Fu-Keung Ip

Squamous cell carcinoma of the nail bed: three case reports.

Squamous cell carcinoma of the nail bed is rare, and the disease is often misdiagnosed as a benign condition. Digital amputation is often performed because of the delay in diagnosis and the involvement of the distal phalanx. Between March 1999 and March 2002, 3 patients presented to the Pamela Youde Nethersole Eastern Hospital, Hong Kong, with squamous cell carcinoma of the nail bed. Two of the patients underwent a digit-salvaging procedure—namely, wide local excision and flap coverage—and their functional outcome was satisfactory. The remaining patient received partial amputation of the thumb without significant functional loss. A high degree of suspicion is thus needed to detect squamous cell carcinoma of the nail bed; a biopsy of chronic recurrent nail bed lesions should be performed.

Bone–Periosteum–Bone Graft Reconstruction for Chronic Ulnar Instability of the Metacarpophalangeal Joint of the Thumb—Minimum 5-Year Follow-Up Evaluation

PURPOSE The present study evaluated prospectively the functional and radiological results of a consecutive series of 7 patients who had bone-periosteum-bone (BPB) grafts harvested from the iliac crest for treatment of chronic ulnar instability of the metacarpophalangeal (MCP) joint of the thumb after a minimum of 60 months. METHODS Seven thumbs from 7 patients were entered into a prospective study for surgical treatment of chronic finger joint instability. Treatment consisted of reconstruction of the ulnar collateral ligament of the MCP joint of the thumb by a BPB graft harvested from the iliac crest. Stability, range of motion, pinch grip, and radiographs were evaluated at least 60 months after surgery. RESULTS All 7 patients had full active range of motion of the treated thumb at the final follow-up evaluation (average, 75 months after surgery). All patients had equal stability and normal pinch grip when comparing with the untreated thumb. The mean time off work was 3 months for 6 patients who were injured at work. At final follow-up evaluation, radiographs showed all grafts incorporated without implant complications, no osteoarthritis changes were noted, and stress radiographs showed that all patients had normal stability in the treated thumb when compared with the untreated thumb. CONCLUSIONS Chronic ulnar instability of the MCP joint of the thumb reconstructed with BPB graft harvested from the iliac crest is an effective and safe method to allow restoration and maintenance of a stable, pain-free thumb. The results of the current study support the long-term durability of this method. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Minimally invasive management of trans-scaphoid perilunate fracture-dislocations.

This retrospective study evaluates the functional and radiological results of a series of acute trans-scaphoid dorsal perilunate fracture-dislocations treated operatively by minimally invasive technique. Twenty-one patients had surgery performed by one of three surgeons between 1994 and 2006, and all cases involved: (1) closed reduction of the carpus; (2) closed reduction and percutaneous screw fixation of the scaphoid fracture; and (3) closed reduction and multiple Kirschner wire stabilisation of the carpal dissociation. Seventeen males and four females with an average age of 29 years were evaluated. Ninety five per cent of internally fixed scaphoid healed at a mean time of 16 weeks. Radiographic alignment of the carpus was satisfactory in 17 cases. The average Mayo wrist score was 80 with three excellent and two poor results. There was one patient with asymptomatic DISI deformity. Two patients had radiographic evidence of mid-carpal arthritis. One patient with a scaphoid nonunion required surgical repair with bone grafting. The results of this study suggest that a minimally invasive technique for treating acute trans-scaphoid perilunate fracture-dislocations can be considered as an alternative to open approaches.

Palmar fixation of dorsally displaced distal radius fractures using locking plates with SmartLock locking screws

We performed a prospective cohort study on a consecutive series of 35 unstable, dorsally displaced distal radius fractures, which were treated with palmar locking plates and SmartLock locking screws. There were 17 men and 18 women with a mean age of 44 years who were reviewed at a mean follow-up of 10 months. All the fractures healed at a mean time of 7 weeks. Radiographs did not show any change in alignment from the initial postoperative period until fracture union. The average Mayo wrist score was 90 after fracture union. One patient had an early loss of fracture reduction and one patient developed complex regional pain syndrome. There was no difference in the quality of life before and after surgery. Palmar plate fixation using SmartLock locking screws is effective and safe in stabilising unstable dorsally displaced distal radius fracture and produces good radiological and functional outcomes.

The effectiveness of capsular decompression for internal fixation of intracapsular hip fractures

Purpose. To compare the results of screw fixation plus capsular decompression versus screw fixation alone for managing intracapsular hip fractures. Methods. Of 201 patients with intracapsular hip fractures, 99 underwent screw fixation with capsular decompression (capsular decompression group) and 102 underwent screw fixation alone (control group). The incidence and time to development of avascular necrosis of the femoral head, union rate, time to union, and other clinical parameters were compared. Results. In patients with displaced fractures, the incidence of avascular necrosis was significantly higher in the control than capsular decompression group, whereas the time to development of this complication was significantly shorter. Conclusion. Capsular decompression did not improve the union rate and time to union in undisplaced intracapsular hip fractures, but in displaced fractures it appeared to reduce the incidence and delay the onset of avascular necrosis.

Elderly patients with two episodes of fragility hip fractures form a special subgroup

Purpose. To identify the demographic features of patients aged 65 years or older admitted with 2 episodes of fragility hip fractures. Methods. From July 2003 to December 2004 inclusive, 50 consecutive elderly patients underwent surgery for a second episode of hip fracture. Patients in a very poor physical condition and therefore unfit for surgery were excluded. Risk factors of fractures in both episodes and whether risk factors were corrected after the first episode were analysed. Detailed radiological assessment and charting of elderly mobility scores and Barthel index were completed and the one-year mortality rate documented. The rehabilitation periods for the 2 episodes of hip fracture were compared. Results. Most patients were female and had trochanteric fractures. In patients aged 65 to 75 years, the incidence of femoral neck fracture occurred as often as trochanteric fracture; while trochanteric fracture was predominant in older patients. Subclinical osteomalacia and undiagnosed hyperthyroidism was found in 3 of the 7 younger patients. Only 30% of them were on treatment for osteoporosis after the first fracture, which underlines the importance of osteoporosis treatment in these patients. Conclusion. Elderly patients with 2 episodes of fragility hip fractures form a special subgroup among geriatric hip fracture patients. Fall prevention programmes and treatment for osteoporosis are recommended.

A modified technique of interpositional arthroplasty in treating the Basal joint arthritis of the thumb in a Chinese population.

We performed a retrospective review of 22 thumbs in 22 Chinese patients attending for the basal joint arthritis of the thumb over the last 14 years. There were 16 women and six men with a mean age of 50 years old. All were treated surgically by partial trapeziectomy and volar oblique ligament reconstruction with flexor carpi radialis tendon and interpositional arthroplasty with a free palmaris longus tendon ball after failure of conservative treatment. The mean follow-up time was 48 months. Radiographs did not show any differences in the arthroplasty space index, arthroplasty space, trapezial space ratio and scaphoid-thumb metacarpal distance at the pre-operative evaluation and at the final follow-up evaluation. There was significant difference in the pain score, grip strength, Kapandji score and functional status before and after surgery at final follow-up period. One patient had complex regional pain syndrome which was resolved after receiving a course of anti-inflammatory drugs and physiotherapy. The authors suggest that the modified technique of partial trapeziectomy with tendon interpositional arthroplasty is a safe and effective method in treating basal joint arthritis of the thumb with good short term functional and radiological outcomes and minimal complication.

Exostosis in the Hand: Case Series and Literature Review

Introduction: This study reviews the exostosis in hand in our locality and compares those in the literature. Methods: A retrospective study was conducted by reviewing the cases collected from 2000 to 2010. Literatures were also reviewed to look into the current concept of exostosis in the hand. Results: There were nine patients with a total of 11 lesions of exostosis in the hand. Two cases were parosteal osteochondroma (Nora lesion). The male to female ratio was 4:5. The average presented age at the first consultation was 49.7 years of age. The most common site was distal phalanx. Six lesions had incorrect preoperative diagnoses by clinical assessment and standard two-view radiographs of the hand. Three of the six lesions were corrected after intraoperative Xi-scan screening. Conclusion: The clinical picture of exostosis in the hand in our locality seems to be different from that of Western countries. Lesions of the hand were difficult to be visualized in the radiographs due to overlapping of bones. Xi-scan may help in making the diagnosis.

Review of Partial Fasciectomy for Dupuytren's Contracture in Southern Chinese Patients

Dupuytren’s contracture is a fibroproliferative disease of the palmar fascia producing fascial fibrosis in nodular or cord form, and results in flexion contracture of the involved fingers. In contrast to Western populations, Dupuytren’s contracture, especially the severe form of the disease, is not common in Southern Chinese patients: there have been only scant reports from the Southern Chinese region. In addition, the natural history and surgical outcome may be different from those of Western patients. The purpose of our study was to evaluate the clinical outcomes of Southern Chinese patients with Dupuytren’s contracture treated with partial fasciectomy through a Bruner’s incision. Twenty-nine Chinese patients (45 fingers) with Dupuytren’s contracture were reviewed retrospectively from 1999 to 2008. All patients underwent partial fasciectomy performed under general anaesthesia. The ranges of movement of the metacarpophalangeal (MCPJ) and proximal interphalangeal (PIPJ) joints were measured preoperatively and during follow-up to assess the degree of correction after surgery. A total of 34 out of 45 fingers (75.6%) and 30 out of 45 fingers (66.7%) had regained a full range of movement of the MCPJs and PIPJs, respectively. In addition, 26 out of 29 patients (89.6%) had an improvement in extension of their MCPJs, and 20 out of 29 patients (68.9%) showed a gain in extension of their PIPJs. One in 29 patients (3.4%) developed a wound infection and needed further surgery for debridement. One patient had recurrent PIPJ contracture after partial fasciectomy (3.4%). None of our patients had a neurovascular injury or wound healing problem. We conclude that partial fasciectomy with a Bruner’s incision yields satisfactory results in Southern Chinese patients that are comparable to results from Western studies.

Neurilemmomas of the Hand—A Review of the Clinical Presentation, Surgical Outcome, and Potential Risk Factors: 手部的神經鞘瘤 -- 臨床表現,手術結果和潛在危險因素的綜述

Introduction Neurilemmoma of the hand may not usually present with the classic triad (mass, differential mobility, Tinels sign). Failure to recognize a neurilemmoma may result in the inadvertent injury of nerves. Preoperative diagnosis is very important and challenging. Materials and Methods A retrospective study of patients who underwent surgery for neurilemmoma of the hand between 2001 and 2013 was conducted. Their clinical presentation, surgical outcome and potential risk factors were reviewed. Results Twenty-eight cases of neurilemmoma arising from digits and hands in 28 patients were retrieved for study. Seventeen were male and 11 were female; the mean age at surgery was 57.1 years old and mean follow-up was 15.4 months. Nineteen lesions were on the volar side and the others were on the dorsal side. Volar digital nerve was the most common site of involvement. All patients presented with a mass, with an average duration of symptoms of 41.1 months; 35.7% had local tenderness. Differential mobility and Tinels sign could be elicited in 39.3% and 21.4%, respectively. Correct preoperative diagnosis was made only in 25% of cases. At final follow-up, 82.1% of patients was symptom-free. Numbness, local tenderness and hypertrophic scar were reported in 7.1%, 7.1% and 3.6% of patients, respectively. No recurrence and no wound complications were noted. No reoperation was necessary. Multiple lesions and a positive Tinels sign were associated with less satisfactory outcome and increased risk of postoperative complications as shown by the statistical analysis. Conclusion Neurilemmoma should be one of the differential diagnoses when dealing with hand masses. Tinels sign should be done routinely on examination to facilitate correct preoperative diagnosis. Loupe magnification should be used during operation for optimal surgical outcome.