Trapezoid Advancement Flaps for the Treatment of Severe Upper Extremity Burn Contractures Limiting the Risk of Recurrence.

INTRODUCTION: Severe postburn contractures can lead to partial or total loss of function of the limbs, with devastating socioeconomic and psychosocial impact on the individual, especially in low- and middle-income countries. We present a surgical technique for the treatment of severe burn contractures with the purpose of limiting recurrence of the contracture after surgery, which was developed based on the observation that in most burn contractures, one side of a contracture has unburnt, soft, and pliable healthy skin. By advancing this skin as a flap over the joint crease, a bridge of healthy tissue is interposed. We postulate that the pliable skin, together with the fact that secondary wound contracture progresses away from the joint in the skin-grafted areas adjacent to the flap and not over a mobile joint, promote healing, prevent skin graft breakdown, and limit recurrence of the contracture in the long term. METHODS: We retrospectively analyzed data of all patients who have undergone surgery for severe burn contractures of elbow and axilla by means of our technique on the MV Africa Mercy between January 2013 and February 2014. RESULTS: In 27 patients (19 female, 8 male) with a mean age of 16.4 years, shoulder range of motion improved significantly from preoperative 111.0° to postoperative 149.4° of abduction-adduction. The elbow range of motion improved from preoperative 76.6° to postoperative 108.6° of flexion-extension, with a significant reduction in the residual elbow contracture from 60.5° preoperatively to 18.5° postoperatively. The average follow-up was 3 months (range, 1.5-7 months). CONCLUSIONS: We conclude that this relatively simple and safe technique limits the risk for early postoperative healing complications and recurrence of the contractures in the long term.

Infraorbital Subcutaneous Intravascular Lobular Capillary Hemangioma After Rhinoplasty.

BACKGROUND: Lobular capillary hemangioma (LCH; also referred to as pyogenic granuloma) is a common benign vascular tumor that is characterized by proliferation of capillaries with a lobular architecture. Lobular capillary hemangioma can involve superficial cutaneous, mucosal, or subcutaneous structures; the subcutaneous and intravascular variant is very rare. METHODS: A 26-year-old female patient presented with a small infraorbital mass that was slowly growing within the last 6 months. She reported no pain but an uncomfortable feeling of pressure in this area. Six months before symptom onset, the patient had undergone a closed rhinoplasty with osteotomies without any reported complication. RESULTS: An excisional biopsy was performed via a transconjunctival approach, and the histopathological findings were characteristic for a subcutaneous intravascular LCH. At the 3-month follow-up, the patient was asymptomatic with no evidence of a recurrent lesion. CONCLUSION: To our knowledge, this is the first report of a subcutaneous intravascular LCH after rhinoplasty. We would like to draw the attention of stakeholders to this rare condition and raise awareness among clinicians to what seems to be a late finding after rhinosurgery.

The Frontal View of the Nose: Lighting Effects and Photographic Bias.

BACKGROUND: Most aesthetic rhinosurgeons rely on proper photographic documentation of the nose using several different views. The frontal view is probably the most important, but it is also the most demanding. OBJECTIVES: In the frontal view, delicate, 3-dimensional (3D) anatomic structures require special photographic skills. Lighting is crucial for detail rendition and 3D reproduction of the nose, and for apparent photographic bias. METHODS: We compared the quality of reproduction and photographic bias with different symmetric and asymmetric lighting in common clinical practice described in the literature. The photographs were compared for anatomic reproduction, shadowing, 3-dimensionality, and apparent changes of nasal shape (bias). RESULTS: Symmetric lighting did not satisfy the demands of the rhinosurgeons because of marginal 3-dimensionality, reduced detail rendition, or photographic bias. Strongly asymmetric lighting altered the nasal shape adversely for bias depending on the side of illumination, but led to very good 3-dimensionality. Slightly asymmetric lighting demonstrated the best results for detail rendition and 3-dimensionality. CONCLUSIONS: Classic symmetric quarter light is a practicable lighting technique with limitations in the rendition of detail and 3-dimensionality. Slightly asymmetric lighting offered a perfect compromise, with substantially improved detail rendition and 3-dimensionality. Strongly asymmetric lighting may lead to photographic bias depending on the side of illumination. Frontal documentation of the nose with asymmetric lighting should, therefore, always be performed in duplicate, with asymmetric lighting from the right side and from the left side, to prevent misleading interpretations.

The Africa Temporal Scalp Flap: A Novel Flap for Facial Reconstruction.

Although a number of flaps exist for nasal reconstruction, severe scarring of the forehead after burn injury led to the development of a novel two-stage flap based on the superficial temporal artery. The Africa Temporal Scalp (ATS) flap is composed of an axial ascending part on the superficial temporal artery, and a descending anterior extension for reconstruction of the midface. This is a retrospective analysis of all patients who underwent ATS flap surgery on the MV Africa Mercy. During the 7.5-year period, the ATS flap was applied to 45 facial reconstructions, with a median age of 28 years (range 19 months to 51 years). The main indications were previous burn injury (n = 27, 60%) and noma (n = 15, 33.3%). The majority of the flaps were used to reconstruct the lower third of the nose (n = 39, 86.7%), and the remaining six were for the lips or cheek. Experience allowed for earlier division than 3 weeks depending on the length of the flap, and the recipient site. There was one partial flap loss, one infection requiring revision, and two injuries to frontal branch of the facial nerve. The ATS flap is a novel two-stage flap that has proved especially versatile when forehead flaps are unavailable for nasal reconstruction due to extensive forehead scarring. The ATS flap reliably provides ample supple skin, and the donor site is effectively obscured from view, located in the periphery of the face.

Early Postoperative Recovery after Modified Ultra-Minimally Invasive Sonography-Guided Thread Carpal Tunnel Release.

Thread carpal tunnel release (TCTR) has been reported to be safe and effective for the treatment of carpal tunnel syndrome. The aim of this study is to evaluate the modified TCTR for safety, efficacy, and postoperative recovery. Seventy-six extremities in 67 patients undergoing TCTR were analyzed pre- and postoperatively using clinical parameters and patient-reported outcome measures. Twenty-nine men and 38 women with a mean age of 59.9 ± 18.9 years underwent TCTR. The mean postoperative time to resume activities of daily living was 5.5 ± 5.5 days, analgesia was completed after 3.7 ± 4.6 days, and return to work was achieved after a mean of 32.6 ± 15.6 days for blue-collar workers and 4.6 ± 4.3 days for white-collar workers. The Boston Carpal Tunnel Questionnaire (BCTQ) and Disability of Arm, Shoulder, and Hand (DASH) scores were comparable with previous studies. Overall, two persistent compressions and one recurrence required open reoperation (3.9%). All three had been operated in the initial phase, and none required reoperation after an additional safety step was introduced. No other complications occurred. TCTR surgery appears to be a safe and reliable technique with almost no wound and scarring and a potentially faster recovery time than open techniques. Although our technical modifications may reduce the risk of incomplete release, TCTR requires both ultrasound and surgical skills and has a considerable learning curve.

[Bone Reconstruction in the Upper Extremity other than the Scaphoid with the free vascularized Medial Femoral Condyle]. / Knochenrekonstruktion an der oberen Extremität mittels eines freien vaskularisierten Knochentransplantates aus der medialen Femurkondyle ohne Berücksichtigung des Skaphoids.

PURPOSE: To evaluate whether a vascularized bone graft from the medial femur condyle (MFC) can successfully be used to reconstruct small bone defects (< 4 cm) on the upper extremity other than the scaphoid. PATIENTS AND METHODS: In 7 patients at the age of 28 to 66 years 8 vascularized bone grafts from the MFC were used to reconstruct bone defects on the upper extremity other than the scaphoid. Bone healing, complications, donor side morbidity, and patient´s satisfaction were evaluated. Follow-up was 3 to 40 months. Indications were: two nonunion of the distal radius in spite of several surgical procedures, one defect of the distal radius following a radius fracture with osteoarthritis of the radiocarpal joint, one acute trauma with partial loss of the carpus and radius due to an explosion injury, reconstruction of the first metacarpal (MC) following resection of a giant cell tumour, and three fusions between the 1st and 2nd MC as a salvage procedure after several surgical procedures at the saddle joint. RESULTS: There was a regular bony healing in 4 of the 8 cases; delayed bony healing was seen in three cases after 7, 8, and 9 months. In one case there was only a partial bony healing. Two donor side haematomas required surgical revision. Patient's satisfaction was high with 7 painless cases. CONCLUSION: Free vascularized bone grafts from the medial femur condyle can successfully be used to reconstruct bone defects up to 4 cm of the upper extremity other than the scaphoid.

[Perioperative Diagnostics of Peripheral Nerve Lesions and Compression Syndromes: Position Paper of the German-Speaking Group for Microsurgery of Peripheral Nerves and Vessels]. / Diagnostik von peripheren Nerven bei Läsionen und Kompressionssyndromen: Positionspaper der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie ­ (DAM).

The treatment of peripheral nerve pathologies requires a rapid and precise diagnosis. However, the correct identification of nerve pathologies is often difficult and valuable time is lost in the process. In this position paper of the German-Speaking Group for Microsurgery of Peripheral Nerves and Vessels (DAM), we describe the current evidence for various perioperative diagnostics for the detection of traumatic peripheral nerve lesions or compression syndromes. In detail, we evaluated the importance of clinical examinations, electrophysiology, nerve ultrasound and magnetic resonance neurography. Additionally, we surveyed our members for their diagnostic approach in this regard. The statements are based on a consensus workshop on the 42nd meeting of the DAM in Graz, Austria.

Chronic Recurrent Multifocal Osteomyelitis in a Child's Hand: Case Report and Review.

We present a 9-year-old girl with persistent pain and swelling of the left wrist. X-ray, magnetic resonance imaging (MRI) and bone biopsy led to the diagnosis of chronic recurrent multifocal osteomyelitis (CRMO), affecting phalangeal and metacarpal bases and distal carpal bones on the ulnar side of the wrist. She was treated with non-steroidal anti-inflammatory drugs and complete remission with no long-term sequelae was achieved. CRMO is a rare auto-inflammatory condition with infrequent involvement of the hand. The current literature is discussed. The aim of this report is to raise awareness of the condition to reduce the time to diagnosis and unnecessary antibiotic treatment and to prevent permanent disability due to the progression of the disease. Level of Evidence: Level V (Therapeutic).

A detailed analysis of long-term outcomes following reconstruction for congenital thumb hypoplasia.

This retrospective study analyses long-term outcomes of reconstruction for congenital thumb hypoplasia Grades 2 and 3 A. In 22 thumbs (mean follow-up 9 years), instability of the metacarpophalangeal joint was found in 20 thumbs regardless of the method of reconstruction, double breasting of local tissue with or without adductor pollicis advancement or use of a slip of flexor digitorum superficialis to supplement local tissue. There was a trend towards a greater global strength, higher Kapandji score and better subjective function score when the abductor digiti minimi was used as an opposition transfer as compared with the flexor digitorum superficialis. Results for motion and subjective parameters were consistent with comparable studies though these comparisons are compromised by different methods of classification and assessment. Consistent application of an expanded Blauth grading system and a formal hypoplastic thumb score will improve the ability to compare pre- and postoperative status, different techniques and results from different centres.Level of evidence: IV.

A Rare Finding in Dupuytren's Disease - Heterotopic Ossification.

We present the case of a severe and long-standing Dupuytren's contracture where intraoperatively an ossified nodule was encountered within the diseased tissue. Histologically palmar fibromatosis in contact with cartilaginous tissue with central ossification could be confirmed, compatible with metaplasia. Our finding suggests that metaplastic activity inherent to longstanding, severely diseased Dupuytren's tissue can lead to heterotopic ossification.

Surgical Treatment and Outcomes of Syndactyly: A Systematic Review.

Background: Different techniques are used to release simple and complex congenital syndactyly in order to create an adequate web space, and to separate the fingers to allow independent function. Methods: This article is a systematic review of the literature, aiming to evaluate the evidence for the different techniques and outcome measures utilised. Results: The studies consisted mainly of retrospective, non-controlled descriptive series and a few retrospective cohort studies. The level of evidence is predominantly poor. Conclusions: Although recommendations in favour of any particular surgical technique cannot be given based on evidence, a number of conclusions can be drawn out of the existing literature with regards to the design of the incisions for finger separation, use of pulp flaps and grafts.

Vascular anomalies of the upper limb.

Vascular anomalies are common in the upper extremities, but there continues to be a relative paucity of information about them in publications dealing with surgery in the hands and upper limbs. The wide spectrum of pathology and an inconsistent use of terminology make vascular anomalies susceptible to incorrect diagnosis and as a result, to misdirected management. This article aims to provide an update on vascular anomalies relevant to the upper limbs, focusing on significant advances in pathogenesis and genetics, classification systems, diagnosis and treatment.

Surgical techniques for reconstruction of the hypoplastic thumb.

The reconstruction of a congenital hypoplastic thumb usually involves release of a tight first web space, metacarpophalangeal joint stabilization, reconstruction of intrinsic muscle function, and extrinsic tendon reconstruction, as appropriate. Numerous surgical options and combinations are available, but the approaches vary among surgeons who work in the field of congenital hand surgery and the empirical evidence that allows for evaluation of the results of techniques is scarce. Both the pre-operative assessment and intra-operative findings of all thumb elements - bone, joints, and soft tissues - should be considered in the surgical decision-making and eventually define the methods of reconstruction. This article summarizes the different reconstructive options.

Congenital Great Toe Hypoplasia Equivalent to a Grade 3 Hypoplastic Thumb in a Patient with VACTERL Association.

Lower limb malformations in VACTERL patients are extremely rare and the most common anomalies are found in the tibial ray. We present the case of a 15 month old male with VACTERL and, additionally, a hypoplastic hallucal ray of the right foot in conjunction with a floating preaxial polydactyly. The great toe hypoplasia is similar to a grade 3b thumb hypoplasia with absence of the proximal two-thirds of the first metatarsal on the plain X-ray. We would like to draw the attention of hand surgeons to anomalies of the tibial ray, which, although rare, are the most common pattern of lower limb malformations in VACTERL association. All patients with VACTERL defects should be assessed for these additional findings.

The Austrian Flag - Severe Carpal Tunnel Syndrome: A Case Report.

In severe carpal tunnel syndrome a continuum of neural changes takes place depending on the degree and duration of the compression, beginning with breakdown of the blood-nerve barrier, followed by endoneurial oedema and, subsequently, perineurial thickening and ischemia. Persisting chronic compression will eventually result in axonal degeneration. We report a case of longstanding carpal tunnel syndrome with amyloid deposits and the unusual intraoperative 'Austrian flag' sign.