A new incision in the correction of radial longitudinal deficiency: The double Y sliding flap approach.

One concern in the surgical treatment of radial longitudinal deficiency (RLD) is certainly the skin incision. Over the years many different types have been proposed and used. We propose a new skin incision technique: a double Y sliding flap with the main body along the dorsal wrist crease, followed by raising a proximal and a distal flap providing wide access to the dorsal surface of the wrist joint. After correction of the wrist deformity, skin triangles are resected on the radial and ulnar sides of the incision. Then the skin of the distal flap is slid radially and proximally, filling the defect left by the resected radial triangle, while the proximal flap is slid in the opposite direction, enabling transverse closure along the ulnar side of the incision. The final scar comprises a central body along the dorsal wrist crease, and a radial branch. The aim of this study was to analyze the clinical results of this new double Y sliding flap approach for the surgical treatment of type III and IV RLD. We retrospectively reviewed medical records of surgical correction of RLD using our new incision, between January 2016 and December 2018 in our department of hand surgery. Endpoints comprised correction of redundant skin, scar appearance, and complications. Twelve limbs in 9 patients treated with this double Y sliding flap approach were reviewed: correction of redundant skin was systematic, only 2 limbs showed postoperative complications (1 case of notable edema and 1 of delayed wound healing), and scar aspect was graded good in 11 of the 12 cases. The double Y sliding flap was safe, with minimal complications, adequate skin restoration, wide exposure of the wrist, and esthetically good scar. LEVEL OF EVIDENCE: IV.

Impact of COVID-19 on hand surgery in Italy: A comparison between the Northern and the Southern regions.

The aims of this study were to evaluate the impact of the COVID-19 pandemic on emergency and elective hand surgery in four Italian regions that had either a high (Lombardy and Piemonte) or a low (Sicilia and Puglia) COVID-19 case load to discuss problems and to elaborate strategies to improve treatment pathways. A panel of hand surgeons from these different regions compared and discussed data from the centers they work in. The COVID-19 pandemic had an enormous impact on both elective and emergency surgery in Italy, not only in highly affected regions but also - and paradoxically even at a higher extent - in regions with a low COVID-19 case load. A durable and flexible redesign of hand surgery activities should be promoted, while changing and hopefully increasing human resources and enhancing administrative support. Telematics must also be implemented, especially for delivering rehabilitation therapy.

Collagenase clostridium histolyticum in patients with Dupuytren's contracture: results from POINT X, an open-label study of clinical and patient-reported outcomes.

In POINT X, a study designed to reflect clinical practice and patient treatment choices, 254 European patients received open-label collagenase for Dupuytren's contracture. The most severely affected joint was treated first in 74% of patients. In total, 52%, 41%, 7%, and 1% of patients selected the little, ring, middle, and index finger, respectively; 79% had one or two joints treated. Only 9% of patients (n = 24) received 4 or 5 injections. The mean improvement in total passive extension deficit (TPED) was 34° on day 1, improving further by day 7 to 42°. This secondary improvement was maintained by day 90 and month 6. The mean number of injections/joint was 1.2 for the metacarpophalangeal joint and 1.25 for the proximal interphalangeal joint. Median time to recovery was 4 days; the mean improvement in hand function was clinically relevant as measured by the Unité Rhumatologique des Affections de la Main (URAM) score. In total, 87% and 86% of patients and physicians, respectively, were very satisfied or satisfied with treatment at month 6, although correlation between TPED and patient satisfaction was weak (Spearman -0.18, 95% CI -0.32 to -0.06). Collagenase was well tolerated, with 10 (3.9%) patients experiencing severe adverse events. As a real-world study, the POINT X findings can be generalized to the at-large population.

Dupuytren contracture recurrence project: reaching consensus on a definition of recurrence.

The aim of this study was to determine a definition of recurrence of Dupuytren disease that could be utilized for the comparison of the results independently from the treatment used. 24 hand surgeons from 17 countries met in an international consensus conference. The participants used the Delphi method to evaluate a series of statements: (1) the need for defining recurrence, (2) the concept of recurrence applied to the Tubiana staging system, (3) the concept of recurrence applied to each single treated joint, and (4) the concept of recurrence applied to the finger ray. For each item, the possible answer was given on a scale of 1-5: 1=maximum disagreement; 2=disagreement; 3=agreement; 4=strong agreement; 5=absolute agreement. There was consensus on disagreement if 1 and 2 comprised at least 66% of the recorded answers and consensus on agreement if 3, 4 and 5 comprised at least 66% of the recorded answers. If a threshold of 66% was not reached, the related statement was considered "not defined". A need for a definition of recurrence was established. The presence of nodules or cords without finger contracture was not considered an indication of recurrence. The Tubiana staging system was considered inappropriate for reporting recurrence. Recurrence was best determined by the measurement of a specific joint, rather than a total ray. Time 0 occurred between 6 weeks and 3 months. Recurrence was defined as a PED of more than 20° for at least one of treated joint, in the presence of a palpable cord, compared to the result obtained at time 0. This study determined the need for a standard definition of recurrence and reached consensus on that definition, which we should become the standard for the reporting of recurrence. If utilized in subsequent publications, this will allow surgeons to compare different techniques and make is easier to help patients make an informed choice.

The Italian CUMI.

The purpose of this review is to evaluate the historical development, growth and evolution in the past decade of the Italian network for emergencies of the hand. The complete story from its roots to model of efficiency that required so many efforts and fatigue to be created and tuned up.

[Camptodactyly: early nonoperative treatment]. / Il trattamento conservativo precoce nella camptodattilia.

PURPOSE: To analyse the classifications and the conservative protocols used by hand surgery operative's units and published in the last 15 years. To draw a comparison between those classifications and protocols and the ones used in our unit. MATERIAL AND METHODS: The published conservative treatments have been analysed and then our protocol has been described through the analysis of three cases currently treated in our division. RESULTS: It has been highlighted that camptodactyly classifications are not homogeneous. Moreover, in conservative treatment, different typology and posology of splints have been adopted. Our unit uses the Foucher's classification to define the type of splint that it is necessary. CONCLUSIONS: Despite the authors choose different types of splint, they agree that in the most cases of camptodactily the initial approach is conservative. In our unit static and dynamic splints are made directly on the patient's hand and they are monitored with goniometrical measurements, obtaining great results.

[A peculiar lead poisoning: a concern of team achievement]. / Un caso di intossicazione anomala da piombo: l'importanza di un'intervento multidisciplinare.

We describe a case of lead poisoning in a worker after hand and forearm trauma with fracture of radius and multiple fractures of metacarpal bones and hand phalanges and tissue infiltration of lead oxide (PbO) paste. Orthopedic surgery was immediately performed. After 20 days the patient had abdominal colic pain episodes and severe stipsis and blood lead level (BLL) was 60 mcg/mL with urinary lead level (ULL) of 238 mcg/24 h. After mobilization test with calcium disodium edetate were observed a high increase of BLL (180 mcg/dL) and UBL (17,000 mcg/24h). An initial anemia was observed and became severe (Hb 7.6 g/dL). A NMR exam and echography showed forearm subcutaneous lead paste infiltration and the patient underwent to a second surgical debridement with local low temperature (5 degrees C) irrigation of saline and CaNa2EDTA made the removal of the hardened lead paste. The day after, oral succimer (DMSA) chelation treatment was started with recovery of lead poison.

Arthroscopic assisted bone grafting for early stages of Kienböck's disease.

Kienböck's disease is known for its difficulty in being diagnosed and treated at early stages; option treatments are few and most of them quite aggressive. The author describes his experience with arthroscopic assisted lunate bone grafting. Three patients with diagnosis of stage I avascular necrosis of the lunate (average age: 45 years), were treated. Before surgical procedure, the patients underwent to a conservative treatment. After harvesting the bone graft from the volar surface of the radius, arthroscopic bone grafting was performed. At an average follow-up of 13.5 months (9-15), all the patients show a normal density of the lunate and no arthritic changes in radiographs. The MRI confirmed the lunate vascularity. The number of patients is definitely small, due also to the rarity of the disease and the difficulty in diagnosis, but, despite the very high learning curve, could be the proper first choice of treatment.

[Hand management in recessive dystrophic bullous epydermolysis]. / Il trattamento della mano nel paziente affetto da epidermolisi bollosa distrofica recessiva.

PURPOSE: Recessive distrofic epidermolysis bullosa creates severe hand deformities with disabling functional limitations. Hand surgeon should perform surgery when deformity inibits function, in order to restore the pinch. MATERIALS AND METHOD: We present our experience on 44 patients and 58 operated hands, with the following schema: hand degloving, grafting of the first web and intraoperative dynamic splinting. RESULTS: In 30 patient with an 8 years follow up, 25 had had good or excellent results, and the 5 remaining shows early recurrence. CONCLUSION: Association of a correct surgical approach and adequate intra and post-operative rehabilitation improve hand function and a slow down inevitable recurrence.

Efficiency of Hyaloglide in the prevention of the recurrence of adhesions after tenolysis of flexor tendons in zone II: a randomized, controlled, multicentre clinical trial.

Hyaloglide is a hyaluronan-based gel based on a novel auto-crosslinked technology designed to reduce postsurgical adhesions. Its efficacy was assessed in a multicentred randomized controlled trial comparing the results of flexor tenolysis in zone 2 following failed flexor tendon repairs. In the control group a standard release was performed. In the treated group, Hyaloglide was applied into the flexor sheath and around the site of tenolysis. Forty-five patients, 19 controls and 26 treated with Hyaloglide, were enrolled in 13 centres. All the patients were evaluated at 30, 60, 90 and 180 days after surgery by testing Total Active Motion, Quick-DASH questionnaire and number of working days lost after surgery. Patients in the Hyaloglide group had a statistically better recovery of finger motion at all time intervals and returned earlier to work and daily activities. The use of Hyaloglide did not appear to increase the complication rate.

Reconstruction of the distal finger with partial second toe transfers by means of an exteriorised pedicle.

This study reports the outcome of a series of ten microsurgical fingertip reconstructions with partial toe transfers in which the vascular pedicle was exteriorised and subsequently excised after the transfer had become established. The aim of this technique was to provide better aesthetic and functional outcomes. The technique was successful and without complication in nine of the ten patients who had excellent functional and aesthetic outcomes. Arterial thrombosis resulted in partial necrosis of the fingertip in the other case.

A comparison of endoscopic and open trigger finger release.

The main complaint of the patients after an open trigger finger release is a discomfort at the incision site. In this prospective study, we compared the two consecutive groups of patients with trigger fingers. One was treated by an open approach and the other by the endoscopic release of the A1 pulley. Pre- and post-operative evaluation at seven, 30 and 90 days showed a faster recovery from the discomfort with a faster return to daily and working activities, after the endoscopic procedure.

Arthroscopic evaluation and treatment by tendon interpositional arthroplasty of first carpometacarpal joint arthritis.

Basal joint arthritis of the thumb is usually seen in females beginning from the fourth and fifth decades. In the last two decades, arthroscopic techniques have brought new chances of diagnosis and treatment for this condition. In this paper, the authors describe the indications and their experience concerning arthroscopic hemitrapezectomy and tendon interposition using the palmaris longus tendon. A series of 16 patients with a maximum follow-up of 12 months is analysed. All of the 16 patients were followed and assessed with grasp strength, pinch strength, DASH and MAYO evaluation score both pre- and post-operatively at 12 months follow-up. According to the MAYO score, there were six excellent results, six good, three fair and one poor. No complications occurred. According to our preliminary results, this procedure with the proper indications gives a valid option for the treatment of thumb carpometacarpal joint arthritis in stages I and II according to Eaton's classification.

Scaphotrapeziotrapezoid joint arthritis: a pilot study of treatment with the scaphoid trapezium pyrocarbon implant.

Isolated scaphotrapeziotrapezoid osteoarthritis is rare but can cause weakness and wrist pain. We present the results of a pilot study of interposition arthoplasty with a scaphoid trapezium pyrocarbon implant (STPI) by an open and arthroscopic approach for this problem. We performed this procedure in 10 hands in eight patients, all women, with a mean age of 60.5 (range 51-70) years. The average follow-up was 19 (range 2-24) months. Pre-operative X-rays in all cases identified an isolated degenerative arthritis of the scaphotrapeziotrapezoid joint. Average DASH evaluation pre-operatively of 49 was reduced to 39. All of the patients had functional improvement and returned to daily activities after 3 months. The results of this pilot study suggest that the STPI may prove a useful compromise treatment for this problem.

The surgical treatment of the first carpometacarpal joint arthritis: evaluation of 400 consecutive patients treated by suspension arthroplasty.

Arthritis of the first carpometacarpal joint is a widespread disease in Western countries. It affects predominantly women with marked impairment in daily life activities. Its aetiopathogenesis is well described, while its treatment still controversial. The authors report their experience with 400 consecutive patients with established clinical and radiological findings of carpometacarpal joint arthritis treated by suspension arthroplasty with Ceruso's modified Weilby's technique. At 12 months follow-up, we were able to assess 315 patients using MAYO's score pre- and post-operatively, obtaining 86 excellent results, 134 good, 62 fair and 33 poor. As for complications, there were seven infections, 32 persistent pain and 42 limited range of motion. According to our experience the treatment modality of suspension arthroplasty with Ceruso's modified Weilby's technique represents the procedure of choice in indicated cases of first carpometacarpal joint arthritis in advanced stages according to Eaton-Littler classification.

[The ulnar longitudinal deficiency: proposition of a descriptive classification]. / Déficiences longitudinales ulnaires: proposition d'une classification descriptive.

Ulnar longitudinal deficiency is an extended malformation sometimes involving the whole upper extremity, even including sometimes the opposite side. The clinical and radiological aspects are variable and none of the existing classifications takes into account all the possible deformities. Multiple decisive factors in the surgical indications are missing such as shoulder stability, elbow position (extension or flexion with or without pterygium), orientation of the hand (internal rotation), wrist inclination and number of digits. Based on a review of our 46 clinical cases as well as the published cases in the literature we have developed a simple way to describe each level.

[Secondary treatment of digital mutilations: reconstruction or amputation]. / Le traitement secondaire des mutilations digitales: reconstruction ou amputation.

Decision for stump improvement, shortening or reconstruction after finger mutilation is based on multiple factors. Some of them belong to the patient, age, psychological background, job and leisure activities and cosmetic expectation. Others belong to the injury, its mechanism and the anatomical lesions. Abstention, prostheses and rehabilitation are among the options. Conventional techniques are not to be forgotten as age remains an ultimate frontier in microsurgical reconstruction to obtain a good sensory result. Function and appearance are closely linked for a useful and a used hand.

[Progressive bone lengthening of the hand in congenital malformations. 41 cases]. / L'allongement par distraction progressive du squelette de la main dans les malformations congénitales. A propos de 41 observations.

PURPOSE OF THE STUDY: We retrospectively reviewed the experience of two Hand Units with progressive bone distraction lengthening, collecting 41 cases of hand skeleton lengthening for congenital malformations. MATERIAL AND METHODS: The Ilizarov callostasis method was used in 31 cases and in 10 cases bone union was reestablished at a second stage with an iliac graft (2 cases), vascularized metacarpal bone graft (one case), and vascularized (one case) or nonvascularized (3 cases) toe epiphysis. In the last three cases of index lengthening, the distal part was translocated to the tip of the third, deepening at the same stage the first web. The most frequently treated malformation was symbrachydactyly (22 cases). RESULTS: Mean lengthening was 2.3 cm (0.9 to 3.5) with a mean treatment duration of 3.8 months (1.5 - 8.2). The "lengthening index" was 0.59. There was a significant difference between phalanx and metacarpal lengthening, but the amount of lengthening or treatment duration were not affected by technique (Ilizarov vs bone grafting) or age. The complication rate was 32%. There were two complete failures, one extensor tendon tear, 3 pin tract infections (one requiring interruption of the lengthening), 2 cases of relevant pain, 2 delayed unions, 2 angulations and 1 callus fracture, 1 metacarpophalangeal dislocation and 1 joint stiffness. DISCUSSION: Despite advances in micorsurgical toe transfer, there are still indications for bone lengthening in congenital malformations. The apparent simplicity of the technique can mask a certain number of complications, emphasizing the need for surgical experience. Progressive bone lengthening in congenital deformity has the advantage of preserving sensitivity and avoiding bone resorption. Callostasis does not increase the duration of treatment compared to bone graft.

[Value of a new first web space reconstruction in congenital hand deformities. A study of 54 patients]. / Apport d'une nouvelle plastie à la reconstruction de la première commissure dans les malformations congénitales. A propos d'une série de 54 patients.

INTRODUCTION: Only a few studies are available in the literature on the specific problem of the congenital contracture or absence of the first web in hand deformities, and first web reconstruction. MATERIAL AND METHODS: Sixty-seven first web plasties in 54 patients were retrospectively analyzed: they included 44 cases of classical plasties, i.e., Z-plasty (21 cases); dorsal flap plasty of the index (19 cases), thumb (1 case), or the hand (10 cases), and 16 cases of' pseudo-kite flap. RESULTS: The results were difficult to assess, as the syndromes were dissimilar and the deformities were not comparable (e.g., Apert syndrome versus Poland syndrome). However, it was found that the 'pseudo-kite' technique which was applicable to certain cases resulted in a web extension of 3.2 cm without any deepening. DISCUSSION: No method of classical assessment can be used to comprehensively evaluate the results of first web reconstruction due to the wide variability in clinical characteristics, the lack of patient cooperation in this young age group, the possible MPJ articular thumb instability, and growth factors. Although 4-flap Z-plasty is an adequate technique for non-severe first web deformities, the 'pseudo-kite' flap approach is useful in more severe cases. In 13 cases, a peroperative measurement before and following plasty was made, and a significant increase (205%) in planimetric and stereotactic gain compared to pre-plasty findings was noted. CONCLUSION: It does not seem logical to have a particular preference for a certain approach when considering first web reconstruction in congenital malformations. Each technique has its advantages and disadvantages, depending on patient age, the type of malformation, the state of the thumb, the extent of the first web deformity and the possible presence of scar tissue.