H. J. C. R. Belcher

A Comparison of Trapeziectomy with and without Ligament Reconstruction and Tendon Interposition

Forty-three patients were randomly allocated to undergo either trapeziectomy alone (control) or with a ligament reconstruction and tendon interposition (LRTI) using an abductor pollicis longus tendon slip. The patients were reviewed at a median 13 (range, 7–29) months after surgery. The demographic characteristics, severity of disease and pre-operative clinical measurements of the two study groups were indistinguishable but LRTI lengthened the operation by approximately 15 minutes. Both groups expressed equal satisfaction with the operation and there were no significant differences between the two treatment groups. Simple trapeziectomy is an effective operation for osteoarthrosis at the base of the thumb and the addition of a ligament reconstruction was not shown to confer any additional benefit.

Adverse Effect of Porcine Collagen Interposition after Trapeziectomy a Comparative Study

Twenty-six hands in 26 adults with osteoarthrosis of the thumb trapeziometacarpal joint were randomised to undergo either trapeziectomy alone (control) or with the interposition of porcine dermal collagen xenograft (Permacol™). The study was terminated prematurely because of apparent reactions to the implants in six of 13 patients. The collagen interposition group required more frequent review on clinical grounds and were discharged later after surgery. Three of the implants have been removed and histology revealed foreign body reactions in all. There was no difference in thumb movement or power after surgery between the two groups. However, improved grip strength was observed and improved function were reported only in the control group. Permacol patients reported greater pain and were less satisfied with their operations than control patients. We conclude that interposition of Permacol is detrimental to the results of trapeziectomy.

Visual Estimation of Finger Angles: Do we Need Goniometers?:

Seventy-one plastic surgeons and therapists, of varying levels of seniority and experience, were asked to examine a resin cast of an adult male hand and use estimation to measure the angles of the metacarpophalangeal and interphalangeal joints of each digit. Visual estimation by all subjects was inaccurate by a mean of approximately 25% (median percentage error 22, range 1–100). Consultants were the most accurate, whilst physiotherapists were the least. Regular goniometer users were no more accurate. However, hand surgery experience correlated with accuracy, as did a stated interest in hand surgery. Although visual accuracy improves with experience, it is still an inaccurate technique. We, therefore, recommend that goniometers should be used for measuring angles in hand surgery patients.

A Comparison of Metacarpophalangeal Joint Silastic Arthroplasty with or Without Crossed Intrinsic Transfer

Forty-three hands in 36 adults undergoing Silastic interposition arthroplasty of the index, middle, ring and little finger metacarpophalangeal joints for rheumatoid arthritis were randomly allocated to undergo replacement with or without crossed intrinsic transfer. The patients were reviewed at a median of 17 (range, 7–50) months after surgery. The demographic characteristics and pre-operative clinical measurements of the two groups were indistinguishable. Both groups showed improvement in ulnar drift and an altered arc, but no change in total range of motion at the metacarpophalangeal joints. Grip strength and pulp to pulp pinch were significantly and comparably improved in both groups. There was no difference in pain scores or perceived function between the treatment groups. It is concluded that crossed intrinsic transfer does not significantly affect the outcome of Silastic interposition arthroplasty of the metacarpophalangeal joints in rheumatoid patients.

Median nerve contusion during endoscopic carpal tunnel release

Median nerve contusion occurred in two patients treated by endoscopic carpal tunnel release. We discuss the possible cause of this complication and how to avoid it.

Centro-central union for the prevention of neuroma formation after finger amputation.

Sixty digits undergoing terminalization were randomized to undergo either simple transection of the digital nerves (control) or direct suture of the nerves to each other (centro-central union, CCU). Thirty-one digits were available for review with a minimum follow-up of one year following the surgery. Assessment was by visual analogue scales (VAS) and clinical examination. Measurements included static two-point discrimination (S2PD) for sensation, dolorimetry for stump tenderness and grip-strength. Resting pain, cold intolerance and perceived tenderness were comparable in the two groups. Perceived and observed touch sensitivity were better in the control group but the stumps in this group were more tender than those in the CCU group. We conclude that CCU results in more comfortable stumps but causes greater loss of sensitivity. It is a simple and worthwhile adjunct to digital amputation.

Endoscopic carpal tunnel release: practice in evolution

This study reports on 565 consecutive endoscopic carpal tunnel releases using the Agee one‐portal technique of which 25 (4.4%) were converted to the open technique. The follow‐up period was from 4 to 52 months. Immediate symptomatic relief was reported in 562 wrists (99.5%). There were 25 complications (4.4%) including pillar pain (8 wrists), digital neuropraxia (n = 6), median nerve contusion (n = 3), incomplete division of the flexor retinaculum (n = 3), superficial infection (n = 3), reflex sympathetic dystrophy (n = 1), and tenderness of the scar (n = 1). We describe the evolution of our selection of patients and surgical technique. We recommend caution in performing ECTR in short patients who are liable to have small wrists because of the risk of contusion of the median nerve. We present some technical modifications that may make the technique safer.

Anthropometry and Endoscopic Carpal Tunnel Release

A prospective study was performed in 100 consecutive endoscopic carpal tunnel releases (ECTR) to assess the effect of a number of anthropometric measures on the ease of introduction of the ECTR system into the carpal tunnel. Ease of access to the carpal tunnel correlated with the wrist circumference, height and age of patients. Surgeons should be aware that ECTR is likely to be more difficult in small patients with small wrists and should have a higher threshold for conversion to the open technique to avoid neurological complications.

A COMPARISON OF TRAPEZIECTOMY VIA ANTERIOR AND POSTERIOR APPROACHES

Forty-three hands in 41 adults with osteoarthrosis of the trapeziometacarpal joint were allocated randomly to undergo a trapeziectomy through either an anterior approach or the posterior (dorsoradial) approach. Forty hands were available for review at a median of 33 months postoperatively. The demographic characteristics, severity of disease and pre-operative measurements of the two groups were indistinguishable. Trapeziectomy resulted in significantly improved objective and subjective function in both groups, but the anterior approach group had better outcomes for power, scar tenderness and satisfaction. Scar-related complications were three times more common in the posterior group. Trapeziectomy is a good method of treating osteoarthritis of the thumb base, but outcomes for the anterior approach are equally good or better than with the posterior.

Cold Intolerance Following Collagenase Clostridium histolyticum Treatment for Dupuytren Contracture

Modern studies often point to Avicenna (980e1037 AD) as being the first to distinguish nerves from tendons. Our investigations, however, indicate that Al-Akhawayni Bukhari (?e983 AD) introduced nerves and tendons as 2 distinct structures. Our letter summarizes some of the many scientific contributions of this eminent predecessor of Avicenna. Abubakr Rabi-ibn Ahmad Akhawayni Bukhari (Joveini in Latin) was a Persian scholar. He contributed to the Islamic Golden Age’s (ninth through 12th centuries AD) scholarly achievements. He authored the Hidayat al-Muta’allemin fi al-Tibb (Learner’s Guide to Medicine). In the Hidayat, Al-Akhawayni presented his knowledge on various medical matters. Among them was subject matter relating to the components of the musculoskeletal system and their function and anatomical structure. In chapter “al-Ghol fi-al-A’asab” (“Discourse on the Nerves”), Al-Akhawayni described the nerves originating from the brain and spinal cord. He classified them as sensory andmotor. Then, he described the ligaments, introduced the bones as their origins, and noted their role in connecting the bones together. In the next chapter, entitled “al-Ghol fi-al-Azolat” (“Discourse on the Muscles”), Al-Akhawayni pointed to the presence of tendons connected to themuscles and explained their action. He stated, “When the muscle is being shortened, this ‘vatar’ [tendon] pulls the bone towards the muscle to move the body part .” He mentioned that tendons do not originate from the brain