A New Arthroscopic Classification of Triangular Fibrocartilage Complex Disorders.

Introduction The use of wrist arthroscopy has become a prerequisite for diagnosis and treatment of triangular fibrocartilage complex (TFCC) disorders. Since Palmer's landmark paper, many new arthroscopic descriptions of TFCC tears have been published but there is no currently available updated comprehensive arthroscopic classification of TFCC lesions. Purpose We recently described the arthroscopic anatomy of the TFCC as viewed from a 3-4 portal. Our purpose was to propose a new TFCC disorders classification based on this new arthroscopic TFCC description. Methods We included all currently described TFCC disorders to the best of our knowledge into our arthroscopic, functional, and vascular anatomical concept. We also included patient's specific ulnar variance and distal radial ulnar joint coronal inclination as baseline treatment-oriented parameters. The fresh or chronic, reparable or nonreparable nature of some types of TFCC tears were considered as separate parameters. Results The proposed classification includes disc "D" (degenerative or traumatic), reins "R" (traumatic), and wall "W" (traumatic) lesions. Combined lesions of those three parts of the TFCC may be easily identified. This new classification should facilitate future analysis of isolated or combined TFCC disorders whether they are degenerative and/or traumatic. Discussion The authors present a new three-dimensional-three-part arthroscopic updated description of TFCC disorders with relevance to etiology and treatment principles.

Arthroscopic Management of Distal Radius Fractures and Malunions.

Articular congruity is the most important prognostic factor when dealing with a distal intra-articular radius fracture or the correction of intra-articular malunion. This article details our approach with tips and tricks for effectively managing these complex injuries with the aid of dry arthroscopy.

Hand Allodynia, Lack of Finger Flexion, and the Need for Carpal Tunnel Release.

PURPOSE: The clinical features of classic carpal tunnel syndrome are well known. However, some patients who may respond equally well to carpal tunnel release (CTR) display atypical signs and symptoms. The chief differential features are allodynia (painful dysesthesias), lack of finger flexion, and, on examination, pain on passive finger flexion. The goal of the study was to present the clinical features, increase awareness, facilitate accurate diagnosis, and report the outcomes after surgery. METHODS: Thirty-five hands, from 22 patients with the main features of allodynia and lack of full finger flexion, were gathered in the period 2014-2021. The other common complaints included sleeping disturbances (20 patients), hand swelling (31 hands), and shoulder pain on the same side as the hand problem with limited range of motion (30 sides). The Tinel or Phalen signs were obscured by the pain. However, pain with passive flexion of the fingers was universally present. All the patients were treated with carpal tunnel release through a mini-incision approach: four patients had a trigger finger, which was treated concomitantly in six hands, and one patient underwent contralateral CTR for carpal tunnel syndrome with a more standard presentation. RESULTS: At a minimum of 6 months of follow-up (mean, 22 months; range, 6-60 months), the pain decreased by 7.5 ± 1.9 points on the Numerical Rating Scale, which ranges from 0 to 10. The pulp-to-palm distance improved from 3.7 to 0.3 cm. The mean Disabilities of the Arm, Shoulder, and Hand score decreased from 67 to 20. The mean Single-Assessment Numeric Evaluation score for the whole group was 9.7 ± 0.6. CONCLUSIONS: Hand allodynia and lack of finger flexion may be indications of median neuropathy in the carpal canal, which responds to CTR. Awareness of this condition is important because the uncharacteristic clinical presentation may not be considered an indication for surgery that can be beneficial. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Postoperative Imaging of the Wrist and Hand.

In this article we will do an overview of the general and specific complications that occur after the most common wrist and hand surgeries. Knowledge of the different surgical techniques is essential for postoperative imaging evaluation. General complications include infection, complex regional pain syndrome, problems related with the surgical approach (open or arthroscopic) and bone healing problems. The most frequent fractures of the wrist with specific complications are distal radius fractures and scaphoid fractures as associated with tendon ruptures secondary to friction, nonunion or secondary malignment. We will briefly review the different approaches for triangular fibrocartilage injuries, including acute and degenerative lesions. Scapholunate instability is the most common instability and an important indication for surgery with pin fixation in the acute setting and arthroplasty or arthrodesis in the chronic irreparable injuries. One of the most common surgeries of the wrist is carpal tunnel release, although complications are uncommon, radiologists should be familiar with the normal appearance and pathological changes after surgery. Trapeziometacarpal joint osteoarthritis is frequent especially in postmenopausal women and has several treatment options depending on the stage.

Triangular Vascularized Free Fibula Flap for Massive Carpal Reconstruction.

Massive carpal loss following trauma, tumor, or infection poses a difficult reconstructive challenge. There are limited reconstructive options for such cases, particularly when the metacarpal bases are also lost. We describe a method of carpal reconstruction using closing wedge osteotomies in a triangular vascularized free fibular flap, and a proposed algorithm for the management of metacarpal instability in this setting.

Postoperative Imaging of Ulnar Wrist Pain.

Ulnar wrist pain, caused by a broad spectrum of bone and soft tissue injuries, is the most common clinical condition of the wrist. Multiple surgical techniques and their variants in the treatment of these injuries are constantly evolving. Postoperative evaluation of the wrist for many surgeons is limited to serial clinical and radiographic monitoring. However, imaging methods such as ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and arthrographic techniques (arthrographic CT and arthrographic MRI) play a fundamental role in diagnosing and managing postsurgical complications.The several critical aspects in evaluating the postsurgical wrist imaging spectrum are familiarity with the surgical techniques, knowledge of the original clinical problem, understanding the strength and limitations of the different radiologic modalities, and effective communication between surgeon and radiologist.

Informe sobre el trasplante de 250 dedos del pie a la mano consecutivos. Indicaciones, resultados, fracasos y nuevas aplicaciones / Report on 250 consecutive toe to finger transplants. Indications, results, failures, and new applicactions

Propósito. Las transferencias de dedos del pie constituyen un arma fundamental en la rehabilitación de las lesiones de mano. Sin embargo, no gozan de mucha popularidad dada la posibilidad de fracaso y por las hipotéticas secuelas en la zona donante. Presentamos nuestra experiencia clínica, haciendo especial hincapié en las complicaciones y las nuevas aplicaciones. Material y métodos. En el periodo febrero de 1995 - enero de 2010 hemos realizado 250 transferencias de dedos del pie para amputaciones de todos o parte de los dedos. En las amputaciones de todos los dedos (23 casos) se trasplantaron el hallux de un pie y el 2.° y 3.er dedos del pie contralateral para lograr una pinza trípode. El resto de los casos corresponden a amputaciones multidigitales, simples o parciales de dedos, siendo 69 casos pulgares y el resto, dedos trifalángicos. Resultados. La tasa de reintervención por isquemia aguda fue del 16% (10% intraoperatoria), con una supervivencia final del 98,8% (3 fracasos) tras la revisión quirúrgica. No hubo ninguna necrosis parcial. Respecto a la zona donante, un paciente fue intervenido por presentar un neuroma; el resto no refirió ningún tipo de molestias a la marcha, en el seguimiento a largo plazo. Conclusiones. En nuestra experiencia, las transferencias de dedos del pie son un método seguro en la reconstrucción de lesiones graves de la mano. La secuela del pie es proporcional a la cantidad de dedos que se tomen, y es bien aceptada por el paciente, en especial en las graves lesiones (AU)

Purpose. Toe-to-hand transfers are an essential part of hand rehabilitation after loss of a finger. Despite this, the likelihood of failure and the hypothetical morbidity in the donor area, made this procedure not very popular among surgeons. The purpose of this paper is to present our clinical experience, highlighting the pitfalls and the new indications. Material and methods. Between February 1995-January 2010 we performed 250 toe-to-hand transfers for finger amputations. In metacarpal hands (23 cases) we transferred the hallux from one foot and the 2nd and 3rd from the other, to achieve a three-fingered (tripod) grasp. The rest of the patients had multi-digital, simple or partial amputations. In 69 the thumb was reconstructed and the rest of transfers were for finger reconstructions. Results. Re-operation rate due to acute ischaemia was 16% (10% intraoperative) and the overall success rate was 98.8% (3 failures). There was no partial necrosis in any case. Regarding the donor side, one patient was operated on due to a painful neuroma; the rest did not have complaints in the donor area. Conclusions. In our experience toe-to hand transfers are a safe and reliable method to rehabilitate severe hand injuries. Donor site morbidity is directly related to the number of toes harvested, and is well-tolerated by the patients, especially in severe injuries (AU)

Reconstrucción mamaria. Experiencia preliminar con colgajos perforantes / Breast reconstruction. Preliminary experience with perforator flaps

Presentamos nuestra experiencia en 9 pacientes mastectomizadas, seis de ellas radiadas, reconstruidas en fase crónica con colgajos microquirúrgicos de perforante (ocho de la arteria epigástrica inferior y uno de la arteria glútea superior). El seguimiento mínimo tras la reconstrucción ha sido de 12 meses. Todos los casos sobrevivieron. En uno se produjo una complicación intraoperatoria: la avulsión del pedículo, que se pudo solucionar sin consecuencias. En dos casos hemos observado pequeñas áreas de necrosis grasa que evolucionaron favorablemente con tratamiento conservador. La valoración de los resultados estéticos por parte de las pacientes ha sido muy satisfactoria. En nuestra opinión, los colgajos de perforante constituyen una excelente opción reconstructora, incluso en pacientes sometidas a radioterapia. Su vascularización y vitalidad permiten reconstruir una mama con un magnífico resultado estético y una mínima morbilidad. No obstante, hay que considerar la complejidad técnica y el mayor riesgo de complicaciones vasculares en casos de radioterapia previa (AU)