COVID-19: Initial experience of an international group of hand surgeons.

The emergence of the COVID-19 pandemic has severely affected medical treatment protocols throughout the world. While the pandemic does not affect hand surgeons at first glance, they have a role to play. The purpose of this study was to describe the different measures that have been put in place in response to the COVID-19 pandemic by hand surgeons throughout the world. The survey comprised 47 surgeons working in 34 countries who responded to an online questionnaire. We found that the protocols varied in terms of visitors, health professionals in the operating room, patient waiting areas, wards and emergency rooms. Based on these preliminary findings, an international consensus on hand surgery practices for the current viral pandemic, and future ones, needs to be built rapidly.

A porcine model for robotic training harvest of the rectus abdominis muscle.

Conventional open surgical approaches for the harvesting of the rectus abdominis muscle carry a high risk of morbidity. It is possible to reduce these risks by using laparoscopy or robot-assisted techniques. This work hypothesizes that a porcine model could be used for learning the robot-assisted collection of the rectus abdominis. The rectus abdominis was taken in 3 stages in 3 pigs: installation of the robot, surgical approaches with 4 trocars, dissection and collection of the muscle. The average operating time was 1h20min and the average muscular length was 16cm. Our results showed a learning curve for the robot-assisted harvesting of the rectus abdominis on a porcine model.

Rotational stability test for the diagnosis of radial collateral ligament rupture in the fingers: Anatomical study.

Diagnosing rupture of the radial collateral ligament (RCL) of the finger metacarpophalangeal (MCP) joints is difficult. The aim of this cadaver study was to validate a rotational test for the MCP after RCL transection. With the MCP and proximal interphalangeal joints in flexion, rotation along the axis of the proximal phalanx was applied through an extended distal interphalangeal joint to 36 cadaver fingers. Each finger's pulp described an arc of pronation and supination that was noted on the palm. The test was repeated three times: before transection, after transection of the proper collateral ligament (CL) and after transection of both the proper and accessory CLs. Rotational arcs were measured in pronation and supination. Mean length of the pronation arc after transection of the main RCL was 17.53mm, while it was only 12.41mm before transection for the supination arc. Mean length of the pronation arc after transection of both CLs was 22.83mm compared to only 11.93mm before transection. Our results show a significant difference in pronation stability of the MCP joint after transection of the RCL proper. We can conclude that this rotational stability test is a valid test for diagnosing RCL rupture in MCP joints.

Is there a relevance of suction drainage in non-septic wrist surgery?

INTRODUCTION: No rational argument leads to conclude to the benefit or the innocuousness of drainage in non-septic wrist surgery. HYPOTHESIS: The goal of this study was to validate the hypothesis that for those indications drainage is unnecessary. MATERIAL AND METHOD: We reviewed 1001 consecutive cases, concerning 885 patients, 58 years old in average. RESULTS: Out of 1001 procedures, 9 patients were operated on both sides, 145 were operated twice of which 130 for the implantation and then the removal of surgical material. None were reoperated for hematomas. Three patients were initially treated for an osteosynthesis using an anterior plate of distal radius and secondarily reoperated due to sepsis, one of them twice. The material was removed from two patients. The average time of tourniquet for those 3 osteosynthesis was significantly superior (84.33min) to the average time for the 595 other anterior distal radius plates (45.35min). CONCLUSION: The results of our study show that suction drainage in non-septic wrist surgery is unnecessary. LEVEL OF EVIDENCE: III descriptive retrospective study.

Resistance of primary microsurgical repair of palmar digital nerves to finger mobilization: A cadaver study.

The aim of this study was to assess the resistance of microsurgically repaired proper palmar digital nerves (PPDN) to mobilization. Thirty-nine PPDN from fresh forearms cadavers were transected and then sutured using 10/0 nylon. After skin closure, each finger was forcefully flexed and extended 10 times. Out of the 39 repaired nerves, two were elongated and four were ruptured; this amounts to a 15.38% complication rate. We recommend immobilization of nerve repairs, although this contradicts most recent studies.

Technical feasibility of robot-assisted minimally-invasive neurolysis of the lateral cutaneous nerve of thigh: About a case.

To limit the risk of iatrogenic neuroma and recurrence after surgical treatment of meralgia paresthetica, some authors have recently developed a technique of endoscopic neurolysis of the lateral cutaneous nerve of thigh (LCNT) below the level of the inguinal ligament. We report the case of a robot-assisted endoscopic technique underneath the inguinal ligament. A 62-year-old patient suffering of idiopathic meralgia paresthetica for the past 18 months received a Da Vinci robot-assisted minimally-invasive 10cm long neurolysis, of which 1/3 was situated above the level of the inguinal ligament and 2/3 below it. The patient was discharged the following day without complications. At 6-months follow-up the pain was rated 0/10 compared to 5/10 pre-operatively. Robot-assisted endoscopic neurolysis of the LCNT retains the advantages of conventional endoscopy and enables to approach the nerve in the most frequently compressed zone underneath the inguinal ligament. The three-dimensional view offered by robotic surgery facilitates the dissection. The superiority of this technique remains to be demonstrated by comparing it to conventional techniques.

Assessment of the structures at risk during wrist arthroscopy: a cadaveric study and systematic review.

UNLABELLED: We assessed the proximity of neurological structures to arthroscopic portals in a cadaveric study and through a systematic review. Arthroscopy was performed on ten cadaveric wrists. Subsequently the specimens were dissected to isolate the superficial branch of the radial nerve, the dorsal branch of the ulnar nerve, the posterior interosseous nerve and the extensor tendons. We measured the distances from the nerves to common portals. For the systematic review Pubmed and EMBASE were searched on the 31 May 2014 for cadaveric studies reporting the proximity of neurological structures to any arthroscopic wrist portal. In the cadaveric study, partial injuries were seen to six extensor tendons and one posterior interosseous nerve; it was assumed this was due to creation of the portals. Seven published studies were included in the systematic review. The dorsal sensory branch of the ulnar nerve was found to be at risk by performing the 6 Ulnar, 6 Radial and ulnar midcarpal portals, the sensory branch of the radial nerve by the 1-2 and 3-4 portals and the posterior interosseous nerve by the 3-4 and 4-5 portals. LEVEL OF EVIDENCE: V.

Plastic and reconstructive robotic microsurgery--a review of current practices.

INTRODUCTION: We sought to review the current state of robotics in this specialty. METHODS: A Pubmed and Medline search was performed using key search terms for a comprehensive review of the whole cross-section of plastic and reconstructive practice. RESULTS: Overall, 28 publications specific to robotic plastic and reconstructive procedures were suitable for appraisal. CONCLUSION: The current evidence suggests robotics is comparable to standard methods despite its infancy. The possible applications are wide and could translate into superior patient outcomes.

Fractures and dislocation of the base of the thumb metacarpal.

Acute traumatic lesions of the base of the first metacarpal are frequent and their consequences can affect the opposition of the thumb. They usually occur after trauma in compression along the axis of the thumb in flexion. Restoring the anatomy and biomechanics of the trapeziometacarpal joint is essential when treating these injuries, hence why surgical treatment is usually indicated. We distinguish trapeziometacarpal dislocations, small-fragment and large-fragment Bennett's fractures, articular three-fragment Rolando and comminutive fractures and extra-articular fractures of the base of the first metacarpal. All carry the risk of narrowing of the first web. Recent studies have described poor results with conservative treatment. Surgical techniques are varied: percutaneous surgery, open surgery and arthroscopic surgery. The techniques of osteosynthesis are various: locking plates, and direct or indirect screw fixation or pinning. The prognosis depends on the quality of the restoration of the mobility of the trapeziometacarpal joint.

Pull out stent: a trick to improve the intravascular stenting technique.

The intravascular stent technique (IVaS) was developed to simplify the anastomosis of submillimeter blood vessels. One variation of the IVaS called the "clip stent", improved the patency of anastomosed vessels. The goal of this study was to analyze a subsequent technical variation called the "pull out stent", which aims to reduce trauma to the vessel. Our experimental study comprised 4 groups of 10 rats. Anastomosis of the tail artery was performed with 10-0 nylon suture using either interrupted sutures (group I), IVaS (group II), "clip stent" (group III), or "pull out stent" (group IV). The "pull out stent" technique consisted of 3 steps: introduction of the stent (intraluminal and then transluminal introduction of a 4-0 nylon monofilament followed by introduction of the other end into the opposite lumen), anastomosis, and then removal of the stent. The anastomosis procedure time was longer in group III than in group IV. The number of stitches and the patency were similar in all groups. There were more leaks in group I. The "pull out stent" was faster, less traumatic to the vessel wall, allowed for more regular sutures and caused fewer leaks than the other stenting techniques. One possible clinical application is the anastomosis of digital veins as part of replantation or toe transfers, especially in children.

Can ring finger injuries be prevented by pre-weakened rings? Three clinical cases.

Prevention of finger trauma can be directly related to the manufacture of pre-weakened rings. We report on three clinical cases of finger injuries caused by pre-weakened rings. Lesions were less severe than conventional ring finger injuries, such as those caused by iron fences. Surgery was required in all three cases and chronic cold sensitivity was noted in one case. This small series advocates the imposition of a ring manufacturing standard at the European level. Given this lack of consensus, the idea is to prevent injuries by developing rings with intentional weak points that open automatically in case of trauma. These pre-weakened rings have never been subject to clinical study to demonstrate their potential safety.

The MetaHUS(®) fixation system versus pinning and plating in 5th metacarpal neck fractures.

The treatment of fifth metacarpal neck fractures is controversial. The aim of this work was to modify the intermetacarpal pinning technique with an external connector, and to compare the results of this modified technique to those of intramedullary pinning and locking plate techniques. Our series included 56 extra-articular fractures of the neck of the fifth metacarpal treated by intramedullary pinning (group A), locking plate Aptus(®) MEDARTIS™ (group B) and MetaHUS(®) Arex™ (group C); the last one consisted in intermetacarpal percutaneous pinning and connecting the pins externally. There were no statistically significant differences for all criteria except active mobility, which was less important for group B. In groups A and B, 6 complications were noted, in group C, one. Our results showed that blocked intermetacarpal K-wires is a technique of choice for the treatment of displaced fifth metacarpal neck fractures, not only because it is easy to assemble and to remove, but also because it allows immediate active mobilization.

[Courses in microsurgical techniques in France and abroad]. / État des lieux de l'enseignement des techniques microchirurgicales en France et à l'étranger.

The objective of this work was to determine the state of current training programs for microsurgery in France and abroad. Our survey of microsurgery training programs determined the registration volume, program contents, and number of students in France, and looked at registration volume and teaching time for programs abroad. Data were obtained from the Internet, university administration, those responsible for university diploma programs, and students. There were 18 university diploma programs in microsurgery in France. The average list price was €1,129 for an average of 19 hours of theoretical training and 100 hours of practice. Evaluation methods varied, but all required at least vascular anastomosis in rats. In 2011-2012, 148 students were enrolled and 126 graduated (85% passing rate). Abroad, 16 basic courses were listed in the USA, Europe and Asia. Nine advanced courses were offered. The average price was $1,346 for 36 hours of practice in the basic courses and $1,955 for over 50 hours of training in advanced courses. None of these courses gave out a diploma. Our results show that in France, university diploma programs in microsurgery are heterogeneous and the French College should consider updating them. Globally, a study is underway by the International Microsurgical Simulation Society.

Hand injuries due to firework devices: a series of 58 cases.

Fireworks or firecrackers can cause serious accidents. They are classified from K1 to K4 according to the amount of powder they contain. In Alsace (France), a type-K1 firecracker is available on the free market and the K2 and K3 ones are prohibited. The aim of this study was to reveal the effects of measures taken in order to prevent repercussions related to hand injuries caused by fireworks. Patients who fell victim to firework incidents have been recorded since 2006, starting date of the prevention campaign. Records have been taken on the circumstances, the group of firecracker, the level of injury and the severity of the injury in four stages. Our series included 62 hands from 58 patients (average age: 25 years), including two women. Most of them sustained their injury during the night of New Year's Eve. The study dealt with 21 K1, and 35 K2 or K3. We registered 29 cases of grade I, 2 grades II, 21 grades III and 9 grades IV. One patient died. The numbers of consultations, K2/K3 injuries and number of surgeries increased from 2006 to 2012. Our results show that firework-related injuries to the hand are serious, pluridigital, multistage and/or bilateral. Prevention was ineffective but should be improved and strengthened, as a total ban on fireworks is a counterproductive measure.

Use of the Konnyaku Shirataki noodle as a low fidelity simulation training model for microvascular surgery in the operating theatre.

The aim of this study was to test the feasibility of a type of Japanese noodle, named "shirataki konnyaku", for microsurgery training in the operating room. Thirteen surgical residents without experience in microsurgery had to perform two microsurgical anastomoses: one on a model of a femoral artery of a rat (control) and one on a model of a konnyaku shirataki. Two quantitative variables (time in minutes and number of stitches to perform the anastomosis) and two qualitative variables (patency and tightness of the anastomosis) were measured. Sixty anastomoses were performed with the control model and 62 anastomoses with the konnyaku model. The time of the anatomosis was significantly higher in the control group. The number of stitches was similar in both groups. The patency of the anastomosis was significantly lower in the control group. The tightness (no leak) of the anastomosis was significantly higher in the control group. The "konnyaku shirataki" model could improve the teaching of microsurgery due to its availability, low cost and structural similarity to the animal model.

Support for partial lesions of the flexor tendons of the fingers: a retrospective study of 36 cases.

The treatment of traumatic partial injuries of the flexor tendons of the fingers is seldom published. The only published clinical series states that the therapeutic approach depends on the existence or absence of a preoperative trigger. We hypothesized that the therapeutic attitude mainly depends on the percentage of the injured cross-section. Our retrospective series included 36 partial lesions of 31 fingers in 29 patients. The average age was 42 years, there were 19 men. We noted 8 lesions in zones I, 21 in zone II and 2 in zone III. The average percentage of the injured cross-section was 35% and ranged from 10% to 90%. If the lesion was less than 50% (29 tendons), a tangential resection was performed. If the lesion exceeded 50% (seven tendons), a direct suture was performed, supplemented by a running suture. At a follow-up of 34 months, the average pain on a visual analogue scale was 0.7. The average percentage of strength compared to the contralateral side was 93%. The Quick DASH score was 6.2. The range of motion averaged 214° with extremes ranging from 90° to 260°. We observed no cases of hypertrophic callus, neither through the MRI nor through the ultrasonography. Complications such as trigger finger, pseudoblocage or rupture were not observed. Based on our results, in case of partial injury of a flexor tendon, we propose to perform a tangential resection in cross-section lesions up to 50%, and a suture for those which exceeded 50%.

Feasibility of an endoscopic approach to the axillary nerve and the nerve to the long head of the triceps brachii with the help of the Da Vinci Robot.

Surgery to transfer the axillary nerve and the nerve of the long head of the triceps presents two obstacles: 1) the access portals are not standardized and 2) the nerves are for their larger part approached through large incisions. The goal of this study was to explore the feasibility of an endoscopic microsurgical approach. The posterior aspect of a cadaver shoulder was approached through three communicating mini-incisions. The Da Vinci robot camera was installed on a central trocart, and the instrument arms on the adjacent trocarts. A gas insufflation distended the soft tissues up to the lateral axillary space. The branches of the axillary nerve and the nerve to the long head of the triceps brachii muscle were identified. The dissection of the axillary nerve trunk and its branches was easy. The posterior humeral circumflex veins and artery were dissected as well without any difficulty. Finding the nerve to the long head of the triceps brachii was found to be more challenging because of its deeper location. Robots properties allow performing conventional microsurgery: elimination of the physiologic tremor and multiplication of the movements. They also facilitate the endoscopic approach of the peripheral nerves, as seen in our results on the terminal branches of the axillary nerve and the nerve to the long head of the triceps brachii.

Successful thumb reconstruction after tumor resection by immediate toe transfer in a 67-year-old patient: case report and literature review.

Age is a limiting factor for microsurgery. We report the case of a 67-year-old patient with a malignant tumor on the right thumb, treated by amputation and immediate reconstruction by partial transfer of the hallux, with an excellent result, but venous swelling at the fourth day that required a controlled bleeding for 3 days. In the light of this observation, we think that there is no age limit for reconstruction of a thumb by toe transfer, either cosmetically or functionally.