Outcomes of staged reconstruction of Zone 2 flexor tendon injuries in recent wide-awake surgical settings and an earlier case series

We report outcomes of patients who were managed with two-stage tendon grafting for neglected Zone 2 flexor tendon injuries from 2012 until 2019. The patients were divided into two cohorts: recent series (Series 1) included patients treated with local anaesthesia and epinephrine (16 fingers, from 2015), and earlier series (Series 2) included patients treated with either general or local intravenous anaesthesia and tourniquet (12 fingers, before 2015). The patients in Series 1 achieved statistically better mean total active motion of the operated fingers and grip compared with the contralateral hand than the earlier series ( p = 0.03, p = 0.01, respectively). With the Tang grading system, excellent and good results were achieved in 13 and six fingers of the patients in Series 1 and Series 2, respectively. We conclude that wide-awake second stage of staged flexor tendon grafting provides fine-tuned adjustment of length and tension of the graft, but we cannot conclude about comparative outcomes between two series because the sample size is small and the earlier series was operated by the same surgeons with lower expertise level. Level of evidence: IV

Comparison of Results Based on the Number of Kirschner Wires of Different Diameters in Antegrade Intramedullary Fixation of Fifth Metacarpal Neck Fractures

Purpose: The purpose of this study was to compare the clinical and radiological results of patients with fifth metacarpal neck fractures using different sizes and numbers of Kirschner wires (K-wire).Methods: A single institutional retrospective review identified 67 patients with a fifth metacarpal neck fracture between January 2015 and July 2020. The minimum follow-up time was 6 months and they were all treated within 6.4 days of the initial injury. Either one K-wire (1.6 mm), two K-wires (1.1 mm), or three K-wires (0.9 mm) was used. We analyzed the bone union period, and K-wire removal period, duration of surgery, total active motion, intramedullary diameter, pre/postoperative shortening, and pre/postoperative angulation clinically. We used a Method of Shortening Stipulated to measure shortening and the Medullary Canal-lateral view method for angulation. The intramedullary diameter was measured in the mid-shaft of the fifth metacarpal bone in the coronal view. Total active motion was measured at the time of follow-up in our outpatient department.Results: Clinical and radiological parameters showed no statistically significant differences. Even though it did not present a statistical significance, the absolute mean duration of surgery was the shortest in a single K-wire group. Conclusion: The clinical and radiological outcomes of surgery were comparable regardless of the number of K-wires inserted. However, we could look forward to gaining potential benefit from shortened operation time in a single K-wire group. Since stable fixation can be obtained even if one K-wire is used, inserting one thick K-wire into the intramedullary canal can be an alternative according to the surgeon’s preference.

Perkutane, antegrade K-Draht-Osteosynthese bei Fingergrundgliedfrakturen: Vergleich zwischen frühfunktioneller und statischer Nachbehandlung

Zusammenfassung Ziel Diese retrospektive Studie vergleicht die klinischen Ergebnisse der frühfunktionellen Nachbehandlung mit den Ergebnissen mittels 6-wöchiger Schienenruhigstellung nachbehandelter Fingergrundgliedfrakturen nach perkutaner, antegrader K-Draht-Osteosynthese. Patienten und Methoden Von insgesamt 90 Patienten, die zwischen 2010 und 2017 aufgrund einer isolierten Fingergrundgliedfraktur nach geschlossener Reposition mittels perkutaner, antegrader K-Draht-Osteosynthese operativ versorgt wurden, konnten 46 (17 Frauen und 29 Männer mit einem mittleren Alter von 42,8 Jahren) im Mittel nach 18,5 Monaten nachuntersucht werden. Bei 28 Patienten war eine frühfunktionelle, bei 18 eine statische Nachbehandlung erfolgt. Beide Gruppen unterschieden sich nicht statistisch signifikant bzgl. des Alters, der Geschlechtsverteilung, der Frakturlokalisation und -morphologie, des Unfallmechanismus und der Dauer der Operation. Bei der Nachuntersuchung wurde die aktive und passive Beweglichkeit des operierten Fingers (total active motion [TAM] und total passive motion [TPM], Fingerkuppen-Hohlhand-Abstand [FKHA], Nagelrand-verlängerter-Handrückenebenen-Abstand [NHREA]) und des korrespondierenden, unverletzten Fingers der Gegenseite gemessen und in Relation zueinander gesetzt (TAMrel, TPMrel). Des Weiteren wurde die Kraft bei verschiedenen Griffformen bestimmt und in Relation zur Kraft der unverletzten Gegenseite gesetzt. Intra- und postoperative Komplikationen, der DASH-Score und die Zeit bis zur Wiederaufnahme der Arbeitstätigkeit wurden erfasst. Ergebnisse Keine signifikanten Unterschiede zwischen den beiden Gruppen konnten bzgl. der Häufigkeit von Komplikationen und notwendiger Revisionen, der Fingerbeweglichkeit und Kraft festgestellt werden. Patienten mit aktiver Nachbehandlung kehrten im Vergleich zu Patienten mit statischer Nachbehandlung jedoch signifikant früher an ihre Arbeitsplätze zurück (2,5 vs. 9,0 Wochen nach operativer Versorgung, p = 0,035). Der DASH-Score in der Gruppe mit aktiver Nachbehandlung war mit 1,7 Punkten etwas niedriger als in der Gruppe mit statischer Nachbehandlung mit 2,5 Punkten (p = 0,269). Schlussfolgerung Patienten mit frühfunktioneller Nachbehandlung waren signifikant kürzer arbeitsunfähig. Zum Nachuntersuchungszeitpunkt fand sich kein Unterschied in der globalen Fingerbeweglichkeit beider Gruppen. Bei gegebener Compliance kann auf eine postoperative Ruhigstellung verzichtet werden.

Digital Replantations: Comparison Veins Anastomoses first versus Arteries Anastomoses first

Purpose This retrospective study analyses the effect performing veins anastomoses before arteries anastomoses in digital replantation. Patients and methods 38 adult patients with replantation of 12 thumbs and 39 fingers, in whom the veins anastomoses were performed prior to the arteries anastomoses, were compared with 29 patients with replantation of 9 thumbs and 30 fingers, in whom the arteries anastomoses were done first, with respect to the survival rate, total active motion, grip strength, and duration of the replantation. Results There was no significant difference between the two groups with respect to the survival rates, total active motion, and grip strength, while the duration of the replantation was significantly shorter in patients, in whom the veins anastomoses were performed prior to the arteries anastomoses (2 hours and 50 minutes versus 3 hours and 42 minutes; p < 0.001). Conclusion Performing veins anastomoses before arteries anastomoses in digital replantations reduces the replantation time significantly without influencing the survival rate and the clinical outcome.

FUNCTIONAL OUTCOME IN PERCUTANEOUS ELASTIC STABLE INTRAMEDULARY NAILING TECHNIQUE OF METACARPAL BONE FRACTURE

AIMS AND OBJECTIVES: The aim of this study was to evaluate functional outcome of metacarpal fractures managed by percutaneous elastic stable intramedullary nails along with its functional outcome. METHOD: The extra-articular metacarpal fracture were managed by inserting two pre-bent elastic stable nails in antegrade manner after making entry point (dorso-medialy and dorso-lateraly) through base of the metacarpal bone. The nails act as three point xation and provide stable xation. Early mobilisation is commenced for providing early healing and decrease postoperative decreased range of motion at metacarpophalangeal/interphalangeal joints and stiffness. Nails were removed 3 week after radiological sign of union. RESULTS: 32 extra-articular metacarpal fractures treated with percutaneous elastic stable nails were evaluated between 1 2 September 2018 to 31 August 2020. The functional outcome was assessed using disability arm shoulder and hand (DASH) score with mean score th 1 of 2 at 6 month follow-up and total active motion (TAM) score which was excellent in 81.2% of the patients (n=26), good in 9.4% of cases (n=3), fair in 9.4% of the cases (n=3).All fracture proceeded to bony union. CONCLUSIONS: It was concluded that indirect reduction and early xation with percutaneous elastic stable intramedullary nailing with 2 nails is very safe and effective treatment modality for extra-articular metacarpal fracture with excellent functional outcome.

Retrograde Intramedullary Screw Fixation for Metacarpal Fractures: A Systematic Review

Common forms of fixation of metacarpal fractures have historically included percutaneous Kirschner wire fixation, plates and screws, and, more recently, intramedullary screw fixation. Retrograde intramedullary screws (RISs) are a novel modality first described 10 years ago. The purpose of this review is to critically evaluate the published literature assessing outcomes of RIS fixation for metacarpal fractures and create a complication profile for this novel technique. A comprehensive literature search was performed using electronic databases for both clinical and biomechanical studies in relation to RIS fixation published from 2000 to 2020. A total of 19 studies (13 clinical and 6 biomechanical) met the inclusion criteria. The clinical studies examined 603 metacarpal fractures and demonstrated adequate functional outcomes in terms of grip strength, total active motion, and time to return to work. The biomechanical studies examined 80 metacarpal fractures, finding that load to failure in RISs was often equal to or higher than Kirschner wires but less than plate and screws. The complication rate in reviewed studies was 2.8%, with the most prevalent complications being stiffness and extension lag. RIS use in metacarpal fractures appears to provide adequate stability with satisfactory clinical outcomes and minimal complications, although more high-quality studies are needed to fully examine this modality.

Einfluss des Beginns auf das Ergebnis einer spezialisierten Handrehabilitation bei beruflichen Handverletzungen

Zusammenfassung Ziel Ziel der Studie war die Auswertung der Ergebnisse einer spezialisierten interdisziplinären Handrehabilitation in Abhängigkeit vom zeitlichen Abstand zwischen der Verletzung und dem Beginn der Rehabilitation. Patienten und Methoden Mit Hilfe von punktebasierten Fragebögen (Disability of the Arm, Shoulder and Hand Score [DASH-Score], European Quality of Life 5 Dimensions [EQ-5D]) und objektiven Messparametern (TAM = Total Active Motion bei Fingerverletzungen, ROM = Range of Motion bei Handgelenksverletzungen, Grobkraft) wurden die Ergebnisse von 76 Patienten mit Verletzungen von Fingern und Handgelenken oder einem komplexen regionalen Schmerzsyndrom (CRPS) zu Beginn, am Ende und bei der Nachuntersuchung 12–16 Wochen nach Ende der semistationären Rehabilitation analysiert. Die Patienten wurden in Gruppen mit einem frühen (< 120 Tage nach Trauma) bzw. späten Beginn der Rehabilitation aufgeteilt. Ergebnisse Patienten mit frühem Beginn der Rehabilitation hatten bei der Nachuntersuchung signifikant bessere Ergebnisse beim DASH-Score als auch beim Bewegungsausmaß des Handgelenkes. Auch waren signifikant mehr Patienten mit frühem Rehabilitationsbeginn zum Ende der Rehabilitation als auch bei der Nachuntersuchung arbeitsfähig als Patienten mit spätem Beginn der Rehabilitation. Insbesondere Patienten mit Fingerverletzungen und CRPS profitierten von einem frühen Beginn der Rehabilitation. Schlussfolgerung Ein früher Beginn der Rehabilitation nach Finger- und Handverletzungen sowie bei einem CRPS führt zu funktionell besseren Ergebnissen, wobei vor allem Patienten mit CRPS von einem frühen Beginn profitieren.

Functional Outcome Following Hand and Wrist Level Replantation: A Retrospective Review

Objective: Amputations of fingers and significant parts of upper limbs are common following industrial injuries. This study was aimed at assessing the functional outcome in patients with hand replantation following amputation at the level of distal forearm or wrist. Methods: Patients presenting with amputation at the level of wrist and forearm between Jan 2015 and December 1018, with adequate follow up were included. The function in terms of total active motion at the fingers and wrist, sensory recovery, and patient satisfaction and DASH scores at the final follow up were noted. Results: Four cases of replantation at the level of wrist and one replantation at distal forearm level were included in the study. A total of 3 patients were excluded for various reasons. The average follow-up period was 38 months. The average total active motion of fingers achieved was 212○ . All patients recovered protective sensations. Conclusion: Replantation of amputated major upper limb parts restores useful function and should be attempted. Minimizing ischaemia time, secure fixation, primary repair of structures and early motion are determinants of reasonable functional outcome. Level of evidence: IV.

Range of Motion Following Extensor Tendon Splitting vs. Tendon Sparing Approaches for Plate Osteosynthesis of Proximal Phalangeal Fractures – A Systematic Review and Meta-Analysis

Background: Several approaches to plate fixation of the proximal phalanx have been proposed, such as the dorsal extensor splitting approach and the lateral or dorso-lateral extensor sparing approach, which aims to minimise invasiveness to promote native extensor tendon glide. This study aimed to meta-analyse the outcomes of these two approaches. Methods: A systematic review of electronic databases was undertaken, and the outcomes of comparative studies meta-analysed. Results: Three studies were included for meta-analysis. Total active motion (TAM) was significantly greater in the extensor sparing group compared to the extensor splitting (Mean difference 8.52 degrees, 95%CI 0.8–16.36, p = 0.03). Conclusions: This study demonstrates that there is preliminary evidence favouring the use of extensor sparing approaches when fixing proximal phalanxes – however, this result requires validation with randomised controlled trials.

The Use of an Adipofascial Flap to Prevent Extensor Tendon Adhesions After Plating of the Proximal Phalanx of the Fingers: A Comparative Study

Background: Extensor tendon adhesions occurring after proximal phalangeal (P1) fractures are not uncommon. A previous report described the use of an adipofascial flap (AFF) to prevent adhesions after dorsal plating of the P1. The purpose of the study is to examine the results of open reduction and internal fixation with the use of an AFF (F group) and without (N group, that is, no flap used) in a larger group of patients. Methods: A retrospective study involving a period of 11 years was conducted involving results of 21 unstable fractures of the P1 of the fingers in 18 patients. In all, 12 fingers were treated without any flap (N group) and 9 fingers were treated with the AFF (F group). For each patient, the total active motion (TAM) ratio, and the grip strength (Jamar) ratio were assessed, and adverse effects and the 10-point visual analogue scale (VAS) score were recorded. For statistical analysis, sample characteristics were described using mean ± standard deviation and median, and a Bayesian approach was used for inferential analysis. Results: In the F group, the TAM ratio (84% ± 13% vs 65% ± 17%) was higher with a lower rate of adverse effects (OR: 0.067, 95% CI, 0.0035-0.58,) and a lower VAS score with evidence of the positive effect of the AFF. The Jamar ratio was similar in the 2 groups (F group 80% ± 25% vs N group 79% ± 19%) with no associated effect of the AFF on grip strength. Conclusions: The AFF is a reliable tool to reduce adhesions between plates and the extensor apparatus of the P1 and may be useful to improve finger function after plating of P1 fractures. Type of study/LOE: Therapeutic, Retrospective, Level IV