Clinical Study Between Percutaneous Ultrasound-Guided Release and Open Classic Surgery in Treating Multiple Trigger Fingers.

Background: A trigger finger is recognized as the most common hand tendinopathies that reduce functional ability. The present study compares the clinical outcomes of open classic release surgery with ultrasound-guided percutaneous surgery in cases of multiple finger involvement. Materials and Methods: A cohort study has been performed from March 2019 to December 2020 by participating 34 trigger finger patients with multiple involvements. These patients were treated using classical open release and ultrasound-guided percutaneous release methods and both methods were compared in patients. The pain severity and functional ability obtained from the quick disabilities of the arm, shoulder, and hand (Quick-DASH) test scores were compared. Results: The pain intensity in the classical open surgery patients was not significantly different from the ultrasound-guided group, and a one-month follow-up showed that the pain intensity in the ultrasound-guided patients was significantly less than in the other group (P = 0.02). Besides, no significant difference was observed between the functional abilities before and after the one-month follow-up. Indeed, the two groups had the same situations. Also, the recovery time in the ultrasound-guided percutaneous release group was significantly faster than in the other group. These cases had statistical differences as P = 0.001 and P < 0.001, respectively. The surgical release was 100% successful in both groups. The patients' satisfaction rates in the ultrasound-guided and open classic surgery treatment methods were 94.1 and 76.4%, respectively. Conclusions: Classical open release and ultrasound-guided percutaneous surgery could successfully treat multiple trigger fingers. However, ultrasound-guided percutaneous surgery provided faster recovery and less pain intensity than the other method.

Effect of Amniotic Membrane Nerve Wrapping in Final Results of Traumatic Peripheral Nerve Repair.

BACKGROUND: Preventing perineural adhesions and scars formation in the traumatic peripheral injuries is very important on the recovery process. We aimed to evaluate the effect of using the amniotic membrane wrapping on the results of surgical treatment of damaged peripheral nerves. METHODS: This cohort study included 30 patients with symptoms of acute peripheral nerve injuries due to penetrating trauma in the forearm or wrist in January 2019 to November 2020 referred to the Hand and Microsurgery Department, 15 Khordad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. In 15 patients, after nerve repair, amniotic membrane coverage was used around the nerve, all patients were followed for 12 months. Ultrasound study for neuroma formation and nerve regeneration was determined based on EMG and NCV findings. The modified Medical Research Councile classification (MRCC) was used to evaluate of motor and sensory recovery. RESULTS: In the amniotic membrane wrapping group, all patients had nerve regeneration and functional nerve recovery occurred after 12 months. In the control group, 5 patients (33.4%) did not have nerve recovery and had functional and sensory impairment. In terms of functional capabilities; there was a significant difference in pinch strength, grip power and MRCC scoring between the two groups. Moreover, the mean volume of neuroma in these patients who used amniotic membrane covering was 2.7 mm3 and in the control group, it was 3.9 mm3 (P=0.001). Five patients who did not have a damaged nerve, the neuroma volume was 4.8 ± 0.9 mm3. CONCLUSION: The use of amniotic membrane covering is effective methods in the improve results of peripheral nerve repair and nerve function recovery.

Management of Symptomatic Lipoma of the Hand: A Case Series and Review of Literature.

Soft tissue lipoma is one of the most common benign tumors rarely forming in hand. In this study, 11 cases of symptomatic hand lipoma were investigated. The chief complaint was a palpable mass in all 11 patients, out of whom 6 (55%) cases presented with neurological symptoms, including paresthesia and numbness in the median, ulnar, and superficial radial nerve pathways. One patient had an intramuscularly painful forearm with a large mass presentation. In the finger, the clinical manifestations were radial anesthesia of the finger. The mass sizes were above 5 cm3 and less than 5 cm3 in seven and four patients, respectively. The mean follow-up period was 25 months. No patient demonstrated a recurrence during the follow-up period. Although lipoma is a benign tumor and often presents itself as a palpable mass in the hand, it can cause neurological symptoms and decreased function. Regardless of the size of the tumor, mass removal can prevent symptoms.

Satisfaction and Functional Outcome of Surgical Treatment in Patients with Brachial Plexus Injury: A Decade of Retrospective Comparative Study.

Background: Brachial plexus injury (BPI) is a severe peripheral nerve injury resulting in physical disability. Few studies have investigated the postoperative functional status. We aimed to evaluate the satisfaction with surgical treatment in patients with BPI referred to the Panzdah-e Khordad Hospital, Tehran, Iran from 2011 to 2021. Methods: In this descriptive-analytical retrospective comparative study, physical examination, along with BrAT, and DASH questionnaires were used to evaluate the patients' status. Then the collected data on the patients' functional status and movements were collected. To compare the mean of quantitative variables before and after the surgery, the dependent t-student was used. Results: Generally, the patients stated that they still had considerable difficulty doing most of the items of the questionnaires. Nevertheless, there was a significant difference between the following variables before and after surgery; shoulder abduction goniometry (0-150) and force (M0:M5), shoulder external rotation goniometry (0-90) and force (M0:M5)), shoulder forward flexion goniometry (0-180) and force (M0:M5)), elbow flexion goniometry (0- 150), elbow extension force (M0:M5), and wrist and finger muscle force (M0:M5) (P<0.001). Conclusion: Posterior approach in BPI surgery was associated with good outcomes in terms of shoulder external rotation and abduction. However, patients still suffered from difficulties in daily activities.

Impact of COVID-19 pandemic on plastic surgery activities and residency programs in a tertiary referral centre in Iran.

Background: On March 11, 2020, the World Health Organization (WHO) announced the COVID-19 outbreak as a new pandemic. In the meantime, plastic surgeons postponed their appointments due to the fair and rational allocation of medical supplies. These limitations made all junior and senior residents perform operations only on traumatic patients rather than those needing reconstructive procedures. This study aims to determine the effects of the COVID-19 pandemic on plastic surgery training programs in Iran. Also, the number of canceled surgeries will be determined to see the effects of the pandemic on the patients. Methods: This retrospective case study considers a six-month timeframe in two consecutive years before and after the COVID-19 pandemic. For this purpose, the researchers evaluated the number of surgeries, types of procedures, age distribution, and gender distribution. The training program data of plastic surgery residents were collected from their logbooks and then analyzed in IBM SPSS Statistics 26. Differences were considered significant if p < 0.05 at a 95% confidence level. Results: The total number of surgeries decreased by 23.5% after the COVID-19 outbreak (p < 0.05). There was a 29.9% reduction in trauma cases, -78.9% in aesthetic surgeries, -17.7% in reconstructive surgeries, -51.8% in craniofacial surgeries, and -59.5%in microscopic surgeries for each resident. Conclusions: This study provides an insight into the severity of the pandemic effects on the plastic surgery training programs and the patients. The reduced number of surgeries led to a depletion in surgical skills training. These effects will not wear off immediately after the pandemic; therefore, it is necessary to observe whether the pandemic will have any lasting effects on this subspecialty.Level of evidence: Level IV, risk/prognostic study.

The Incidence of Ossified Superior Transverse Scapular Ligament during Nerve Transfer through Posterior Shoulder Approach.

BACKGROUND: The purpose of this study was to assess the incidence and importance of bony bridge that covers the supra scapular notch during posterior approach to transfer accessory nerve to suprascapular nerve. METHODS: Between 2010 and 2015, the frequency and importance of suprascapular bony bridge instead of transverse ligament was assessed among patients with brachial plexus injury candidate to shoulder function restoration by accessory to suprascapular nerve transfer through posterior approach. RESULTS: Forty three patients, 41 male and 2 female, (mean age: 32.5 years, range 14 to 36) were included in this study. Five male patients (11.6%) had a complete bony rim on the superior scapular notch. Suprascapular nerve release needed osteotomy of the bony bridge and related equipment. CONCLUSION: Although all previous cadaveric studies among different ethnic groups had reported the prevalence between 0.3 to 30% of suprascapular canal, this in vivo study showed the incidence of 11.6%. Preoperative alertness about this variation could make the exploration and release of the suprascapular nerve easier and reduce the risk of nerve injury or failing to anatomize it. LEVEL OF EVIDENCE: IV.

Contralateral medial pectoral nerve transfer with free gracilis muscle transfer in old brachial plexus palsy.

BACKGROUND: There is a very small chance of success for nerve reconstruction in patients with old total brachial plexus palsy who visit after 2 y or suffer from flail upper extremity after the failure of previous operations. MATERIALS AND METHODS: For these individuals, the surgeon has to find a recipient motor nerve to perform free gracilis muscle transplantation. In this study, contralateral medial pectoral nerve from the intact side was transferred to the damaged side as a recipient nerve. Then, in the second operation, approximately 15 mo later, the free gracilis muscle transfer was performed. The gracilis muscle was removed and transferred to provide elbow and finger flexion. RESULTS: In a retrospective study (over 10 y), we reviewed 68 patients for whom this method had been performed. After 1 y, the results were investigated using the Medical Research Council grading system. Five patients did not participate in the study, and the muscle underwent necrosis in two patients. M3 and M4 muscle power was regained in 26 (42.6%) and 21 (34.4%) patients, respectively. CONCLUSIONS: Contralateral pectoral nerve transfer followed by free muscle transplantation can be a good option for patients with old total brachial plexus palsy.

Early Low-Level Laser Therapy Improves the Passive Range of Motion and Decreases Pain in Patients with Flexor Tendon Injury.

BACKGROUND: To obtain the best result from flexor tendon repair surgery, proper surgical technique, appropriate materials, good rehabilitation, and patient satisfaction are essential to consider. Nevertheless, no general unique protocol still exists between researchers, for a suitable treatment plan. OBJECTIVE: The aim of the present random clinical trial (RCT) was to determine the adjuvant effect of low-level laser therapy (LLLT) on healing tendon injury in patients. MATERIALS AND METHODS: In an RCT, 97 patients (114 fingers) with sharp injury in three zones of their hands were randomly divided into LLLT and control groups, using the unequal treatment allocation approach. Thirty-nine patients (31 males and 8 females, 46 fingers) were enrolled in the LLLT group, receiving 8-10 sessions of LLLT (red and infrared lasers) over the flexor tendon repaired area. In the control group, 58 patients were included, 20 patients did not come back for follow-up, and 38 patients (29 males and 9 females, 46 fingers) participated in the study. Patients were visited in days 28 - 32 after surgery. Passive range of motion (PROM), pain severity of groups, and patient satisfaction from LLLT were all recorded. The two observers, blind to the LLLT group assessed the data independently. RESULTS: In two groups, no rupture was observed during 4 weeks postsurgery. None of the patients in the control group was able to perform the full passive flexion. There was a significant increase in PROM (t = 82.925, p = 0.000) and a significant pain reduction (t = -11.96, p = 0.000) in the LLLT group, compared with the control group. All Patients in the LLLT group were satisfied. CONCLUSIONS: LLLT is a proper adjuvant therapy in flexor tendon repair. Evidently, LLLT promotes tendon healing, alleviates the pain, and assists flexibility of soft tissue and joints, leading to the tremendous improvement in patient cooperation and compliance.

Synchronous Soleus and Reverse Sural Flap for Large Soft Tissue Defect Reconstruction of Leg.

BACKGROUND: Extended Soft tissue defect of leg including middle and distal parts always has been a challenge for many plastic surgeons and also a frustrated problem for patients and families. To introduce the use of the soleus muscle and reverse sural flaps as synchronous surgical treatment alternative of the leg bone exposure with large soft tissue defect, this study was conducted. METHODS: The medical records of patients undergoing transposition of the soleus muscle for treating exposed bone in the leg and simultaneous sural flap were retrospectively analyzed from January 2009 to July 2014, while gathering information on the used muscle was to cover the lesion. RESULTS: Twelve patients with varying ages between 22 and 58 years (10 males and 2 females) were enrolled. The main initial injury was trauma (84.8%), consisting of tibia and/or fibula fractures. Only 1 patient developed insignificant distal flap necrosis who was treated subsequently with surgical debridement and flap re-advancement. CONCLUSION: The treatment of bone exposure with local muscle flaps (soleus and sural) enables obtaining satisfactory results in covering of exposed structures, favoring local vascularization and improving the initial injury. It offers the advantage of providing a treatment in only one surgical procedure, an earlier recovery and reduced hospital stay. Sometimes, this method may be applied instead of free tissue transfer.

The Mid-Term Changes of Pulmonary Function Tests After Phrenic Nerve Transfer.

BACKGROUND: In the restoration of elbow flexion, the phrenic nerve has proven to be a good donor, but considering the role of the phrenic nerve in respiratory function, we cannot disregard the potential dangers of this method. OBJECTIVES: In the current study, we reviewed the results of pulmonary function tests (PFT) in four patients who underwent phrenic nerve transfer. PATIENTS AND METHODS: We reviewed the results of serial spirometry tests, which were performed before and after phrenic nerve transfer surgery. RESULTS: All patients regained Biceps power to M3 strength or above. None of our patients experienced pulmonary problems or respiratory complaints, but a significant reduction of spirometric parameters occurred after surgery. CONCLUSIONS: This study highlights the close link between the role of the phrenic nerve and pulmonary function, such that the use of this nerve as a transfer donor leads to spirometric impairments.

A comparative study on tendon transfer surgery in patients with radial nerve palsy.

BACKGROUND: Lesions in peripheral nerves are highly prevalent in the upper extremity. The present study compares different tendon transfer surgeries in patients with radial nerve palsy. METHODS: Fifty patients with radial nerve palsy were randomly selected among patients who referred to Tehran 15(th) Khordad Hospital during 2006-2011. They were divided into two groups of 17 and 33 subjects. Single tendon transfer surgery was performed on 33 and ternary tendon transfer surgery on 17 patients and were compared. RESULTS: No significant difference was noticed in the range of motion of metacarpophalangeal joint, proximal interphalangeal joint and distal interphalangeal joint joints between the two groups. There was also no significant difference in the results of single tendon and ternary tendon transfer surgeries between the two groups. There was no need to sacrifice three tendons in tendon transfer surgeries on patients with radial nerve palsy. CONCLUSION: Single tendon transfer surgery may help establishing a finger extension while indicates to its considerable advantages of surgical simplicity, shorter surgery time, less complications and surgery scars.

Nerve stripper-assisted sural nerve harvest.

BACKGROUND: Sural nerve has the favorite length and size for nerve graft interposition. Here two techniques, that is, "stocking seam" and "stair-step" or "stepladder," have been used for harvesting sural nerve. The first technique results in an unsightly scar at the posterior calf, and the latter one takes a long time to perform and exert undue traction to the graft during harvesting. The purpose of this article is to describe our experience in harvesting the sural nerve by a nerve stripper. PATIENTS AND METHODS: A nerve stripper was used for harvesting sural nerve in 35 adult patients (in 6 patients, sural harvesting was done bilaterally), 27 men and 8 women. Thirty-one sural nerve harvests were done by closed technique (i.e., harvesting of sural nerve only by two incisions, one in the posterior of the lateral malleolus and the other in popliteal fossa), in 8 others by limited open technique, and in 2 cases, there was early laceration of the sural nerve at the beginning of the study. The contralateral sural nerve was harvested in one patient and medial antebrachial nerve in another by open technique. RESULTS: The mean length of the retrieved sural nerve was 34.5 cm in the closed technique group and 35 cm in the limited open technique group. We detected advancing Tinel's sign in all nerve stripper-assisted sural nerve harvested group members in both the closed and limited open groups. CONCLUSION: Sural nerve harvesting by the nerve stripper is a reliable and simple technique, and it is applicable as a routine technique. Applying controlled rotatory movements of the nerve stripper instead of pushing can result in satisfactory harvesting of the sural nerve without early laceration.

Comparison of three different methods of dressing for partial thickness skin graft donor site.

BACKGROUND: Split- thickness skin graft is one of the most common operations in plastic surgery. It is always painful and patient discomfort from donor site often is more significant than recipient site. There is not still a standard method for treatment of the donor site. The purpose of this study was to determine the best method of dressing the donor site among three different methods with respect to the rate of healing, pain, secretion, infection and cost. METHODS: The study includes 60 patients that were randomly divided into three groups. Donor site and thickness of the graft was the same and were dressed with one of the methods including Method A: Paraffin fine mesh gauze, Method B: Nitrofurazone soaked fine mesh gauze and Method C: Dry fine mesh gauze. Each method included an intermediate layer of sterile plastic sheet witch was covered with 10 layers of dry gauze. Comparison with respect to the rate of healing, pain, secretion, infection and cost was done. RESULTS: Thirty seven patients were men and 23 were women. The mean age of the patients was 27.2 years. There was a significant difference between three methods in average time of repair and superiority of dressing with Method B was noted. Pain severity was the least in Method B and difference between the methods was significant. Dressing with Method B had the least secretion and there was a statistically significant difference between three methods. There was no statistically significant difference in cost of the management. CONCLUSION: This study showed that dressing the donor site with nitrofurazone ointment soaked gauze used as the first layer of dressing and intermediate layer of sterile plastic sheet which was covered with 10 layers of dry gauze was the best method of dressing and had the least complications.

Flexor tendon retrieval in zone I and II: a new modified technique.

In this article we set out to describe a simple and modified Sourmelis technique for tendon retrieval in zone I and II. In this modified technique, a long loop of nylon suture is used and hence there is no need for the stage 4 of Sourmelis technique. The purpose of this paper is to illustrate this modification.

The running Y-V plasty for treatment of linear and cord-like burn contractures.

Linear and cord-like burn scar contractures are commonly treated by severing the scar in a transverse direction and skin grafting or performing Z-plasties. However, skin grafts may result in suboptimal take and contract gradually and the Z-plasty requires undermining flaps in scarred skin which may lead to the distal tip necrosis. In this article the authors present their experience with multiple Y-V plasty technique. From May 2005 to September 2009, 44 linear and narrow cord-like burn contractures in various regions of upper and lower extremities of 32 patients were treated by multiple Y-V plasty technique. The contracted scars were treated successfully in all of the patients. No major post-operative complications or contracture recurrence were observed during the follow up period of 6 to 24 months in this series of patients. By creating a longer length, running Y-V plasty can relax the contracted scar. Considering the advantages and excellent results in the treated patients in this study group, and also other presented series, multiple Y-V plasty can be recommended as a very useful and safe technique for the treatment of linear and cordlike burn contractures.

End-to-side anastomosis for limb salvage in the single artery of a traumatized extremity.

BACKGROUND: The purpose of this article is to describe and highlight our experience of end-to-side anastomosis technique in such cases for limbs salvage in the single artery of a traumatized extremity with free-flap transfer. METHODS: Thirty-two traumatized patients in need of free-flap transfer for their extremity reconstruction were referred to our hospital from March 2006 to November 2008. Angiography was performed in all patients. A single artery was confirmed in 11 cases (Gustilo IIIC). End-to-side anastomosis was applied for limb salvage in single-artery extremity reconstruction, such as preserving recipient's flow and preserving donor's flow in 11 patients. RESULTS: The anastomosis arteries included the popliteal artery (n=3), posterior tibial artery (n=2), peroneal artery (n=5) and radial artery (n=1). The mean time from the injury to the flap reconstruction was 34 days. All patients had severe fracture or bone deficit plus soft tissue defect. Postoperative hospital stay was 12-18 days. Time interval between the injury and referral was 27-45 days. Split thickness skin graft was performed in eight patients. CONCLUSION: Free-flap transfer by end-to-side anastomosis for limb salvage with a single artery is a safe procedure, so a vein graft and T and Y shape anastomosis are not necessary.

Multiple trigger fingers in a musician: a case report.

Trigger finger is a common disease which particularly occurs in middle-aged women. We present a rare case of a male musician with six trigger fingers (five in the left hand and one in the right hand). Mostly these fingers had been used for playing the guitar. The patient had previously been treated with local steroid injections in his fingers, however no response was seen. Therefore, we performed a surgical procedure. Four weeks after surgery, the patient could play the guitar without discomfort in his hands.

Comparison of sole to palm reconstruction using the combined medial plantar and medial pedis free flaps and abdominal pedicle flap for extensive palm injuries.

The coverage of soft- tissue defects of the hand specially volar side needs special consideration. Although certain local flaps have been described and used for resurfacing the palm, Extensive injury requires distant or free flaps for coverage. Abdominal pedicle flap has been traditionally used for extensive hand injuries, however there is no doubt that one of the ideal tissues for resurfacing the volar of hand is plantar tissue. We reconstructed the hand with a new procedure of combined medial plantar and medial pedis free flap , and compared it with 15 cases, whom their extensive palm injuries reconstructed with abdominal pedicle flap. The result was significantly better in respect to sensation, Texture of the Hand and patient satisfaction in compare of abdominal flap.

Division of the first dorsal compartment of the hand into two separated canals: rule or exception?

BACKGROUND: Tendon entrapment of the first dorsal compartment of the wrist, the de Quervain disease, is a common cause of wrist and hand pain and disability. A group of 50 consecutive patients operated for the treatment of de Quervain disease from 2003 through 2006 were prospectively studied to determine the variation in the pattern of the first extensor compartment. METHODS: Eighty-six percent of the patients were females, and 14% were males. In 80% of the cases the nondominant and in 20% the dominant hand was involved. These interesting findings may rule out the occupation's relation to de Quervain disease. RESULTS: Our study revealed that the compartment is completely separated into two canals in 86% of the patients which was significantly higher than that reported in similar studies. CONCLUSION: The existence of two separated compartments for abductor pollicis longus and extensor pollicis brevis tendons should be considered as a common finding during operation to prevent incomplete treatment and recurrence of the symptoms.