Benefits of WALANT in palliative upper limb surgery after nerve injury.

Wide-Awake Local Anesthesia No Tourniquet (WALANT) may be a satisfactory anesthesia alternative for the management of upper limb peripheral nerve palsy sequelae. The main advantages are the possibility of active patient cooperation through intraoperative active mobilization, comfort and cost reduction. The legislation about WALANT in France remains unclear; the modalities of lidocaine epinephrine injection should be redefined. For palliative upper limb surgery, WALANT allows the surgeon to adjust the tension on the tendon transfer intraoperatively. Level 1 studies are needed to evaluate the effectiveness of WALANT relative to standard anesthesia techniques (regional/general anesthesia).

Primary digital localization of extra-axial extra-osseous soft-tissue chordoma: A case report.

We report a case of digital extra-axial extra-osseous soft-tissue chordoma located in a flexor synovial sheath of the little finger of the left hand. Histology-immunohistochemistry (brachyury) analysis after broad en-bloc resection confirmed the diagnosis. Exhaustive MRI assessment of the entire spine, skull and pelvis found no other locations. No recurrence was reported at last follow-up. Hand surgeons should be aware of the diagnosis and treatment of brachyury-positive extra-axial soft-tissue chordomas, whence the importance of recognizing its typical and differential characteristics to guide optimal therapeutic strategy.

Applying the WALANT technique to surgical treatment of distal radius fractures.

The Wide-Awake Local Anesthesia No Tourniquet (WALANT) method is a recent anesthesia option for surgery of the upper limbs based on the injection of an anesthetic solution containing adrenaline at the surgical site, hence circumventing tourniquet use. In a prospective study, we compared the functional outcomes using this anesthesia technique with those of the regional anesthesia (RA) technique for the surgical care of distal radius fractures (DRF). From November 2019 to June 2020, a non-randomized, single-center study was conducted with a cohort of 41 patients suffering from a DRF and who received volar plate fixation at a university hospital center. Twenty-one patients had WALANT surgery and 20 had RA with installation of a tourniquet. Over a period of 7 months, the clinical and radiological outcomes as well as the QuickDASH functional score were evaluated. Recovery of wrist function return to work, and analgesic withdrawal for the WALANT group occurred earlier than for the RA group. No noticeable differences were found regarding surgery duration or radiographic results. Using WALANT, functional wrist recovery occurs earlier than with RA. In our study, earlier analgesic stoppage, a quicker return to work and resumption of activity were observed with WALANT. As such, it should become part of the therapeutic arsenal for surgical treatment of DRF.

Three-dimensional reconstruction of the upper limb from anatomical slices of the Korean visible human: simulation and educational application.

PURPOSE: Digital anatomy is a novel emerging discipline. Use of virtual reality brings a revolution in educational anatomy by improving retention and learning outcomes. Indeed, virtual dissection is a new learning tool for students and surgeons. Three-dimensional vectorial models of the human body can be created from anatomical slices obtained by lengthy series of cryosection from the visible human projects. The aim of this paper is to show how these mesh models could be embedded into an Acrobat® 3dpdf interface, to produce an easy-to-use fully interactive educational tool. METHODS: The learning of this method and its practical application were evaluated on a multicentric cohort of 86 people divided into 3 groups, according to the duration of their training (1, 2 or 3 days, respectively). Participants learned how to use the Mesh tool and how to model 3D structures from anatomical sections. At the end of the training, they were given a survey form. Participants were also asked to rate the training (Poor; Average; Good; Very Good; Excellent). RESULTS: Ninety four percent of the subjects rated the device as excellent and would continue to use digital anatomy in their practice. CONCLUSION: This result is the Diva3d® virtual dissection table, a powerful educational tool for anatomists and students. It could also be the basis of future simulation tools for hand surgeons training.

Fingertip reconstruction by palmar bipedicular island flap in long fingers (modified neurovascular Tranquilli-Leali flap): A dual-center study.

When bone is exposed, fingertip defects may require a flap procedure. Many types are available, with little consensus about which one is best. But each one has its own disadvantages: esthetic (claw nail deformity), neurological (sensory disorders) or functional (stiffness). The purpose of this study was to evaluate a palmar bipedicular island flap (our modification of the Tranquilli-Leali flap) for fingertip reconstruction. We retrospectively analyzed the prospective data of 42 patients with a mean follow up of 16.4 months (6-30 months) operated in two hospital facilities. Thirty-three patients were men. Mean age was 39.5 years (12-83 years) and 24 (57.1%) were smokers. In 23 cases (54.8%), the trauma was work-related. A crush mechanism was identified in 29 patients (69%). According to Allen's classification of fingertip injuries, there were 26 cases of stage II, 14 cases of stage III and 2 cases of stage IV. All procedures were performed on an emergency basis, within 24 hours of the trauma. No claw nail deformity was observed. The mean discrimination in the Weber test was 3.8mm (2-6mm). The mean Total Active Motion (TAM) was 268.3° (255-275°). The patient satisfaction was graded at 8.7 on a 10-point scale. Results were considered as excellent in 15 cases and good in 23 cases. The modified palmar bipedicular island flap makes the old Tranquilli-Leali flap - which has a poor reputation in the hand surgeon community-simpler and safer to use. This flap restores proper balance between skin, bone and nail in Allen stage II and III fingertip amputations.

Hand injury without any deficit: Is systematic surgical exploration justified?

Out of 100,000 inhabitants, 700 to 4000 suffer a hand wound each year. Numerous hand wounds that may not have a clinically evaluated deficit, actually have damage to a major structure after surgical exploration in the operating room (OR). The aim of our study was to evaluate the incidence of major structure damage within a population of patients presenting a hand wound with no deficit on the clinical examination. Every patient older than 12 years, consulting for a wound deeper than the dermis with no clinical signs of major structure damage underwent surgical treatment and exploration of the wound under regional anesthesia in the OR. After each surgery, the surgeon filled out an anonymous study form describing the wound characteristics and the potential findings of major structure damage. Of the 145 wounds with normal clinical examination, we found that 58.6% had a major structure damaged. Given that damage to any major structure in the hand can lead to functional sequela, and the fact that a well-conducted clinical examination by a qualified hand surgeon is not sufficient to eliminate major structure damage, we recommend systematic surgical exploration of hand wounds, even when no clinical deficit is evident. LEVEL OF EVIDENCE III.: Type of sudy: diagnostic study.

Endoluminal minimally invasive surgery for chronic exertional compartment syndrome: a new technique.

INTRODUCTION: Fasciotomy is the usual treatment for chronic exertional compartment syndrome of the lower limb. For esthetic reasons, minimally invasive techniques have been developed but can generate complications. Herein, we report the use of the KnifeLight during minimally invasive anterior and lateral compartment release in view of reducing these complications, within a feasibility study. MATERIAL AND METHODS: This study was conducted on four cadavers (eight legs) and then an athletic patient (two legs). RESULTS: The technique was carried out on all cases with no complications. The patient's result was excellent. DISCUSSION: The KnifeLight can be used to perform a fasciotomy of the leg's anterior and lateral compartments. It seems to provide the operator with additional safety compared to other minimally invasive techniques. CONCLUSION: This is a simple, reliable, and reproducible technique that deserves to be better known.

Tendon rupture of the flexor digitorum profundus of the little finger secondary to hamate non-union.

Several cases of hamate fracture and non-union have been reported. The hook of the hamate acts as a pulley for the flexor tendons for the little and ring fingers. Hamate non-union is frequently associated with irritation of the adjacent soft tissues. We report the case of hamate non-union that was only detected because of a flexor digitorum profundus tendon rupture in the little finger, associated with tendinopathy of both flexor tendons of the ring finger.

Collagenase clostridium histolyticum in patients with Dupuytren's contracture: results from POINT X, an open-label study of clinical and patient-reported outcomes.

In POINT X, a study designed to reflect clinical practice and patient treatment choices, 254 European patients received open-label collagenase for Dupuytren's contracture. The most severely affected joint was treated first in 74% of patients. In total, 52%, 41%, 7%, and 1% of patients selected the little, ring, middle, and index finger, respectively; 79% had one or two joints treated. Only 9% of patients (n = 24) received 4 or 5 injections. The mean improvement in total passive extension deficit (TPED) was 34° on day 1, improving further by day 7 to 42°. This secondary improvement was maintained by day 90 and month 6. The mean number of injections/joint was 1.2 for the metacarpophalangeal joint and 1.25 for the proximal interphalangeal joint. Median time to recovery was 4 days; the mean improvement in hand function was clinically relevant as measured by the Unité Rhumatologique des Affections de la Main (URAM) score. In total, 87% and 86% of patients and physicians, respectively, were very satisfied or satisfied with treatment at month 6, although correlation between TPED and patient satisfaction was weak (Spearman -0.18, 95% CI -0.32 to -0.06). Collagenase was well tolerated, with 10 (3.9%) patients experiencing severe adverse events. As a real-world study, the POINT X findings can be generalized to the at-large population.

The psychotic mummified hand: an unusual hand injury complication.

The authors report the case of a patient with psychotic symptoms secondary to a posttraumatic stress disorder following a work-related hand injury. The somatic presentation was a "mummified" hand neglected for several years in a splint without any care. The psychiatric analysis concluded that this was part of a delusion of persecution expressing a conflict against the patient's employer and insurance company. Surgical treatment was limited to a hand cleaning with hardware removal. Despite 3 years of antipsychotic medication the patient was still suffering from delusion and the hand remained neglected at the last follow-up.

Novel approach for posttraumatic panarthritis of the wrist using a pyrocarbon interposition arthroplasty (Amandys(®)): Preliminary series of 11 patients.

OBJECTIVES: In case of posttraumatic radiocarpal destruction, failure of first row carpectomy or partial arthrodesis, there are two options, total prosthesis of the wrist or panarthrodesis. Both solutions have limitations. The aim of our study was to evaluate an alternative therapy: interposition arthroplasty with pyrocarbon implant at follow-up of minimum 6months. METHODS: This is a retrospective monocentric study with clinical and radiological evaluation. This study includes 11 patients with a mean age of 55.2years. There were four failures of first row carpectomy, a failure of partial arthrodesis, a case of post-infection osteoarthritis, four cases of stage IV SNAC wrists and one siliconitis after a scaphoid implant. RESULTS: At the average follow-up of 11 months, pain was improved in nine cases. The average flexion was 36.5° and average extension, 35°. The average strength was 8.3kg. Two implant dislocations occurred, only one required second look surgery for implant replacement. However, in this patient, pain remained severe and required panarthrodesis. In another patient, a second panarthrodesis was performed for resistant pain. CONCLUSIONS: The interposition arthroplasty with pyrocarbon seems to give encouraging results as an alternative therapy. It gives satisfactory mobility, pain relief, but moderate strength. It has the advantages of a simple technique and does not preclude manual activities. A long-term validation is, of course, necessary.

Trapeziometacarpal joint osteoarthritis after proximal row carpectomy: treatment with a total joint arthroplasty.

The authors report a case of trapeziometacarpal osteoarthritis in a 58-year-old woman with low functional demand. The patient had a proximal row carpectomy for posttraumatic radiocarpal arthritis. The authors decided to perform arthroplasty using a total GUEPAR trapeziometacarpal prosthesis to conserve carpal stability of the first column. Eight years after the surgery, the patient is free of pain and her thumb movement is similar to the opposite thumb. No radiographic changes were observed. No similar cases have been reported in the literature. Prosthesis insertion could be a reasonable option for this indication to give long-term painless mobility and stability.

Nerve repair using a composite graft of vein and denatured skeletal muscle: morphologic analysis.

Five groups of six rats each underwent sciatic resection, bridged with a 20-mm-long graft. Five different types of graft were used: (1). vein; (2). fresh muscle; (3). denatured muscle; (4). vein and fresh muscle; and (5). vein and denatured muscle. Denaturation was obtained by dry thermal shock in a microwave oven. Morphologic analysis took place at 6 months. The macroscopic appearance of the graft was continuous in all type 4 and 5 animals. Morphometric analysis within the graft revealed a significantly greater number of fibers in type 3 animals. Average fiber diameter and g ratio were higher, although not significantly, in type 5 animals. Distal to the graft, average fiber diameter and g ratio were significantly higher in type 5 rats. Denaturation by exposure to thermal shock significantly improves axonal regeneration, both quantitatively and qualitatively. The regeneration rate seems to be more rapid within denatured muscle. Denaturing muscle by exposure to thermal shock provides an excellent guide for axonal regrowth, but axonal leaks may occur. This problem is solved by a muscle-in-vein graft technique.

Brachial plexus injuries in scapulothoracic dissociation.

The rare condition of scapulothoracic dissociation (STD) is characterized by a lateral displacement of the scapula from the thoracic cage following severe trauma to the scapular girdle. This study presents an analysis of five STDs. There were three supraclavicular brachial plexus palsies and two retro- and infraclavicular palsies. Recovery of elbow flexion was obtained in only two cases. Nerve damage dominates the prognosis and nerve recovery only rarely occurs. Nerve surgery should attempt to reestablish elbow flexion.

The wrist of the formula 1 driver.

OBJECTIVES: During formula 1 driving, repetitive cumulative trauma may provoke nerve disorders such as nerve compression syndrome as well as osteoligament injuries. A study based on interrogatory and clinical examination of 22 drivers was carried out during the 1998 formula 1 World Championship in order to better define the type and frequency of these lesions. METHODS: The questions investigated nervous symptoms, such as paraesthesia and diminishment of sensitivity, and osteoligamentous symptoms, such as pain, specifying the localisation (ulnar side, dorsal aspect of the wrist, snuff box) and the effect of the wrist position on the intensity of the pain. Clinical examination was carried out bilaterally and symmetrically. RESULTS: Fourteen of the 22 drivers reported symptoms. One suffered cramp in his hands at the end of each race and one described a typical forearm effort compartment syndrome. Six drivers had effort "osteoligamentous" symptoms: three scapholunate pain; one medial hypercompression of the wrist; two sequellae of a distal radius fracture. Seven reported nerve disorders: two effort carpal tunnel syndromes; one typical carpal tunnel syndrome; one effort cubital tunnel syndrome; three paraesthesia in all fingers at the end of a race, without any objective signs. CONCLUSIONS: This appears to be the first report of upper extremity disorders in competition drivers. The use of a wrist pad to reduce the effects of vibration may help to prevent trauma to the wrist in formula 1 drivers.

Palmar perilunate fracture-dislocation of the carpus.

We report an uncommon palmar translunate, transhamate carpal fracture dislocation. CT-scans with three-dimensional reconstruction were most helpful for the assessment of the injury, which was treated operatively through a palmar approach. The lunate and hamate fractures were fixed using mini-screws and the radial styloid fracture and the scaphoid were reduced and stabilized with K-wires.