Effects of Mirror Neurons-Based Rehabilitation Techniques in Hand Injuries: A Systematic Review and Meta-Analysis

Background: Hand trauma requires specific rehabilitation protocol depending on the different structures involved. According to type of surgical intervention, and for monitoring pain and edema, post-operative rehabilitation of a hand that has experienced trauma involves different timings for immobilization. Several protocols have been used to reduce immobilization time, and various techniques and methods are adopted, depending on the structures involved. Objective: To measure the effects of mirror neurons-based rehabilitation techniques in hand injuries throughout a systematic review and meta-analysis. Methods: The protocol was accepted in PROSPERO database. A literature search was conducted in Cinahl, Scopus, Medline, PEDro, OTseeker. Two authors independently identified eligible studies, based on predefined inclusion criteria, and extracted the data. RCT quality was assessed using the JADAD scale. Results: Seventy-nine suitable studies were screened, and only eleven were included for qualitative synthesis, while four studies were selected for quantitative analysis. Four studies were case reports/series, and seven were RCTs. Nine investigate the effect of Mirror Therapy and two the effect of Motor Imagery. Quantitative analyses revealed Mirror Therapy as effective for hand function recovery (mean difference = −14.80 95% Confidence Interval (CI) = −17.22, −12.38) (p < 0.00001) in the short term, as well as in long follow-up groups (mean difference = −13.11 95% Confidence Interval (CI) = −17.53, −8.69) (p < 0.00001). Clinical, but not statistical, efficacy was found for manual dexterity (p = 0.15), while no benefit was reported for range of motion. Conclusions: Mirror neurons-based rehabilitation techniques, combined with conventional occupational and physical therapy, can be a useful approach in hand trauma. Mirror therapy seems to be effective for hand function recovery, but, for motor imagery and action observation, there is not sufficient evidence to recommend its use. Further research on the efficacy of the mirror neurons-based technique in hand injury is recommended.

An Italian Validation of ABILHAND-Kids for Children With Cerebral Palsy

Limitations in hand function are common among children with cerebral palsy (CP), with almost 50% presenting an arm-hand dysfunction. However, there is no standardized assessment tool available in Italian for evaluating bimanual performance for this population. Our objective in this study was to evaluate the psychometric properties of an Italian translation of the ABILHAND-Kids (ABILHAND-Kids-IT) among children with CP. We examined internal consistency using Cronbach's Alpha and Omega coefficients, and we investigated test-retest reliability with intraclass correlation coefficients (ICC). We performed explorative factor analysis (EFA) to investigate structural validity. We calculated Pearson's correlation coefficients between the ABILAND-Kids IT and the Manual Ability Classification System (MACS) to assess criterion validity; and, to demonstrate the score variability of the ABILHAND-Kids-IT, we used analyses of variance (ANOVAs) to compare the 181 children with CP in this sample with their levels on the MACS. We enrolled 181 children with CP in the study. EFA confirmed a uni-dimensional scale. We obtained internal consistency on both Cronbach's Alpha and Omega coefficient of 0.98, and a one-week test-retest reliability analysis revealed an ICC with 95% of confidence interval of .992. The ANOVA revealed significant score variability (p < 0.01) and the Pearson correlation coefficient comparing the ABILHAND-Kids-It score with the MACS was -0.929 (p < 0.01). We conclude that the ABILHAND-Kids-IT is valid and reliable for use with Italian children with CP.

Hand and Upper Limb Malformations in Italy: A Multicentric Study

Background: Although hand and upper limb malformations are quite frequent, up to now very few reports have been published on epidemiology. The aim of this study is to evaluate the number of infants who presented with hand and upper limb malformations from 2010 to 2015 in Italy. Methods: A retrospective analysis of a pediatric population presenting with hand and upper extremity malformations was carried out, gathering reports achieved from eight Italian Centers of pediatric hand surgery. Other factors such as gender, date and region of birth, family distribution of malformations and associated syndromes, were analysed. Results: Out of 3,100,421 live births, 765 children presented with hand and upper limb malformations. The incidence was 2,5/10,000 live births with a predominance of males and the right side. Radial polydactyly was the anomaly with the highest percentage, closely followed by simple syndactyly, simbrachidactyly and complex syndactyly. Less common conditions were the triphalangic thumb, thumb in palm, proximal radioulnar synostosis and Sprengel deformity. Inheritance of and familial predisposition to those malformations was recorded in 25 cases, while 84 children presented with syndromes related to hand anomalies. Conclusions: In conclusion the incidence of hand and upper extremity malformations in Italy is lower than that registered in other countries. The retrospective nature of the study combined with the fact that some defects frequently evade pediatric hand surgeon consultations are some possible limitations of the study. However, our data confirmed that, in spite of the decrease in the birth rate in Italy, the trend of congenital hand disorders maintained a stable trend. We aim to integrate this study with a prospective analysis and to involve the institutional health authorities in other countries so as to register the correct incidence of hand and upper extremity defects.

Role of the Cadaver Lab in Lymphatic Microsurgery Education: Validation of a New Training Model

BACKGROUND

Microsurgical transplantation of vascularized lymph nodes (VLNT) or lymphatic vessels (VLVT) alongside derivative lymphaticovenous procedures are promising approaches for treatment of lymphedema. However, clinically relevant training models for mastering these techniques are still lacking. Here we describe a new training model in human cadaver and validate its use as training tool for microsurgical lymphatic reconstruction.

METHODS

10 surgeons with previous exposure to microsurgery were trained in a controlled environment. Lymphatic vessel mapping and dissection in 4 relevant body regions, harvesting of five different VLNTs and one VLVT were performed in 5 fresh-frozen cadavers. The number of lymphatic vessels and lymph nodes for each VLNT were recorded. Finally, the efficacy of this model as training tool was validated using the Dundee Ready Education Environment Measure (DREEM).

RESULTS

The average cumulative DREEM score over each category was 30,75 (max = 40) while individual scoring for each relevant category revealed highly positive ratings from the perspective of teaching (39,3), training 40,5 (max = 48) and self perception of the training 30,5 (max = 32) from all participants. The groin revealed the highest number of lymphatic vessels (3.2 ± 0.29) as all other regions on the upper extremity, while the gastroepiploic VLNT had the highest number of lymph nodes (4.2 ± 0.37).

CONCLUSIONS

This human cadaver model represents a new, reproducible "all-in-one" tool for effective training in lymphatic microsurgery. Its unique diligence in accurately reproducing human lymphatic anatomy, should make this model worth considering for each microsurgeon willing to approach lymphatic reconstruction.

The Versatility of the Free Vastus Lateralis Muscle Flap: Orbital Reconstruction After Removal of Complex Vascular Malformation in a Pediatric Patient

Introduction: Vascular orbital lesions in pediatric population represent a demanding therapeutic challenge which requires a multidisciplinary team. In severe cases, orbital enucleation can be considered. Surgical management of enucleated orbital region in children, differently from the adults, represents a challenging procedure owing to the intrinsic relation between volume replacement and normal orbital growth. Many reconstructive options have been proposed, and many donor sites have been utilized for this purpose but each one have demonstrated potential disadvantages. Despite its well-known versatility, no report of the vastus lateralis free flap in children requiring orbital reconstruction exists in literature. Herein, we propose this surgical strategy as a valid option for the reconstruction of an extended orbital defect in a pediatric patient suffering from a mixed type of vascular malformation. Material and Methods: A patient was referred from a foreign country with an unclear medical history, presenting exorbitism and exophthalmos, proptosis of the eyeball, visus 4/10, and limited ocular motility. We made clinical-instrumental investigations with a diagnosis of complex vascular malformation. It expanded in intraorbital and retrorbital space with bulb anterior dislocation and optic nerve involvement. We performed an emptying of the orbital content via transconjunctival and via coronal incision with eyelid preservation. A free vastus lateralis muscle flap was used for reconstruction, filling the orbital cavity. We anastomosed the flap on the superficial temporal artery. An ocular conformator was then positioned. Results: We report the result at 12 months, showing a good orbital rehabilitation with an adequate prosthetic cavity, a good recovery of volume and facial symmetry, guaranteeing balanced orbital and periorbital growth. There were no major or minor complications associated with the procedure. Discussion: The reconstruction of the orbit remains a "surgical challenge" both in adults, whose goal is the restoration of volume, adequate symmetry and facial esthetics, and children, in which correcting the asymmetry has the additional objective to balance orbital growth. Many reconstructive techniques have been proposed, including the use of free flaps. The versatility of the free vastus lateralis muscle flap is well-known. It offers adequate amount of tissue with minimal morbidity to the donor site, provides a long pedicle, gives the possibility of simultaneous work in a double team, and has a constant anatomy and a safe and rapid dissection. There are no descriptions of its use for pediatric orbital reconstructions. Conclusions: In our opinion, the free vastus lateralis flap should be included as one of the best option for orbital pediatric reconstruction after enucleation.

The use of interstitial echo-guided diode laser 980-nm for deep vascular anomalies in pediatric patients: a preliminary study

A wide range of therapeutic options is available to treat vascular anomalies, arising from the systemic therapies to surgery or using lasers. The purpose of this preliminary study is to assess the effectiveness of treatment of vascular anomalies anywhere in the body, along with the use of interstitial echo-guided 980 nm diode laser. The analysis occurs through accurate angio magnetic resonance imaging (MRI) pre- and post-treatment measurements. We enrolled all the patients (16) affected on vascular malformations everywhere in the body, treated from January to August 2012. We obtained excellent results in 6 patients (37.5%) with mean mass reduction of 85%, good in 9 patients (56%) with mean mass reduction of 65% and unsatisfactory in 1 patient (6%). In pediatric patients, low-flow vascular malformations resistant to progressive sclerotherapy or in critical anatomical sites, benefit of echo guided interstitial 980-nm diode laser.

Early Surgical Excision of Giant Congenital Hemangiomas of the Scalp in Newborns: Clinical Indications and Reconstructive Aspects

Background:

Infantile hemangioma is the most common vascular tumor in newborns, with an incidence from 12 to 23% among preterm infants with low weight at birth and a female to male ratio of 3:1. The head and neck is the most frequently affected area (60%), and the scalp is a typical site for such large lesions.

Objective:

We describe some clinical and medical aspects in comparison with the surgical approach to giant infantile hemangioma of the scalp.

Methods:

The indications to treatment are discussed. An outcome basis evaluation, by reviewing some clinical cases, is provided to help readers better understand when and how to undergo surgery safely.

Conclusion:

Early excision of huge infantile hemangioma of the scalp is the treatment of choice if feasible within 5 months of age.

Early reconstruction of the abdominal wall in giant omphalocele

Omphalocele is the most common congenital defect of the abdominal wall. Mortality rate is between 20 and 70% and early closure of the abdominal wall, within 10 days of life, is vital to the successful outcome of the surgical treatment. The authors describe the use of two bipedicled flaps of abdominal skin to correct the defect of the midline as soon as the reduction of all viscera has been accomplished.

Juvenile Active Ossifying Fibroma with Massive Involvement of the Mandible

Fibro-osseous lesions of the maxillofacial complex are often difficult to diagnose from both a clinical and a histopathologic point of view. The parameters for the diagnosis of juvenile active ossifying fibroma are as follows: a patient under 15 years of age, localization of the tumor, the radiologic aspect, and the tendency to recur. Although many authors favor conservative surgery rather than radical en bloc resection, immediate recurrence characterized by a high aggressive growth rate and the absence of a distinct separation between the tumor and the adjacent bone requires ex- tensive surgery, with wide demolition of the involved bone.

Malignant tumors of the orbital region. Analysis of cases examined from 1986 to 1995

OBJECTIVE

To present a retrospective study of 154 orbital tumors examined from 1986 to 1995.

METHODS

We analyzed the clinical behavior and the degree of local malignity also in relationship with the particular anatomical characteristics of this site.

RESULTS

In this are, it is not rare finding tumors with a scarce cutaneous extension but a deep involvement including the bone, or of recurrences after a previous insufficient treatment with an aggressive clinical course.

CONCLUSION

The principles for the surgical approach are: exeresis as radical as possible, one-stage operation for tumoral resection and reconstruction, bringing of trophic tissue able to sustain any complementary treatment, easy and fast execution, and short clinical course.