Journal of Hand Surgery (European Volume)

An overview of the current state of outcome measurement after hand surgery is presented. The paper focuses on the development, application and strengths and weaknesses of subjective assessment techniques. It also reviews the existing questionnaires and suggests recommendations for use in research or clinical practice.

This study was designed to evaluate correlations between the hand injury severity scoring system (HISS) and measures of impairment and disability obtained 6 months after a hand injury. A statistically significant positive correlation was found between the severity of the injury (HISS) and residual impairment, as measured with the American Medical Association’s (AMA) “Guides to the evaluation of permanent impairment, 4th edition”. No statistically significant correlation was found between the severity of the injury (HISS) and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, which measures disability from the patient’s perspective. There was however a statistically significant correlation between AMA total body impairment measured and the results of the DASH questionnaire. The results indicate the potential of the HISS for predicting the final impairment after hand injuries.

The role of continuous bupivacaine infusion either into the wound or as a local nerve block, following hand surgery was investigated in 100 patients. After excluding six patients with complex pain problems in whom neither the bupivacaine infusion nor any other conventional analgesic techniques provided adequate analgesia post-operatively, 86 of 94 (91%) patients were adequately treated for post-operative pain by this system during the first night after surgery, when pain is presumed to be greatest. This system also provided adequate on-going analgesia for up to 1 week after surgery controlling nerve pain and allowing mobilization of tendons after tenolysis. Continuous bupivacaine infusion is of particular use in these two groups of patients and after major hand injuries, when considerable pain can be anticipated. Pain during the first night was not controlled adequately by the bupivacaine infusion system in eight of the 94 patients (8%). All eight had a technical failure of the system, which was rectified in six cases to restore adequate analgesia by the infusion system. Two patients developed infection at the infusion cannula insertion site, which occurred only after 1 week and was successfully treated by removal of the cannula and oral antibiotics.

The natural history of an untreated isolated scapholunate interosseus ligament injury remains unclear, although it is commonly assumed that patients continue to suffer with pain, stiffness and weakness of the wrist and ultimately develop secondary osteoarthritis (SLAC wrist). In this study, we evaluated the clinical condition of 11 patients with an arthroscopically proven interosseus scapholunate ligament injury, but without any radiological signs of either DISI deformity or scapholunate gapping, who had declined further treatment at an average follow-up of 7 years. Whilst there was on going pain and functional limitation in all cases, there was no rapid progression to degenerative change (SLAC wrist).

Since 1989 scapholunate fusion has been performed on 13 patients with chronic scapholunate instability causing debilitating symptoms. These cases were reviewed at a mean 93 (range, 60–132) months after surgery. Establishing whether bony fusion had been achieved proved extremely difficult even after CT scanning, but fusion was unequivocally achieved in four cases. Ten patients were subjectively satisfied with their treatment. Two patients who had no symptomatic improvement subsequently underwent total wrist arthrodesis. A method of fusing the scaphoid and lunate is described, though we accept that a firm fibrous union may be all that is achieved in most patients. However, this appears sufficient to restore stability with a high patient satisfaction.

During limited intercarpal fusion it is sometimes difficult to determine correct screw length and staple size. This is because of overlap, and the shape and orientation of the carpal bones on radiography. One hundred complete sets of dry cadaver carpal bones were measured to provide an anatomical database of carpal bone measurements. This should help prevent inadvertent overpenetration of fixation devices during surgery.

The aim of the study was to estimate the incidence of trauma-related distress and mood disorders in the early stages after acute traumatic hand injuries and identify characteristics associated with these reactions. Data were obtained from 112 patients by means of mailed questionnaires and medical records. Nearly half of the patients had increased levels of intrusive and avoidance symptoms, indicating trauma-related distress. One-third showed signs of a mood disorder. Mood disorders were associated with the need for help with activities of daily living, pain and avoidance symptoms. The study showed that emotional problems in the early stages after injury are related to the consequences of both the injury and the traumatic experience. Negative reactions to the sight of the hand were associated with both trauma-related distress and mood disorders, suggesting that observation of the reactions to the sight of the hand could help to identify patients in need of psychological support.

Early parental experiences of having a child with obstetric brachial plexus palsy were examined to determine whether there were any areas of dissatisfaction and, if so, whether these resulted from their distress and a need to blame someone, or from problems in the communication of bad news. A high level of dissatisfaction was reported with similar levels of dissatisfaction found in a mildly injured group that did not require surgery, and a severely injured group that did. This suggests either that degree of dissatisfaction is not related to degree of disability, or that dissatisfaction was due to factors other than a reaction to their child having a problem. Support was found for the latter as the parents reported details of problems in communication, particularly the giving of inaccurate and misleading information.

We report a modification of the original Tang technique of tendon repair which uses fewer sutures and has fewer knots on the tendon surface. The modified method consists of six longitudinal and two horizontal strands that form an “M” configuration within the tendon and four dorsal longitudinal strands made with a single looped suture. Thirty-six fresh pig flexor tendons were divided and repaired with either the modified Tang or the Tang method. The tendons were subjected to linear or 90° angular loading in an Instron tensile machine. The gap formation strength and ultimate strength of the modified Tang repair was statistically identical to those of the Tang method under linear tension. Under angular tension, the ultimate strength of the modified Tang method was greater than that of the Tang method.

Mechanisms behind the onset and progression of Dupuytren’s disease are poorly understood. Both myofibroblasts and transforming growth factor beta 1 (TGF-β₁) have been implicated. We studied fibroblast cultures derived from nodules or cords of Dupuytren’s contracture tissue to determine the proportion of myofibroblasts present in comparison with flexor retinaculum fibroblast cultures. We identified myofibroblasts by immunohistochemical staining for α-SMA. We then investigated the effects of TGF-β₁ stimulation on these fibroblasts.

Basal myofibroblast/fibroblast proportions were 9.7% in nodule cell cultures, 2.7% in cord cell cultures and only 1.3% in flexor retinaculum cell cultures. Nodule and cord myofibroblast proportions increased to 25.4% and 24.2%, respectively, in response to TGF-β₁ treatment. Flexor retinaculum cell cultures showed no response to TGF-β₁ stimulation.

Fibroblasts cultured from specific regions of Dupuytren’s tissue retain myofibroblast features in culture. TGF-β₁ stimulation causes an increased myofibroblast phenotype to similar levels in both nodule and cord, suggesting that previously quiescent cord fibroblasts can be reactivated to become myofibroblasts by TGF-β₁. This could be an underlying reason for high recurrence rates seen after surgery or progression following injury.

The purpose of our study was to determine the most favourable combination of core suture material and peripheral repair technique for Kessler tendon repair. Thirty freshly thawed pig flexor tendons were repaired by a Kessler technique, either with braided polyester or monofilament nylon suture. A peripheral augmentation was done using one of the three techniques – running, cross-stitch and Halsted. All repairs were tested by cyclic loading, followed by load-to-failure. During cyclic loading six of the 15 tendons with a nylon core failed, but none with a braided polyester core. Irrespective of peripheral technique, the monofilament nylon core suture allowed early central cyclic gapping, resulting in failure of the repair. During load-to-failure testing, the running stitch proved weakest and the cross-stitch repair toughest.

This article describes the use of a miniplate and cortical screws in the treatment of five cases of flexor digitorum profundus (FDP) tendon avulsion. One case was type II, three cases were type III and one case was type IV. Near normal joint congruity was restored together with bony union in all cases. Six months after surgery four cases had near normal range of motion at the distal interphalangeal joint compared with the contralateral uninjured finger. These four patients were to return to their previous activities without restriction by 3 months. One repair of a type III avulsion ruptured but the distal interphalangeal joint was pain free and stable and the patient declined further surgery. Miniplate fixation offers some advantages over existing methods of repair and adds to the range of techniques available for reattachment of the FDP tendon in these injuries.

Distal division of the flexor digitorum profundus (FDP) within 10 mm of its insertion is commonly treated in the same manner as avulsion of the FDP, using the “button” technique or bone suture anchor fixation. Button and bone suture anchor fixation techniques have been associated with significant complications. Importantly, both lead to shortening of the FDP which may cause flexion contracture at the distal interphalangeal joint. This study compared the breaking strength of a multistrand distal suture with reattachment using the “button-on-the-nail” technique in a laboratory cadaver model of distal FDP division. The data showed that multistrand distal suture repair was at least as strong as reattachment and has the theoretical advantage of avoiding some of the acknowledged complications of reattachment techniques.

The wrist and hand X-rays of 75 black patients with rheumatoid arthritis were scored according to the Larsen criteria. The mean Larsen score for left hands was 9.6 (range 0–100) and for the right hands was 10:3 (range 0–100), whereas the score for the wrists were 2.5 (range 0–5) for the left and 2.7 (range 0–5) for the right. Our conclusion is that rheumatoid wrist involvement in black patients was more or less the same as reported in other series, but finger joint involvement was considerably less. This finding must influence surgical decision-making and also the interpretation of results of drug trials, whenever black patients are involved.

Four hundred and fifty five young children (0–6 years old) were treated for hand injuries between 1996 and 2000. Boys (61%) were injured more often and a higher number of injuries occurred during May and September. Fingertip injuries were the most common injuries (37%), and were often caused by jamming in doors at home. Fractures were caused by falls and punches and tendon/nerve injuries by sharp objects. The incidence of hand injuries increased from 20.4/10,000/year in 1996 to 45.3/10,000/year in 2000. Only 4% of the children had complex injuries but these placed a high demand on resources. The incidence of injuries was not higher amongst children from immigrant families.