Feasibility of a fascial flap to avoid anterior transposition of unstable Ulnar nerve: A cadaver study.

Background: Compression of the ulnar nerve at the elbow is the second most frequent site of nerve compression in the upper limb. Upon release, anteposition of the nerve may be necessary to avoid dislocation of the latter when unstable. Numerous techniques are described in the literature (subcutaneous transposition, intramuscular transposition, subfascial transposition, medial epicondylectomy …), none of which is without complications. Based on Han's work, the authors propose a technique of covering the ulnar nerve with epicondylar fascial flap, avoiding transposition, but ensuring good stability of the ulnar nerve. Methods: As part of the SICM (Italian Society of Hand Surgery) cadaver dissection course (ICLO, Verona, Italy) the authors dissected 36 elbows, of which 20 presented subluxation of the ulnar nerve after its decompression. The fascial flap was therefore made on these 20 elbows, coming from 14 different donors (9 men, 5 women) with an average age of 78 years. The diameter of the ulnar nerve was then measured (at the level of the passage in the cubital canal), the diameter of the newly formed canal, the difference between the two previous measurements (residual space in the flexed elbow canal), and it was verified whether the ulnar nerve was unstable once covered by the flap. Results: The mean diameter of the ulnar nerve was 5.1 mm (range 4-6), while the mean diameter of the neo-canal was 10.1 mm (range 8-11) in elbow extension and 8.9 mm (range 7-10) in elbow flexion. The remaining space in the flexed elbow canal was 3.8 mm (range 3-5).In none of the 20 cases the ulnar nerve was dislocated after having made the fascial flap. Conlusions: In light of the results obtained, the authors think that the use of the epicondylar fascial flap may be a solution to keep in mind to avoid dislocation of the ulnar nerve when it becomes unstable following its decompression. This work obviously needs clinical confirmation on living patients. Level of evidence: V.

Microsurgical training in vein anastomoses: the use of systemic heparin in a rat model.

OBJECTIVE: To investigate whether the use of systemic heparin could be useful for vein microvascular anastomoses in microsurgical training on rats. DESIGN: Femoral end-to-end venous anastomoses were performed on both thighs of 40 wistar rats by two microsurgery trainees from October 2018 to February 2019 (80 anastomoses in total). We divided the rats into 2 groups of 20 specimens (40 femoral end-to-end anastomoses) each: group A received no heparin administration; group B received subcutaneous systemic heparin administration before starting dissection. We compared both vein patency after the procedures. RESULTS: Patency tests showed no difference between the two groups after 5 minutes. At the delayed test after 120 minutes, vein patency was significantly better in the systemic heparin group (85,0% vs 55,0%). Even though both trainees judged practicing on both groups very instructive, they found useful performing anastomoses when heparin was administrated. CONCLUSION: We suggest including the use of systemic heparin in microsurgery training programs, especially for the beginners. Systemic heparin administration in rat models is educative for trainees.

A functional "metacarpal-hand" after a firework injury obtained without any flap or toe-transfer.

A 37-year old male patient with a right-hand firework injury. An extreme hand reconstruction was performed. The second and third rays were sacrificed enlarging the first space. The diaphysis of the second metacarpal bone became a tubular graft to reconstruct the fourth metacarpal. The thumb consisted only in the first metacarpal bone. The result was satisfactory, according to the wishes and needs of the patient, a three-finger hand with an opposable thumb, obtained in only one surgical treatment and without using free flaps. The concept of an "acceptable hand" is related to the surgeon's and patient's opinions.

Clinical usefulness of nutraceutics with acetyl-L-carnitine, α-lipoic acid, phosphatidylserine, curcumin, C, E and B-group vitamins in patients awaiting for carpal tunnel release during COVID-19 pandemic: a randomized controlled open label prospective study.

BACKGROUND AND AIM OF THE WORK: Carpal Tunnel Syndrome (CTS) is provoked by the compression of the median nerve, leading to nerve ischemia, endoneural edema, venous congestion, and subsequent metabolic alterations. Conservative treatments could be considered. The present study investigates the efficacy of a specific blend of a 600 mg dietary integrator composed of acetyl-L-carnitine, α-lipoic acid, phosphatidylserine, Curcumin, C, E and B1, B2, B6 and B12 vitamins in patients with mild to moderate CTS. METHODS: The present investigation involved the outpatients who were planned to undergo open surgical decompression of the median nerve awaiting surgery from June 2020 and February 2021. CTS surgery has been significantly reduced in our institutions during the COVID-19 pandemic. Patients were randomized into Group A (dietary integration 600 mg twice day for 60 days) and Group B (control group, no drug administration). Clinical and functional improvement was prospectively measured after 60 days Results: One-hundred forty-seven patients completed the study, 69 from group A and 78 from group B. BCTQ was significantly improved with the drug administration, as well as BCTQ symptoms subscale, and the pain. BCTQ function subscale and Michigan Hand Questionnaire was not significantly improved. Ten patients in group A (14.5%) declared that they didn't need further treatment. No major side effects were noticed. CONCLUSIONS: Dietary integration could be considered as an option in patients who could not undergo surgery. Symptoms and pain could improve, but surgery remains the gold standard for recovery of function in mild to moderate CTS.

Surgical treatment of carpometacarpal thumb arthritis with trapeziectomy and intra-tendon (FCR) suspension with one-loop APL: comparative cohort study.

BACKGROUND: One of the current choices of treatment for Trapeziometacarpal (TMC) joint arthritis is trapeziectomy with ligament reconstruction and tendon interposition arthroplasty. The Ceruso's technique consists of complete trapezial excision and abductor pollicis longus (APL) tendon suspension. The APL tendon is tied to the flexor carpi radialis (FCR) tendon with two loops, one around it and one inside, and then used as interposition tissue. The purpose of the present study was to compare two different techniques of a trapeziectomy with ligament reconstruction and tendon interposition arthroplasty using the Abductor Pollicis Longus (APL) tendon, which is only Once Looped Around (OLA) versus Once Looped Inside (OLI) the Flexor Carpi Radialis (FCR) tendon. METHODS: A single-center, retrospective study (Level of evidence: III) has been conducted on sixty-seven patients older than 55 years (33 OLI, 35 OLA), assessing clinical outcomes for at least 2 years of post-surgery follow-up. The outcomes were to assess and compare surgical outcomes comparing the two groups, in terms of subjective and objective evaluation for both groups at the last follow-up (primary outcome), and at the intermediate follow-ups (three and six months). Complications were also assessed. RESULTS: The authors found an improvement in pain, range of motion, and function, with equivalent results for both techniques. No subsidence was observed. FCR tendinitis was significantly reduced with OLI, as well as the need of post-operative physiotherapy. CONCLUSIONS: The one-loop technique allows for reduced surgical exposure, providing excellent suspension and clinical outcomes. Intra FCR loop should be preferred to improve post-surgical recovery. LEVEL OF EVIDENCE: Level III study. This is a retrospective cohort study (written according to STROBE guidelines).

Does the Use of Gelled Platelet-Rich Plasma during Fixation of Subacute Proximal Pole Scaphoid Fractures Help? - A Single Centre Experience.

Background: Subacute proximal pole scaphoid fractures (1 month to 6 months) have a higher risk of non-union. The aim of the present retrospective analysis is to evaluate the efficacy of gelled platelet-rich plasma (GPRP) as additional treatment to antegrade headless screw fixation of proximal pole scaphoid fractures. Methods: Forty-one patients were divided into two groups based on surgical treatment received: screw fixation alone (group A) and screw fixation and GPRP application at the fracture site (group B). A short cast was maintained for 4 weeks after surgery. Outcome measures included time to union, need for additional procedures, time to return to work, disabilities of the arm, shoulder, and hand (DASH) questionnaire, Michigan Hand Questionnaire (MHQ) and Mayo wrist score (MWS).Time to union was determined by monthly radiographs and confirmed by a computerized tomographic (CT) scan done at 4 months. Results: Union was achieved in 85.7% of patients in group A and in 100% of patients in group B. Patients in group B showed a faster time to healing (2.3 ± 0.4 months vs 3.1 ± 0.7 months, p = 0.0001) and earlier return to work (10.4 ± 2.2 vs 15.1 ± 2.9, p = 0.0001). There were no significant differences in patient-rated outcomes scores between the two groups at final follow-up. Conclusions: Internal fixation alone is effective in treating subacute proximal pole scaphoid fractures. GPRP application improves bone healing and functional recovery. Level of Evidence: Level III (Therapeutic).

Elastic stable intramedullary fixation using epibloc versus crossed kirschner wires fixation for distal forearm fractures in children: A retrospective analysis.

Background: Childrens' distal forearm fractures (DFFs) could be treated conservatively with closed reduction and immobilisation, but post-reduction displacements often occur. Displaced DFF should be surgically fixed, to avoid further displacement. Nevertheless, immobilisation after surgery is recommended. Epibloc system (ES), a system of stable elastic nail fixation, is widely used to stabilise adults extra-articular distal radius fractures, with advantages to not requiring post-surgical immobilisation. The present investigation represents a retrospective analysis of paediatric patients with DFF treated with ES applied with a minimal technical variation, to fix both ulna and radius fractures using a unique device. Materials and Methods: A retrospective analysis was performed on 44 children (age 6-11 years) who underwent closed reduction and internal fixation because of DFF (both ulna and radius). Group A (21 patients): ES fixation. Group B (23 patients): K-wires and short arm cast fixation. The primary outcome was the subsistence of reduction monitored through X-rays. The secondary outcome was the measurement of active range of motion (AROM) and the time of recovery. Results: No differences were observed comparing Group A and B in terms of the maintenance of reduction (P > 0.05). Seven days after the implant removal, patients in Group A reached significantly better results compared to patients in Group B in terms of AROM (P < 0.05). No differences were revealed in terms of complications between the two groups. Conclusion: ES applied with a minimal technical variation is safe and effective in treating distal ulna and radius fractures, with minimal requirement of post-surgical rehabilitation.

Secondary Wrist Arthritis in Active Workers: Does Capitate Pyrocarbon Resurfacing (RCPI) Improve Proximal Row Carpectomy? A Retrospective Cohort Study.

Background: Proximal Row Carpectomy (PRC) is a widespread, safe and effective salvage surgical procedure for wrist arthritis. Some authors believe that PRC results in low grip strength (GS), due to the loss of carpal height, supporting the idea to discourage PRC in high-demanding patients. Resurfacing Capitate Prosthesis Implant (RCPI) allows extending the indication for PRC also in case of deformity and/or arthritis of the head of capitate, with possible implications of clinical outcomes, including GS. Methods: Retrospective multicentre study on a population of active workers, affected by secondary post traumatic wrist arthritis, who underwent PRC (27 patients) or PRC + RCPI (20 patients), Primary outcome was to assess GS between PRC and PRC + RCPI. Secondary outcome was to assess CHR and to search for any possible contributors to GS. Active range of motion (AROM), hand function (DASH, Work-DASH, VAS, PRWHE), pain, time to return to work, job maintenance, major complications and general satisfaction were also assessed. Results: PRC + RCPI results in more GS maintenance compared with PRC alone, with higher values of CHR. CHR values were associated with GS with a good correlation. According to linear regression model analysis within PRC + RCPI group (GS-CHR), it is esteemed that the increase in parameter CHR is associated with an increase in parameter GS. Looking at a multiple linear regression model analysis built on the whole sample (GS% increase - (group × CHR) + GS% pre-operative). It is estimated that the increase of one unit of the GS coefficient is associated with an increase in GS% increase. Furthermore, higher pre-operative GS values positively influence post-operative GS. No differences were revealed between the two treatments in terms of the remaining secondary outcomes. Conclusions: PRC alone and PRC + RCPI are both effective salvage procedures for wrist arthritis. RCPI provides a better GS preservation, in part due to the carpal height preservation.

The Italian Version of the Michigan Hand Outcomes Questionnaire (MHQ): Translation, Cross-Cultural Adaptation and Validation.

Background: Patient-reported outcome measures are largely used in clinical practice and scientific community. Michigan hand questionnaire (MHQ) is widely recognized as a standardized reliable instrument for the assessment of any kind of hand disorders. Aim of the study: translation, cross-cultural adaptation and validation of the Italian version of MHQ. Methods: The study was composed by two phases. Phase 1 consisted in translation and cross-cultural adaptation of MHQ, from original language version (English) into Italian, according to the standard procedure of translation and back translation. The final Italian version of MHQ was tested on 136 Italian patients with hand disorders (Phase 2), in addition to Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, Visual analogue scale (VAS) for pain assessment and grip strength, to psychometric properties of the new version, 55 patients repeated the questionnaire after 7 days for test-retest to assess the reproducibility of the questionnaire. All data were subsequently analyzed (descriptive statistics, multitrait analysis, reliability and construct validity assessment). Results: Phase 1 was performed without major problems, thus the final Italian version was approved for Phase 2. The questionnaire was clear and easily understood (missing data 0-2.9%). Multitrait analysis brought very good results for each outcome measure. High reliability (Cronbach's alpha: 0.91-0.99) and very good reproducibility (Intraclass correlation coefficients: 0.83-0.98) were revealed. High to moderate correlation was found between MHQ and DASH, grip strength and VAS. Conclusions: The Italian version of MHQ has demonstrated to be reliable and valid.

Skin manifestations in COVID-19 patients, state of the art. A systematic review.

INTRODUCTION: Since COVID-19 has become a pandemic, extensive literature has been produced. The commonest symptoms of COVID-19 disease are fever, cough, anosmia, and lymphocytopenia. However, other apparently less common clinical symptoms have been described, including skin lesions. We conducted a systematic review to evaluate skin involvement in COVID-19. METHODS: The authors performed a systematic review of literature, in accordance with the Preferred Reporting Items for Systematic and Meta-Analysis (PRISMA). The search was reiterated until May 06, 2020. RESULTS: Overall, 1593 patients (M/F ratio: 1 : 9) with suspect of COVID-19 were examined. The mean age was 37.8 (range 0-91) years. Among the analyzed patients, 84 (5.3%) were pediatrics (<18 years). Chilblains are very common among skin lesions and represent almost half of all skin lesions reported (46%); in 75% of patients with cutaneous manifestation, the latter presented before other typical clinical manifestation of COVID-19. Vasculitis or thrombosis was identified in almost 70% of patients who suffered from skin manifestations. CONCLUSION: The present study highlights the importance of skin involvement in COVID-19. Limbs should be examined to eventually foresee the onset of further typical symptoms. Chilblains can be considered typical features. Studies with higher scientific evidence are required.

Hand's aneurysmal bone cyst: A rare localization. Case report and systematic literature review.

Aneurysmal bone cysts are benign, rare bony tumours frequently observed among children and young adults principally located in the long bones, pelvis, and spine and rarely in other anatomical district such as the hand. We report the case of a 12-year-old girl with an aneurysmal bone cyst, in active stage, involving the still-open epiphysis of the fourth metacarpal of the right hand, which was in a first time treated by curettage, and 3 months later, occurring a recurrence, by a radically excision of the bone and reconstruction with a graft from the iliac crest. At 10-year follow-up the patient had good cosmetic results and a functioning hand. We also performed a systematic Literature review in order to retrieve the key information regarding: the diagnosis, the clinical features and the treatment.

Feasibility of Homodigital Flexor Digitorum Superficialis transposition, a new technique for A2-C1 pulleys reconstruction: A kinematic cadaver study.

INTRODUCTION: Homodigital flexor digitorum superficialis transposition (HFT) is proposed as a new technique for A2-C1 pulley reconstruction. Flexor digitorum superficialis is transposed on the proximal phalanx and inserted on the pulley rims, crossing over flexor digitorum profundus and acting as a pulley. MATERIALS AND METHODS: The kinematic feasibility was investigated in a cadaveric bowstring model (after A2 and C1 pulley removal) on 22 fingers (thumb excluded). RESULTS: HFT was effective in restoring the correct flexion of proximal and distal interphalangeal joints, compared to bowstring model. No adverse events were registered. CONCLUSION: HFT is a feasible technique. Clinical application is encouraged.

Extraphyseal distal radius fracture in children: is the cast always needed? A retrospective analysis comparing Epibloc system and K-wire pinning.

INTRODUCTION: Closed reduction and internal fixation are a widespread surgical treatment for pediatrics displaced extraphyseal distal radius fractures. Post-surgical cast immobilization is usually needed. Epibloc system (ES) is a device used to fix Colles fractures in adults, not requiring post-surgical immobilization. The aim of the study is to investigate the effectiveness of ES in a pediatric population suffering from displaced extraphyseal distal radius fractures. METHODS: We retrospectively analyzed 52 patients (age 8-12 years) who underwent CRIF. Patients were divided into two groups. Group A (25 patients): ES osteosynthesis. Group B (27 patients): K-wires and short arm cast osteosynthesis. The primary outcome is the maintenance of reduction in radiographs (displacement on frontal and lateral view). The secondary outcome is the reaching of the complete active range of motion recovery (compared with the contralateral side) and the time needed to obtain it. The need of further additional treatment (physiotherapy) and the presence of complication were also assessed. RESULTS: Reduction was equally maintained in both groups (p > 0.05). Physiotherapy was mandatory for 11 patients in group B; only for 3 patients in group A, the difference was statistically significant (p = 0.03) according to Fisher test. Otherwise, the difference was not statistically significant regarding complications. (p > 0.05). At the last follow-up, complete functional recovery was reached in all patients. CONCLUSIONS: Functional recovery is faster, and postoperative physiotherapy is rarely required with ES. This device allows us to go beyond the traditional concept of mandatory postoperative immobilization after pediatric wrist fractures surgery.

Unusual Intranodular Collagenase Injection: A Case of Bilateral Ledderhose Disease.

Ledderhose disease (LD) is a rare plantar fibromatosis of the foot, frequently associated with Dupuytren disease. Collagenase of Clostridium hystoliticum has recently revolutionized the way to treat Dupuytren disease. Nevertheless, the literature is still critically lacking about the use of collagenase injection in LD. We report a case of a man with bilateral symptomatic LD treated with collagenase. Injections (0.58 mg of collagenase of C. hystoliticum) were performed into nodules. Forced extension after injection was not performed. The patient could walk normally immediately after procedure. The procedure was a complete success without side effects or complications on either foot. Currently, at 14 months after treatment of the right foot and 12 months after treatment of the left foot, no recurrence has been observed. Collagenase injection was only effective in treating symptomatic LD in this one patient we reported on.

Seven-year clinical outcomes after collagenase injection in patients with Dupuytren's disease: A prospective study.

INTRODUCTION: This investigation is a prospective cohort study examining the use of Clostridium histolyticum collagenase injection (CCH) for the treatment of Dupuytren's disease (DD) with a 7 years follow-up. METHODS: Forty-five monodigital DD patients were injected with CCH on a single joint. Assessment included measurement of residual passive extension deficit (PED), function (using QuickDASH) and patient satisfaction. RESULTS: 86.7% of PIPJ and 65.6% of MPJ had a worsening of PED. Nevertheless, thirty-nine patients (86.7%) concluded their treatment with only one injection, without any further treatment. CONCLUSION: CCH provides a long-term effective solution. Recurrence occurs, especially in PIPJ, with acceptable rates.

Modified Matti-Russe technique using a "butterfly bone graft" for treatment of scaphoid non-union.

INTRODUCTION: Autologous bone grafts are used to treat scaphoid non-union with shortening and humpback deformity. The superiority of internally fixed bone graft to embedded bone graft has not been clearly proven. METHODS: Retrospectively analyzed 42 cases of scaphoid waist non-union treated using the "butterfly bone graft" (modified Matti-Russe technique). RESULTS: Complete healing was reached by all patients, with an average time of 4.4 (SD ± 0.7) months. Mayo Wrist Score improved from and QuickDASH score significantly improved in all patients after treatment. CONCLUSIONS: Butterfly bone graft is effective and reliable in treating scaphoid non-union with shortening and humpback deformity.

Intramedullary nailing for treatment of forearm non-union: Is it useful? - A case series.

INTRODUCTION: Intramedullary osteosynthesis is often considered a second-order method for treatment of forearm non-union. METHODS: We evaluated clinical and functional results from 49 patients affected by radio and/or ulna non-union treated using intramedullary nailing, with possible tricortical autologous bone grafting. Healing rate (primary outcome), healing time and functional status have been assessed. RESULTS: Healing was observed in 46 cases (93.9%), the average healing time was 6.3 (SD ± 2.5) months. Excellent result (Anderson score) was reached in 38 cases (77.6%), satisfactory in 7 cases (14.3%). CONCLUSIONS: Forearm non-unions represent a therapeutic challenge. Intramedullary nailing is a successful option of treatment.

Comparison of Shape Memory Staple and Gelled Platelet-Rich Plasma versus Shape Memory Staple alone for the Treatment of Waist Scaphoid Nonunion: A Single-Center Experience.

Purpose The aim of this study was to analyze the results of two different methods of surgical treatment of waist scaphoid nonunions (SNUs). We retrospectively analyzed data from 87 patients referred to our department from January 2010 to December 2017 who were surgically treated for waist SNU. Methods The mean period of time passed from trauma was 11.2 (±5.6) months. Patients were divided into two groups based on surgical treatment received: volar exposure osteosynthesis with shape memory staple (SMS) (group A) and volar exposure osteosynthesis with SMS and gelled platelet-rich plasma (GPRP) application at the bone defect level (group B). A cast (thumb excluded) was maintained for 4 weeks. Healing was checked clinically (pain, QuickDASH [Disabilities of the Arm, Shoulder, and Hand] score, Mayo Wrist Score) and radiologically (standard X-ray). Results Union was achieved in 40 patients in group A (95.2%) and in all patients in group B (45 patients; 100%). A statistically significant difference was observed in the improvement of the Mayo Wrist Score, QuickDASH score, and pain (measured through the visual analog scale) after 3 months from surgery ( p = 0.02). Conclusion SMS is effective in treating waist SNU at more than 6 months from trauma. GPRP application can improve bone healing and upper limb function. Level of Evidence This is a retrospective observational Level III study.