近指间关节掌侧关节镜的初步临床应用

目的探讨一种新的手指关节镜入路:近指间关节掌侧关节镜入路的安全性及初步临床应用。方法利用inside-out技术在近指间关节侧方掌板深面建立入路, 可观察到近指间关节掌侧结构并进行关节腔内操作。自2018年5月至2020年9月, 我科利用该技术行关节掌侧游离骨折块取出4例、松解单纯掌板挛缩4例、关节腔内增生滑膜切除2例。结果所有手术均达术前目标, 4例掌侧骨块均在关节镜下取出;挛缩的掌板经镜下刨刀打磨后变薄, 经手法松解后可在镜下见屈肌腱显露, 可将挛缩的关节完全被动伸直;关节肿痛患者经镜下滑膜切除后, 肿痛消退。10例患者中1例出现术后手指麻木, 术后6周麻木自行缓解。结论近指间关节掌侧入路较为安全, 可完成关节掌侧病变的处理, 初步临床应用取得良好效果。     

手部近指间关节闭合性损伤的基础与临床研究

目的 探讨近指间关节(proximal interphalangeal joint,PIP)闭合性损伤的解剖特点及不同结构损伤的治疗及预后.方法 通过对20个成年人新鲜尸体手指标本的解剖学研究,了解近指间关节损伤及关节囊挛缩发生的机制.临床上对21例近指间关节损伤的患者进行手术.结果 解剖学研究发现,副韧带及掌板近侧损伤对近指间关节活动度无明显影响.侧副韧带损伤主要破坏关节侧方的稳定性,掌板损伤主要破坏关节前后方的稳定性.21例术后随访3～13个月,平均7个月.各指近指间关节主动屈、伸活动范围:屈曲60°～95°,平均78°;背伸0°～15°,平均8°.被动屈、伸活动范围:屈曲71°～98°,平均82°;背伸0°～18°,平均11°.结论 对于掌板及侧副韧带损伤,应尽早进行手术修复及止点重建,可防止关节囊挛缩.     

吻合血管的趾指间关节移植一例

患者 男,1982年右手被机器轧伤,在当地医院清创缝合。伤口愈合后,右中指屈伸功能受限,1988年入我院。检查:右中指近侧指间关节骨性强直。关节背侧皮肤菲薄,有贴骨瘢痕。手指感觉、血运正常。X线片示:右中指近指间关节骨性融合。行吻合血管的趾间关节移植术恢复指间关节功能。在臂丛麻醉下手术。右中指近侧指间关节背侧做“S”形切口,显露指问关节。将指骨颈部至中     

手指间关节滑膜软骨瘤病1例

患者男性,70岁,左示指近指间关节肿痛数年,加重半年就诊。检查:左示指近指间关节背侧可触及0.5mm×0.3mm大小硬物,压痛明显,游离动度约1mm。左示指功能良好,无外伤史。X线示:左示指近指间关节面毛糙。局麻下行探查手术,术中见左示指近指间关节背侧滑膜腔内有3.5mm×2.5mm×1.5mm肿物,质硬,形似大米粒,将其摘除后切除滑膜,病理诊断:左示指近指间关     

内固定治疗闭合性近侧指间关节背侧脱位伴中节指骨掌侧基底骨折

目的 探讨内固定治疗闭合性近侧指间关节背侧脱位伴中节指骨掌侧基底骨折的疗效.方法 对20例闭合性近侧指间关节背侧脱位伴中节指骨掌侧基底骨折的患者行克氏针内固定治疗,术后指体用微型支具或石膏托固定3～4周,并进行功能恢复性锻炼.结果 20例均获随访,时间3～6个月.X线片示骨折复位愈合、关节在位.近侧指间关节主动屈伸活动范围:伸0～20(18±1)°,屈30～90(68±5)°;被动屈伸活动范围:伸5～20(15±2)°,屈50～100(78±8)°.结论 内固定手术治疗闭合性近侧指间关节背侧脱位伴中节指骨掌侧基底骨折效果较好.     

微型钛板螺钉融合手指近指间关节的临床研究

目的 探讨应用微型钛板螺钉融合手指近指间关节的手术疗效.方法 采用塑形后的微型钛板螺钉对29例(44指)男性患者的手指近指间关节进行融合,手术均采用背侧入路.结果 术后29例均获得4～7个月的随访,伤口无感染及皮肤坏死,融合关节临床愈合时间为6～8周,X线片骨性愈合时间为2～3个月,无延迟愈合、骨不连或畸形愈合.结论 本术式操作简单,掌握容易;缩短骨性愈合时间;大大降低骨不连的发生率、畸形愈合率、针道感染及骨髓炎的发病率.     

微型钛板螺钉融合手指近指间关节的临床研究

目的 探讨应用微型钛板螺钉融合手指近指间关节的手术疗效.方法 采用塑形后的微型钛板螺钉对29例(44指)男性患者的手指近指间关节进行融合,手术均采用背侧入路.结果 术后29例均获得4～7个月的随访,伤口无感染及皮肤坏死,融合关节临床愈合时间为6～8周,X线片骨性愈合时间为2～3个月,无延迟愈合、骨不连或畸形愈合.结论 本术式操作简单,掌握容易;缩短骨性愈合时间;大大降低骨不连的发生率、畸形愈合率、针道感染及骨髓炎的发病率.     

掌指关节镜的应用解剖研究

目的研究掌指关节的解剖结构特点，为该关节镜的开展提供解剖学基础。方法对10个正常新鲜尸体的掌指关节，进行关节内、外解剖结构的大体解剖学研究。并对另外10个掌指关节进行关节镜观察，将镜下所见与大体解剖结果进行对比分析。结果掌指关节镜的入点选择在指伸肌腱的两侧，可以最大限度地避开指背静脉和神经，通过关节镜可以清楚地观察到全部的指骨关节面和绝大部分的掌骨关节面、掌板、籽骨、侧副韧带和关节囊等结构。结论掌指关节镜能清楚地观察掌指关节内的解剖结构，可用于明确关节内病变的诊断和辅助治疗。     

阻挡支具治疗近指间关节掌侧撕脱骨折

目的 探讨采用背侧阻挡支具固定治疗近指间关节掌侧撕脱骨折的疗效.方法 2007年8月至2010年4月,对10例近指间关节EatonⅡ型和较稳定的Ⅲ型损伤患者,采用背侧阻挡支具治疗.从受伤到接受治疗时间为2～14d,平均8d.背侧阻挡支具限制近指间关节背伸,鼓励屈曲活动,4～6周后去除支具,全面进行功能练习.结果 10例均获得随访,随访时间为3～6个月,平均4.5个月,近指间关节主动活动范围平均92°(87°～96°),与对侧健指关节活动范围相当.手功能评定采用Incavo评定法,临床结果全部为优.所有患者对治疗过程及效果满意.结论 背侧阻挡支具治疗近指间关节EatonⅡ型和较稳定的Ⅲ型损伤,可获得满意的疗效.方法简单、廉价而并发症少,是治疗此类损伤的首选方式.     

内窥镜下手术治疗拇外翻的实验研究

目的 关节镜下行拇外翻手术的可行性及方法 .方法 采用10具新鲜保留踝关节的足部标本进行模拟手术.首先建立内远背侧入路和内远跖侧入路,以骨磨钻磨除跖骨头内侧的骨赘,再建立内近侧人路,直到最终完全切除.从内远跖侧人路向内近侧入路方向作关节囊的紧缩缝合.建立外远侧入路和外近侧人路,松解外侧关节囊、拇内收肌斜头和跖籽骨韧带.最后,收紧缝合线,拇外翻畸形得到矫正.另外在20具防腐标本上作了进一步解剖学测量.结果 全部标本均成功完成手术.早期5例标本手术时间平均为108 min,发生1例肌腱挫伤、2例皮神经损伤、3例关节面软骨轻微损伤.后期5例标本手术时间平均为63 rain,未发生任何副损伤.各入路与周围血管、神经、肌腱等结构之间有一定的安全距离.结论 内窥镜下手术治疗拇外翻足可行的,并且具有很好的安全性和可靠性.     

Arthroscopy of the proximal interphalangeal joints of the finger

Cadaveric studies were carried out to evaluate the technique, portals and possible indications for arthroscopy of the proximal interphalangeal joints of the finger. We suggest horizontal placement of the hand instead of using a traction tower, as it is important to be able to flex the joint freely. The recommended arthroscopic portals are either between the central slip and the lateral bands of the extensor mechanism or between the lateral band and the collateral ligament. A blunt technique of introduction is used to avoid iatrogenic cartilage damage and possible digital nerve injury.     

Anterior tenoarthrolysis for severe flexion contracture of the fingers (the "TATA" operation): a review of 50 cases

The "hook finger", with both proximal interphalangeal (PIP) and distal interphalangeal (DIP) joint flexion contractures, often after multiple previous operations, is difficult to treat. This paper reports the results of 50 fingers in 49 patients in which the TATA (Téno-Arthrolyse Totale Antérieure) salvage procedure, described by Saffar in 1978, was carried out. Thirty-seven of 50 (74%) of these fingers had had at least one previous operation, most on the flexor apparatus. The mean PIP and DIP extension deficit pre-operatively was 133 degrees with a mean PIP lag of extension of 83 degrees . With a mean follow-up of 7.8 years, 45 fingers were improved, five were not and none was worsened. The mean PIP and DIP extension deficit postoperatively was 47 degrees , with a mean PIP lack of extension of 31 degrees . The overall gain in extension deficit of both joints was 86 degrees and of the PIP was 52 degrees . One PIP joint developed septic arthritis immediately after surgery. The benefit of this salvage operation is mainly in the change of the active range of motion to a more functional arc.     

Impact of simulated proximal interphalangeal arthrodeses of all fingers on hand function

PURPOSE: To evaluate the impact of simulated proximal interphalangeal (PIP) arthrodeses on hand performance and to assess the resulting compensatory metacarpophalangeal (MCP) joint motions in healthy subjects. METHODS: Fifteen healthy subjects were tested under 2 conditions: (1) with unrestricted distal interphalangeal, PIP, and MCP joints and (2) with the PIP joint fixed at 40 degrees of flexion in all 4 fingers of 1 hand and unrestricted MCP and distal interphalangeal joints. Subjects performed the Jebsen hand function test and 13 activities of daily living. Perceived difficulty in performing tasks was assessed with a study-specific questionnaire. The motion of each finger was monitored using a motion analysis system. RESULTS: The average time to complete the Jebsen test did not increase significantly with simulated PIP arthrodesis, nor did subjects perceive the tasks to be more difficult. Activities of daily living tasks requiring power grasp did not show significant increases in MCP flexion or abduction. Precision handling tasks requiring greater PIP joint flexion did show increased MCP flexion and were associated with greater perceived difficulty. CONCLUSIONS: Our study showed a minimal overall impact from simulated arthrodeses of all 4 fingers at the PIP joints in 40 degrees of flexion when measured by selected lower-demand activities of daily living in healthy subjects. Precision handling tasks that normally use higher degrees of PIP joint flexion, however, were perceived to be more difficult to perform and required greater compensatory motion at the MCP joints. This study does not address directly the impairment that patients with generalized hand arthritis may experience after PIP joint arthrodesis. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic, Level I.     

Diagnostic and operative arthroscopy of the ankle. An experimental approach

To determine safe and effective placements of the arthroscope, 14 freshly amputated ankle joint specimens were used for experimental diagnostic and operative procedures. Preoperatively, chondral and osteochondral lesions, articular defects, and loose bodies were created within the ankle joint. The following arthroscopic portals were investigated: anteromedial, anterocentral, anterolateral, posteromedial, and posterolateral. Overlapping of vision fields was noted with the three anterior portals. Optimum visualization of a lesion was obtained when the arthroscope was placed on the same side as the lesion. Lesions on the posterior aspect of the talar dome and within the posterior talar pouch required the posterior placement of the arthroscope for optimum visualization. The use of the anterocentral approach, with a 2.7-mm arthroscope yields good visualization of the anterior aspect of the joint, and very often, of the posterior compartment. Anatomic guidelines for the avoidance of neurovascular structures and the exact placement of the arthroscope in both anterior and posterior portals are presented and were specifically defined in two additional fresh ankle specimens.     

携带微型皮瓣的第二趾近趾间关节移植修复手指近指间关节缺损

目的 探讨采用携带微型皮瓣的游离第二趾近趾间关节移植修复手指近指间关节缺损的临床疗效.方法 对23例28指近指间关节缺损的患者,采用吻合血管的第二趾近趾间关节游离移植,其中全关节移植18指,半关节移植10指.结果 23例28指微型皮瓣全部存活,术后伤口均Ⅰ期愈合,无感染及骨髓炎发生.所有移植骨关节均愈合,临床愈合时间为4～8周,骨性愈合时间为6～10周;术后随访时间为5～16个月,平均9个月,移植关节均未出现退行性改变.1例2指半关节移植者术后移植关节向掌侧脱位,经手术再次矫形获得成功.移植近指间关节屈曲活动度为35°～90°,平均65°.参照关节活动度TAN/TAF评定标准评定:优10指,良14指,可2指,差2指;优良率为86%.结论 采用携带微型皮瓣的游离第二趾近趾间关节移植修复手指近指间关节缺损,功能恢复满意,关节活动可满足日常生活的需要,能很好地改善关节的功能.     

Surgical treatment of degenerative osteoarthritis of the fingers

Degenerative osteoarthritis of the long fingers is rare and surgical management is often necessary if there is joint pain, however this indication should not only be based on radiographic imaging. The specific anatomical problems of the metacarpophalangeal (MCP), proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints are described. The surgical approach for each joint is described as well as functional management, in particular that of the extensor apparatus. Mobility should always be preserved for the MCP, arthroplasties are recommended for the PIP except for the index, and arthrodesis for the DIP. The different and most frequently used implants are described as well as the indications and expected results. The indications are discussed in relation to the limited results in the literature as well as the preferences of a panel of French hand surgeons.     

Clinical outcomes of primary skin closure with Y-V and Z-plasties for Dupuytren's contracture: use of one-stage skin closure

Y-V or Z-plasties are a useful one-stage technique for skin closure after aponeurotomy. However, we know no details about postoperative improvement, particularly at each joint. The purpose of this study was to evaluate the clinical outcomes of primary skin closure with Y-V and Z-plasties for Dupuytren's contracture. We retrospectively reviewed the postoperative results of 23 patients (25 hands, 29 fingers). The preoperative severity of the contracture evaluated by the Meyerding classification was grade I in 11 fingers, II in two fingers, and III in 16 fingers. In total, 26 metacarpophalangeal (MP) joints and 27 proximal interphalangeal (PIP) joints were treated. In each finger we assessed clinical outcomes according to the percentage improvement in extension and a modified version of Tubiana's classification. Primary wound closure was possible in all cases. The mean contracture values were improved from 46.5° preoperatively to 4.2° postoperatively for the MP joint and from 43.9° to 22.4° for the PIP joint. The mean percentage improvement in extension for the MP joint was 92% and for the PIP joint 56%. The rate for the PIP joint of the little finger was 40% and for the other fingers 78%. In total, 83% of the fingers had satisfactory results. For Dupuytren's contracture, primary skin closure with Y-V and Z-plasties gives satisfactory results, more so with involvement of the MP than the PIP joint and less so with involvement of the little finger.     

Correction of swan neck deformity in rheumatoid arthritis using a new lateral extensor band technique

Swan neck deformity is a progressive and disabling condition that commonly affects rheumatoid arthritic hands. During a 4-year period, 101 fingers in 43 patients had this deformity corrected using a new procedure combining the distally based extensor lateral band technique described by Littler and the flexor digitorum superficialis (FDS)-palmar plate pulley introduced by Zancolli. The ranges of motion of the metacarpophalangeal, proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints were assessed pre-operatively and 12 months after surgery. An average PIP joint hyperextension of -13.3 degrees was converted to +13.4 degrees . The ranges of motion of the proximal and DIP joints were significantly different (Student's t-test). No patient suffered recurrence of the deformity during an average follow-up of 20 months. This new technique improves some unappealing aspects of previous techniques and provides a stable and reliable correction of swan neck deformity.     

Clinical outcomes of primary skin closure with Y-V and Z-plasties for Dupuytren's contracture: Use of one-stage skin closure

Abstract

Y-V or Z-plasties are a useful one-stage technique for skin closure after aponeurotomy. However, we know no details about postoperative improvement, particularly at each joint. The purpose of this study was to evaluate the clinical outcomes of primary skin closure with Y-V and Z-plasties for Dupuytren's contracture. We retrospectively reviewed the postoperative results of 23 patients (25 hands, 29 fingers). The preoperative severity of the contracture evaluated by the Meyerding classification was grade I in 11 fingers, II in two fingers, and III in 16 fingers. In total, 26 metacarpophalangeal (MP) joints and 27 proximal interphalangeal (PIP) joints were treated. In each finger we assessed clinical outcomes according to the percentage improvement in extension and a modified version of Tubiana's classification. Primary wound closure was possible in all cases. The mean contracture values were improved from 46.5° preoperatively to 4.2° postoperatively for the MP joint and from 43.9° to 22.4° for the PIP joint. The mean percentage improvement in extension for the MP joint was 92% and for the PIP joint 56%. The rate for the PIP joint of the little finger was 40% and for the other fingers 78%. In total, 83% of the fingers had satisfactory results. For Dupuytren's contracture, primary skin closure with Y-V and Z-plasties gives satisfactory results, more so with involvement of the MP than the PIP joint and less so with involvement of the little finger.     

Endoskopie in der Handchirurgie

Diagnostic and therapeutic arthroscopic procedures have become indispensable in the surgery of the large joints. With smaller instruments being developed, it is not astonishing that arthroscopy becomes more and more involved in hand surgery as well. Whereas arthroscopy of the wrist has been established, an increasing number of procedures for the carpometacarpal I (CMC-I) joint are being developed, especially for the treatment of CMC-I arthritis. For diagnostic and therapeutic means regarding the metacarpophalangeal (MCP) as well as proximal and distal interphalangeal (PIP/DIP) joints, arthroscopy plays a minor role so far. This article gives an overview of the most frequent arthroscopic procedures for the traumatized wrist.