Complications of hand surgery

Hand surgery involves the surgical treatment of hand conditions and encompasses small bone fixation, arthroscopy, joint replacement and reconstruction of tendon and nerves. Complications following surgery to the hand may be due to patient factors, surgical decisions and the complex anatomy of the hand. Here we describe the complications associated with common surgical interventions for both elective and traumatic injuries to the hand. Following hand surgery, a balance between immobilisation and early range of motion is offset by the risk of wound complications, non-union of fractures and tendon re-rupture with stiffness and reduced range of motion of the digits. Superficial infection is relatively common following procedures to the hand, however long-term sequelae are rare. Implant failure, subsidence, instability and reduced range of motion are seen following arthroplasty procedures. Complex regional pain syndrome offers a significant challenge following injury to the hand and specifically after surgical procedures. Surgeons should consider the risk of particular surgical techniques, other perioperative factors and patient factors that may contribute to the development of complications following hand surgery. Patients should be adequately counselled in order to make an informed decision regarding the management of their condition.     

The mucopolysaccaridoses

The mucopolysaccaridoses are a collection of rare genetic conditions where there is a defect in lysosomal storage causing an accumulation of glycosaminoglycans. There are seven different forms of mucopolysaccaridosis (MPS), each with a different enzymatic mutation and thus each form has similar but separate clinical features. There are multiple effects of glycosaminoglycan deposition including musculoskeletal manifestations such as joint problems and growth arrests. Common treatments of the orthopaedic complications include hip arthroplasty, cervical spine surgery and epiphyseal stapling to correct genu valgum. Presently, the only curative treatment for MPS is haematopoietic stem cell transplantation. Enzyme replacement therapy is a future target for all forms of MPS and a range of therapies are currently in development.     

Fixation of ankle fragility fractures by tibiotalocalcaneal nail

Introduction Fragility fractures of the ankle are difficult to treat by conventional fixation due to poor bone quality, compromised soft tissues, and inherent instability. Conservative management of these patients also has its problems. Materials and methods We retrospectively reviewed 13 patients who underwent intramedullary nailing through the tibiotalocalcaneal joints in an attempt to achieve the dual aims of fracture control and early mobilisation. The Olerud and Molander scale was used as outcome measures. Results There were 12 females and 1 male with a mean age of 78.9 (range 64–93). Half of the patients were discharged from hospital within the first 2 weeks after the operation. All achieved a comparable function to their pre-operative state. The mean follow-up period was 11 months (range of 2–62 months). Six are now deceased from unrelated causes. The mean Olerud and Molander score was 50 (range 30–65). All the radiographs showed evidence of fracture union with no changes in the overall alignment of the joint. Conclusion Given the low survivorship of this frail group of patients the main objectives are achieving early mobilisation whilst maintaining good fracture position. In our experience, tibiotalocalcaneal nailing is a very useful and successful way of treating fragility fractures of the ankle because it has a low risk of complications and restores function with impressive patient satisfaction. The potential benefits of this technique, we believe, outweigh the disability ensued from subtalar joint fusion.     

The cadaveric anatomy of the distal radius: implications for the use of volar plates

INTRODUCTION

Fractures of the distal radius are common upper limb injuries, representing a substantial proportion of the trauma workload in orthopaedic units. With ever increasing advancements in implant technology, operative intervention is becoming more frequent. As growing numbers of surgeons are performing operative fixation of distal radial fractures, an accurate understanding of the relevant surgical anatomy is paramount. The flexor carpi radialis (FCR) tendon forms the cornerstone of the Henry approach to the volar cortex of the distal radius. A number of key neurovascular structures around the wrist are potentially at risk during this approach, especially when the FCR is mobilised and placed under retractors.

METHODS

In order to clarify the safe margins of the FCR approach, ten fresh frozen human cadaver limbs were dissected. The location of the radial artery, the median nerve, the palmar cutaneous branch of the median nerve and the superficial branch nerve were measured with respect to the FCR tendon. Measurements were taken on a centre-to-centre basis in the coronal plane at the watershed level. In addition, the distances between the tendons of brachioradialis, abductor pollicis longus and flexor pollicis longus, and the radial artery and median nerve were measured to create a complete picture of the anatomy of the FCR approach to the distal radius.

RESULTS

The structure most at risk was the palmar cutaneous branch of the median nerve. It was located on average 3.4mm from the FCR tendon. The radial artery and the main trunk of the median nerve were located 7.8mm and 8.9mm from the tendon. The superficial branch of the radial nerve was 24.4mm from the FCR tendon and 11.1mm from the brachioradialis tendon.

CONCLUSIONS

Operative intervention is not without complication. We believe a more accurate understanding of the surgical anatomy is key to the prevention of neurovascular damage arising from the surgical management of distal radial fractures.     

Does preoperative anxiety and depression predict satisfaction after total knee replacement?

Background and purposeApproximately one fifth of patients are not satisfied with the outcome of total knee arthroplasty (TKA). Preoperative variables associated with poorer outcomes are severity and chronicity of pain, psychological disease, poor coping strategies and pain catastrophisation. Psychological disease may be expressed as anxiety and depression. It is unclear whether anxiety and depression before TKA are constitutional or result from knee pain. The aim of this study was to explore the association of anxiety and depression with knee pain and function using specific outcome measures.MethodsForty consecutive patients undergoing TKA completed Hospital Anxiety and Depression Scale (HAD) and Oxford Knee Scores (OKS) preoperatively and at 3 and 6 months postoperatively.ResultsThe HAD and OKS significantly improved post-operatively (p < 0.001). There was a greater change between the preoperative and postoperative scores in the OKS than the HAD. The severity of preoperative anxiety and depression was associated with higher levels of knee disability (coefficient ? 0.409, p = 0.009). Postoperatively reduction in anxiety and depression was associated with improvement in knee disability after 3 (coefficient ? 0.459, p = 0.003) and 6 months (coefficient ? 0.428, p = 0.006).InterpretationThe difficulty in interpreting preoperative anxiety and depression and the outcome of TKA is establishing whether they are the cause or effect of pain in the knee. As anxiety and depression improve with knee pain and function, this study suggests that knee pain contributes to the psychological symptoms and that a successful TKA offers an excellent chance of improving both.     

(ii) Benign soft tissue tumours of the hand

Soft tissue tumours of hand are common. This article reviews the most relevant literature with regards to epidemiology, diagnosis and management.     

Reliability and Responsiveness of Patient-Reported Outcome Measures of Neck Disability to Physical Therapy: Comparison of the Copenhagen,Northwick Park,and Neck Bournemouth Questionnaires and the Neck Disability Index

ObjectiveThe purpose of this study was to identify the external and internal reliability and responsiveness of the validated patient-reported outcome measures (PROMs) of neck pain to a standardized regimen of physiotherapy administered acutely after mild whiplash injury using the clinically significant improvement components of the Patient Global Impression of Change (PGIC) as the outcome measure.MethodsEighty-six patients with neck pain alone were referred for physiotherapy within 2 weeks of whiplash injury. They completed the Copenhagen, Northwick Park (NP), and Neck Bournemouth (NBQ) questionnaires and the Neck Disability Index (NDI) before starting and after treatment when they also completed the PGIC. Treatment comprised deep soft tissue massage, myofascial releases, muscle energy techniques, joint articulation and manipulation techniques, and a home exercise program. The duration of treatment was between 3 and 6 weeks. A PGIC of 6 or 7 was considered to be clinically significant improvement.ResultsThe external reliability of the PROMs was >0.7 and internal >0.87. All components of the PROMs contributed to the final score except headache in the Copenhagen and upper-limb dysesthesia in the NP. The most reliable questionnaire was the NBQ, which was significantly more responsive than the Copenhagen (P = .008). The NBQ was slightly more responsive than the NDI and NP. The NBQ and NDI were successfully completed more frequently than the NP and Copenhagen.ConclusionThe NP, NDI, and NBQ are all reliable and responsive measures of change after physiotherapy for neck pain after acute whiplash injury.     

Shoulder hemiarthroplasty for fracture with a conservative rehabilitation regime

INTRODUCTION: Standard rehabilitation regime following hemiarthroplasty for trauma is early mobilisation to prevent the development of a stiff shoulder. However, an aggressive early rehabilitation may lead to non-union of the greater tuberosity. We hypothesise that a delayed rehabilitation will result in a good union rate without undue risk of shoulder stiffness. MATERIALS AND METHODS: Between December 1996 and June 2003, 40 patients with three or four part fracture of proximal humerus with or without dislocation, not amenable to open reduction and internal fixation underwent hemiarthroplasty with reconstruction of tuberosities and a conservative rehabilitation regime at our centre (age range of 39-92 with a mean of 68). Pathologic fractures and non-cooperative and/or demented patients were excluded. Patients were kept in a sling for 4 weeks before physiotherapy was commenced. They were reviewed at an average of 55 months (12-95) for assessment of pain, range of movement, activities of daily living and strength. Radiographs were taken to evaluate the union of the greater tuberosity. RESULTS: One patient lost to follow up. In 12.8% of the patients (mainly elderly, with mean age of 78.8) the greater tuberosity failed to heal. In those with a healed greater tuberosity the average elevation was more than 130 degrees , and the average external rotation was 40 degrees . A total of 51.3% of the patients had excellent results, 33.3% had satisfactory and 15.4% had unsatisfactory results. CONCLUSION: Postoperative immobilisation did not result in excessive stiffness and excellent functional results were achieved, especially in those younger than 70 years of age. However, tuberosity union could not be guarantied in very old patients.