Novel Mini-Invasive Surgical Technique for Treating Fifth Metacarpal Neck Fractures: A Case Report.

BACKGROUND Fracture of the fifth metacarpal of the hand is due to trauma to the clenched fist. The non-displaced fracture can be treated by splinting and immobilization, but fracture dislocation requires individualized management to ensure the return of function. The Jahss maneuver for reduction of volar displaced metacarpal neck fractures involves flexion of the metacarpophalangeal and proximal interphalangeal joint at 90°, with the proximal phalanx used to reduce the metacarpal head. This report is of a 25-year-old male Italian pianist with a displaced fifth metacarpal neck fracture successfully treated by reduction using the Jahss maneuver and K-wire attachment of subchondral bone to the metacarpal. CASE REPORT A pianist presented with a trauma to his right hand due to punching a wall. Radiograph images demonstrated an angulated, displaced right fifth neck fracture. A specific approach was decided, considering the complexity of the musical movements and the patient's performance needs. After fracture's reduction by the Jahss maneuver, 2 retrograde cross-pinning K-wires were inserted at the subchondral bone of the metacarpal head. Healing under splinting was uneventful, and the K-wires were removed after 45 days. At 4 months after surgery, the patient had complete recovery of both range of motion and strength. CONCLUSIONS Our technique avoided piercing the metacarpophalangeal joint capsule, preventing extensor tendon damage, dislocation, instability, and pain and retraction of the extensor cuff. This novel mini-invasive technique successfully achieved early metacarpophalangeal joint motion, joint stability, and complete recovery of movements in all planes.

Evaluating Arterialized Vein in Thumb Replantation using Indocyanine Green Angiography: A Case Report.

BACKGROUND The absence of valid vessels for the anastomosis constitutes a contraindication to replantation, but the need for arterial vessels in good condition has recently been questioned and some authors have proposed the arterialization of the veins with promising results. However, this method is not routine in replantation and it is unclear what conditions can establish venous congestion and loss of the replanted segment. CASE REPORT We detail a case where indocyanine green aids in evaluating arterialization of a vein during thumb replantation in a 40-year-old smoker following a crush injury. Multiple attempts to anastomose the princeps pollicis and its collateral vessel failed due to a thrombus formation, leaving the finger non-perfused despite urokinase treatment. To confirm the absence of reperfusion, we administered 0.3 mg/kg of indocyanine green through an upper limb peripheral vein. Observing no reperfusion, we located a suitable radial dorsal vein and performed an arteriovenous anastomosis at the proximal phalanx level. Indocyanine Green Angiography (IGA) revealed a slightly delayed reperfusion but a effective venous outflow. We did not consider it necessary to perform additional venous anastomoses other than the single dorsal radial venous anastomosis. CONCLUSIONS This single case report shows the potential of indocyanine green as a valid aid to evaluate the perfusion of the replantation and also any early venous congestion, being able to modify the operative plan accordingly.

Traumatic peripheral nerve injuries: a classification proposal.

BACKGROUND: Peripheral nerve injuries (PNIs) include several conditions in which one or more peripheral nerves are damaged. Trauma is one of the most common causes of PNIs and young people are particularly affected. They have a significant impact on patients' quality of life and on the healthcare system, while timing and type of surgical treatment are of the utmost importance to guarantee the most favorable functional recovery. To date, several different classifications of PNIs have been proposed, most of them focusing on just one or few aspects of these complex conditions, such as type of injury, anatomic situation, or prognostic factors. Current classifications do not enable us to have a complete view of this pathology, which includes diagnosis, treatment choice, and possible outcomes. This fragmentation sometimes leads to an ambiguous definition of PNIs and the impossibility of exchanging crucial information between different physicians and healthcare structures, which can create confusion in the choice of therapeutic strategies and timing of surgery. MATERIALS: The authors retrospectively analyzed a group of 24 patients treated in their center and applied a new classification for PNI injuries. They chose (a) five injury-related factors, namely nerve involved, lesion site, nerve type (whether motor, sensory or mixed), surrounding tissues (whether soft tissues were involved or not), and lesion type-whether partial/in continuity or complete. An alphanumeric code was applied to each of these classes, and (b) four prognostic codes, related to age, timing, techniques, and comorbidities. RESULTS: An alphanumeric code was produced, similar to that used in the AO classification of fractures. CONCLUSIONS: The authors propose this novel classification for PNIs, with the main advantage to allow physicians to easily understand the characteristics of nerve lesions, severity, possibility of spontaneous recovery, onset of early complications, need for surgical treatment, and the best surgical approach. LEVEL OF EVIDENCE: according to the Oxford 2011 level of evidence, level 2.

Topography of the deep branch of the ulnar nerve between genders: a cadaveric study with potential clinical implications.

The lack of meticulous knowledge concerning the topographical anatomy of the deep branch of the ulnar nerve (DUN) may pose difficulties, leading to a delay or a misdiagnosis of a DUN injury. Identification of the DUN is quite difficult without precise anatomical landmarks as reference points. The current study investigates the topography of the DUN between genders, taking as a reference point a well-known landmark, the Kaplan line, used in hand surgery for carpal tunnel release. Twenty-two (15 males and 7 female) fresh frozen adult cadaveric hands were dissected by using magnifying loupes (3.5 and 5.0 x). We marked values proximal to the Kaplan line as positive (+), while we marked distal ones as negative (-). The mean distance DUN-Kaplan line was 1.69 ± 4.45 mm. In male hands, the mean distance was 4.17 ± 1.88 mm, distal to the Kaplan line, while in females, the mean distance was -4.92 ± 0.69 mm proximal to the Kaplan line. Gender dimorphism was detected, with higher statistically significant values in male hands (p = 0.001). Cadaveric studies of the DUN topography, course, and distribution pattern are uncommon. The current study provides an accurate description of the DUN topography, taking the Kaplan line as a reference point, emphasizing gender differences. The DUN is located distally in males and proximally in females. Knowledge of these predictable anatomical relations may help hand surgeons intraoperatively when dealing with a DUN lesion, because of hand trauma or during the decompression of the DUN.

Volar Plate Interposition Arthroplasty of the Proximal Interphalangeal Joint: A Novel, Modified Malerich's Technique.

The choice of prosthetic or autologous reconstruction for proximal interphalangeal (PIP) joint arthroplasty in degenerative osteoarthritis represents a challenge for hand surgeons, especially in consideration of complications and patient's quality of life. We report the case of a 49-year-old woman who developed diffuse arthritis of the finger joints, especially at the PIP joint of the third right finger. Radiographs showed destruction of the PIP joint, large osteophytes, marked narrowing of joint space, severe sclerosis, and deformation of bone contour. Through a volar approach, we removed the osteophytes, reshaped the joint, and performed an arthroplasty with volar plate interposition. The patient had an improved range of motion at 3 months postoperatively. This case study gives a detailed description and discussion, together with literature revision, of volar plate interposition arthroplasty to treat PIP osteoarthritis, as an alternative to other methods.

Reverse posterior interosseous flap: different approaches over the years - A systematic review.

The posterior interosseous flap (PIOF), as fasciocutaneous flap, represents an interesting option in reconstructive surgery of the upper limb. The PIOF allows coverage of losses of substance of the dorsal side of the hand and, with technical modifications, up to the proximal interphalangeal (PIP) joint without any need of microsurgical technique or the sacrifice of the main vascular axes for the hand. Its dimensions can reach up to 22 cm x12 cm and have excellent versatility since it can incorporate vascularized bone grafts and tendon grafts for complex substance losses. Despite the above-mentioned advantages, among the factors that limit its diffusion, indeed, there is the complex dissection technique originally described. Several authors also report a variable incidence of venous congestion, attributing it to the reverse flow vascularity of the flap. However, in the hands of experienced surgeons, this flap has a negligible incidence of complications. For these reasons, the authors performed a systematic review of the literature to organize the various technical updates over the years to extend the indications of the PIOF and reduce the incidence of complications, thus providing a valuable tool for reconstructive surgeons.

Xeroderma Pigmentosum: A Genetic Condition Skin Cancer Correlated-A Systematic Review.

Background: Xeroderma pigmentosum (XP) is a rare autosomal recessive disorder of UV radiation-induced damage repair that is characterized by photosensitivity and a propensity for developing, among many others, skin cancers at an early age. This systematic review focused on the correlation between the clinical, pathological, and genetic aspects of XP and skin cancer. Methods: A systematic review was conducted through a literature search of online databases PubMed, Cochrane Library, SciELO, and Google Scholar. Search terms were "Xeroderma pigmentosum", "XP", "XPC", "Nucleotide excision repair", "NER", "POLH", "Dry pigmented skin", and "UV sensitive syndrome" meshed with the terms "Skin cancer", "Melanoma", and "NMSC". Results: After 504 abstracts screening, 13 full-text articles were assessed for eligibility, and 3 of them were excluded. Ten articles were selected for qualitative assessment. Conclusions: Patients with XP usually suffer shorter lives due to skin cancer and neurodegenerative disease. Deletion/alteration of a distinct gene allele can produce different types of cancer. The XPC and XP-E variants are more likely to have skin cancer than patients in other complement groups, and the most common cause of death for these patients is skin cancer (metastatic melanoma or invasive SCC). Still, aggressive preventative measures to minimize UV radiation exposure can retard the course of the disease and improve the quality of life.

Development of Histologically Verified Thyroid Diseases in Women Operated for Breast Cancer: A Review of the Literature and a Case Series.

BACKGROUND: The possible relationships between breast and thyroid diseases have been reported in the literature. The purpose of our study was to evaluate the occurrence of histologically verified thyroid pathologies in women who were diagnosed with breast cancer and, after mastectomy/quadrantectomy complemented by oncological treatment, were thyroidectomized based on their periodic thyroid evaluation. PATIENTS AND METHODS: Our series consist of 31 women with a mean age of 62.9 ± 10.9 years (range, 45-81) treated for breast cancer (18 right-sided, 11 left-sided, and 2 bilateral), of whom 29 were thyroidectomized, since two women who developed Graves' disease refused thyroidectomy. These 31 women belong to a cohort of 889 women who referred to the Breast Surgery Unit of our university hospital during the period January 2010 through December 2020. RESULTS: The mean time interval between breast cancer and thyroid pathologies was 48.1 ± 23.4 months (range, 12-95). The final diagnosis at histopathology was infiltrating ductal breast carcinoma in 26 women (with 2/26 patients having bilateral carcinoma) and infiltrating lobular breast carcinoma in the other 5 women. Ten of the twenty-nine thyroidectomized women (34.5%) had a thyroid malignancy on histology: five papillary carcinomas, three papillary micro-carcinomas and two follicular carcinomas. Two of the five women with papillary carcinoma also had histological evidence of chronic lymphocytic thyroiditis/Hashimoto's thyroiditis, which was also detected in another five women with benign thyroid diseases. CONCLUSIONS: We suggest that breast cancer survivors should be made aware of the possible increased risk of thyroid pathologies (including thyroid malignancy) so that they can undergo screening and follow-up.

Lumbrical Muscles Neural Branching Patterns: A Cadaveric Study With Potential Clinical Implications.

BACKGROUND: Lumbrical muscles originate in the palm from the 4 tendons of the flexor digitorum profundus and course distally along the radial side of the corresponding metacarpophalangeal joints, in front of the deep transverse metacarpal ligament. The first and second lumbrical muscles are typically innervated by the median nerve, and third and fourth by the ulnar nerve. A plethora of lumbrical muscle variants has been described, ranging from muscles' absence to reduction in their number or presence of accessory slips. The current cadaveric study highlights typical and variable neural supply of lumbrical muscles. MATERIALS: Eight (3 right and 5 left) fresh frozen cadaveric hands of 3 males and 5 females of unknown age were dissected. From the palmar wrist crease, the median and ulnar nerve followed distally to their terminal branches. The ulnar nerve deep branch was dissected and lumbrical muscle innervation patterns were noted. RESULTS: The frequency of typical innervations of lumbrical muscles is confirmed. The second lumbrical nerve had a double composition from both the median and ulnar nerves, in 12.5% of the hands. The thickest branch (1.38 mm) originated from the ulnar nerve and supplied the third lumbrical muscle, and the thinnest one (0.67 mm) from the ulnar nerve and supplied the fourth lumbrical muscle. In 54.5%, lumbrical nerve bifurcation was identified. CONCLUSION: The complex innervation pattern and the peculiar anatomy of branching to different thirds of the muscle bellies are pointed out. These findings are important in dealing with complex and deep injuries in the palmar region, including transmetacarpal amputations.

Surgical Reconstruction of Severe Tophaceous Gout in the Hand: A Customized Approach.

Tophaceous gout can represent a major problem for hand surgeons when it turns into aggressive nodules, spreading and destroying soft tissue and bone. The combination of ablative and reconstructive surgery may also be complex when the patient refuses amputations and multiple segments are involved. We present a difficult case, where a customized approach, chosen according to the different features of the osteoarticular and tendon involvement of fingers, adopted different solutions for the four affected rays. A patient suffering from severe gout arthritis with osteoarticular destruction in both hands refused amputations and was treated with several reconstructive procedures. After excision of the tophaceous deposits, a long bone autograft, two segmental cement spacers together with distal arthrodeses, and an osteoarticular allograft were used. Functional pinches were maintained in both hands, even at a 13-year follow up, with the allograft preserved and working. On the other hand, significant osteolysis and bone resorption in all the segments that had undergone stabilization was documented, producing extrusion of both cement and distal interphalangeal joint fusion screws. Pre- and postoperation range of motion, visual analogue scale, disabilities of the arm, shoulder, and hand score, and pinch strength tests showed reduced pain and improved function. A review of literature is presented in particular regarding different reconstructive approaches. Combining different techniques in the same hand can lead to successful osteoarticular reconstruction after tophi resection, above all to avoid amputation. However, long-term follow up shows that functional osteoarticular reconstructions seem to be more stable, whereas osteolysis may damage bone grafts used for arthrodesis and produce screw extrusion.

Giant sacral schwannoma excised under intraoperative neuromonitoring in an elderly patient: case report.

Schwannomas are mainly benign tumors arising from the Schwann cells of the peripheral nerve sheath. These tumors can often be associated with non-specific symptoms, such as abdominal heaviness. In this article, we present a detailed description of the surgical management of a giant sacral schwannoma in an elderly patient, for which intraoperative neuromonitoring made it possible to distinguish easily the nerves of the sacral plexus from which the tumor originated and to remove it without complications. Treatment of these rare and symptomatic giant tumors is still a challenge for surgeons; to treat adequately these tumors; a multidisciplinary approach is required to ensure an optimal therapeutic approach to reduce the risk of recurrence and, on the other hand, is not associated with unnecessary iatrogenic neurological damage.

Polydeoxyribonucleotide: A Promising Biological Platform to Accelerate Impaired Skin Wound Healing.

The normal wound healing process is characterized by a complex, highly integrated cascade of events, requiring the interactions of many cell types, including inflammatory cells, fibroblasts, keratinocytes and endothelial cells, as well as the involvement of growth factors and enzymes. However, several diseases such as diabetes, thermal injury and ischemia could lead to an impaired wound healing process characterized by wound hypoxia, high levels of oxygen radicals, reduced angiogenesis, decreased collagen synthesis and organization. Polydeoxyribonucleotide (PDRN) has been used to improve wound healing through local and systemic administration thanks to its ability to promote cell migration and growth, angiogenesis, and to reduce inflammation on impaired wound healing models in vitro, in vivo and clinical studies. In light of all these observations, the aim of this review is to provide a full overview of PDRN applications on skin regeneration. We reviewed papers published in the last 25 years on PubMed, inserting "polydeoxyribonucleotide and wound healing" as the main search term. All data obtained proved the ability of PDRN in promoting physiological tissue repair through adenosine A2A receptor activation and salvage pathway suggesting that PDRN has proven encouraging results in terms of healing time, wound regeneration and absence of side effects.

Studying nerve transfers: Searching for a consensus in nerve axons count.

Axonal count is the base for efficient nerve transfer; despite its capital importance, few studies have been published on human material, most research approaches being performed on experimental animal models of nerve injury. Thus, standard analysis methods are still lacking. Quantitative data obtained have to be reproducible and comparable with published data by other research groups. To share results with the scientific community, the standardization of quantitative analysis is a fundamental step. For this purpose, the experiences of the Italian, Austrian, German, Greek, and Iberian-Latin American groups have been compared with each other and with the existing literature to reach a consensus in the fiber count and draw up a protocol that can make future studies from different centers comparable. The search for a standardization of the methodology was aimed to reduce all the factors that are associated with an increase in the variability of the results. All the preferential methods to be used have been suggested. On the other hand, alternative methods and different methods have been identified to achieve the same goal, which in our experience are completely comparable; therefore, they can be used indifferently by the different centers according to their experience and availability.

Nodular fasciitis of the anterior chest wall mimicking myxofibrosarcoma: A case report and literature review.

Nodular fasciitis is a benign tumor of soft tissues originating from the proliferation of fibroblasts and myofibroblasts, generally developing between the subcutaneous tissue and the underlying muscular layer. Nodular fasciitis predominantly localizes in the upper extremities, trunk, head and neck. Biomolecular and immunohistochemical analyses result essential to demonstrate the benign origin of the process, also confirmed by very low recurrence rate after complete excision, which represents the gold standard for treatment. We report the case of a 36 years-old man who developed a nodular protuberance clinically evident in the upper-left side of the thorax. We further, highlight the main characteristics of this rare neoplasm trough a thorough review of the literature.

Corneal nerves in diabetes-The role of the in vivo corneal confocal microscopy of the subbasal nerve plexus in the assessment of peripheral small fiber neuropathy.

The cornea's intense innervation is responsible for corneal trophism and ocular surface hemostasis maintenance. Corneal diabetic neuropathy affects subbasal nerve plexus, with progressive alteration of nerves' morphology and density. The quantitative analysis of nerve fibers can be performed with in vivo corneal confocal microscopy considering the main parameters such as corneal nerve fibers length, corneal nerve fibers density, corneal nerve branching density, tortuosity coefficient, and beadings frequency. As the nerve examination permits the detection of early changes occurring in diabetes, the invivo corneal confocal microscopy becomes, over time, an important tool for diabetic polyneuropathy assessment and follow-up. In this review, we summarize the actual evidence about corneal nerve changes in diabetes and the relationship between the grade of alterations and the duration and severity of the disease. We aim at understanding how diabetes impacts corneal nerves and how it correlates with sensorimotor peripheral polyneuropathy and retinal complications. We also attempt to analyze the safety of the most common surgical procedures such as cataract and refractive surgery in diabetic patients and to highlight the specific risk factors. We believe that information about the corneal nerve fibers' condition obtained from the in vivo subbasal nerve plexus investigation may be crucial in monitoring peripheral small fiber polyneuropathy and that it will help with decision-making in ophthalmic surgery in diabetic patients.

Principles of Cortical Plasticity in Peripheral Nerve Surgery.

Cortical plasticity is a finely regulated process that allows the central nervous system (CNS) to change in response to internal and external stimuli. While these modifications occur throughout normal brain development, interestingly, they are also elicited after peripheral nerve injury and surgery. This article provides an overview of the principle mechanisms of synaptic, neuronal, cortical and subcortical neuroplasticity, with special attention to cortical and subcortical modifications-as suggested by modern neuroimaging techniques-after peripheral nerve surgery. The main nerve transfer techniques for the superior extremities and their effect on cortical plasticity are also described.

Prevention of symptomatic neuroma in traumatic digital amputation: A RAND/UCLA appropriateness method consensus study.

INTRODUCTION: The appearance of a symptomatic neuroma following finger amputation is a devastating consequence for patient's quality of life. It could be cause of chronic neuropathic pain. The prevention of neuroma formation is a challenging effort for hand surgeons. The biological mechanisms leading to neuroma formation are mostly unknown and different preventing procedures have been tried without certain results. In this paper, a panel of Italian hand surgeons have been asked to express appropriateness about potentially preventive techniques of neuroma formation following the RAND/UCLA appropriateness protocol. METHODS: A literature review was preliminarily performed identifying the most employed methods to reduce the pathologic nerve scar. Afterwards, the selected panelists were asked to score the appropriateness of each procedure in a double scenario: in case of a sharp amputation or in a tear injury. The appropriateness was evaluated according to RAND/UCLA protocol. RESULTS: Nine Italian hand surgeons were included in the panel. Of them 5 were orthopaedic surgeons, 4 plastic surgeons. The identified appropriate procedures were: revision amputation should be done in operating room, the neurovascular bundles should be identified and is mandatory to treat surrounding soft tissues. Only in case of clean-cut amputation, it is appropriate to perform a proximal extension of the dissection, to use diathermocoagulation and coverage with local flaps. Procedures such as shortening in tension of the nerve stump, bone shortening, implantation of the nerve end in the soft tissue, treatment in the emergency room and, in both scenarios, certain results are evaluated as uncertain. DISCUSSION: In order to prevent the formation of a distal stump neuroma few methods were judged appropriate. It is mandatory to identify the neurovascular bundles and treat also the surrounding tissues, but no certain results could be obtained with local flap, bone shortening and other ancillary surgical acts. Moreover, it is not possible to guarantee the non arising of neuroma in any cases, also when every procedure has been temped. CONLUSIONS: The prevention of distal neuroma is actually a challenge, without a well known strategy due to the variability of response of nervous tissue to injury.