Journal of Hand Surgery (European Volume)

Prolonged ischaemia sometimes occurs in replantation and free flap surgery. The re-establishment of circulatory flow to the ischaemic tissue leads to a cascade of events which augments tissue necrosis. This paper reviews the pathophysiology of this ischaemia-reperfusion injury and discusses different methods to modulate this injury.

This study compares two currently available prostheses for the reconstruction of rheumatoid joints. A single operator performed 72 resection arthroplasties with Swanson or Sutter prostheses being randomly allocated. Assessment of each patient was carried out preoperatively, and at 6 months and 12 months postoperatively by a single investigator. In the Swanson group an improvement of the flexion arc was seen, from 29° to 44° at 6 months but this reduced to 36° at 12 months. In the Sutter group there was no significant difference between flexion arcs pre- and postoperatively. Grip strength improved in the Swanson group, but not in the Sutter group. Extensor lag was improved in both groups. Patient satisfaction measured by linear analogue scales for pain, function and deformity was high in both groups

Since January 1990, 237 replantations or revascularizations have been attempted in 192 patients with distal traumatic amputations of the digits. The amputations were complete in 182 digits and incomplete in 55 digits. Sixty-three amputations were in zone I and 174 in zone II (Tamai’s classification). The overall success rate was 91%. Twelve digits failed in zone I and ten in zone II. We conclude that zone I and zone II replantation or revascularization is quick and worthwhile, providing acceptable sensation, appearance and near-normal function.

Relatively little is known about the effects of chronic transection on human peripheral nerves. In this study intraoperative biopsies were obtained from proximal and distal nerve stumps and intervening neuromas resected before peripheral nerve reconstruction. Biopsies were collected from ten patients following differing types of nerve injury, with delays to repair ranging from 8 to 53 months. Nerves were examined by light and electron microscopy. In general, reinnervation was poor, although even following the most severe injuries, all of the distal stumps contained some regrowing axons, which were always associated with Schwann cells. Denervated Schwann cells, arranged in typical bands of Bungner were consistently present in each distal stump. Our findings confirm that the morphology of chronically denervated human peripheral nerves is essentially similar to that described in experimental models.

The experiments in this paper were concerned with the recovery of function and ease of application of an entubulation technique using a biodegradable, controlled release glass tube (CRG) for the repair of a transected peripheral nerve. The peroneal nerves of 15 New Zealand White rabbits were repaired with either a CRG tube filled with freeze-thawed muscle, or a conventional freeze thawed muscle graft (FTMG). These were compared with controls in which a CRG was used to enclose the cut ends of a nerve separated by a 1 cm gap. Electrophysiological and morphometric assessment was carried out 6 months after repair. No statistical difference was found in any test between the FTMG and the CRG tube filled with freeze thawed muscle. The CRG tube and 1 cm gap produced inferior levels of recovery of function when compared with the other two repair groups.

The effects of continuous passive motion (CPM) on nerve regeneration following nerve repair were investigated. In 26 rabbits, the medial popliteal nerve was transected and microsurgically repaired. Half of the animals were treated with cast immobilization and the rest with 70° arc CPM. Both treatments were discontinued on day 14. After sacrifice on day 100, no animal showed separation at the suture line. Mean nerve conduction velocity was slightly slower in the CPM than in the immobilization group. Mean fibre density was also slightly less in the CPM group but the difference was not significant. Mean fibre diameters, fibre diameter distributions, and soleus-muscle wet weights were similar in the two groups.

We investigated pressures at 1 cm intervals along the carpal tunnel in 39 patients with carpal tunnel syndrome (CTS) and 12 controls. Pressures were measured for relaxed and gripping hand positions in combination with neutral, extended, and flexed wrist positions. Patient pressures exceeded control pressures, were below the previously reported 30 mmHg threshold for four of five locations in the relaxed neutral position and were typically greater in extension than in flexion. In the neutral position, both patient and control pressures were slightly above threshold levels just distal to the tunnel. Maximum intratunnel pressures were generally found in the central part of the tunnel and minimum pressures in the distal tunnel. Gripping hand pressures in the tunnel were lowest with the wrist flexed. In both controls and CTS patients, only in the neutral wrist and relaxed hand positions were pressures highest at the point where nerve conduction studies have indicated the nerve is most likely to be compromised (in the midpalm just distal to the distal margin of the carpal tunnel).

We prospectively studied 266 hands in 133 patients with carpal tunnel syndrome (CTS) in order to evaluate: the incidence of bilateral CTS symptoms; correlation between severity, duration of symptoms and bilateral occurrence of CTS; agreement of clinical and neurophysiological findings; and the neurophysiological findings in asymptomatic hands in unilateral CTS, The incidence of bilateral clinical CTS in our population was 87%. Neurophysiological impairment of median nerve was observed in about half of the asymptomatic hands. Follow-up of patients with unilateral CTS showed that contralateral symptoms developed in most cases. We found a significant positive correlation of bilateral CTS with the duration of symptoms, whereas there was no correlation with the severity of symptoms. Our data suggest that bilateral impairment of median nerve is the rule in patients with CTS and probably it has been underestimated in previous studies.

We looked for crossing cutaneous nerve branches during standard open carpal tunnel release and attempted to preserve them. Open carpal tunnel release was performed on 34 hands in 29 patients. Crossing cutaneous nerves were identified in 47% of hands and successfully preserved in each case. No patient experienced postoperative pillar pain or scar hypersensitivity.

This is a case report of a 17-year-old youth with carpal tunnel syndrome ant congenital macrodactyly.

Carpal tunnel syndrome is the commonest peripheral compressive neuropathy. Typically, sensory symptoms predominate at presentation with motor dysfunction seen in more chronic cases. Isolated motor compression is rare. We present a case of selective median nerve motor neuropathy caused by a carpal tunnel ganglion.

Anterior transposition of the ulnar nerve is a widely used treatment for cubital tunnel syndrome, but neurolysis performed at the time of surgery may impair the blood supply to the ulnar nerve. This study compared the results of intramuscular anterior transposition of the ulnar nerve with or without preserving the extrinsic vessels of the ulnar nerve in 35 patients. The postoperative nerve conduction velocity and the clinical results were better in the group in which the extrinsic vessels were presented.

This study presents a review of 26 cases of radial tunnel syndrome in 25 patients seen in a single hand consultant’s practice over a period of 2.5 years. The protocol for diagnosis was the reproduction of patient’s symptoms on pressure over a palpable tender spot along the course of the radial tunnel, painful resisted supination or resisted middle finger extension, all of which were abolished on infiltration of the tender area with a local anaesthetic solution. The presence of at least two out of three objective signs was necessary for the diagnosis. Initially all cases were treated conservatively, by steroid injection in 25 and physiotherapy in one, with long-term relief of pain in 16. Nine failures were treated surgically, with complete relief of pain in seven. Radial tunnel syndrome should be considered in the differential diagnosis of pain around the hand and or elbow.

Piezoresistive sensors, applied to the fingertips of non-sensate fingers, were used for the detection of touch and pressure in four patients with recent median nerve repairs, and in one patient using a myoelectric prosthesis. The signals from the sensors, produced by the tactile stimuli, were processed and transposed as electrical stimuli to sensate skin of the ipsi- or contralateral arm by the use of skin electrodes. With this setup the test subjects could rapidly learn to differentiate between tactile stimuli applied to different fingers, thereby regaining spatial, resolution in the hand. All five patients rapidly improved their ability to regulate the power of pinch grip without the help of vision. The patient with a hand prosthesis rapidly learned to discriminate between four different levels of pressure, applied to the thumb by four different Semmes-Weinstein monofilaments (75, 125, 280 and 450 g). These results indicate that the system is of potential value for patients lacking sensibility or using prostheses.

The cellular changes in the epitenon, endotenon and synovial sheath were investigated in a rabbit model after a partial transverse laceration was made on the plantar aspect of the flexor digitorum profundus proximal to the synovial sheath (which was not injured). Fibroblasts, macrophages and mast cells within the epitenon, endotenon and synovial sheath were counted on electron micrographs. The epitenon and uninjured synovial sheath became engorged with fibroblasts and macrophages following injury. The number of synovial fibroblasts showed the greatest increase during the first week after injury, In comparison, the endotenon exhibited a delay in cellular response with initial apoptosis, as judged by positive P53 staining. However, hypercellular activity was seen within the endotenon at 12 weeks postoperatively.

Tendon samples cultured in vitro produced cells (TC) with fibroblast-like morphology and confluence occurred within 5 weeks. Histological staining demonstrated proteoglycan and collagen secretion by TC. Immunohistochemical staining revealed type I collagen but no type III. Assay of total collagen demonstrated a rapid increase in synthesis with time in culture. Cultures allowed to become ‘superconfluent’ spontaneously formed three-dimensional structures after about 4 weeks, which became macroscopic, tendon-like structures (TLS). Cells within TLS seemed under cell-generated tension. Haematoxylin and eosin staining of sections of tendon, of TLS and of TC cultures demonstrated similarities in morphology. These studies were performed using human and rabbit cells and findings were similar for the two species, but with some differences in cell metabolism. Skin fibroblasts were also cultured as a comparison.

A prospective study of postoperative mobilization of flexor tendon repairs in zone 5 was conducted over a 2-year period between 1994 and 1996 using a controlled active motion (active extension - active flexion) regimen of mobilization. Fifty-two patients, who had a total of 151 flexor digitorum superficialis (FDS) and 103 flexor digitorum profundus (FDP) divisions, were available for review at a mean follow-up of 10 months. Of the 161 fingers with division of one or both flexor tendons, 66% exhibited independent FDS function and 90% achieved good or excellent results of digital range of motion. No rupture of an FDP tendon repair occurred during the study period. The data allowed us to define a new method of classifying the results of treatment of these injuries in terms of the injured wrists as a whole and not simply as a series of isolated observations for each individual finger with divided flexor tendons. The results of recovery of independent FDS action and range of finger movement achieved for injuries in which the flexors of all four fingers had been divided indicate a statistically significant interdependence of injuries of finger flexors of adjacent fingers at the wrist. Multivariate analysis showed the presence of a “spaghetti wrist” injury to have a significant adverse effect on the recovery of the independent FDS action but not on the recovery of the digital range of motion.

The need for lateral release or “venting” of the A2 and A4 pulleys either to facilitate repair of the flexor tendon(s) or to allow free gliding of the repair(s) was examined in 126 consecutive zone 2 flexor tendon injuries within the tendon sheath and distal to the distal edge of the A2 pulley (zones 2A and 2B of Tang’s classification) in which at least one flexor tendon had been completely divided. This study showed that 81 (64%) of these repairs required venting of one or the other pulley. It was necessary to vent the A4 pulley between 10 and 100% of its length in 71 (56%) of the fingers and to vent the distal edge of the A2 pulley by 4 to 10 mm in 10 (8%) of the fingers.

We present the case of a rock climber with a rupture of the A3 flexor sheath pulley. The diagnosis was confirmed with Colour Doppler Imaging (CDI) and with B-mode ultrasound imaging, and the surgical repair was evaluated in the same way. Vertical displacement of the flexor tendon meant that using CDI measurements of the longitudinal movements was not possible. However, using computer analysis of digitized B-mode images from texture patterns identified in the tendons, the vertical and longitudinal components of movement during flexion were calculated. The repair of the pulley was shown to produce tendon movement ratios nearer those of the control digit of the opposite hand.

The cases histories of 51 rheumatoid arthritis patients (58 hands) were examined retrospectively with respect to the incidence of tendon rupture. Factors that were associated with tendon rapture such as X-ray changes in the wrist joint and clinical findings of the hand preceding the tendon rupture were statistically analysed. In a separate study, prophylactic tenosynovectomy and wrist synovectomy were performed on 42 joints in 35 patients who had two or more risk factors. This group of patients was then analysed for subsequent tendon rupture and recurrent synovitis. The risk factors for the extensor tendon rupture in the dorsal wrist joint were found to be: dorsal dislocation of the distal ulna; a scallop sign on X-ray; and tenosynovitis persisting for at least 6 months. Prophylactic surgery effectively prevented rupture of the tendons in patients who had two or more risk factors for extensor tendon rupture.

Sixteen ruptured extensor tendons were repaired in seven rheumatoid hands using autogenous palmaris longus tendon as a free interposition graft. The patients were reviewed at an average of 17 months (range, 5–45) after repair. Subjectively all patients were satisfied with the clinical results, and achieved a return to their level of ability before tendon rupture. A biomechanical model suggests that tendon repair using an interposition graft, rather than a traditional end-to-side tendon transfer retains the anatomical axis of tendon function, and achieves greater forces during active finger extension.

Doxorubicin and epirubicin are strong antineoplastic agents widely used in chemotherapy. One major complication of their use is skin sloughing after subcutaneous extravasation, the degree of which is often underestimated. Both drugs have a tendency to produce liquefying necrosis in soft tissue and chronic ulcers if extravasation occurs. Three cases of extravasation, their surgical treatment and final results are presented. In cases of doxorubicin and epirubicin extravasation it is very important to perform an early extensive surgical débridement with delayed closure to avoid-long hospitalization and disabling results.

We describe a V-Y palmar flap that allows both skin advancement and scar lengthening, and which has proved useful in the treatment of Dupuytren’s disease.

We have used a dorsal V-flap, or chevron flap, to expose the proximal interphalangeal joint. A retrospective clinical study of its use in 16 patients over 5 years is presented, including indications, functional return of movement, and complications. Long-term follow-up showed an average range of active movement of 70° (range, 13–84°). Surgical exposure of the joint was better than other dorsal approaches and overall recovery of movement was not significantly compromised. Alternative surgical techniques such as the dorsal longitudinal split, dorsolateral split and palmar approach are compared in a group of 36 cases.

Trapeziectomy for the treatment of trapeziometacarpal arthritis is an in vivo model of an isolated lesion of the scaphotrapeziotrapeziod ligament complex. We analysed the radiological changes in the wrist retrospectively in 86 patients after trapeziectomy. On standardized PA and lateral films the revised carpal height ratio, the radiolunate angle, the scapholunate angle and the ulnar translation were compared pre- and postoperatively. None of these parameters showed a statistically significant change after operation. Grouping the patients into shorter (< 36 months) and longer (> 36 months) follow-ups also failed to show any significant differences.

Our experience in the treatment of 50 scaphoid nonunions treated with Herbert screw fixation is reviewed. Success rates fell off as the duration of nonunion before treatment increased. However, this appeared to be related to the increased incidence of avascular necrosis with time rather than simply the factor of time alone. In this series the major adverse determinants for outcome were avascular necrosis and a history of previous surgery for nonunion. Failure to graft in a selected group with an intact cartilaginous envelope or a stable firm fibrous union did not affect results. The heterogeneous nature of any series of scaphoid nonunions is emphasized and the difficulties in comparing results with cohorts unmatched for the various adverse factors discussed is stressed.

Scaphoid nonunion with avascular necrosis of the proximal pole remains a difficult problem. We have endeavoured to heal the fracture, restore scaphoid height and revascularize the proximal pole of the scaphoid by means of a vascularized dorsal interposition graft from the distal radius. The procedure has resulted in union of six of ten fractures. Fractures that healed had not been treated by a previous bone grafting procedure. Dissatisfaction was due to loss of motion in patients who had healed fractures, and pain in those patients with persistent non-unions.

Fifteen hands with congenital metacarpal fusions were treated operatively by osteotomy combined either with the use of a silicone block or a distraction device. The aim of the silicone block was to separate the fused metacarpals, but it was buried in the metacarpals at follow-up, with recurrence of fusion. By the distraction technique, 13 mm of lengthening was obtained. The average length of the little metacarpal was 88% of that of the long finger metacarpal. Both methods were effective in correcting the abduction deformity of the little finger by a mean of 34°, and increasing the range of motion of the metacarpophalangeal joint to 28° of active flexion. Although the distraction method took longer than the silicone block method, the final appearance of the hand was better.

A case is reported of spontaneous contracture of both little fingers in a patient with systemic lupus erythematosus. Operative release of abductor digiti minimi produced a good result. It seems likely that the cause of the contracture of ADM may have been myositis related to SLE.

We report a case of a flexor sheath tenosynovitis caused by Mycobacterium marinum.