Wide-awake anesthesia in Dupuytren's contracture treated with collagenase.

The injection of collagenase followed by cord manipulation is one of the most popular treatments for Dupuytren's contracture. This is traditionally performed under local anesthesia or regional nerve block potentially with sedation. Neither the treatment with collagenase, nor the wide-awake anesthesia are novel techniques for hand surgeons. Nevertheless, we report the first experience of cord manipulation using the wide-awake approach. In this prospective study, we compared the pain perception of patients who underwent wide-awake anesthesia versus traditional local anesthesia. We recorded the pain sensation on a visual analog scale (VAS) (0 to 10) during anesthetic injection, during cord manipulation and before discharge. Wide-awake anesthesia significantly reduced pain levels during anesthetic injection (p=0.003) and cord manipulation (p=0.0009). Pain levels did not differ significantly right before discharge in the two groups (p=0.54). Wide-awake anesthesia can be successfully applied to cord manipulation after collagenase injection in Dupuytren's contracture. This way, it is possible to improve the patient's subjective perspective of the procedure.

Multi-dorsal metacarpal artery perforator adipofascial turnover flap for index to little finger reconstruction: Anatomical study and clinical application.

Reconstruction of the dorsum of the hand and fingers is one of the main challenges in hand surgery. Regional flaps from the forearm, free flaps, or pocket procedures are options when multiple digits are injured with tendon damage and bone exposure. These procedures can be technically demanding and are often plagued by a texture mismatch. We conducted an anatomical study of 20 fresh frozen hands. The second, third and fourth intermetacarpal spaces were analyzed with the aim of defining the vascular foundation of dorsal hand adipofascial-turnover flaps based on dorsal metacarpal artery (DMA) perforators, analyzing their potential for reconstruction procedures on the dorsum of the hand. In three cases, the 4th intermetacarpal space lacked the DMA. A mean of 3.5 arterial communications were found between the DMA and palmar arterial system. Each hand had 11 ± 2 dorsal skin perforators, which were equally distributed among different intermetacarpal spaces. At least one perforator was present in each one-third of the space. The most distal perforators were the largest in all spaces but missing in two hands. A clinical case of multiple index finger to little finger reconstruction with this new multi-dorsal metacarpal artery perforator (mDMAP) adipofascial turnover flap is presented. Our anatomical study confirmed previous descriptions of the anatomy of the dorsum of the hand. It supports the safety of the mDMAP adipofascial turnover flap based on all distal arterial perforator for the simultaneous reconstruction of index to little finger injuries. Similarly, adipofascial turnover flaps can be raised from more proximal perforators arising from DMAs if more than one intermetacarpal space is included.