Total Wrist Replacement Outcomes in the Asian Pacific Population - A Single-Centre Result.

Background: Total wrist replacement (TWR) is rarely done in the Asia-Pacific region. The aim of this study is to report the surgical outcomes and experience of TWR in patients with advanced arthritis. Methods: This is a retrospective review of all TWR patients in the Department of Orthopaedics and Traumatology, Prince of Wales Hospital, Hong Kong, which is a university tertiary centre, from January 2004 to March 2023. Recorded demographic parameters include gender, age upon surgery, pathology, types of implants and follow-up period. The surgical outcome parameters include range of motion, grip strength, wrist function assessment, radiological and clinical complications and any related secondary operations. Postoperative X-ray and clinical notes were reviewed. All wrist function assessments were performed by specialised occupational therapists according to protocol. Results: The study included a total of 12 wrists of 10 patients, all Chinese-Asian, with a mean age of 61.4 years at surgery. Larsen grade V arthritis constituted 50% and grade IV 16.7% of the patients, amongst which 33% had volar subluxation. The mean follow-up period was 97.4 months (21-205 months). The mean grip strength was 64.2% of the unaffected side. The mean postoperative Disabilities of Arm, Shoulder and Hand (DASH) score was 41.12% and patient-rated wrist/hand evaluation (PRWE) score 18.0. Complication incidence was 16.67% for loosening, 8.3% for metallosis and 8.3% for infection. One patient required conversion to total wrist arthrodesis due to metallosis. No patient suffered from dislocation, periprosthetic fracture and infection. Conclusions: TWR is an effective and safe alternative to total wrist arthrodesis with comparable outcomes. Our series outcomes are satisfactory and in line with literature. With meticulous soft tissue release and balancing, volar subluxation can also be corrected and may not be a contraindication. Level of Evidence: Level IV (Therapeutic).

Clinical and Radiological Outcome of Osteoscopic-Assisted Treatment of Enchondroma in Hand with Artificial Bone Substitute or Bone Graft: A 7-Year Case Series and Literature Review.

Background: This study aims to look at the intermediate-term clinical, functional and radiological outcomes of patients with enchondroma in hand treated with osteoscopic-assisted curettage and artificial bone substitute or bone graft. The addition of osteoscopy allows direct visualisation of the bone cavity during and after curettage of tumour tissue without the need of creating a large opening in the bone cortex. This could lead to better clearance of tumour tissue and lower risk of iatrogenic fracture. Methods: A total of 11 patients who received surgery from December 2013 to November 2020 were retrospectively reviewed. All cases had histological diagnosis of enchondroma. Patients with a follow-up period of less than 3 months were excluded. The mean duration of follow-up was 20.9 months. For the clinical outcome, we measured the total active motion (TAM) and graded with Belsky score grip strength. For the functional outcome, the Quick Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH) score was used. For the radiological outcome, we evaluated the X-ray for bone cavity filling defect, new bone formation according to the system proposed by Tordai. Results: The mean TAM of patients was 257º. A total of 60% patients had Belsky score grading excellent, 40% patients had Belsky score grading good. The mean percentage of grip strength compared with the contralateral side was 86.2%. The mean QuickDASH score was 7.7. For the wound aesthetic rating by patients, 81.8% patients reported as excellent. For the radiological outcome, the postoperative X-ray of all patients showed bone filling defect less than 3 mm. The mean time to complete bone consolidation was 3.8 months. None of the patients showed any radiological signs of recurrence. Conclusions: Our study showed that patients with enchondromas in hand treated with this minimally invasive method demonstrated good functional and radiological outcome. Its application may also be extended into treating other benign bone lesions in hand. Level of Evidence: Level IV (Therapeutic).

Ultrasonography Findings of the Carpal Tunnel after Endoscopic Carpal Tunnel Release for Carpal Tunnel Syndrome.

OBJECTIVE: To investigate changes in the median nerve, retinaculum, and carpal tunnel on ultrasound after successful endoscopic carpal tunnel release (ECTR). MATERIALS AND METHODS: This prospective study involved 37 wrists in 35 patients (5 male, 30 female; mean age ± standard deviation [SD], 56.9 ± 6.7 years) with primary carpal tunnel syndrome (CTS). An in-house developed scoring system (0-3) was used to gauge the clinical improvement after ECTR. Ultrasound was performed before ECTR, and at 1, 3, and 12 months post-ECTR. Changes in the median nerve, flexor retinaculum, and carpal tunnel morphology on ultrasound after ECTR were analyzed. Ultrasound parameters for different clinical improvement groups were compared. RESULTS: All patients improved clinically after ECTR. The average clinical improvement score ± SD at 12 months post-ECTR was 2.2 ± 0.7. The median nerve cross-sectional area proximal and distal to the tunnel decreased at all time intervals post-ECTR but remained swollen compared to normal values. Serial changes in the median nerve caliber and retinacular bowing after ECTR were more pronounced at the tunnel outlet than at the tunnel inlet. The flexor retinaculum had reformed in 25 (68%) of 37 wrists after 12 months. CONCLUSION: Postoperative changes in median nerve and retinaculum parameters were most pronounced at the tunnel outlet. Even in patients with clinical improvement after ECTR, nearly all ultrasound parameters remain abnormal at one year post-ECTR. These ultrasound parameters should not necessarily be relied upon to diagnose persistent CTS after ECTR.

Hand Surgery in Hong Kong.

Hand surgery in Hong Kong was borne out of necessity. It has been changing with the social, economic, and political situations. The spectrum of hand surgeries evolves with time, from infection-related hand surgeries to microsurgical or non-microsurgical operations on the huge volume of industrial hand injuries, to a wider variety of reconstructions on rheumatological, congenital upper limbs, traumatic, neurological diseases, etc, to minimally invasive surgeries on hand, wrist, and elbow. Hand surgery was deeply-rooted in orthopaedics in Hong Kong and is inseparable from microsurgeries, which have built a strong foundation for any kind of its future development.

Neurovascular Island Flap for Pulp and Nail Augmentation in Thumb Duplication Reconstruction: A Surgical Method With Long-Term Follow-Up.

PURPOSE: Pulp and nail atrophy and asymmetry are commonly seen in thumb duplication. In hypoplasia of both digits, conventional reconstruction or Bilhaut-Cloquet procedure and its modifications may not be possible or may lead to a poor cosmetic outcome. The purpose of the study was to review a reconstruction technique with a neurovascular island flap developed to improve the aesthetic and functional results of treatment. METHODS: Fourteen patients with thumb duplication aged 8 to 18 months were operated between 2002 and 2013 in our center. All patients had significant hypoplasia and asymmetry of the pulp and nail of the digit planned to be retained. A neurovascular island flap including part of the pulp tissue, nail bed, with or without the associated phalangeal bone, was raised from the planned ablated digit base on its single neurovascular bundle. The nail bed, nail fold, and pulp tissue from the 2 digits were apposed with fine sutures under magnification. All patients were followed to monitor the aesthetic, functional, and radiological outcome. RESULTS: The mean follow-up period was 7 years, 11 months. Thirteen patients underwent the flap procedure and all flaps survived. In 1 patient, the flap procedure was aborted because the vascular pedicle was not well formed. The nail width and pulp circumference were restored to a similar size as the contralateral thumb. CONCLUSIONS: In selected cases of thumb duplication with significant pulp hypoplasia and nail asymmetry, the neurovascular island flap is a safe and effective means to restore size and symmetry. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

MRI of the Carpal Tunnel 3 and 12 Months After Endoscopic Carpal Tunnel Release.

OBJECTIVE. The purpose of this study was to study changes in the median nerve, retinaculum, and carpal tunnel on MRI after successful endoscopic carpal tunnel release (ECTR). SUBJECTS AND METHODS. In this prospective study, 35 wrists in 32 patients (five men, 27 women; mean age, 56.7 ± 6.8 [SD] years) with nerve conduction test-confirmed primary carpal tunnel syndrome were evaluated from May 2013 to September 2016. Clinical scores ranging from 0 to 4 (no improvement to symptoms completely resolved) and MRI morphologic features of median nerve and carpal tunnel were evaluated at baseline and 3 and 12 months after ECTR. The paired t test was used to compare MRI parameters before and after ECTR and their relationships to clinical improvement scores. RESULTS. All patients' conditions improved after ECTR with mean clinical improvement scores of 2.94 ± 1.0 at 3 months and 3.49 ± 0.56 at 12 months. Although median nerve swelling did decrease proximally, the nerve remained swollen (> 15 mm2) and flattened in all areas, even 12 months after ECTR. Additional changes occurred in median nerve caliber-change ratio, relative signal intensity, and carpal tunnel cross-sectional area. A retinacular gap was present in 33 (94%) wrists 3 months and six (17%) wrists 12 months after ECTR, and increased retinacular bowing persisted. CONCLUSION. After ECTR, undue swelling and flattening of the median nerve persist as long as 12 months after surgery, even in patients with a good surgical outcome. One should be wary of using these MRI findings as signs of persistent neural compression. The retinaculum reforms in most patients within 12 months of surgery but with a more bowed configuration.

Necrotizing fasciitis induced by Vibrio vulnificus in patients without marine contact in Hong Kong.

Necrotizing fasciitis caused by Vibrio species is a life-threatening soft tissue infection with rapid progression and high mortality. The classic history of Vibrio species-induced necrotizing fasciitis is the infection of wounds by direct invasion or contact with contaminated seawater or raw seafood, especially in immunocompromised patients. We present two cases of Vibrio vulnificus necrotizing fasciitis in the upper limb without any wounds or seawater contact and with good past medical history. Both underwent timely surgical debridement and resulted with good functional outcome. Although rare, as clinicians, we need to have a high index of suspicion for the possibility of V. vulnificus necrotizing fasciitis despite no risk factors and give timely and appropriate treatment and, more importantly, patient survival.

Cross-sectional area of the median nerve at the wrist: Comparison of sonographic, MRI, and cadaveric measurements.

BACKGROUND: This study compares median nerve cross-sectional area (CSA) measurements at the wrist obtained with ultrasound (US) and magnetic resonance imaging (MRI) using cadaveric measurements as the gold standard. METHODS: Median nerve CSA was measured using US and MRI in 9 cadaveric wrists obtained from 5 subjects at 5 locations: distal forearm, proximal to tunnel inlet, at tunnel inlet, at tunnel outlet, and distal to tunnel outlet and then on identical cadaveric transverse sections obtained with a bandsaw. All US, MRI, and cadaveric measurements were repeated to determine reliability. Median nerves of 10 patients with clinical carpal tunnel syndrome (CTS) were measured with US and MRI using an identical method US. RESULTS: Median nerve CSA MRI measurements correlated better (Pearson correlation: 0.80-0.95, P < .05) with cadaveric measurements than with US measurements (Pearson correlation: 0.61-0.79, P < .05). Median nerve CSA US measurements (8.6-12.5 mm2 , P < .05) were smaller at all levels than MRI (11.3-14.7 mm2 ) or cadaveric (11.0-14.9 mm2 ) measurements while MRI and cadaver measurements were similar at all levels. Median nerve CSA MRI measurements in CTS patients were larger than US measurements at all levels. CONCLUSION: Median nerve CSA measurements by MRI are larger than US measurements and correlated better with cadaveric measurements. Median nerve CSA criteria used for diagnosing CTS on US are not likely to be applicable to MRI.

Arthroscopic bone grafting with percutaneous fixation in treating scaphoid nonunion / 中华骨科杂志

Objective@#To analyze the clinical effects of arthroscopic autologous bone grafting and percutaneous fixation in treating scaphoid nonunion.@*Methods@#From May 2013 to August 2017, a total of 25 cases of patients including 20 males and 5 females with unilateral scaphoid fractures and nonunion were reviewed, with mean age of 35.80±2.41 years (18-65 years). The duration from injury to treatment was averaged 11.70±1.90 months (5-18 months). All of the cases sustained waist and proximal end fractures. X-ray and CT scan showed sclerosis and bone resorption without any callus at the fracture sites. However, there were no serious deformities and wrist arthritis. The patients suffered pain and weakness at the radial side of the wrist. The type of the fractures were Slade-Geissler's III-VI, including grade III 4 cases, grade IV 13 cases, grade V 7 cases and grade VI 1 case. The patients were treated with arthroscopic debridement of the sclerotic bone, autologous bone grafting, percutaneous screw (9 cases) or K-wires fixation (16 cases) and immobilization by plaster for 3 weeks after operation, followed by functional rehabilitation training. Bone union was assessed by serial plain radiographs and CT scan regularly. The functional effects were evaluated by comparing the modified Mayo wrist score with the visual analogue scale (VAS) for pain, range of motion (ROM) and the grip strength, which were measured before operation and at 18 months after operation.@*Results@#All cases were followed up. Bone union was achieved in all of 25 nonunion. The average radiological union duration was 10.24±2.10 weeks (6-20 weeks). The average VAS score decreased from 6.75±1.10 preoperatively to 1.33±0.21. The mean ROM of wrist was improved to 168.48°±12.41° (92.90% of that of the normal side), compared to that of 135.24°±17.47° preoperatively (79.80% of that of the normal side). The mean grip strength showed improvement from an average of 35.68±3.81 kg (80.46% of that of normal side) preoperatively to 48.75±4.42 kg (90.65% of that of normal side). The average modified Mayo wrist score improved from 61.52±6.32 preoperatively to 85.88±8.37.@*Conclusion@#Arthroscopic autologous bone grafting with percutaneous cannulated screw and K-wires fixation is an effective and minimally invasive treatment for scaphoid nonunion, which could protect the blood supply of the fracture sites, decrease the surgical complications, promote bone healing and lead to a faster recovery.

Palmer Midcarpal Instability: An Algorithm of Diagnosis and Surgical Management.

Background Palmar midcarpal instability (PMCI) is an uncommon form of nondissociative carpal instability. However, it is an important cause of chronic ulnar wrist pain. Diagnosis can be difficult and high index of suspicion is mandatory. Pathomechanics and optimal treatment of PMCI remain uncertain. We propose an algorithm of clinical diagnosis and evaluate the outcome of our management. Materials and Methods Between 2000 and 2011, 16 patients, including 7 males and 9 females, of a mean age of 33.9 diagnosed with PMCI were reviewed for their clinical, radiologic, and arthroscopic features. All patients presented with ulnar wrist pain in their dominant hands except in one. Initial management included a disease-specific anticarpal supination splint. Refractory cases were evaluated by arthroscopy and treated by arthroscopic thermal shrinkage using radiofrequency appliance as an interim or definite surgical intervention. Shrinkage was targeted at the ulnocarpal ligament at the radiocarpal joint and triquetrohamate ligament at the midcarpal joint. Nonresponsive or recurrent cases were managed by a novel technique of dorsal radiocarpal ligament reconstruction procedure using a pisiform-based split flexor carpi ulnaris (FCU) tendon graft. Results In all cases, the midcarpal clunk test was positive with pain. Other common clinical features included lax ulnar column, carpal supination, volar sagging of the wrist, increased pisostyloid distance, wrist pain aggravated by passive hand supination and not by passive forearm supination, and increased wrist pain upon resisted pronation, which could be partially alleviated by manually supporting the pisostyloid interval. Common arthroscopic findings were excessive joint space at triquetrohamate interval and reactive synovitis over the ulnar compartments. Nine patients (56.3%) responded well to splinting alone at an average follow-up of 3.3 years. Arthroscopic thermal shrinkage was performed in five patients with recurrence in two patients. Five patients received split FCU tendon graft for ligament reconstruction. All patients showed improvement in the wrist performance score (preop 21.0, postop 36.6 out of 40) and pain score (preop 10.0, postop 2.2 out of 20) at the final follow-up of average 86 months (range: 19-155 months). Grip strength improved from 66.9 to 82.0% of the contralateral side. Wrist motion slightly decreased from a flexion/extension arc of 132 to 125 degrees. Three patients were totally pain free, one had mild pain, and one had moderate fluctuating pain. All patients returned to their original works. X-ray showed no arthrosis. Conclusion PMCI is an uncommon but significant cause of chronic ulnar wrist pain. We have developed a clinical algorithm for diagnosis of the condition. The natural history seems to favor a benign course. Conservative treatment with an anticarpal supination splint is recommended as the initial management. Surgical options for resistant cases include arthroscopic thermal shrinkage or soft tissue reconstruction. The reconstruction of the dorsal radiocarpal ligament using a pisiform-based split FCU tendon graft provides reliable restoration of the carpal stability with good long-term outcome and few complications. This should be considered a viable alternative to limited carpal fusion.

Arthroscopic Transplantation of Osteochondral Autograft for Treatment of Cartilage Defects in the Wrist.

Focal chondral lesions are a common cause of chronic wrist pain, with no ideal treatment. The authors developed arthroscopic transplantation of osteochondral autograft from lateral femoral condyle to distal radius with satisfactory outcome in 4 consecutive patients between December 2006 and December 2010. In all cases, graft incorporation was completed by 3 months to 4 months postoperation. All patients showed improvement in wrist function with no pain at follow-up at an average of 70.5 months (range 24-116 months). Second-look arthroscopy in 3 patients confirmed the preservation of normal articular cartilage. Patient satisfaction was high with no complications.

MR imaging of the traumatic triangular fibrocartilaginous complex tear.

Triangular fibrocartilage complex is a major stabilizer of the distal radioulnar joint (DRUJ). However, triangular fibrocartilage complex (TFCC) tear is difficult to be diagnosed on MRI for its intrinsic small and thin structure with complex anatomy. The purpose of this article is to review the anatomy of TFCC, state of art MRI imaging technique, normal appearance and features of tear on MRI according to the Palmar's classification. Atypical tear and limitations of MRI in diagnosis of TFCC tear are also discussed.

Kienböck Disease and Arthroscopy: Assessment, Classification, and Treatment.

The assessment and management of Kienböck Disease (KD) has always been a conundrum. The Lichtman classification has traditionally been used to guide treatment based on imaging. Arthroscopy provides a direct visualization of the articular surface, allows probing of the surfaces, and enables minimally invasive techniques to be performed. The Lichtman-Bain classification is a new classification that takes into account the osseous, vascular, and cartilage aspects of the lunate and the secondary effects on the wrist. It identifies the important prognostic factors including age, the status of the lunate, and the status of the wrist. With arthroscopy, the articular surfaces of the lunate can be assessed to better understand the status of the lunate. The lunate can be defined as intact, compromised, or not reconstructable. If the lunate is intact then lunate decompression (forage) and arthroscopic assisted bone grafting can be performed. If the lunate facet and capitate are functional, then a proximal carpectomy can be performed. This can be performed as an arthroscopic procedure. Assessment of the wrist includes assessment of the adjacent articular surfaces of the central column articulations (radiocarpal and midcarpal articulations). Instability of the proximal carpal row can also be assessed. The radioscaphoid articulation is often preserved except in late KD, which allows the scaphocapitate fusion to be a good surgical option. This can now be performed as an arthroscopic procedure. Once the radioscaphoid articulation is degenerate, a salvage procedure is required.

Arthroscopic-Assisted Combined Dorsal and Volar Scapholunate Ligament Reconstruction with Tendon Graft for Chronic SL Instability.

Background Both the dorsal and the volar portion of the scapholunate interosseous ligament (SLIL) are major stabilizers of the scapholunate (SL) joint. Most reconstruction methods to restore SL stability do not address the volar constraints and frequently fail to reduce the SL gapping. Wrist arthroscopy allows a complete evaluation of the SL interval, accompanying ligament status, and associated SL advanced collapse (SLAC) wrist changes. It enables simultaneous reconstruction of the dorsal and palmar SL ligaments anatomically with the use tendon graft in a boxlike structure. Materials and Methods From October 2002 to June 2012, the treatment method was applied in 17 patients of chronic SL instability of average duration of 9.5 months (range 1.5-18 months). There were three Geissler grade 3 and 14 grade 4 instability cases. The average preoperative SL interval was 4.9 mm (range 3-9 mm). Dorsal intercalated segment instability (DISI) deformity was present in 13 patients. Six patients had stage 1 SLAC wrist change radiologically. Concomitant procedures were performed in four patients. Description of Technique With the assistance of arthroscopy and intraoperative imaging as a guide, a combined limited dorsal and volar incision exposed the dorsal and palmar SL interval without violating the wrist joint capsule. Bone tunnels of 2.4 mm were made on the proximal scaphoid and lunate. A palmaris longus tendon graft was delivered through the wrist capsule and the bone tunnels to reduce and connect the two bones in a boxlike fashion. Once the joint diastasis is reduced and any DISI malrotation corrected, the tendon graft was knotted and sutured on the dorsal surface of the SL joint extra-capsularly in a shoe-lacing manner. The scaphocapitate joint was transfixed with Kirschner wires (K-wires) to protect the reconstruction for 6-8 weeks. Results The average follow-up was 48.3 months (range 11-132 months). Thirteen returned to their preinjury job level. Eleven patients had no wrist pain, and six had some pain on either maximum exertion or at the extreme of motion. The average total pain score was 1.7/20 compared with the preoperative score of 8.3/20. The postoperative average total wrist performance score was 37.8/40, with an improvement of 35%. The average extension range improved for 13%, flexion range 16%, radial deviation 13%, and ulnar deviation 27%. Mean grip strength was 32.8 kg (120% of the preoperative status, 84% of the contralateral side). The average SL interval was 2.9 mm (range 1.6-5.5 mm). Recurrence of a DISI deformity was noted in four patients without symptoms. Ischemic change of proximal scaphoid was noted in one case without symptoms or progression. There were no major complications. All patients were satisfied with the procedure and outcome. Conclusion Our method of reconstructing both the dorsal and volar SL ligament, in a minimally invasive way, is a logical and effective technique to improve SL stability. The potential risk of ischemic necrosis of the carpal bone is minimized by preservation of the scaphoid blood supply, the small size of the bone tunnels created, and the inclusion of the capsule at the reconstruction site.

Irreducible volar subluxation of the proximal interphalangeal joint due to radial collateral ligament interposition: case report and review of literature.

Irreducible volar subluxation should be considered when assessing a patient with flexion deformity of the proximal interphalangeal finger joint (PIPJ). Primary assessment requires careful examination of the collateral ligaments and extensor tendon. Preoperative imaging such as ultrasound and MRI can help identify the interposed structures and plan the subsequent operation. Although rare, irreducible volar subluxation due to radial collateral ligament interposition is an important entity to be aware of. Prompt and appropriate management can prevent joint stiffness and loss of function.

Malignant schwannoma of the radial nerve with unusual presentation: a case report.

Malignant schwannoma (MPNST) is a rare tumor. Many of these cases occur in patients with neurofibromatosis type I (NF-1) and they usually present as a mass lesion which rapidly increase in size with or without neurological symptoms. Here we present an unusual case of MPNST along the radial nerve in which the patient has no underlying neurofibromatosis type I.

A baby with symmetrical hand injuries and rhabdomyolysis following nonfatal electrocution by an unusual mechanism.

Childhood electrical injuries are rare in the city of Hong Kong. We report the case of a 21-month boy with severe electrical injuries of both hands and explored underlying mechanism for the incident. Meticulous orthopedic repair and reconstruction ensures satisfactory cosmetic and functional outcomes. Our case concurs with the literature that young children may be predisposed to this mode of incident with their curious exploring hands. Despite regulations on electrical home safety standards, extension power boards can still pose a dangerous risk for severe morbidity in the household with young children. Prevention strategies often involve commonsense approach in home safety measures such as (1) use proper fuses in electrical boxes, (2) do not overload outlets, (3) use insulated and grounded electrical cords, (4) keep electrical cords away from a child's reach, and (5) cover electrical outlets so children will not stick items in the outlet.

Arthroscopic reconstruction of triangular fibrocartilage complex (TFCC) with tendon graft for chronic DRUJ instability.

PURPOSE: To report the 10-years' experience of a novel arthroscopic assisted anatomical TFCC reconstruction in treatment of chronic DRUJ instability resulting from irreparable TFCC injuries. MATERIALS AND METHODS: 15 patients (7 males, 8 females) with mean age of 37 (17-49) suffering from irreparable TFCC injuries received arthroscopic assisted reconstruction using palmaris longus graft. Three skin incisions were made with creation of one radial and one ulna tunnel for passage of graft following the path of dorsal and palmar radio-ulnar ligaments under fluoroscopic and arthroscopic guidance. The joint capsule was kept intact. Early mid-range forearm rotation was started since 4th week postoperatively. RESULTS: The mean follow-up was 85.53 months (32-138). Mayo wrist score improved from 62.5 to 88 (p<0.05). Comparing contralateral side, total prono-supination range increased from 76.6% to 92.1% and grip strength increased from 56.1% to 76.9%. Twelve patients resumed previous jobs. No evidence of DRUJ arthritis was noticed. Complications included 2 late graft ruptures and one unexplained dystonia. CONCLUSIONS: Our arthroscopic assisted approach on TFCC reconstruction is safe, produces comparable results as the standard technique and may achieve better range of motion with less soft tissue dissection and earlier mobilization.

Wrist Arthroscopy under Portal Site Local Anesthesia (PSLA) without Tourniquet.

UNLABELLED: Purpose wrist arthroscopy is typically performed under general or regional anesthesia with the aid of a tourniquet to maintain a bloodless field. We have been using portal site local anesthesia (PSLA) for wrist arthroscopy without a tourniquet since 1998. The aim of the study was to assess the efficacy, safety, and complications of PSLA and whether this can be recommended for routine wrist arthroscopy. Method We conducted a retrospective study, identifying 111 consecutive cases of wrist arthroscopies performed from January 2007 to December 2009. All cases were performed under PSLA. The effectiveness of PSLA was assessed by analyzing whether the procedure required adjuvant forms of anesthesia. The subjective effectiveness was assessed via phone questionnaires. Results Sixty-eight male and 43 female patients were identified. The average age was 43.2 (range 16-77). The indications included chronic wrist pain of unknown origin (30), posttraumatic arthritis (27), rheumatoid arthritis (5), ganglion (30), triangular fibrocartilage complex (TFCC) injury (14), infectious (1), and carpal instability (4). The average duration of the procedures was 73 minutes (range 20-255 minutes). Therapeutic procedures were performed in all 111 cases in addition to a routine diagnostic assessment. These included arthroscopic debridement (82) synovectomy (6), ganglionectomy (30), TFCC repair (3), TFCC debridement (11), radial styloidectomy (2), wafer procedure (4), thermal shrinkage (2), distal scaphoidectomy (1), and synovial biopsy (4). All procedures could be completed uneventfully. Most patients tolerated the procedure well throughout the operation, and the satisfaction level was high. No complication was encountered. Discussions We concluded that PSLA technique is a feasible mode of anesthesia in selected patients. LEVEL OF EVIDENCE: Level IV.

Do we need to repair the nerves when replanting distal finger amputations?

Distal replantation is an excellent model to study the results of nerve repair. We aim to demonstrate differences in aesthetic, sensory, and functional outcomes in fingertip replantation, with and without nerve repair. We recruited 28 fingers in 28 patients, who had successful distal replantation in 5 years. Half of the fingers had nerves repaired. Mean follow-up was 39 months. Symptoms of pain, numbness, cold intolerance, scar hypersensitivity, pulp atrophy, and weakness were reported. Nail width, pulp length, 2-point discrimination, Semmes-Weinstein test, and power were evaluated. We used chi-square tests of independence to examine association between nerve repair and symptoms, and independent T tests and Mann-Whitney U tests to analyze difference between replantation with and without nerve repair according to objective results. Chi-square tests reviewed no significant association between nerve repair and symptoms. Mann-Whitney U tests showed no significant difference between the groups, with and without nerve repair. All fingers showed mean 2-point discrimination of 5.6 mm, and Semmes-Weinstein test results of green in 3 fingers and blue in 17. There was no significant difference in overall outcomes in repairing nerve or not in distal finger replantation. Both groups had satisfactory outcomes. Possibly, spontaneous neurotization is present, and nerve repair is not necessary, which may help to shorten the operation time and decrease extensiveness of surgeries.