Single-stage Congenital Polysyndactyly Release: Outcomes and Long-term Followup.

The current surgical strategy for syndactyly is multistage operations in which every other web is released, leaving adjacent webs unoperated for the next stage to avoid a presumed possible digital vascular compromise. In this series, we present our experience with single-stage multiple syndactylies release. A total of 7 patients, including 2 patients with bilateral hand involvement, were included. Dorsal and volar triangular flaps were created for commissure reconstruction, and zigzag manner volar and dorsal incisions were made to release the webbed fingers. Sterile thermoplastic splints were molded directly over the skin grafts without any dressing or tie-over. Following the surgical operation, minimal flexion contracture was seen in three patients that needed future correction procedures. Cosmesis and functional outcome were acceptable. This study shows that the release of all webs in 1 setting can be accomplished by no vascular compromise, and there is no need for a preoperative vascular imaging study.

Palmar approach for fixation of metacarpal fractures.

Between 2018 and 2020, 14 patients with closed metacarpal fractures requiring open reduction were operated on via a palmar approach. Reduction and fixation were done with screws or plates. We assessed range of motion, grip strength, Mayo score, possible nerve damage and cosmesis. The range of motion and grip strength were fully restored by 6 months after operation. Transient paraesthesiae in the digital nerve territory occurred in two patients and had resolved by 3 months. In selected patients the palmar approach for metacarpal shaft fractures can provide satisfactory cosmesis and function of the hand. This method can be useful in patients with history of hypertrophic scarring or in patients who would prefer to avoid a visible scar on the dorsum of the hand.Level of evidence: IV.

Plantar Skin Defect Reconstruction: A Large Series With a 15-Year Follow-up.

Extensive plantar skin defects pose a difficult situation for reconstructive surgeon, but the decision of reconstruction with multiple operations or primary below knee amputation is still open to discussion. Sole of the foot is a specialized tissue; it is important to reconstruct "like for like," that is, a kind of tissue that can endure the wear and tear of daily life and this description fits only "foot skin"; in other words, there is no better substitute for weight-bearing plantar skin, heel and forefoot, except the plantar skin itself. In this article, we present our 25 years' experience of the plantar skin defect surgery with long-term follow-up. Our long-term poor results of foot reconstruction with skin and/or muscle flaps is compared with the durable and ulcer-free midsole flap reconstructions. In a total of 22 patients, 8 latissimus dorsi musculocutaneous flaps, 11 mid sole flaps, and 1 groin flap, 1 reverse sural flap, and 1 free rectus muscle flap were used to resurface the plantar area. The patients underwent mid sole flap were satisfied with their results; however, the patients underwent latissimus dorsi flap were not completely satisfied and 2 of these patients had below knee amputation due to recurrent ulcerations and osteomyelitis. We recommend free vascularized or pedicled plantar skin flaps as the best choice for small, less than two thirds of plantar skin, heel and forefoot defects, and in extensive defects, and for defects of more than two thirds of plantar skin, amputation might be the better solution.

A Modified Surgical Technique for Minimally Invasive Arthroscopic Total Wrist Fusion.

Background Arthroscopic total wrist arthrodesis is a procedure with minimal violation of extensor compartments and less scar formation, compared with open wrist arthrodesis. In this paper, we would like to present our experience with a modified surgical technique for arthroscopic total wrist arthrodesis. Description of Technique After an arthroscopic cartilage removal through radiocarpal and midcarpal portals, the operation is continued under fluoroscopic control. In this technique, four wires are inserted separately in four various directions (as described in the paper), followed by insertion of self-tapping cannulated screw, under fluoroscopic control. Patients and Methods In this prospective study, a total of four patients underwent arthroscopic total wrist arthrodesis using our surgical technique within a period of 2 years. All four patients were followed for a minimum of 3 months for possible complications and functional outcome. Results The results were satisfactory, and no complication was observed. All the patients had complete union after 12 weeks, and the fusion was radiographically complete in all cases by 12 weeks. All patients were happy with their functional outcomes. Conclusion Using the described modified arthroscopic technique, we did four total wrist arthrodeses with minimal scar, no complication and acceptable functional results.

Endoscopic carpal tunnel release: a 5-year experience.

BACKGROUND: Endoscopic carpal tunnel release (ECTR) has gained recognition as an alternative to the current gold standard, the open carpal tunnel release (OCTR). Detailed technical points for the ECTR have not been explained in the literature, especially for surgeons who are considering trying this technique. OBJECTIVES: In this paper, we present our 5-year experience with the ECTR and special emphasis will be placed on less frequently discussed technical points, such as the optimal site to make the skin incision and the signs to look for in a completely divided retinaculum. PATIENTS AND METHODS: In this prospective nonrandomized clinical trial, 176 patients with carpal tunnel syndrome who underwent surgical operation using the Agee uni-portal endoscopic carpal tunnel release technique, over a period of 5 years, were included. The "Hand Questionnaire", a standard questionnaire for hand surgery, was used to evaluate the patients at one, three, six and twelve month post-operative time points. Pain and scar tenderness were measured using the visual analog scale system. We propose the 'most proximally present wrist crease' for the skin incision and the 'proximal to distal sequential division of the retinaculum' as our methods of choice. Two signs, named 'railroad' and 'drop in', are proposed and these will be discussed in detail as hallmarks of complete retinaculum release. RESULTS: Of the 176 patients who underwent the ECTR operation, 164 cases (93.2%) had no or very little pain at the one year postoperative visit, and nearly all of the patients reported no relapse of symptoms at the previously mentioned postoperative time points. Patient satisfaction and functional recovery was comparable to other published ECTR studies, and showed better short-term results of this technique over the OCTR. One deep seated infection, three cases of transient index finger paresthesia due to scope pressure on the median nerve, and one case of median nerve branch transection, were observed. Scar complications, including; tenderness, redness and pain, were significantly lower in the proximally placed incision in comparison with the distally placed incision (P < 0.005). CONCLUSIONS: The 'most proximally present wrist crease' and the 'distal to proximal division of the retinaculum' using the two signs of 'railroad' and 'drop in' to confirm a complete division of retinaculum are proposed techniques that should be considered in order to produce good outcomes in ECTR. The 'railroad' sign is the parallel standing of the retinaculum edges, and the 'drop in' sign is the dropping of the retinaculum edge into the scope denote a completely divided retinaculum.

Ectopic major transplantation for salvage of upper and lower extremity amputations.

OBJECTIVE: Ectopic tissue transplantation is not a new idea. Godina and his colleagues pioneered this method in the 1980s. This method is a last resort method of preserving an amputated body part, which consists of banking the amputated segment in an ectopic area and returning it to its native place at a later date. In this article we present our experience with this demanding procedure. METHODS: Debridement was the mainstay of this procedure. The stump and amputated part are carefully debrided and the stump was either closed primarily or covered by a flap. The amputated part was transplanted to one of several banking sites in the body and at a later date it will be transferred to its native site in an elective setting. RESULTS: Seven patients meeting the set criteria for ectopic transplantation were enrolled in this study. The overall success rate was about 70%, lower than expected but these are cases of severe crush injury. Although the functional recovery of these patients are very low, all of the successful cases except one could find a job as a janitor or light manual worker. No patient could return to his previous job. CONCLUSION: Ectopic transplantation of body parts is an accepted method of treatment of severely crushed extremity or finger injuries. In our country an amputee has very little chance of finding a job instead a disabled person can. In addition in Iran cultures amputation is seen as punishment of either the God or the society, so it is not well accepted and many patients persist on saving the limb even with no functional recovery. None of our successful cases could return to his previous occupation but almost all of them could find a job as janitors or light manual workers.

Necrotizing fasciitis of the upper extremity, case report and review of the literature.

ABSTRACT: Necrotizing fasciitis is a rare, life-threatening infection most commonly seen in patients with diabetes mellitus, intravenous drug abuse, and immunocompromised conditions. The extremities are the primary sites of involvement in as many as two thirds of the cases. In a significant proportion of patients, the extremities are involved as a result of trauma, needle puncture or extravasation of drugs. The infection is usually polymicrobial. Treatment involves broad-spectrum antibiotics and multiple surgical debridements or amputation. We present a patient with necrotizing fasciitis of the upper limb and present our experience with this often lethal condition.

Early coverage of upper extremity electrical injury wounds.

BACKGROUND: An appropriate and well-timed surgery has great impact on a patient's treatment and can prevent further damage to partially injured structures which if untreated will be lost leading to severe disability. In the present study we report our experience with early coverage of electrically injured upper extremity vital structures with encouraging results. OBJECTIVES: The aim of this study was to evaluate the results of early flap coverage (less than two weeks) after electrical injury in the induced wounds of upper extremity. MATERIALS AND METHODS: The records of electrically injured patients referred during a 10- year period to Firuzgar Medical Center were evaluated. After one or two sessions of debridement, the wounds were covered by distant or pedicled flaps and the results were evaluated according to the number of surgeries, complications and return to work time. RESULTS: Thirty patients were registered in this study, mean age at the time of injury was 26.43 (SD = 10.41) years; 40% of patients had right upper extremity injury, 23.3% had left and 36.7% had bilateral injury. 43.4% of patients had no complications, amputation rate was 23.3% and nerve injury was seen in 13.3% of patients. Mean days of return to work was 132.57 (SD = 64.99). In 11 patients distant flaps were used, 9 patients with graft only and 7 patients had a combination of graft and regional flaps.The dominant hand involvement in electrical injury is very high. CONCLUSIONS: We suggest that the routine treatment protocols of serial debridement until all the wound acquires a bed of granulation tissue should be revised, because the vital structures such as tendons and nerves will have undergone dessication necrosis and a young worker will be crippled for life. Early coverage of partially injured vital structures is gaining acceptance and this paper confirms the above mentioned treatment protocol.

Surgically induced digital distal syndactyly for prevention of digital growth deformities around the joints: a new technique.

BACKGROUND: Correction of digit deformities at or near the Joints is performed easily ; however, maintaining the result is often difficult either due to noncompliance of the patient to wear the postoperative splints or problems related to unequal growth of bones or normal tissues compared to the scarred or operated side. OBJECTIVES: The aim of this study was to overcome the above mentioned problems for which we propose the "Distal d Digit Syndactyly" technique. MATERIALS AND METHOD: This method is based on the concept of suturing the distal phalanx of the deformed digit to the normal adjoining finger to help prevent the recurrence of the anomaly during the child's growth period or the very important three or four postoperative months of scar maturation in the adult. After the correction of deformity of the finger or toe, "Distal Syndactyly" is created by two flaps on the adjoining digits; one base is dorsally hinged and the other one volar and after elevating the flaps they are sutured together. During the three postoperative weeks care is taken that this attachment is not disrupted and after healing a "distal syndactyly" is created which is very durable and in children it stretches with growth and does not impede the digit's growth. RESULTS: Eleven patients with congenital and traumatic digit anomalies were treated. The recurrence of the problem was prevented in 9 patients; in 2 patients with intact Syndactyly the contracture recurred by stretching the Syndactyly skin. The period of the "Joining" ranged from 6 months to three years and cosmetic appearance was acceptable to the patient and parents. CONCLUSION: This technique by joining a deformed digit to a normally growing adjacent digit prevents the postoperative recurrence of the contracture or growth induced deviation in the digits of noncompliant patients especially children.

A simple and light weight external fixator for distraction advancement manoplasty.

BACKGROUND: With the growing interest in long bone distraction several types of distractors have been introduced; all have the same principle of an outer structure which acts like a scaffold and the distracting mechanism is a separate device which is mounted on this outer structure. OBJECTIVES: We have used a simple and very light weight external fixator we designed and discuss the results of distraction and advantages of this device . MATERIALS AND METHODS: We applied our distractor to treat 14 men and four women, with a mean age of 39 years. There were three thumbs and 23 fingers; 26 digits (18 patients) lengthened by distraction callotasis and second stage bone grafting evaluated accordingly. RESULTS: All patients but one were satisfied with the results and a stable pinch and grip was obtained. After lengthening, all patients maintained sensation of the finger pulp, as assessed by the Semes - Weinstein test. CONCLUSIONS: The superiority of this device for manoplasty lies in its simplicity of construction in addition to being, lightweight and also eases of application.

Management of treadmill hand injuries using soft tissue distraction.

BACKGROUND: In the modern day cities, home treadmill usage is increasing. Toddlers are prone to a special injury by the treadmill, during workout the toddler tries to get on the belt and the roller action pulls the fingers under the belt and get caught between the belt and a metal rod under the machine and the belt scrapes the fingers. If untreated some of these injuries will lead to flexion contracture. The usual treatment is release of contracture and skin grafting, however, graft discoloration and recurrence of contracture are the complications of this method and the patients usually seek treatment for the brown discoloration of the grafts at a later age. OBJECTIVES: In this study we assess the results of Z-plasty in combination with soft tissue distraction without skin grafting with long term usage of splint as an alternative treatment for these patients. MATERIALS AND METHODS: In this retrograde descriptive cross-sectional study, we evaluated the patients presented with treadmill hand injuries between the years 2006 and 2011. Demographic data including age and sex in addition to other information including location of trauma, severity of trauma, time elapsed between the trauma and treatment, type of treatment including wound care and surgical method and treatment outcomes were assessed. RESULTS: A total of 8 patients (3 girls and 5 boys) following finger treadmill injury were assessed. 15 fingers in 7 patients had volar injury. The middle finger was the most commonly injured finger. In all patients a minimum of 2 fingers were injured and in just 1 patient 3 fingers were injured. In long-term follow-up all the patients had acceptable volar skin and complete ROM of the fingers. CONCLUSIONS: Due to discoloration of the skin graft and recurrence of contracture following skin graft as the sole treatment for the injury, application of Z-plasty with soft tissue distraction and long term splints seems to be a proper alternative treatment for these patients.