Efficacy and safety of Dynavisc® gel in prevention of scar adhesions recurrence after flexor tendons tenolysis in zone 2. Multicenter retrospective cohort study.

AIM: Dynavisc® is a novel surgical product made of carboxymethylcellulose (CMC) and Polyethylene Oxide (PEO) designed to reduce post-surgical adhesions in tendons surgery. A multicenter retrospective cohort study was performed to investigate the clinical safety and efficacy of the Dynavisc® gel in reducing post-surgical adhesions after flexor tenolysis in zone 2. MATERIAL OF STUDY: Thirty-one patients suffering from stiff finger after flexor tendon repairs in zone 2 treated with standard release with (18 Dynavisc®-treated group) or without (13 controls) anti-adhesion gel application into the flexor tendon sheath and around the site of the tenolysis, were collected in five different hand surgery units. Safety profile and functional outcomes (based on TAM test and the The Quick-DASH questionnaire) were examined from patients' charts and analyzed. RESULTS: The application of Dynavisc® posed no safety concerns and it was not related to any additional complication. The Dynavisc®-treated group showed greater progressive improvement of TAM value in all visits with superior TAM value at T(90) and T(180) compared to the control group. DISCUSSION: Tendon adhesions are the main cause of flexor tendon surgery failure. Multiple strategies (i.e. robust tendon repair, early rehabilitation and lubricant or barrier agents) have been proposed to minimize their formation. Among different products described in the literature Dynavisc® showed a significant role in limiting adhesions formation in a recent experimental study. CONCLUSIONS: This clinical study confirm the safety of Dynavisc® gel application in hand surgery demonstrating its potential long-term benefits after flexor tendon tenolysis. KEY WORDS: Flexor Tendon Repair, Tendon Adhesions, Tenolysis.

Vascularized fibular flap and custom-made synthesis in post-traumatic ulnar diaphyseal pseudarthrosis: a case report.

BACKGROUND: Although isolated fractures of the ulnar shaft are considered common and relatively benign injuries, numerous complications can arise especially in the context of suboptimal care pathways. For pediatric patients, however, there is no single indication of the surgical approach. In the context of the management of these complications, it is known that the vascularized fibular graft has numerous advantages and indications in the treatment of recurrent pseudarthrosis. However, in revision surgery the frequent occurrence of anatomical subversions requires the use of fixation means adapted to the individual patient. We present a clinical case of an adult patient suffering from post-traumatic ulnar pseudarthrosis treated with autologous vascularized fibula grafts and 3D-planned custom-made plate. CASE PRESENTATION: A 38-year-old Ivorian woman came to our attention with a painful nonunion of the ulnar shaft and significant dysmorphism of the left forearm, with shortening and flexion of the limb as an outcome of unspecified road trauma in childhood. No alterations of the nerve compartment were reported. As far as detectable, she had undergone autologous bone grafting and implantation of questionable synthetic means, without acute treatment. Since we evaluated the patient (2012), we have performed two debridement surgeries, associated with autologous avascular bone graft from the iliac crest and plate fixation (2012 and 2014). In both cases, rupture of the fixation media was observed. In 2021, the pseudarthrosis was treated with a vascularized fibular bone graft. The subverted radius and ulna anatomy and poor bone quality required patient-specific reconstruction of the pseudarthrosic ulna from a 3D scan and the production of custom-made plate and screws, supported by the creation of special guides for drilling and by optimizing the positioning of screws with preoperative digital models. In the postoperative period, regular follow-up visits with X-rays evaluations were performed at 1, 3 and 6 months after surgery. No inflammatory reactions or local rejection were found. The fibula graft healed at the proximal ulnar junction six months after the operation while it took eight months to heal at the distal junction. Functionally, we observed a pain reduction and a range-of-motion preservation. CONCLUSIONS: The multiple failures of diaphyseal reconstruction with avascular bone grafts have forced the indication to the vascularized fibular flap. This case is a unique experience but we believe that the association between vascularized bone graft and the potential for customization through 3D planning represents a valid surgical potentiality in complex cases of post-traumatic reconstruction.

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.

Short arm cast is as effective as long arm cast in maintaining distal radius fracture reduction: Results of the SLA-VER noninferiority trial.

BACKGROUND: Distal radius fractures (DRFs) are a common challenge in orthopaedic trauma care, yet for those fractures that are treated nonoperatively, strong evidence to guide cast treatment is still lacking. AIM: To compare the efficacy of below elbow cast (BEC) and above elbow cast (AEC) in maintaining reduction of manipulated DRFs. METHODS: We conducted a prospective, monocentric, randomized, parallel-group, open label, blinded, noninferiority trial comparing the efficacy of BEC and AEC in the nonoperative treatment of DRFs. Two hundred and eighty patients > 18 years of age diagnosed with DRFs were successfully randomized and included for analysis over a 3-year period. Noninferiority thresholds were defined as a 2 mm difference for radial length (RL), a 3° difference for radial inclination (RI), and volar tilt (VT). The trial is registered at Clinicaltrials.gov (NCT03468023). RESULTS: One hundred and forty-three patients were treated with BEC, and 137 were treated with AEC. The mean time of immobilization was 33 d. The mean loss of RL, RI, and VT was 1.59 mm, 2.83°, and 4.11° for BEC and 1.63 mm, 2.54°, and 3.52° for AEC, respectively. The end treatment differences between BEC and AEC in RL, RI, and VT loss were respectively 0.04 mm (95%CI: -0.36-0.44), -0.29° (95%CI: -1.03-0.45), and 0.59° (95%CI: -1.39-2.57), and they were all below the prefixed noninferiority thresholds. The rate of loss of reduction was similar. CONCLUSION: BEC performs as well as AEC in maintaining the reduction of a manipulated DRF. Being more comfortable to patients, BEC may be preferable for nonoperative treatment of DRFs.

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).

Four-Corner Arthrodesis Using a Dedicated Dorsal Circular Plate.

BACKGROUND: Scaphoid excision and 4-corner fusion is a standard procedure for advanced carpal collapse. The purpose of this study was to evaluate its effectiveness using a specific designed locking plate of the latest generation. METHODS: Between October 2012 and December 2015, 12 patients underwent this procedure using the Flower (KLS Martin Group, Tuttlingen, Germany) circular locking plate. The surgical technique is standardized. Three patients were affected by a scapholunate advanced collapse and 9 patients by a scaphoid nonunion advanced collapse. All patients underwent a computed tomographic scan to study the real achievement of the fusion. RESULTS: Only 2 patients did not show complete fusion. All the patients with successful fusion returned to previous work and manual activities. CONCLUSIONS: Four-corner arthrodesis with circular locking plate is an alternative surgical treatment for carpal arthritic collapse.

Prosthetic Replacement of the Scaphoid Proximal Pole: Should It Be the Future?

BACKGROUND: Scaphoid proximal pole fractures with avascular necrosis represent a complex surgical problem. Many reconstruction techniques are based on osteosynthesis with a vascularized or nonvascularized bone graft. These procedures do not allow early mobilization and therefore sometimes lead to unsatisfying functional results. In some cases, it is possible to perform a scaphoid hemiarthroplasty using a pyrocarbon implant (adaptive proximal scaphoid implant [APSI]) in place of the necrotic proximal pole, allowing an early mobilization and delaying palliative treatments such as 4-corner arthrodesis or proximal row carpectomy. METHODS: In this study, we reviewed all patients who had undergone a scaphoid hemiarthroplasty using APSI in our institutions from 1999 to 2017; the F.U. was performed through radiographic, clinical, and subjective (Disabilities of the Arm, Shoulder, and Hand) analysis. RESULTS: The performances of scaphoid proximal pole implants are encouraging; radiographic, clinical, and subjective outcomes were good, and the functional recovery proved to be fast and reliable over time. CONCLUSIONS: This study reports our experience in the use of APSI implants, which proved to be a good alternative to traditional techniques for treating avascular necrosis of the proximal pole, still allowing further surgical steps in case of clinical worsening over time (wrist osteoarthritis). These patients are usually young and present high functional demands. Our experience is promising, but we believe that further evaluation over time will be needed.

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.

Consensus based recommendations for diagnosis and medical management of Poland syndrome (sequence).

BACKGROUND: Poland syndrome (OMIM: 173800) is a disorder in which affected individuals are born with missing or underdeveloped muscles on one side of the body, resulting in abnormalities that can affect the chest, breast, shoulder, arm, and hand. The extent and severity of the abnormalities vary among affected individuals. MAIN BODY: The aim of this work is to provide recommendations for the diagnosis and management of people affected by Poland syndrome based on evidence from literature and experience of health professionals from different medical backgrounds who have followed for several years affected subjects. The literature search was performed in the second half of 2019. Original papers, meta-analyses, reviews, books and guidelines were reviewed and final recommendations were reached by consensus. CONCLUSION: Being Poland syndrome a rare syndrome most recommendations here presented are good clinical practice based on the consensus of the participant experts.

Robot-assisted arm training for treating adult patients with distal radius fracture: a proof-of-concept pilot study.

BACKGROUND: Fracture of the distal radius is a common wrist injury. As to its management after orthopedic (conservative or surgical) treatment, there is weak evidence for conventional rehabilitation interventions. Despite the increasing interest for robot-assisted arm therapy as to neurological disabilities and its growing diffusion in rehabilitation facilities, no previous study investigated the feasibility of robotic training on arm orthopedic impairment. AIM: To evaluate the feasibility in terms of efficacy of robot-assisted arm training on upper limb impairment in patients with fracture of the distal radius. DESIGN: Proof-of-concept, pilot, randomized controlled trial. SETTING: University hospital. POPULATION: Twenty adult outpatients with distal radius fracture due to wrist injury. METHODS: All participants underwent ten, 1-hour (40 minutes of arm training + 20 minutes of conventional occupational therapy) training sessions, five days a week for two consecutive weeks. They were randomly assigned to two groups: patients allocated to the Robotic Arm Training group received arm training by means of a robotic device and patients allocated to the Conventional Arm Training group performed arm training following a conventional rehabilitation program. All patients were evaluated before, immediately after treatment and at four weeks of follow-up. The following outcomes were considered at the affected arm: forearm pronation/supination and wrist extension/flexion passive and active range of motion; maximal pinch and grip strength; the Patient-Rated Wrist and Hand Evaluation. RESULTS: No difference was found between groups as to the primary (wrist active and passive range of motion) and secondary (pinch and grip strength; Patient-Rated Wrist and Hand Evaluation Score) outcomes at all time points. Within-group comparisons showed similar improvements at all time points as to all outcomes considered in both groups. CONCLUSIONS: Our preliminary findings support the hypothesis that robot-assisted arm training might be a feasible tool for treating upper limb impairment in adult patients with distal radius fracture treated conservatively or surgically. CLINICAL REHABILITATION IMPACT: The treatment of arm impairment consequent to distal radius fractures by means of robot-assisted arm training may allow therapists to focus on functional rehabilitation during occupational (individual) therapy and supervise (more than one) patients simultaneously during robotic training sessions.

Proposal for Treatment of Severe Dupuytren Disease in 2 Steps: Progressive Distraction With External Fixator and Collagenase - A Preliminary Case Series.

Background: We want to describe a treatment for advanced Dupuytren disease using a spanning external fixator (EF) applied dorsally to produce progressive extension, followed by collagenase injection. Methods: Between October 2014 and September 2016, a total of 22 fingers from 18 patients were treated with an EF. The devices were implanted under local anesthesia, and the patients were instructed to gradually extend the hinge to gain a progressive extension. The EF was removed in an outpatient clinic setting after obtaining a complete extension of the treated joint in a mean of 19 days (range 15-22 days), and a collagenase injection was performed in the residual cord after a mean of 20 days (18-24 days), followed by splinting. Results: All patients were evaluated at an average follow-up of 14 months (range 3-23 months): the total average residual flexion deformity was 9.7° (range 0°-19°) with a correction of 107.2° (range 94°-138°), the average flexion deformity of the proximal interphalangeal joint was 7.4° (range 0°-15°) with a correction of 64.4° (range 46°-92°), and the average flexion deformity of the metatarsophalangeal joint was 2.4° (range 0°-9°) with a correction of 42.8° (range 15°-59°). No complications were reported in relation to EF treatment. Two cases of cutaneous laceration after collagenase injection were observed, neither of which required any additional treatment. Conclusions: All patients obtained a regression from 2 to 3 stages in disease severity only with EF. We had no report of complications due to the device. After collagenase injection and splinting, we obtained further finger extension with a mean total residual flexion deformity of 9.7° at 14-month follow-up.

Interposition Arthroplasty Versus Hematoma and Distraction for the Treatment of Osteoarthritis of the Trapeziometacarpal Joint.

BACKGROUND: Various surgical techniques were reported with excellent result for the treatment of trapeziometacarpal joint arthritis. However, the best treatment option was not defined yet. METHODS: This randomized prospective study compared the result of two surgical techniques: tendon interposition arthroplasty (64 patients) and K. wire distraction (56 patients) after trapeziectomy for stage 3 or 4 osteoarthritis of the trapeziometacarpal joint. RESULTS: After a mean follow-up period of 6.8 (range, 3-10) years it was possible to observe a higher rate of pain relief following trapeziectomy with K. wire suspension, but no significant differences in strength, range of motion and DASH score between the two groups. On lateral unloaded radiographs the height of the space between the base of the thumb metacarpal and the scaphoid showed a mean value of 6.5 mm for both groups; the average distance between the metacarpal base and the trapezium was not statistically significant in the two groups. Complications were observed only in patients treated with trapeziectomy and interposition arthroplasty and were represented by tendinitis of the FCR in 15% of cases. CONCLUSIONS: We demonstrate that the trapezium excision and bone space distraction technique requires a smaller incision, a shorter surgical time, an easier surgical technique, and a less painful recovery, maintaining overlapping levels of functional restore.

Use of integra artificial dermis to reduce donor site morbidity after pedicle flaps in hand surgery.

PURPOSE: To assess the results obtained with Integra artificial dermis to cover donor site following the harvesting of pedicle flaps for hand reconstruction. METHODS: Between April 2010 and August 2013, 11 patients (8 men and 3 women; mean age, 37 y) were treated with Integra Dermal Regeneration Template (Integra LifeSciences, Inc., Plainsboro, NY) to cover donor defects after raising pedicle flaps for hand and finger reconstruction: radial forearm flap (4 cases), ulnar artery perforator flap (2 cases), and heterodigital island flap (5 cases). After neodermis formation the silicone layer of the artificial dermis was removed (on average after 22 days) and a split- or full-thickness epidermal autograft placed. RESULTS: No infections, hematoma, or bleeding were recorded during the entire phase in which the artificial skin was applied. Two patients experienced a partial skin graft loss. Median follow-up was 20 months, and results included an average Vancouver Scar Scale rating of 2.7 and an average DASH score of 39. There were no cases of graft adherence to the underlying tendons or muscles. CONCLUSIONS: Favorable cosmetic and functional outcomes were obtained using a dermal regeneration template for the treatment of donor site defects. Despite the drawback of an additional surgical procedure (secondary skin graft), the use of this artificial skin produced soft-tissue augmentation and graft-skin quality, reducing donor site morbidity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Treatment of painful median nerve neuromas with radial and ulnar artery perforator adipofascial flaps.

PURPOSE: To review the outcomes of 8 patients with painful median nerve neuromas at the wrist treated with external neurolysis and covered with pedicled perforator adipofascial flaps. METHODS: Between 2004 and 2010, we treated 8 patients, who had a mean age of 37 years, and who had posttraumatic painful median nerve neuromas at the level of the wrist but with retained median nerve function . All of them reported neuropathic pain and had a positive Tinel's sign over the site of the presumed neuroma. The surgical procedure included external neurolysis and coverage with an ulnar artery perforator adipofascial flap (4 patients) or with a radial artery perforator adipofascial flap (4 patients). Patients were reviewed after a mean follow-up of 41 months (range, 18-84 mo). Preoperative and postoperative pain was measured with a visual analog scale. RESULTS: Pain improved from a preoperative mean value of 7.8 to a postoperative mean value of 3.6. There was complete resolution of pain in 5 patients, mild pain persisted in 2 patients, and 1 patient reported no improvement. No complications occurred at the donor site. CONCLUSIONS: Vascularized soft tissue coverage of painful median nerve neuromas is an effective treatment. We do not believe that a free flap is of any particular advantage over a local pedicle flap which we suggest using to protect the median nerve. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Alternative method for thumb reconstruction. Combination of 2 techniques: metacarpal lengthening and mini wraparound transfer.

Amputation at the proximal phalanx or at the metacarpophalangeal joint can be treated by pollicization of a finger, osteoplastic reconstruction, free microvascular transfer of a toe, or distraction lengthening. The best technique to use to treat these cases depends on the place of amputation and the patient's age, sex, occupation and functional demands. In the past 6 years, we treated 4 patients by lengthening the thumb metacarpal ray and adding a mini wraparound flap from the great toe. All the subjects were female with an average age of 22 years. All 4 patients had sustained traumatic amputations: 2 at the metacarpophalangeal joint and 2 at the base of the proximal phalanx. Distraction was completed approximately 65 days after osteotomy, obtaining an average lengthening of 23 mm. To achieve bone consolidation, the lengthener was left in place for 127 days on average. Microsurgical thumb reconstruction was performed around 3 months after consolidation of the osteotomy. There were no failures or cases of postoperative vascular compromise. The average pinch power was 66% of the opposite hand. The static 2-point discrimination of the reconstructed thumb was 8 mm (range, 7-10 mm). All patients reported being satisfied with the treatment, although 1 patient was partially dissatisfied due to the prolonged length of the treatment. Donor site morbidity was minimal. This procedure is mainly chosen by selected patients who refuse standard microsurgical thumb reconstruction because it requires a longer treatment period.

The use of external fixation in complex trauma of upper limb.

From 1997 to 2003 (7 years follow-up) we treated 33 complex traumas of the upper limbs with the use of external fixation: forearm or humeral complete amputation, complex crash, sometimes with hand crash associated. Often a revascularisation was necessary like as a secondary skin coverage for soft tissue loss or following ischaemic necrosis. Three patients were reluctant to agree to a secondary amputation for large soft tissue necrosis and infection. A high percentage of cases need a successive operation because of bone non-union. Revision of our casistic helps us answer the following: how complex and long is the prognosis of this kind of patient, which are the most important choices we have to make, how important is the length of time taken to make a decision and what are the weak spots in the treatment of these traumas.