Xinzhong Shao

Pull-Out Wire Fixation for Acute Mallet Finger Fractures With K-Wire Stabilization of the Distal Interphalangeal Joint

PURPOSE The aim of this study was to describe and assess a surgical technique for the treatment of mallet finger fractures using a pull-out wire with K-wire stabilization of the distal interphalangeal (DIP) joint in extension. METHODS From May 2003 to January 2008, we performed pull-out wire fixation of the fracture fragment with stabilization of the DIP joint using a K-wire in 65 closed mallet finger fractures in 65 patients with a mean age of 32 years (range, 18-48). The mean time between the injury and surgery was 8 days (range, 0-19 d). In this cohort, the mean joint surface involvement was 39% (range, 30% to 49%) and all injuries were associated with DIP joint subluxation. Fifteen days after surgery, the digits were assessed for skin necrosis, skin breakdown, and wound and wire track infection. Patient follow-up lasted 24 to 27 months, with a mean period of 25.5 months. The fingers were assessed for loss of extension and flexion of the DIP joints. We graded the results using Crawfords criteria. RESULTS Fracture reduction was maintained and all fractures united. We found no skin necrosis, skin breakdown, infection, or nail deformities. At the final follow-up, the mean extensor loss of the DIP joints was 7° (range, 0° to 37°). The mean flexion loss of the DIP joints was 1° (range, 0° to 15°). We noted extensor loss of the joint less than 10° in 57 digits and 10° to 15° (mean, 13°) in 8 digits. Based on Crawfords criteria, 52 digits were excellent, 8 were good, 4 were fair, and one was poor. CONCLUSIONS Pull-out wire fixation of the reduced fracture fragment and K-wire stabilization of the DIP joint is a useful technique for the treatment of mallet finger fractures. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Reconstruction of Thumb Pulp Defects Using a Modified Kite Flap

PURPOSE We report on a modified kite flap for the reconstruction of thumb pulp defects. We performed nerve repair to improve thumb pulp sensation. METHODS From May 2005 to December 2008, 42 thumbs in 42 patients were treated. The average size of the thumb pulp defects was 2.1 × 2.6 cm (range, 1.6 × 1.8 cm to 2.8 × 3.1 cm). The mean flap size was 2.5 × 2.9 cm (range, 1.8 × 2.2 cm to 3.2 × 3.5 cm). The radial branch of the second dorsal digital nerve was coapted to one of the proper digital nerves of the thumb. The required average length of the nerve branch was 1.2 cm (range, 0.7 to 1.6 cm). At follow-up, flap sensation was assessed using a static 2-point discrimination (2PD) test. For comparison, we also included 32 patients without nerve repair from April 2003 to April 2005. Outcomes were rated using the modified American Society for Surgery of the Hand Guidelines for Stratification of 2PD. RESULTS In the study group, full flap survival was achieved in 40 thumbs, and partial distal flap necrosis was noted in 2 thumbs. At final follow-up (mean, 26 mo; range, 24 to 27 mo), we obtained a fair result, with a mean 2PD of 7.9 mm (range, 7 to 10 mm) on all flaps. In the comparison group without nerve repair, there were 26 fair and 6 poor results, with a mean 2PD of 12 mm (range, 8 to 18 mm) at final follow-up (mean, 24 mo; range, 22 to 26 mo). There was a highly significant difference between the 2 groups. CONCLUSIONS We suggest performing nerve repair to improve the sensation of the kite flap when reconstructing a thumb pulp defect. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.

Second Dorsal Metacarpal Artery Flap From the Dorsum of the Middle Finger for Coverage of Volar Thumb Defect

PURPOSE The second dorsal metacarpal artery flap from the middle finger is a reconstructive technique that can be used to repair extensive volar defects in a normal-length thumb. However, few reports advocate using it for coverage of volar thumb defects. In this article, an anatomic study of 9 flaps used for resurfacing thumb defects is presented along with the clinical experience of the authors. METHODS From 2004 to 2006, 9 patients (6 men and 3 women; mean age, 33 years; range, 18-51 years) with extensive volar defects of their normal-length thumbs had reconstruction using the described technique. In all cases, the first dorsal metacarpal artery flap technique was unable to be used because of injury. Donor sites were covered using full-thickness skin grafts. After surgery, the thumb was immobilized with a splint, followed by rehabilitation. During the follow-up period, which lasted 24 to 30 months, flap-site skin quality, scar contractures, and finger mobility were assessed. The range of motion of the hand was measured by a goniometer. Sensibility was evaluated by the 2-point discrimination test and the Semmes-Weinstein monofilament test. Cold intolerance was also assessed. RESULTS Patient postoperative courses were uneventful, and all flaps survived completely without complication. Good coverage was obtained in all cases. Full active range of motion was observed in all patients in both the donor finger and the thumb. The mean Semmes-Weinstein sensitivity and 2-point discrimination scores of the flap were 4.02 g and 8.4 mm, respectively. Mild cold intolerance was observed in all of the thumbs. CONCLUSIONS The second dorsal metacarpal artery flap from the middle finger is a single-stage flap that produces good results. Although its pedicle length is limited, it is reliable and can be used as an alternative for reconstruction of extensive thumb-pulp defects, especially when the first dorsal metacarpal artery flap cannot be used. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Carpal tunnel release with subneural reconstruction of the transverse carpal ligament compared with isolated open and endoscopic release

We report a new surgical technique of open carpal tunnel release with subneural reconstruction of the transverse carpal ligament and compare this with isolated open and endoscopic carpal tunnel release. Between December 2007 and October 2011, 213 patients with carpal tunnel syndrome (70 male, 143 female; mean age 45.6 years; 29 to 67) were recruited from three different centres and were randomly allocated to three groups: group A, open carpal tunnel release with subneural reconstruction of the transverse carpal ligament (n = 68); group B, isolated open carpal tunnel release (n = 92); and group C, endoscopic carpal tunnel release (n = 53). At a mean final follow-up of 24 months (22 to 26), we found no significant difference between the groups in terms of severity of symptoms or lateral grip strength. Compared with groups B and C, group A had significantly better functional status, cylindrical grip strength and pinch grip strength. There were significant differences in Michigan Hand Outcome scores between groups A and B, A and C, and B and C. Group A had the best functional status, cylindrical grip strength, pinch grip strength and Michigan Hand Outcome score. Subneural reconstruction of the transverse carpal ligament during carpal tunnel decompression maximises hand strength by stabilising the transverse carpal arch.

The Use of a Third Metacarpal Base Osteoarticular Flap for Treatment of Metacarpophalangeal Joint Traumatic Defects

PURPOSE To describe the use of a pedicled osteoarticular flap harvested from the base of the third metacarpal for the treatment of traumatic defects of the metacarpophalangeal (MCP) joints. METHODS From February 2006 to January 2008, we included in the study 15 patients with posttraumatic defects of the MCP joints. The mean age of the patients was 35 years. The injured MCP joints were located in the thumb (n = 6) and index (n = 4), middle (n = 4), and ring fingers (n = 1). Of the 15 patients, 10 presented with acute injuries and 5 with old injuries. At follow-up, we assessed active motion and pinch strength and compared all measurements with those from the opposite hand. In patients with old MCP joint injuries, we also compared preoperative and postoperative motion and pinch strength. We assessed hand function using the Disabilities of the Arm, Shoulder, and Hand questionnaire. RESULTS At the final follow-up (mean, 28 mo), the mean motion arc of the reconstructed MCP joints and the opposite joints was 46° and 91°, respectively, and the mean pinch strength of the injured and opposite sides was 5.4 and 7.1 kg, respectively. For the 5 patients with old injuries to the fingers, the mean preoperative and postoperative motion arc was 2° and 43°, and the mean preoperative and postoperative pinch strength was 1.6 and 5.3 kg, respectively. The mean Disabilities of the Arm, Shoulder, and Hand score of the entire patient series was 9, whereas the mean preoperative and postoperative scores of the 5 patients with old injuries were 44 and 17, respectively. CONCLUSIONS The use of a pedicled osteoarticular flap harvested from the base of the third metacarpal is a reliable technique for the treatment of traumatic defects of the MCP joints.

Treatment of a Bennett Fracture Using Tension Band Wiring

PURPOSE To describe and assess a tension band wiring technique for the treatment of Bennett fractures and to compare this technique of open reduction and internal fixation versus closed reduction and percutaneous pinning. METHODS From July 2005 to April 2008, we treated 56 Bennett fractures in 56 patients using tension band wiring. The mean age of the patients was 32 years. There were 37 dominant hands and 19 nondominant hands. The mean time between the injury and operation was 5 days. In this open tension band fixation group, the mean joint surface involvement was 39%, and all injuries were associated with carpometacarpal joint subluxation. At final follow-up, we assessed the thumbs for range of motion and assessed the hands for pinch and grip strength. For comparison, we also included 21 patients who were treated using closed reduction and percutaneous pin fixation from January 2003 to May 2005. RESULTS We noted no fixation failures in the open reduction internal fixation group. Radiographic fracture healing was achieved in all patients at a mean time of 4 weeks. Patient follow-up averaged 39 months. At final follow-up, the mean extension-flexion arc of the first carpometacarpal joint was 49°. Mean thumb abduction was 82° and mean pinch and grip strength of the injured hands were 7.4 and 43.0 kg, respectively. There were no significant differences between groups regarding the extension-flexion arc of the first carpometacarpal joint and grip strength. The 2 groups were similar in thumb abduction and pinch strength. CONCLUSIONS Open tension band wiring is a useful and reliable technique and presents another fixation option for the treatment of Bennett fractures.

Treatment of Bony Boutonniere Deformity with a Loop Wire

Boutonniere deformity associated with a dorsal avulsion fracture of the central slip overlying the proximal interphalangeal joint results in loss of extension of the joint and hyperextension of the distal interphalangeal joint. This article reports a surgical technique for treatment of the injury in 21 digits, which involves application of loop stainless steel wire. We also present the long-term results using the technique on the digits. Loop wire fixation is a successful surgical technique for the treatment of displaced central slip avulsion fracture.

Coverage of dorsal-ulnar hand wounds with a reverse second dorsal metacarpal artery flap.

This article introduces the use of a modified reverse dorsal hand flap harvested from the radial portion of the dorsal hand and wrist and the distal portion of the dorsal forearm for reconstruction of a large defect involving the third to fifth metacarpophalangeal (MCP) joints and the proximal phalanges. From May 2005 to August 2008, a modified reverse dorsal hand flap was transferred in 12 hands in 12 patients (9 male and 3 female). The mean age at flap transfer was 34.2 years (range: 23 to 50 years) old. All flaps survived. At final follow-up (mean, 28 months; range: 25 to 32 months), the mean active range of motion arcs of the third, fourth, and fifth MCP joints were 85 degrees (range: 65 to 97 degrees), 84 degrees (range: 60 to 90 degrees), and 83 degrees (range: 58 to 94 degrees), respectively. Our technique is useful and reliable for coverage of a large defect involving the third to fifth MCP joints and the proximal phalanges.

Osteoarticular Pedicle Flap From the Capitate to Reconstruct Traumatic Defects in the Head of the Proximal Phalanx

PURPOSE To describe the reconstruction of traumatic defects in the head of the proximal phalanx using an osteoarticular pedicle flap from the capitate. METHODS From January 2004 to December 2007, we treated 15 patients with traumatic defects of the head of the proximal phalanx at our institution. All of these injuries involved 1 condyle of the proximal phalanx. There were 11 male and 4 female patients; the mean age was 32 years. The injuries occurred in the index (n = 6), middle (n = 7), and ring (n = 2) fingers. At the final follow-up, we assessed space narrowing of the proximal interphalangeal joint and flap necrosis using plain radiography. We measured active motion and pinch and grip strength of the hand and compared all measurements with those on the opposite side. Patients rated injured-joint pain and donor-joint pain using a visual analog scale. We assessed hand function using the Disabilities of the Arm, Shoulder, and Hand scale. RESULTS Patient follow-up averaged 52 months. At the final follow-up, we noted narrowing of the proximal interphalangeal joint in 3 cases, but we observed no flap necrosis. The mean active motion arc of the injured and opposite proximal interphalangeal joints was 50° and 96°, respectively. The mean pinch strength of the injured and opposite hands was 5.8 and 6.5 kg, respectively. The mean grip strength of the injured and opposite hands was 39 and 40 kg, respectively. We noted mild recipient joint pain in 6 patients and mild donor joint pain in 1 patient. The mean score of the Disabilities of the Arm, Shoulder, and Hand questionnaire was 9. CONCLUSIONS We used an osteoarticular pedicle flap from the capitate to resurface traumatic defects of the head of the proximal phalanx. This approach is acceptable for restoring the contour of the phalangeal head.

Repair of soft-tissue defect close to the distal perforating artery using the modified distally based medial fasciocutaneous flap in the distal lower leg.

In this study, we modified distally based posterior tibial artery perforator flaps for repair of soft-tissue defects close to the distal perforating artery in the distal lower leg. The flap was designed along the axial network around the saphenous nerve. Flap transfer was performed in 45 cases. The size of the defects after debridement ranged from 4 × 3 cm to 20 × 8 cm (mean, 13 × 5.5 cm). Flap size ranged from 9 × 3 cm to 25 × 10 cm (mean, 16 × 7 cm). In this series, 41 flaps survived completely. Venous congestion was not observed. At a mean follow-up of 16.5 months, all flaps matched the recipient sites in color, texture, and thickness. Donor site morbidity was minimal. The modified distally based posterior tibial artery perforator flap is a reliable and useful option for coverage of the soft-tissue defect close to the distal perforating artery in the distal lower leg.