A new sign allowing diagnosis in the pathologies of the extensor tendons of the hand

Retrospective study of radial dome osteotomy with volar plate fixation versus K-wires in Madelung's deformity: long-term follow-up

PURPOSE

The emerging role of the locking plate improved the technique also in corrective osteotomies in Madelung's deformity, but there is a lack of analyses between the fixation techniques, as well as little information in functional outcomes and long-term follow-up. The current study compared the outcomes, pitfalls, and advantages of volar plate and screws fixation versus K-wires fixation in a long-term follow-up.

METHODS

Twenty-eight children presenting the "distal radius" variant of Madelung's deformity underwent Vickers ligament release and distal radial dome osteotomy between 2009 and 2015. Twenty-three children (20 females and 3 males, mean age 15 years and 7 months at surgery and 24 years and 8 moths at follow-up), with 26 operatively treated wrists, were available for follow-up. A retrospective two-cohort study, evaluating clinically and radiologically results, has been conducted with a mean eight years and seven months follow-up.

RESULTS

Bone union and pain relief were obtained in all cases, as well as improvements in wrist motion and radiographic indices. A statistically significant correlation was identified between the volar plate fixation and an improved lunate subsidence on X-ray, and a trend towards an improved DASH score in the cohort with plate and screws, as well as significant improvement in wrist extension and supination always in the plate fixation cohort.

CONCLUSIONS

The long-term follow-up enabled the patients to report on more definitive outcomes in terms of functional and cosmetic improvements. Volar plate fixation is an effective technique allowing for simple post-operative management and earlier rehabilitation program with improved clinical and radiographic outcomes.

Outpatient paediatric hand surgery: strategy in healthcare implementation and cost-efficient manner

The increasingly cost of health care is a relevant problem as well as prolonged waiting time for admission also in emergencies. Effective cost containment measures and expenditure controls are needed to achieve and maintain clinical and organizational appropriateness. Outpatient management has proven to be the most useful method for lower-cost treatment in less severe pathologies, requiring surgery without hospitalization. The current study provided to evaluate how this model was successfully applied also to the paediatric population in hand surgery. Methods. A retrospective cohort study of 645 patients from 8 to 18 years (mean age 14.9) was performed in children treated in outpatient setting from 2015 to 2019. The direct costs were evaluated as well as the mean waiting time for surgery, comparing the data with the previous five-year period. The mean reduction in waiting time for children emergencies was 57% (from 72 to 31 h) due to the Outpatient setting into a dedicated Day-Surgery Service organizational model. The visual graphed data showed a general clear growing trend towards outpatient surgery in adults and children. The overall effect was a 29.2% of reduction in spending between expected and achieved costs, recovering resources toward the increasing technology and innovation expenditures. Outpatient paediatric hand surgery was an effective and attractive option which leaded to decreased individual and social costs, with increased clinical and organizational appropriateness. Thus, reduced delay in treatment and provided benefits for children and familiars.

Piezoelectric Bone Surgery. Overview in Applications and Proof of Feasibility in Hand and Plastic Surgery

PURPOSE

Piezoelectric bone surgery was already extensively used in a number of surgical procedures ranging from dental to maxillofacial surgery. The authors aimed to determine whether piezosurgery was suitable and advantageous for performing osteotomies in Hand and Plastic reconstructive surgery.

METHODS

The authors overviewed a variety of applications for Piezosurgery^® Device, from Mectron, in bone reconstructive surgery with over the last 8 years. An overall number of 156 bone cutting procedures in adults and children was described at the phalanges, metacarpal bones and distal radius level, as well as in bone graft harvesting and bone remodeling following carpal scaphoid nonunion, scapho-lunate bone-ligament-bone reconstruction and fibula free flap in maxillofacial defects.

RESULTS

The consolidation rate was 87.5% in scaphoid nonunion grafting and fixation. Bone healing was achieved in all other cases. No intra-operative complications were recorded.

CONCLUSION

Piezosurgery^® allowed high precision in bone cutting as well as custom-made graft and surface roughness were obtained, while preserving nerves, vessels and tendons integrity. The instrument may be handling moved into the surgical space in absence of vibrations, with a clear view onto the bone. The mechanical and biological characteristics of the piezoelectrical effect perfected this technique as an effective and useful instrument in Hand and Plastic surgery. The selective bone cutting properties avoided injuries to the surrounding soft tissues and thermal damage of the bony cells. Best advantages were described in feasibility and flexibility for intra-articular osteotomies, custom-made grafts and reconstructive microsurgical techniques.

Upper limb traumatic injuries: A concise overview of reconstructive options

Different options for upper limb reconstruction are described in literature: advancement or rotation flaps, regional flaps and free flaps are the most common. Local and regional flaps can represent the reconstructive options for small defects while large wounds require the use of free flaps or distant pedicled flaps. In case of large wound, the use of free flaps rather than distant pedicle flaps is usually preferred. To choose the best reconstructive option, it is essential for the surgeon to have a general overview about the different methods.

In this review the Authors will refer to the most commonly used methods to cover soft tissues injuries affecting the dorsum and the palm of the hand and the forearm (excluding fingers). The aim is to show all flap reconstructive options so as to support the inexperienced surgeon during the management of traumatic injuries of the upper limb.

•

Reconstruction of traumatic injuries of the upper limbs can be challenging.

•

Small defects can be covered by local and regional flaps while large wounds need the use of free or distant pedicled flaps.

•

The literature shows different opinions whether to use pedicled flaps (regional or distant) or free flaps.

•

Dermal substitutes can be considered in patients who are not suitable for flaps reconstruction.

•

Patient related factors and surgical background can significantly interfere with the surgical reconstructive solution.

The Challenges in restoration of extensor tendons function at the hand

INTRODUCTION

The authors discuss challenges in extensor function restoration at the finger level following distal posterior interosseous or tendon complex injuries, according to the typologies of lesions or the specific patient requirements.

MATERIALS

The authors report on two cases describing challenging resolutions. One patient with EDC lag from zone 6B to 8 requiring FCU prolonged with cadaveric grafts.  One young patient with distal posterior interosseous lesion requiring selective tendon transfers to EPL and EIP to restore selective and autonomous index extension.

RESULTS

In both cases the main goals were obtained, achieving high index of patient satisfaction and excellent outcomes with the restoration of the extension of the fingers.  Conclusions: In distal posterior interosseous nerve lesion, high demanding patients may require selective function to restore fine motor skills, such as autonomous index extension. In extensor tendons loss of substance from zone 6 to 8, involving musculotendinous junction proximally and short remnants distally, by-pass tendon transfer prolonged with cadaveric grafts is required. The authors highlight the techniques available as escape plan according to the necessary solutions.

Retrospective study in clinical governance and financing system impacts of the COVID-19 pandemic in the hand surgery and microsurgery HUB center

Introduction

The authors presented a retrospective study in the surgical activity of the HUB center for Hand Surgery and Microsurgery in Emilia-Romagna comparing the data between March and April 2020, in the peak of Covid pandemic, with the same period in 2019.

Materials and methods

During the two months period of March–April 2020 versus 2019 the authors analyzed the surgical procedures performed in elective and emergency surgery with hospitalization and Day or Outpatient surgery regime. Surgical treatments with no hospitalization were planned in the Day-Surgery Service. The financing system impacts were analyzed according to the Diagnosis Related Groups (DRG), the costs accounting method mostly used in European countries.

Results

An overall reduction of 68.5% was recorded in surgical procedures, with a more relevant reduction of 92.3% in elective surgery and a significantly less relevant reduction of 37.2% in urgent one. Replantation did not present a reduction in number of cases, while cutting lesions of tendons at the hand and fingers increased such as the bone and ligament injuries during domestic accidents. The negative impact in the financial system recorded a reduction of 32.5%.

Discussion

The epidemiology of hand trauma looks not only at the artisanal and industrial injuries, but also mostly at the accidents in daily life activities. The data of the study evidenced the significantly increase in the injuries occurring in the domestic environment. Elective surgery was canceled. The 86% of surgical procedures performed were urgent ones and the 72.8% of these were possible in Day and Outpatient surgery with significantly reduction in hospitalization. All procedures followed a rigid process for patient and healthcare workers with regard for personal protection and safety. Telemedicine was arranged in emergencies, and economic damage was analyzed also in the following rebound effect during summer period.

Conclusions

The significantly less reduction recorded in urgent surgery vs the more relevant reduction in elective one showed how the hand injuries remained a major issue also during the lockdown. The data highlighted the relevant role of the organizational aspects of the surgical procedures and planning in hand trauma. Despite the financial impact of the elective surgery, the presence of a functional and skill Emergency Service and Day-Surgery Service resulted fundamental in the efficacy and efficiency of the patient management and in containment of economic damage. The telemedicine was significantly limited by liability and risk management issues.