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Professor Caroli always aspired to the creation of a single European hand surgery federation, combining the individual national societies in Europe. Caroli inherited from Bonola the great passion for hand surgery and he became Professor of Orthopaedic and Hand Surgery at the University of Modena in 1981. Professor Caroli authored over 200 scientific articles and one of the most beautiful monographs of hand surgery I "The Hand" i (available in Italian only). [Extracted from the article]

(1) Background: Osteoid osteoma (OO) is one of the most common benign bone tumors. This type of osteogenic tumor is generally characterized by a well-defined lytic area with a vascularized central nidus surrounded by sclerosis and bone thickening. The wrist and hand bones are infrequent sites for osteoid osteoma: only 10% of the cases arise in these areas. Standard treatments are surgical excision and radio-frequency ablation (RFA), both with advantages and disadvantages. This study aimed to compare the two techniques to prove if RFA could be a potential alternative to surgery in the treatment of OO of the hand. (2) Methods: Patients treated for OO of the hand between January 2011 and December 2020 were evaluated and data was collected regarding the lesions' characteristics and the treatment outcome. Each patient was followed up for 24 months and VAS pain (Visual Analogue Scale), DASH (Disability of the Arm, Shoulder and Hand), and PRWE (Patient-Related Wrist Evaluation) scores were collected. (3) Results: A total of 27 patients were included in the study: 19 surgical and 8 RFA. Both treatments showed a significant improvement in pain and functionality. Surgery was associated with a higher complication rate (stiffness and pain), while RFA was associated with a higher recurrence rate (2/8 patients). RFA allowed for a speedier return to work. (4) Conclusions: We believe that osteoid osteoma treatment with RFA in the hand should be an available alternative to surgery as it allows rapid pain relief and a swift return to work. Surgery should be reserved for cases of diagnostic uncertainty or periosteal localization. [ABSTRACT FROM AUTHOR]

Background: Multiple techniques for corrective osteotomy have been developed in recent years with the same aims: to improve the radiographic parameters and improve motion, pain and grip strength. Volar fixed-angle plates have added a new concept to the treatment of distal radius fractures thanks to the low morbidity of the surgical approach and the strength of the final construct, allowing early mobilization and return to function. Materials and methods: Between 2005 and 2012, 20 patients with symptomatic dorsally malunited extra-articular fractures of the distal radius underwent corrective osteotomy using a volar locking plate without additional bone graft. At a mean follow-up of 50 months, all the patients were clinically and functionally evaluated. Results: All measurements of pain, final range of motion and grip strength significantly improved compared with preoperative measurements. The mean preoperative DASH score reduced from 54 points preoperatively to 25 postoperatively. Based on the modified Mayo wrist score, we obtained 14 excellent and six good results. Palmar tilt improved from an average of 23° to 11°. Radial inclination improved from an average of 29° to 22°, and ulnar variance decreased from an average of 3.6 mm to 0.9 mm. There were two cases of transient median neuroapraxia that resolved before the 6-week follow-up appointment. No other major complications, including non-union and infection, were observed. Conclusion: The volar approach and locking plate, without necessarily the use of bone grafting, proved to be an effective approach for addressing symptomatic and even severe deformities of the distal radius. Type of study/level of evidence: Therapeutic IV [ABSTRACT FROM AUTHOR]

Background: Implants based on the polyetheretherketon (PEEK) polymer have been developed in the last decade as an alternative to conventional metallic devices. PEEK devices may provide several advantages over the use of conventional orthopedic materials, including the lack of metal allergies, radiolucency, low artifacts on magnetic resonance imaging scans and the possibility of tailoring mechanical properties. The purpose of this study was to evaluate the clinical results at 12-month follow-up using a new plate made of carbon-fiber-reinforced polyetheretherketon for the treatment of distal radius fractures. Materials and methods: We included 40 consecutive fractures of AO types B and C that remained displaced after an initial attempt at reduction. The fractures were classified according to the AO classification: 21 fractures were type C1, 9 were type C2, 2 were type C3, 2 were type B1 and 6 were type B2. Results: At a 12-month follow-up no cases of hardware breakage or loss of the surgically achieved fracture reduction were documented. All fractures healed, and radiographic union was observed at an average of 6 weeks. The final Disabilities of Arm, Shoulder and Hand score was 6.0 points. The average grip strength, expressed as a percentage of the contralateral limb, was 92 %. Hardware removal was performed only in one case, for the occurrence of extensor tenosynovitis. Conclusion: At early follow-up this device showed good clinical results and allowed maintenance of reduction in complex, AO fractures. Type of study/level of evidence: Therapeutic IV. [ABSTRACT FROM AUTHOR]

Introduction: The purpose of this retrospective study is to compare the clinical, functional outcome and complications occurrence between tension band wiring (TBW) and plate fixation both for simple and comminuted displaced olecranon factures. Materials and methods: Between January 2005 and June 2012 (minimum 1-year follow-up), 78 consecutive patients with Mayo type IIA and IIB fractures were treated with the following methods: tension band wire or plate and screws fixation. The primary outcome of this study was the functional outcome, assessed by the following self-administered evaluation scales: the disabilities of the arm, shoulder and hand, and the Mayo Elbow Performance Score. Secondary outcome measures included the assessment of pain level, analysis of passive range of motion, and the occurrence of any early or late complications. Results: Comparing the clinical results between the two groups, at mean 33 months follow-up, no significant differences in the functional and clinical outcome were observed. Complications were reported in 48 and 17 % of cases, following TBW and plate fixation in patients treated for type IIA fractures, and similarly in 40 and 23 % of cases in type IIB fractures, respectively. Hardware removal was more frequently performed in TBW group: 38 versus 17 % for type IIA fractures and 20 versus 6 % for type IIB fractures. Conclusions: The findings of this study indicate that both with the use of TBW and plate fixation excellent/good clinical outcomes with minimal loss of physical capacity, little pain and disability can be obtained in the majority of patients with simple and comminuted displaced olecranon fractures. Hardware removal was most frequently observed after TBW. Level of evidence: Therapeutic IV. [ABSTRACT FROM AUTHOR]

Digital trauma amputations and digital agenesis strongly affect the functionality and aesthetic appearance of the hand. Autologous reconstruction is the gold standard of treatment. Unfortunately, microsurgical options and transplantation procedures are not possible for patients who present contraindications or refuse to undergo transplantation from the toe (e.g. toe‐to‐thumb transplantation). To address these issues, osseointegrated finger prostheses are a promising alternative. The functional assessments registered during follow‐up confirmed the promising outcomes of osseointegrated prostheses in the treatment of hand finger amputees. This review outlines (a) a detailed analysis of osseointegrated finger metallic components of the implants, (b) the surgical procedures suggested in the literature, and (c) the functional assessments and promising outcomes that demonstrate the potential of these medical osseointegrated devices in the treatment of finger amputees. [ABSTRACT FROM AUTHOR]

Background: The incidence of median nerve injuries in pediatric elbow dislocations is approximately 3% and avulsion of the open medial epicondylar epiphysis in the pediatric population is one predisposing factor that may explain this age predilection. These lesions can be difficult to diagnose in the acute phase because symptoms tend to be mild or delayed, consequently their management can be challenging and functional outcome poorer.Methods: We present the case of an unrecognized median nerve entrapment in a 16-year-old boy with posterior dislocation of the elbow and a medial epicondyle fracture, treated initially with close reduction and open stabilization with a cannulated screw. Assessment is supported by a review of similar reported cases available in literature.Results: We discuss the diagnostic approach and the surgical options that can be used for this type of injury.Conclusions: High clinical suspicion of entrapment is imperative in presence of signs of damage to the median nerve in the pediatric patient immediately after the reduction of an elbow dislocation. If diagnosis of entrapment is made the therapeutic choice between neurolysis and nerve graft depends on the lesion severity. In the presence of a Fourrier's type 4 lesion, neurolysis should be avoided, while nerve resection and grafting are recommended. [ABSTRACT FROM AUTHOR]

Background: Clinical manifestations of camptodactyly are varied and no official consensus on the etiopathogenesis or best treatment is available. Conservative treatment is generally preferred and, in refractory patients, surgery might be considered. However, reported results of surgery are often unsatisfactory and it is difficult to compare outcomes as different classification systems are adopted. We reported the outcomes of surgical treatment of camptodactyly with the Malek cutaneous approach and stepwise release, assessed using the Siegert classification. Methods: A retrospective analysis of paediatric patients (≥1 and ≤18 years) with congenital camptodactyly refractory to conservative management (flexion contracture >30°), treated with Malek cutaneous approach and stepwise release surgery between June 2009 and June 2019 with at least 1 year of follow-up was performed. Pre- and post-operative clinical and radiographic assessments were evaluated for degrees of flexion contractures and early (<30 days) or late (>30 days) complications were recorded. Results: A total of 59 patients underwent surgery, of whom 38 (64%), including 42 fingers, were enrolled; mean patient age was 8 years (range 1–18). Post-operative mean flexion contracture was significantly improved (p > 0.001) and no infections were recorded. Mean follow-up was 6 years (range 1–10) and proximal interphalangeal joint extension deficits were rated according to Siegert classification as excellent (69%), good (12%), or fair (9.5%) and poor (9.5%). Conclusions: The Malek cutaneous approach and stepwise release of the retracting soft tissues allow prompt evaluation of the anatomical structures involved in the deformity and seem to be an effective surgical correction in the long term. Level of Evidence: Level IV (Therapeutic) [ABSTRACT FROM AUTHOR]

Clinical study of a series of ten patients treated between 2004 and 2009 for non-unions of the ulna. The patients have been treated with osteosynthesis using a dynamic compression plate and biological enhancement of the consolidation using bone graft and autologous platelet injection. The follow-up consisted of clinical and radiographic assessment. Functional scores used were the Visual Analogue Scale (VAS) for pain and the Disability Assessment for the Shoulder and Hand (DASH) questionnaire. The mean time of follow-up was 21 months. Considering both clinical and radiological criteria, bony union was achieved in 9/10 cases on average time of 4 months. According to the system of Anderson, 5 patients provided an excellent result, 2 a satisfactory result, 2 an unsatisfactory result and 1 treatment resulted in failure. At follow-up, the mean VAS score for pain in the upper limb was 1 (range, 0-4) at rest and 2 (range, 0-7) during activities. The physical function and symptoms of the upper limb, evaluated with the DASH questionnaire, scored 17 points. In conclusion, at a mean 21 months follow-up, there was high success regarding both forearm alignment, clinical and functional results. The use of three combined methods provides high success regarding both radiological and clinical results, even if we have no information on the prevalent efficacy of one particular method. [ABSTRACT FROM AUTHOR]

Purpose: The emerging role of the locking plate improved the technique also in corrective osteotomies in Madelung's deformity, but there is a lack of analyses between the fixation techniques, as well as little information in functional outcomes and long-term follow-up. The current study compared the outcomes, pitfalls, and advantages of volar plate and screws fixation versus K-wires fixation in a long-term follow-up. Methods: Twenty-eight children presenting the "distal radius" variant of Madelung's deformity underwent Vickers ligament release and distal radial dome osteotomy between 2009 and 2015. Twenty-three children (20 females and 3 males, mean age 15 years and 7 months at surgery and 24 years and 8 moths at follow-up), with 26 operatively treated wrists, were available for follow-up. A retrospective two-cohort study, evaluating clinically and radiologically results, has been conducted with a mean eight years and seven months follow-up. Results: Bone union and pain relief were obtained in all cases, as well as improvements in wrist motion and radiographic indices. A statistically significant correlation was identified between the volar plate fixation and an improved lunate subsidence on X-ray, and a trend towards an improved DASH score in the cohort with plate and screws, as well as significant improvement in wrist extension and supination always in the plate fixation cohort. Conclusions: The long-term follow-up enabled the patients to report on more definitive outcomes in terms of functional and cosmetic improvements. Volar plate fixation is an effective technique allowing for simple post-operative management and earlier rehabilitation program with improved clinical and radiographic outcomes. [ABSTRACT FROM AUTHOR]

We present a case of a 22-year-old patient with an important expansive neoformation of the soft tissues near the proximal phalanx of the fourth finger of the right hand. There was no evidence of past direct traumas, wounds, or local infections. The Rx, CT scan and MRI exams showed a lesion of the soft tissues measured around 3 × 2 × 2.8 cm, without hinting at a connection with the bone structure with a hypointense signal in T1 and an isointense signal in T2. First diagnostic speculations pointed at a giant cell tumor of the tendon sheath (GCTTS). Since there seemed to be no indication of a malignant tumor, it was decided to execute an excisional biopsy on the patient, rather than an eco-guided core needle. The imaging studies of the histological characteristics showed spindle-shaped elements with low-grade atypia, fibromyxoid and osseous stroma in different maturity stages, and always delimited by osteoblast cells. Osteoclastic giant cells were also found, as well as foci of osseous metaplasia peripherally aligned around proliferating cell aggregates. Considering all the following data, the final diagnosis clearly indicated a fibro-osseous pseudotumor of digits (FOPD). At the last checkup after 6 months, the wound healed correctly and without any restriction in finger movement. Level of evidence: Level V, diagnostic study. [ABSTRACT FROM AUTHOR]

Purpose: Piezoelectric bone surgery was already extensively used in a number of surgical procedures ranging from dental to maxillofacial surgery. The authors aimed to determine whether piezosurgery was suitable and advantageous for performing osteotomies in Hand and Plastic reconstructive surgery. Methods: The authors overviewed a variety of applications for Piezosurgery® Device, from Mectron, in bone reconstructive surgery with over the last 8 years. An overall number of 156 bone cutting procedures in adults and children was described at the phalanges, metacarpal bones and distal radius level, as well as in bone graft harvesting and bone remodeling following carpal scaphoid nonunion, scapho-lunate bone-ligament-bone reconstruction and fibula free flap in maxillofacial defects. Results: The consolidation rate was 87.5% in scaphoid nonunion grafting and fixation. Bone healing was achieved in all other cases. No intra-operative complications were recorded. Conclusion: Piezosurgery® allowed high precision in bone cutting as well as custom-made graft and surface roughness were obtained, while preserving nerves, vessels and tendons integrity. The instrument may be handling moved into the surgical space in absence of vibrations, with a clear view onto the bone. The mechanical and biological characteristics of the piezoelectrical effect perfected this technique as an effective and useful instrument in Hand and Plastic surgery. The selective bone cutting properties avoided injuries to the surrounding soft tissues and thermal damage of the bony cells. Best advantages were described in feasibility and flexibility for intra-articular osteotomies, custom-made grafts and reconstructive microsurgical techniques. [ABSTRACT FROM AUTHOR]

Peripheral Nerve Sheath Tumors (PNSTs) are extremely uncommon and it is almost certain that no individual upper limb surgeon will gain great experience in a lifetime with these lesions. Benign and malignant PNSTs are separately analyzed in this descriptive review and discussed focusing the attention towards the most important features. A comprehensive and summarized overview of this topic is offered to the reader in order to improve the complex management of these tumors from diagnosis to treatment. A systematic search in PubMed was carried out using the keywords (and synonyms) written below in order to find relevant and most cited papers. Reckoning the rarity of the pathology, few selected case reports were taken into account. A compendium of each PNST was created to sum up the personal experience of the Authors who wrote the articles, critically inspected and analyzed. Every section of the paper is meant to provide useful tips to the reader. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to compare the outcomes of patients undergoing two different dorsal capsuloplasty techniques, the senior author modified Viegas' and the Berger's ones in order to determine which of them could provide the best functional outcome, while also improving the radiological findings at long-term follow-up. Methods: This retrospective study included a population of 40 patients suffering from chronic partial scapho-lunate ligament injury corresponding to type III in Geissler's classification. Patients were divided into two groups of 20 patients each where group A underwent Viegas' capsuloplasty while group B underwent Berger's one. Pre- and postoperative evaluations included patients' related wrist/hand evaluation test, grip strength test, radio-lunate and scapho-lunate angles analysis, and flexion-extension range of motion evaluation. Statistical analysis was performed. Both capsuloplasty techniques evaluated represent an effective treatment for chronic partial lesions of the SL ligament (Geissler type III). Results: Both techniques resulted in resolution of pain with significant improvement of all clinical, functional, and radiological parameters, although there were marked differences between them. Indeed, higher recovery of autonomy, grip strength, wrist flexion, and reduction in the scapho-lunate angle were observed in patients that underwent Viegas'capsuloplasty. Moreover, both work and sport resumption rates were higher even though the difference wasn't statistically significant. Conclusions: By direct comparison between the two techniques, it emerged that the modified Viegas' capsuloplasty was more effective than Berger's in terms of recovery of grip strength, disability, shooting of the wrist joint (especially flexion), and correction of the carpal angles (particularly the scapho-lunate angle). We believed that the modified Viegas' technique may be regarded as a better choice for the treatment of chronic partial lesions of the SL ligament (Geissler type III). Level of evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

This case report aims to point out the importance of having in mind anatomical variation in the blood supply to the hand even in emergency settings. A 39-year-old patient presented at our emergency department with a wound on the distal anterolateral third of the left forearm with skin loss, degloving injury of the thumb starting from the 1st metacarpal, exposure of the proximal two thirds of the 1st metacarpal bone, and both radial and ulnar digital arteries of the thumb damaged. A 10-cm-long vein graft was anastomosed in termino-later fashion between the dorsal branch of the radial artery and the uninjured distal part of the ulnar collateral digital artery of the thumb, successfully re-establishing its blood supply. Starting from the 1st postoperative day, the thumb was warm and pink while the other fingers were pale and capillary filling was absent. An urgent arteriography of the left upper extremity demonstrated the presence of normal radial artery, hypoplastic ulnar artery, dominant median artery, and absence of vascularization of the 2nd, 3rd, 4th, and 5th fingers. By the end of 2nd week, the patient underwent amputation of the four fingers at the distal metacarpal level. Anatomical anomalies of hand arterial blood supply are not uncommon, even though rarely reported in literature. Therefore, an instrumental study should be performed before attempting any arterial intervention even in emergency settings. Nevertheless, further studies should be performed to identify ready-to-use tools to make surgeons aware of any anatomic variations in order to avoid such complications.Level of Evidence: Level V, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Intra-articular incarceration of the epicondylar fragment occurs in 5-18 % of all cases of medial epicondyle fracture. It requires stable fixation to allow early motion, since elbow stiffness is the most common complication following medial epicondyle fracture. In this retrospective study, we report the clinical and functional outcomes and the complications that occurred following open reduction and screw fixation of medial epicondyle fractures with intra-articular fragment incarceration. Methods: Thirteen children who had a fracture of the medial epicondyle with incarceration of the fragment in the elbow joint (type III) were surgically treated in our university hospital between 1998 and 2012. There were eight male and five female patients. The mean age at the time of injury was 13 years (range 9-16). Operative treatment consisted of open reduction and internal fixation with one or two 4.0-mm cannulated screws under fluoroscopic control. Results: All of the patients were clinically reviewed at an average follow-up of 29 months. The overall range of motion limitation was about 5° for flexion-extension and 2° for pronation-supination. The score was excellent in all patients (mean 96.3). Complications occurred in four (31 %) children: two cases of symptomatic screw head prominence, irritation with partial lesion of the distal triceps myotendinous junction in one patient, and median nerve entrapment syndrome in one patient. Conclusions: In conclusion, open reduction and screw fixation yielded excellent clinical and functional outcomes for the treatment of medial epicondyle fractures with intra-articular fragment incarceration. However, particular attention is should be paid when treating these potentially serious injuries in order to minimize the risk of possible complications. Level of evidence: Therapeutic IV. [ABSTRACT FROM AUTHOR]

Purpose: There is no consensus on the optimal treatment of bony mallet finger in the paediatric population due to a lack of studies in children. The Ishiguro technique is simple and less invasive, and treatment with K-wire fixation seems to provide better results for extension lag in bony mallet finger according to the literature. A retrospective cross-sectional study with long-term follow-up was performed to evaluate the functional and clinical outcomes of this method in children. Preoperative and intraoperative predictors of outcome were investigated., Methods: From June to December 2022, we evaluated 95 children who underwent extension K-wire block from 2002 to 2012. Eighty-four children were included (mean age 14.8 ± 1.68 years) for a mean long-term follow-up of 11.6 ± 2.3 (8-16) years. Clinical and radiographic features were assessed. Pain and functional outcomes were assessed using Crawford criteria, range of motion (ROM) at the distal interphalangeal joint (DIPJ), loss of extension, and VAS scale. Univariate and multivariate regressions were used to assess which variables might predict the worst outcomes at long-term follow-up., Results: Bone union and pain relief were always achieved. There were no complaints of potential growth impairment or nail deformity. 82.1% of patients showed excellent and good results. Fifteen patients had fair results., Conclusions: Although there are currently no significant differences between surgery and orthosis in adults, the Ishiguro technique is more effective in children when it comes to outcomes in the treatment of mallet fingers. A high percentage of excellent and good results were achieved, and no epiphyseal damage or nail deformity was reported. A strong and significant correlation was found between the worst outcomes and either delayed treatment time or excessive flexion angle., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

The fingertip is a complex anatomical structure that is frequently injured, especially in manual workers. Different classifications have been reported, considering injury orientation, level and geometry. To optimize treatment planning, the area of soft-tissue defect should be considered. Treatment aims to conserve as long a finger as possible, restore sensation (S3 + or more) and ensure a pleasant esthetic appearance. When amputation occurs, the best treatment is replantation when conditions allow. When this is not possible, the fingertip should be used as a composite graft or the nail complex can be grafted and soft tissue reconstructed, according to the preferred method. In defect without amputation or if the distal part of the finger is not present or not useful, many reconstructive techniques have been described. Depending on the injury, patient characteristics and requirements and the surgeon's skills and experience, the treatments vary from secondary healing to free flaps. In this paper, the various treatment options are described and discussed. Nowadays, considering most variables, the best treatment in fingertip injury is secondary healing with occlusive or non-occlusive dressing, even in case of bone exposure. This simple solution is able to restore a nearly normal fingertip with good sensation without further injuring the hand., (Copyright © 2024 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Purpose: Injuries of the scapholunate ligament (SL) and of the triangular fibrocartilage complex (TFCC) represent the main ligament injuries of the traumatic wrist. A double injury of the SL and TFCC ligaments is quite common in the trauma setting, and clinical examination is fundamental. MRI allows to detection of a TFCC and SL ligament injury, but wrist arthroscopy is still the gold standard for diagnosis. We present the clinical results of the combined reconstruction of chronic scapholunate ligament and TFCC injury., Materials and Methods: Fourteen patients were treated at our hospital with a combined scapholunate ligament and TFCC complex repair. All patients were surgically treated by the same senior author, after a diagnostic arthroscopy that revealed a lesion of both structures. A comparison between the pre-operative and post-operative pain and function was carried out using VAS, Disability of Arm, Shoulder and Hand score (DASH) and Patient-Related Wrist/Hand Evaluation score (PRWHE). Wrist range of motion and strength were also compared following surgery., Results: All patients had a mean follow-up of 54 months. A statistically significant improvement was observed both with the reduction in pain (VAS from 8.9 to 5) and with the improvement of functionality scores (DASH from 63 to 40 and PRWHE from 70 to 57) and with the increase in ROM and strength. In only one patient (7%), because of pain and instability, a supplement operation was needed (Sauve-Kapandji procedure) 3 months after the initial surgery., Conclusions: The simultaneous repair of the SL and TFCC complex has shown a good success rate in both decreasing pain and regaining functionality., (© 2023. The Author(s), under exclusive licence to Istituto Ortopedico Rizzoli.)

Objectives: To carry out a radial forearm flap, the radial artery is usually harvested, incurring severe donor site morbidity. Advances in anatomical knowledge discovered constant radial artery perforating vessels, enabling the subdivision of the flap into smaller components suitable for a wide range of differently shaped recipient sites, with marked reduction of downsides., Material and Methods: Eight pedicled or free shape-modified radial forearm flaps were used to reconstruct upper extremity defects between 2014 and 2018. Surgical technique and prognosis were examined. Skin texture and scar quality were assessed on the Vancouver Scar Scale while function and symptoms on the Disabilities of the Arm, Shoulder and Hand score., Results: At a mean follow-up of 39 months, no cases of flap necrosis, impaired hand circulation or cold intolerance were found., Conclusion: The shape-modified radial forearm flap is not a new technique, but is poorly known by hand surgeons; in contrast, our experience showed it to be reliable, with acceptable functional and esthetic outcomes in selected cases., (Copyright © 2023 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Fingertip amputations represent an important spectrum of injuries, and most are avulsions or crush trauma. There is no consensus about one single standard treatment, and a wide number of techniques are available. The authors present the P3 flap as an option for covering fingertip defects with bone exposure, avoiding painful scars in the pulp area, without a donor site. This study included 12 fingertips with amputated segment not available for replantation. Volar oblique fingertip defects and transverse amputations with bone exposure, not more proximal than Hirase Zone IIB, were included. Defects were less than 2 cm. The patients were followed up for an average of 6 months. The aesthetic and functional outcomes and fingertip discrimination recovery were evaluated at 6 months by the static two-point discrimination (2-PD) test and DASH score (quick version). The average postoperative 2-PD test at 6 months was 5.9 mm (range from 5 to 8 mm). The mean healing time of the fingertip was 4 weeks. Nail deformity was reported in three cases with level IIB of amputation. None of the P3 flaps failed, and local infection was not reported. The average DASH score at 6 months was 1.1. The mean time to return to work was 38 days (range from 30 to 53). The P3 flap proposed in this study demonstrates a reliable single-stage technique, performed under local anesthesia, for fingertip defect reconstruction, avoiding skin incision and scars in the pulp region and preserving digital length and nail bed., Competing Interests: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: Scapholunate ligament injury is the most common cause of carpal instability. This retrospective case series aimed to assess the effectiveness and the maintenance of the results obtained by reconstructing the scapholunate ligament with a bone-ligament-bone autograft through an arthroscope-assisted minimally invasive approach., Methods: Thirty-six patients were enrolled initially but only 31 constituted the final population study (23 male, eight female; median age, 38 years; age range, 18 to 55 years). Radiographic (posteroanterior and true lateral radiographs to assess the scapholunate gap, radiolunate, and capitolunate angles; computed tomographic scan; magnetic resonance images), functional [grip strength (Jamar test and pinch test), active range of motion], and subjective (patient-rated wrist evaluation test) outcome measurements were collected. Minimum follow-up was 50 months., Results: Grip strength and wrist mobility were significantly improved from the preoperative values and improved over time. No scapholunate synostosis or carpal bone necrosis was observed. No wrist showed any sign of arthrosis or progression towards wrist instability. Only four patients had scapholunate gap greater than 3 mm., Conclusions: The proposed technique for scapholunate reconstruction, providing a biologic reconstruction of both the volar and dorsal portion of the scapholunate ligament and avoiding extensive capsulotomy, obtained significant functional outcomes improvement that was maintained over time and prevented degenerative changes to the articular surfaces., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2022 by the American Society of Plastic Surgeons.)

The increasingly cost of health care is a relevant problem as well as prolonged waiting time for admission also in emergencies. Effective cost containment measures and expenditure controls are needed to achieve and maintain clinical and organizational appropriateness. Outpatient management has proven to be the most useful method for lower-cost treatment in less severe pathologies, requiring surgery without hospitalization. The current study provided to evaluate how this model was successfully applied also to the paediatric population in hand surgery. Methods. A retrospective cohort study of 645 patients from 8 to 18 years (mean age 14.9) was performed in children treated in outpatient setting from 2015 to 2019. The direct costs were evaluated as well as the mean waiting time for surgery, comparing the data with the previous five-year period. The mean reduction in waiting time for children emergencies was 57% (from 72 to 31 h) due to the Outpatient setting into a dedicated Day-Surgery Service organizational model. The visual graphed data showed a general clear growing trend towards outpatient surgery in adults and children. The overall effect was a 29.2% of reduction in spending between expected and achieved costs, recovering resources toward the increasing technology and innovation expenditures. Outpatient paediatric hand surgery was an effective and attractive option which leaded to decreased individual and social costs, with increased clinical and organizational appropriateness. Thus, reduced delay in treatment and provided benefits for children and familiars., (© 2021. Istituto Ortopedico Rizzoli.)

This article summarizes the current views and proposed approaches to treating soft tissue defects of the hand. The article also outlines some key considerations of digital reconstruction. There are many options in treating soft tissue defects. For defects of the hand, local flaps are primarily considered if the defects are small or moderate in size. A vascularized free flap is only considered for a defect of large size (3 cm long or larger). Thumb reconstruction is of primary importance, while reconstruction of two fingers is necessary when all fingers are lost. Reconstructions of a missing distal part of a finger or reconstruction of an entire finger if only one finger is lost are cosmetic restorations; functionally these defects do not need reconstruction. Sensation is of great importance in repair or reconstruction of the tip of the thumb or finger. Therefore, sensory evaluation is a key factor in assessing and selecting the best options of surgery.

Background: Although hand and upper limb malformations are quite frequent, up to now very few reports have been published on epidemiology. The aim of this study is to evaluate the number of infants who presented with hand and upper limb malformations from 2010 to 2015 in Italy. Methods: A retrospective analysis of a pediatric population presenting with hand and upper extremity malformations was carried out, gathering reports achieved from eight Italian Centers of pediatric hand surgery. Other factors such as gender, date and region of birth, family distribution of malformations and associated syndromes, were analysed. Results: Out of 3,100,421 live births, 765 children presented with hand and upper limb malformations. The incidence was 2,5/10,000 live births with a predominance of males and the right side. Radial polydactyly was the anomaly with the highest percentage, closely followed by simple syndactyly, simbrachidactyly and complex syndactyly. Less common conditions were the triphalangic thumb, thumb in palm, proximal radioulnar synostosis and Sprengel deformity. Inheritance of and familial predisposition to those malformations was recorded in 25 cases, while 84 children presented with syndromes related to hand anomalies. Conclusions: In conclusion the incidence of hand and upper extremity malformations in Italy is lower than that registered in other countries. The retrospective nature of the study combined with the fact that some defects frequently evade pediatric hand surgeon consultations are some possible limitations of the study. However, our data confirmed that, in spite of the decrease in the birth rate in Italy, the trend of congenital hand disorders maintained a stable trend. We aim to integrate this study with a prospective analysis and to involve the institutional health authorities in other countries so as to register the correct incidence of hand and upper extremity defects.

Purpose: This retrospective study analyses the effect performing veins anastomoses before arteries anastomoses in digital replantation., Patients and Methods: 38 adult patients with replantation of 12 thumbs and 39 fingers, in whom the veins anastomoses were performed prior to the arteries anastomoses, were compared with 29 patients with replantation of 9 thumbs and 30 fingers, in whom the arteries anastomoses were done first, with respect to the survival rate, total active motion, grip strength, and duration of the replantation., Results: There was no significant difference between the two groups with respect to the survival rates, total active motion, and grip strength, while the duration of the replantation was significantly shorter in patients, in whom the veins anastomoses were performed prior to the arteries anastomoses (2 hours and 50 minutes versus 3 hours and 42 minutes; p < 0.001)., Conclusion: Performing veins anastomoses before arteries anastomoses in digital replantations reduces the replantation time significantly without influencing the survival rate and the clinical outcome., Competing Interests: Each author declares that he or she has no commercial associations (e. g. consultancies, stock ownership, equity interest, patent/licensing arrangement etc.) that might pose a conflict of interest in connection with the submitted article., (Thieme. All rights reserved.)

Background: We present the case of a 22 y.o. male patient suffering from scaphoid non-union with avascular necrosis of the proximal pole and initial degenerative arthritis., Case Report: He referred to our institution with functional impairment and persistent pain (VAS 8\10). The patient underwent the positioning of the small size Adaptive Proximal Scaphoid Implant (APSI), without fixation, through an open dorsal approach and radial styloidectomy. The post-operative course was uneventful, and the patient could resume his daily routine without limitations. 5 years later the patient returned to our department referring a dorsal perilunate dislocation on the same hand. Unexpectedly no implant dislocation occurred and we were able to reduce the perilunate dislocation maintaining the same implant. At 30-month follow-up the patient was pain free (VAS 0\10) with almost completely recovered function of the hand and wrist., Conclusion: In order to minimize implant dislocation, both an adequate scaphoid resection and the choice of the right implant size (which should be lightly downsized compared to the scaphoid resection) are of paramount importance. At the same time, the capsuloplasty should be carefully performed at the right tension, providing adequate stability to the implant. This technique provided satisfactory functional results in a long-term follow-up, even in a young and active patient. Moreover, it does not preclude or complicate the possibility of resorting to different surgical procedures in case of necessity, whilst maintaining the same implant.

Purpose: Piezoelectric bone surgery was already extensively used in a number of surgical procedures ranging from dental to maxillofacial surgery. The authors aimed to determine whether piezosurgery was suitable and advantageous for performing osteotomies in Hand and Plastic reconstructive surgery., Methods: The authors overviewed a variety of applications for Piezosurgery ® Device, from Mectron, in bone reconstructive surgery with over the last 8 years. An overall number of 156 bone cutting procedures in adults and children was described at the phalanges, metacarpal bones and distal radius level, as well as in bone graft harvesting and bone remodeling following carpal scaphoid nonunion, scapho-lunate bone-ligament-bone reconstruction and fibula free flap in maxillofacial defects., Results: The consolidation rate was 87.5% in scaphoid nonunion grafting and fixation. Bone healing was achieved in all other cases. No intra-operative complications were recorded., Conclusion: Piezosurgery ® allowed high precision in bone cutting as well as custom-made graft and surface roughness were obtained, while preserving nerves, vessels and tendons integrity. The instrument may be handling moved into the surgical space in absence of vibrations, with a clear view onto the bone. The mechanical and biological characteristics of the piezoelectrical effect perfected this technique as an effective and useful instrument in Hand and Plastic surgery. The selective bone cutting properties avoided injuries to the surrounding soft tissues and thermal damage of the bony cells. Best advantages were described in feasibility and flexibility for intra-articular osteotomies, custom-made grafts and reconstructive microsurgical techniques., Competing Interests: Conflict of InterestAll the authors declare they have no financial interests, no commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangement, etc.) that might pose a conflict of interest in connection with the submitted article., (© Indian Orthopaedics Association 2021.)

Introduction: The authors discuss challenges in extensor function restoration at the finger level following distal posterior interosseous or tendon complex injuries, according to the typologies of lesions or the specific patient requirements., Materials: The authors report on two cases describing challenging resolutions. One patient with EDC lag from zone 6B to 8 requiring FCU prolonged with cadaveric grafts.  One young patient with distal posterior interosseous lesion requiring selective tendon transfers to EPL and EIP to restore selective and autonomous index extension., Results: In both cases the main goals were obtained, achieving high index of patient satisfaction and excellent outcomes with the restoration of the extension of the fingers.  Conclusions: In distal posterior interosseous nerve lesion, high demanding patients may require selective function to restore fine motor skills, such as autonomous index extension. In extensor tendons loss of substance from zone 6 to 8, involving musculotendinous junction proximally and short remnants distally, by-pass tendon transfer prolonged with cadaveric grafts is required. The authors highlight the techniques available as escape plan according to the necessary solutions.

The pivot flap can treat volar oblique defects of the fingers distal to the distal interphalangeal joint. We present our experience in 11 fingers (11 patients) using this flap, including some modifications that optimize flap harvesting, mobilization, inset, and vascular supply and outcomes. The flaps harvested had an average size of 2.4 × 2.0 cm. The patients were followed for an average of 21 months (range 12 to 36) after surgery. Sensitivity of the flap was evaluated with the Semmes-Weinstein monofilaments test and static two-point discrimination test. Cold intolerance was also evaluated. The pivot flap with the modifications demonstrates a reliable technique for fingertip defect reconstruction. The results, in terms of sensitivity and functional recovery, seem promising. Level of evidence: IV.

The treatment of chronic scapholunate ligament tears in patients with high demand, such as young athletes, is difficult as traditional techniques are associated with some loss of wrist motion and grip strength. This retrospective investigation studied young athletes (≤20 years old) with chronic scapholunate ligament lesions and a minimum follow-up of 24 months, treated with a modified Viegas dorsal capsuloplasty. Twenty-six young athletes (mean age 17 years) were included. A partial scapholunate ligament tear (Geissler III) was seen in 25 patients. At the last follow-up, a significantly different improvement was seen in all measured parameters and all patients could return to their original competitive activity, within 6 months (range 4-12) after surgery. Level of evidence: IV.

Vascular anomalies are mainly divided into two groups: vasoproliferative/vascular neoplasms (e.g., hemangioma), and vascular malformations (VMs). The main difference between the two resides in the histopathological assessment, while vascular tumors are true neoplasm, typically congenital with rapid postnatal growth, and eventual slow regression; VMs have a single endothelial cell lining, tend to be regarded as acquired despite being congenital in nature, can undergo sudden and massive growth, miming neoplastic proliferation. Arteriovenous malformation (AVMs) are one type of fast flow VMs, with a four-stage natural history, and potentially disruptive evolution. Magnetic resonance is the gold-standard for diagnosis and pre-operative planning while computer tomography is particularly valuable for AVMs involving bones, and selective angiography can define source / draining vessels for sclerotherapy and surgical planning. Given their unpredictable evolution, AVMs shouldn't be treated until symptomatic, complicated, or aesthetically unacceptable. Surgical resection should be preceded by arterial embolization from 24 to 72 hours, which must be extensive in order to reduce the risk of recurrence. Pain due to ischemic condition is one of the most common and debilitating symptoms of AVM, while gassosus gangrene is the most feared complication as they can become pabulum for bacteria overgrowth eventually resulting in necrotizing fasciitis. Given their clinical evolution, VMs pose physicians at great challenge in identifying the best-suited treatment for each case. It is of paramount importance to be able to make accurate diagnosis, understand the basic physiology, and use appropriate diagnostic and treatment modalities to optimize outcome. Proper multidisciplinary approach along with constant psychological support is the basis for a successful final outcome. Aim of this work was to provide a deeper insight into these relatively uncommon pathology and related hardship that afflicts both patients and their families.

Malunion can occur in 11 to 28% of Distal Radius Fractures and can result in radius shortening and ulnar plus with wrist deviation, pain and disability. We aimed to report particular cases of extra-articular distal radius fracture malunion with severe radial deviation and ulnar plus treated by corrective osteotomy of distal radius with bone graft associated to ulnar procedure. One of these patients was firstly operated with ulna subtraction osteotomy synthesized with plate and in a second stage with distal radius corrective addition osteotomy with homologous bone graft, plate and external fixator. Two other cases were treated in a single-step by radius addition osteotomy and caput ulnae Darrach resection. These three patients were followed-up from 2 to 12 years, successfully observing the maintenance of anatomical correction and recovery of ROM and strength with good pain relief and return to daily activities. After Darrach procedure external-fixation wasn't needed and pronation-supination was better. Darrach procedure can solve ulna plus and improve ROM in pronation-supination with a quicker healing, avoiding the risk of ulnar non-union. Darrach's procedure associated to addition corrective osteotomy of distal radius can be a valid treatment for distal radius severe malunion, in patients with low-moderate functional demand. In conclusion, the surgeon should choose the right corrective treatment after the complete evaluation of the patient and his functional needs.