Multifactorial Analysis of Treatment of Long-Bone Nonunion with Vascularized and Nonvascularized Bone Grafts.

Introduction The purpose of the study was to evaluate the results of treatment of the nonunion of long bones using nonvascularized iliac crest grafts (ICGs) or vascularized bone grafts (VBGs), such as medial femoral condyle corticoperiosteal flaps (MFCFs) and fibula flaps (FFs). Although some studies have examined the results of these techniques, there are no reports that compare these treatments and perform a multifactorial analysis. Methods The study retrospectively examined 28 patients comprising 9 women and 19 men with an average age of 49.8 years (range: 16-72 years) who were treated for nonunion of long bones between April 2007 and November 2018. The patients were divided into two cohorts: group A had 17 patients treated with VBGs (9 patients treated with MFCF and 8 with FF), while group B had 11 patients treated with ICG. The following parameters were analyzed: radiographic patterns of nonunion, trauma energy, fracture exposure, associated fractures, previous surgeries, diabetes, smoking, age, and donor-site morbidity. Results VBGs improved the healing rate (HR) by 9.42 times more than the nonvascularized grafts. Treatment with VBGs showed a 25% decrease in healing time. Diabetes increased the infection rate by 4.25 times. Upper limbs showed 70% lower infection rate. Smoking among VBG patients was associated with a 75% decrease in the HR, and diabetes was associated with an 80% decrease. Conclusion This study reports the highest success rates in VBGs. The MFCFs seem to allow better clinical and radiological outcomes with less donor-site morbidity than FFs.

Distraction Arthroplasty for Basal Thumb Osteoarthritis: 10-Year Follow-Up.

PURPOSE: Trapeziectomy has frequently been used to treat basal thumb osteoarthritis. However, complications, such as shortening of the thumb ray and reduced mobility and strength, can occur. The aim of this study was to present a 10-year follow-up of distraction arthroplasty without trapeziectomy. METHODS: Fifteen patients were followed for a mean of 121 months (range, 121-124 months). Subjective outcomes were evaluated with the Disabilities of the Arm, Shoulder, and Hand questionnaire, while the pain intensity was assessed with a Visual Analog Scale both before surgery and at the end of follow-up. Objective outcomes were obtained using the Kapandji score and an assessment of grip and pinch strength. Preoperative and final postoperative x-rays were obtained to evaluate metacarpal subsidence and progression of trapezial-metacarpal joint arthritis. RESULTS: The Visual Analog Scale score was reduced from 9.4 ± 0.5 before surgery to 2.5 ± 1 at follow-up. The mean Disabilities of the Arm, Shoulder, and Hand questionnaire score was 75.6 ± 12.6 before surgery and 16.9 ± 4 at 10 years. Hand grip strength of the operated side (26 ± 5.5 kg) achieved 95% of functionality compared to the opposite side, while key pinch strength (6.4 ± 1.6 kg) reached 93%. A Kapandji opposition score of 10 points was found in 12 patients, a score of 9 was found in 1, and a score of 8 was found in 2. CONCLUSIONS: Distraction arthroplasty of the trapeziometacarpal joint ensures good results in long-term follow-up, when performed in patients with stage I-II basal thumb osteoarthritis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

A Helpful Assistant for Disinfection in Hand Surgery Procedures: The LocArm Holder.

Background: Although there is no consensus regarding the best skin disinfection technique, whatever antiseptic solution is used, the "prep and drape" portion of most upper extremity procedures requires the presence of at least one operative room assistant or scrub nurse to elevate and hold the hand and forearm. Nonetheless, especially in a busy hand surgery practice and during fast procedures, an operative room assistant or scrub nurse are frequently not available leading to a reduced time efficiency between procedures. Purpose: This article describes an innovative easy-to-use and hands-free device that helps the surgeon during disinfection of the skin and the setup of the surgical field by keeping elevated the upper limb with respect for tissues. Methods: The development of the surgical arm holder starts from three easily available and washable thermoplastic splint sheets 40 × 60 cm with 2.5 cm thickness. The final device measures 40 × 25 × 15 cm and is placed underneath the proximal third of the humerus in order to keep the upper limb suspended at about 10-15 cm from the operating table. A retrospective analysis of the "surgical malpractice claims" and institutional non-conformities registered in the period 2011-2020 was conducted in our Hospital looking for bone or soft tissue complications related to the use of the device. Results: Three thousand one hundred eighty-seven surgical procedures were performed between 2011 and 2020 using this device. The retrospective analysis of all "surgical malpractice claims" showed no skin lesions, no neurological complications (such as neuroapraxia), no need for secondary bone procedures or interference with the draping process. Conclusion: Our device proved to be a low-cost, easy to use and alternative solution helping surgeons during the disinfection phase, improving hospital pre-operative flow and reducing the need for other staff members to be engaged in holding the upper limb in the operating room.

Volar locking plate vs cast immobilization for distal radius fractures: a systematic review and meta-analysis.

Introduction: The aim of this systematic review and meta-analysis was to evaluate whether volar locking plate (VLP) fixation leads to better clinical and radiological outcomes than those of closed reduction and cast immobilization for the treatment of distal radius fractures (DRFs). Materials and methods: A comprehensive literature search was performed in PubMed, Web of Science, and Cochrane databases up to January 2022. Inclusion criteria included randomized controlled trial (RCT) studies comparing VLP fixation with cast immobilization for DRFs. Investigated parameters were Patient-Rated Wrist Evaluation questionnaire, Disabilities of the Harm, Shoulder, and Hand score (DASH), range of motion (ROM), grip strength, quality of life (QoL), radiological outcome, and complication and reoperation rate, both at short- and mid-/long-term follow-up. Assessment of risk of bias and quality of evidence was performed with Downs and Black's 'Checklist for Measuring Quality'. Results: A total of 12 RCTs (1368 patients) were included. No difference was found for ROM, grip strength, QoL, and reoperation, while the DASH at 3 months was statistically better in the VLP group (P < 0.05). No clinical differences were confirmed at longer follow-up. From a radiological perspective, only radial inclination (4°) and ulnar variance (mean difference 1.1 mm) at >3 months reached statistical significance in favor of the VLP group (both P < 0.05). Fewer complications were found in the VLP group (P < 0.05), but they did not result in different reintervention rates. Conclusions: This meta-analysis showed that the surgical approach leads to a better clinical outcome in the first months, better fracture alignment, and lower complication rate. However, no differences in the clinical outcomes have been confirmed after 3 months. Overall, these findings suggest operative treatment for people with higher functional demand requiring a faster recovery, while they support the benefit of a more conservative approach in less demanding patients.

Is a Vascularized Interphalangeal Unicondylar Transfer Worth the Efforts? Surgical Technique and Clinical Application.

Interphalangeal joints (IPJ) play a key role in hand function for performing activities of daily living and are frequently involved in complicated injuries resulting in significant functional limitations such as secondary arthritis and stiffness being the most challenging. In adult patients with more than 5 mm bone loss of the proximal articular surface who request a functional interphalangeal joint with minimal pain a vascularized joint transfer is a treatment choice. A unicondylar loss more than 5 mm wide in a 22-year-old carpenter is reported and illustrates our experience with a vascularized unicondylar transfer showing the advantages compared to the "classic" total joint transfer or distal interphalangeal (DIP) joint arthrodesis. By using this technique at the 12-month follow-up, we achieved no donor site complications, a good graft alignment, a good joint congruity, complete bone healing and a normal vascular patency with no signs of bone malunion or resorption of the graft.

Finger Amputation after Pinning of the Distal Interphalangeal Joint for Acute Closed Tendinous Mallet Finger: A Rare but Devastating Complication.

The best treatment for mallet fingers is still a matter of debate. Numerous splints with different designs to keep the distal interphalangeal (DIP) joint in extension have been described in literature. The outcomes of splint treatment are generally good with occasional reports of minor skin complications. Percutaneous Kirschner-wire pinning of the DIP joint for closed tendinous mallet finger represents a alternative treatment modality that reliably immobilises the joint and does not need much patient compliance or use of an external splint. We report a rare but devastating complication of percutaneous pinning of the DIP joint for closed tendinous mallet finger. Level of Evidence: Level V (Therapeutic).

The Use of an Adipofascial Flap to Prevent Extensor Tendon Adhesions After Plating of the Proximal Phalanx of the Fingers: A Comparative Study.

BACKGROUND: Extensor tendon adhesions occurring after proximal phalangeal (P1) fractures are not uncommon. A previous report described the use of an adipofascial flap (AFF) to prevent adhesions after dorsal plating of the P1. The purpose of the study is to examine the results of open reduction and internal fixation with the use of an AFF (F group) and without (N group, that is, no flap used) in a larger group of patients. METHODS: A retrospective study involving a period of 11 years was conducted involving results of 21 unstable fractures of the P1 of the fingers in 18 patients. In all, 12 fingers were treated without any flap (N group) and 9 fingers were treated with the AFF (F group). For each patient, the total active motion (TAM) ratio, and the grip strength (Jamar) ratio were assessed, and adverse effects and the 10-point visual analogue scale (VAS) score were recorded. For statistical analysis, sample characteristics were described using mean ± standard deviation and median, and a Bayesian approach was used for inferential analysis. RESULTS: In the F group, the TAM ratio (84% ± 13% vs 65% ± 17%) was higher with a lower rate of adverse effects (OR: 0.067, 95% CI, 0.0035-0.58,) and a lower VAS score with evidence of the positive effect of the AFF. The Jamar ratio was similar in the 2 groups (F group 80% ± 25% vs N group 79% ± 19%) with no associated effect of the AFF on grip strength. CONCLUSIONS: The AFF is a reliable tool to reduce adhesions between plates and the extensor apparatus of the P1 and may be useful to improve finger function after plating of P1 fractures. TYPE OF STUDY/LOE: Therapeutic, Retrospective, Level IV.

Metallic foreign body in the ulnar nerve in the Guyon's canal and Review of the Literature.

The authors present a rare case of a 61-year-old patient with a metal foreign body inside the ulnar nerve in the Guyon's canal. After the surgical removal the motor function was not impaired. At 6-month follow up from the surgical removal, the patient showed a complete motor and sensory function.

The Influence of Low- and High-Negative-Pressure Liposuction and Different Harvesting Sites on the Viability and Yield of Adipocytes and Other Nucleated Cells.

BACKGROUND: The volume effect of fat grafting is highly dependent on the presence of viable adipocytes and other nucleated cells within the lipoaspirate. We suspected that one of the crucial factors influencing cell viability is the negative pressure applied during the fat graft harvesting and the suitability of various harvest sites when compared to others. Despite much discussion, there is no consensus on the optimal negative pressure or the best site for harvesting so we designed an experiment to test this. METHODS: Fat graft taken under low negative pressure (- 200 mmHg) or high negative pressure (- 700 mmHg) from the thigh or abdominal regions from 21 healthy human donors was evaluated. The principal variables studied were: a) total number and viability of nucleated cells, b) liposuction duration and c) blood admixture. Other variables studied were body mass index, the impact of age and enzymatic digestion. RESULTS: The absolute number and viability of nucleated cells and the blood admixture did not differ significantly between lipoaspirates obtained under different vacuum conditions or from different regions. The time taken to acquire the same volume of lipoaspirate was significantly increased using low negative pressure. The time taken to collect cells in the thigh region significantly increased with increasing BMI but this correlation was not found when harvesting in the abdominal region. The BMI and age did not impact the results in any of the measured variables. The enzymatic digestion rate was independent of the negative pressure used to harvest. CONCLUSION: Our results indicate that neither the negative pressure used nor the area chosen has any significant influence on the viability and yield of harvested cells. The time taken to obtain lipoaspirate using low pressure is significantly longer than when using high pressure. No significant difference was found in the value of blood admixture using different vacuum pressures, and no correlation exists between the body mass index and the cell viability or age of the patients and the time of liposuction. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .

The Influence of High and Low Negative Pressure Liposuction and Various Harvesting Techniques on the Viability and Function of Harvested Cells-a Systematic Review of Animal and Human Studies.

BACKGROUND: An understanding of fat grafting methodology, techniques and patient-related factors is crucial when considering fat grafting. Multiple factors can influence the success of a fat graft and consequently the outcome of the procedure. The aim of this systematic review is to elucidate the influence of negative pressure and various techniques of fat harvesting on the viability and function of cells, particularly adipocytes and adipose-derived stem cells. METHODS: We conducted a literature search from 1975 to 2020 using the PubMed bibliography, ScienceDirect, SCOPUS and the Google Scholar databases which produced 168,628 articles on the first pass. After applying all the exclusion criteria by two independent reviewers, we were left with 21 articles (level IV of Oxford Centre for Evidence-Based Studies and Grade C of Grade Practice Recommendation from the American Society of Plastic Surgeons) on which this review is based. RESULTS: From 11 studies focused on different negative pressures, no one found using high negative pressure advantageous. Summarising 13 studies focused on various harvesting techniques (excision, syringe, and pump-machine), most often equal results were reported, followed by excision being better than either syringe or liposuction. CONCLUSION: From our systematic review, we can conclude that the low negative pressure seems to yield better results and that the excision seems to be the most sparing method for fat graft harvesting. However, we have to point out that this conclusion is based on a very limited number of statistically challengeable articles and we recommend well-conducted further research. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The use of sentinel skin islands for monitoring buried and semi-buried micro-vascular flaps. Part I: Summary and brief description of monitoring methods.

Micro-vascular flaps have been used for the repair of challenging defects for over 45 years. The risk of failure is reported to be around 5-10% which despite medical and technical advances in recent years remains essentially unchanged. Precise, continuous, sensitive and specific monitoring together with prompt notification of vascular compromise is crucial for the success of the procedure. In this review, we provide a classification and brief description of the reported methods for monitoring the micro-vascular flap and a summary of the benefits over direct visual monitoring. Over 40 different monitoring techniques have been reported but their comparative merits are not always obvious. One looks for early detection of a flap's compromise, improved flap salvage rate and a minimal false-positive or false-negative rate. The cost-effectiveness of any method should also be considered. Direct visualisation of the flap is the method most generally used and still seems to be the simplest, cheapest and most reliable method for flap monitoring. Considering the alternatives, only implantable Doppler ultrasound probes, near infrared spectroscopy and laser Doppler flowmetry have shown any evidence of improved flap salvage rates over direct visual monitoring.

The use of sentinel skin islands for monitoring buried and semi-buried micro-vascular flaps. Part II: Clinical application.

Despite the high success rate of micro-vascular flaps, anastomosis compromise occurs in 5-10% and that can lead to flap failure. Reliable monitoring of the flap is therefore of similar importance to that of the precise surgical procedure itself. Multiple methods have been reported for monitoring of the flap vitality, the first one being direct visual monitoring. In buried flaps direct visualisation is not feasible or is unreliable. In these cases we can extend the buried flap to expose a segment of it to act as a monitoring sentinel. For the purpose of this review we used our clinical experience as a starting point, and for the extended information and expertise we conducted a search of the PubMed database. Over 40 monitoring techniques have been reported to-date. Direct visual monitoring is still generally used method with a reliability of up to 100% and an overall success rate of up to 99%. Direct visualisation remains as the simplest, cheapest and yet a very reliable method of flap monitoring. In this review we provide a description of various possible techniques for externalising part of a buried flap, define the tissues that can be used for this purpose and we summarise the procedures that should be followed to achieve the best reliability and validity of monitoring the skin island.

An Atypical Lipomatous Tumor of the Forearm: A Case Report.

Introduction: Atypical lipomatous tumor (ALT) is a rare, well-differentiated and low-grade liposarcoma originating in deep soft tissue compartments of extremities and trunk. The optimal surgical treatment in the upper extremity is still controversial. Some Authors suggest the wide excision of the mass including the sacrifice of the muscle-surrounding tumor, others recommend the marginal resection of the lesion. Case Report: We report a case of a 58-year-old patient who underwent the "simple" marginal resection of an ALT in the forearm by sparing the muscles surrounding the lesion. After 60 months, the patient is asymptomatic with no recurrence of the mass and a total recovery for activities of daily living. Conclusion: Based on our experience the simple marginal resection "en bloc" is the gold standard for skilled hand surgeons to preserve neurovascular structure with no recurrences at medium-term follow-up.

Sonographic Follow-Up of Patients With Cubital Tunnel Syndrome Undergoing in Situ Open Neurolysis or Endoscopic Release: The SPECTRE Study.

Background:The measurement of cross-sectional area (CSA) is a diagnostic tool to detect entrapments syndrome. The aim of this study was to compare the clinical outcome in elbows undergoing endoscopic and "in situ" open cubital tunnel release for cubital tunnel syndrome (CuTS) using ultrasound-related changes in the largest CSA of the ulnar nerve. The purpose is to determine the association between clinical outcome and CSA. Methods: From May 2011 to April 2016, 60 patients with CuTS were prospectively followed and not randomly divided in two groups: 30 patients undergoing an endoscopic release (ER) and 30 patients with "in situ" open neurolysis (OR). A sonographic examination was performed by the senior authors at baseline and 3, 6, and 12 months after surgical decompression. Results: CSA values were statistically significantly lower in the ER. Hand grip strength difference with Jamar test was not statistically significant a 12 months (39 kg vs 27 kg). Static-2 point discrimination test difference was only statistically significant lower in the endoscopic group at 3, 6 and 12 months but not clinically relevant (5 mm vs 6 mm). The American Shoulder and Elbow Surgeons-Elbow questionnaire (ASES-e) function score, ASES-e Pain score, and ASES-e Satisfaction score were not statistically significant different between the two groups at 3, 6, and 12 months post operatively. Conclusions: The study confirms that in spite of lower values of CSA in the ER, there is not a statistically significant difference between the two techniques in terms of subjective outcomes. Ultrasound (US) measurements seem to have a limited value in clinical results of patients treated for entrapment neuropathy of the ulnar nerve.Type of study/LOE: Prognostic Level III.