COVID-19: Initial experience of an international group of hand surgeons

The emergence of the COVID-19 pandemic has severely affected medical treatment protocols throughout the world. While the pandemic does not affect hand surgeons at first glance, they have a role to play. The purpose of this study was to describe the different measures that have been put in place in response to the COVID-19 pandemic by hand surgeons throughout the world. The survey comprised 47 surgeons working in 34 countries who responded to an online questionnaire. We found that the protocols varied in terms of visitors, health professionals in the operating room, patient waiting areas, wards and emergency rooms. Based on these preliminary findings, an international consensus on hand surgery practices for the current viral pandemic, and future ones, needs to be built rapidly.

A porcine model for robotic training harvest of the rectus abdominis muscle

Conventional open surgical approaches for the harvesting of the rectus abdominis muscle carry a high risk of morbidity. It is possible to reduce these risks by using laparoscopy or robot-assisted techniques. This work hypothesizes that a porcine model could be used for learning the robot-assisted collection of the rectus abdominis. The rectus abdominis was taken in 3 stages in 3 pigs: installation of the robot, surgical approaches with 4 trocars, dissection and collection of the muscle. The average operating time was 1h20min and the average muscular length was 16cm. Our results showed a learning curve for the robot-assisted harvesting of the rectus abdominis on a porcine model.

Is there a relevance of suction drainage in non-septic wrist surgery?

INTRODUCTION

No rational argument leads to conclude to the benefit or the innocuousness of drainage in non-septic wrist surgery.

HYPOTHESIS

The goal of this study was to validate the hypothesis that for those indications drainage is unnecessary.

MATERIAL AND METHOD

We reviewed 1001 consecutive cases, concerning 885 patients, 58 years old in average.

RESULTS

Out of 1001 procedures, 9 patients were operated on both sides, 145 were operated twice of which 130 for the implantation and then the removal of surgical material. None were reoperated for hematomas. Three patients were initially treated for an osteosynthesis using an anterior plate of distal radius and secondarily reoperated due to sepsis, one of them twice. The material was removed from two patients. The average time of tourniquet for those 3 osteosynthesis was significantly superior (84.33min) to the average time for the 595 other anterior distal radius plates (45.35min).

CONCLUSION

The results of our study show that suction drainage in non-septic wrist surgery is unnecessary.

LEVEL OF EVIDENCE

III descriptive retrospective study.

Resistance of primary microsurgical repair of palmar digital nerves to finger mobilization: A cadaver study

The aim of this study was to assess the resistance of microsurgically repaired proper palmar digital nerves (PPDN) to mobilization. Thirty-nine PPDN from fresh forearms cadavers were transected and then sutured using 10/0 nylon. After skin closure, each finger was forcefully flexed and extended 10 times. Out of the 39 repaired nerves, two were elongated and four were ruptured; this amounts to a 15.38% complication rate. We recommend immobilization of nerve repairs, although this contradicts most recent studies.

Assessment of the structures at risk during wrist arthroscopy: a cadaveric study and systematic review

We assessed the proximity of neurological structures to arthroscopic portals in a cadaveric study and through a systematic review. Arthroscopy was performed on ten cadaveric wrists. Subsequently the specimens were dissected to isolate the superficial branch of the radial nerve, the dorsal branch of the ulnar nerve, the posterior interosseous nerve and the extensor tendons. We measured the distances from the nerves to common portals. For the systematic review Pubmed and EMBASE were searched on the 31 May 2014 for cadaveric studies reporting the proximity of neurological structures to any arthroscopic wrist portal. In the cadaveric study, partial injuries were seen to six extensor tendons and one posterior interosseous nerve; it was assumed this was due to creation of the portals. Seven published studies were included in the systematic review. The dorsal sensory branch of the ulnar nerve was found to be at risk by performing the 6 Ulnar, 6 Radial and ulnar midcarpal portals, the sensory branch of the radial nerve by the 1-2 and 3-4 portals and the posterior interosseous nerve by the 3-4 and 4-5 portals.

LEVEL OF EVIDENCE

V.

Fractures and dislocation of the base of the thumb metacarpal

Acute traumatic lesions of the base of the first metacarpal are frequent and their consequences can affect the opposition of the thumb. They usually occur after trauma in compression along the axis of the thumb in flexion. Restoring the anatomy and biomechanics of the trapeziometacarpal joint is essential when treating these injuries, hence why surgical treatment is usually indicated. We distinguish trapeziometacarpal dislocations, small-fragment and large-fragment Bennett's fractures, articular three-fragment Rolando and comminutive fractures and extra-articular fractures of the base of the first metacarpal. All carry the risk of narrowing of the first web. Recent studies have described poor results with conservative treatment. Surgical techniques are varied: percutaneous surgery, open surgery and arthroscopic surgery. The techniques of osteosynthesis are various: locking plates, and direct or indirect screw fixation or pinning. The prognosis depends on the quality of the restoration of the mobility of the trapeziometacarpal joint.

Pull out stent: a trick to improve the intravascular stenting technique

The intravascular stent technique (IVaS) was developed to simplify the anastomosis of submillimeter blood vessels. One variation of the IVaS called the "clip stent", improved the patency of anastomosed vessels. The goal of this study was to analyze a subsequent technical variation called the "pull out stent", which aims to reduce trauma to the vessel. Our experimental study comprised 4 groups of 10 rats. Anastomosis of the tail artery was performed with 10-0 nylon suture using either interrupted sutures (group I), IVaS (group II), "clip stent" (group III), or "pull out stent" (group IV). The "pull out stent" technique consisted of 3 steps: introduction of the stent (intraluminal and then transluminal introduction of a 4-0 nylon monofilament followed by introduction of the other end into the opposite lumen), anastomosis, and then removal of the stent. The anastomosis procedure time was longer in group III than in group IV. The number of stitches and the patency were similar in all groups. There were more leaks in group I. The "pull out stent" was faster, less traumatic to the vessel wall, allowed for more regular sutures and caused fewer leaks than the other stenting techniques. One possible clinical application is the anastomosis of digital veins as part of replantation or toe transfers, especially in children.

Support for partial lesions of the flexor tendons of the fingers: a retrospective study of 36 cases

The treatment of traumatic partial injuries of the flexor tendons of the fingers is seldom published. The only published clinical series states that the therapeutic approach depends on the existence or absence of a preoperative trigger. We hypothesized that the therapeutic attitude mainly depends on the percentage of the injured cross-section. Our retrospective series included 36 partial lesions of 31 fingers in 29 patients. The average age was 42 years, there were 19 men. We noted 8 lesions in zones I, 21 in zone II and 2 in zone III. The average percentage of the injured cross-section was 35% and ranged from 10% to 90%. If the lesion was less than 50% (29 tendons), a tangential resection was performed. If the lesion exceeded 50% (seven tendons), a direct suture was performed, supplemented by a running suture. At a follow-up of 34 months, the average pain on a visual analogue scale was 0.7. The average percentage of strength compared to the contralateral side was 93%. The Quick DASH score was 6.2. The range of motion averaged 214° with extremes ranging from 90° to 260°. We observed no cases of hypertrophic callus, neither through the MRI nor through the ultrasonography. Complications such as trigger finger, pseudoblocage or rupture were not observed. Based on our results, in case of partial injury of a flexor tendon, we propose to perform a tangential resection in cross-section lesions up to 50%, and a suture for those which exceeded 50%.

Canaletto implant in revision surgery for carpal tunnel syndrome: 21 case series

Revision carpal tunnel surgery varies from 0.3% to 19%. It involves a delayed neurolysis and prevention of perineural fibrosis. Despite numerous available procedures, the results remain mediocre. The aim of this study is to evaluate the results of the Canaletto implant in this indication. Our series includes 20 patients (1 bilateral affection) reoperated for carpal tunnel between October 2008 and December 2009. After the first operation, the symptom-free period was 112 weeks, on average. The average incision was 27 mm. After neurolysis, the Canaletto implant was placed in contact with the nerve. Immediate postoperative mobilization was commenced. Sensory (pain, DN4, and hypoesthesia), motor (Jamar, muscle wasting), and functional (disabilities of the arm, should, and hand; DASH) criteria were evaluated. Nerve conduction velocity (NCV) of the median nerve was measured. Average follow up was 12.1 months. All measurements were improved after insertion of the Canaletto implant: pain (6.45-3.68), DN4 (4.29-3.48), Quick DASH (55.30-34.96), Jamar (66.11-84.76), NCV (29.79-39.06 m/s), hypoesthesia (76.2-23.8%), wasting (42.9-23.8%). Nevertheless, four patients did not improve, and pain was the same or worse in six cases. Our results show that in recurrent carpal tunnel syndrome, Canaletto implant insertion gives results at least as good as other techniques, with the added advantage of a smaller access incision, a rapid, less invasive technique, and the eliminated morbidity of raising a flap to cover the median nerve.

Long-term review of five leg replantations: emergency strategy and examples of lengthening of the leg on nerve regeneration

The success rate for leg replantation has improved with the development of shortening-lengthening protocols. We checked whether this success was maintained long term in five cases of emergency reimplantation. The significant initial shortening of 93 mm, on average, enabled direct internal osteosynthesis, secondary lengthening was initiated swiftly, in the proximal metaphyseal area, and average lengthening was 85 mm. Consolidation was achieved in all cases within normal time periods, with an average inequality in residual length of 8mm. The speed of nerve regeneration was on average 1.926 mm/day, twice faster than usual after simple nerve suturing. At average follow-up of more than 11 years, all patients were walking. We conclude that nerve lengthening stimulates nerve regeneration, and that the results of this protocol, involving extensive initial debridement compensated by secondary lengthening, have enabled the limitations on unilateral leg replantation to be reduced.

Head movement trajectory in three-dimensional space during orienting behavior toward visual targets in rhesus monkeys

Head movement trajectories in three-dimensional space were studied in two monkeys with their heads free during natural and spontaneous orienting behavior toward objects of interest displayed in a horizontal plane. The main interest of this study lies in understanding the process responsible for behavioral variability during the execution of head movements, with special reference to "units of movement." The head movements were recorded by an optoelectronic movement analyzer working with passive markers. Algorithms have been designed to reconstruct the three-dimensional trajectories of the center of gravity of the head. Simultaneously, electromyographic activity in the four pairs of suboccipital muscles was studied. A quantitative evaluation of the involvement of the head in orienting behavior toward visual targets shows that the gaze shift is always produced by eye movements in combination with head movements, even with target eccentricities of less than 10 degrees. On the basis of 80 trials performed by the two monkeys, head trajectories and recruitment patterns of the four pairs of suboccipital muscles have been analyzed. We have been able to identify four elementary kinematic units which can be described as a rightward or leftward turning associated with a contralateral or ipsilateral bending. Each of these four elementary units are underlain by a precise fixed recruitment pattern in the four pairs of suboccipital muscles. These four sets of motor strategies can be combined in order to offer a certain amount of plasticity from which the animal builds its own head trajectory.