Reduction in ionizing radiation exposure during minimally invasive anterior plate osteosynthesis of distal radius fracture: Naive versus deliberate practice.

This study aimed to decrease surgeon exposure to ionizing radiation through a new learning technique, "deliberate practice", which consists in improving performance by setting goals with feedback. The hypothesis was that exposure to ionizing radiation during distal radius fracture surgery using the minimally invasive plate osteosynthesis (MIPO) technique decreased faster with "deliberate" practice than with "naïve" practice. Radiographic dosimetry was measured in the first 30 fractures operated on by MIPO by 6 surgeons. The first 3 surgeons operated "naively" (Group 1) and the next 3 according to the "deliberate" procedure (Group 2). Group 2 received weekly feedback (number of exposed hands, number of fluoroscopic views, exposure duration, and X-ray dose). An expert, using fluoroscopic images and surgical videos, provided suggestions for improvement. Mean number of exposed hands was 23.66 in Group 1 and 1.9 in Group 2. Mean number of fluoroscopic views was 78.31 and 35.0, respectively. Mean X-ray exposure time was 74.34 and 32.89 s, respectively. Mean dosimetry was 1.40 mGy (and 0.59 mGy, respectively. The hypothesis was thus confirmed: dosimetry decreased faster in Group 2 than in Group 1. Teaching this deliberate practice should be generalized, to decrease the growth phase and increase the plateau phase of the learning curve.

Immobilization protocols following trapeziectomy for osteoarthritis of the thumb: 2 weeks versus 4 weeks.

We compared the clinical outcomes of post-trapeziectomy protocols according to their duration. The main hypothesis was that there would be no significant difference in postoperative function whether immobilization duration was 2 or 4 weeks. The secondary hypotheses were that there would be no significant difference in postoperative pain, motion, or strength. 40 trapeziectomies were reviewed. Two weeks' postoperative commissural immobilization was systematic. Patients were then divided in two groups. For the first 20 patients (group I), immobilization stopped at 2 weeks. For the next 20 patients (group II) it was replaced by a splint for further 2 weeks. We compared mean pre- and post-operative (10-20 weeks) function (QuickDASH score), pain (visual analog scale - VAS), thumb opposition (Kapandji score) and strength (palmar pinch test) between the two groups. There was no significant difference between groups in postoperative values or in pre- to post-operative progression. The main hypothesis was confirmed: there was no significant difference in the postoperative function whether the immobilization was for 2 or 4 weeks. The secondary hypotheses regarding postoperative pain, motion and strength were also confirmed.

Iatrogenic hand trauma in institutionalized brain-injured patients: About 2 cases.

The objective of this work was to draw the attention of caretakers for institutionalized brain-injured patients to the risk of iatrogenic trauma associated with improper manipulation of the fingers during hand opening for grooming. Two clinical cases of chronic open dislocation of the thumb and the fifth finger in institutionalized brain-injured patients were reviewed. Interrogation of the patients and their relatives did not reveal either the date or the mechanism of the injury. In the light of these two cases, it appears that better training of caretakers should make it possible to avoid iatrogenic trauma during hygiene care of institutionalized brain-injured patients.

Risk of septic spread during surgical management of digital flexor tendon sheath phlegmon: Exsanguination by mechanical compression versus simple elevation.

This study aimed to demonstrate that there was no risk of extension of infection in performing mechanical exsanguination before inflating the tourniquet for surgical treatment of digital flexor tendon sheath phlegmon. The series comprised 96 patients, with a mean age of 47 years (range, 18-87 years) and 37 women. Group I included 47 patients in whom exsanguination was performed with a Velpeau band before inflating the pneumatic tourniquet at the root of the limb. In Group II, which included 49 patients, the tourniquet was inflated after simple elevation of the limb. Six patients underwent revision surgery for recurrence or osteoarticular complications: 4 (8.5%) in Group I and 2 (4.1%) in Group II, the difference between two groups being non-significant (p = 0.6378). In conclusion, mechanical exsanguination before inflating the tourniquet did not incur risk of complications in surgical management of digital flexor tendon sheath phlegmon.

Organization of outpatient consultations at a hand surgery department in a French university hospital during the COVID-19 lockdown.

The COVID-19 health crisis has greatly impacted the organization of outpatient consultations, especially in hand surgery. Five reorganization stages were described during the crisis (from week 11 to week 21 in 2020): preparatory stage, 1st organizational stage, wait-and-see stage, 2nd organizational stage, and progressive return stage. The number of patients seen on-site decreased 64% in 2020 compared to 2019, while 78% of consultations were canceled. The logistics (teleconsultation, dedicated COVID-19 patient pathways) and human resources (sick leave, telework, reassignment to other departments) were adapted to ensure that patients who are usually seen in our hand surgery department received adequate care.

Revision surgery for carpal tunnel syndrome: a retrospective study comparing the combination of Canaletto® and Dynavisc® gel versus Dynavisc® gel alone.

The aim of this study was to assess the value of using a Canaletto® implant in combination with a gel composed of carboxymethylcellulose and polyethylene oxide in the surgical treatment of recurrent carpal tunnel syndrome (CTS). The case series included 31 patients with 32 hands operated for the second time for recurrent (22 cases) or recalcitrant (9 cases) CTS by neurolysis. The average patient age was 62 years. Dynavisc® gel alone was applied around the median nerve in the first 16 cases (Group I). The Canaletto® implant combined with Dynavisc® gel was used in the last 16 cases (group II). With an average follow up of 8 months (for group I) and 11 months (for group II), the pre/postoperative variation in pain assessed with a visual analog scale was 1.38/10 (group I) and 2.04/10 (group II), the QuickDASH score was 20.1/100 (Group I) and 20.48/100 (Group II), grip strength was 8% (Group I) and 20% (Group II), sensory nerve conduction speed was 23.20 m/s (group I) and 15.51 m/s (group II) and distal motor latency was 1.55 m/s (group I) and 1.21 m/s (group II). Ten patients recovered from hypoesthesia in both groups, 6 patients in group I and 2 patients in group II regained good trophicity of their superficial thenar muscles. Two patients from group II had not improved clinically although their electromyography had become normal. One patient from group II suffered a postoperative infection that required removal of the Canaletto® implant. He subsequently improved slightly. Our study found that for recurrent or recalcitrant CTS, the combination of Dynavisc® anti-adhesion gel around the median nerve and a Canaletto implant® after neurolysis results in outcomes that are as good as Dynavisc® alone, with a significant improvement of the QuickDASH score without the Canaletto®. In conclusion, the use of Dynavisc® gel alone around the median nerve after neurolysis seems to be as effective as other techniques described in literature but less invasive or time-consuming, and not associated with donor site morbidity such as the flexor tendon sheath.

Flexor tendon complications in distal radius fractures treated with volar rim locking plates.

Volar locking plates used for treating distal radius fractures can damage the flexor tendon. Fractures distal to the watershed line can be fixed using volar rim locking plates. The aim of our study was to report the incidence of flexor tendon lesions when using these plates. Our case series included 15 patients (7 women, 8 men), aged 59 years on average (23-88) who underwent distal radius fixation using a volar rim plate (Extradistale®, Newclip Technics™, Haute Goulaine, France). Eight patients had complications: seven cases of synovitis treated by synovectomy with a satisfactory final outcome, 10 cases of partial tendon ruptures treated by synovectomy and tendon repair in two cases, and five cases of complete rupture that were not repaired at the patient's requests. Our working hypothesis was not verified as we found flexor tendon complications in half our patients. When the fracture is distal to the watershed line, we recommend removing the plate after bone healing, never after the 3rd month postoperative.

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.

Comparison of a standard locking screw versus a double-threaded cortical compression screw for fixation of die-punch fragments in distal radius fractures with volar plating.

The aim of this study was to use a compression screw in the epiphyseal medial orifice of a volar plate to reduce and stabilize the die-punch fragment in distal radius fractures (DRF) undergoing open reduction and internal fixation (ORIF). The main hypothesis was that the range of motion (ROM) in supination would be poorer when a standard screw was used. Our case series included 19 patients with an average age of 59 years (24-91) (SD -35.32) (10 male patients and 9 females) who underwent ORIF of DRFs with a volar plate. Group I included 10 patients in which the die-punch fragment was fixed with a standard locking screw and group II included the 9 patients in which the die-punch fragment was fixed with an angle stable compression screw through both cortices. At the 6-month follow-up visit, the average ROM in flexion was 83% in group I and 81% in group II (-2.327 [-13.657; 8.960]), the ROM in extension was 91% and 89% (-2.754 [-13.410; 7.602]), the ROM in pronation was 100% and 102% (+3.178 [-5.242; 11.457]), the ROM in supination 100% and 97% (-3.171 [-10.825; 4.537]), the pain level was 0.6/10 and 1/10 (+0.106 [-0.809; 0.977]), the QuickDASH score was 8.1/100 and 17.17/100 (+5.790 [-2.934; 15.012]), the PRWE was 6.2/100 and 22/100 (+13.109 [4.416; 22.779]) and the grip strength was 95% and 74% of the contralateral side (-12.478 [-24.832; 0.538]). No complications, nonunions or revision surgery were reported in the two groups. One case of secondary displacement of the die-punch fragment occurred in each group. The main hypothesis was not proven. In conclusion, despite what several biomechanical studies have suggested, the use of double-threaded compression screws for die-punch fragment fixation in DRFs does not improve the clinical outcomes compared to standard locking screws.

3D printing in hand surgery.

While 3D printing in hand surgery is still in its infancy, it offers new avenues in research, teaching, and personalized medicine. For these reasons, some surgeons may want to jump on the bandwagon of this trendy technology. But we cannot forget that its superiority over conventional techniques has not been demonstrated. Surgeons who want to work with 3D printed objects must master their use and the entire manufacturing process, otherwise they risk becoming dependent on engineers and/or medical device companies.

Comparison of tactile sensitivity measured with a new digital esthesiometer (Beam Test) relative to Semmes-Weinstein monofilament analog esthesiometer.

The assessment of tactile sensitivity uses many tests, of which monofilaments are considered the best. The aim of this study was to develop a tactile sensitivity test, similar to the monofilament test, which eliminates the error risk related to manipulations by the observer, and to establish a correspondence scale. We studied 29 healthy subjects (18 women and 11 men) with a mean age of 27.8 years. The Semmes-Weinstein monofilament (SWM) analog esthesiometer and a digital beam esthesiometer (DBE) were used. We evaluated the tactile sensitivity threshold on the fingertip of each subject's dominant index using the SWM and the DBE. The DBE test consisted of applying the index against the tip of the beam. During a cycle of four elevations/depressions, the subject would press a button each time he/she felt pressure. The test was repeated three times. The screen displayed an average force value between 0 and 200 allowing the result to be expressed in grams (g). The minimum perceived force was 0.06656g (0.023, 0.166) on average with the SWM test and 0.51773g (0.4824, 0.8062) with the DBE test. Our results confirm the DBE test suppresses the observer's manipulations and that a SWM correspondence scale can be established. With the DBE test, the normal sensation ranged from 0.4824g to 0.757g and light touch decreased from 0.758g to 0.8062g. The threshold value of pathological tactile sensitivity was 0.8063g. The DBE test could therefore be used for preventive diagnosis of carpal tunnel syndrome in occupational medicine.

Surgical treatment of phlegmons of the digital flexor tendon sheaths at the early stage: Lavage by conventional open technique versus ultrasound-guided percutaneous technique.

The aim of this work was to analyze the results of a percutaneous drainage technique with 2 catheters during surgical treatment of phlegmons of the finger flexor tendon sheath. Our series included 32 patients with a phlegmon of flexor tendon sheaths, including 19 men and 13 women, mean age 43.4years. The first 16 patients (group I) were treated by a conventional open technique for the lavage and drainage of the affected tendon sheath. The last 16 (group II) were treated by an ultrasound-guided percutaneous lavage technique with 2 catheters: one proximal and one distal. In the case of impermeability of the digital canal, conversion by open technique was carried out. In group II, the ultrasound-guided percutaneous lavage was 5 times successful. Failure of the proximal catheter alone was noted once, whereas failure of the distal catheter alone was noted 7 times. The failure of both catheters was noted 3 times. At a mean follow-up of 19.7 days, mean handgrip strength was 56.5% compared to the contralateral side in group I and 82% in group II (P<0.05). However, there was no significant difference for pain, QuickDASH, total active mobility between group I and group II. Pain was at 1.4/10 for group I and 1.4/10 for group II. QuickDASH was measured at 27/100 for group I and 22.27/100 for group II. Total active mobility was 227° for group I and 243° for group II. In conclusion, surgical treatment of the phlegmons of the finger flexor tendon sheath with an ultrasound-guided percutaneous lavage technique gives significantly better short-term grip strength than the conventional open technique.

Arthrodesis of the thumb metacarpophalangeal joint: Conventional open technique with a locking plate or compression pins versus minimally invasive technique with compression pins or screws.

Arthrodesis of the thumb metacarpophalangeal (MCP) joint usually leads to satisfying results when performed with an open technique. The main complication is adhesion of the extensor tendons that sometimes requires hardware removal associated with tenolysis. The goal of this study was to assess whether a minimally invasive technique could reduce the risk of this complication. Arthrodesis of the thumb MCP was performed using an open technique with a locking plate or compression pins in 12 cases (group I) and using a minimally invasive technique with compression pins or screws in 12 cases, for a total of 24 patients aged 48.9 years on average, among which 15 were women. At the last follow-up, the average pain level was rated at 2/10 in group I and 2.3/10 in group II. The QuickDASH was 40.70/100 in group I and 36.24 in group II, grip strength was 79% of the contralateral side in group I and 51% in group II. Pinch strength was 81% of the contralateral side in group I and 45% in group II. Fusion was achieved in all cases in group I and in 7 of 12 cases in group II. Surgical revision for non-union was needed in 5 cases in group II, with hardware removal and tenolysis performed in 2 cases. The non-unions were observed in non-rheumatoid cases. While the two groups were not identical, arthrodesis of the thumb MCP using a minimally invasive technique with compression pins or screws seems to give satisfying results for rheumatoid cases in which no cartilage remains.

Designing a minimally-invasive, ultrasound-guided, percutaneous flexor tendon sheath lavage technique: a cadaver study.

The goal of this study was to develop a minimally-invasive, ultrasound-guided percutaneous flexor tendon sheath lavage technique on cadaver model. Two catheters were inserted using ultrasound guidance at the proximal and distal ends of the tendon sheath in 20 fingers from cadaveric forearms. Percutaneous injection of a saline solution colored with methylene blue resulted in anterograde lavage of the flexor tendon sheath. The technique was successful in 13 out of 20 cases. The proximal catheter was in the correct position in 17 cases and the distal catheter was correctly positioned in 15 cases. The flexor tendons were continuous in all cases and had puncture wounds in 9 cases. Based on our study, this minimally-invasive, ultrasound-guided percutaneous lavage of the flexor tendon sheath was effective in 65% of cases and safe in 100% of cases in the index, middle and ring fingers. If this percutaneous lavage fails, it is always possible to switch to a conventional open technique.

Revision surgery in carpal tunnel syndrome: a retrospective study comparing the Canaletto® device alone versus a combination of Canaletto® and Dynavisc® gel.

The aim of our study was to demonstrate the benefits of combining the Canaletto® implant with carboxymethylcellulose/polyethylene oxide gel in the surgical treatment of carpal tunnel syndrome (CTS) recurrences. Our case series included 39 patients (40 hands, one bilateral case) who underwent revision surgery for recurrent CTS (28 cases) or resistant CTS (12 cases). The mean age of the patients was 56 years. The Canaletto® only was implanted in the first 21 cases (group I). In the following 19 cases (group II), Dynavisc® gel was added to the protocol and applied around the median nerve when the Canaletto® was implanted. At 12 months' follow-up (group I) and 11 months' follow-up (group II), the pre-versus post-operative difference between the average values of the DN4 neuropathic Pain Score was 0.55/10 in group I and 2.25/10 in group II; the Pain Score was 2.23/10 (in group I) and 2.52/10 (in group II); the Quick DASH Score was 18.98/100 (group I) and 19.06/100 (in group II); the hand grip strength was 19.55% (group I) and 28.53% (group II); the sensory nerve conduction velocity was 8.67 m/s (group I) and 10.27 m/s (group II); the distal motor latency was 1.05 m/s (group I) and 1.75 m/s (group II). Nine patients recovered from hypoesthesia in both groups, 5 patients regained satisfactory trophism of the thenar muscles in group I and 3 patients in group II. No improvement whatsoever was noted in 2 patients in group II, despite the electromyogram being normal. One patient from group II suffered an infection that required revision surgery to remove the Canaletto®; this led to a moderate improvement. Our results show that when resistant or recurrent CTS is diagnosed, the combined treatment of an anti-adhesion gel such as Dynavics® around the median nerve with the Canaletto® implant after performing secondary neurolysis leads to satisfactory post-operative outcomes. Compared to other techniques described in the current literature, our technique is less invasive, quicker and associated with minimal morbidity of the surgical site.