Abstract
Rhee SH et al. PRS 2012: 129(3); 694–703
Summary of findings
The study was designed to assess the clinical and radiological outcome of a method of retrograde Kirshner (K) wiring in 109 patients with 125 fractures in three institutions.
The authors describe the introduction of 2–3 K wires through the dorsal distal metacarpal head, passing it across the fracture once reduced and exiting through the dorsum of the metacarpal base. Inclusion criteria included metacarpal neck and shaft fractures with >30 degree dorsal apex angulation in the ring and little finger and >15 degrees in the index and middle fingers. The post-operative care was not clearly explained with the authors stating that a plaster splint was applied in theatre in the position of function but active finger exercises were encouraged from day two. This would clearly have been impossible with the plaster in situ. They then describe changing to a short arm cast three weeks after surgery to allow full metacarpophalangeal (MCP) joint and proximal interphalangeal (PIP) joint movement prior to K wire removal at five weeks.
At final follow up (average 10 months) the mean range of motion of the MCP joint was the same as the other side with no rotational mal-alignment, good radiographic angular correction (9.7 SD 4.3 degrees apex dorsal angulation in neck fractures and 7.0 SD 3.7 degrees in shaft fractures) and no non-unions. Complications included three superficial pin site infections, nine patients with a temporary extensor lag that resolved after the K wires were removed and two cases of temporary sensory disturbance that resolved by final follow up.
Strengths of the paper
This is an interesting, although not novel technique, with reasonable outcomes across several centres.
Weakness of the paper
Many of the little finger metacarpal neck fractures included in this study have previously been shown to do well without surgery. Indeed, one of the disappointing features of this paper was the wide variety of fracture configurations that were included. Analysis based on specific fracture types may have been more illuminating.
Conclusions
This technique might be useful on occasion, but penetration of the MCP joint to treat an extra-articular fracture may not be embraced as a routine procedure by most hand surgeons. This paper is unlikely to change practice significantly.
Claire Simpson MBChB(Hons), FRCS (Tr & Orth)
ATP Hand Fellow, Birmingham Hand Centre,
Birmingham, UK
Van Rijssen AI et al. PRS 2012: 129(2); 469–477
Summary of findings
This single centre, randomized trial evaluated recurrence rates after needle fasciotomy in comparison to the standard technique of limited fasciectomy in 115 patients with a minimum follow-up of five years.
Needle fasciotomy was more successful at treating metacarpophalangeal (MP) joint contractures (55%) than proximal interphalangeal (PIP) joint contractures (26%), but was only just over half as effective as limited fasciectomy in straightening either joint. A successful correction was defined as a reduction in contracture to a passive extension deficit of 0–5 degrees for each joint six weeks after the index procedure. Recurrence was defined as an increase in the passive extension deficit of at least 30 degrees, compared with the six week values. This occurred significantly sooner and more frequently after needle fasciotomy (85% at 5 y) than after limited fasciectomy (21% at 5 y). Despite this, patient satisfaction rates were similar with more patients preferring needle fasciotomy as a treatment if they suffered a recurrence.
Strengths of the paper
This is a well-executed study presenting interim results to follow on from preliminary results published previously. This paper now provides objective, long-term follow-up data regarding this population.
Weakness of the paper
Few significant weaknesses.
Conclusions
Despite the high recurrence rate, needle fasciotomy remains a useful tool for surgeons treating Dupuytren’s disease. This study provides objective data that will enable patients and surgeons to make an informed decision regarding treatment options. It provides a useful comparator for assessing treatment with collagenase.
Christian West
ATP Hand Fellow, Pulvertaft Hand Unit, Royal Derby
Hospital, Derby, UK.
Karstanje J-WH et al. J Bone Joint Surg Am. 2012; 94(5): 394–402
Summary of findings
In this study the authors sought to quantify the excursion of the middle finger flexor digitorum profundus (FDP) tendon during five different mobilization regimes.
The authors cited previous cadaveric studies showing that the position of adjacent fingers influenced tendon excursion in an injured finger. They hypothesized that the variable position of adjacent digits used in different rehabilitation programmes might affect movement of repaired tendons in the injured digit. This study was designed to quantify those differences, in particular focusing on whether or not any limitation in available excursion of the injured digit’s tendons might be sufficient to allow significant tendon adhesions to occur, thus affecting the final outcome.
Eleven healthy subjects were studied using ultrasound video imaging at Verdan’s zone V, while carrying out various mobilization regimes including an active four-finger mobilization protocol, a passive four-finger mobilization protocol and three modified Kleinert protocols.
Active flexion of all digits produced the greatest profundus excursion (23.4 mm of absolute FDP movement and 11.2 mm of excursion relative to the surrounding mobile tissues). One of the experimental modifications of the Klienert regime performed least well (7.6 mm of absolute excursion and 5.6 mm of relative excursion). Passive flexion involving all of the digits produced greater tendon excursions than single-digit mobilization techniques.
Strengths of the paper
This study provides quantitative data regarding middle finger FDP flexor excursion albeit in healthy subjects using an interesting imaging technique.
Weakness of the paper
The majority of the techniques studied in this paper used passive mobilization techniques in contrast to a controlled active mobilization regime favoured in most units in the UK.
Measurement of tendon excursion at the wrist requires some supposition of reciprocal movement in the fibro-osseous tunnel of the finger. This reciprocal movement may not directly follow after an injury and subsequent surgery have occurred to increase the local resistance to smooth tendon gliding in the finger.
Conclusions
This evidence seems to offer further support for the use of active mobilization regimes following flexor tendon injury. In addition, this paper describes a dynamic imaging technique that might be useful in further studies.
S Lipscombe BSc FRCS (Tr&Orth)
ATP Hand Fellow, Wythenshawe Hospit