Full-field noise-correlation elastography for in-plane mechanical anisotropy imaging.

Elastography contrast imaging has great potential for the detection and characterization of abnormalities in soft biological tissues to help physicians in diagnosis. Transient shear-waves elastography has notably shown promising results for a range of clinical applications. In biological soft tissues such as muscle, high mechanical anisotropy implies different stiffness estimations depending on the direction of the measurement. In this study, we propose the evolution of a noise-correlation elastography approach for in-plane anisotropy mapping. This method is shown to retrieve anisotropy from simulation images before being validated on agarose anisotropic tissue-mimicking phantoms, and the first results on in-vivo biological fibrous tissues are presented.

Techniques of nail anesthesia.

Nail anesthesia is systematic in nail surgery. It is usually performed by the surgeon, a few minutes ahead of the procedure. Several techniques and substances are available. The rules of anesthesia must be respected for surgery to be comfortable, with the whole operated zone anesthetized. The surgeon has to select appropriate type of anesthesia according to the surgical indication, patient age and comorbidities; the local anesthetic must be chosen; contraindications must be respected; the injection site must be selected; the quantity must be determined; and the patient must be monitored for any complications. All these steps are mandatory, before, during and after nail anesthesia, for nail surgery to be painless and safe.

The comparative efficacy of nerve transfer versus tendon transfer in the management of radial palsy: A systematic review and meta-analysis.

Background: There is no clear census as to which operative technique provides better recovery for radial nerve injuries. Therefore, in this systematic review, we examined the functional recovery, patient-reported outcomes, and complications of tendon transfer (TT) and nerve transfer (NT). Methods: Five electronic databases were searched for studies (>10 cases per study) comparing NT and TT regardless of the study design (observational or experimental). Manual search was also conducted. The quality was assessed by the NIH tool. Outcomes included functional recovery, patient-reported outcomes (DASH score, satisfaction, and inability to return to work), and complications. The prevalence was pooled across studies using STATA software, and then, a subgroup analysis based on the intervention type. Results: Twenty-one studies (542 patients) were analyzed. Excellent recovery, assessed by the Bincaz scale, was higher in the TT group (29 % vs. 11 %) as well as failure to extend the fingers (49 % vs. 9 %). No significant difference was noted between both groups regarding DASH score (mean difference = -2.76; 95 % CI: -12.66: 6.93). Satisfaction was great in the TT group (89 %) with a limited proportion of patients unable to return to work (7 %). Complications were slightly higher in the TT group (8 % vs. 7 %) while 18 % of patients undergoing TT requiring revision surgery. Radial deviation was encountered in 18 % of patients in the TT group and 0 % in the NT group. The quality was good, fair, and poor in 2, 13, and 6, respectively. Conclusions: In radial nerve injuries, although tendon transfer may seem to provide better functional motor recovery than nerve transfer, it is associated with a higher rate of failure to extend the finger. Given the large confidence interval, the accuracy of this finding is questioned. However, a great proportion of those patients require revision surgery afterward. Additionally, tendon transfer is associated with a greater complication rate than nerve transfer, particularly radial deviation.

A Cadaveric Study Examining the Accuracy of Wireless Hand-Held Guided Ultrasound Injections Versus Blind Injections in the Flexor Tendon Sheath.

Purpose: Hand-held ultrasound (HHUS) is gaining popularity among clinicians. Although its use for procedural guidance could have several advantages in hand surgery, other surgeons may wonder about its added benefits. This cadaveric study aimed to examine the hypothesis of increased accuracy of wireless HHUS-guided injections versus that of blind injections into the flexor sheath. Methods: Our series included 20 fresh cadaveric hands with 80 fingers randomly assigned to 2 groups. In group A, 10 hands were randomly assigned to receive a landmark injection and then received a blinded injection to the flexor tendon sheath (FTS). In group B, 10 hands were blinded in the same manner and received an ultrasound-guided injection with HHUS. Methylene blue was injected, and anatomic dissection was performed to evaluate the injection accuracy based on the dye's filling pattern in the FTS as stage I (no filling), stage II (<50% filling), and stage III (>50% filling). Statistical analysis was performed, and P <.05 indicated a significant difference. Results: One finger was excluded because of severe Dupuytren contracture. In group A, 39 blind injections of the FTS were performed, with 82% (32/39) fingers achieving stage III filling. In group B, 40 ultrasound-guided FTS injections were performed, with 90% (36/40) of fingers achieving stage III filing. Our study did not reveal any superiority in accuracy when ultrasound guidance was used (P = .35). Conclusions: Hand-held ultrasound-guided FTS injections were not more accurate than blind injections performed by an experienced hand surgeon. These findings suggest that blind injections can be used as routine practice when performed by experienced operators to treat trigger finger. However, the use of HHUS may offer other advantages in hand surgery practice. Clinical relevance: Ultimately, choosing to perform HHUS-guided injection versus blind injection to treat trigger finger depends on the surgeon's experience and preference for a particular technique.

Semi-occlusive dressing versus surgery in fingertip injuries: A randomized controlled trial.

OBJECTIVES: No gold-standard treatment has been established for the management of distal digital amputation in Ishikawa zones II and III. The objective of this study was to compare the results of management of fingertip amputation by semi-occlusive dressing versus surgery. The principal hypothesis was that a semi-occlusive dressing results in better recovery of sensory function than a digital flap. METHODS: We conducted a prospective, randomized, multicenter study of 44 patients: 23 managed conservatively with semi-occlusive dressing, and 21 surgically with digital flap. RESULTS: Mean follow-up was 12 months. Mean healing time was 4.9 weeks in the semi-occlusive dressing group and 3.6 weeks in the surgery group. There was no significant difference between groups for sensory recovery of fine touch (p = 0.198) or 2-point discrimination (p = 0.961). No infections were reported in either group. Hook-nail deformity was more frequent in the semi-occlusive dressing group, particularly in case of amputation in zone III. CONCLUSIONS: Semi-occlusive dressing enabled satisfactory healing and sensitivity recovery without increasing the risk of infection. However, in zone III amputation, we advocate surgical treatment with a digital flap, due to poor trophicity and the frequency of hook-nail deformity seen with conservative management. LEVEL OF EVIDENCE: II.

Accuracy of Wireless Hand-Held Guided Ultrasound Injections in the Trapeziometacarpal Joint: A Cadaveric Study.

Background Symptomatic trapeziometacarpal osteoarthrosis can be treated with an ultrasound-guided injection in the early stages. This cadaveric study aimed to assess the hypothesis suggesting enhanced accuracy and reliability of hand-held ultrasound (HHUS) injections compared to blind injections into the trapeziometacarpal joint (TMC). Materials and method Our series included 20 fresh cadaveric hands, with a total of 20 TMC randomly assigned to two groups. In group A, 10 TMC received a blinded injection, and in group B, 10 TMC received an ultrasound-guided injection with HHUS. Methylene blue was injected, and anatomical dissection was performed to assess the intra-articular location of the dye. The injection was considered accurate if the intra-articular synovial fluid was stained after opening the articular capsule on the dorsal approach. If there was no injection, it was inaccurate. A statistical analysis was performed, and p <.05 indicated a significant difference. Results Two thumbs were excluded during the study due to an existing trapeziectomy. In group A, 10 blind injections of TMC were performed, with 70% (7/10) of injections graded as accurate. In group B, eight ultrasound-guided injections were performed, with 75% (6/8) achieving accuracy. A Fisher's exact test was performed, and the results indicated no statistically significant difference in injection accuracy between the two groups (P = 1, odds ratio = 0.788). Conclusion Hand-held ultrasound guided TMC injections were not more accurate than blind injections performed by an experienced hand surgeon. Nonetheless, additional studies with a larger sample and comparative studies with conventional cart-based machines are necessary to evaluate the potential of this newly accessible device.

Influence of surgical performance on clinical outcome after osteosynthesis of distal radius fracture.

INTRODUCTION: Clinical outcome after surgery depends on the surgeon's level of expertise or performance. The present study of minimally invasive plate osteosynthesis (MIPO) with anterior plate for distal radius fracture assessed whether clinical outcome correlated with surgeon performance. METHODS: The series included 30 distal radius fractures: 15 operated on by 4 level III surgeons (Group 1) and 15 by 4 level V surgeons (Group 2), utilizing the MIPO technique. The surgical performance of all 8 surgeons was assessed using the OSATS global rating scale. Clinical outcomes were assessed at 3 months' follow-up using the modified Mayo score (MMS), in 4 grades: 0-64 (poor), 65-79 (moderate), 80-89 (good), and 90-100 (excellent). The QuickDASH score (QDASH) was also calculated, and complications were recorded. RESULTS: Median MMS was better for level V (75 = fair result) than level III surgeons (62 = poor result). Median QDASH score likewise was better in group 2 (9.1) than group 1 (22.7). In group 1, there were 2 paresthesias in the median nerve territory, 1 type-1 complex regional pain syndrome, and 1 hypoesthesia in the scar area. Mean correlation between the 2 scores was -0.68. Group 1 patients were on average 7 years older. The number of patients, number of surgeons and distribution of OA A and C fractures were almost identical in the two groups. On MMS, the overall result of the two groups was moderate (70.5), which can be explained by short mean follow-up. DISCUSSION: Quality of the clinical outcome on MMS and QDASH increased with surgical performance, with fewer complications. In the patients' interest, protocols for improving surgical performance should be implemented, for example, through deliberate practice.

Technique, Indications and Limitations of a Minimally Invasive Approach to Treat Distal Radius Fractures and Malunions.

The minimally invasive flexor carpi radialis approach can be used for volar locking plate fixation of distal radius fractures. It offers the advantage of preserving ligamentotaxis, which facilitates the reduction and the small size of the scar improves the esthetic result of the procedure. It is indicated for extra-articular fractures of the distal radius. In the case of an intra-articular fracture, an arthroscopy may be associated. In the case of a proximal diaphyseal extension of the fracture, a second proximal approach can be added in order to use a longer plate. Relative contraindications are comminuted articular fractures in elderly osteoporotic patients. Functional and radiological results are comparable to those obtained with the extented flexor carpi radialis approach. A conversion of the procedure for a larger incision is always possible in the case of a difficult reduction.

Learning curve and influencing factors of performing microsurgical anastomosis: a laboratory prospective study.

Despite being a critical component of any cerebrovascular procedure, acquiring skills in microsurgical anastomosis is challenging for trainees. In this context, simulation models, especially laboratory training, enable trainees to master microsurgical techniques before performing real surgeries. The objective of this study was to identify the factors influencing the learning curve of microsurgical training. A prospective observational study was conducted during a 7-month diploma in microsurgical techniques carried out in the anatomy laboratory of the school of surgery. Training focused on end-to-end (ETE) and end-to-side (ETS) anastomoses performed on the abdominal aorta, vena cava, internal carotid and jugular vein, femoral artery and vein, caudal artery, etc. of Wistar strain rats under supervision of 2 expert anatomical trainers. Objective and subjective data were collected after each training session. The 44 microsurgical trainees enrolled in the course performed 1792 anastomoses (1577 ETE, 88%, vs. 215 ETS, 12%). The patency rate of 41% was independent from the trainees' surgical background and previous experience. The dissection and the temporary clamping time both significantly decreased over the months (p < 0.001). Technical mistakes were independently associated with thrombosis of the anastomoses, as assessed by the technical mistakes score (p < 0.01). The training duration (in weeks) at time of each anastomosis was the only significant predictor of permeability (p < 0.001). Training duration and technical mistakes constituted the two major factors driving the learning curve. Future studies should try and investigate other factors (such as access to wet laboratory, dedicated fellowships, mentoring during early years as junior consultant/attending) influencing the retention of surgical skills for our difficult and challenging discipline.

Pullout strength of connected pins in hand surgery: Effect of pin diameter and insertion angle.

OBJECTIVE: The purpose of this study was to examine the effect of insertion angles on the pullout strength of connected pins using a synthetic model simulating a hand bone. MATERIAL AND METHODS: The material consisted of Sawbones® (20 mm×20 mm × 60 mm), fixation pins secured to a connecting rod much like an external fixator, an electric drill (speed 1,290 rpm) and a tensile testing machine. The Sawbones® were drilled with different pin diameters (1.2 mm, 1.5 mm, and 1.8 mm) and insertion angles (100°, 110° and 120°). A vertical displacement of 1 mm/min was applied until the pins were extracted (maximum force). RESULTS: The pullout strength increased with the insertion angle of the connected pins. It also increased with their diameter. Regardless of the pin diameter, the load-displacement curve during the pullout test had 4 sections (peak 1, ascending slope, peak 2, descending slope) that corresponded to the combined frictional force and contact force between the pins and Sawbones®. DISCUSSION: Our study findings showed that, theoretically, for wrist or hand fractures treated with connected pins, the larger the diameter and insertion angle, the better the mechanical holding power of the pins. LEVEL OF EVIDENCE: I, experimental study.

Anterior plating technique for distal radius: comparing performance after learning through naive versus deliberate practice.

BACKGROUND: Surgical teaching is most often carried out in the operating theatre through mentorship, and the performance of surgical procedures is rarely measured. The objective of this article is to compare the progression in learning curves of junior surgeons trained in the anterior plating technique for the distal radius on a nonbiological model according to three different methods. METHODS: The materials comprised 12 junior surgeons of level 1 or 2 (as per Tang and Giddins) divided into three groups: control (G1), naive practice (G2), and deliberate practice (G3). The three groups watched a demonstration video of a level 5 expert. The four G1 surgeons (two level 1 and two level 2) saw the video only once, and each inserted five plates. The four G2 surgeons (two level 1 and two level 2) inserted five plates and watched the video before each time. The four G3 surgeons (two level 1 and two level 2) saw the video before the first plate insertion. Before posing the subsequent four plates, the four G3 surgeons watched their own video, and the expert indicated their errors and how to avoid them next time. A 12-criteria OSATS defined on the basis of the 60 videos, each graded from one (min.) to five (max.), was used to measure the objective surgical performance per plating (min. 12; max. 60) and per series of five plate fixations (min. 60, max. 300). RESULTS: The total average objective performance of G1 was 44.73, of G2 was 50.57 and of G3 was 54.35. Change in objective performance was better for G3 (13.25) than G2 (5) or G1 (3.75). For all groups, the progression in objective performance was better amongst level 1 surgeons (9) than level 2 surgeons (5.6). CONCLUSION: Surgical teaching is based on mentorship and experience. However, since "see one, practice many, do one" has started to replace "see one, do one, teach one", learning techniques have increasingly relied on procedure simulators. Against this background, few studies have looked at measuring the performance of surgical procedures and improved learning curves. Our results appear to suggest that deliberate practice, when used in addition to mentorship, is the best option for shortening the growth phase of the learning curve and improving performance. Deliberate practice is a learning technique for surgical procedures that is complementary to mentorship and experience, which allows the growth phase of the learning curve to be shortened and the objective performance of junior surgeons to be improved.

Medical economic study of outpatient versus inpatient surgical management of distal radius fractures.

INTRODUCTION: France aims to have more than 70% of its surgical procedures performed in an outpatient setting by 2022. HYPOTHESIS: The primary hypothesis of this study was that outpatient management of distal radius fractures with volar plating was more cost-effective than inpatient hospitalization. The secondary hypothesis was that more than 70% of these cases could be managed in an outpatient setting. MATERIALS AND METHODS: The series included 255 fractures that were operated on between February 2015 and February 2016. These were reviewed using 4 patient-specific criteria (age, ASA score, eligibility for an outpatient procedure, and anticoagulant therapy) and 4 injury-specific criteria (AO classification, open wound, nerve involvement, and other locations). Our outpatient rate was compared to the national rate and the net income was calculated according to the length of stay. RESULTS: Our series reported an outpatient rate of 77.25% with a mean age of 54years (19/95) and an inpatient rate of 22.75% with a mean age of 74 years (30/94). The national rate in 2018 was 34.8%. While outpatient procedures generated an operating profit of +€191.64, hospitalizations of 1 to 17 nights resulted in an operating loss. The overall economic assessment of the 255 fractures included in our series showed an operating loss of €22,113.78. DISCUSSION: Our primary hypothesis was confirmed since the outpatient management of distal radius fractures was more cost-effective than inpatient hospitalization. The secondary hypothesis was also confirmed since more than 70% of cases in our series were treated in an outpatient setting. CONCLUSION: Most distal radius fractures requiring a surgical intervention should be treated in an outpatient setting. LEVEL OF EVIDENCE: IV.

Acute Essex-Lopresti Syndrome: About a Case of Brachioradialis Tendon Transfer.

Background The classic treatment for acute Essex-Lopresti syndrome is closed reduction percutaneous pinning (CRPP) of the distal radioulnar joint (DRUJ). This work aimed to verify whether it was possible to add a transfer of the brachioradialis tendon to the pinning. Case Description The patient was a 39-year-old right-handed man, climbing instructor, who sustained the Mason II fracture and disjunction of the DRUJ. A transfer of the brachioradialis tendon severed from its muscle attach that was made through a bone tunnel passing through the radius and the neck of the ulna. The clinical and radiological result at the 6-month follow-up was satisfactory. Literature Review and Clinical Relevance Our results in a single case showed that the brachioradialis tendon transfer was useful in acute Essex-Lopresti syndrome.

K-wire pullout strength in hand surgery: Impact of diameter, threading length and drilling speed.

INTRODUCTION: The aim of the present study was to assess the impact, combined and in interaction, of diameter, threading length and drilling speed on K-wire pullout strength in a synthetic model of a hand bone. MATERIAL AND METHODS: The material comprised Sawbones® (20 ×20×50mm), K-wires (diameter 1.2mm, 1.5mm, 1.8mm; threading 0mm, 5mm, 10mm, 15mm), a universal chuck with T handle and a drill (speed 0, 320, 500, 830, 1,290rpm), and tensile testing machine and a digital decision aid. The Sawbones® were drilled, varying diameter, threading and speed. The Statistical Design of Experiments (SDOE) methodology enabled the number of trials to be reduced from 300 to 70. Tensile tests at 1mm/s was imposed on the K-wire up to pullout (pullout strength). RESULTS: There was no interaction between threading length and diameter effects or between drilling speed and diameter effects, but a strong interaction between drilling speed and threading length effects. CONCLUSION: Before using K-wires for internal fixation in wrist or hand fracture, the surgeon has to select their characteristics, optimal holding power being theoretically ensured by large diameter wires with long threading inserted by a high-speed drill. LEVEL OF EVIDENCE: I, experimental study.

Relationship between surgeons' position and the duration of the procedure during minimally invasive osteosynthesis of distal radius fractures.

This study aimed to assess the influence of the surgeon's position on procedure time in MIPO (Minimally Invasive Plate Osteosynthesis) for distal radius fracture. The hypothesis was that there was a correlation between procedure time and the surgeon's position in relation to the operated side. Thirteen surgeons (12 right-handed, 1 left-handed) operated on 421 distal radius fractures: 208 right-sided (R) and 213 left-sided (L). Surgeons stood either at the patient's head (H) or the feet (F). Procedure time and scar size were measured. Regardless of operated side (right or left), mean surgery time was 35.5 min (range, 14-71) with the surgeon at the head and 40.5 min (range, 11-119) with the surgeon at the feet. The difference (5 min) was statistically significant. When the right side was operated on, surgery time was 34.2 min (range, 14-66) with surgeon at the head and 41.1 min (range, 11-86) at the feet. The difference (6 min) was statistically significant. No other comparisons were significant. There was no correlation with surgeon's experience. Given that 1 min of operating room time costs between €10.80 and €29, savings of €54 to €145 per procedure can be achieved. The study hypothesis was confirmed, with a correlation between the surgeon's position in relation to the operated side and the duration of the operation. In conclusion, we recommend that surgeons position themselves at the patient's head for of distal radius fracture MIPO.

Intramedullary percutaneous fixation of metacarpal fractures: screw versus connected K-wires.

The purpose of the present study was to determine clinical and radiographic outcomes in patients treated with limited-open retrograde intramedullary headless screw fixation for metacarpal neck and shaft fractures (group I) versus percutaneous antegrade and retrograde intramedullary double pinning linked by a connector (group II). We designed a retrospective comparative study, with the inclusion of two groups (20 patients each) of metacarpal unstable fractures. Both groups showed similar outcomes at the final follow-up, except for extension lag (significantly better in group II) and return to sport (significantly better in group I). Intramedullary screw fixation did not accelerate bone union and range of motion recovery in the early follow-up. In conclusion, limited-open retrograde intramedullary headless screw fixation and percutaneous connected antegrade and retrograde intramedullary double pinning are both reliable techniques of fixation for metacarpal neck and shaft fractures. LEVEL OF EVIDENCE: III.

Time-of-flight and noise-correlation-inspired algorithms for full-field shear-wave elastography using digital holography.

SIGNIFICANCE: Quantitative stiffness information can be a powerful aid for tumor or fibrosis diagnosis. Currently, very promising elastography approaches developed for non-contact biomedical imaging are based on transient shear-waves imaging. Transient elastography offers quantitative stiffness information by tracking the propagation of a wave front. The most common method used to compute stiffness from the acquired propagation movie is based on shear-wave time-of-flight calculations. AIM: We introduce an approach to transient shear-wave elastography with spatially coherent sources, able to yield full-field quantitative stiffness maps with reduced artifacts compared to typical artifacts observed in time-of-flight. APPROACH: A noise-correlation algorithm developed for passive elastography is adapted to spatially coherent narrow or any band sources. This noise-correlation-inspired (NCi) method is employed in parallel with a classic time-of-flight approach. Testing is done on simulation images, experimental validation is conducted with a digital holography setup on controlled homogeneous samples, and full-field quantitative stiffness maps are presented for heterogeneous samples and ex-vivo biological tissues. RESULTS: The NCi approach is first validated on simulations images. Stiffness images processed by the NCi approach on simulated inclusions display significantly less artifacts than with a time-of-flight reconstruction. The adaptability of the NCi algorithm to narrow or any band shear-wave sources was tested successfully. Experimental testing on homogeneous samples demonstrates similar values for both the time-of-flight and the NCi approach. Soft inclusions in agarose sample could be resolved using the NCi method and feasibility on ex-vivo biological tissues is presented. CONCLUSIONS: The presented NCi approach was successful in computing quantitative full-field stiffness maps with narrow and broadband source signals on simulation and experimental images from a digital holography setup. Results in heterogeneous media show that the NCi approach could provide stiffness maps with less artifacts than with time-of-flight, demonstrating that a NCi algorithm is a promising approach for shear-wave transient elastography with spatially coherent sources.

Homogenization of the management of acute paronychia with abscess formation within the context of an evaluation of professional practices.

INTRODUCTION: There is no consensus in the literature, or even within the same team, on the most appropriate treatment option for acute paronychia with abscess formation. The performance of an evaluation of professional practices (EPP) using a clinical audit measures the quality of our practices with the aim of standardizing them. Therefore, the primary objective of this study was to develop a clinical pathway for the management of acute paronychia with abscess formation. The secondary objectives were to evaluate our professional practices using a clinical audit before and after the dissemination of the clinical pathway and then recommend strategies for improving our management of acute paronychia with abscess formation. MATERIALS AND METHODS: A working group was established that designed an audit grid comprised of 15 items. Thirty patients (Group 1) who had an acute paronychia with abscess formation were included and their health records were analyzed using this audit grid. The working group then developed a clinical pathway for the management of acute paronychia with abscess formation. Thirty new patients (Group 2) were included after the dissemination of this clinical pathway and their records were analyzed using the same audit grid. RESULTS: Our clinical pathway for the management of acute paronychia was validated by the local infectious disease committee of our university hospital center. The difference between groups 1 and 2 was significant (p<0.05) for eight items. There was no significant difference in the rate of surgical revision between the two groups. DISCUSSION: This EPP enabled us to develop a clinical pathway that detailed the processes for managing acute paronychia with abscess formation, and in particular it provided indications for antibiotic therapy and its limitations. LEVEL OF EVIDENCE: IV, retrospective study.