Hand Surgery in Thailand.

Modern hand surgery in Thailand started after the end of World War II. It is divided into 4 phases. In the initial phase (1950-1965), the surgery of the hand was mainly performed by general surgeons. In 1965-1975, which was the second phase, many plastic surgeons and orthopaedic surgeons graduated from foreign countries and came back to Thailand. They played a vital role in the treatment of the surgery of the hand and set up hand units in many centers. They also contributed to the establishment of the "Thai Society for Surgery of the Hand," which still continues to operate. In the third phase (1975-2000), there was a dramatic development of microsurgery because of the rapid economic expansion. There were many replantation, free tissue transfers, and brachial plexus surgeries in traffic and factory-related accidents. The first hand-fellow training program began in 1993. In the fourth phase (since 2000), the number of hand injuries from factory-related accidents began declining. But the injury from traffic accidents had been increasing both in severity and number. Moreover, the diseases of hand that relate to aging and degeneration had been on the rise. Thai hand surgeons have been using several state-of-the-art technologies such as arthroscopic and endoscopic surgery. They are continuing to invent innovations, generating international publications, and frequently being invited as speakers in foreign countries.

Nerve Transfers to Restore Shoulder Function.

The restoration of shoulder function after brachial plexus injury represents a significant challenge facing the peripheral nerve surgeons. This is owing to a combination of the complex biomechanics of the shoulder girdle, the multitude of muscles and nerves that could be potentially injured, and a limited number of donor options. In general, nerve transfer is favored over tendon transfer, because the biomechanics of the musculotendinous units are not altered. This article summarizes the surgical techniques and clinical results of nerve transfers for restoration of shoulder function.

Polyester tape scapulopexy for chronic upper extremity brachial plexus injury.

PURPOSE: To report the results of scapular stabilization for winging in patients with chronic upper brachial plexus injury. METHODS: Eight patients, mean age 36 years, who had a winged scapula after successful restoration of major shoulder function by nerve transfer underwent scapular stabilization to the ribcage using polyester tape. The follow-up period ranged from 24 to 40 months (mean, 38 mo). Data collection included radiographic analysis, active range of motion measurement, University of California Los Angeles shoulder score, and visual analog scale pain score. RESULTS: All patients had clinical improvement with resolution of scapular winging. Five patients had no winging and 3 had mild winging after the surgery. Mean active forward flexion increased from 101° preoperatively to 127° postoperatively. Mean active shoulder abduction increased from 91° preoperatively to 121° postoperatively. Mean University of California Los Angeles shoulder score improved from 17 to 27 and mean visual analog scale pain score improved from 6.1 to 0.7. In addition, mean lateral deviated angle increased from 4° from neutral preoperatively to 9° at the last follow-up. All patients reported satisfaction with postoperative appearance. CONCLUSIONS: Outcomes of polyester tape scapulopexy in the short to intermediate term were favorable in terms of improved appearance, upper extremity function, and pain reduction in patients with winged scapula resulting from chronic upper brachial plexus injury, and with successful restoration of shoulder motion by previous nerve transfers. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Surgical anatomy of the axillary nerve branches to the deltoid muscle.

Variations in the innervation of the posterior deltoid muscle by the anterior branch of the axillary nerve have been reported. The objective of this study is to clarify the anatomy of the axillary nerve branches to the deltoid muscle. One hundred and twenty-nine arms (68 right and 61 left) from 88 embalmed cadavers (83 male and 46 female) were included in the study. The anterior and posterior branches of the axillary nerve were identified and their lengths were measured from the point of emergence from the axillary nerve to their terminations in the deltoid muscle. In all cases, the axillary nerves split into two branches (anterior and posterior) within the quadrangular space and none split within the deltoid muscle. In all specimens, the anterior and middle parts of the deltoid muscle received their nerve supplies from the anterior branch of the axillary nerve. The posterior part of the deltoid muscle was supplied only by the anterior branch of the axillary nerve in 2.3% of the specimens, from the posterior branch in 8.5%, and from both branches in 89.1%. There were two sub-branches of the anterior branch in 4.7% of the specimens. The anterior branch of the axillary nerve supplied not only the anterior and middle parts of the deltoid muscle but also the posterior part in most cases (91.5%).

Proximal ulnar stump stability after using the pronator quadratus muscle transfer combined with the Suavé-Kapandji procedure in rheumatoid wrist.

The pronator quadratus muscle transfer combined with the Sauvé-Kapandji procedure was used to treat the distal radioulnar joint disorder in ten rheumatoid wrists for prevention against instability of the proximal ulnar stump. All patients were female with a mean age of 46.6 years. The mean follow-up time was 24.2 months. Postoperatively, supination increased in all patients with a mean of 50 degrees. Pain decreased significantly and none complained of prominence of the proximal ulnar stump in normal pronated position and during a tight grip. The wrist radiographs of both coronal and sagittal planes in normal and stress fisting views were used to evaluate the postoperative static and physiologic loaded stability of the proximal ulnar stump. It had shown this procedure provided good static proximal ulnar stump stability in both coronal and sagittal planes. However, in physiologic loaded condition, it was able to provide stability only in the sagittal plane.

Computed tomography-guided core needle biopsy versus incisional biopsy in diagnosing musculoskeletal lesions.

PURPOSE. To compare computed tomography (CT)- guided core needle biopsy (CNB) with incisional biopsy in diagnosing musculoskeletal lesions. METHODS. 62 men and 50 women aged 12 to 83 (mean, 45) years who underwent a CT-guided CNB were compared with 31 men and 33 women aged 9 to 81 (mean, 53) years who underwent an incisional biopsy. All specimens had final pathology report to compare with. Comparisons were made in terms of (1) diagnostic rate, (2) accuracy in distinguishing benign from malignant lesions, (3) accuracy in distinguishing low- from high-grade sarcomas, (4) accuracy for histological diagnosis, and (5) complication and repeated biopsy rates. RESULTS. The diagnostic rate of CT-guided CNB and incisional biopsy was not significantly different (92.9% vs. 96.9%, p=0.33), nor were the accuracy in distinguishing benign from malignant lesions (100% vs. 98.4%, p=0.37), the accuracy in distinguishing low- from high-grade sarcomas (100% vs. 100%, p=1.00), the accuracy for specific diagnosis (75.9% vs. 85.2%, p=0.17), the repeated biopsy rate (6.3% vs. 4.7%, p=0.75), and the complication rate (0.9% vs. 4.7%, p=0.14). The accuracy for specific diagnosis was higher for bone than soft-tissue lesions for both CT-guided CNB (87.0% vs. 59.5%, p=0.002) and incisional biopsy (87.0% vs. 77.3%, p=0.43). The accuracy of CT-guided CNB for specific diagnosis of benign soft-tissue tumours as well as infection and inflammation was relatively low. CONCLUSION. CT-guided CNB is safe, easy to perform, efficient, and less invasive, and should be considered as a first-line biopsy for musculoskeletal lesions.

Surgical anatomy of the radial nerve branches to triceps muscle.

The objectives of the study are to demonstrate the innervation patterns of the triceps muscles and the most suitable branch of the radial nerve for nerve transfer to restore the motor function of the deltoid muscle in patients with complete C5-C6 root injury. Seventy-nine arms (40 left arms and 39 right arms) from 46 embalmed cadavers (24 male and 22 female) were included in the study. The nerves to the triceps were dissected from the triceps muscles (long head, lateral head, and medial head). The lengths of the branches were measured from the main trunk. The distance from the inferior margin of the teres major muscle to the origin of the nerve to the long head, lateral head, and medial head of the triceps were recorded as well. The first branch was the nerve to the long head of the triceps in 79 arms (100%). The second branch was the nerve to the upper medial head in 30 arms (38%), nerve to the medial head in 8 arms (10.1%), nerve to the upper lateral head in 35 arms (44.3%) and nerve to the lateral head in 6 arms (7.6%). The patterns of branches to the triceps were classified according to our dissections. The nerve to the long head of the triceps was constant as the first branch of the nerve to the triceps branch of the radial nerve in the vicinity of the inferior margin of the teres major muscle.

Simultaneous intercostal nerve transfers to deltoid and triceps muscle through the posterior approach.

PURPOSE: This study reports the results of restoring the deltoid and triceps functions in patients with C5, C6, and C7 root avulsion injuries by simultaneously transferring 4 intercostal nerves to the anterior axillary nerve and the nerve to the long head of the triceps through the posterior approach. METHODS: Nine patients with C5, C6, and C7 root avulsion injuries underwent spinal accessory nerve transfer to the suprascapular nerve combined with transfer of the third and fourth intercostal nerves to the anterior axillary nerve for shoulder reconstruction. Simultaneous transfer of the fifth and sixth intercostal nerves to the radial nerve branch of the triceps was done to restore elbow extension. RESULTS: For shoulder function, 8 patients had M4 recovery and 1 patient had M2 recovery. Average shoulder abduction and external rotation were 69° and 42°, respectively. For elbow extension, 3 patients achieved M3 recovery, 5 patients had M2 recovery, and 1 patient had M1 recovery. CONCLUSIONS: Reconstruction of 2 muscles with intercostal nerves is possible when both muscles act synergistically, such as shoulder abduction and elbow extension. Two intercostal nerves are adequate to transfer for deltoid reconstruction but not enough for elbow extension against gravity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Giant cell tumor of the distal phalanx of the biphalangeal fifth toe: a case report and review of the literature.

Giant cell tumor of the distal phalanx of a toe is rather unusual. We report an unusual case of giant cell tumor arising at the distal phalanx of the left biphalangeal fifth toe in a 13-year-old boy. This was treated successfully with curettage and packing with bone substitution.

End-to-side radial sensory to median nerve transfer to restore sensation and relieve pain in C5 and C6 nerve root avulsion.

PURPOSE: To report the results of end-to-side nerve transfer of the superficial radial nerve into the median nerve for restoration of sensation and pain relief at the dorsal radial aspect of the hand in C5 and C6 root avulsion. METHODS: Eight patients with a mean age of 32 years, with paresthesia and pain at the dorsal radial aspect of the hand due to upper brachial plexus injuries, had end-to-side nerve transfer of the superficial radial nerve into the ulnovolar part of the median nerve. Five patients had S0 and 3 patients had S1 sensory evaluation at the dorsal radial aspect of the affected hand. We evaluated patients for pain using a visual analog scale. We assessed sensory recovery with the Semmes-Weinstein monofilament test and British Medical Research Score, respectively. The follow-up period ranged from 24 to 36 months (average, 28 mo). RESULTS: Six patients had S2 and 2 patients had S3. All patients perceived at least one number lower of the Semmes-Weinstein filament in the dorsal radial aspect of the affected hand compared with the preoperative status. The best result was perception of the 3.61 filament in 2 patients. No downgrading of the donor nerve was observed after surgery. All patients had relief of pain 2 weeks after surgery, and the pain decreased dramatically at the last follow-up. CONCLUSIONS: This method is a reliable, effective, and simple procedure. We recommend this sensory nerve transfer as an additional procedure to the combined motor nerve transfers to relieve pain and restore sensation in the dorsal radial aspect of the hand in patients who have C5 and C6 root avulsion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Incidence of osteonecrosis from histopathological study following fracture neck of femur.

This prospective study was aimed to evaluate the incidence of osteonecrosis in Thai patients with fracture neck of femur Forty-three patients who had sustained fracture were enrolled in the present study. The overall incidence of osteonecrosis was 72.1%. Incidence of osteonecrosis was 53.3% among patients who underwent surgery within 1 week after injury and 82.1% among those who underwent surgery after that time but there was no statistical difference (p-value = 0.07. Regarding displacement of fracture, the present study found the incidence of osteonecrosis was 100% among patients with undisplaced (Garden type 1 and 2) fractures and 60.0% and 76.9%, respectively among those with displaced fractures (Garden type 3 and 4). Most histological changes according to Ficat and Arlet Method of undisplaced fractures were stage 1 and 2 and the displaced fracture was stage 2. It reveals a high rate of osteonecrosis following fracture neck of femur but mostly in early reversible change. There was no significant statistical difference regarding age, duration, type of fracture, and co-morbidity.

Restoration of winged scapula in upper arm type brachial plexus injury: anatomic feasibility.

BACKGROUND: The patients who have C5-C6 root avulsion in brachial plexus injury, suffered from loss of elbow flexion, shoulder abduction and winged scapula. The purpose of study is to provide anatomic feasibility of thoracodorsal nerve (medial and lateral branches) and long thoracic nerve for restoration of the shoulder function caused by winged scapula. MATERIAL AND METHOD: To study the length of thoracodorsal nerve and long thoracic nerve from the apex of the posterior axillary line to the insertion of the latissimus dorsi muscle and the serratus anterior muscle respectively, 10 fresh cadavers were dissected. The distance between the thoracodorsal nerve and long thoracic nerve, and the numbers of fascicles and axon were measured by histomorphometry. We transferred the lateral branch of the thoracodorsal nerve to the long thoracic nerve in order to restore the serratus anterior muscle function. RESULTS: The mean length of the thoracodorsal nerve from apex of posterior axillary line to bifurcation before separation to medial and lateral branches was 31.5 mm. The average length of the thoracodorsal nerve and long thoracic nerve from bifurcation to the insertion of the latissimus dorsi muscle and the serratus anterior muscle were 10.3, 82.2, and 99.5 mm, respectively. The distance between the lateral branch of the thoracodorsal nerve and long thoracic nerve was 33.4 mm. The mean number of myelinated nerve fiber of the thoracodorsal nerve medial and lateral branches and long thoracic nerve were 973.8, 1843.3 and 1135.3 axons, respectively. CONCLUSION: The anatomic study of the thoracodorsal nerve and long thoracic nerve showed that the lateral branch of the thoracodorsal nerve is proper in the length and numbers of axon to transfer to the long thoracic nerve for restoration of shoulder function caused by the winged scapula.

Nerve transfer to serratus anterior muscle using the thoracodorsal nerve for winged scapula in C5 and C6 brachial plexus root avulsions.

PURPOSE: To report the results of nerve transfer to the serratus anterior muscle using the thoracodorsal nerve for winged scapula in C5 and C6 brachial plexus avulsion. METHODS: Five patients with a mean age of 27 years with loss of shoulder abduction due to upper brachial plexus injuries and with winged scapula had nerve transfer using 1 branch (1 medial and 4 lateral) of the thoracodorsal nerve to the long thoracic nerve. The spinal accessory nerve and the nerve to the long head of the triceps were used simultaneously for nerve transfer to the suprascapular nerve and the axillary nerve, respectively. The follow-up period ranged from 24 to 33 months (mean, 28 months). RESULTS: All patients recovered serratus anterior muscle function. Two patients had no winged scapula, whereas 3 patients had mild winged scapula after the surgery at the last follow-up evaluation. The result was excellent for 2 patients, good for 2 patients, and fair for 1 patient. The mean arcs of motion of shoulder abduction and external rotation were 134 degrees and 124 degrees , respectively. No notable weakness of shoulder adduction was observed. CONCLUSIONS: Use of the branch of the thoracodorsal nerve ensured adequate return function of the serratus anterior muscle by decreasing or correcting winged scapula in upper brachial plexus injury. We recommend nerve transfer for winged scapula for achieving optimum shoulder function. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Palliative limb salvage using a retrograde nail-cement composite after intercalary resection of a distal femoral osteosarcoma: a case report.

Malignant lower-limb metaphyseal and diaphyseal bone tumours that have not yet invaded the epiphysis can usually be managed with limb-sparing surgery. Reconstructions using intercalary allografts, autoclaved autografts, extracorporeally irradiated autografts, vascularised autografts, and distraction osteogenesis have all achieved favourable results. In patients with metastatic disease and a short life expectancy, reconstruction with allografts or autografts should be carefully considered because a long recovery period is needed. An intercalary endoprosthesis provides immediate stability, a short recovery period and a low implant failure rate. Nonetheless, it may be expensive when there is inadequate space for stem insertion, necessitating a custom-made endoprosthesis. We present a 12-year-old boy with stage-III osteosarcoma of the metaphysis and diaphysis of the femur who underwent knee joint salvage and reconstruction with a retrograde, locked, intramedullary nail surrounded with methylmethacrylate. At the one-month follow-up, the patient could walk unassisted. At the 2-year follow-up, his Musculoskeletal Tumor Society score was 83%. The patient died from lung metastases at 31 months. He had not experienced any complications with the reconstruction.

Nerve transfer to deltoid muscle using the intercostal nerves through the posterior approach: an anatomic study and two case reports.

PURPOSE: To evaluate the feasibility of restoring the deltoid function in patients with C5 through C7 root avulsion injuries by transferring 2 intercostal nerves to the anterior branch of the axillary nerve through a posterior approach. The preliminary results of the clinical application of this procedure also are reported. METHODS: The study was performed on 10 fresh cadavers. The lengths of the third, fourth, and fifth intercostal nerves from the costochondral junction to the midaxillary line were recorded. The distance from the pivot point at the midaxillary line to the anterior branch of the axillary nerve was recorded as the tunnel length. All histomorphometric measurements of the axon number were recorded. Based on the anatomic study, the fourth and fifth intercostal nerves were transferred directly to the anterior branch of the axillary nerve in 2 patients. RESULTS: The average distances from the costochondral junction of the third, fourth, and fifth intercostal nerves to the pivot points were 12, 15, and 16 cm, respectively. The average tunnel distances of the third, fourth, and fifth intercostal nerves were 11, 13, and 15 cm, respectively. The average numbers of myelinated nerve fibers of the third, fourth, and fifth intercostal nerves were 742, 830, and 1,353, respectively. At the 2-year follow-up evaluation the preliminary clinical results showed that the deltoid recovered against resistance (M4). The range of motion for shoulder abduction and external rotation were both 95 degrees in the first case and 105 degrees and 95 degrees , respectively, in the second case. Useful functional recovery was achieved and classified as a good result in both patients. CONCLUSIONS: This anatomic study with 2 case reports supports the idea that transfer of 2 intercostal nerves to the anterior branch of the axillary nerve through the posterior approach could be an alternative method for reconstruction of the deltoid muscle in C5 through C7 root avulsion injuries. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Combined nerve transfers for C5 and C6 brachial plexus avulsion injury.

PURPOSE: To report the results of combined nerve transfer in C5 and C6 brachial plexus avulsion injury. METHODS: Fifteen patients had nerve transfers: spinal accessory nerve to the suprascapular nerve, a part of the ulnar nerve to the biceps motor branch, and the nerve to the long head of the triceps to the anterior branch of the axillary nerve. Patients were evaluated with regard to elbow flexion, shoulder abduction, and shoulder external rotation. RESULTS: All patients had recovered full elbow flexion: 13 scored M4 and 2 scored M3. Thirteen of the 15 patients obtained good results. The weight the patients could lift ranged from 0 to 7 kg. All patients had recovery of the deltoid function: 13 scored M4 and 2 scored M3. All 15 patients achieved useful functional recovery. Ten patients experienced excellent recoveries and 5 were classified as having good results. The mean shoulder abduction was 115 degrees . Shoulder external rotation strength was scored as M4 in 9 patients, M3 in 4 patients, and M2 in 2 patients. The range of motion of external rotation that was measured from full internal rotation averaged 97 degrees . No clinical donor nerve deficits were observed. CONCLUSIONS: We recommend combined nerve transfers for C5 and C6 avulsion root injuries. These nerve transfers have the advantage of a quick recovery time as a result of the short regeneration distance without nerve graft. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.

Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part I: an anatomic feasibility study.

PURPOSE: To experimentally evaluate the feasibility of restoring the motor function of the deltoid muscle in patients with complete C5-C6 root injury (upper brachial plexus injury) by transferring the nerve to the long head of the triceps to the anterior branch of the axillary nerve through a posterior approach. METHODS: The study was performed on shoulder girdles of 36 formalin-embalmed cadavers. The number, diameter, and length of the branches of the axillary nerve at the level of the quadrilateral space were noted. The length and diameter of the nerves to the long head and to the lateral head of triceps at the level of triangular space were recorded. The distances from the acromion angle to the bifurcation of the anterior branch of the axillary nerve, to the origins of the nerve to the long head, and to the origin of the lateral head of the triceps were recorded as well. Nerve biopsy specimens of the axillary nerve and the nerve to the long head of the triceps were obtained from 6 fresh cadavers for histomorphometric evaluation. RESULTS: The average length of the anterior branch of the axillary nerve in this study, measured from the quadrilateral space to the innervating site, was 44.5 mm (range, 26-62 mm), and the average length of the nerve to the long head of triceps, measured from its origin to the innervating site, was 68.5 mm (range, 30-69 mm). The average diameter of the anterior branches of the axillary nerve and the nerve to the long head of the triceps were 2.1 and 1.1 mm, respectively. The average number of axon fibers in the anterior branch of the axillary nerve was 2,704 and in the nerve to the long head of the triceps was 1,233. CONCLUSIONS: Using the acromial angle as the landmark, the combined length of the two 2 nerves was longer than the distance between them. The diameter, the number of axons, and the anatomic proximity of the nerve to the long head of the triceps make it a potential source for reinnervation of the anterior branch of the axillary nerve by direct nerve transfer without nerve grafting through posterior approach for the management of upper brachial plexus injuries.

Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part II: a report of 7 cases.

PURPOSE: This study reports the results of nerve transfer to the deltoid muscle using the nerve to the long head of the triceps. METHODS: Seven patients with an average age of 25 years with loss of shoulder abduction secondary to upper brachial plexus injuries had nerve transfer using the nerve to the long head of the triceps to the anterior branch(es) of the axillary nerve through the posterior approach. The spinal accessory nerve was used simultaneously for nerve transfer to the suprascapular nerve. The follow-up period ranged from 18 to 28 months (average, 20 mo). RESULTS: All patients recovered deltoid power against resistance (M4) at the last follow-up evaluation. Useful functional recovery was achieved in all 7 patients; 5 had excellent recoveries and 2 had good results. The average shoulder abduction was 124 degrees. No notable weakness of elbow extension was observed. CONCLUSIONS: This method is a reliable and effective procedure for deltoid reconstruction in brachial plexus injury (upper-arm type) and should be combined with spinal accessory nerve transfer to the suprascapular nerve to obtain good shoulder abduction.