Techniques to prevent symptomatic neuroma in digital amputations.

The occurrence of a symptomatic neuroma on a digital amputation stump, whether traumatic or not, is a frequent complication that affects the patient's quality of life. The objective of this study was to analyze the complications inherent to the various techniques used to manage the nerves when performing digital amputation. We compared different surgical nerve management techniques to determine if one technique is more effective than another in preventing neuroma occurrence. We reviewed 105 patients over a 5-year period. A DN4 score greater than 4 and the modified Tinel test (percussion) showing a trigger zone allowed us to clinically diagnose symptomatic neuroma-related pain. We found 23 symptomatic neuromas out of 131 digital amputations. Twelve neuromas were found when the nerves had been neglected (12/33), eight were found in nerves treated by stripping (8/60), three when nerves were treated by stripping and thermal ablation (3/18). No neuroma was found in the five cases of centrocentral union of the two proper palmar digital nerves, in the 5 nerves buried in the bone or in the 9 nerves subjected to thermal ablation only. Management of the nerve is essential for the prevention of neuromas in digital amputations. New techniques such as bone burial and centrocentral union of the two stumps appear to be particularly effective.

Scaphotrapeziotrapezoid osteoarthritis: From the joint to the patient.

Scaphotrapeziotrapezoid osteoarthritis (STT OA) is common and often associated with thumb basal joint arthritis. Pain at the base of the thumb on the volar aspect and during resisted extension is characteristic of symptomatic STT OA. If conservative treatment fails, surgical treatment may be offered. In case of STT OA, treatment may range from arthrodesis to trapeziectomy (isolated or associated with ligament reconstruction and/or interposition). Any preoperative intracarpal instability (DISI) can be exacerbated by resecting more than 3 or 4 mm of the distal pole of scaphoid. For peritrapezial osteoarthritis, trapeziectomy is the logical solution, but it exposes the patient to known complications: loss of strength, long recovery, trapeziometacarpal impingement. Initial treatment of thumb basal joint arthritis by arthroplasty is also an option. Treatment of both sites is also possible by interposition of pyrocarbon implants. In all cases (isolated or associated STT OA) and no matter the technique chosen, maintaining the scaphoid height (arthrodesis, resection < 3 mm and/or associated interposition) and performing oblique trapezoidal osteotomy (to prevent scaphoid-metacarpal impingement) are the two crucial elements of surgical treatment.

Influence of the level of arterial resection on the replanting and revascularization results in hand surgery: prospective study over 22 months.

The objective of this work was to assess whether the injury mechanisms are responsible for histological arterial lesions. This prospective single-center study included adults with wrist or hand arterial injury. Arterial resection of at least 2 mm from the proximal and distal stumps was performed before the arterial anastomosis. Histological analysis of the arterial stumps was performed. An ultrasound was performed 1 month postoperatively to check arterial patency. A clinical and functional evaluation was done at 1 month postoperative, then every 3 months. From 2018 to 2020, 46 patients were included with a maximum follow-up of 13 months. There were 35 cuts, 2 crush injuries, 8 amputation and 1 blast injury. Macroscopically, 37% of the margins were considered damaged. Histological analysis showed significant damage in 59% of the sections (27 out of 46 patients) with 50% for crush injury, 55% for cuts by mechanical tool, 62% for cuts by power tool, 62% for amputations and 100% for blasts. The failure rate was 9%: 2 replantations and 2 asymptomatic thromboses diagnosed by ultrasound. Postoperative pain on VAS was 1.75/10, range of motion was 87%, Quick DASH was 8%, SF36 PCS was 69% and SF36 MCS was 70%. Factors influencing the success or failure of anastomosis were the mechanism of injury (p = 0.02), associated nerve damage (p = 0.014) and length of proximal arterial cut (p = 0.046). Histological arterial lesions seem to correlate with the injury mechanism. Cuts caused by glass or crush injuries do not seem to require arterial resections of more than 2 mm. A continuation of the study with a larger number of subjects may generate statistically significant results.

Functional evaluation following emergency arthroplasty of the proximal interphalangeal joint for complex fractures with silicone implant.

The proximal interphalangeal (PIP) joint is particularly vulnerable to trauma. In comminuted fractures, arthroplasty with a silicone implant is a treatment option that may be controversial in an emergency setting. This joint destruction is usually accompanied by soft tissue injuries (skin and tendon damage, devascularization) making the reconstruction all the more complex. The aim of our work was to evaluate emergency finger silicone implants for complex and comminuted fractures of the PIP joint as well as clinical and radiological complications. In this single-center, retrospective study, 13 patients operated between January 2007 and January 2019 on an emergency basis with a Neuflex® PIP arthroplasty were reviewed. This PIP joint reconstruction was associated with the soft tissue repair at the same time (skin cover, tendons, nerves) in all patients. The average age was 57.7 years with a male predominance (92%). The injuries were caused by a domestic accident in 61% of cases. The average follow-up was 4.7 years. The average total active motion arc was 183.8°. The average QuickDASH score was 24. There was one case of broken implant with no functional consequence. No infection or instability was reported. Silicone implant arthroplasty is a simple, reliable, fast, and durable solution for complex PIP fractures when conservative treatment is impossible. This solution is an alternative to arthrodesis or even finger amputation.

Fingertip amputations treated with occlusive dressings.

The aim of this study was to analyze a series of patients who suffered a distal finger amputation and who were treated with occlusive dressings. A retrospective study was done of 19 patients from a single hospital. At the review, an independent examiner evaluated the time required for wound healing, the number of occlusive dressings used, fingertip trophic skin changes, epicritic sensitivity using the Weber two-point discrimination (2PD) test, sensitivity based on the monofilament test, complications, the presence of dysesthesia or cold intolerance, and the QuickDASH score. The mean follow-up was 12.6 months (6-25). A mean of 3.2 occlusive dressings (3-5) were used per patient, and the mean healing time was 4.3 weeks (4-5). The skin texture, fingertips and nail bed were good or excellent in 18 cases. The 2PD test was good or normal in 16 cases. Eighteen patients were satisfied or very satisfied with the outcome. The mean QuickDASH score was 5.53 (0-20.45). In the literature, the recovery of tactile sensation is good after use of occlusive dressings (2PD of 2.5 to 4.0mm). The mean sensitivity reported in various studies is better than that observed after use of a skin flap. While the sample size in our study was small, the functional outcome and appearance were good. Thus we prefer using occlusive dressings in Zone 1 and 2 fingertip amputations, and flaps in zones 3 and 4 to ensure better fingertip viability and sensation.