Proximal toe wrap-around: a coverage technique for circumferential skin defects of the fingers.

Circumferential skin defects of the fingers are a technical challenge. Although rare, their management should respect tissue organization and functional abilities. We report two cases of circumferential skin defect. Management used individually tailored "wrap-around" flaps taken from the hallux. The sample concerned the proximal cutaneous sheath of the first toe and the neurovascular pedicle of the first inter-metatarsal space. Nail and toe pad were spared. Both cases had complex circumferential skin defect of the finger, involving the neuro-vascular pedicle. Postoperative results were favorable, without functional limitation. The wrap-around technique provided skin coverage and also neurovascular pedicle reconstruction. Donor site damage was limited, with no functional consequences. This technique is a valuable option for management of circumferential skin defect of the finger.

Nerve entrapment complicating neurogenic thoracic outlet syndrome surgery: A 10-year retrospective study.

Neurogenic thoracic outlet syndrome results from compression of the brachial plexus. The symptoms are mainly pain, upper-limb weakness and paresthesia. Management always starts with a rehabilitation program, but failure of rehabilitation may necessitate surgery. In practice, we observed that several patients developed secondary distal nerve entrapment in the months following surgery, with no preoperative compression. We aimed to assess the occurrence of distal nerve entrapment after surgery for neurogenic thoracic outlet syndrome in a retrospective cohort study. Seventy-four patients were included; 82% females; mean age, 39.4 ± 9.4 years. There were 36.5% with high intensity and 63.5% with low to moderate intensity work. Eighteen (24.3%) developed secondary upper-limb entrapment at 10.6 ± 5.8 months after surgery. Sixteen had a single entrapment and 2 had two different entrapments. In 10 cases (50%) the ulnar nerve was involved at the elbow, in 7 (35.0%) the radial nerve at the radial tunnel, and in 3 (15.0%) the median nerve. No differences were found between patients with and without secondary nerve entrapment in gender (p = 0.51), mean age (p = 0.44), symptom duration (p = 0.92) or work intensity (p = 0.26). Further studies are needed to confirm these results and to shed light on the underlying mechanisms.

Anatomic feasibility study of a sartorius myocutaneous flap with a distally based pedicle and proximal skin paddle.

INTRODUCTION: We conducted an anatomic feasibility study of a sartorius myocutaneous flap with a distally based pedicle and proximal skin paddle to cover soft tissue defects of the knee region. HYPOTHESIS: A recent anatomic study by Mojalla showed that the sartorius muscle had 2 distinct pedicles, making it possible to isolate this muscle on its distal pedicle and harvest it with a skin paddle. MATERIALS AND METHODS: This anatomic study was conducted on 10 lower limbs. The 2 criteria assessed were (1) the viability of our proximal skin paddle and (2) the arc of rotation and coverage obtained with this myocutaneous flap. RESULTS: We identified 7 proximal skin paddles after the injection of India ink into the distal pedicle of the sartorius muscle. In all cases, the arc of rotation of the flap allowed coverage of the knee region. The mean distance between the inferior edge of the skin paddle and the proximal border of the patella (DBAP) was measured at 13cm, and the mean distance between the superior edge of the flap paddle and the anterior superior iliac spine (DASIS) at 16cm. The average skin paddle size was 14 by 7cm. DISCUSSION: Our anatomic study demonstrated the feasibility of our sartorius flap with a distally based pedicle and proximal skin paddle. This technique may be a viable alternative when using gastrocnemius flaps is not feasible, or the surgeon lacks the microsurgical skills to perform free flaps. LEVEL OF EVIDENCE: IV; descriptive anatomic study.

Possible role of the botulinum toxin in the management of neurogenic thoracic outlet syndrome: a systematic review.

INTRODUCTION: Thoracic outlet syndrome (TOS) is related to the compression and/or the traction of the upper-limb neurovascular bundle, responsible for a chronic painful impairment. Neurogenic TOS (NTOS) is the most common manifestation. It remains a challenging diagnosis and its treatment is also difficult. Botulinum toxin (BTX) has been described to help both the diagnosis and the symptoms improvement. EVIDENCE ACQUISITION: A systematic literature research was performed using PubMed, ScienceDirect, and Embase databases to collect studies reporting the use of BTX in NTOS management. We followed the PRISMA guidelines, and the included studies were evaluated using the GRADE approach. EVIDENCE SYNTHESIS: We included 10 original articles representing 555 patients. Various outcomes were considered, and results varied from a study to another. Symptoms relief varied from an absence of BTX effectiveness to 84.1% of improvement; relief duration was also reported from none to 88 days. BTX injections were debatable predictors of surgical procedure successes due to low evidence. There was a huge gap between the studies concerning side-effects of the BTX procedures, from none to 100% of the patients. CONCLUSIONS: There is no evidence for considering BTX injection as a validated tool for the management of NTOS. There might be a slight effect on symptoms, but outcomes are very variable, which prevents further interpretations. The use of BTX should be evaluated in larger prospective cohorts with more standardized outcomes.

Joint capsule innervation does not explain the difference in symptoms between scaphotrapezial and trapeziometacarpal osteoarthritis.

OBJECTIVES: Peritrapezial osteoarthritis (OA) includes scaphotrapezial and trapeziometacarpal OA. In clinical practice, scaphotrapezial OA seems better tolerated than trapeziometacarpal OA, with fewer complaints and better tolerance. The difference in pain could be linked to a difference in joint capsule innervation, perhaps with fewer nerve fibers in the scaphotrapezial than the trapeziometacarpal joint. MATERIALS AND METHODS: We performed a histologic evaluation of these two joints to compare their respective innervation in 17 cadaveric specimens with peritrapezial OA. Radiographic scoring confirmed the presence of peritrapezial OA. Mean Kellgren-Lawrence score was 2.2 ± 1.1 in the trapeziometacarpal joint and 1.5 ± 0.7 in the scaphotrapezial joint (p = 0.08). RESULTS: There was no difference between scaphotrapezial and trapeziometacarpal joints in number of neurofilaments: 5.2 ± 3.9 and 4.4 ± 4.5, respectively (p = 0.20). A significant difference was found in S100 staining (myelinated structures), with a higher rate in the scaphotrapezial joint: 11.8 ± 7.5 vs 6.6 ± 5.2 (p = 0.005). CONCLUSION: The present study suggests that lower tolerance of trapeziometacarpal OA is not due to a difference in joint capsule innervation. On the contrary, we found a higher rate of myelinated tissues in the scaphotrapezial joint. These results suggested other pain pathways to explain clinical observations.

Anatomic feasibility study of osteocutaneous free flap from the proximal ulna.

OBJECTIVE: The present anatomic study aimed to assess the feasibility of an osteocutaneous free flap harvested from the proximal ulna for reconstruction after complex hand trauma. METHOD: Nineteen upper limb specimens free of scarring in the elbow region were injected in the brachial artery. After S-shaped incision centered on the medial epicondyle, a systematic approach to the epitrochlear-olecranal groove exposed the superior ulnar collateral artery and ulnar nerve. Bone and skin perforators were screened for during dissection and their emergence with respect to the medial epicondyle was assessed. Pedicle length was also assessed. The skin paddle was harvested in the distal part of the S incision and the operative site was closed by local skin plasticity. RESULTS: Bone and skin perforators from the superior ulnar collateral artery were found in all 19 specimens. Mean pedicle length from the artery was greater than 9cm in all cases. The skin perforator emerged at a mean 19mm distally from the medial epicondyle, and the bone perforator at a mean 40mm. DISCUSSION: An osteocutaneous free flap can be harvested from the proximal ulna and medial side of the elbow. As bone and skin perforators were found in all 19 cases, this flap can be used routinely. Harvesting, however, systematically involves ulnar nerve release and anterior transposition. This osteocutaneous free flap harvested from the proximal ulna offers an alternative for osteocutaneous defects in the hand, with harvesting from the same limb. CONCLUSION: In this anatomic series, an osteocutaneous free flap could in all cases be harvested from the posterior ulnar recurrent artery via a medial elbow approach. Safety and efficacy remain to be demonstrated in in vivo reconstruction. LEVEL OF EVIDENCE: III.

Use of hand hydraulic dynamometers as an overall evaluation of the upper-limb weakness in patients with thoracic outlet syndrome.

Patients with neurogenic thoracic outlet syndrome report pain and upper-limb weakness. They complain about weakness occurring on the entire upper-limb, especially at the hand and the shoulder levels. Hydraulic dynamometers can reliably assess the strength of the hand, and isokinetic shoulder testing can provide accurate and reliable evaluations of the rotators strength. Yet, isokinetic proximal assessment needs expensive tools, whereas hydraulic hand dynamometers are cheap and easy to use. We aimed to assess the correlation between the isokinetic shoulder strength and the hand grip and the key pinch strength. The grip strength was evaluated with a hydraulic hand dynamometer and the key pinch with a pinch gauge. Isokinetic rotators strength tests were performed using a Humac Norm® dynamometer at 60 and 180°/s. One-hundred and thirty patients had been included, 72% of women, mean age of 39.8 ± 9.5. Symptomatic hands presented a strength deficit of 12.2% on the grip (p < 0.0001) and 10% on the key pinch (p = 0.01). Isokinetic strength was lower on the symptomatic shoulders at 60 and 180°/s concerning medial rotators [-10.3 and -8.8%, respectively (p = 0.02)] and lateral rotators [-10.8 and -10%, respectively (p = 0.04 and p = 0.03)]. There was a moderate correlation between the grip strength of the symptomatic upper-limbs and the isokinetic rotators strength (p < 0.001). The key pinch strength was moderately correlated to the isokinetic medial and lateral rotators strength at 60°/s (p < 0.001). Hand dynamometers could prove useful during medical consultations or in outpatient management to assess upper-limb overall weakness, but isokinetic measurement remains the gold standard for a precise evaluation.

Use of Electroneuromyography in the Diagnosis of Neurogenic Thoracic Outlet Syndrome: A Systematic Review and Meta-Analysis.

Neurogenic thoracic outlet syndrome (NTOS) is a disabling condition. Its diagnosis remains challenging and is mainly guided by examination. Yet, electrophysiological evaluations are the gold standard for diagnosis of entrapment syndromes. We aimed to assess the interest of electrophysiological evaluation to diagnose NTOS. A systematic literature research was performed using PubMed, ScienceDirect, Embase, Cochrane and Google Scholar databases to collect studies reporting results of electrophysiological assessment of patients with NTOS. Then, a meta-analysis was conducted. Nine studies were eligible and concerned two hundred and thirteen patients. Results were heterogenous among studies and the quality of evidence was very low to moderate. Data could not evaluate sensitivity or specificity of electrophysiological evaluations for NTOS. The meta-analysis found significantly decreased amplitudes of medial antebrachial cutaneous nerve SNAP (sensory nerve action potential), ulnar SNAP, median CMAP (compound motor action potential) and ulnar CMAP. Needle examination found abnormalities for the abductor pollicis brevis, first dorsal interosseous and adductor digiti minimi. Unlike most upper-limb entrapment syndromes, nerve conduction assessment only provided clues in favour of NTOS. Decreased amplitude for ulnar SNAP, medial antebrachial cutaneous SNAP, median CMAP and ulnar CMAP should be assessed, as well as needle examination. Larger studies are needed to evaluate the sensitivity and specificity of electrophysiology in NTOS diagnosis.

Thoracic Outlet Syndrome in Sport: A Systematic Review.

Thoracic outlet syndrome (TOS) is a rare and heterogeneous syndrome secondary to a compression of the neurovascular bundle in the thoracic outlet area. Muscle hypertrophy is recognized to induce vascular or neurogenic compression, especially in sports involving upper-arm solicitation. Athletes represent a distinctive population because of a specific management due to an ambitious objective, which is returning to high-level competition. We evaluated the scientific literature available for the management of TOS in athletes. Article research extended to March 2021 without other restriction concerning the date of articles publication. The search was performed independently by two assessors. A first preselection based on the article titles was produced, regarding their availability in English or French and a second preselection was produced after reading the abstracts. In case of doubt, a third assessor's advice was asked. Case reports were selected only if the sport involved was documented, as well as the level of practice. Cohorts were included if data about the number and the sport level of athletes were detailed. Seventy-eight articles were selected including 40 case reports, 10 clinical studies and 28 reviews of literature. Baseball pitchers seem to be highly at risk of developing a TOS. The surgical management appears particularly frequent in this specific population. The prognosis of TOS in athletes seems to be better than in the general population, possibly due to their better physical condition and their younger age. Some studies showed interesting and encouraging results concerning return to previous sport level. Literature shows a strong link between TOS and certain sports. Unfortunately, this syndrome still lacks rigorous diagnostic criteria and management guidelines for athletes.

Shoulder Isokinetic Strength Deficit in Patients with Neurogenic Thoracic Outlet Syndrome.

Neurogenic thoracic outlet syndrome (NTOS) is an impairing painful condition. Patients usually report upper-limb pain, weakness and paresthesia. Shoulder weakness is frequently reported but has never been described with objective strength evaluation. We aimed to compare isokinetic shoulder strength between patients with NTOS and healthy controls. Patients and controls were prospectively evaluated with an isokinetic strength test at 60 and 180°/s, and an endurance test (30 repetitions at 180°/s) of the shoulder rotators. Patients were functionally assessed with QuickDASH questionnaires. One hundred patients and one hundred healthy subjects were included. Seventy-one percent of patients with NTOS were females with a mean age of 39.4 ± 9.6. They were compared to controls, 73% females and the mean age of 38.8 ± 9.8. Patients' mean QuickDASH was 58.3 ± 13.9. Concerning the peak of strength at 60°/s, the symptomatic limbs of patients with NTOS had significantly 21% and 29% less strength than the control limbs for medial and lateral rotators, respectively (p ≤ 0.001). At 180°/s, the symptomatic limbs had significantly 23% and 20% less strength than the controls for medial and lateral rotators, respectively (p ≤ 0.001). The symptomatic limbs had significantly 45% and 30% less endurance than the controls for medial and lateral rotators, respectively (p ≤ 0.001). These deficits were correlated to the QuickDASH. Patients with NTOS presented a significant deficit of strength and endurance of the shoulder rotators correlated to disability. This highlights the interest in upper-limb strength evaluation in the diagnostic process and the follow-up of NTOS.

Long-term outcome of a "short" anterograde homodigital neurovascular island flap with a simple or double V-Y plasty.

INTRODUCTION: Anterograde homodigital neurovascular island flaps are very useful for reconstructing proximal fingertip amputations with exposed bone but have the disadvantage of bringing about proximal interphalangeal joint (PIPJ) stiffness. The addition of a single or double V-Y plasty increases mobility without having to extend the dissection beyond the PIPJ. The purpose of this study was to examine the long-term functional outcome of patients who received a "short" anterograde homodigital neurovascular island flap with a single or double V-Y plasty. Our primary hypothesis was that this flap did not induce PIPJ stiffness and our secondary hypothesis was that it preserved good fingertip sensation. MATERIALS AND METHODS: This was a retrospective study of patients operated between August 2017 and February 2019. The inclusion criteria were the following: a fingertip amputation caused by either a crush or laceration injury with exposed bone, treated during the acute phase of the injury or for secondary necrosis (attempted replantation or subtotal amputation) and classified as type II oblique palmar, type III or type IV amputations according to the Allen classification system. The assessment criteria were: joint mobility, sensory evaluation with the two-point discrimination and Semmes-Weinstein monofilament tests, time to healing, postoperative complications, postoperative splinting, duration of work stoppage, perioperative smoking, cold intolerance, touch hypersensitivity, nail deformity and excluded finger. RESULTS: Nine patients (mean age 53.9 years [32-67]) were operated, of which eight long fingers and one thumb. One procedure was complicated by skin flap necrosis. At the mean follow-up of 22.4 months [16-31], the mean mobility for the metacarpophalangeal joint (MCPJ), proximal interphalangeal joint and distal interphalangeal joint (DIPJ) were 92-0-0°, 97.8-1.5-0° and 60.3-6.8-0°, respectively. In comparison to the contralateral side, a significant difference was only detected in the DIPJs. The mean two-point discrimination in the proximal portion of the flaps were 7.1mm on the ulnar side (p<0.05) and 7.6mm on the radial side (p<0.01), while in the distal portion they were 7.3mm (p<0.01) and 7.8mm (p<0.01). The Semmes-Weinstein monofilament test also detected significantly reduced sensation. CONCLUSION: The combination of a "short" anterograde homodigital neurovascular island flap with a single or double V-Y plasty seems to avoid PIPJ stiffening while preserving good fingertip sensation. LEVEL OF EVIDENCE: IV; retrospective study.

Secondary finger amputation after a work accident.

INTRODUCTION: The main aim of the present study was to compare motives between patients requesting secondary finger amputation following or unrelated to a work accident. The secondary objective was to assess correlation between sick leave duration and motive for amputation following a work accident. METHOD: A single-center retrospective study was conducted over an 11-year period in a hand clinic. Cases of secondary totalizing post-traumatic finger amputation at metacarpal base level were included. Exclusion criteria comprised non-traumatic amputation, age<16 years and thumb amputation. In all, 216 patients met the inclusion criteria. The main endpoints assessed motives in requests for secondary metacarpal base amputation: esthetic, functional or administrative. Secondary endpoints comprised accident-to-surgery interval, gender and age, amputated digit and dominant-side involvement. RESULTS: Motive correlated significantly with gender (p<0.05). Administrative motives almost exclusively concerned males (21 males, 1 female) and predominantly concerned work accidents (19 vs. 3). Accident-to-surgery intervals were significantly longer in case of administrative motive (25.7 months, vs. 10.8 months for functional and 9 months for esthetic motives). Accident-to-surgery intervals were significantly longer in case of work accidents (15.2 vs. 9.5 months). DISCUSSION: Age and gender influenced patients' attitudes in post-traumatic finger amputation. Work-accident status influenced attitudes in a quarter of cases; we consider it unlikely that this can be reduced to claims for compensation, but that it is rather a matter of undiagnosed pathological grief. These findings highlight the importance of early follow-up of victims of traumatic amputation and early screening for pathological grief.

Traumatic upper-limb amputation: The process toward acceptance.

INTRODUCTION: After traumatic upper-limb amputation (TULA), one-third of patients develop traumatic pathological grief (PG). However, are the other two-thirds unscathed? The main aim of the present study was to assess the rate of TULA victims claiming to have dealt with the consequences and showing no PG. The secondary objective was to determine positive and negative factors enabling and preventing coping. METHOD: A retrospective clinical study was conducted over an 11-year period in all adult TULA cases in our department. Assessment was on questionnaire. PG was assessed on the ICG (Inventory of Complicated Grief). Factors were assessed on physical, psychological, social, functional, esthetic and epidemiological criteria. Statistical analysis used StatView software, with the significance threshold set at p<0.05. RESULTS: Functional and social impacts were significantly greater in case of PG. Thumb amputation was significantly associated with PG, while PG was significantly less frequent in case of amputation at the metacarpal base. Patients in PG had significantly more often undergone neuroma resection or stump revision surgery. DISCUSSION: Fewer than a half of TULA victims achieved cure. Long-term prognosis depends on the patient's ability to accept the new situation, much more than on amputation level. Patients need support from the very first minutes, with follow-up extended well belong scar healing. Onset and healing of the narcissistic wound are inevitably delayed compared to skin healing.

Psychological effects of traumatic upper-limb amputations.

INTRODUCTION: The main aim of the present study was to determine the existence of pathological grief in victims of traumatic upper-limb amputation. The secondary objective was to determine risk factors for onset of pathological grief. METHOD: A retrospective clinical study was conducted for an 11-year period, including all cases of traumatic upper-limb amputation in adults. Patients were assessed on a questionnaire including an adaptation of the Inventory of Complicated Grief (ICG). Risk factors were assessed on surgical, personal occupational and subjective criteria. Statistical analysis on StatView software used matched Chi2 tests for comparisons, with the significance threshold set at p<0.001. RESULTS: With 1058 questionnaires sent out, the response rate was 52%; 3% of returned questionnaires were non-interpretable. Thirty-nine percent showed a state of pathological grief. Risk factors comprised lack of attempted replantation (p<0.001), isolated thumb amputation (p<0.001), and multi-digit or macro-amputation (p<0.001). Subjective esthetic blemish or the feeling of being mutilated was significantly associated with pathological grief (both p<0.001). DISCUSSION: Traumatic upper-limb amputation victims incurred a risk of pathological grief (main endpoint), with identifiable risk factors (secondary endpoint). Victim accompaniment and screening for risk of pathological grief are essential to limit the psychological impact of trauma and promote social and occupational reintegration.

Optimization of the homodigital antegrade island flap for fingertip reconstruction: New dissection sequence based on cadaver study findings.

INTRODUCTION: The homodigital antegrade island flap pedicled on the proper palmar digital artery is very useful for covering fingertip defects. However, it has its drawbacks, such as the risk of stiffness due to retractile scars and the need for extensive dissection with long-lasting dysesthesia in some cases. In clinical studies, expanding the skin paddle with V-shaped incisions increases the flap's advancement. We wanted to know whether making these V incisions for paddle expansion would make dissection on the volar side of the proximal interphalangeal joint unnecessary. METHODS: A cadaver study was performed with four fresh-frozen upper limbs. Sequential dissection was carried out on 32 flaps, allowing us to compare the advancement obtained and the area of the flap's paddle between each step. RESULTS: Crossing the palmar crease of the proximal interphalangeal joint provides only 2mm advancement of the homodigital antegrade flap. Adding one or two V-shaped incisions in the flap with limited dissection provides additional advancement of 4.1mm (p<0.05) and 6.9mm (p<0.05) relative to the standard flap. DISCUSSION: Our study shows the possibility of increasing the homodigital antegrade flap's advancement - without having to extend the dissection proximally to the PIP joint - by making V-shaped incisions in the paddle. Based on our findings, we have proposed a new flap dissection sequence.