Retrospective study of Ishiguro's technique for mallet bone finger in children: long-term follow-up and analysis of predictors in outcomes.

PURPOSE: There is no consensus on the optimal treatment of bony mallet finger in the paediatric population due to a lack of studies in children. The Ishiguro technique is simple and less invasive, and treatment with K-wire fixation seems to provide better results for extension lag in bony mallet finger according to the literature. A retrospective cross-sectional study with long-term follow-up was performed to evaluate the functional and clinical outcomes of this method in children. Preoperative and intraoperative predictors of outcome were investigated. METHODS: From June to December 2022, we evaluated 95 children who underwent extension K-wire block from 2002 to 2012. Eighty-four children were included (mean age 14.8 ± 1.68 years) for a mean long-term follow-up of 11.6 ± 2.3 (8-16) years. Clinical and radiographic features were assessed. Pain and functional outcomes were assessed using Crawford criteria, range of motion (ROM) at the distal interphalangeal joint (DIPJ), loss of extension, and VAS scale. Univariate and multivariate regressions were used to assess which variables might predict the worst outcomes at long-term follow-up. RESULTS: Bone union and pain relief were always achieved. There were no complaints of potential growth impairment or nail deformity. 82.1% of patients showed excellent and good results. Fifteen patients had fair results. CONCLUSIONS: Although there are currently no significant differences between surgery and orthosis in adults, the Ishiguro technique is more effective in children when it comes to outcomes in the treatment of mallet fingers. A high percentage of excellent and good results were achieved, and no epiphyseal damage or nail deformity was reported. A strong and significant correlation was found between the worst outcomes and either delayed treatment time or excessive flexion angle.

Fingertip injuries and their reconstruction, focusing on nails.

The fingertip is a complex anatomical structure that is frequently injured, especially in manual workers. Different classifications have been reported, considering injury orientation, level and geometry. To optimize treatment planning, the area of soft-tissue defect should be considered. Treatment aims to conserve as long a finger as possible, restore sensation (S3 + or more) and ensure a pleasant esthetic appearance. When amputation occurs, the best treatment is replantation when conditions allow. When this is not possible, the fingertip should be used as a composite graft or the nail complex can be grafted and soft tissue reconstructed, according to the preferred method. In defect without amputation or if the distal part of the finger is not present or not useful, many reconstructive techniques have been described. Depending on the injury, patient characteristics and requirements and the surgeon's skills and experience, the treatments vary from secondary healing to free flaps. In this paper, the various treatment options are described and discussed. Nowadays, considering most variables, the best treatment in fingertip injury is secondary healing with occlusive or non-occlusive dressing, even in case of bone exposure. This simple solution is able to restore a nearly normal fingertip with good sensation without further injuring the hand.

Patient-matched osseointegrated prostheses for thumb amputees: a cadaver and feasibility study.

Thumb amputations affect 50% of hand functionality. Common solutions consist of microsurgical treatments or silicone vacuum prosthesis. Not all patients are eligible for microsurgical treatment and the use of vacuum prosthesis is often discouraged because of their instability. On the contrary, osseointegrated prosthesis provide stable retention and osseoperception. This cadaveric study evaluated the process of a patient-matched osseointegrated prosthesis for the treatment of thumb amputees. Computed tomography (CT) medical images reconstruction provided information on metacarpal stump, used as input for the parametric screw design. Preoperative planning guided the surgeons in the surgery: postoperative placement confirmed the accuracy of the preoperative planning. Surgeons were directly involved in the implant design to meet their requirements and patient needs. Implants were inserted into cadaveric specimens in one-stage surgery. A similar process can be adopted and exploited for the treatment of different levels of thumb amputations and long finger amputations.

Combined repair of scapholunate ligament (SL) and triangular fibrocartilage complex (TFCC) lesions in chronic trauma of the wrist: surgical treatment of 14 patients.

PURPOSE: Injuries of the scapholunate ligament (SL) and of the triangular fibrocartilage complex (TFCC) represent the main ligament injuries of the traumatic wrist. A double injury of the SL and TFCC ligaments is quite common in the trauma setting, and clinical examination is fundamental. MRI allows to detection of a TFCC and SL ligament injury, but wrist arthroscopy is still the gold standard for diagnosis. We present the clinical results of the combined reconstruction of chronic scapholunate ligament and TFCC injury. MATERIALS AND METHODS: Fourteen patients were treated at our hospital with a combined scapholunate ligament and TFCC complex repair. All patients were surgically treated by the same senior author, after a diagnostic arthroscopy that revealed a lesion of both structures. A comparison between the pre-operative and post-operative pain and function was carried out using VAS, Disability of Arm, Shoulder and Hand score (DASH) and Patient-Related Wrist/Hand Evaluation score (PRWHE). Wrist range of motion and strength were also compared following surgery. RESULTS: All patients had a mean follow-up of 54 months. A statistically significant improvement was observed both with the reduction in pain (VAS from 8.9 to 5) and with the improvement of functionality scores (DASH from 63 to 40 and PRWHE from 70 to 57) and with the increase in ROM and strength. In only one patient (7%), because of pain and instability, a supplement operation was needed (Sauve-Kapandji procedure) 3 months after the initial surgery. CONCLUSIONS: The simultaneous repair of the SL and TFCC complex has shown a good success rate in both decreasing pain and regaining functionality.

Osteoid Osteoma of the Hand: Surgical Treatment versus CT-Guided Percutaneous Radiofrequency Thermal Ablation.

(1) Background: Osteoid osteoma (OO) is one of the most common benign bone tumors. This type of osteogenic tumor is generally characterized by a well-defined lytic area with a vascularized central nidus surrounded by sclerosis and bone thickening. The wrist and hand bones are infrequent sites for osteoid osteoma: only 10% of the cases arise in these areas. Standard treatments are surgical excision and radio-frequency ablation (RFA), both with advantages and disadvantages. This study aimed to compare the two techniques to prove if RFA could be a potential alternative to surgery in the treatment of OO of the hand. (2) Methods: Patients treated for OO of the hand between January 2011 and December 2020 were evaluated and data was collected regarding the lesions' characteristics and the treatment outcome. Each patient was followed up for 24 months and VAS pain (Visual Analogue Scale), DASH (Disability of the Arm, Shoulder and Hand), and PRWE (Patient-Related Wrist Evaluation) scores were collected. (3) Results: A total of 27 patients were included in the study: 19 surgical and 8 RFA. Both treatments showed a significant improvement in pain and functionality. Surgery was associated with a higher complication rate (stiffness and pain), while RFA was associated with a higher recurrence rate (2/8 patients). RFA allowed for a speedier return to work. (4) Conclusions: We believe that osteoid osteoma treatment with RFA in the hand should be an available alternative to surgery as it allows rapid pain relief and a swift return to work. Surgery should be reserved for cases of diagnostic uncertainty or periosteal localization.

P3 Flap: Technique for Fingertip Reconstruction.

Fingertip amputations represent an important spectrum of injuries, and most are avulsions or crush trauma. There is no consensus about one single standard treatment, and a wide number of techniques are available. The authors present the P3 flap as an option for covering fingertip defects with bone exposure, avoiding painful scars in the pulp area, without a donor site. This study included 12 fingertips with amputated segment not available for replantation. Volar oblique fingertip defects and transverse amputations with bone exposure, not more proximal than Hirase Zone IIB, were included. Defects were less than 2 cm. The patients were followed up for an average of 6 months. The aesthetic and functional outcomes and fingertip discrimination recovery were evaluated at 6 months by the static two-point discrimination (2-PD) test and DASH score (quick version). The average postoperative 2-PD test at 6 months was 5.9 mm (range from 5 to 8 mm). The mean healing time of the fingertip was 4 weeks. Nail deformity was reported in three cases with level IIB of amputation. None of the P3 flaps failed, and local infection was not reported. The average DASH score at 6 months was 1.1. The mean time to return to work was 38 days (range from 30 to 53). The P3 flap proposed in this study demonstrates a reliable single-stage technique, performed under local anesthesia, for fingertip defect reconstruction, avoiding skin incision and scars in the pulp region and preserving digital length and nail bed.

Shape-modified radial forearm flap: does it still have a role in upper extremity reconstruction?

OBJECTIVES: To carry out a radial forearm flap, the radial artery is usually harvested, incurring severe donor site morbidity. Advances in anatomical knowledge discovered constant radial artery perforating vessels, enabling the subdivision of the flap into smaller components suitable for a wide range of differently shaped recipient sites, with marked reduction of downsides. MATERIAL AND METHODS: Eight pedicled or free shape-modified radial forearm flaps were used to reconstruct upper extremity defects between 2014 and 2018. Surgical technique and prognosis were examined. Skin texture and scar quality were assessed on the Vancouver Scar Scale while function and symptoms on the Disabilities of the Arm, Shoulder and Hand score. RESULTS: At a mean follow-up of 39 months, no cases of flap necrosis, impaired hand circulation or cold intolerance were found. CONCLUSION: The shape-modified radial forearm flap is not a new technique, but is poorly known by hand surgeons; in contrast, our experience showed it to be reliable, with acceptable functional and esthetic outcomes in selected cases.

Long-Term Outcomes of Arthroscope-Assisted Bone-Ligament-Bone Reconstruction for Nonstatic Scapholunate Ligament Injury.

BACKGROUND: Scapholunate ligament injury is the most common cause of carpal instability. This retrospective case series aimed to assess the effectiveness and the maintenance of the results obtained by reconstructing the scapholunate ligament with a bone-ligament-bone autograft through an arthroscope-assisted minimally invasive approach. METHODS: Thirty-six patients were enrolled initially but only 31 constituted the final population study (23 male, eight female; median age, 38 years; age range, 18 to 55 years). Radiographic (posteroanterior and true lateral radiographs to assess the scapholunate gap, radiolunate, and capitolunate angles; computed tomographic scan; magnetic resonance images), functional [grip strength (Jamar test and pinch test), active range of motion], and subjective (patient-rated wrist evaluation test) outcome measurements were collected. Minimum follow-up was 50 months. RESULTS: Grip strength and wrist mobility were significantly improved from the preoperative values and improved over time. No scapholunate synostosis or carpal bone necrosis was observed. No wrist showed any sign of arthrosis or progression towards wrist instability. Only four patients had scapholunate gap greater than 3 mm. CONCLUSIONS: The proposed technique for scapholunate reconstruction, providing a biologic reconstruction of both the volar and dorsal portion of the scapholunate ligament and avoiding extensive capsulotomy, obtained significant functional outcomes improvement that was maintained over time and prevented degenerative changes to the articular surfaces. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Osseointegrated Metallic Implants for Finger Amputees: A Review of the Literature.

Digital trauma amputations and digital agenesis strongly affect the functionality and aesthetic appearance of the hand. Autologous reconstruction is the gold standard of treatment. Unfortunately, microsurgical options and transplantation procedures are not possible for patients who present contraindications or refuse to undergo transplantation from the toe (e.g. toe-to-thumb transplantation). To address these issues, osseointegrated finger prostheses are a promising alternative. The functional assessments registered during follow-up confirmed the promising outcomes of osseointegrated prostheses in the treatment of hand finger amputees. This review outlines (a) a detailed analysis of osseointegrated finger metallic components of the implants, (b) the surgical procedures suggested in the literature, and (c) the functional assessments and promising outcomes that demonstrate the potential of these medical osseointegrated devices in the treatment of finger amputees.

Surgical Treatment of Camptodactyly with Malek Cutaneous Approach and Stepwise Release: A Retrospective Multi-centre Study.

Background: Clinical manifestations of camptodactyly are varied and no official consensus on the etiopathogenesis or best treatment is available. Conservative treatment is generally preferred and, in refractory patients, surgery might be considered. However, reported results of surgery are often unsatisfactory and it is difficult to compare outcomes as different classification systems are adopted. We reported the outcomes of surgical treatment of camptodactyly with the Malek cutaneous approach and stepwise release, assessed using the Siegert classification. Methods: A retrospective analysis of paediatric patients (≥1 and ≤18 years) with congenital camptodactyly refractory to conservative management (flexion contracture >30°), treated with Malek cutaneous approach and stepwise release surgery between June 2009 and June 2019 with at least 1 year of follow-up was performed. Pre- and post-operative clinical and radiographic assessments were evaluated for degrees of flexion contractures and early (<30 days) or late (>30 days) complications were recorded. Results: A total of 59 patients underwent surgery, of whom 38 (64%), including 42 fingers, were enrolled; mean patient age was 8 years (range 1-18). Post-operative mean flexion contracture was significantly improved (p > 0.001) and no infections were recorded. Mean follow-up was 6 years (range 1-10) and proximal interphalangeal joint extension deficits were rated according to Siegert classification as excellent (69%), good (12%), or fair (9.5%) and poor (9.5%). Conclusions: The Malek cutaneous approach and stepwise release of the retracting soft tissues allow prompt evaluation of the anatomical structures involved in the deformity and seem to be an effective surgical correction in the long term. Level of Evidence: Level IV (Therapeutic).

Piezoelectric Bone Surgery. Overview in Applications and Proof of Feasibility in Hand and Plastic Surgery.

PURPOSE: Piezoelectric bone surgery was already extensively used in a number of surgical procedures ranging from dental to maxillofacial surgery. The authors aimed to determine whether piezosurgery was suitable and advantageous for performing osteotomies in Hand and Plastic reconstructive surgery. METHODS: The authors overviewed a variety of applications for Piezosurgery® Device, from Mectron, in bone reconstructive surgery with over the last 8 years. An overall number of 156 bone cutting procedures in adults and children was described at the phalanges, metacarpal bones and distal radius level, as well as in bone graft harvesting and bone remodeling following carpal scaphoid nonunion, scapho-lunate bone-ligament-bone reconstruction and fibula free flap in maxillofacial defects. RESULTS: The consolidation rate was 87.5% in scaphoid nonunion grafting and fixation. Bone healing was achieved in all other cases. No intra-operative complications were recorded. CONCLUSION: Piezosurgery® allowed high precision in bone cutting as well as custom-made graft and surface roughness were obtained, while preserving nerves, vessels and tendons integrity. The instrument may be handling moved into the surgical space in absence of vibrations, with a clear view onto the bone. The mechanical and biological characteristics of the piezoelectrical effect perfected this technique as an effective and useful instrument in Hand and Plastic surgery. The selective bone cutting properties avoided injuries to the surrounding soft tissues and thermal damage of the bony cells. Best advantages were described in feasibility and flexibility for intra-articular osteotomies, custom-made grafts and reconstructive microsurgical techniques.

Retrospective study of radial dome osteotomy with volar plate fixation versus K-wires in Madelung's deformity: long-term follow-up.

PURPOSE: The emerging role of the locking plate improved the technique also in corrective osteotomies in Madelung's deformity, but there is a lack of analyses between the fixation techniques, as well as little information in functional outcomes and long-term follow-up. The current study compared the outcomes, pitfalls, and advantages of volar plate and screws fixation versus K-wires fixation in a long-term follow-up. METHODS: Twenty-eight children presenting the "distal radius" variant of Madelung's deformity underwent Vickers ligament release and distal radial dome osteotomy between 2009 and 2015. Twenty-three children (20 females and 3 males, mean age 15 years and 7 months at surgery and 24 years and 8 moths at follow-up), with 26 operatively treated wrists, were available for follow-up. A retrospective two-cohort study, evaluating clinically and radiologically results, has been conducted with a mean eight years and seven months follow-up. RESULTS: Bone union and pain relief were obtained in all cases, as well as improvements in wrist motion and radiographic indices. A statistically significant correlation was identified between the volar plate fixation and an improved lunate subsidence on X-ray, and a trend towards an improved DASH score in the cohort with plate and screws, as well as significant improvement in wrist extension and supination always in the plate fixation cohort. CONCLUSIONS: The long-term follow-up enabled the patients to report on more definitive outcomes in terms of functional and cosmetic improvements. Volar plate fixation is an effective technique allowing for simple post-operative management and earlier rehabilitation program with improved clinical and radiographic outcomes.

Soft and tissue repair of the hand and digital reconstruction.

This article summarizes the current views and proposed approaches to treating soft tissue defects of the hand. The article also outlines some key considerations of digital reconstruction. There are many options in treating soft tissue defects. For defects of the hand, local flaps are primarily considered if the defects are small or moderate in size. A vascularized free flap is only considered for a defect of large size (3 cm long or larger). Thumb reconstruction is of primary importance, while reconstruction of two fingers is necessary when all fingers are lost. Reconstructions of a missing distal part of a finger or reconstruction of an entire finger if only one finger is lost are cosmetic restorations; functionally these defects do not need reconstruction. Sensation is of great importance in repair or reconstruction of the tip of the thumb or finger. Therefore, sensory evaluation is a key factor in assessing and selecting the best options of surgery.

Modified dome osteotomy and anterior locking plate fixation for distal radius variant of Madelung deformity: a retrospective study.

PURPOSE: Dome osteotomy of the distal radius with Vickers ligament release is an established method of treatment for Madelung deformity. Many different surgical procedures have been proposed in literature but techniques, patient inclusion and efficacy evaluations are heterogeneous. MATERIALS AND METHODS: A retrospective review of children affected by 'distal radius' Madelung deformity and treated with a standardized surgical procedure (modified reverse dome osteotomy of the distal radius and volar fixation with a small locking plate) between 2010 and 2018 at a single center was performed. The technique used in this study, reversing the shape of the classical dome osteotomy, allowed for an improved three-planar correction of the distal radial epiphysis and volar plate fixation allowed for an increased stability and reduced soft tissue morbidity. A structured follow-up including a prompt post-operative rehabilitation program (without wrist immobilization) was established. Pain relief, functional outcome and cosmetic appearance were assessed with a structured clinical assessment, DASH Score and radiographic assessment, accordingly. RESULTS: A total of 15 wrists in 13 children (12 females, mean age of 15.6 years, range 11-19) were included. The mean follow-up time was 3.8 years. Bone union and pain relief were obtained in all cases. Improvement in the range of motion was detected in extension, supination and flexion of the wrist. Radial inclination was increased by 15.3° and lunate subsidence by 4.1 mm. CONCLUSIONS: The use of volar fixation with a small locking plate and immediate post-operative rehabilitation for reverse dome osteotomy of the distal radius in pediatric patients affected by 'distal radius' Madelung's deformity is stable and effective.

Outpatient paediatric hand surgery: strategy in healthcare implementation and cost-efficient manner.

The increasingly cost of health care is a relevant problem as well as prolonged waiting time for admission also in emergencies. Effective cost containment measures and expenditure controls are needed to achieve and maintain clinical and organizational appropriateness. Outpatient management has proven to be the most useful method for lower-cost treatment in less severe pathologies, requiring surgery without hospitalization. The current study provided to evaluate how this model was successfully applied also to the paediatric population in hand surgery. Methods. A retrospective cohort study of 645 patients from 8 to 18 years (mean age 14.9) was performed in children treated in outpatient setting from 2015 to 2019. The direct costs were evaluated as well as the mean waiting time for surgery, comparing the data with the previous five-year period. The mean reduction in waiting time for children emergencies was 57% (from 72 to 31 h) due to the Outpatient setting into a dedicated Day-Surgery Service organizational model. The visual graphed data showed a general clear growing trend towards outpatient surgery in adults and children. The overall effect was a 29.2% of reduction in spending between expected and achieved costs, recovering resources toward the increasing technology and innovation expenditures. Outpatient paediatric hand surgery was an effective and attractive option which leaded to decreased individual and social costs, with increased clinical and organizational appropriateness. Thus, reduced delay in treatment and provided benefits for children and familiars.

Hand and Upper Limb Malformations in Italy: A Multicentric Study.

Background: Although hand and upper limb malformations are quite frequent, up to now very few reports have been published on epidemiology. The aim of this study is to evaluate the number of infants who presented with hand and upper limb malformations from 2010 to 2015 in Italy. Methods: A retrospective analysis of a pediatric population presenting with hand and upper extremity malformations was carried out, gathering reports achieved from eight Italian Centers of pediatric hand surgery. Other factors such as gender, date and region of birth, family distribution of malformations and associated syndromes, were analysed. Results: Out of 3,100,421 live births, 765 children presented with hand and upper limb malformations. The incidence was 2,5/10,000 live births with a predominance of males and the right side. Radial polydactyly was the anomaly with the highest percentage, closely followed by simple syndactyly, simbrachidactyly and complex syndactyly. Less common conditions were the triphalangic thumb, thumb in palm, proximal radioulnar synostosis and Sprengel deformity. Inheritance of and familial predisposition to those malformations was recorded in 25 cases, while 84 children presented with syndromes related to hand anomalies. Conclusions: In conclusion the incidence of hand and upper extremity malformations in Italy is lower than that registered in other countries. The retrospective nature of the study combined with the fact that some defects frequently evade pediatric hand surgeon consultations are some possible limitations of the study. However, our data confirmed that, in spite of the decrease in the birth rate in Italy, the trend of congenital hand disorders maintained a stable trend. We aim to integrate this study with a prospective analysis and to involve the institutional health authorities in other countries so as to register the correct incidence of hand and upper extremity defects.

Update on Peripheral Nerve Sheath Tumors in Upper Extremity: A Descriptive Review.

Peripheral Nerve Sheath Tumors (PNSTs) are extremely uncommon and it is almost certain that no individual upper limb surgeon will gain great experience in a lifetime with these lesions. Benign and malignant PNSTs are separately analyzed in this descriptive review and discussed focusing the attention towards the most important features. A comprehensive and summarized overview of this topic is offered to the reader in order to improve the complex management of these tumors from diagnosis to treatment. A systematic search in PubMed was carried out using the keywords (and synonyms) written below in order to find relevant and most cited papers. Reckoning the rarity of the pathology, few selected case reports were taken into account. A compendium of each PNST was created to sum up the personal experience of the Authors who wrote the articles, critically inspected and analyzed. Every section of the paper is meant to provide useful tips to the reader.

Palmar fracture-dislocation of the trapezoid with median nerve contusion. Case report and literature review.

Complete dislocations of the trapezoid are very uncommon injuries. The authors present a case of open palmar trapezoid fracture-dislocation with significant displacement of the fracture, acute carpal tunnel syndrome and other concomitant carpometacarpal injuries. A review of the literature search for palmar trapezoid dislocations and treatments was performed.

Vascularized bone grafts for post-traumatic defects in the upper extremity.

Vascularized bone grafts (VBGs) are widely employed to reconstruct upper extremity bone defects. Conventional bone grafting is generally used to treat defects smaller than 5-6 cm, when tissue vascularization is adequate and there is no infection risk. Vascularized fibular grafts (VFGs) are mainly used in the humerus, radius or ulna in cases of persistent non-union where traditional bone grafting has failed or for bone defects larger than 6 cm. Furthermore, VFGs are considered to be the standard treatment for large bone defects located in the radius, ulna and humerus and enable the reconstruction of soft-tissue loss, as VFGs can be harvested as osteocutaneous flaps. VBGs enable one-stage surgical reconstruction and are highly infection-resistant because of their autonomous vascularization. A vascularized medial femoral condyle (VFMC) free flap can be used to treat small defects and non-unions in the upper extremity. Relative contraindications to these procedures are diabetes, immunosuppression, chronic infections, alcohol, tobacco, drug abuse and obesity. The aim of our study was to illustrate the use of VFGs to treat large post-traumatic bone defects and osteomyelitis located in the upper extremity. Moreover, the use of VFMC autografts is presented.