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Unlabelled: Common peroneal nerve palsy has been reported to be the most frequent lower extremity palsy characterized by a supinated equinovarus foot deformity and foot drop. Dynamic tendon transposition represents the gold standard for surgical restoration of dorsiflexion of a permanently paralyzed foot. Between 1998 and 2005, we operated on a selected series of 16 patients with traumatic complete common peroneal nerve palsy. In all cases, we performed a double tendon transfer through the interosseous membrane. The posterior tibialis tendon was transferred to the tibialis anterior rerouted through a new insertion on the third cuneiform and the flexor digitorum longus was transferred to the extensor digitorum longus and extensor hallucis longus tendons. All 16 patients were reviewed at a minimum followup of 24 months (mean, 65 months; range, 24-114 months). The results were assessed using the Stanmore system questionnaire and were classified as excellent in eight, good in five, fair in two, and poor in one. Postoperative static and dynamic baropodometric evaluations also were performed. The proposed procedure, which provides an appropriate direction of pull with adequate length and fixation, is a reliable new method to restore balanced foot dorsiflexion correcting the foot and digit drop and producing a normal gait without the use of orthoses.Level Of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Articular comminuted fracture dislocations of the base of the middle phalanx represent a major challenge for the surgeon. The treatment goal is a nonpainful, stable, and functional proximal interphalangeal joint, which is achieved through concentric joint reduction and restoration of joint stability. Fracture pattern rarely results in sagittal bone loss involving the entire ulnar or radial pilon of the base of the second phalanx. In these cases, the choice of treatment can be particularly challenging as the loss of a pillar of the articular base causes angular deviation at the joint level, thus causing the loss of finger joint flexion and overlap of the adjacent finger. We present a novel nonvascularized osteochondral graft, which we named hemi- hemi -hamate osteochondral graft , a modified version of the traditional hemi-hamate arthroplasty, that is suitable for the reconstruction of bone loss involving the whole anteroposterior hemiarticular surface of the base of the P2., (© 2023 The Authors.)

Introduction: The appearance of a symptomatic neuroma following finger amputation is a devastating consequence for patient's quality of life. It could be cause of chronic neuropathic pain. The prevention of neuroma formation is a challenging effort for hand surgeons. The biological mechanisms leading to neuroma formation are mostly unknown and different preventing procedures have been tried without certain results. In this paper, a panel of Italian hand surgeons have been asked to express appropriateness about potentially preventive techniques of neuroma formation following the RAND/UCLA appropriateness protocol., Methods: A literature review was preliminarily performed identifying the most employed methods to reduce the pathologic nerve scar. Afterwards, the selected panelists were asked to score the appropriateness of each procedure in a double scenario: in case of a sharp amputation or in a tear injury. The appropriateness was evaluated according to RAND/UCLA protocol., Results: Nine Italian hand surgeons were included in the panel. Of them 5 were orthopaedic surgeons, 4 plastic surgeons. The identified appropriate procedures were: revision amputation should be done in operating room, the neurovascular bundles should be identified and is mandatory to treat surrounding soft tissues. Only in case of clean-cut amputation, it is appropriate to perform a proximal extension of the dissection, to use diathermocoagulation and coverage with local flaps. Procedures such as shortening in tension of the nerve stump, bone shortening, implantation of the nerve end in the soft tissue, treatment in the emergency room and, in both scenarios, certain results are evaluated as uncertain., Discussion: In order to prevent the formation of a distal stump neuroma few methods were judged appropriate. It is mandatory to identify the neurovascular bundles and treat also the surrounding tissues, but no certain results could be obtained with local flap, bone shortening and other ancillary surgical acts. Moreover, it is not possible to guarantee the non arising of neuroma in any cases, also when every procedure has been temped., Conlusions: The prevention of distal neuroma is actually a challenge, without a well known strategy due to the variability of response of nervous tissue to injury., Competing Interests: Declaration of Competing Interest All authors declare no conflict of interest., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Suprascapular nerve (SSN) entrapment is usually ascribed to static or dynamic compression. When no cause of compression is found, SSN entrapment is defined as idiopathic. Focal hourglass-like constriction (H-LC) of the SSN that results in muscle paralysis represents an unusual condition that may be misinterpreted and erroneously diagnosed as SSN entrapment or as neuralgic amyotrophy., Methods: With the aim of finding clinical and surgical clues that could differentiate the traditional form of idiopathic SSN entrapment from the rare H-LC, a series of 6 cases of SSN palsy caused by H-LC is presented., Results: All but 1 supraspinatus muscle recovered M5 muscle strength. The Constant shoulder score was excellent in 3 patients, good in 1, fair in 1, and poor in 1., Discussion: If a diagnosis is not made in time, H-LC may evolve from mild to severe nerve torsion that may require a shift in surgical procedure from epineurotomy and external neurolysis to focal resection and suture. If an incorrect therapy is chosen, the chance of recovery might be definitively compromised with the persistence of muscle palsy. Conversely, when SSN palsy persists despite notch decompression, especially when it is performed with a limited open approach or arthroscopically, concerns about the real etiology and location of nerve compression responsible for the nerve palsy may arise., Conclusion: When approaching SSN pathology, H-LC should be considered as a potential cause of nerve palsy, as it may represent a contraindication for a limited open approach or arthroscopic decompression., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

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., (© Georg Thieme Verlag KG Stuttgart · New York.)

Isolated collateral ligament ruptures in the metacarpophalangeal joints of the fingers seem to be more frequent than described. For ligament repair, dorsal access is generally described, but the proper method by which to proceed inside the joint is unclear and left to the surgeon's discretion and experience. With the technique we propose, it is possible to explore the interior of the joint from the top, allowing an easy and complete examination of the entire length of the ligament. This proposed method allows for a better identification of the lesion and the area of ligament reinsertion, facilitating technical decision-making, and reducing the operating time.

Purpose: Although vein conduits filled with fresh skeletal muscle have been used to bridge nerve defects both experimentally and clinically with good results, this approach has never been considered a valuable tool for reconstruction of nerve defects, and the technique has been abandoned. The purpose of this study was to evaluate the application of muscle-in-vein conduits for secondary digital nerves reconstruction, with particular emphasis on the surgical technique and results., Methods: We present a retrospectively selected consecutive series of 21 digital nerve defects in 17 patients who were treated with vein conduits filled with fresh skeletal muscle for secondary nerve reconstruction. After a minimum follow-up of 18 months, all patients were studied with static and moving 2-point discrimination, Semmes-Weinstein monofilament testing, Visual Analog Scale, and Disabilities of the Arm, Shoulder, and Hand questionnaire. Outcome data were stratified according to the American Society for Surgery of the Hand guidelines, the modified Highet and Sander's criteria, and the Logic Tree., Results: The average nerve gap bridged with the muscle-in-vein conduit was 2.2 cm (range, 1-3.5 cm). We classified 14 of 22 reconstructed nerves as excellent or good according to American Society for Surgery of the Hand guidelines, whereas 17 were between S4 and S3 using modified Highet and Sander's criteria. The Logic Tree yielded results between S4 and S3 in 14 of 21 reconstructed nerves. The average Disabilities of the Arm, Shoulder, and Hand survey scores were 22.5 for the disability/symptoms module and 21.4 and 17 for the sports/music and work subcomponents, respectively., Conclusions: Use of muscle-in-vein conduits should be considered and promoted for sensory nerve reconstruction for a number of reasons: the encouraging results with the technique; the abundant availability of both donor tissues; the flexibility of the conduit resulting from the combination of muscle and vein; the simplicity with which tubes can be fashioned; immunological compatibility; and the absence of adjunctive costs., Type of Study/level of Evidence: Therapeutic IV., (Copyright 2010 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

In contrast with previous research, it was recently demonstrated that hourglass-like constriction is not exclusive to the elbow region. We present a report of a patient who had an axillary nerve and a suprascapular nerve hourglass-like constriction, found 7 years apart.

Translation of laboratory results to the patient is a critical step in biomedical research and sometimes promising basic science and preclinical results fail to meet the expectations when translated to the clinics. End-to-side (ETS) nerve regeneration is an example of an innovative neurobiological concept, which, after having generated great expectations in experimental and preclinical studies, provided very conflicting results when applied to clinical case series. A number of basic science studies have shown that ETS neurorrhaphy, in fact, is able to induce collateral sprouting from donor nerve's axons, allowing for massive repopulation of the distal nerve stump. Experimental studies have also shown that ETS neurorrhaphy can recover voluntary control of skeletal muscles and that voluntary motor function recovery can be achieved both with agonistic and antagonistic donor nerves, thus widening the potential clinical indications. However, clinical case series reported so far, did not meet these promises and results have been rather conflicting, especially regarding repair of proximally located mixed nerves. In contrast, ETS reconstruction of distal sensory nerve lesions led to a more positive outcome and, most importantly, consistent results among international centers carrying out clinical trials. Concluding, ETS is a promising microsurgical approach for nerve coaptation, based on a convincing and innovative neurobiological concept. However, conflicting clinical results and disagreement among surgeons regarding its employment suggest that this technique should still be considered an ultima ratio, reserved for cases where no other repair technique can be attempted. New data coming from neurobiological research will help further enlarge the clinical indications of ETS nerve reconstruction, explain the different results found in laboratory animals and humans, and contribute to new treatments and rehabilitation strategies aimed at improving the efficacy of nerve regeneration after ETS neurorrhaphy.

Four patients with severe contracture of the first web space were treated with an anterolateral thigh perforator flap. The flap size ranged from 10 to 13 cm in length and from 7 to 8 cm in width. The donor site was closed directly and thinning of the flap was performed in all cases. All flaps survived and there were no re-explorations. Web space opening was maintained over the follow-up period. There was an average postoperative increase of the angle of the first web space of 61 degrees. The thinned anterolateral thigh flap provides a pliable vascularized tissue for resurfacing the skin after release of severe contracture of the first web space and represents a reliable alternative to other flaps.

Background: Perforator flaps have been introduced for various kinds of reconstruction and resurfacing; in particular, the free thin anterolateral thigh flap is becoming one of the most preferred options for reconstruction of soft-tissue defects., Methods: Between 1999 and 2002, the authors used this flap as a free flap for nine cases for covering hand defects after burn, crushing injuries, or severe scar contracture release. There were eight men and one woman, the mean age of the patients was 31 years, and the size of the flaps ranged from 7 x 3.5 cm to 15 x 9 cm; thinning was performed in all flaps., Results: All flaps survived completely, and the donor site was closed directly in seven cases; in two cases, the exposed muscle was covered with split-thickness skin graft., Conclusions: The anterolateral thigh flap was thin enough for defects on the dorsum and/or palm of the hand and for first web reconstruction after scar contracture release. It has many advantages in free flap surgery including a long pedicle with a suitable vessel diameter, and the donor-site morbidity is acceptable. The thin anterolateral thigh flap is a versatile soft-tissue flap that achieves good hand contour with low donor-site morbidity.

A heterodigital neurovascular reverse-flow flap island flap for extensive pulp defects is described. A dorsolateral flap from the middle phalanx, based on the digital artery, is harvested from the adjacent uninjured finger. The common digital artery between the injured finger and the donor finger is ligated and transected just before its bifurcation. At this point the 2 converging branches of the digital arteries can be entirely mobilized as a continuous vascular pedicle for the flap. The vascularization is now supplied by reverse flow through the proximal transverse digital palmar arch of the injured finger; to provide sensation, the dorsal branch of the digital nerve from the donor finger must be included in the flap. This technique is indicated for large pulp defects with bone exposure of index and middle finger pulps, which are important for sensation.

In the past 12 years, 16 thumb defects at, or distal to, the interphalangeal joint were reconstructed using a great toe mini wrap-around flap. A flap including the entire nail and most of the distal phalanx of the great toe was used. Fifteen of the grafts survived. The sensory recovery of the reconstructed thumb was good as assessed by 2-point discrimination test with an average of 10 mm (range 5-15), and there were no complaints of cold intolerance. This technique results in good cosmetic appearance, and all patients were pleased with the cosmetic aspect of the thumb and there was no significant morbidity at the great toe donor site. The final decision to reconstruct a distal thumb amputation is influenced by gender, job, and age of the patients. The great toe mini wrap-around flap is an excellent reconstruction technique in selected patients.

Vascularized bone graft is most commonly applied for reconstruction of the lower extremity; indications for its use in the reconstruction of the upper extremity have expanded in recent years. Between 1993-2000, 12 patients with segmental bone defects following forearm trauma were managed with vascularized fibular grafts: 6 males and 6 females, aged 39 years on average (range, 16-65 years). The reconstructed site was the radius in 8 patients and the ulna in 4. The length of bone defect ranged from 6-13 cm. In 4 cases, the fibular graft was harvested and used as a vascularized fibula osteoseptocutaneous flap. To achieve fixation of the grafted fibula, plates were used in 10 cases, and screws and Kirschner wires in 2. In the latter 2 cases, an external skeletal fixator was applied to ensure immobilization of the extremity. The follow-up period ranged from 10-93 months. Eleven grafts were successful. The mean period to obtain radiographic bone union was 4.8 months (range, 2.5-8 months). Fibular grafts allow the use of a segment of diaphyseal bone which is structurally similar to the radius and ulna and of sufficient length to reconstruct most skeletal defects of the forearm. The vascularized fibular graft is indicated in patients with intractable nonunions where conventional bone grafting has failed or large bone defects, exceeding 6 cm, are observed in the radius or ulna., ((c) 2004 Wiley-Liss, Inc.)

Ring avulsion injuries have long presented complex management problems. Despite microsurgical advances, it is difficult to achieve good functional results in complete degloving injuries or amputations, and their management remains somewhat controversial. Ten patients with class IV injuries according to Kay's classification were treated from 1986 to 2000. In this study the authors subdivided class IV injuries into those with amputation distal to the insertion of the flexor digitorum superficialis tendon (class IVd, 5 cases); those with amputation proximal to the insertion of the flexor digitorum superficialis tendon (class IVp, 3 cases); and complete degloving injuries leaving the tendons intact (class IVi, 2 cases). Replantation was done in class IVi and class IVd injuries, and 6 cases were revascularized successfully. In all these patients range of motion was complete at the metacarpal and proximal interphalangeal joints, but reestablishing sensibility was more difficult. Patients with class IVp injuries were treated by surgical amputation of the digit. Modifications of Kay's classification system based on anatomic injury is more predictive of functional outcome for completely amputated ring avulsion injuries. The authors conclude that complete ring avulsion amputations are salvageable, with acceptable functional results in select patients.

Fingertip injuries can be treated in different ways, including shortening with primary closure, skin grafts, and local or distant flaps. Nail bed involvement complicates fingertip reconstruction and may influence the choice of treatment. Local flaps can usually replace the pulp and provide a satisfactory functional and aesthetic result, whereas reconstruction of the fingernail apparatus is more difficult. In the period between 1998 and 2001, 12 fingertip injuries with nail bed involvement were treated with a combination of local flaps (Tranquilli-Leali and Venkataswami flaps) and the eponychial flap. The eponychial flap described by Bakhach is a backward cutaneous translation flap that lengthens the nail plate and restores a good appearance of the nail apparatus. This technique is simple to use and can be used with different flaps for pulp reconstruction.

This study reports results in 12 patients treated with "completely vascularized single-stage approaches," so defined because skin, tendon, and nerve are transferred as a compound flap, and all are vascularized. A free dorsalis pedis cutaneotendinous flap was used in 7 patients, while a radial forearm cutaneotendinous island flap was transposed in 5 patients. A dorsalis pedis flap provides four vascularized extensor tendons (extensor digitorum comunis tendons), and the radial artery flap permits the inclusion of one completely vascularized tendon (palmaris longus) and two "strips" of vascularized tendons (flexor carpi radialis and brachioradialis). The flaps survived in all cases, and the transferred tendons were functioning well. The dorsalis pedis flap can be employed in the reconstruction of cutaneotendinous defects of the dorsum of the hand which require the use of three or four tendons grafts. We suggest the use of forearm cutaneotendinous flaps in cases of reconstruction of one or two extensor tendons. The "completely vascularized single-stage reconstruction" avoids prolonged hospitalization and results in a rapid restoration of near-normal function and appearance of the hand., (Copyright 2003 Wiley-Liss, Inc.)

The reconstruction of complex cutaneous tendinous dorsal hand injuries represents a problem that is not easy to solve. The transferral in a single surgical stage, with a single flap, of skin, tendons, and nerves, all completely vascularized, is probably the ideal solution. Between 1988 and 1999 the one-stage reconstruction method was used in 13 patients. A cutaneous tendinous dorsalis pedis free flap was used in 7 cases, and a cutaneous tendinous radial forearm island flap with an inverted flow was used in 6. The dorsalis pedis flap allows for the inclusion of 4 tendons that are completely vascularized (extensor digitorum communis), while the radial flap allows us to completely insert a single tendon (palmaris brevis) and two vascularized tendinous strips taken from the flexor carpi radialis and from the brachioradialis. All of the flaps transferred survived perfectly with good functional recovery. One-stage reconstruction that is "completely vascularized" allows us to reduce the amount of time spent in hospital, the number of operations, and above all it provides cosmetic and functional results that are close to normal. The dorsalis pedis flap is indicated in cases of cutaneous tendinous dorsal hand injuries that require the simultaneous reconstruction of three or four extensor tendons. On the other hand, the radial flap may be used in situations where it is necessary to reconstruct only 1 or 2 tendons.