Serious Complications of the Percutaneous A1 Pulley Release: Case Reports and Literature Review.

Percutaneous first annular pulley (A1 pulley) release, which has been increasingly used to treat trigger fingers, has been widely established as a safe and simple procedure. Multiple studies have reported positive results of percutaneous A1 pulley release. In this study, however, we report cases of patients who developed complications after undergoing percutaneous A1 pulley release at local clinics. A total of six patients visited our hospital for infectious complications after percutaneous A1 pulley release. Various sequelae such as damage to normal structures, insufficient procedure, and tissue necrosis were observed during the exploration. A retrospective study was conducted to identify the cause and trend of the observed complications by instruments (HAKI knife or needle). In the HAKI knife group, there was a tendency for damage to normal structures, while in the needle group, an insufficient release or serious soft tissue necrosis was observed. Based on these cases, our findings confirm the existence and characteristics of infectious complications following the percutaneous A1 pulley release. We further identify that the type of instrument used predicts the nature of complications. Thus, reliable and skilled performance of the procedure by experts is essential for safe treatment.

Hand Reconstruction Using Anterolateral Thigh Free Flap by Terminal Perforator-to-Digital Artery Anastomosis: Retrospective Analysis.

This study aimed to analyze cases of anterolateral thigh (ALT) free flap used for hand reconstruction with terminal perforator-to-digital artery anastomosis. Patients who underwent ALT free flap placement with terminal perforator-to-digital artery anastomosis for hand reconstruction between January 2011 and August 2021 were included. The number, length, and diameter of the perforators and veins, flap size, and operative time were investigated through a retrospective review of charts and photographs. The occurrences of arterial thrombosis, venous thrombosis, arterial spasm, and flap necrosis were analyzed. In total, 50 patients were included in this study. The mean diameter and length of the perforators were 0.68 mm and 3.25 cm, respectively, and the mean number of veins anastomosed was 1.88, with a mean diameter of 0.54 mm. Complications included four cases of arterial thrombosis, one case of venous thrombosis, seven cases of partial necrosis, and one case of total flap failure. Regression analysis showed that a longer perforator was associated with arterial thrombosis whereas larger flap size and number of anastomosed veins were associated with partial necrosis ( p < 0.05). The terminal perforator-to-digital artery anastomosis offers advantages in using compact free flaps with short pedicle lengths to cover small hand defects.

The "Swing-Door" Regrafting of Donor Site: An Alternative Method for Split-Thickness Skin Graft in the Hand.

Background Skin defects in the hands are common injuries, and autologous skin grafting is the ideal treatment. However, complications can occur at the donor and recipient sites. This study compares the "Swing-door" technique with conventional skin grafting. Methods From August 2019 to February 2023, 19 patients with skin defects of hand underwent the "Swing-door" split-thickness skin graft (STSG) technique. The thin epithelial layer was elevated with proximal part attached. Skin graft was harvested beneath. Donor site was then closed with epithelial flap like a "Swing-door". The outcomes were evaluated in terms of healing time, scar formation, and pain at the donor and recipient sites. The data were compared with the conventional STSG. Results The "Swing-door" group had lower graft take percentages, but complications did not significantly differ between the two groups. The "Swing-door" technique resulted in better cosmetic outcomes, as evidenced by lower Vancouver Scar Scale scores, faster donor site epithelialization, and reduced pain and discomfort during the early postoperative period, as measured by Visual Analog Scale. Conclusion The "Swing-door" STSG is a useful alternative for treating hand skin defects.

Single or double Kirschner wire fixation: which provides better outcomes for pediatric proximal phalanx base fractures?

PURPOSE: The most common hand fracture in children is seen at the base of the proximal phalanx. This study aims to compare clinical outcomes of single versus double Kirschner wire pinning for pediatric proximal phalanx base fractures. PATIENTS AND METHODS: The retrospective study enrolled patients who underwent closed K-wire pinning for proximal phalanx base fractures from January 2016 to February 2022. We divided patients into two groups based on the number of K-wire inserted (single versus double). Demographics, removal of implant, complication rate were analyzed. Patients were asked to answer the Michigan Hand Outcomes Questionnaire (MHQ) by telephone. Data including fracture type, diaphyseal axis-metacarpal head angle (DHA) and Total Active Flexion Scale (TAFS) were analyzed. RESULTS: This study included 37 pediatric patients with proximal phalanx base fractures, treated with either single (n = 10) or double K-wire (n = 27) fixation. The mean operation time was significantly shorter for the single K-wire group. No significant differences were observed in complication rates, TAFS, implant removal times, MHQ, or pre- and post-operative DHA between the two groups. CONCLUSION: The single K-wire technique demonstrates similar effectiveness to the double K-wire technique in treating pediatric proximal phalanx base fractures, with the added benefit of shorter operation time. Therefore, the choice between using one or two K-wires should be determined based on the surgeon's proficiency and preference.

Division of a single free flap in multiple digit reconstruction.

BACKGROUND: Single free flaps are a commonly used reconstructive method for multiple soft tissue defects in digits. We analyzed the flap size, division timing, and degree of necrosis in cases with various types of flap division. METHODS: We conducted a retrospective review of the medical charts of patients who had undergone single free flap reconstruction for multiple soft tissue defects across their digits from 2011 to 2020. The flap types included were the lateral arm free flap, venous forearm free flap, thenar free flap, hypothenar free flap, anterolateral thigh free flap, medial plantar free flap, and second toe pulp free flap. Flap size, anastomosed vessels, division timing, and occurrence of flap necrosis were retrospectively investigated and then analyzed using the t-test. RESULTS: In total, 75 patients were included in the analysis. The success rate of the free flaps was 97.3%. All flaps were successfully divided after at least 17 days, with a mean of 47.17 days (range, 17-243 days) for large flaps and 42.81 days (range, 20-130 days) for the medium and small flaps (P=0.596). The mean area of flap necrosis was 2.38% in the large flaps and 2.58% in the medium and small flaps (P=0.935). Severe necrosis of the divided flap developed in two patients who had undergone flap division at week 6 and week 34. CONCLUSIONS: In cases where blood flow to the flap has been stable for more than 3 weeks, flap division can be safely attempted regardless of the flap size.

Fingertip reconstruction with a subcutaneous flap and composite graft composed of nail bed and volar pulp skin.

BACKGROUND: Fingertip injuries are very common; however, the reconstruction of volar pulp defects with nail bed defects is challenging in the absence of the amputated segment. We reconstructed fingertip amputations with nail bed defects using a new surgical approach: a subcutaneous flap and composite graft. METHODS: We treated 10 fingertip amputation patients without an amputated segment, with exposed distal phalangeal bone and full-thickness nail bed defects between February 2018 and December 2020. All patients underwent two-stage surgery: in the first stage, a subcutaneous flap was performed to cover the exposed distal phalanx, and in the second stage, a composite graft, consisting of nail bed, hyponychium, and volar pulp skin, was applied over the subcutaneous flap. RESULTS: All flaps survived and all composite grafts were successful. The wounds healed without any significant complications, including the donor site. The average follow-up duration was 11.2 months (range, 3-27 months). The new nail and the shape of the volar pulp were evaluated during follow-up. All patients were satisfied with their natural fingertip shapes and the new nails did not have any serious deformities. CONCLUSIONS: A subcutaneous flap in combination with a composite graft fitting the shape of the defect could be another option for fingertip injuries without amputated segments.

Reconstruction of Digit Soft Tissue Defects With the Fourth Common Digital Artery Perforator Flap.

PURPOSE: The hand has unique skin characteristics. Intrinsic flap donors are limited due to functional specificity and compactly connected structures. The hypothenar area is a reliable option for the reconstruction of finger defects. We performed anatomic studies elucidating the blood supply of this area and hypothesized that the fourth common palmar digital artery perforator free flap can be used to reconstruct soft tissue defects in fingers with minimal donor site morbidity. METHODS: From November 2017 to February 2020, 30 procedures of fourth common digital artery perforator free flaps were performed to cover digital skin defects. A retrospective chart review was performed, and the cases were analyzed. RESULTS: The mean patient age was 42.4 years (range, 1-75 years; median age, 40 years). Defects were located at the fingertip (n = 12), the dorsum (n = 3), the palmar (n = 9) aspect of the finger, and both the dorsal and palmar aspects of the finger (n = 6). Indications included emergent coverage (n = 13), coverage after necrosis (n = 11), oncological resection (n = 1), and contracture release (n = 5). The defect size ranged from 1.5 × 0.8 cm (1.2 cm2) to 6 × 2.5 cm (15 cm2). The perforator was located approximately 1 cm proximal to the distal palmar crease as it arose from the fourth common digital artery at a right angle. It continued to the ulnar border of the hand through the superficial fascia of the hypothenar muscles before running in a proximoulnar direction toward the dorsum of the hand. The diameter of the perforator was between 0.5 and 0.7 mm. All flaps survived. One case required a split-thickness skin graft for donor site closure, and all others could be closed primarily. CONCLUSIONS: The fourth common digital artery perforator is a versatile flap and can be used for both palmar and dorsal defects, including for the fingertip. The location of the perforator used differs from previous descriptions but is routinely and reliably located. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Warty (condylomatous) carcinoma of the back: a case report.

Warty carcinoma (WC), known as condylomatous carcinoma, generally derives from genito-urethral area. Its symbolic lesion is the exophytic and verruciform mass associated with human papillomavirus infection. A 90-year-old female presented with growing cauliflower-like mass in her back. A wide excision was performed for two masses. It was finally confirmed as WC throughout histopathological findings-arborescent papillomatosis, hyperkeratosis and acanthosis. The patient was an ordinary housewife and there was no recurrence and any postoperative complication 6 month after the surgery. Accordingly, careful physical examination and history-taking as well as wide-excision securing safety margin are essential, especially for senile patients.

Microsurgical Free Tissue Options for Fingertip Reconstruction.

Fingertip injuries occur commonly owing to trauma in everyday life. Performing amputation or stump revision for a fingertip injury can make it possible to quickly return to daily life, but causes functional and cosmetic problems. We believe that free flaps are the ideal way to minimize donor site morbidity and provide satisfactory reconstruction. Fingertips have different anatomic characteristics on the dorsum, volar aspect, and pulp, so it is necessary to select the appropriate free flap. Sometimes for larger defects, composite tissue transfer can be considered for reconstruction. This article discusses various free flap options for different fingertip defects.

Partial second toe pulp free flaps in early childhood.

BACKGROUND: The introduction of the partial second toe pulp free flap has enabled superior aesthetic and functional results for fingertip reconstruction in adults. Children undergoing fingertip amputation for various reasons have limited options for reconstruction. Conventional treatment could shorten the finger, leading to poor cosmesis and function. We report 18 years of our experiences with fingertip reconstruction using partial second toe pulp free flaps in patients in early childhood. METHODS: Medical charts of children who had undergone fingertip reconstruction using partial second toe pulp free flaps from 2001 to 2018 were retrospectively reviewed. The surgical procedures were identical to those for adults, except for the usage of 11-0 nylon sutures. Patients' demographic data, vessel size, flap dimensions, length of the distal phalanx, and functional outcomes over the course of long-term follow-up were documented. The statistical analysis was performed with the Student t-test, the Mann-Whitney U test, and Pearson correlation analysis. RESULTS: Eighteen toe pulp flaps in 17 patients (mean age, 3.0 years) were identified. All the flaps survived without any major complications. In long-term follow-up, the flap-covered distal phalanges showed growth in line with regular development. There was no donor-site morbidity, and all children adapted to daily life without any problems. In two-point discrimination tests, the fingertip sensation recovered to almost the same level as that in the contralateral finger. CONCLUSIONS: Partial second toe pulp free flaps are an excellent option for fingertip reconstruction in young children, as well as in adults.

Arterial or venous free flaps for volar tissue defects of the proximal interphalangeal joint: A comparison of surgical outcomes.

BACKGROUND: For volar soft tissue defects of the proximal interphalangeal (PIP) joint, free flaps are technically challenging, but have more esthetic and functional advantages than local or distant flaps. In this study, we compared the long-term surgical outcomes of arterial (hypothenar, thenar, or second toe plantar) and venous free flaps for volar defects of the PIP joint. METHODS: This was a single-center retrospective review of free flap coverage of volar defects between the distal interphalangeal and metacarpophalangeal joint from July 2010 to August 2019. Patients with severe crush injuries (degloving, tendon or bone defects, or comminuted/intra-articular fractures), thumb injuries, multiple-joint and finger injuries, dorsal soft tissue defects, and defects >6 cm in length were excluded from the study, as were those lost to follow-up within 6 months. Thirteen patients received arterial (hypothenar, thenar, or second toe plantar) free flaps and 12 received venous free flaps. Patients' age, follow-up period, PIP joint active range of motion (ROM), extension lag, grip-strength ratio of the injured to the uninjured hand, and Quick Disabilities of Arm, Shoulder & Hand (QuickDASH) score were compared between the groups. RESULTS: Arterial free flaps showed significantly higher PIP joint active ROM (P=0.043) and lower extension lag (P=0.035) than venous free flaps. The differences in flexion, grip strength, and QuickDASH scores were not statistically significant. CONCLUSIONS: The surgical outcomes of arterial free flaps were superior to those of venous free flaps for volar defects of the PIP joint.

Long-term outcomes of nail bed reconstruction.

BACKGROUND: There are various reconstructive options for nail bed defects. However, it is challenging not to leave a deformity. In this study, we investigated differences in outcomes depending on the reconstruction method, attempted to determine which method was better, and analyzed other factors that may affect outcomes. METHODS: The long-term outcomes of nail bed reconstruction were reviewed retrospectively. We performed three types of reconstruction depending on the defect type: composite grafts of severed segments, nail bed grafts from the big toe, and two-stage surgery (flap coverage first, followed by a nail bed graft). Subsequent nail growth was evaluated during follow-up, and each outcome was graded based on Zook's criteria. The reconstruction methods were statistically analyzed. Other factors that could contribute to the outcomes, including age, the timing of surgery, germinal matrix involvement, defect size, and the presence of bone injuries, were also compared. RESULTS: Twenty-one patients (22 digits) who underwent nail bed reconstruction were evaluated. The type of reconstruction method did not show a significant relationship with the outcomes. However, patients who sustained injuries in the germinal matrix and patients with a defect larger than half the size of the nail bed had significantly worse outcomes than the comparison groups. CONCLUSIONS: The result suggest that no operative method was superior to another in terms of the outcomes of nail bed reconstruction. Nevertheless, involvement of the germinal matrix and defect size affected the outcomes.

Botulinum toxin type A suppresses pro-fibrotic effects via the JNK signaling pathway in hypertrophic scar fibroblasts.

Hypertrophic scar is a dermal fibroproliferative disease characterized by the overproduction and deposition of extracellular matrix, and the hyperproliferation and enhanced angiogenesis of fibroblasts, along with their enhanced differentiation to myofibroblasts. Botulinum toxin type A shows potential for prevention of hypertrophic scar formation; however, its effectiveness in attenuating skin fibrosis and the related mechanism are unclear. In this study, human scar fibroblasts were cultured and stimulated with botulinum toxin type A, and the changes in fibroblast proliferation, migration, and protein expression of pro-fibrotic factors were evaluated with colorimetric, scratch, and enzyme-linked immunosorbent assays and western blotting, respectively. Botulinum toxin type A treatment decreased the proliferation and migration of human scar fibroblasts compared with those of untreated controls. Protein expression levels of pro-fibrotic factors (transforming growth factor ß1, interleukin-6, and connective tissue growth factor) were also inhibited by botulinum toxin type A, whereas the JNK phosphorylation level was increased. Activation of the JNK pathway demonstrated the inhibitory effects of the toxin on human scar fibroblast proliferation and production of pro-fibrotic factors, suggesting that the suppressive effects of botulinum toxin type A are closely associated with JNK phosphorylation. Overall, this study showed that botulinum toxin type A has a suppressive effect on extracellular matrix production and scar-related factors in human scar fibroblasts in vitro, and that regulation of JNK signaling plays an important role in this process. Our results provide a theoretical basis, at the cellular level, for the therapeutic use of botulinum toxin type A.

Ultrasound-guided intra-articular injection of hyaluronic acid and ketorolac for osteoarthritis of the carpometacarpal joint of the thumb: A retrospective comparative study.

Intra-articular hyaluronic acid (HA) is widely used to treat symptomatic osteoarthritis (OA) in the carpometacarpal joint (CMCJ) of the thumb. However, although apparently effective and relatively safe, intra-articular HA injections act relatively slowly. Therefore, a nonsteroidal anti-inflammatory drug could be added for more prompt pain relief. The aim of this study was to compare the efficacy and safety of ultrasound (US)-guided intra-articular injection of HA and ketorolac with that of HA alone in patients with OA of the CMCJ of the thumb.Seventy-four patients identified by chart review to have a diagnosis of OA of the CMCJ of the thumb received either a US-guided intra-articular injection of 0.5 mL of sodium hyaluronate and 0.5 mL of ketorolac (n = 38) or 0.5 mL of sodium hyaluronate and 0.5 mL of saline (n = 36). Disabilities of the arm, shoulder, and hand (DASH) and verbal numeric scale (VNS) pain scores were recorded before and 1, 3, and 6 months after injection. Univariable analyses (using the chi-squared test) and multiple logistic regression analysis were performed to evaluate the relationship between potential predictors of the outcome (treatment allocation, patient age and sex, duration of pain, and Eaton-Littler classification) and therapeutic effects.The DASH and VNS scores were improved at 1, 3, and 6 months postinjection in both groups. The onset of pain relief was significantly more rapid (at 1 month) after the injection containing HA and ketorolac than after the injection containing HA alone. In 55.3% of cases, pain and function were improved postinjection compared with baseline and remained so for up to 6 months. The success rate was not significantly different between the assessments at 1, 3, and 6 months, and the univariable analyses did not identify any statistically significant potential predictors of the outcome. Multiple logistic regression analysis did not identify any independent predictors of a successful outcome at midterm follow-up.The onset of analgesic action was more rapid after an injection containing HA and ketorolac than after 1 containing HA alone in patients with OA of the CMCJ of the thumb. There were no serious complications.

Three-Dimensional Computed Tomography Analysis of Stability Following Two- and Three-Point Fixation With Biodegradable Plates Among Patients With Zygomatic Fracture.

BACKGROUND: Open reduction followed by internal fixation has been regarded as the most effective technique for the surgical repair of zygomatic fractures. However, the ideal number and locations of internal fixation points to maintain stable reduction remain controversial. Using 3-dimensional computed tomography, we aimed to compare the stability of 2-point and 3-point fixation among patients who had undergone surgical repair of zygomatic bone fractures. METHODS: The study included 22 patients (17 men, 5 women) with unilateral zygomatic bone fractures who had undergone open reduction with 2-point or three-point fixation using biodegradable materials (11 patients in each group). The authors measured the lateral projection and height of the zygoma at 2 landmark points (zygomaticofacial foramen and frontozygomatic suture). In each group, bony displacement was analyzed between the preoperative and immediate postoperative phases, and between the preoperative and follow-up phases. Differences in stability between the 2 groups were analyzed by comparing values between the immediate postoperative and follow-up phases. RESULTS: The 2-point group exhibited a lower rate of complex fractures at the frontozygomatic suture than the 3-point group (18.2%, 63.6%, respectively). In both groups, the authors observed significant differences in the lateral projection of the zygomaticofacial foramen between the preoperative and immediate postoperative phases, and between the preoperative and follow-up phases. No significant differences in stability were observed between the groups. CONCLUSION: Our findings demonstrated that 2-point fixation of the zygoma with biodegradable materials is as stable as 3-point fixation. It could be initially considered when open reduction of frontozygomatic suture was not essential.

Retained large glass fragments for over 40 years in the maxillofacial region.

Foreign body (FB) impaction in the maxillofacial area could be caused by knives, glass fragments, and vegetative materials. We present the rare case of a 62-year-old man with a large glass FB in the left cheek retained for over 40 years. He had traffic accident over 40 years ago and glass fragments impacted on his left cheek. Glass fragments were retained around the zygomatic arch with dimpled scar and unclear serous discharge, but other facial motor or sensory dysfunction was not observed. We confirmed three glass fragments with radiologic examination including plain radiograph and computed tomographic image. Under general anesthesia, impacted glass fragments were removed through the direct incision on the dimpled scar and the additional incision on the left lateral canthal area. Remnant FBs were not seen on an intraoperative C-arm radiograph. After 2 days of irrigation for inflammation control, the dimpled wound was sutured. The wound was healed without major complication and the original dimpled scar was much improved.

Postoperative Changes in Isolated Medial Orbital Wall Fractures Based on Computed Tomography.

The treatment has been improved on the accurate reduction of blow-out fracture for many decades. But still, it has been limited to reduce completely when surgeons are approaching by conventional technique. The authors analyzed the postoperative results using computed tomography (CT) scans after conventional open reduction of isolated medial wall fracture. Thirty-seven patients with isolated medial wall fracture were reviewed. All patients underwent preoperative, immediate, and postoperative CT scans. Two surgeons have performed the surgery by conventional open reduction with transcaruncular approach and absorbable mesh insertion. The authors evaluated changing orbital volume and distance, comparing the immediate and 6 months postoperative outcomes with preoperative outcome. The differences between immediate postoperative and 6 months postoperatively data were statistically evaluated. The authors used the distant value to minimize bias of CT view selection. Significant differences from the 2 kinds of data were observed (P < 0.05 for volume, P < 0.01 for distance, Paired t test). Bone remodeling process after conventional open reduction of orbital wall has not been fully understood. Most popular technique is conventional open reduction and mesh insertion but it is not easy for surgeons to reduce fractured bones completely. The authors analyzed the bone remodeling after incomplete reduction. These results suggest that the decreased measurements might be caused from the scar contracture with fibrosis. This research is very limited to explain the change while bone remodeling is progressed. Further research should be continued to discover the understanding of the process.

Postoperative Changes After Closed Reduction of Nasal Fracture.

Nasal bone fracture is the most common facial fracture; however, surgery does not guarantee reduction and complications, such as undercorrection, overcorrection, and deviation, may occur. By analyzing findings of computed tomography (CT) immediately and at 3 months postoperatively, we evaluated the accuracy of reduction and long-term changes to the nasal bone.Patients with pure nasal bone fracture were evaluated from January 1, 2010 to December 31, 2011. First, we categorized fracture types according to the Stranc-Robertson classification system, using preoperative CT findings (ie, F1, F2, L1, and L2). We categorized each result of reduction by immediate postoperative CT scan findings as "Excellent," "Good," "Fair," and "Poor," with "Excellent" and "Good" ratings being considered a "Success." We evaluated changes to the nasal bone at 3 months after reduction, using the same grade.A total of 128 patients were analyzed. The results of patients in the F1 group were better than those of other patients immediately postoperatively, whereas those of the L2 group were worse. The overall success rate was 49.2% (58/118). At 3 months postoperatively, 33 cases exhibited an improvement to a higher grade, whereas 25 cases improved from an unacceptable outcome to a successful outcome, with the overall success rate being 70.3% (83/118).Immediately postoperative CT scans can be helpful for surgeons in determining whether a secondary adjustment is necessary. Incompletely reduced nasal bone showed spontaneous improvement in bony arrangement according to our study, so simple observation could be a choice.