Incision techniques for trigger thumb release: a comparison of outcomes of four types of skin incision.

Although trigger thumb release is commonly performed, there is no consensus on the optimal skin incision. This study aimed to compare outcomes of four incision techniques, including V-shaped, oblique, transverse and longitudinal incisions. Outcomes included the Michigan Hand Outcomes Questionnaire, satisfaction with the treatment and postoperative complications. The results of 875 patients who underwent trigger thumb release were assessed. All groups demonstrated improvement in self-reported hand function (range of 10-14 points), pain (25-27 points) and aesthetics (4-7 points) from baseline to 3 months postoperatively with no differences between incision techniques. Of the patients, 76% reported good or excellent satisfaction with the outcome of treatment. Satisfaction and complication rates of the different incision techniques were similar. These findings imply that there is no clear benefit of one type of incision over another for trigger thumb release, suggesting that surgeons may use the technique of their preference.Level of evidence: III.

Determining the Minimally Important Change of the Michigan Hand outcomes Questionnaire in patients undergoing trigger finger release.

INTRODUCTION: The Michigan Hand outcomes Questionnaire (MHQ) is a widely used instrument to evaluate treatment results for hand conditions. Establishing the Minimally Important Change (MIC) is essential for interpreting change in outcome that is clinically relevant. PURPOSE OF THE STUDY: The purpose of this study was to determine the MIC of the MHQ total and subscale scores in patients undergoing trigger finger release. STUDY DESIGN: This is a prospective cohort study conducted between December 2011 and February 2020. METHODS: Patients completed the MHQ prior to surgery and 3 months postoperatively. The MIC of the MHQ was determined using 5 anchor-based methods (ie, 2 anchor mean change methods and 3 receiver operating characteristic methods). The median MIC value was determined to represent the triangulated MIC. RESULTS: A total of 1814 patients were included. The MIC for the MHQ total score ranged from 7.7 to 10.9, with a triangulated estimate of 9.3. The MIC estimates for 5 of 6 of the MHQ subscales ranged from 7.7 to 20.0. No MICs could be determined for the MHQ subscale "aesthetics" due to low correlations between the anchor questions and MHQ change scores. CONCLUSIONS: These MIC estimates can contribute to the interpretation of clinical outcomes following trigger finger release and for assessment of power in prospective trials.

Complications and Functional Outcomes following Trigger Finger Release: A Cohort Study of 1879 Patients.

BACKGROUND: Although trigger finger release is considered a safe procedure, large cohort studies reporting consistent complication rates and functional outcomes are scarce. Further insight into outcomes of this commonly performed procedure is essential for adequate treatment evaluation and patient counseling. Therefore, the aim of this study was to assess the complication rates and functional outcomes following trigger finger release. METHODS: This is an observational multicenter cohort study of patients undergoing trigger finger release. The primary outcome included the occurrence of complications. The secondary outcome was change in hand function (Michigan Hand outcomes Questionnaire) from baseline to 3 months postoperatively. RESULTS: Complications were observed in 17.1 percent of 1879 patients. Most complications were minor, requiring hand therapy or analgesics (7.0 percent of all patients), antibiotics, or steroid injections (7.8 percent). However, 2.1 percent required surgical treatment and 0.2 percent developed complex regional pain syndrome. The Michigan Hand Outcomes Questionnaire total score improved from baseline to 3 months postoperatively with 12.7 points, although the authors found considerable variation in outcomes with less improvement in patients with better baseline scores. CONCLUSIONS: This study demonstrates that trigger finger release results in improved hand function, although complications occur in 17 percent. Most complications are minor and can be treated with nonsurgical therapy, resulting in improved hand function as well. However, additional surgical treatment is required in 2 percent of patients. In addition, the authors found that change in hand function depends on the baseline score, with less improvement in patients with better baseline scores. Future studies should investigate factors that contribute to the variability in treatment outcomes following trigger finger release. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Factors associated with self-reported pain and hand function following surgical A1 pulley release.

Surgical A1 pulley release can considerably reduce pain and improve hand function, but individual outcomes are highly variable. This study aimed to identify factors contributing to self-reported pain and hand function 3 months postoperatively. We included 2681 patients who had received surgical treatment for a trigger finger or thumb and who completed the Michigan Hand outcomes Questionnaire (MHQ). Hierarchical linear regression models were used to investigate patient and clinical characteristics associated with postoperative pain and hand function. For both pain and hand function, the most influential factors associated with worse outcomes were worse MHQ scores at baseline (ß 0.38 and 0.33, respectively) and ≥3 preoperative steroid injections (ß -0.36 and -0.35). These factors indicated that patients with severe preoperative symptoms represent a group with a more advanced disease that is more difficult to treat. These findings can assist clinicians in patient counselling, expectation management and decision-making about the timing of the intervention.Level of evidence: II.

Covering of an exposed vascular graft in the groin with an external oblique muscle rotational flap.

Abdominal muscles, such as the oblique- and transverse muscles, find their blood supply from multiple segmental pedicles from the iliac artery. Besides its superior vascularization, its release is simple, leaving two abdominal muscles for securing abdominal wall strength. The release of the muscle and coverage of the graft requires partial muscle mobilization and is a minor reconstruction, but extension of the mobilization cranially enables coverage of larger defects. We present a case of an infected vascular graft in the groin successfully preserved through coverage with an external oblique muscle flap.

The laparoscopically harvested omentum as a free flap for autologous breast reconstruction.

BACKGROUND: In autologous breast reconstruction, abdominal based flaps are by far the most common choice from the wide range of free flaps available. In selected cases, a laparoscopically harvested omental free flap (LHOFF) can be used. Patient satisfaction has not been reported until now. In this article, we report our experience using LHOFF in breast reconstruction including our technique, patient satisfaction, and donor/recipient site complications. PATIENTS AND METHODS: Between 2007 and 2014, six patients underwent autologous breast reconstruction with LHOFF. Four patients had undergone radical mastectomy and two patient developed prosthesis complications after lumpectomy and breast augmentation. The omentum was harvested laparoscopically. The gastroepiploic vessels were anastomosed to the internal mammary vessels. A retrospective chart review was performed to retrieve surgical data. All the patients completed a questionnaire about their outcome. RESULTS: Mean weight of the omentum was 224 g. There were no flap failures. Two patients required a second surgical procedure due to complications. In one patient, a salvage procedure was required due to a venous thrombosis, whereas in the other, there was necrosis of the skin flap. No abdominal complications or volume loss occurred. Mean follow-up was 30.5 months. The aesthetic results were very satisfactory with minimal scars and good breast volume. CONCLUSION: Autologous breast reconstruction using an LHOFF can be used effectively in selected cases. The aesthetic results are pleasing with minimal scarring, good volume, and a soft, natural feeling breast.

Long-term outcome of the cheek advancement flap, a report of 41 cases.

BACKGROUND: Due to incidental occurrence of ectropion as a late complication of cheek advancement flaps, this study investigated the long-term effects of these flaps for post-Mohs' reconstruction of the cheek aesthetic. METHODS: All the patients who underwent a cheek advancement flap in the Catharina Hospital Eindhoven between January 2006 and January 2013 where included and assessed by means of a retrospective chart review and a survey about the long-term outcome and patient satisfaction. RESULTS: A retrospective chart review was performed on all 54 eligible patients, and 41 (76%) of these patients participated in the study. The mean follow-up was 3.5 years (SD = 2.0, range = 1-7 years). Early complications were ectropion (6%), infection (2%), dog-ears (1%), haematoma (4%), and distal tip necrosis (2%). Late outcome and complications were sensory neuropathies (41%), late ectropion (7%), hypopigmentation of scars (29%), contractures (27%), and abnormal hair distribution (17%). Patients rated their reconstruction as good or excellent in 87% of cases. CONCLUSIONS: The cheek advancement flap is a suitable technique for reconstruction of large cheek skin defects after excision of skin malignancies. However, patients should be informed that long-term complications, including ectropion, can occur. Additional follow-up might lead to an early detection of these late effects.

Treatment of mallet fingers in Dutch hospitals: a nationwide survey of practice.

OBJECTIVE: The aim of this study was to create an overview of the treatment of mallet fingers in Dutch hospitals. METHODS: A national online questionnaire was used to determine the treatment of mallet fingers in Dutch emergency units. RESULTS: Data were received from 58 units (response rate 97%). All the emergency units treated an uncomplicated mallet finger with a splint. The treatment of complicated mallet fingers was less uniform. The departments of general, orthopaedic and plastic surgery were involved in the treatment and their involvement varied according to the type of mallet finger and showed variations in the follow-up treatment. CONCLUSION: There is a general consensus on the treatment of uncomplicated mallet fingers. The follow-up treatment of uncomplicated lesions as well as the treatment of complicated mallet fingers should be fields of future research.

[Interpretation of hand injuries: 10 tips]. / De interpretatie van handletsels: 10 tips.

The treatment of hand injuries is an important part of the daily practice of healthcare professionals in primary, secondary and tertiary care. The complex anatomy and the specific physical examination required may make it difficult for a healthcare professional to establish a proper diagnosis. Based on the literature and our personal experience in hand surgery, we will describe 10 practical tips. These 10 tips will contribute to the detection of small lesions in daily practice.

Facial reconstruction following Mohs micrographic surgery: a report of 622 cases.

BACKGROUND: Around 100 to 200 patients undergo surgical reconstruction every year at our department of plastic and reconstructive surgery after Mohs micrographic surgery for nonmelanoma skin cancer. OBJECTIVE: The aim of this report is to provide an overview of the type of facial reconstructions performed and investigate whether we achieved increased, definitive closure rates of the defect on the day of the excision after further improving the collaboration between the involved departments. METHODS: All patients who underwent facial reconstruction at the Department of Plastic and Reconstructive Surgery following Mohs micrographic surgery between January 2006 and January 2011 were retrospectively systematically reviewed. RESULTS: A total of 564 patients with 622 defects were identified. The different reconstructions used per aesthetic unit are described. The number of cases in which a reconstruction was performed on the same day as the resection significantly increased from 31 to 81% (p < .001). CONCLUSION: Facial reconstruction following Mohs micrographic surgery is challenging. The type of reconstruction used depends on the type of defect and patient characteristics. A structured multidisciplinary approach improves the process from defect to reconstruction and can facilitate referrals.

Evaluation of the lower limb vasculature before free fibula flap transfer. A prospective blinded comparison between magnetic resonance angiography and digital subtraction angiography.

Introduction The aim of this study was to compare magnetic resonance angiography (MRA) with digital subtraction angiography (DSA) in the preoperative assessment of crural arteries and their skin perforators prior to free fibular transfer. Patients and methods Fifteen consecutive patients, scheduled for free vascularized fibular flap transfer, were subjected to DSA as well as MRA of the crural arteries of both legs (n = 30). All DSA and MRA images were assessed randomly, blindly, and independently by two radiologists. Each of the assessors scored the degree of stenosis of various segments on a 5 point scale from 0 (occlusive) to 4 (no stenosis). The Cohen's Kappa coefficient was used to assess the agreement between DSA and MRA scores. In addition, the number of cutaneous perforators were scored and the assessors were asked if they would advise against fibula harvest and transplantation based on the images. Results A Cohen's Kappa of 0.64, indicating "substantial agreement of stenosis severity scores" was found between the two imaging techniques. The sensitivity of MRA to detect a stenosis compared with DSA was 79% (CI 95%:60-91), and a specificity of 98% (CI 95%: 97-99). In 53 out of 60 assessments, advice on suitability for transfer were equal between DSA and MRA. The median number of cutaneous perforators that perfuse the skin overlying the fibula per leg was one for DSA as well as MRA (P = 0.142).Conclusions A substantial agreement in the assessment of stenosis severity was found between DSA and MRA. The results suggest that MRA is a good alternative to DSA in the preoperative planning of free fibula flap transplantation.

Multilayer reconstructions for defects overlying the Achilles tendon with the lateral-arm flap: long-term follow-up of 16 cases.

UNLABELLED: Defects of the Achilles tendon and the overlying soft tissue are challenging to reconstruct. The lateral-arm flap has our preference in this region as it provides thin pliable skin, in addition, the fascia and tendon can be included in the flap as well. The aim of this report is to share the experience the authors gained with this type of reconstruction. The authors report the largest series in the published reports today. PATIENTS AND METHODS: A retrospective review was performed of all patients treated between January 2000 and January 2009 with a lateral-arm flap for a soft-tissue defect overlying the Achilles tendon. RESULTS: In the reviewed period, 16 soft-tissue defects overlying the Achilles tendon were reconstructed, with a mean follow-up of 63 months. In three cases, tendon was included into the flap and in two, a sensory nerve was coapted. Fifteen cases (94%) were successful, one failed. In seven cases, a secondary procedure was necessary for thinning of the flap. CONCLUSION: The lateral-arm flap is a good and safe option for the reconstruction of defects overlying the Achilles tendon.

Similar risk for hemangiomas after amniocentesis and transabdominal chorionic villus sampling.

AIM: In an earlier study we have shown that transcervical chorionic villus sampling in excess of 90 mg increases the risk for hemangiomas of infancy three- to four-fold compared to amniocentesis. In the present study we investigated whether transabdominal chorionic villus sampling (TA-CVS), in which the samples are smaller, carries the same risk. MATERIAL AND METHODS: Retrospectively, data were analyzed from 200 consecutive TA-CVS procedures and 200 consecutive amniocentesis procedures. Forty-two TA-CVS procedures and 27 amniocentesis procedures were excluded on predefined criteria. Questionnaires were sent to the parents asking if there was any skin mark on the child: vascular, pigmented or otherwise. All hemangiomas were clinically confirmed. RESULTS: In the TA-CVS group, 118/158 questionnaires (75%), and in the amniocentesis group 134/173 questionnaires (77%) were returned. Based on the results of the questionnaire (i.e. mentioning of any skin lesion), 24 children in the TA-CVS group and 42 children in the amniocentesis group qualified for a physical examination. In the TA-CVS group 11/118 children (9%) had one or more hemangiomas. In the amniocentesis group 6/134 children (4%) had one or more hemangiomas. There was no statistical difference between the two groups (P = 0134). CONCLUSION: These results suggest that TA-CVS does not cause an increase in the prevalence of hemangioma compared to amniocentesis. A larger series is, however, necessary to confirm this.

Untreated hemangiomas: growth pattern and residual lesions.

BACKGROUND: Hemangiomas of infancy can give rise to alarm because of their rapid growth and occasional dramatic appearance. The objective of this study was to investigate the growth pattern of hemangiomas and risk factors for residual lesions. METHODS: A follow-up study was performed of patients with hemangiomas that were clinically monitored between 1985 and 2000 and who did not receive any treatment. The data were retrieved from medical files. Patients (parents) were asked to complete a questionnaire and invited to our outpatient clinic where the questionnaire was discussed and physical examination was performed. The growth phases of the hemangioma were documented, the timeline of these phases was constructed, and an assessment was made of the residual lesion if present. RESULTS: In 97 patients, 137 hemangiomas were evaluated. A precursor lesion was present in 48 percent of children. Maximum size was reached in 8 months. Involution started at a median age of 2 years and was completed at a median age of 4 years. Residual lesions were present in 69 percent of cases. Superficial nodular hemangiomas showed significantly more residual lesions (74 percent) than the deep hemangiomas (25 percent) (p < 0.001; odds ratio, 8.4; 95 percent confidence interval, 2.4 to 29.1). Untreated infection, ulceration, or bleeding produced a scar in 97 percent of the cases. CONCLUSIONS: Epidermal invasion of the hemangioma is of predictive value for residual lesions. There is no correlation between the growth pattern of a hemangioma and the risk for a residual lesion. This may add to a more detailed prediction of outcome and may help to decide which patient should be treated or not.

The deep inferior epigastric artery perforator flap for autologous reconstruction of large partial mastectomy defects.

BACKGROUND: Breast conservation surgery in the treatment of early stage breast cancer has become increasingly utilized as a means to avoiding mastectomy. While partial mastectomy defects (PMDs) may often be cosmetically acceptable, some cases warrant consideration of reconstructive options, and while several reconstructive options have been described in this role, a series of deep inferior epigastric perforator (DIEP) flaps has not been reported to date. METHODS: A cohort of 18 patients undergoing PMD reconstruction with a DIEP flap were included. Patient-specific data, operation details, cosmetic results, and complication rates were assessed. Oncologic outcomes, in particular recurrence rates, were also evaluated. RESULTS: In our series there were no cases of partial or total flap necrosis, and overall complications were low. There were two cases of wound infection (both had undergone radiotherapy), managed conservatively, and one case of reoperation due to hematoma. There were no cancer recurrences or effect on oncologic management. Cosmetic outcome was rated as high by both patients and surgeon. The results were thus comparable with other reconstructive options. CONCLUSION: Although autologous reconstruction has an established complication rate, our results suggest that the DIEP flap may be of considerable value for delayed reconstruction of selected larger partial mastectomy defects.

Surgical technique: The intercostal space approach to the internal mammary vessels in 463 microvascular breast reconstructions.

The internal mammary vessels are one of the most frequently used recipient sites for microsurgical free-flap breast reconstruction, and an accepted technique to expose these vessels involves removal of a segment of costal cartilage of the rib. However, in some patients, cartilage removal may result in a visible medial chest-wall depression that requires corrective procedures. We, therefore, use an intercostal space approach to the internal mammary vessels, as there is minimal disturbance of the costal cartilage with this technique. We have developed and performed our technique over an 8-year period in 463 microvascular breast reconstructions, and present it here as it contains modifications not previously described that may be of interest to other surgeons. There was no serious morbidity associated with the intercostal space approach, the internal mammary vessels were reliably and safely exposed in all these cases and the flap success rate was 95.8%.

A clinical review of 9 years of free perforator flap breast reconstructions: an analysis of 675 flaps and the influence of new techniques on clinical practice.

The aim of this study is to review our 9-year experience with deep inferior epigastric perforator (DIEP) breast reconstructions to help others more easily overcome the pitfalls we experienced. A chart review was conducted for all 543 patients who had 622 DIEP breast reconstructions in our clinic between January 2000 and January 2009. In this time, there were an additional 28 superior gluteal artery perforator and 25 superficial inferior epigastric artery reconstructions, bringing the total free flap reconstructions to 675. In the early years, the success rate was 90.7%, the average operative time was 7 hours and 18 minutes, and the complication rate was 33.3%; these have improved to 98.2%, 4 hours and 8 minutes, and 19.3%, respectively. We describe our selection criteria, preoperative vascular mapping, surgical techniques, and postoperative monitoring as they relate to these improvements in outcome, operative time, and complications. The DIEP flap is a safe and reliable option in breast reconstructions. By acquiring experience with the flap and introducing new and improving existing techniques we have improved the ease of the procedure and the success rate and have shortened the operative time.

Treatment options for mallet finger: a review.

BACKGROUND: Mallet finger is a common injury. The aim of this review is to give an overview of the different treatment options of mallet injuries and their indications, outcomes, and potential complications. METHODS: A literature-based study was conducted using the PubMed database comprising world literature from January of 1980 until January of 2010. The following search terms were used: "mallet" and "finger." RESULTS: There are many variations in the design of splints; there are, however, only a few studies that compare the type of splints with one another. Splinting appears to be effective in uncomplicated and complicated cases. Equal results have been reported for early and delayed splinting therapy. To internally fixate a mallet finger, many different techniques have been reported; however, none of these studies examined their comparisons in a controlled setting. In chronic mallet injuries, a tenodermodesis followed by splinting or a tenotomy of the central slip is usually performed. If pain and impairment persist despite previous surgical corrective attempts, an arthrodesis of the distal interphalangeal joint should be performed. CONCLUSIONS: Uncomplicated cases of mallet injuries are best treated by splinting therapy; cases that do not react to splinting therapy are best treated by surgical interventions. Controversy remains about whether mallet injuries with a larger dislocated bone fragment are best treated by surgery or by external splinting.

Hemangioma in the newborn: increased incidence after chorionic villus sampling.

OBJECTIVES: This study was designed to compare the effects of transcervical chorionic villus sampling (CVS) and amniocentesis on the prevalence of hemangiomas of infancy. METHODS: This is a cohort study of 250 consecutive assessable transabdominal amniocentesis procedures and 250 consecutive assessable transcervical CVS procedures performed between January and September 2002. Parents were asked to fill out a questionnaire regarding the presence of any type of skin lesions. Based on the responses to the questionnaire, children were invited to undergo a physical examination to confirm hemangiomas. RESULTS: Questionnaires were returned in 78% of the CVS group (195/250) and in 72% of the amniocentesis group (180/250). Based on the responses in the questionnaire, 78 children in the CVS group and 42 in the amniocentesis group underwent a physical examination. One or more hemangiomas were present in 53 of 195 (27.2%) children in the CVS group versus 17 of 180 (9.4%) children in the amniocentesis group (odds ratio 3.6, 95% CI: 2.0-6.5). There was no difference in congenital abnormalities between the two groups. CONCLUSION: Transcervical CVS is associated with a significantly increased prevalence of hemangiomas compared with amniocentesis. The clinical features of these hemangiomas do not differ from natural hemangiomas and complications of these hemangiomas are very rare.

An overview of methods for vascular mapping in the planning of free flaps.

INTRODUCTION: The aim of this overview is to describe the various methods for vascular mapping of flaps together with their advantages and drawbacks. MATERIALS AND METHODS: The PubMed database was used. Relevant search terms included 'flap' in combination with 'hand-held Doppler' (HHD), 'colour duplex sonography' (CDS), 'digital subtraction angiography' (DSA), 'computed tomography angiography' (CTA) and 'magnetic resonance angiography' (MRA). All studies found between January 2000 and January 2010 was evaluated. RESULTS: A total of 72 articles were found. Of these, 62 were usable for this overview. Recommendations could not be found for all types of flaps. Therefore, no uniform guidelines can be provided; some findings are, however, unequivocal. In general, HHD is cheap and easy to use, but relatively unreliable in determining the exact site of emergence at fascia level of perforators. CTA and MRA provide the best three-dimensional images. CTA offers more detailed images, MRA has the advantage however of not using radiation. CDS can be of value to offer information about the amount of flow in vessels or in cases in which CTA or MRA are contraindicated. DSA appears to be fading out slowly. CONCLUSION: CTA and MRA are currently the best methods available to map the vasculature of donor sites of perforator flaps with variable anatomy such as anterolateral thigh (ALT) and deep inferior epigastric perforator (DIEP). In flaps with standard anatomy and superficial vasculature, HHD or no mapping at all remains the method of choice.