Comparison of the Wide-Awake Approach and Conventional Approach in Extensor Indicis Proprius-to-Extensor Pollicis Longus Tendon Transfer for Chronic Extensor Pollicis Longus Rupture.

BACKGROUND: The wide-awake approach enables surgeons to perform optimal tensioning of a transferred tendon intraoperatively. The authors hypothesized that the extensor indicis proprius-to-extensor pollicis longus tendon transfer using the wide-awake approach would yield better results than conventional surgery. METHODS: A retrospective analysis was performed of the prospectively collected data of 29 consecutive patients who underwent extensor indicis proprius-to-extensor pollicis longus tendon transfer. Patients were treated with the wide-awake approach (group A, n = 11) and conventional surgery under general anesthesia (group B, n = 18). The groups were compared retrospectively for thumb interphalangeal and metacarpophalangeal joint motion, grip and pinch strength, specific extensor indicis proprius-to-extensor pollicis longus evaluation method (SEEM), and Disabilities of the Arm, Shoulder and Hand questionnaire score at 6 weeks and 2, 4, 6, and 12 months postoperatively. RESULTS: Group A showed significantly better interphalangeal joint flexion and total arc of motion at 6 weeks and 2, 4, and 6 months, and significantly better metacarpophalangeal joint flexion and total arc of motion at all time points. Interphalangeal and metacarpophalangeal joint extension showed no difference at all time points. Group A showed significantly better specific extensor indicis proprius-to-extensor pollicis longus evaluation method scores at 2 and 4 months, and Disabilities of the Arm, Shoulder and Hand questionnaire scores at 4, 6, and 12 months. Grip and pinch strength showed no difference at all time points. The complication rate and duration until return to work were not different between groups. CONCLUSION: Compared with the conventional approach, the wide-awake approach showed significantly better results in the thumb's range of motion and functional outcomes, especially in the early postoperative periods. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Soft-Tissue Surgery for Camptodactyly Corrects Skeletal Changes.

BACKGROUND: This study demonstrates the potential for radiographic and clinical improvement with surgical correction of camptodactyly. Although historically these radiographic changes have been held to be permanent, the authors encourage surgical intervention for digits with severe flexion contracture or progressive radiographic changes before skeletal maturity is reached. METHODS: The authors assessed 18 consecutively operated fingers in nine skeletally immature patients in whom advanced radiographic articular changes had occurred. Mean preoperative flexion contracture was 63 degrees (range, 35 to 105 degrees). The average age of the patients was 11 years (range, 4 to 15 years) at the time of surgery. Clinical response to surgery was studied, but radiographic articular changes were followed postoperatively as a primary outcome. RESULTS: Each patient demonstrated the classic preoperative radiographic joint changes on radiographic films at the affected proximal interphalangeal or distal interphalangeal joint. All patients had substantial clinical improvement postoperatively. Two digits had extensive radiographic damage, requiring proximal interphalangeal joint arthrodesis. Fifteen of the remaining 16 digits (94 percent) had substantial improvement or full restoration of radiographic articular congruency at average follow-up of 9 months (range, 3 to 18 months). The only joint that did not remodel fully was the one that did not have complete clinical correction. CONCLUSIONS: Even in patients with severe radiographic changes from camptodactyly, surgery can effectively improve range of motion. Once radiographic articular changes become apparent, surgical correction should be undertaken not only to prevent further joint damage but also to reverse these radiographic changes before skeletal maturity is reached. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Effects of motor imagery on hand function during immobilization after flexor tendon repair.

OBJECTIVE: To determine whether motor imagery during the immobilization period after flexor tendon injury results in a faster recovery of central mechanisms of hand function. DESIGN: Randomized controlled trial. SETTING: Tertiary referral hospital. PARTICIPANTS: Patients (N=28) after surgical flexor tendon repair were assigned to either an intervention group or a control group. INTERVENTION: Kinesthetic motor imagery of finger flexion movements during the postoperative dynamic splinting period. MAIN OUTCOME MEASURES: The central aspects of hand function were measured with a preparation time test of finger flexion in which subjects pressed buttons as fast as possible following a visual stimulus. Additionally, the following hand function modalities were recorded: Michigan Hand Questionnaire, visual analog scale for hand function, kinematic analysis of drawing, active total motion, and strength. RESULTS: After the immobilization period, the motor imagery group demonstrated significantly less increase of preparation time than the control group (P=.024). There was no significant influence of motor imagery on the other tested hand function (P>.05). All tests except kinematic analysis (P=.570) showed a significant improvement across time after the splinting period (P

Safety and efficacy of percutaneous trigger finger release.

Twenty-five A1 pulleys in 5 fresh cadaveric hands and 13 trigger fingers in 11 patients were released percutaneously with a 19 gauge needle, as described by Eastwood et al., to determine the efficacy and safety of the technique. Over 90% of the length of each individual finger and thumb A1 pulley were successfully released in the cadaveric digits with no injuries to the A2 pulley, nerves, or vessels. Superficial abrasions were noted in four superficialis tendons. In our surgical series, complete clinical release (eradication of triggering) was achieved in each digit. In 8 of 13 digits, the A1 pulley was found to be completely divided on open exploration. In five digits, while triggering was eliminated, some of the A1 pulley remained intact. There were no complications. Because of the proximity of digital nerves, we do not perform percutaneous release in the index finger or thumb.

Alumina ceramic prosthesis arthroplasty of the metacarpophalangeal joint in the rheumatoid hand. A 2-4-year follow-up study.

Swanson's finger implant is being widely used to improve deformity of the thumb and finger and to restore function in the rheumatoid hand. Breakage of the implant and implant synovitis have been the most troublesome complications. The authors developed an alumina ceramic finger prosthesis to lessen these complications. This prosthesis was used for the metacarpophalangeal joint in 5 cases of flexion deformity of the thumb and in 21 cases (82 digits) with ulnar drift deformity. These cases were followed for 24-62 months (average, 38 months). Postoperative extension of the thumb was limited to 18 degrees and flexion was 48 degrees, on average. Postoperative range of motion was 30 degrees. The average limitation of extension of all digits was 18 degrees, and the average flexion was 54.5 degrees. The average range of motion was 36.5 degrees. Flexion deformity of the metacarpophalangeal joint of the thumb disappeared after operation, and ulnar drift was reduced to less than 10 degrees deviation in 87.8%. No dislocation or fracture of the prosthesis has been found on roentgenologic examination during short-term follow-up study. This prosthesis is useful for reducing deformity of the thumb and the finger in the rheumatoid hand. Postoperative extension of the metacarpophalangeal joint, however, has been unsatisfactory. The design of the prosthesis should be improved so that the rotational center of the metacarpophalangeal joint is located palmarly.

Silicone implants.

Infection has not been considered in this article with each individual implant. The incidence is low indeed. In the only publication concerned primarily with the topic of infection following silicone implant surgery, Millender et al. reviewed 2105 implants of varying kinds. There were ten infections, seven of which were with Staphylococcus aureus. The onset was remarkably late--17 days after surgery on average. In seven cases the implant had to be removed and the eventual result was good, being likened to that obtained after an excisional arthroplasty. Reviewing the complications that occur with the various implants, it becomes evident that there are three primary concerns--fracture, subluxation, and synovitis. Fracture occurs primarily in the wrist and the metacarpophalangeal implants. The incidence of fracture in the wrist implant is 8.6, 9.4, and 19.8 per cent, giving an average of the means of 12.6 per cent. In the metacarpophalangeal joint, the incidence with the Swanson design is variously 1.9, 26.2 and 21 per cent, the average of the means being 16.4 per cent. The Niebauer design is reported as having a fracture rate of 29.7 and 38 per cent, for an average of the means of 33.9 per cent. The somewhat lower incidence of fracture of the wrist implant is offset by the fact that, in contrast to the situation with the smaller joint, the fracture is almost always symptomatic, requiring treatment. Largely for this reason, silicone wrist arthroplasty is limited mainly to the rheumatoid patient, being little used for post-traumatic arthritis. Subluxation of implants occurs mainly with the carpal replacements. The incidence in independent reports are 56.5 and 50 per cent, for an average of the means of 53.3 per cent with the scaphoid; 20, 20, and 50 per cent for an average of the means of 30 per cent with the lunate; and 5.3, 10, 11.2, 29, and 32 per cent for an average of the means of 17.5 per cent with the trapezium. In the case of the trapezium, excision of a portion of the trapezoid, supplemented where necessary by ligament reconstruction to support the first metacarpal, appears to give the hope of lowering the incidence of subluxation to an acceptable level. With the lunate, preservation of an anterior shell may give satisfactory results but judgment should await longer term studies of larger groups. The scaphoid implant gives most cause for concern, both because the incidence is high and because the solutions offered have either failed or are too recent to judge and perhaps too radical to accept.(ABSTRACT TRUNCATED AT 400 WORDS)