Journal of Hand Surgery (European Volume)

The clinical results of past and current hinge, flexible and third generation designs of MP prosthetic joints are reviewed. The hinged prostheses did not achieve acceptable short term clinical results while the silastic and third generation prostheses provided good results with correction of deformity and adequate range of motion (ROM). These good short term results did, however, get progressively worse with the recurrence of deformities and loss of ROM. It is evident that while most of the existing prostheses can relieve pain and restore appearance, none provide the degree of stability and ROM that is required to restore normal function to the MP joint. The moderate results could be partly due to the stage of the disease at which the surgery is carried out. At present, surgery on patients with rheumatoid arthritis is undertaken at a stage in the disease where the muscles and the ligaments surrounding the joint, and the bone, are generally in a poor condition. Surgery at this stage is really only a salvage procedure.

A technique of IP joint arthroplasty is described using costal cartilage with accompanying perichondrium. All patients presented following trauma to the IP joints; their ages ranging from 15 to 45 years. Five out of six cases showed improvement of symptoms and function following reconstruction of the traumatized joint.

19 patients (mean age 59.8 years) underwent fibrous stabilization of the wrist for rheumatoid arthritis. 17 patients were reviewed after a mean follow up of 24.5 months (range 13–40 months). There were four excellent, 11 good, and two poor results according to modified Koka and D’Arcy (1989) criteria. The poor results were due to deep infection in one patient and an unbalanced wrist due to ruptured radial extensors in another. The pre-operative range of wrist movement was an important determinant of the frequency of radio-carpal and/or mid-carpal fusion and the final post-operative range of movement.

Radio-lunate arthrodesis of the rheumatoid wrist is an established technique which has been in use for more than 12 years. The evolution of 26 operated wrists and 20 non-operated wrists has been studied with a mean follow-up of 5 years. The results show that although radio-lunate arthrodesis can prevent dislocation of an unstable wrist, it cannot prevent deterioration. Collapse, ulnar translation, tilt of the lunate, and the inter-carpal instability continued with time, whether the wrists were operated on or not. The speed of deterioration was dependent on the type of rheumatoid arthritis and is faster in the disintegration type than in the osteoarthritis or the ankylosis type. The technique is applicable to the osteoarthritis type of rheumatoid arthritis, in the middle stage (2 to 4a according to the Larsen-Alnot classification). At that stage, the ankylosis type and the disintegration type, and the osteoarthritis type at an advanced stage, are better treated by total arthrodesis or total prosthetic arthroplasty.

11 male patients with rheumatoid arthritis and 14 with osteoarthritis had total arthrodesis of the wrist. All patients with rheumatoid arthritis and ten (71%) of those with osteoarthritis had distal ulnar excision, two of the latter as a secondary procedure for impingement. Seven patients with osteoarthritis and none of the rheumatoid patients developed painful instability of the distal end of the ulna following excision. It is suggested that, in male patients with rheumatoid arthritis, distal ulnar excision with wrist arthrodesis produces excellent results with no complications. However, in male patients with osteoarthritis attempts should be made to avoid excessive shortening and ulnar impingement. If distal ulnar surgery is required, a procedure that does not affect the stability of the distal radio-ulnar joint should be performed rather than distal ulnar excision.

The rotational stability of the proximal carpal row was tested on six unembalmed human cadaver hand specimens. The physiological load conditions were simulated by loading the wrist flexor and extensor tendons. Pure torque was introduced to the lunate, scaphoid and triquetrum, one at a time, by means of a dynamometer wrench, forcing the bones loaded to perform a flexion-extension motion. A truly stable state of equilibrium could be found in the normal wrist only under axial load. A uni-directional coupling was observed through the scapho-lunate ligament as a counteraction to a tendency for the lunate to extend and the scaphoid to flex. The triquetrum and lunate moved together, showing close coupling in both directions. As conclusion: a stable wrist can be defined as one which, while being loaded within a physiological range of stress, does not deviate from a stable state of equilibrium (the ability to return to a single position when disturbed) at any point within the whole physiological range of motion.

Analysis of radiographs of 52 wrists showed that, from ulnar to radial deviation, the amount of scaphoid shortening and ulnar translation of the scaphoid varies in a normal distribution. There is a significant correlation between the two measurements, such that the more the scaphoid shortens the less it translates and vice versa. Females subjects were more likely to have greater scaphoid shortening and less translation. It is felt that carpal kinematics thus cover a spectrum from the “row” theory to the “column” theory which is normally distributed and that women are more likely to have a column type wrist. This variation may affect the result of treatment of scapho-lunate dissociation by techniques such as scapho-lunate fusion. A “CR index” is proposed so that the tendency of a wrist towards row or column theory can be quantified. This may be used to predict the success of some surgical procedures in the treatment of scapho-lunate dissociation.

Seven wrists in six patients with ulno-carpal abutment syndrome were treated by a subchondral distal ulna resection (wafer procedure). The average follow-up was 36 months. Wrist function was evaluated using a clinical scoring chart. The parameters were pain, range of motion, grip strength and activities. One patient had a poor result, one a fair result and the remaining had good to excellent results. In all cases grip strength showed dramatic improvement. Complications were limited to palpable subcutaneous nylon sutures requiring removal in three patients and extensor carpi ulnaris tendinitis in one.

One female and seven male patients (median age 25.5) presented with traumatic avulsion of the triangular fibrocartilage complex (TFCC), type 1B according to Palmer’s classification. Reattachment of the TFCC near its anchoring point was combined with an intraarticular shortening osteotomy of the ulnar head. This provides an excellent approach to the TFCC and a well vascularized anchoring surface. The mooring point is biomechanically appropriate and the tissues with the best biomechanical properties are used. The functional results with a mean follow-up of 3 years were encouraging, as demonstrated by the significant improvement of pain (P = 0.017). All patients were able to return to their previous occupation; no further surgery was necessary to the distal radio-ulnar joint and no impairment of pronation and supination was detected. The final wrist score reflects the subjective results defined by the patient. However the correlation is not linear and the wrist scores are superior to the degree of satisfaction defined by the patient.

Isolated dislocation of trapezoid is rare. We report here a new case of open dorsal dislocation of the trapezoid following a high energy crush injury of the left hand in a factory worker. It was associated with multidigital mutUation and metacarpal fractures.

Stereoscopic macroradiography was used to study the pattern of union of scaphoid fractures. Of 21 patients who had partial union of a scaphoid fracture, 13 united on the ulnar side and five on the radial side only. In three it was on both sides but delayed in the centre. Where there was initial union on the ulnar side, all progressed to complete union, including two patients with displaced fractures. Four out of five patients with initial union on the radial side had displaced fractures, and three of these went on to non-union. We conclude that in those patients with partial union of a scaphoid fracture, if union is seen on the ulnar side, the fracture is likely to unite completely, whereas if there is partial union on the radial side, there is a high risk of non-union.

For appraisal of anterior wedge-shaped grafts for the humpback deformity of the scaphoid, a retrospective study of 27 cases with old scaphoid fractures or non-unions was carried out. 11 cases were treated with Herbert screw fixation and anterior wedge-shaped graft and the other cases with other methods. For the assessment of carpal alignment, radio-lunate and scapho-lunate angles were measured with peri-operative radiographs. For the clinical assessment, the scoring system of Cooney was applied. In 25 cases, primary bone union was obtained with one attempt and in two cases, with the second operation. Union was achieved in a mean of 3.4 months. The post-operative wrist score ranged from 65 to 100 with an average 81.2 points. There was a statistically significant relationship between the wrist score and the post-operative scapho-lunate angulation of the affected wrist. The humpback deformity of scaphoid non-union should be treated precisely with carpal realignment surgery or anterior wedge-shaped bone graft.

32 patients with scaphoid non-union were examined to clarify the relationship between pre-operative radiographic sclerosis in the proximal fragment and signal intensity on magnetic resonance imaging (MRI). In addition, the correlation between changes in signal intensity in the proximal fragment and surgical outcome after bone grafting and internal fixation was investigated. Proximal fragment sclerosis was observed in seven patients. Comparison of the T1 and T2-weighted images with those of the 25 patients without proximal fragment sclerosis revealed no differences. Therefore, there was no relationship between sclerotic changes on plain radiography and the degree of avascularity of the proximal fragment assessed by MRI. None of the patients who had low signal intensity on both T1 and T2-weighted images achieved union within 5 months after surgery. Thus the detection of signal intensity on both T1 and T2-weighted images can be useful to predict the prognosis after the surgery.

A case of volar dislocation of the lunate, associated with transient ulnar nerve palsy, is described in a 39-year-old man, with temporary avascular changes of the left lunate.

A case of median nerve injury caused by an unsuspected foreign body is described. The mechanism was not recognized at the time of injury. The suspicion of a penetrating missile injury was raised only with the aid of radiographs. At operation the foreign body was found in the substance of the median nerve.

28 patients with low velocity gunshot wounds of the brachial plexus were treated at Groote Schuur Hospital from 1980 to 1991. Delayed exploration of the brachial plexus (up to 7 months after injury) was performed in nine (30%) of the patients. The other 19 patients did not have exploration of the plexus; most of these patients showed signs of recovery within 2 to 4 weeks of injury. Injury to the subclavian or axillary artery occurred in nine (30%) of the cases.

The average length of follow-up of the patients was 19 months (range 2–90 months). Of the 19 patients treated non-operatively, 15 (79%) had an excellent or good result and four (21%) a fair result. The indications for surgery were the absence of improvement within 3 months of injury or persistent pain. Surgery was indicated for significant pain in five of the nine patients; post-operatively two had complete relief of pain, two improvement in the pain and one no improvement. Of the nine surgically treated patients, three (33%) had a good result, two (22%) a fair result and four (45%) a poor result. The potential for recovery was not dependent on the severity of the injury at presentation or the presence of vascular injury but on the appearance of signs of recovery within 4 weeks of injury.

The middle trunk of an injured brachial plexus was reconstructed using a vascularized graft of the lower trunk, which was expendable because of irreparable damage to the C8 and T1 nerve roots. The graft was transferred on a vascular pedicle of mesoneurium. Useful recovery was achieved at 3 years. This technique helps to overcome the problems of limited supply and secondary sensory deficit of grafts from peripheral nerves, but is possible only if the plexus is explored early, before mobilization and transfer of nerve trunks is precluded by scarring.

A 68-year-old lady developed digital pain within days of the excision of a palmar ganglion. This was found to be due to a mass of hyperplastic Pacinian corpuscles compressing the digital nerve. Immunohistochemistry was carried out on the resected corpuscles using antisera to a range of neuropeptides. Possible mechanisms of hyperplasia are discussed.

Single portal endoscopic carpal tunnel release was carried out in 107 hands of 88 patients. There were 11 complications. These included incomplete release (2), post operative scarring around the median and ulnar nerves (2), laceration of the superficial palmar arterial arch (1), reflex sympathetic dystrophy (2), palmar fasciitis (1), and wound inflammation (3).

In two cases there was no relief of symptoms. In one there was incorrect diagnosis and in another, incorrect indication for endoscopic carpal tunnel release. The follow-up was from 3 to 18 months with an average of 6.8 months. The overall results of the patients in this series are being presented in another paper. Of the 107 procedures, 73 were rated as having an excellent, 25 good, three fair, and six poor results.

The case of laceration of the superficial palmar arterial arch is discussed in detail in the paper. The two cases of reflex sympathetic dystrophy and the one case of palmar fasciitis had mild clinical features and resolved within 3 months. The inflammation in three of the wounds at the wrist resolved within 2 days of removal of the percutaneous sutures. These three patients had returned to heavy hand activities within a few days of surgery.

A prospective randomized study was undertaken of 50 consecutive patients undergoing surgery for idiopathic carpal tunnel syndrome to determine the value of splintage of the wrist following open carpal tunnel release. Patients were randomized to either be splinted for 2 weeks following surgery or to begin range-of-motion exercises on the first post-operative day. Subjects were evaluated at 2 weeks, 1 month, 3 months, and 6 months after surgery by motor and sensory testing, physical examination, and a questionnaire. Variables assessed included date of return to activities of daily living, dates of return to work at light duty and at full duty, pain level, grip strength, key pinch strength, and occurrence of complications. Patients who were splinted had significant delays in return to activities of daily living, return to work at light and full duty, and in recovery of grip and key pinch strength. Patients with splinted wrists experienced increased pain and scar tenderness in the first month after surgery; otherwise there was no difference between the groups in the incidence of complications. We conclude that splinting the wrist following open release of the flexor retinaculum is largely detrimental, although it may have a role in preventing the rare but significant complications of bowstringing of the tendons or entrapment of the median nerve in scar tissue. We recommend a home physiotherapy programme in which the wrist and fingers are exercised separately to avoid simultaneous finger and wrist flexion, which is the position most prone to cause bowstringing.

Provision of stable sensate skin is of great importance in reconstruction of the injured thumb. Island flaps based on the dorsal metacarpal arteries were used to resurface ten injured thumbs, and the degree of retained sensibility was assessed using static and moving two-point discrimination and the pick-up test. Results show that these flaps are capable of providing stable full-thickness skin cover in a single procedure and functional sensibility is retained in most cases.

The second dorsal metacarpal artery island flap, previously advocated for use in small thumb defects only, has been successfully used as a large wraparound flap in two cases. In one of these it was used with free bone graft to increase the length of the thumb and an excellent functional result was achieved.

The incidence of cold-induced vasospasm after hand injuries has been reported to be as high as 100%, following replanted digital amputations. The exact cause of this problem is obscure, no specific treatment is available and little is known about the long-term prognosis. Further knowledge is therefore needed in order to advise patients concerning future job potential at an early stage. In a previous paper we evaluated the incidence and severity of cold intolerance 2 years after digital replantation. The incidence of cold-induced vasospasm then was high as well as the discomfort experienced by the patients. We carried out a follow-up of patients previously examined 10 years ago. Our results show that cold induced vasospasm in replanted digits does not improve with time. Patients with moderate symptoms may perceive improvement, probably due to a change of habits. Patients with severe problems did not experience improvement and should be given early advice to seek work in warm surroundings to reduce the discomfort.

Historical descriptions of the ulnar artery as the dominant vessel to the hand appear to be inconsistent with clinical experience. Anatomical dissections and radionucleotide flow studies of the ulnar and radial arteries at the wrist were performed. These failed to demonstrate any difference between the anatomical dimensions of these vessels, but the radial artery was shown to have a statistically greater blood flow compared to the ulnar artery. This finding suggests that, contrary to popular opinion, the radial artery is the dominant vessel to the hand.

We present a previously undescribed injury of avulsion of the ulnar collateral ligament of the thumb IP joint. Stress radiographs may be used to confirm the diagnosis in cases of clinical suspicion.

The recent development of small bone suture anchors has created potential applications in reconstructive surgery of the hand and wrist. A combined laboratory and clinical study was devised to evaluate their use. 16 paired fingers (32 in all) from eight cadaveric hands were disarticulated at the MP joint with a 10 cm tail of FDP tendon. The FDP insertion was released in all specimens. In 16 fingers reinsertion was performed with the classic Bunnell technique; in the paired 16 fingers, the repair utilized Acufex 2 mm anchors.

There was no significant difference between the two groups regarding load-to-failure at approximately 40 Newtons. The mean stiffness of the anchor repairs was significantly greater than the Bunnell repairs.

19 consecutive patients were prospectively enrolled with a tendon or ligament repair of the hand or wrist using bone anchors. The average age was 41 years and the average length of follow-up was 24 months. All repairs were stable at the time of follow-up. Bone anchors were simple to insert, required less dissection and surgical time than the Bunnell technique and appeared to be reliable in both laboratory and clinical settings.

Three cases of hamato-metacarpal fracture-dislocation with fracture of the shaft or base of the fourth metacarpal and dorsal dislocation of the fifth metacarpal are described. In one case this was associated with coronal fracture of the hamate. An oblique radiograph of the hand with the forearm pronated 15° and 45° provided a good view of the extent of the fourth and fifth carpometacarpal injury. Treatment with open reduction and internal fixation achieves good clinical results.

A case of traumatic, simultaneous, double dislocation of the fifth metacarpal bone is presented. Closed reduction was easily achieved and held with transarticular, crossed Kirschner wire fixation.

Unstable dorsal fracture dislocations of the PIP joint of a finger commonly result in joint stiffness following immobilization or open reduction and internal fixation (Green and Rowland, 1984). The Agee dynamic external fixator, or force couple splint (Agee, 1978Agee, 1987), was introduced in an attempt to avoid this complication and maintains a concentric reduction whilst allowing a full range of joint movement. The splint is constructed from three Kirschner wires and is activated by a single rubber band. A force couple is created across the proximal interphalangeal joint levering the base of the middle phalanx towards the palm whilst simultaneously lifting the distal end of the proximal phalanx dorsally to restore joint reduction. However, this technique is not without complications (Agee, 1987). We report a swan-neck deformity resulting from this treatment.

Many fingertip injuries in childhood involve the nail bed. Deformities of the nail are a frequent result of failure to repair the nail bed at the time of injury. Secondary correction of nail deformities seldom achieves good results. We present the results of our experience in the management of 19 children with 22 injuries involving the nail bed. All achieved normal nail growth and the overall result of the repair was good in 91%. Complications were few and parental satisfaction with the management was high. Every effort should be made to perform a meticulous primary repair of all nail bed injuries.

207 cases of digital amputation (261 digits) with vascular defects were replantated during the past two decades. The vascular defect was managed with various methods. 240 digits (92%) survived with good post-operative circulation and recovery of function. The methods of management of arterial defects were as follows: 1) Digital artery transfer from adjacent digits in 25 thumbs and three index fingers. All had survived. 2) Arterial transplantation: in 12 digits, arteries from the contralateral side or from the digits that were unsuitable for replantation were grafted to fill the arterial defects. All of these fingers survived. 3) Vein graft: superficial veins were taken to reconstruct the defects of the digital arteries in 59 digits, with 55 digits surviving and four failing. 4) Ulnar digital arterial flap of the ring finger. This technique was used in four digits with composite artery and soft tissue loss. All the cases survived. 5) Implantation of the arteries into the distal amputation parts. This was done in two digits with no arteries for anastomosis in the distal parts. The management of venous defects was as follows: 1) Transfer of veins from the adjacent digits. Five digits treated with this technique survived well. 2) Vein graft. Six digits survived but one failed. 3) A venous flap was done in six digits and all the digits survived after this procedure. 4) Arterio-venous anastomosis: this was used in 20 digits without suitable veins for anastomosis in replantation of the digit distal to the DIP joint level. 5) Replantation without venous return: a fish-mouth incision and heparin irrigation was used for venous drainage in 19 digits, with survival of 14. 6) The palmar venous system was anastomosed in 84 digits without dorsal veins for suture. 77 digits survived. 7) Venous fascial flap transfer: A composite venous fascial flap was harvested from the adjacent fingers. The flap was turned over on the side close to the injured finger to make an anastomosis of the veins with those in the distal amputated part. A skin graft was placed over the flap without a tie-over dressing. The pedicle was divided 3 weeks later. All the 16 digits with this technique survived well.

In five cases of total root avulsion injury of brachial plexus, the thenar branch of the median nerve and the deep branch of the ulnar nerve were sutured to the branches of the femoral nerve during the procedure of intercostal, phrenic, accessory nerve transfer to the nerve trunks. The suture of the distal median or ulnar nerve in the hand to the femoral nerve was to maintain intrinsic muscles and prevent their atropy before arrival of nerve regeneration from the proximal end. The suture of the nerves was protected by wrapping it by abdominal flaps. The median and the ulnar nerve branches were separated from the femoral nerve when the NAP or SEP became detectable (about 1.5 years after the initial surgery). Good function of intrinsic muscles of the hand was observed in these five cases during the course of follow-up of the initial surgery, but the nerve recovery was not good after resuture of the median and the ulnar nerves. It was suggested from this preliminary clinical observation that suture of the distal median and ulnar nerves with the other nerves is effective in preservation of intrinsic muscle function, but recovery of intrinsic muscle function by resuture of the median and the ulnar nerves is not good.

A new technique of qualitative staining of peripheral nerve fibres was developed using the technique of enzyme-linked immunosorbent assays (ELISA). In 15 Wistar rats and five Harbin rabbits, the antibody IgGs labelled with rabbit-anti-rat enzyme was prepared. This was used to stain the sural nerves of the rats. In six sheep and human sural, radial and posterior interosseous nerves taken from fresh cadavers, the antibody IgGs labelled with sheep-anti-human enzyme was made. Nerve slices were sectioned from the nerve trunks and reacted with the enzyme-labelled antibody IgGs serum. The rat sural nerve and human sural, radial and posterior interosseous nerves showed good contrast of staining 25 minutes later. The sensory nerve fascicles were stained blue or brown blue, but the motor fascicles were negative. The period of staining was tested at 25 minutes, 55 minutes, and 115 minutes, and no obvious difference was observed in the colour of staining in these three groups. This technique was used in six nerves (two radial, two median, one ulnar and one tibial) in clinical cases. Differentiation of the sensory and motor nerve fascicles was possible. Contrast of colour in nerves at secondary nerve repair was less obvious than that in primary repair.

This paper reports the clinical results of reconstructing flexor tendon sheath by a chemically treated absorbable semi-permeable polylactic membrane. This membrane was shown in previous experimental studies to be absorbed 24 weeks after operation and created a good pseudosynovial sheath for tendon gliding. Since January 1989, 80 cases (110 fingers) with flexor tendon lacerations in zone 2 were treated by this technique. These included 52 fingers with primary tendon repair and 58 fingers with free tendon grafts at secondary surgery. The biological membrane was used to repair the defect of the sheath in primary surgery, and in secondary tendon grafting the membrane was wrapped as a tube around the graft and fixed to the graft by suture at its distal end and to the A1 pulley in its proximal end. Controlled passive finger flexion using Kleinert rubber band fraction was commenced 3 days after surgery and active motion after 3 weeks. The cases were followed for 1 to 4 years. The results of repair were excellent in 29 fingers, good in 54, fair in 15, and poor in 3 by the TAM system. The rate of excellent and good results was 82.0%. One case of primary repair developed rupture of the repair due to wound infection.

The dissociated Schwann cells (SCs) taken from the adult rat sciatic nerve undergoing Wallerian degeneration were cultured in serum-free medium. The SCs serum-free conditioned medium (SC-SF-CM) was collected, ultrafiltrated and concentrated. The proteins secreted by SCs in SC-SF-CM ultrafiltrated-concentrated solution were analyzed by SDS-PAGE. It was found that there were 14 protein bands, which molecular weight were from more than 94 KDa to less than 43 KDa, with their main band at 65 KDa. By immunoblotting (Western Blot) for anti-2.5S NGF antibody, NGF was identified to exist in the proteins secreted by SCs. SC-SF-CM ultrafiltrated-concentrated solution was also separated by Disc-PAGE at 4°C, then electroluted, concentrated and collected. By biological activity examination for motor neuro-trophic substances, one protein zone (B⁺) of these was identified to have motor NTF activity, which contain five protein bands from 65 KDa to 34 KDa.