The Role of Microsurgery in Coverage of Defects of the Hand.

Soft tissue defects of the hand may result from trauma, infection, vascular disease, and after resection of tumors. Microsurgery has evolved to a stage where it is relatively commonplace today but procedures such as free flaps still incur significant time, manpower, cost, and material resources. The aim of this article is to articulate the specific situations in hand reconstruction when microsurgery is superior to nonmicrosurgical reconstructive options. The benefits of microsurgical reconstruction include a variety of important metrics, such as improved function, better tissue match, less donor site morbidity, and reduced downtime for the patient.

Challenges and Solutions in Prosthetic Fitting of Digits after Flap Reconstruction.

Surgical reconstruction can restore length and function, but cannot adequately resolve the problem of disfigurement. Prosthetic fitting can play a complementary role in enhancing the aesthetic outcomes post reconstruction. However, complex reconstruction involving flaps coupled with the surgical imperative for limb length preservation can lead to outcomes where the reconstructed stumps are challenging to fit with prosthesis. This article describes how prosthetic fitting was tackled in a case of a triple-digit amputation after reconstruction that presented with finger stumps that were bulky, long and stiff in extension contracture, compounded by the presence of substantive scar tissues. We discuss major prosthesis modifications that were unconventional but necessary to enable fitting, the techniques involved, as well as the aesthetic and functional considerations behind the modifications. The results showed that enhanced aesthetic appearance, together with a marginal improvement in hand function, was achieved post-prosthetically, meeting the patient's and the clinical team's fitting objective. Level of Evidence: Level V (Therapeutic).

Revisiting the reconstructive ladder for soft tissue reconstruction in the lower extremity.

Soft tissue reconstruction of the lower limb has seen a paradigm shift over the past two decades. Typically, these defects arise from trauma, infection or tumor. It is no longer enough to simply achieve coverage. Factors like patient-reported outcomes and aesthetic considerations are essential in the decision-making process. This is especially in light of increasing technological advancement, availability of dermal substitutes, microsurgical expertise and development of the field of microsurgical reconstruction as a whole with more novel flaps and techniques. Advancements in reconstructive modalities have also been equally matched by better emergency medical mobilization, transportation and access, early initiation of subspecialty care, accessibility and types of imaging, as well as oncological advances in radiotherapy and chemotherapy regimens. Yet, this has also meant that our patient profile has expanded to include older patients with more co-morbidities and other considerations such as frailty or the irradiated field which could influence what reconstructive modality is suitable and the goals of reconstruction specific to the patient. Previously deemed unsalvageable limbs are now being successfully reconstructed with good function and aesthesis. In the lower limb, this implicates the ability for early mobilization, range of motion and weight bearing which allow the patient to successfully partake in early rehabilitation. Expedient and reliable healing is also important in the oncological population where a proportion of these patients would need to go on to receive post-operative chemotherapy or radiotherapy. The reconstructive ladder has been what many reconstructive surgeons have been taught upon with regard to the basic principles of pre-operative planning and choosing the appropriate reconstructive modality. In this article, we examine the relevance of the reconstructive ladder in modern practice and the additional considerations in the approach to a soft tissue defect in the lower extremity.

Aesthetic Considerations in Pollicisation Using the Buck-Gramcko Technique.

The Buck-Gramcko (BG) technique of pollicisation has stood the test of time and provides good to excellent prehensile function in thumb hypoplasia. Proponents of the technique favour it because it provides good exposure to the palmar neurovascular structures. However, the skin flap design may occasionally lead to a 'finger-like' appearance with a sharp interdigital cleft and a triphalangeal form. In this report, we describe some of the important aspects of the operative technique so that the outcome is aesthetically pleasing in addition to providing good function. Level of Evidence: Level V (Therapeutic).

Outcomes Associated with Moberg and Modified Moberg Flaps in Thumb Reconstruction: A Systematic Review.

Background: Appropriate thumb function is critical as it is makes up approximately 40% of the hand's function leading to the greatest influence in activities of daily living (ADLs). Local flaps are the primary option for thumb reconstruction, of which the Moberg flap has been reported to have the added advantage of its advancement capacity relative to other flaps. This systematic review aims to describe the outcomes of the Moberg advancement flap and its associated modifications for coverage of palmar thumb defects. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for the conduct of this systematic review. Medline, Embase, CINAHL and Cochrane Library were systematically searched to retrieve relevant citations. Title and abstract as well as full-text assessment were performed in duplicate. Full texts were extracted by one reviewer and data extracted was confirmed by a second. Complication rates and overall means were calculated for the appropriate outcomes. Results: A total of 1,794 citations were retrieved; 15 papers were retained, including 169 patients. The overall mean follow-up was 28.6 months (n = 5 studies). In 136 patients, there was 100% flap viability (n = 12 studies). With regard to thumb aesthetics, 92% (59/64 patients) had favourable outcomes (n = 6 studies). No evidence of postoperative flexion contractures (n = 0/56 patients, 5 studies) was found. Cold intolerance occurred at a rate of 29.8% (n = 17/57, 4 studies) and the infection rate was 10.3% (6/58 patients, 3 studies). Conclusions: Moberg/modified Moberg flaps are a safe option for thumb reconstruction given their associated postoperative outcome and complication profile. Level of Evidence: Level III (Therapeutic).

Surgical Technique: Lateral Plate Osteosynthesis of Proximal Phalanx Fractures.

Dorsal plate fixation of proximal phalanx (PP) fractures is a conventional approach but interferes with the extensor mechanism and results in stiffness. Biomechanical studies have shown that laterally placed plates on the proximal phalanges are equally stable and rigid. This technique obviates the issue of tendon adhesion and may result in better postoperative range of motion and lower secondary procedures such as removal of implant and tenolysis. The low adoption of this technique may be related to lack of familiarity with the surgical approach. We describe our surgical technique with lateral plating of PP fractures and present our case that lateral plate osteosynthesis is an acceptable surgical fixation option for PP fractures, which extends the hand surgeon's armamentarium for more challenging and comminuted fractures.

Randomised controlled trials in hand surgery: a scoping review.

OBJECTIVES: To identify the evidence gaps that exist regarding the efficacy or effectiveness of hand surgery. SETTING: A scoping review. We systematically searched MEDLINE, Embase and CENTRAL databases to identify all hand surgical randomised controlled trials from inception to 7 November 2020. RESULTS: Of the 220 identified randomised controlled trials, none were fundamental efficacy trials, that is, compared surgery with placebo surgery. 172 (78%) trials compared the outcomes of different surgical techniques, and 143 (65%) trials were trauma related. We identified only 47 (21%) trials comparing surgery with non-operative care or injection. CONCLUSION: The evidence supporting use of surgery especially for chronic hand conditions is scarce. To determine optimal care for people with hand conditions, more resources should be aimed at placebo-controlled trials and pragmatic effectiveness trials comparing hand surgery with non-operative care. PROSPERO REGISTRATION NUMBER: CRD42019122710.

Pigmented Nail Lesions: When to Observe, When to Biopsy, When to Widely Excise, and When to Amputate?

Pigmented nail lesions are challenging problems. The differential diagnosis is broad and ranges from common self-limiting conditions, such as subungual hematoma and infection, to potentially fatal conditions, such as subungual melanoma. Clinical assessment and adjuncts, such as dermoscopy and imaging, are usually insufficient to establish a diagnosis, and a nail bed biopsy is often required. However, this is not an innocuous procedure and may result in permanent nail deformity. In addition, subjecting every patient with nail pigmentation to a biopsy will result in an unacceptably high rate of negative test results. Furthermore, histopathologic diagnosis of subungual melanoma remains challenging for several reasons. Once the diagnosis of subungual melanoma is established, the definitive treatment is controversial because the existing guidelines have largely been adapted from those for cutaneous melanoma. This review presents an approach to the diagnosis and management of pigmented subungual lesions and subungual melanoma, in particular, on the basis of the latest available evidence.

Mirror hand-ulnar dimelia: a single centre experience with 13 patients.

Mirror hand-ulnar dimelia (MHUD) is rare congenital disorder with a wide range of clinical and radiographic features. The current nomenclature is confusing and the existing classification systems focus mainly on morphology without providing much guidance for treatment. The goal of this study was to review the clinical and radiological features in 13 children with MHUD that were treated at a single institution. Our findings support the hypothesis that MHUD typically involves the entire upper limb, and the treatment plan should consider the predictors of function at each limb segment. A logical and comprehensive management algorithm is proposed.Level of evidence: IV.

Bias in Hand Surgical Randomized Controlled Trials: Systematic Review and Meta-Epidemiological Study.

PURPOSE: Inappropriately reported or conducted studies may decrease the quality of care due to under- or overestimation of the benefits or harms of interventions. Our aim was to evaluate how often hand surgical randomized controlled trials (RCTs) use and report adequate methods to ensure internal validity, and whether inadequate reporting or methods are associated with the magnitude of treatment effect estimates. METHODS: Data Sources were the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase databases until November 2020. We included published RCTs investigating the effects of any surgical intervention in the hand and wrist region. We assessed internal validity using the Cochrane Risk of Bias (RoB) tool for 6 domains: selection, performance, detection, attrition, selective reporting, and "other" bias. We extracted the primary outcome and calculated the effect size for each study. We used mixed-effect meta-regression to assess whether the RoB modified the magnitude of the effects. RESULTS: For 207 assessed trials, the RoB was unclear or high for 72% in selection, 93% in performance, 88% in detection, 25% in attrition, 22% in selective reporting, and 34% in the "other" bias domain. Trials with a high or unclear risk of selection bias yielded 0.28 standardized mean difference (95% confidence interval, 0.02-0.55) larger effect sizes compared to studies with a low risk. Risks of bias for other domains did not modify the intervention effects. The risk for selection bias declined over time: the odds ratio for a high or unclear RoB was 0.90 (95% confidence interval, 0.85-0.95) per additional year of publication CONCLUSIONS: The internal validity and credibility of hand surgical RCTs can be improved by using established methods to achieve true randomization, blinding of the participants and study personnel, publishing the trial protocol and avoiding selective reporting of the outcomes, and reporting the trial as recommended in the Consolidated Standards of Reporting Trials statement. CLINICAL RELEVANCE: Clinicians should be aware that RCTs that do not use or report proper randomization and allocation concealment may overestimate the treatment effects.

Differential Diagnoses of Pediatric Upper Limb Masses.

PURPOSE: Upper limb masses are one of the most common presentations in the outpatient setting. However, there is a paucity of information in the literature regarding the epidemiology of upper-extremity masses in the pediatric population. The aim of this study was to determine the differential diagnoses and clinical characteristics in children aged ≤18 years presenting with upper limb masses. METHODS: A retrospective review of patients aged ≤18 years managed at our institution over a 5-year period was performed. We obtained information on patient demographics, clinical features, radiological investigations, intraoperative features, and histology. We also evaluated the correlation between the clinical and histopathological diagnoses in patients who underwent surgery. RESULTS: There were 141 upper limb masses in our series. The mean age at presentation was 12 years (SD, 5 years). The most common presenting complaints were asymptomatic swelling, pain, and paresthesia. The majority (128; 91%) of tumors were benign; there were 5 locally aggressive tumors and 6 malignant tumors. The dominant hand was involved in 60 patients. Of 140 patients, 43 (31%) patients had surgery. The procedures included incisional biopsy, excisional biopsy, wide resection, and reconstruction. One patient required a below elbow amputation for an osteosarcoma. CONCLUSIONS: Ten percent of cases represented malignant or locally aggressive disease. We have used our observations to develop a clinical algorithm that can assist clinicians in evaluating and managing children and adolescents presenting with upper-extremity masses. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Radioscaphoid Impingement after Volar Plate Fixation and Bone Grafting of a Non-United Scaphoid Fracture.

Volar plate fixation (VPF) of scaphoid fractures has received increased attention over the past decade. The purported benefits over headless screw fixation are increased rigidity, better purchase of small fragments, the ability to prevent extrusion of bone graft, and to act as a buttress against excessive scaphoid flexion. We report a case of symptomatic radioscaphoid impingement presenting two years after successful VPF for a non-united scaphoid fracture. We performed an arthoscopic evaluation, synovectomy and chondroplasty, followed by open radial styloidectomy and implant removal. This article highlights the pertinent clinical features, relevant imaging, and key intra-operative findings. We have analyzed the factors that led to this complication and have highlighted several technical tips to minimize radiocarpal impingement and ongoing chondral damage.

Secondary Procedures after Severe Upper Extremity Injury.

Upper extremity trauma is one of the most common types of injuries, accounting for 20 to 40 percent of injured patients presenting to the emergency department. In severe upper extremity injury, the likelihood of secondary procedures to improve function and resolve outstanding clinical problems is high. Secondary procedures are performed later than initial primary surgery, usually after wound healing and with a discernible time gap of days, weeks or occasionally longer. They should be considered as separate procedures from the primary surgery, with due diligence given to planning for it. When approaching secondary procedures, the key principles are anchored in early preparation, patient engagement, optimal timing and sequencing, reviewing and considering alternatives, and finally knowing when to stop. Although secondary procedures after upper extremity injuries can be a complex undertaking, the careful application of these principles and considerations will optimise outcomes.

Hand Surgery in Singapore.

Singapore as an island nation is one of three countries in the world that has hand and reconstructive microsurgery (HRM) as an independent specialty. The 52 accredited hand surgeons serving a population of 5.7 million facilitate hassle free access to patients. Hand surgery historically is rooted very much in orthopaedic surgery as in most Asian countries with more than five decades of rapid evolution. Singapore pioneered a structured and systematic training program for HRM and the local surgeons have contributed significantly to the body of knowledge in hand surgery with targeted research and publications with three surgeons being awarded international recognition for their contributions. Singapore continues to contribute significantly to surgical volunteerism regionally through active involvement in the training of regional surgeons through their sustainable volunteer activities and through international fellowships in Singapore hospitals. The future of hand surgery in Singapore will be more competency and multidiscipline based on community-centered approach.

A Cadaveric Study on the Utility of the Levator Scapulae Motor Nerve as a Donor for Brachial Plexus Reconstruction.

PURPOSE: The purpose of the study was to evaluate the utility of the levator scapulae motor nerve (LSN) as a donor nerve for brachial plexus nerve transfer. We hypothesized that the LSN could be transferred to the suprascapular nerve (SSN) or long thoracic nerve (LTN) with a reliable tension-free coaptation and appropriate donor-to-recipient axon count ratio. METHODS: Twelve brachial plexus dissections were performed on 6 adult cadavers, bilaterally. We identified the LSN, spinal accessory nerve (SAN), SSN, and LTN. Each nerve was prepared for transfer and nerve redundancies were calculated. Cross-sections of each nerve were examined histologically, and axons counted. We transferred the LSN to target first the SSN and then the LTN, in a tension-free coaptation. For reference, we transferred the distal SAN to target the SSN and LTN and compared transfer parameters. RESULTS: Three cadavers demonstrated 2 LSN branches supplying the levator scapulae. The axon count ratio of donor-to-recipient nerve was 1:4.0 (LSN:SSN) and 1:2.1 (LSN:LTN) for a single LSN branch and 1:3.0 (LSN:SSN) and 1:1.6 (LSN:LTN) when 2 LSN branches were available. Comparatively, the axon count ratio of donor-to-recipient nerve was 1:2.5 and 1:1.3 for the SAN to the SSN and the LTN, respectively. The mean redundancy from the LSN to the SSN and the LTN was 1.7 cm (SD, 3.1 cm) and 2.9 cm (SD, 2.8 cm), and the redundancy from the SAN to the SSN and the LTN was 4.5 (SD, 0.7 cm) and 0.75 cm (SD, 1.0 cm). CONCLUSIONS: These data support the use of the LSN as a potential donor for direct nerve transfer to the SSN and LTN, given its adequate redundancy and size match. CLINICAL RELEVANCE: The LSN should be considered as an alternative nerve donor source for brachial plexus reconstruction, especially in 5-level injuries with scarce donor nerves. If used in lieu of the SAN during primary nerve reconstruction, trapezius tendon transfer for improved external rotation would be enabled.

Management of Tendon and Bony Injuries of the Distal Phalanx.

Acute tendon and bony injuries of the distal phalanx are challenging injuries because they may result in chronic pain, hypersensitivity, stiffness, and deformity if they are not adequately treated. Flexor tendon avulsions require early surgical repair. Conversely, most extensor tendon injuries and fractures heal well with nonoperative treatment. However, surgery is indicated in selected patients, and meticulous technique is required to achieve good postoperative outcomes. In this article, we outline the pertinent clinical anatomy of the distal phalanx, review the current literature regarding treatment options, and highlight key management points to ensure good clinical outcomes while minimizing complications.

Sustaining a national surgical training programme during the COVID-19 pandemic.

The COVID-19 pandemic has disrupted all segments of daily life, with the healthcare sector being at the forefront of this upheaval. Unprecedented efforts have been taken worldwide to curb this ongoing global catastrophe that has already resulted in many fatalities. One of the areas that has received little attention amid this turmoil is the disruption to trainee education, particularly in specialties that involve acquisition of procedural skills. Hand surgery in Singapore is a standalone combined programme that relies heavily on dedicated cross-hospital rotations, an extensive didactic curriculum and supervised hands-on training of increasing complexity. All aspects of this training programme have been affected because of the cancellation of elective surgical procedures, suspension of cross-hospital rotations, redeployment of residents, and an unsustainable duty roster. There is a real concern that trainees will not be able to meet their training requirements and suffer serious issues like burnout and depression. The long-term impact of suspending training indefinitely is a severe disruption of essential medical services. This article examines the impact of a global pandemic on trainee education in a demanding surgical speciality. We have outlined strategies to maintain trainee competencies based on the following considerations: 1) the safety and wellbeing of trainees is paramount; 2) resource utilization must be thoroughly rationalized; 3) technology and innovative learning methods must supplant traditional teaching methods; and 4) the changes implemented must be sustainable. We hope that these lessons will be valuable to other training programs struggling to deliver quality education to their trainees, even as we work together to battle this global catastrophe.

Emergency Hand and Reconstructive Microsurgery in the COVID-19-Positive Patient.

The case spectrum in hand surgery is one of extremes-purely elective day surgery cases under local anesthesia to mangling limb injuries that require immediate, and frequently, lengthy, surgery. Despite the cancellation of most elective orthopedic and plastic surgical procedures, hand surgeons around the world continue to see a steady stream of limb-threatening cases such as severe trauma and infections that require emergent surgical care. With the increase in community-spread, an increasing number of COVID-19-infected patients may be asymptomatic or have mild, nonspecific or atypical symptoms. Some of them may already have an ongoing, severe infection. The time-sensitive nature of some of these cases means that hand surgeons may need to operate urgently on patients who may be suspected of COVID-19 infections, often before confirmatory test results are available. General guidelines for perioperative care of the COVID-19-positive patient have been published. However, our practices differ from those of general orthopedic and plastic surgery, primarily because of the focus on trauma. This article discusses the perioperative and technical considerations that are essential to manage the COVID-19 patient requiring emergency care, without compromising clinical outcomes and while ensuring the safety of the attending staff.