Extensive limb-sparing surgery with reconstruction for sarcoma of the hand and wrist.

BACKGROUND: Sarcoma rarely involves the hand or wrist. Extensive surgical excision is the current standard of care. At the extremities, such as the hand and wrist, limb-sparing surgery with reconstruction to provide optimal function is increasingly performed. A descriptive case-series study of 16 patients with sarcoma of the hand and wrist managed using limb-sparing surgery is reported here. MATERIAL AND METHODS: Of 19 patients with sarcoma of the hand or wrist treated between 1999 and 2012, 16 were managed using limb-sparing surgery. These were consecutive patients managed at a single-centre and studied retrospectively. The tumour involved the hand in 7 patients and the wrist in 9 patients. The procedure was primary in 6 patients, whereas 10 patients underwent secondary revision surgery. In 12 patients, reconstruction was performed for one or more of the following structures: nerves (n=2), tendons (n=3), bone (n=3), and/or skin (n=8). After surgical excision, the margins were R0 in 15 patients and R1 in 1 patient. At last follow-up, survival, pain, and function as reflected by the DASH and MSTS scores were assessed. RESULTS: After the median follow-up of 4.5years [1-13], 15 patients were alive with no local recurrence and 1 patient had lung metastases. Mean values were 18 [0-49] for the DASH score and 88.8% [53-100] for the MSTS score. DISCUSSION: Limb-sparing surgery reconciles the need to achieve complete tumour excision with the need to restore function. No limits should be placed on tumour excision, given the availability of effective reconstructive methods. The functional outcome depends on the tolerance of adjuvant treatments, most notably radiotherapy. LEVEL OF EVIDENCE: IV, retrospective study.

Prognostic factors in two-stage flexor tendon reconstruction: Is it possible to predict surgical failure?

INTRODUCTION: Two-stage surgical reconstruction of the flexor tendons by the Hunter technique is the salvage option in case of old tears or a severely damaged fibro-osseous canal. HYPOTHESIS: The identification of poor prognostic factors during the assessment of injuries at presentation could help determine indications and predict failures. MATERIALS AND METHODS: We report a retrospective single center series of reconstruction of zone 2 of the flexor digitorum profundus of the long fingers between 2000 and 2012, in 22 patients, mean age 33 years old with a mean follow-up of 36.4 months. RESULTS: The total active range of motion (TAM) of the rays was 110° with a mean range of motion of the PIP and DIP of 71° and 39° respectively. Sixty-three percent of patients were satisfied and 73% returned to their professional activities. A group with good and fair results was determined based on the Strickland classification (68%, 15 patients, mean TAM 126°, mean QuickDASH 22.6) and a group with poor results (32%, 7 patients, mean TAM 77°, mean QuickDASH 43.4). The factors of a poor prognosis were associated injuries to the extensor apparatus, infection (phlegmon) (P=0.023) and joint injuries (P=0.09). DISCUSSION: There are no factors in the literature to predict a poor prognosis except for reconstruction of the flexor pollicis longus. A simplified procedure could provide better results in patients with associated injuries to the extensor apparatus, infection (phlegmon) or osteoarticular damage, in terms of the duration of physical therapy, additional surgery and overall socioeconomic cost. The results in the literature of superficialis finger reconstruction are significantly better (P<0.001). CONCLUSION: Although the Hunter technique is still the reference procedure for the reconstruction of flexor tendons, our study identified prognostic factors of poor functional results such as infection and associated extensor apparatus damage, which should orient the surgeon towards a simplified technique such as the superficialis finger procedure. LEVEL OF EVIDENCE: IV: retrospective study.

Impact of cardiovascular risk factor on the prevalence and severity of symptomatic full-thickness rotator cuff tears.

INTRODUCTION: The natural history of rotator cuff (RC) tears is likely multifactorial. Two theories have been put forward to explain them: extrinsic and intrinsic. Cardiovascular (CV) risk factors may be important in the context of the intrinsic theory. OBJECTIVES: The objectives of this study were to demonstrate the influence of CV risk factors and their cumulative effect on the prevalence of symptomatic full-thickness RC tears and on the severity of these lesions. MATERIAL AND METHODS: A prospective observational case-control study was carried out with 206 consecutive patients undergoing arthroscopic rotator cuff repair. The control population consisted of 100 consecutive patients of the same age who had asymptomatic unoperated shoulders and were being operated in the orthopedics unit. The full-thickness RC tears were classified intraoperatively using the Southern California Orthopaedic Institute (SCOI) classification described by Snyder. CV risk factors were rated as either present or absent: smoking, high blood pressure (HBP), diabetes, alcoholism, dyslipidemia, obesity and CV history. RESULTS: Using a multivariate analysis, two factors were identified as having a significant influence on the prevalence of RC tears: smoking (OR=8.715, 95%CI=4.192-18.118, P<0.0001) and dyslipidemia (OR=4.920, 95%CI=2.046-11.834, P=0.0004). The following factors had a significant effect on the severity of RC tears: smoking (OR=1.98, P=0.0341, 95%CI=1.05-3.74), HBP (OR=3.215, P=0.0005, 95%CI=1.67-6.19) and history of CV disease (OR=6.17, P<0.0001, 95%CI=2.5-14.78). The case patients had an average of 2.09 CV risk factors while the control patients had an average of 0.74 (OR=3.56, 95%CI=2.18-6.33, P=0.0012). The average number of CV risk factors increased as the severity of the tear increased: 0.19 for stage 1, 1.75 for stage 2, 2.75 for stage 3 and 2.90 for stage 4. DISCUSSION: Modification of the vascular background appears to influence the severity and prevalence of tears. This corroborates anatomical studies in which a hypovascular area was identified in the tendon, 10-15 mm from the lesser trochanter attachment. Smoking, high blood pressure and obesity have been identified in other published studies as risks factors for the severity and prevalence of RC tears. However, it will be important to dissociate prevalence issues from that of RC healing in patients with compromised vascularity. CONCLUSION: Cardiovascular risk factors have a significant role in the pathology of RC tears. The prevalence of RC tears is greater in patients who smoke or have dyslipidemia. Their severity is greater in patients who smoke, have high blood pressure or have experienced at least one CV event. The next step will be to study how these factors affect tendon healing, as this information could change our indications for cuff repair.

Secondary restoration of fingertip sensation with Littler's heterodigital neurovascular island flap after ring avulsion injury: report of two cases.

Treatment of ring avulsion injuries is technically challenging. Surgical success depends not only on revascularization and anatomic restoration but also on functional recovery. A functional finger is mobile and sensible. We report two cases of secondary restoration of the finger pulp's sensibility with Littler's heterodigital neurovascular island flap after a ring avulsion injury. Two patients (47-year-old physiotherapist and 21-year-old student) suffered a degloving injury of the 4th finger on the left hand, classified in Urbaniak class III and Kay-Adani class IVd. The emergency treatment consisted in replantation with suture repair of the ulnar proper palmar digital artery; the nerve was not repaired due to its avulsion from the pulp. Four months later, once the vascularization was stable, restoration of the fingertip's sensibility was done using Littler's heterodigital neurovascular island flap. The 3rd finger's ulnar palmar digital pedicle was dissected using a hemi-Bruner incision. The pedicled flap was brought to the host site after being tunneled through the 4th finger's base. A split skin graft was performed at the donor site. After three years of follow-up, two-point discrimination on the 4th finger's radial pulp was 5mm and cortical integration was satisfactory. The donor site had only tactile sensitivity. The DASH (Disabilities of the Arm, Shoulder and Hand) score was 13.3 and 11.7, and the total arc of motion was 90° and 180°, respectively. Littler's flap seems to be appropriate for restoring sensation at fingertip after ring avulsion injuries. Donor site complications seem acceptable.