Wing-Lim Tse

Needle aponeurotomy for Dupuytren's contracture

Purpose. To review the efficacy and safety of needle aponeurotomy for Dupuytrens contracture in Chinese patients. Methods. Seven men and one woman aged 50 to 80 (mean, 67) years underwent needle aponeurotomy for Dupuytrens contracture. Five were manual workers and the other 3 were retired. Their chief complaints were difficulty moving the fingers, clumsiness of the hand, and occasional pain in the palm. No patient had any family history of Dupuytrens contracture. Results. 41 points were released in 13 fingers (3 middle, 3 ring, and 7 little). Immediately after release, the respective mean flexion contracture correction of the metacarpophalangeal and proximal interphalangeal joints were 50 (from 50 to 0) and 35 (from 46 to 11) degrees. At 22-month follow-up, the respective mean residual flexion contracture of both joints were 12 and 27 degrees; the corresponding long-term improvements were 70 and 41%. No patient had a wound complication or neurovascular injury. All had a normal score for Disabilities of the Arm, Shoulder, and Hand. Conclusion. For Chinese patients with Dupuytrens contracture, needle aponeurotomy is safe and effective. Long-term correction is better maintained in metacarpophalangeal than proximal interphalangeal joints (70 vs 41%).

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.

Digital ischaemia: a rare but severe complication of jellyfish sting

We report a case of digital ischaemia in a 31-year-old man who presented with sudden hand numbness, swelling, and cyanosis 4 days after a jellyfish sting. This is a rare complication of jellyfish sting, characterised by a delayed but rapid downhill course. Despite serial monitoring with prompt fasciotomy and repeated debridement, he developed progressive ischaemia in multiple digits with gangrenous change. He subsequently underwent major reconstructive surgery and aggressive rehabilitation. Although jellyfish stings are not uncommon, no severe jellyfish envenomation has been reported in the past in Hong Kong and there has not been any consensus on the management of such injuries. This is the first local case report of jellyfish sting leading to serious hand complications. This case revealed that patients who sustain a jellyfish sting deserve particular attention to facilitate early detection of complications and implementation of therapy.

Local review of treatment of hand enchondroma (artificial bone substitute versus autologous bone graft) in a tertiary referral centre: 13 years' experience.

OBJECTIVE To evaluate the treatment outcomes of enchondroma of the hand with artificial bone substitute versus autologous (iliac) bone graft. DESIGN Historical cohort study. SETTING Tertiary referral centre, Hong Kong. PATIENTS A total of 24 patients with hand enchondroma from January 2001 to December 2013 who underwent operation at the Prince of Wales Hospital and Alice Ho Miu Ling Nethersole Hospital in Hong Kong were reviewed. Thorough curettage of the tumour was performed in all patients, followed by either autologous bone graft impaction under general anaesthesia in 13 patients, or artificial bone substitute in 11 patients (10 procedures were performed under local or regional anaesthesia and 1 was done under general anaesthesia). The functional outcomes and bone incorporation were measured by QuickDASH (shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire) scores and radiological appearance, respectively. The mean follow-up period was 59 months. RESULTS There were eight men and 16 women, with a mean age of 40 years. Overall, 17 cases involved phalangeal bones and seven involved metacarpal bones. Among both groups of patients, most of the affected digits had good range of motion and function after surgery. One patient in each study group had complications of local soft tissue inflammation. One patient in the artificial bone substitute group was suspected to have recurrence 8 years after operation. Among the autologous bone graft group, four patients had persistent donor site morbidity at the last follow-up. In all patients, radiographs showed satisfactory bone incorporation. CONCLUSIONS Artificial bone substitute is a safe and effective treatment option for hand enchondroma, with satisfactory functional and radiographic outcomes. Artificial bone substitute offers the additional benefits of enabling the procedure to be done under local anaesthesia on a day-case basis with minimal complications.

Chapter 35 – Arthroscopic Bone Grafting for Scaphoid Nonunion

The scope is introduced into the 6R portal and the shaver into the 3–4 portal. This approach allows the integrity of the scapholunate ligament to be verifi ed. The quality of the cartilage at the proximal pole of the scaphoid and radial styloid process is also verifi ed. If needed, radial styloidectomy can be performed arthroscopically at this point in the procedure (Chapter 6). Arthroscopic treatment of the nonunion is performed via the midcarpal joint. The scope is introduced into the ulnar midcarpal (MCU) portal and instruments into the radial midcarpal (MCR) portal. The fi rst phase of the arthroscopic procedure consists of complete synovectomy with a shaver.

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 Reconstructive Procedures for Kienböck’s Disease

Advances in arthroscopic technique have allowed a more accurate assessment and classification of the pathological changes in Kienbock’s disease. This assists in decision making and customizing treatment for the individual patient and their wrist disorder. In our practice arthroscopic reconstructive procedures for Kienbock’s disease include lunate excision, proximal row carpectomy and partial wrist fusions. In advanced Kienbock’s disease where the radioscaphoid articulation is still preserved, we utilize scaphocapitate fusion, which bypasses the load to the radioscaphoid articulation, and therefore unloads the lunate. In this article the specific indications and techniques of arthroscopic scaphocapitate fusion, radioscapholunate fusion and proximal row carpectomy are described.