Secondary Intention Healing for Fingertip Amputations in a Tropical Climate.

Background: Various studies have examined occlusive dressings in fingertip amputations and reported good outcomes. Occlusive dressing preserves appropriate pH, cell accumulation and moisture for healing, thereby limiting scar formation and deformity. To our knowledge, no study was performed in tropical Asia. This study aims to demonstrate the viability of healing fingertip amputations through secondary intention using an effective dressing technique, even in warm tropical climates. Methods: All patients who presented to our institution with fingertip amputations from 1 July 2020 to 31 July 2022 were analysed retrospectively. Seventeen patients (15 male, 2 female) of mean age 37.2 ± 9.4 years old with 18 injured digits were retrospectively analysed. Twelve (66.7%) were Allen Type III injuries, and one patient required distal phalangeal K-wire fixation. During the patient's final review, static 2-point discrimination, pulp sensation, fingertip contour and nail deformities alongside the last measured range of motion (ROM) of the injured finger was recorded. Treatment duration and days of leave taken were also summed and assessed. Results: Patients were dressed with semi-occlusive dressing for an average of 20.1 ± 6.83 days. The average total duration of dressing is 36.78 ± 18.88 days over an average of 7.18 ± 4.03 dressing visits. Mean duration of follow-up was 108 ± 63.46 days. Good outcome measures in sensation, pulp contour, nail deformity and ROM similar to existing literature were reported. Conclusions: Occlusive dressing remains a viable and feasible treatment option for fingertip amputation even in a tropical climate. While this simple treatment method may require more effort from patient, wound healing was attained after 36.8 ± 18.9 days of dressing. Level of Evidence: Level IV (Therapeutic).

An All-Arthroscopic Technique of Repairing Foveal Tears of the Triangular Fibrocartilage Complex Using a Bone Anchor-Repair Made Simple.

Traumatic foveal tears of the triangular fibrocartilage complex lead to ulnar-sided wrist pain and instability, resulting in painful motion and loss of grip strength with a severe impact on the overall function of the upper limb. Surgical repair is nothing new and has traversed through the realm of open repair to arthroscopic assisted to all arthroscopic repair techniques over the many decades, with arthroscopic repairs showing better visualization, lesser trauma, and equally favorable patient outcomes. Techniques had varied from using trans osseous tunnels to bone anchors, with or without the usage of special jigs. Here, we describe a simple and fast 3 portal arthroscopic technique of repairing the torn foveal insertion of the triangular fibrocartilage complex using a bone anchor inserted under arthroscopic and fluoroscopic guidance into the fovea. Both the dorsal and volar limbs of the triangular fibrocartilage complex are repaired arthroscopically, resulting in a strong anatomic repair resulting in a stable and pain-free wrist.

Fingertip Replantation: Surgical Technique, Tips, and Tricks.

SUMMARY: Replantation of fingertip amputations restores the original tissue and is the ideal treatment to provide the best aesthetic and functional outcome. However, successful fingertip replantation is considered challenging because it requires supermicrosurgery techniques. This article provides a detailed surgical technique for fingertip replantation and the authors' preferences and recommendations. In the authors' experience, the most important factors for successful fingertip replantation are meticulous vascular dissection, reliable arterial repair, and venous anastomosis to avoid postoperative venous congestion. Proximal arterial dissection until pulsatile bleeding is encountered avoids the zone of vascular injury, and is particularly important in crush or avulsion amputations. Distal arterial dissection is performed until undamaged intima is identified. The authors believe anastomosis to the central artery is reliable even in a Tamai zone II amputation. When an arterial defect is present, the authors recommend using a vein graft to anastomose to the central artery. In addition, the authors highly recommend at least one venous anastomosis to avoid postoperative venous congestion. In Tamai zone I, available veins can be found on the palmar side of the pulp. It is important to search directly below the dermis and remove adipose tissue around the vessels to secure space for anastomosis. The authors consider nerve suture in Tamai zone I and II replantations inessential, because spontaneous sensory recovery can be expected. Postoperative management of venous congestion, spasm in artery, and arterial thrombosis are as important as surgery.

The right turn around: Penrose tourniquet application in paediatrics.

INTRODUCTION: Commercially available tourniquets are ill-suited for paediatric patients with limb circumferences smaller than the required mechanism, forcing surgeons to improvise. This study aimed to quantify pressures exerted by the Penrose tourniquet when applied on a phantom model and evaluate the intra-/inter-rater reproducibility of the technique previously proposed. METHODS: Eight calibrated pressure sensors were distributed evenly along the inner and outer circumference of a silicon-based model. A 30cm-by-3.2 cm ARGYLE Penrose drain, 4-by-4 gauze, marker and ruler were used. The optimal interval for arterial occlusion was determined to be 70% of limb circumference. The tourniquet was secured using two half-knots formed by gauze. RESULTS: Two-turns of the tourniquet about the model generated mean pressures (SD) of 209.43 (SD:35.98 mmHg) (95%CI: 195.85-224.00 mmHg) (outer-sensor) and 246.32 (SD:61.92 mmHg) (95%CI: 221.02-273.49 mmHg) (inner-sensor). Three-turns generated mean pressures of 302.07 (SD:23.98 mmHg) (95%CI: 292.29-312.53 mmHg) (outer-sensor) and 314.44 (SD:56.70 mmHg) (95%CI: 291.25-338.25 mmHg) (inner-sensor). CONCLUSION: The Penrose tourniquet has clinical utility, particularly for patients where commercially available tourniquets are not suitable. Current application techniques generate inconsistent pressures. Using the existing model, further refinement can be done to improve the consistency and safety of the application. We recommend using intervals of slightly more than 70% of limb circumference and only two turns of the Penrose tourniquet during application. LEVEL OF EVIDENCE: V.

Renal impairment and time to fracture healing following surgical fixation of distal radius fracture.

INTRODUCTION: Despite the prevalence of renal impairments, the existing literature examining fracture healing in the upper limb in patients with renal impairment is sparse. This study hence aims to investigate the effect of renal impairment on time to fracture healing after distal radius fracture fixation surgery. MATERIALS AND METHODS: Patients above 50 years old who underwent distal radius fracture fixation via volar plating were included. Time to fracture healing was defined as duration between day of surgery and presence of radiographic union as evidence by bridging of callus or osseous bone. To assess for renal impairment, estimated glomerular filtration rate (eGFR) was calculated based on the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Pre-existing comorbidities were also collected and analysed. RESULTS: Ninety-nine consecutive patients took mean 65.5 ± 8.0 days to fracture healing post-operatively. Patients with renal impairment had longer time to fracture healing than patients without (67.1 ± 50.4 days versus 50.4 ± 31.8 days, p = 0.044). Patients ≥ 65 years also had a longer duration to fracture healing compared to patients < 65 years (mean 63.7 ± 53.0 days versus 50.2 ± 27.2 days, p = 0.033). Similarly, patients with ASA Class I had a shorter mean time to fracture healing than patients with ASA Class II and above (mean 42.5 ± 22.8 days versus 62.8 ± 47.6 days, p = 0.028). CONCLUSIONS: Time to fracture healing post-distal radius fracture fixation was significantly related to renal impairment, age and ASA classification.

The Effect of Hand Dominance, Age, Gender, Fracture Comminution and ASA Status on Time to Fracture Healing Following Surgical Fixation of Distal Radius Fractures.

Background: There is recent renewed interest in the effect of hand dominance on distal radius fractures. Current studies focus on functional or patient-reported outcomes, with lack of studies pertaining to radiological outcomes. The primary aim of this study is to examine the effect of hand dominance on time to fracture healing following surgical fixation of distal radius fracture. We also looked at the effect of age, gender, fracture comminution and American Society of Anaesthesiologists (ASA) status on time to fracture healing. Methods: Patients who underwent distal radius fracture fixation surgery in our department from 1 January 2015 to 31 December 2015 were included. Time to fracture healing was taken from the day of surgery to when radiographic union was present as evidence by bridging callus or osseous bone. We looked at the effect of hand dominance, age, gender, fracture comminution and ASA status on time to fracture healing. Results: One hundred and forty-five consecutive patients (80 females and 65 males) had a mean period of 56.2 ± 41.8 days to fracture healing post-operatively. Patients with dominant hand injury had a shorter duration to fracture healing than patients with non-dominant hand injury (mean 47.3 ± 31.1 days versus 62.1 ± 46.8 days, p = 0.023). Patients ≥ 65 years and with pre-existing medical conditions (ASA Class II and above) had a longer duration to fracture healing (mean 63.7 ± 53.0 days versus 51.9 ± 33.4 days, p = 0.036 and mean 47.9 ± 30.0 days versus 62.0 ± 47.7 days, p = 0.016, respectively). In addition, patients with comminuted fractures took longer to heal than patients with non-comminuted fractures (mean 57.6 ± 33.4 days versus 48.3 ± 20.8 days, p = 0.038). Conclusion: Time to fracture healing post distal radius fracture fixation surgery was significantly related to hand dominance, as well as age, ASA classification and fracture configuration. Dominant wrist injuries had shorter time to fracture healing. Level of Evidence: Level IV (Therapeutic).

Arthrodesis for Primary Osteoarthritis of Trapeziometacarpal Joint Using Multiple Kirschner Wires and Tension Band Wire in Female Patients Older than 40.

Background: The purpose of this study was to evaluate the results of arthrodesis with multiple Kirschner (K)-wires and tension band wire for primary osteoarthritis of trapeziometacarpal (TM) joint in female patients aged 40 years or older. Methods: We retrospectively obtained data regarding all female patients 40 years or older who underwent TM joint arthrodesis for TM joint osteoarthritis with K-wires and tension band wire over a 10-year period from 2009 till 2019. Thumb length, active range of motion (ROM) at the metacarpophalangeal (MCP) joint, active ROM of radial and volar adduction and abduction and key pinch strength was measured. Patient-reported outcomes were assessed using a pain and satisfaction questionnaire and the DASH score. We also recorded postoperative complications. Results: The study included 60 thumbs in 49 patients with an average age 60 years and a mean follow-up of 40 ± 21 months. All but one thumb had radiographic evidence of fusion within 6 months and the union rate was 98%. Key pinch strength increased from 2.3 to 4.9 kg after surgery. Total arc of motion in radial adduction-abduction decreased from 16° to 10°. Total arc of motion in volar adduction-abduction decreased from 25° to 9°. One patient experienced attritional rupture of the flexor pollicis longus tendon attributed to a K-wire penetration into the carpal tunnel. Although 46 thumbs (77%) had no or mild hardware-related symptoms, they underwent hardware removal after solid bone union. In 23 thumbs with follow-up period longer than 48 months, two thumbs developed scaphotrapeziotrapezoid joint arthritis and two thumbs developed metacarpophalangeal joint arthritis. Conclusions: We found that arthrodesis with multiple K-wires and tension band wire is a valuable option in the management of trapeziometacarpal joint osteoarthritis in female patients aged 40 years or older. Level of Evidence: Level IV (Therapeutic).

Tension Reducing Muscle Stretch Protocol to Obtain Full Distal Tendon Excursion: A New Rehabilitation Protocol after Flexor Tendon Repair.

Background: Flexor tendon rehabilitation protocols minimize repair tension by limiting range of movement to prevent tendon rupture. The resultant muscle contracture inhibits finger extension, increases resistance in tendon gliding distally, and progress to proximal interphalangeal (PIP) joint flexion contracture. This study describes our new rehabilitation protocol, the Tension Reducing Muscle Stretch (TRMS), designed to prevent flexor muscle contracture and obtain full distal tendon excursion. Methods: We reviewed retrospectively 14 fingers in 13 consecutive patients with primary repair of complete zone I or II flexor digitorum profundus (FDP) tendon rupture were treated with our protocol between 2007 and 2019. Our rehabilitation following FDP 4-strand repairs consisted of three steps. The first step comprised of exercises from traditional protocols such as Duran, Kleinert, Synergistic-wrist-motion, and Place-and-hold. The second step comprised the TRMS exercise to prevent the onset of muscle contracture. Anatomically, FDP tendons arise from the same FDP muscle belly. TRMS involved placing the affected finger in full passive flexion while unaffected fingers were passively extended to full extension. This made the affected FDP muscle stretched. The final step incorporated the early active flexion motion exercise, in which simple fisting was performed, from a fully extended position. Results: The mean total active motion at the final follow up was 235° (range 170-265). Using the Strickland criteria, eight achieved excellent, four had good, two had fair results. The mean angle of passive extension deficit at the PIP joint at four weeks after surgery was -7° (-30-0), and at the final follow up was -3° (-20-0). No tendon repair was ruptured. Conclusions: This protocol reduced tension in the affected tendon muscle and encouraged tendon excursion distal to the repair site without complications. It allows full tendon excursion and prevents PIP joint contractures.

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.

Long-Term Outcomes of Successful Fingertip Replantation: A Follow-Up of at Least 10 Years.

BACKGROUND: The purpose of this study was to evaluate the long-term outcome of successful fingertip replantations with more than 10 years of follow-up after surgery. METHODS: A total of 34 successfully replanted digits in 31 patients with a mean period to follow-up of 16.5 years were included in this study. The main outcome measures were time to return to work, pain, cold intolerance, sensory recovery, nail deformity, grip strength, range of motion of the thumb interphalangeal or finger distal interphalangeal joint, fingertip atrophy, nonunion, bone shortening, use in activities of daily living, and patient satisfaction. RESULTS: None of the patients reported chronic pain. No cold intolerance was experienced in 32 digits. Semmes-Weinstein monofilament testing showed recovery of protective sensation in 27 digits. The moving two-point discrimination test showed excellent or good recovery in 91 percent of the patients. Sensory recovery was satisfactory, and there was no significant difference regardless of nerve repair or injury type. Moderate to severe nail deformity was found in six digits. Fingertip atrophy was evaluated by comparing the volume of the replanted fingertip with the contralateral digit. The volume was 82 ± 17 percent of the contralateral normal side. There was no significant difference in the volume comparing the level of amputation, injury type, or incidence of postoperative vascular complication. Ninety-seven percent of the patients were satisfied with the results. CONCLUSION: Long-term outcome of fingertip replantation more than 10 years after surgery was found to be favorable.

Elbow flexion strength and contractile activity after partial ulnar nerve or intercostal nerve transfers for brachial plexus injuries.

We compared the outcomes of 23 partial ulnar nerve and 15 intercostal nerve transfers for elbow flexion reconstruction in patients with C56 or C567 brachial plexus injuries using manual muscle power, dynamometric measurements of elbow flexion strength and electromyography. The range of elbow flexion and muscle strength recovery to Grade 3 or 4 were comparable between the two groups. The patients with C567 injuries had significantly stronger eccentric contraction after the partial ulnar nerve transfer than after the intercostal nerve transfer (p < 0.05). Electromyography of individual muscles demonstrated that the patients with partial ulnar nerve transfers were unable to voluntarily isolate biceps contraction and recruited forearm flexors and extensors. The patients after partial ulnar nerve transfer had significantly more activity of the forearm muscles during concentric elbow flexion than after intercostal nerve transfers (p < 0.05). We conclude that partial ulnar nerve transfers were superior to intercostal nerve transfers when assessed quantitatively with the dynamometer to evaluate elbow flexion, although simultaneous recruitment of forearm muscles may have contributed to the increased elbow flexion strength in the patients with the partial ulnar nerve transfer.Level of evidence: III.

The double muscle gastrocnemius-soleus flap in resurfacing large lower limb defects: Modifications and outcomes.

INTRODUCTION: Larger soft tissue defects over critical areas of the lower limb involving the knee and proximal two thirds of the tibia present a challenge to the reconstructive surgeon. Options include a large free flap or pedicled local flaps. The gastrocnemius or soleus flap alone is not sufficient. Combined gastrocnemius-soleus flaps can be used adequately without the need to resort to free flaps. We review the use and outcomes of the combined pedicled gastrocnemius and hemi-soleus double muscle flap to cover large defects of the leg and discuss our technique. MATERIAL AND METHODS: A retrospective review of the patients who underwent the pedicled double muscle (gastrocnemius and soleus) flap for wound resurfacing in our institution between 2008 and 2013 was performed. The patients' case notes were analyzed and data collected included their age, comorbidities, wound characteristics, surgical procedures and post-operative outcomes and complications. RESULTS: There was a total of ten double flaps in ten patients; eight due to trauma and two due to infection. Mean follow up period was 12 months. All flaps achieved primary healing without major complications. There were two cases of minor complications: flap tip necrosis and superficial infection. Nine patients were able to achieve ambulation without aid at final follow up. CONCLUSION: The combined pedicled gastrocnemius and hemisoleus double muscle flap is a useful alternative for reconstruction of large critical soft tissue defects around the knee and leg.

A retrospective review of troubled replantations.

INTRODUCTION: Replantation surgery is an established treatment for amputated digits, and published literature report a high success rate. However, a proportion of replantations do encounter postoperative problems with vascularity, but the incidence is unknown. Although there are studies that look at the factors affecting the success of replantations and the management of postoperative replantations, there is little literature available on this transitional period. We introduce the term "troubled replantation" to describe the replantation that manifests any form of vascular insufficiency after replantation surgery. Our study focuses on reviewing our centre's experience with the management and outcomes of troubled replantations. MATERIALS AND METHODS: Data was collected retrospectively from 389 digital replantations performed in our centre over an 11 year period. We included only single level digital replantations. We analysed the perioperative data, and the measures taken postoperatively to promote their survival. RESULTS: There were a total of 137 troubled digits (35.2%). 53 digits responded to non-surgical measures such as dressing change and bedside bleeding procedures. 27 digits required re-exploration surgery, of which 16 survived. The majority of troubled replantations were due to arterial causes, and manifested signs within the first 48 h. 69 troubled digits (51%) survived. The remainder did not respond to any form of treatment including re-explorations and ultimately failed. CONCLUSION: One third of all replantations are troubled replantations, and half of these eventually fail despite any intervention. As troubled replantations can lead to postoperative failure, it is important to understand this clinical scenario in order to improve immediate postoperative care.

An atypical presentation of a flexor intratendinous ganglion of the hand.

Intratendinous ganglions of the hand are rare. We report an unusual case of a ganglion arising within the flexor tendon in the hand. The intratendinous ganglion arose from the flexor digitorium profundus tendon of the little finger, causing flexion deformity of the finger.