Hand Surgery & Rehabilitation最新文献

“Green nails” or chloronychia results from an infection mostly caused by Pseudomonas sp. but also from other bacterial or fungal contamination. Its presents as a typical triad: green discoloration of the nail plate with proximal chronic paronychia and disto-lateral onycholysis. In a moist environment, Pseudomonas colonizes onycholysis of any origin (traumatic, inflammatory or tumoral). Nail color varies from pale green to dark green, almost black. Treatment consists in cutting of the detached nail plate, brushing the nail bed with a 2% sodium hypochlorite solution twice daily accompanied by moisture eviction by wearing latex gloves over cotton ones for all daily household tasks.

Allodynia is a neuropathic pain triggered by a normally painless stimulus: for example, a slight touch on the skin or slight sensation of hot or cold is extremely painful. Rehabilitation is long and uncertain. Protecting the painful area from stimuli is a priority of care. This type of care is complex and challenging for the care team: the pain caused in manufacturing a classic molded orthosis is unbearable for the patient, and the orthosis has a limited lifetime, and experience shows that it is not possible to produce two identical splints. The present study consisted in creating protective splints by 3D printing, designed from data collected with the 3D surface scanner used in our forensic imaging and anthropology unit. The pros and cons of the 3D orthosis versus standard molded orthoses from the point of view of the patient and the practitioner are discussed, with evaluation of related indications of this technology.

Nail cosmetics is enjoying growing success due to recent technological advances. Manicures can be responsible for mechanical, infectious or allergic adverse effects. Nail cosmetics (e.g., nail varnishes, acrylic false nails, light-curing gels, and adhesive false nails) incorporate substances that harden after solvent evaporation or after polymerization. Allergic reactions can occur, remotely with conventional varnishes and locally with polymerizing substances. Artificial nails incur a risk of carrying infectious agents which can cause serious infection, and should not be used by caregivers.

Recently, there has been a worrisome increase in the frequency of acrylate allergy, due to the appearance of home kits and lack of information in the general public. The infectious, allergic and toxic risks incurred by consumers and professionals regarding manicure or pedicure treatments and the application of nail cosmetics are the subject of recommendations and monitoring measures.

Objective

Thumb osteoarthritis is a frequent pathology, mainly affecting the elderly. The surgical treatment initially described and having proved its worth is total trapeziectomy. Since the advent of trapeziometacarpal prostheses, several studies showed the non-inferiority of this technique on clinical criteria, with superiority in bone sparing, although neither technique demonstrated overall superiority. We therefore examined the specific complications of each surgical technique by analyzing their nature and prevalence through a review of the literature to compare them on these new parameters.

Methods

Seventy-four of the 320 articles reviewed were included, 38 of which concerned trapeziectomy, and 36 concerned prostheses, for a total of 4,865 patients. They were original studies, involving adults undergoing trapeziometacarpal arthroplasty or trapeziectomy, published after 2015, reporting at least one well-described complication.

Results

6.13% of trapeziectomies presented severe complications (in particular thumb collapse and metacarpophalangeal hyperextension), 3.31% moderate complications and 1.90% minor complications, leading to a 2.0% revision rate. 23.88% of prostheses had severe complications (loosening, dislocation and wear), 5.06% moderate complications and 1.36% minor complications, leading to a 12.8% revision rate. In addition, we analyzed more recent prosthesis designs separately, and found lower prevalence of severe complications (16.56%) and revision surgery (4.3%).

Conclusion

Revision surgery for trapeziometacarpal prostheses is usually only a standard trapeziectomy with the same follow-up as first-line trapeziectomy, whereas revision surgery for trapeziectomies is much more complex and the results are uncertain. For this reason, we would reserve total trapeziectomy for revision surgeries and patients with low functional demand for whom a second surgery is not desirable. Further studies could confirm this attitude, especially focusing on the latest generation of dual mobility implants.

Level of evidence

1.

Background

The need for prophylactic antibiotic treatment of hand wounds in children requiring emergency surgical exploration is still controversial. Our starting hypothesis was that the absence of prophylactic antibiotic treatment in this setting (as specified by a decision tree) does not increase the likelihood of surgical site infection.

Methods

A decision tree for antibiotic prescription was developed by a working group in compliance with the guidelines issued by the French High Authority for Health, as part of a clinical pathway. One injection of intravenous antibiotics was prescribed for bite injuries, open joint injuries, injuries left untreated for more than 24 h, and suspected contaminated wounds. All children admitted for surgical treatment of a hand wound between July 2018 and March 2023 were included. Demographic data, antibiotic prescription and onset of postoperative surgical site infection were recorded.

Results

The 238 children included had a mean age of 8 ± 4.8 years; 102 received antibiotics and 136 did not. Eleven children (4.6%) had superficial surgical site infection requiring no revision surgery or antibiotic therapy. 206 children (86.5%) were treated following the decision tree. Ten had superficial surgical site infection: 3 received antibiotics (3.7% of the 80 who were treated) and 7 did not (5.5% of the 126 not treated) (p = 0.74). Thirty-two patients (13.5%) were off-protocol, only 1 of whom received antibiotics for superficial surgical site infection.

Discussion

Applying the decision tree standardized the prescription of antibiotics in hand wounds, was not associated with a significantly greater rate of surgical site infection, and avoided exposure to antibiotics for 61.1% of the children, thus limiting potential adverse events.

Level of evidence

III.

Objectives

Thumb duplication is one of the most challenging pediatric reconstructive hand surgeries. Wassel types II and IV are the most frequent, but also the most complex reconstructions as the duplication arises at the joint level. Ablation and reconstruction, the most widely used technique, aims at achieving a stable, well-aligned, mobile and esthetically acceptable thumb. The paucity of reliable surgical guidelines leads to high rates of suboptimal surgical outcomes. This review evaluated the various reconstruction techniques detailed in the literature and highlighted useful methods to prevent common secondary complications.

Methods

A comprehensive PubMed and Embase literature search was made. Inclusion criteria were Wassel type II and/or IV, pediatric patients, and primary or secondary surgeries. Exclusion criteria were Bilhaut-Cloquet reconstruction and its modifications. Techniques were screened, collected and analyzed for the following secondary complications: instability, axial deformity, and contour deformity.

Results

Thirty-two articles met the inclusion criteria and were reviewed. Postoperative instability was prevented by tightening the joint capsule by plication, advancement of the volar plate, or reconstruction of the collateral ligaments using a periosteal flap or the double-breasting technique. Axial deformity was prevented by arthroplasty, shaving a triangular portion of the metacarpal head, centralization of eccentric tendons, pulley reconstruction using flexor pollicis longus, or corrective osteotomies of the phalangeal or metacarpal bones using the wedge or oblique techniques. Limited range of motion was prevented by first webspace Z-plasty, and soft-tissue contouring was addressed by planned skin incisions and soft-tissue augmentation. Preoperative, perioperative and postoperative considerations, including splinting, imaging and immobilization, were also described.

Conclusion

Despite the ongoing advances and abundant knowledge in reconstructive strategies for thumb duplication, there are few studies that reviewed and analyzed the various reported options. This review provides physicians and trainees with guidance in surgical planning to prevent common secondary complications. Further research should focus on the development of standardized assessment tools, enabling reliable prospective comparative studies on thumb duplication reconstruction.

Level of evidence

IV.

Complications in nail surgery are not that frequent. Apart from complications that are common to every hand procedure, intense pain is the major issue with nail surgery.

To prevent complications, good knowledge of anatomy and physiology is required to avoid misdiagnosis or inappropriate technique. However, some complications, such as postoperative nail dystrophy, are unavoidable, and must be known and discussed with the patient prior to the procedure in order to prevent disappointment that may lead to medico-legal cases.

This paper will discuss the most frequent complications encountered.

Objectives

To explore the clinical application and efficacy of transplantation of free composite flaps supplied by radial osteocutaneous branch of the dorsal branch of the anterior interosseous artery for reconstructing bone and skin defects in the hand.

Material and methods

Anatomically, the radial osteocutaneous branch of the dorsal branch of the anterior interosseous artery has constant collateral anastomoses which can provide a large dorsoradial flap from the dorsum of the forearm. This flap was used for reconstruction in five cases of cutaneous and phalangeal defects.

Results

Reconstruction was successful in all five cases, with consolidated phalanx and good cosmetic results. All donor sites could be closed directly.

Conclusion

Reconstruction with dorsoradial forearm flaps is a reliable procedure which causes minimal trauma. Thus, it is an ideal approach for repairing cutaneous and phalangeal defects.

Objectives

This study aims to present long-term follow-up results of the reverse dorsolateral proximal phalangeal island flap designed for reconstruction of large fingertip and pulp defects.

Methods

We examined 18 patients who underwent reverse dorsolateral proximal phalangeal island flap surgery to address ≥2.5 cm fingertip and pulp defects. Mean follow-up was 84.4 months. Sensitivity assessments were conducted using the Semmes–Weinstein monofilament and 2-point discrimination tests. Additionally, we evaluated finger joint active range of motion, complications and cold intolerance.

Results

Mild venous congestion was observed in 5 flaps. Significant differences were observed in 2-point discrimination and Semmes-Weinstein monofilament tests between the injured and contralateral sides, specifically in the flaps, the dorsal side of the middle phalanx, and the donor site. The flap's mean static 2-point discrimination was 8.3 mm. Restricted distal interphalangeal joint extension was observed in 2 cases. Total active motion with the flap was good or excellent in the injured fingers, but with a significant difference between injured and contralateral fingers. Additionally, 42% of the injured fingers exhibited hook nail deformity, and 2 patients reported cold intolerance. Despite these issues, most patients has high scores for the appearance and satisfaction aspects of the Michigan Hand Outcomes Questionnaire.

Conclusion

In moderate or larger fingertip defects, the reverse dorsolateral proximal phalangeal island flap serves as an alternative for reconstructing both fingertip and pulp issues. However, this option involves sacrificing some sensation in the dorsum of the middle phalangeal finger and the donor area.

Level of evidence

IV, therapeutic study.