Indications and functional outcome of the use of integra® dermal regeneration template for the management of traumatic soft tissue defects on dorsal hand, fingers and thumb.

INTRODUCTION: Few studies have been conducted to explore the utility of the Integra® dermal regeneration template (IDRT) combined with a delayed split-thickness skin graft (STSG) for reconstructing complex dorsal hand, digit, and thumb injuries. This study reports the indications and outcomes for 14 patients treated with this technique via a two-stage process. MATERIALS AND METHODS: We retrospectively reviewed all patients treated by IDRT combined with STSG from May 2015 to October 2018. The inclusion criterion was traumatic or post-infectious soft tissue defects (STDs) of the dorsal hand, fingers, and thumb, not suitable for direct wound closure and requiring local, pedicle, or free flap reconstruction. After debridement, a two-stage procedure was applied, namely IDRT followed by STSG. Indications, functional outcomes, aesthetic results, complications, patient satisfaction, and the STSG take rate were evaluated over a 36-month follow-up using standardised instruments. RESULTS: A total of 14 patients with 15 reconstructions (average age = 48 years) were included. The dominant hand was involved in 50% of cases. Dorsal STDs involved the hand, fingers, thumb, and hand and thumb in 7, 3, 2 and 2 cases, respectively. The mean STD size was 35 cm2 (range: 3-150 cm2). The wound was associated with exposed tendons (without peritenon), bone (without periosteum), and joints (without a capsule) in eight cases (57%). The IDRT/STSG take rate was 97%. The average Vancouver Scar Scale score was 2 (1-4). CONCLUSION: The 36-month follow-up demonstrated that IDRT is a safe and reliable technique that can be considered a viable alternative to flap reconstruction for the management of traumatic STDs in selected patients. The aesthetic outcomes are acceptable, functional recovery of the fingers is excellent, patient satisfaction is very high and the rate of complications is very low.

Treatment of Pisotriquetral Arthritis by Pyrocarbon Interposition Arthroplasty.

Purpose Pisiformectomy is the baseline treatment for pisotriquetral arthritis when medical treatment fails to address the problem. This operation may lead to loss of mobility and strength in the wrist. This study reports the short-term outcomes of a new technique for treating pisotriquetral arthritis using a pisotriquetral interposition arthroplasty with a pyrocarbon implant. Patients and Methods We performed a clinical and radiographic study on a series of eight patients who received this treatment at a mean follow-up of 2.8 years. We also studied the mobility of the implant and did assessed articular instability using dynamic radiology and fluoroscopy. Results We observed one proximal dislocation of the implant in one hand which was reoperated to reposition the implant and strengthen the capsule. All patients were satisfied or very satisfied with their operation and had an average functional recovery period of 1.6 months. At the last follow-up, the Mayo Wrist Score (MWS), Quick Disability of Arm Shoulder and Hand (QDASH), and Patient-Rated Wrist Evaluation (PRWE) scores were 89, 18, and 20, respectively. Postoperatively, there was a 22% improvement in the grip strength of the wrists as well as improved mobility, mainly as regards the radioulnar deviation (47% improvement) and the Visual Analogue Scale (VAS) pain scores decreased from 8 preoperatively to 2 at the latest follow-up. The functional radiologic and fluoroscopic study reported good adaptive mobility of the implant in all the patients, without any indication of pisotriquetral joint instability. Conclusion The short-term results of pisotriquetral arthroplasty using the Pyrocardan implant are encouraging. This new surgical solution appears to be a valid alternative to pisiformectomy or pisotriquetral arthrodesis. Long-term studies are required to confirm these preliminary findings.

Suspected adipose tumours of the hand and the potential risk for malignant transformation to sarcoma: a series of 14 patients.

INTRODUCTION: Lipomas are associated with a variety of symptoms including neuropathies, local compression of the surrounding tissues, aesthetic complaints and may be graded as liposarcomas histologically. This study was performed to review our surgical management at the level of the hand. MATERIALS AND METHODS: Between 2008 and 2013, 14 patients were referred to our department for suspected adipose tumour of the hand. Preoperative MRI was used to assess tumour and surrounding tissue to plan the surgical therapy. We reviewed the clinical history, MRI findings, surgical approach, and outcomes. RESULTS: Complaints leading to consultation were pain in 11 cases, compression neuropathy in 7 cases, aesthetic concern in 8 cases, and limited wrist range of motion in 2 cases. Magnetic resonance imaging was performed in 13 cases, confirming the diagnosis of adipose tumour in all but two cases. These two cases were diagnosed in one case as a ganglion and the other as an epithelioid sarcoma. An amputation of the fifth digit was performed regarding the latter case and the patient received additional radiotherapy. The mean follow-up period was 32 ± 20 months. There was no recurrence of lipoma or sarcoma. CONCLUSION: MRI is useful for diagnosing and planning of the surgical intervention performed in the latter case adipose tumours. Rapidly evolving tumours with subfascial localization are absolute surgical indications. Incision biopsy is mandatory for entities of unknown dignity and for malignant tumours. Interdisciplinary tumour board meetings should discuss each patient before surgery is performed. LEVEL OF EVIDENCE AND STUDY TYPE: IV.

One-stage treatment of delayed 'jersey finger' by Z-step lengthening of the flexor digitorum profundus tendon at the wrist.

The authors report the case of a 19-year-old female with delayed presentation of a type II 'jersey finger' of the fourth dominant digit. A surgical approach was performed, revealing a retracted flexor digitorum profundus tendon within a still patent sheath. The resulting loss of tendon length overruled any possibility of direct reinsertion of the tendon. A lengthening "Z-step" tendinoplasty was then performed on the tendon at the wrist, thus enabling reinsertion at the base of the distal phalanx. The patient then underwent conventional splinting and physiotherapy. Total Active Motion was measured at 220° with a 6-month follow-up. Even though there is no clear consensus concerning management of such cases, different techniques have been described, such as one- or two-stage grafting, or tenotomy at the musculotendinous junction. Lengthening tendinoplasties have been applied by certain authors but only to the flexor pollicis longus tendon. To our knowledge, this is the only reported case of lengthening Z-step applied to a long digit for the repair of type II 'jersey finger' lesions. The satisfactory functional and cosmetic outcome encourages us to consider this one-stage technique in other select cases, in order to gather more formal evidence.

Atypical squamous cell carcinoma of the nail bed with phalangeal involvement.

We report an atypical presentation of squamous cell carcinoma (SCC) of the distal phalanx of the left thumb. On physical examination, there was no clinical evidence of a local lesion, but magnetic resonance imaging (MRI) showed multiple intraosseous cavities filled with fluid. A biopsy specimen showed a well-differentiated SCC, which was treated by amputation of the distal phalanx.