformations were retrospectively reviewed. Prior to incision, 1:1,000,000 tumescent solution was infiltrated subcutaneously surrounding the lesion until the skin turned pale. Amount of tumescent solution injected, the length of surgery, the clarity of the operative field, and the complications were recorded. Clarity of operative field was categorized as totally bloodless, minimum bleeding, acceptable bleeding, and bloody. In the surgeries under local anesthesia, we also recorded self-reported intra-operative pain using VAS score, onset of pain, and conversion of anesthesia.

Results: The injected amount of the tumescent solution ranged from 4.5 to 200 mL, with the length of surgery ranged from 60 to 150 minutes. One out of 5 cases was totally bloodless, 3 cases were minimum bleeding and 1 case was acceptable bleeding. Minor skin necrosis was recorded in 1 patient. Neither intra-operative pain nor conversion from local to general anesthesia was reported.

Conclusions: 1:1,000,000 tumescent solution is effective for resection of slow flow vascular malformation in hand and upper extremity without tourniquet application.

We report the case of an 18-years-old patient with thumb carpometacarpal ligament laxity due to Ehlers-Danlos syndrome who was treated with trapezial opening wedge osteotomy combined with volar ligaments reconstruction. Two years postoperatively she is pain free and the thumb carpometacarpal joint is stable.

With advances in imaging and computing technology the greater capacity to diagnose, plan and deliver care to patients with hand and wrist disorder is being realised. Work in our laboratory, has been able to identify certain specific rules that control wrist motion, and is a step on the pathway to creating a unified theory of carpal mechanics which will incorporate a kinetic biomechanical model. This will allow more precise anatomically based as well as quantitative diagnoses, but also an ability to test a proposed intervention in a "what if" scenario.

Background: This report utilizes 11 years (2003-2013) of clinical records of patients for a retrospective evaluation of the effectiveness of various combinations of diagnostic methods, treatment options and surgical procedures to try to determine the optimal combinations to improve the rate of success for the treatment of septic wrist arthritis.

Methods: Analysis of records of 40 patients treated for septic wrist arthritis in our hospital involving records of physical examination, full blood analysis, biochemical, microbial profiles, type of surgical intervention, length of stay, number of surgical interventions to resolution and the rate of morbidity and mortality. The patients were subdivided into 2 groups, consisting of 6 (mortality) in one group and 34 (non-mortality) in the other. The various parameters as listed above were compared for differences. The patient records included those from immunocompromised elderly patients, with other existing medical complications such as gout, pseudogout, cellulitis and arthritic flare that made accurate diagnosis of septic wrist arthritis challenging.

Results: There is a trend showing better success in the treatment of septic wrist arthritis among patients without co-morbid medical problems. Due to the unavoidable delays in microbial identification, it was noted that escalation of antibiotics should be adopted especially for the immunocompromised patients.

Conclusions: Staphylococcus aureus, the most common microbial pathogen in our findings, point to the need to adopt a lower threshold for escalation of antibiotics for immunocompromised patients with slow reversal of infection in order to reduce morbidity, mortality, number of surgeries and length of post-operative stay.

Background: The purpose of this study is to audit the clinical and functional outcomes of arthroscopic ganglionectomy (AG) in our centre.

Methods: A retrospective study was conducted on all 29 patients who underwent AG from 2007 to 2012 with a mean clinic and telephone follow-up duration of 6 months and 32 months respectively.

Results: A total of 29 patients (17 women and 12 men) with a mean age of 38 years underwent AG. 15 patients (52%) had associated pain with the lump, 24 out of 29 patients (83%) had preoperative ultrasound to confirm the diagnosis. All patients had preoperative wrist radiographs that showed no chronic carpal instability and bony pathology. 26 out of 29 patients (90%) had dorsal wrist ganglions and 3 patients (10%) had volar wrist ganglions. 15 out of 24 ganglions (62.5%) were multiloculated. Mean ganglion size clinically and through wrist ultrasound was 2.5 cm and 1.8 cm respectively. During arthroscopy, ganglion stalk was identified in 14 patients (48%). Average operating time was 69.5 minutes. Intraoperatively, 24 out of 29 patients (83%) had wrist synovitis and 26 patients (90%) had associated carpal ligament laxity. 97% of cases were successfully resected arthroscopically. Recurrence rate was 10% (3 cases). There was no significant difference between preoperative and postoperative range of motion of wrists - the mean wrist flexion ranged from 63 to 59 degrees pre and postoperatively, and the mean wrist extension ranged from 66 to 64 degrees pre and postoperatively. Overall grip strength improved from 27 kg to 32 kg ([Formula: see text]), and there was also a significant improvement in pain scores pre and post-operatively from visual analogue scale (VAS) score of 0.8 to 0.3 ([Formula: see text]). No major intra or post-operative complications occurred. All patients were satisfied in terms of cosmesis.

Conclusions: AG is a safe and reliable alternative to open resection of wrist ganglions. In addition, it can be used as a diagnostic and therapeutic tool for other wrist conditions.

The Oberg, Manske and Tonkin (OMT) Classification of congenital anomalies of the hand and upper limb uses dysmorphological terminology, placing conditions in one of three groups: Malformations, Deformations and Dysplasias. The main group, Malformations, is further subdivided according to whether the whole of the limb is affected or the hand plate alone, and whether the primary insult involves one of the three axes of limb development and patterning or is non-axial. The common surgical diagnoses, such as thumb duplication and thumb hypoplasia, are then placed within this framework. Recently the International Federation of Societies for Surgery of the Hand Scientific Committee for Congenital Conditions approved the OMT Classification as a timely and appropriate replacement of the previously accepted Swanson Classification. This review charts the development of and modifications to the OMT Classification and its current status.