The post-traumatic reconstruction of nail bed defects using a homodigital dorsal adipofascial reverse flap.

Nail bed defects (NBDs) of the distal phalanx, are common and remain challenging to reconstruct. This study aimed to evaluate the clinical outcome of these post-traumatic injuries treated using a homodigital dorsal adipofascial reverse flap (HDARF). Sixteen patients, averaging 43-years-old, were retrospectively reviewed, who underwent the aforementioned procedure from February 2018 to December 2019. Range of motion of the distal interphalangeal (DIP) joint, static Weber's 2-point discrimination sensibility of the pulp, the percentage of nail adherence, complications, patient's satisfaction, subsequent nail regrowth, and flap survival were evaluated upon follow-up. At 26 months average follow-up, the percentage of flap survival was 100%. Complete regrowth of the nail was reported in 11 cases (69%), on average 4.7 months after surgery. A total absence of ungual regrowth was noted in 5 cases (31%). The mean static Weber's 2-point discrimination value of injured finger was 4.25 mm, reconstructed fingers' mean range of motion for the DIP joint was 75 degrees. Patient satisfaction was graded as very satisfying in 11 cases (69%), satisfying in 4 cases (25%), and disappointing in 1 case (6%). The HDARF is a good alternative for the management of NBDs of fingers and thumb. It yielded functionally and aesthetically acceptable results with low donor site morbidity. LEVEL OF EVIDENCE: IV.

Intra-articular injection of autologous bone marrow aspirate concentrate in the treatment of osteoarthritis of the thumb first carpometacarpal joint: A pilot study.

This study aimed to evaluate the effect of bone marrow aspirate concentrate (BMAC) in the treatment of osteoarthritis of the thumb first carpometacarpal joint. Injections were carried out in 27 thumbs. According to the Dell classification, there were 2 stage I, 11 stage II, 13 stage III and 1 stage IV cases. The bone marrow was aspirated from the iliac crest, concentrated by centrifugation, and injected under fluoroscopic control into the pathological thumb. Results were assessed at a mean 16 months' follow-up (range, 8-26). Clinical evaluation comprised QuickDASH and PRWE scores, pain at rest on a numerical analog scale (NAS), and thumb column abduction on goniometry. QuickDASH and PRWE scores were 59 (range, 27-82) and 88 range, 37-125) preoperatively and 29 (range, 0-64) and 50 (range, 1-99) postoperatively, respectively. Mean pain at rest on NAS improved from 7 (range, 1-10) to 4 (range, 0-9). Thumb abduction improved by a mean 18° over preoperative data. No postoperative complications were found. Two patients had to be operated on for inefficacy of injection. This is the first article presenting the effect of an intra-articular injection of BMAC in the thumb first carpometacarpal joint and the results were encouraging. Many patients showed improved quality of life and pain relief. These injections appear to be an effective means of postponing surgery.

Indications, functional results and patient satisfaction after isolated second ray resection following traumatic injury: A retrospective review of 25 patients.

Amputation of the second ray is a surgical treatment option when reconstruction and/or reimplantation fail. The aim of our study was to review the outcomes after transmetacarpal resection of the second ray following a post-traumatic injury and to assess indications, functional outcomes, and patient satisfaction. Between January 2003 and December 2013, 25 patients (6 women and 19 men with a mean age of 51 years) underwent transmetacarpal resection of their second ray after a post-traumatic injury. Sixteen patients were right-handed and 9 were left-handed. Injuries involved the dominant hand in 14 cases (60%). In order to differentiate patients with preserved index finger length preoperatively from those with a shorter, amputated index finger stump, patients were divided into 2 groups. Group 1 included those with an "intact finger" and Group 2 included patients with an "amputated stump". Data collection, including patient satisfaction and functional outcomes, was performed at 83 months postoperative on average. Average length of follow-up was 7.0±1.0 years (range 5-12 years). Group 1 (intact finger) and 2 (amputated stump) included 15 and 10 patients, respectively. Six patients (24%) had primary ray amputation and 19 (76%) had secondary ray amputation. No surgical revision was necessary. In Group 1, the indications were purely functional in all but two cases, whereas aesthetic indications played a role in all patients in Group 2. The average total time off work was 3 months. There was no difference between Group 1 and 2 (P>0.05). However, patients with primary ray resection averaged 10 weeks of lost work compared to 17 weeks for secondary amputation. There was no functional difference between Groups 1 and 2. Scores for cosmetic appearance and patient satisfaction were higher in Group 2. In certain specific situations after complex hand trauma, transmetacarpal amputation of the second ray is indicated as soon as possible, in order to reduce the time off work. Patient satisfaction following this surgical procedure is high, especially in groups with amputated stumps. A 30% decrease in pinch and grip strength is the rule. No secondary surgery is normally required.

Intra-articular nodular fasciitis of the proximal interphalangeal joint of a finger: A case report.

Nodular fasciitis is a benign reactive lesion, often mistaken for a soft-tissue sarcoma in clinical practice. Involvement of the finger is rare, and a finger joint even rarer. We report on the clinical, radiological and histological features of intra-articular nodular fasciitis in a 52-year-old man, originating from the proximal interphalangeal joint of the right ring finger, with cortical erosion of adjacent bone. The discussion is focused on the tumor diagnosis and therapeutic approach, the differential diagnosis and the importance of immunohistochemical staining to establish the final diagnosis.

Acellular dermal matrix: New applications for free flap pedicle coverage - A prospective study in 10 patients.

INTRODUCTION: The goal of lower extremity reconstruction after trauma is the coverage of defects to give patients a healed wound and to let them resume their life, ambulate and return to work, while preventing amputation. In this article, we describe an innovative use of Integra® for free flap pedicle coverage in lower extremity reconstruction. MATERIALS AND METHODS: Between January 2011 and December 2015, ten patients, four women and six men, underwent a lower limb reconstruction with an association of free flap and Integra® to cover the flap pedicle. The mean age of the patients was 38.8±15.6 years at the time of surgery (range of 14-59 years). The mean defect size was 102±54 cm2 (range of 40-160 cm2). The bone and/or tendons were exposed at the level of the middle third of the leg in 2 cases, at the level of the distal leg in 5 cases and at the level of the foot in 3 cases. RESULTS: There were no intra-operative complications. Mean size of Integra® needed for flap pedicle coverage was 12.8±2.3 cm2 (range 10-15 cm2). The mean follow-up was 41±19 months (range 21-70 months). Revision surgery was necessary in three cases due to haematoma of the pedicle. In these cases, the dermal substitute was easily removed while awaiting revision. This allowed flap survival in all cases. A skin graft was performed after a mean time of 3.4±0.8 weeks post-operatively. Complications at the donor site level included one seroma and a case of hypertrophic scar. Complete healing of both the donor and recipient sites was achieved in all cases. CONCLUSIONS: The combination of free flap and Integra® appears to be a useful option in covering complex defects in the lower limb. The dermal substitute avoids skin tension and compression of the pedicle. Haematomas of the pedicle, if they occur, are highly visible and thus easy to manage. We hypothesize that the use of dermal substitute for this specific indication of pedicle coverage will expand in the near future.

Double crush syndrome of the median nerve revealing a primary non-Hodgkin's lymphoma of the flexor digitorum superficialis muscle.

Extranodal manifestations of lymphoma are well described in the literature and occur in 20 to 30% of patients. Skeletal muscle involvement is rare. We describe the case of a patient with non-Hodgkin's lymphoma in a forearm muscle. At the age of 86, the featured patient started experiencing continuous, progressive and high intensity pain that was more frequent at night and localized in the right dominant hand. It was associated with paresthesia and hypoesthesia, primarily in the thumb, index finger and middle finger. Clinical examination and electrodiagnosis led to the diagnosis of carpal tunnel syndrome. The patient underwent carpal tunnel release at a private hand center. The progression was unfavorable. Additional clinical examination and electrodiagnosis showed compression of the anterior interosseous nerve (double crush syndrome). The patient was referred to our university hand center for further management. Magnetic resonance imaging showed a large mass of about 20cm occupying the entire anterior compartment of the forearm and enclosing the median nerve. Biopsies were performed and revealed a diffuse large B-cell primary non-Hodgkin's lymphoma. The patient underwent chemotherapy and radiotherapy. Six months later, the patient was in complete remission. Muscular involvement during lymphoma is rare. Biopsy is mandatory; needless radical surgery can be avoided because lymphoma is primarily a non-surgical disease. The key points of the treatment process are reviewed.

Proximal interphalangeal joint fractures treated with a dynamic external fixator: A multicenter and retrospective study of 88 cases.

Ligamentotaxis is now a well-established treatment method for proximal interphalangeal (PIP) joint fractures. Despite satisfactory results, the technique is considered complex and the devices cumbersome. The aim of this study was to evaluate a miniaturized dynamic external fixator (Ligamentotaxor(®)) for the management of these fractures. Eighty-six patients with 88 fractures of the PIP joint were treated at 10 European hand surgery centers. The device was applied within eight days of the injury and was removed 40-45 days after the injury. Treatment complications included superficial infection (4 cases), osteoarthritis (1 case), and localized but resolving complex regional pain syndrome (4 cases). The fracture healed in all cases. At final follow-up (mean: 15.2 months), average range of motion was 70° (range: 0-110°). Functional results were comparable between the 10 participating centers. Pain occurred upon exertion in 47% of the patients, 40% were sensitive to weather changes and 26% experienced constant pain. The mean QuickDASH score was 15.7 (range: 11-37) and 83.7% of the patients had no limitations during their daily activities. The results of this series are similar to those reported in other studies of PIP fracture treatment with external fixators. This technique is reliable and reproducible. The device is easy to handle by surgeons and well tolerated by patients. We think that this simple, reliable technique could be relevant for the management of PIP joint fractures.

Arterial vascularization of the flexor digitorum superficialis synovial flap. An anatomical study.

Among the various techniques proposed to protect the median nerve from scarring and to provide it with a vascular supply, the synovial flap represents a simple and effective method. The flap is taken from the flexor tendons sheath and results in a thin and richly vascularized tissue that will act as a barrier to scarring and provide neovascularization to improve nerve regeneration and gliding. The aim of this study was to evaluate the arterial vascularization of this flap to assess its reliability. An anatomic study was carried out on 24 fresh upper limbs infused with colored and radiopaque solutions before or after flap elevation. Anatomical findings showed the synovial flap to be supplied by a consistent vascular pedicle arising from the ulnar artery 2 to 5 centimeters proximal to the pisiform bone and running between the flexor tendons of the ring and little fingers. The synovial flap is known to be a simple and effective method for protecting the median nerve. The present study shows that its consistent vascularization makes it a reliable technique. We believe this procedure is relevant for the treatment of recurring carpal tunnel syndrome.

[Perilunate dislocations and fracture-dislocations of the wrist, a review of 17 cases]. / Luxations et fractures-luxations périlunaires du carpe, étude rétrospective d'une série de 17 cas.

INTRODUCTION: The authors present the results of a retrospective series of 17 cases of dislocations or perilunate fracture-dislocations of the carpus, treated in emergency (period of less than 7 days). The objective aim of our study was to evaluate the radioclinical fate prognosis of these lesions pathologies and their social commitment impact. PATIENTS AND METHODS: It is a retrospective study covering the period from July 2004 to December 2009 (or 54 months). Were included in the study, patients hospitalised for a pure dislocation or a perilunate fracture-dislocation authenticated confirmed by an x-ray postero-anterior and lateral views were included. The series included 15 men and two women, nine manual workers, with an average age of 38.9 years. Based on Herzberg radiological classification, the series included six pure perilunate dislocations (35%) and 11 fracture-dislocations (59%) including seven forms trans-scapho-perilunate and four fractures of the lower end of radius. On the profile x-ray, 16 of the lesions were posterior displacement, including 12 stages I lesions (lunatum in place under the radius), and four stage II (lunatum dislocated in front of the radius). A patient had an anterior dislocation stage II, associated with a radial styloid fracture. All patients were operated using surgical treatment, percutaneous, either open pit, or open approaches combining with broaching scapholunate, scaphocapitate and triquetrolunate pinning. Then, an immobilization for 6 weeks was put in place and was performed using a forearm cast. Rehabilitation began as early as the removal of osteosynthesis was done at pin removal. RESULTS: The average decline follow-up in the series was 26 months. The mean score of Cooney was 63/100. There were two excellent results, two good results, seven middle moderate results, and six bad results. The average Quick-DASH score was 24.6/55 and the PRWE 41/150. The average duration of the work stoppage leave was 8 months, including one retired. The average of flexion-extension arc of the traumatized side was 77% (101°) in comparison to the healthy side. The average strength of the traumatized side was 71% (34kg) in comparison with the healthy side. The average radial-ulnar tilt arc of the traumatized side was 67% (37°) in comparison with the healthy side. DISCUSSION: There is no formal radioclinical prognostic in the radioclinic correlation. However, it seems to emerge that the timing and the type of support treatment bear the most important prognostic guarantors of a better result factors. Perilunate fracture-dislocations have major arthrogeneous arthrogenic potential, yet with a despite functional outcome consistent allowing resumption of recovery of past previous activities. It would seem that perilunate fracture-dislocations have a better functional outcome than those of pure dislocations. Thus, this work is the beginning of a long-term study, including a larger number of patients.

[Bladder urothelial carcinoma with acrometastasis: a case report and review of the literature]. / Acrométastase d'un carcinome urothélial de la vessie : à propos d'un cas et revue de la littérature.

The authors report a new case of acrometastasis of the hand, from a urothelial carcinoma of the bladder, in a 46-year-old woman, with a history of left lower lobectomy for bronchial carcinoma. Physical examination revealed a tumor of the dorsal hand, inflammatory and painful. The radiograph showed ill-defined osteolysis of the base of the fourth metacarpal. Two immunohistochemical studies were needed to confirm the origin of the bladder metastasis. The authors propose a review of the literature addressing the difficulty of diagnosis, treatment and poor prognosis of these lesions.

Management of severe hand wounds with Integra® dermal regeneration template.

We report our experience with the use of Integra® for the management of severe traumatic wounds of the hand. Fifteen patients were treated with follow-up ranging from 10 to 37 months. Wounds were associated with an osseous and/or joint and/or tendon exposure. Following Integra® placement, patients were managed with dressings and subsequent split-thickness skin grafting an average of 26 days later. Integra® was successful in achieving durable, functional and aesthetic definitive coverage in 13 of 15 applications while allowing a satisfying pollicidigital prehension. Regarding our clinical experience, Integra® is an effective technique to deal with severe wounds of the hand with exposed tendon and/or bone and/or joint, even in the absence of paratenon or periosteum. This can potentially lessen the need for local rotational or free flap coverage and should be taken into consideration as a viable alternative in traumatic reconstruction of the hand.

[Importance of skin graft in preventing recurrence of Dupuytren's contracture]. / Intérêt de la greffe de peau dans la prévention des récidives de la maladie de Dupuytren.

OBJECTIVE: The aim of the study was to evaluate the ability of full thickness skin grafts to prevent recurrence of aggressive Dupuytren's contracture. PATIENTS AND METHODS: Eighteen patients presenting with bilateral recurrent Dupuytren's contracture were identified and retrospectively reviewed with a mean follow-up of 8.8 years after dermofasciectomy and skin grafting onto at least one hand. RESULTS: Only two patients presented with a complete diathesis of Dupuytren's contracture, such as defined by Hueston, thus confirming that recurrence is still not predictable. Each patient sustained 3.6 procedures on average. Thirteen patients were skin grafted on a single hand and five patients bilaterally. Recurrence occurred in three instances after skin grafting and in all instances when skin graft was not performed. Finally, three peroperative and five postoperative complications were reported. CONCLUSION: Skin grafting was able to prevent further recurrence of recurrent Dupuytren's contracture in 20 out of 23 hands with more than 8 years of follow-up. Since recurrence is still difficult to predict, primary skin grafting remains controversial. Indications for the procedure are more definite once recurrence has occurred.

[Hand involvement in Thevenard's disease: a new "phlegmonous" form. An exceptional case report]. / Atteinte de la main dans la maladie de Thévenard. A propos d'une observation exceptionnelle sur une nouvelle forme "phlegmoneuse".

Thévenard's disease is a rare familial ulcero-mutilating acropathology involving the peripheral nervous system. It typically begins on the feet and only rarely spreads to the hands late in the course of the disease. It first causes cutaneous ulcerations and then secondary osseous deformations and osteoarticular destruction, due to a distal loss of temperature sensation. We report the case of an 87 year old patient who suffered from a particular clinical form, undescribed as yet in the literature and characterized by local and general superinfections predominately on the hands. We term this the "cellulitic" presentation or form of Thévenard's disease.