Journal of Hand and Microsurgery最新文献

Background: Tissue coverage of the hand in a traumatic setting is challenging given the limited treatments available, the functional issues and the risk of amputation in case of failure. Artificial dermal substitutes have been used in reconstructive surgery for decades but their indications and results in hand surgery need to be further evaluated. The aim of our study was to evaluate skin reconstruction of the hand with an artificial dermal substitute in a traumatic setting.

Methods: We retrospectively reviewed patients suffering from traumatic hand wounds defect with neurovascular, and/or osseous, and/or tendinous exposure. Patients underwent reconstruction with an artificial dermal substitute between 2017 and 2020 in a hand-trauma and reimplantation center. Primary outcomes included the success of the dermal substitute and the surgical revisions dues to failure. Patient satisfaction, QuickDASH and Vancouver scar scale (VSS) were also evaluated.

Results: Thirteen cases were retrieved. The average follow-up length was 22 months. Average age was 56,5 years. The mean surface to be covered was 7.9 cm². In eleven patients (85 %) the dermal substitute successfully covered the required surface. Two patients (15 %) required revision, one for finger ray amputation and another for revision of the dermal substitute. Seventy-seven percent of patient were satisfied, the mean QuickDASH was 30.7, and the VSS 6.3.

Conclusion: Dermal substitutes allow skin coverage of traumatized hand particularly when used in first instance immediately after the trauma. They offer good quality scars and good functional results.

Distal Radius Malunion may occur with closed treatment and may result in various complications including stiffness and decrease in grip strength. Several techniques for correction of malunion have been devised and may broadly be classified into either hinge or distraction osteotomies. We present a "Volar Sliding Hinge Osteotomy" technique for correction of extra articular distal radius malunion, even with excessive radial shortening, without the use of distant bone grafts. The outcomes of three consecutive patients who underwent the procedure were also documented. Our technique may present as a good alternative to radial distraction or ulnar shortening osteotomies in correction of extra articular distal radius malunions with significant radial shortening.

Level of evidence: IV.

Purpose: Three-dimensional (3D) technology is rapidly emerging as a valuable tool in the medical and healthcare industry, particularly for performing corrective osteotomies in upper limb extremities. This study involved patients with impaired upper limb function who underwent corrective osteotomies using a computer-assisted 3D surgical planning process with 3D-printed, patient-specific plates. The biomechanical performance of these 3D-printed, patient-specific plates was enhanced while maintaining crucial properties such as corrosion resistance and biocompatibility, ensuring their safety for clinical application in humans. The surgical outcomes were analyzed by visualizing bone healing, and an evaluation was conducted to assess the success of these methodologies by comparing the clinical outcomes achieved with those planned during the surgical planning phase.

Patients and methods: Eight cases involving malunions and deformities were treated using patient-specific bone plates fabricated through metal additive manufacturing. Preoperative computed tomography (CT) scans were used to generate virtual bone models for surgical planning. Normal/anatomical bone alignment was achieved by mirroring the contralateral healthy bone and projecting it onto the affective bone model. Surgical guides and patient-specific bone implants were then designed. These implants underwent an innovative cyclic heat treatment to optimize their strength and ductility for enhanced biomechanical performance.

Results: The final outcomes for the patients were assessed using functional scoring and radiographs. The 3D-printed surgical guides facilitated accurate osteotomy angulation and precise positioning of drilled holes, ensuring optimal placement of customised, mechanically enhanced bone plates. All patients demonstrated improved DASH scores and experienced reduced or no pain after healing.

Conclusions: This study demonstrates the success of personalized treatment for upper limb disorders using 3D-printed, patient-specific plates, which showed improved biomechanical performance after tailored heat treatment. This method of preparing patient-specific implants offers a safe and highly effective approach to treating malunions and deformities in the upper limbs with reduced surgical time.

Plate osteosynthesis is a core modality commonly employed for rigid surgical fixation of middle phalangeal fractures. It is conventionally done via a dorsal extensor-splitting approach, which bears the risk of plate irritation and adhesion formation with the extensor apparatus that can lead to significant postoperative stiffness. While utilizing a lateral surgical approach may avoid this issue, literature on it remains scarce within the context of middle phalangeal fractures. Here, we outline our extensor-sparing technique of lateral plate fixation in middle phalangeal fractures. We demonstrate that it is a feasible and safe method for rigid surgical fixation with favorable clinical outcomes.

Introduction: Our study aims to share our surgical experiences in utilising the dorsoulnar artery perforator-based (DUAP) free flap for reconstruction of medium-sized defects of the digits.

Methods: Five patients, from 2014 to 2022, all of whom sustained critical defects of the digit(s), either due to trauma or infection, underwent resurfacing with an ipsilateral DUAP free flap. The size of the defects ranged from 2.5 to 3.5 cm in width and 3.5 to 7 cm in length. The main outcomes included active range of movement, sensory recovery of the flap, and time to return to work.

Results and techniques: All five patients demonstrated favourable outcomes following reconstruction of medium-sized digital defects using the DUAP free flap. The patients were followed up for an average of 5 months postoperatively. There were no cases of partial or complete flap failure, and none of the cases required re-exploration of anastomoses. Flap neurotisation was performed in selected cases using either end-to-end or end-to-side neurorrhaphy, achieving a 2-point discrimination of up to 7 mm at 10 weeks postoperatively. All donor sites had healed well and demonstrated good final wrist range of movement, even when flaps extended into the ulnar wrist crease. Technicial refinements included adjusting the flap position to accommodate longer pedicle lengths for defects with short recipient vessels or a wider zone of injury, using a cuff of the main ulnar artery for anastomosis in cases of vessel size mismatch, and using either the dorsal digital vein or superficial dorsal hand vein to mitigate venous congestion.End-to-side (ETS) neurotization was performed in one of the cases, which allowed for preservation of thumb sensation.

Conclusion: The DUAP free flap is reliable and consistently reproducible and serves as a good option for reconstruction of medium-sized defects of the digit. It provides satisfactory functional and aesthetic outcomes, minimal donor site morbidity and the potential for sensory restoration through end-to-end and end-to-side neurotisation. Our experience supports the application of this flap beyond pulp defects, especially when selected technical modifications are employed to address the individual anatomical challenges and optimze outcomes.

Level of evidence: 4.

Certification in hand surgery in Europe (EBHS) and the United States (HSE) requires a subspecialty examination. These exams differ in format, and practice exams, such as those published by the Journal of Hand Surgery (European Volume) and the ASSH, are used for preparation. This study aimed to compare the difficulty of the multiple-choice questions (MCQs) for the EBHS and HSE practice exams under the assumption that European MCQs are more challenging. ChatGPT 4.0 answered 94 MCQs (34 EBHS and 60 HSE practice exams) across five attempts. We excluded MCQs with visual aids. Performance was analyzed both quantitatively (overall and by section) and qualitatively. ChatGPT's scores improved after being provided with correct answers, from 59 % to 71 % for EBHS and 97 % for HSE practice exams by the 5th attempt. The European MCQs proved more difficult, with limited progress (<50 % accuracy up to the 5th attempt), while ChatGPT demonstrated better learning with the HSE questions. The complexity of the European MCQs raises questions about the harmonization of certification standards. ChatGPT can help standardize evaluations, though its performance remains inferior to that of humans. The findings confirm the hypothesis that EBHS MCQs are more challenging than the HSE practice exam.

Level of evidence: Exploratory study, level of evidence IV.

Only 4 % of metacarpal fractures affect the distal articular region. In the literature, some studies have ended up causing confusion by mixing up extraarticular neck fractures with subcapital fractures, a term that should only be used to define transverse articular fractures of the head that are distal to the origin of the collateral ligament. Due to the need for anatomical reduction, displaced metacarpal head fractures must be reduced and fixed, mostly by open surgery. Recently, the use of intramedullary fixation has become the method of choice in the treatment of transverse metacarpal diaphyseal and neck fractures. Having this in mind, we describe the so-called "lollipop" technique for the treatment of subcapital metacarpal fractures, in which a cortical mini-fragment screw is inserted through the head by intramedullary retrograde fixation in the diaphysis, leaving the final assembly in the shape of the candy. By using minimal fixation, the already impaired vascularity of the head articular fragments is protected, providing enough rigid stability for the fracture to heal in an anatomical position and allowing early mobility.

Background: Traumatic Brachial Plexus Injury (TBPI) results in significant motor and sensory impairments, impacting daily function, employment, and psychological well-being. While surgical interventions aim to restore function, outcomes remain variable, necessitating comprehensive rehabilitation. Occupational Therapy (OT) plays a crucial role in optimizing upper limb function, addressing psychosocial concerns, and enhancing quality of life. However, limited research exists on its specific impact, particularly in the Indian context.

Objective: This study aimed to evaluate the functional outcomes of OT interventions in adult TBPI patients, assessing their impact on muscle strength, sensation, range of motion, functional performance, and quality of life.

Methods: A prospective longitudinal observational study was conducted at the Occupational Therapy Department of a tertiary healthcare center in Mumbai, India. 33 patients were recruited, with 31 completing the study. Functional outcomes were assessed at baseline and at 3, 6, 9, and 12 months post-intervention using muscle power assessment, sensory evaluation, range of motion, the Brachial Assessment Tool (BrAT), Disabilities of the Arm, Shoulder, and Hand (DASH) score, WHOQOL-BREF, and the Modified Mallet Score.

Results: Significant improvements were observed in muscle power (p = 0.0001), sensation (p = 0.0001). The BrAT score showed significant improvement across all time points, particularly in conservatively managed patients (p < 0.01). DASH scores demonstrated a significant reduction over 12 months (p = 0.0001), with upper plexus injuries showing better recovery than global plexus injuries. WHOQOL-BREF scores improved significantly in physical, psychological, and social domains (p < 0.05). Correlation analysis revealed a strong negative correlation between DASH and BrAT scores (R = -0.84, p = 0.0001) and a moderate positive correlation between BrAT and WHOQOL-BREF (Physical R = 0.57, Psychological R = 0.58, p = 0.0001).

Conclusion: Occupational Therapy significantly enhances functional recovery, independence in daily activities, and psychosocial well-being in TBPI patients. Conservatively managed patients showed greater functional gains compared to surgically managed patients. These findings highlight the critical role of OT in TBPI rehabilitation and the need for standardized OT protocols to improve patient outcomes.

The management of type IIIB thumb hypoplasia in the Asia-Pacific region is predominantly shaped by cultural views, with numerous countries favouring a five-fingered hand. The article discusses the evolution of treatment for type IIIB thumb hypoplasia with thumb preservation and reconstruction and the dilemma of excision and pollicization. Recent research has revealed the limitations of pollicization including joint instability and diminished grip strength. Moreover, several parents, particularly in the Asia-Pacific region, exhibit hesitancy towards thumb excision owing to cultural, psychological, or religious considerations, favouring the retention of a five-fingered hand. This has prompted continuous investigation into alternate techniques that preserve thumb stability while facilitating a functional five-fingered hand. Recent strategies have demonstrated encouraging outcomes comparable to conventional pollicization. In several instances, staged treatments are necessary to provide a five-fingered hand, although the reconstructed thumb may exhibit functional and developmental limits. This alternative procedure has demonstrated favourable functional and aesthetic benefits, with minimal donor morbidity, comparable to that of pollicization.