Search

Summary: Syndactyly is one of the most common congenital differences treated by hand surgeons. Although dozens of techniques for syndactyly release have been described, a reliable method is based on a dorsal rectangular flap for commissure construction and a combination of interdigitating zigzag flaps and skin grafts for digital coverage. In this article, the authors present a detailed description of syndactyly release emphasizing principles integral to successful outcomes., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Summary: Pollicization can be performed for secondary thumb reconstruction after traumatic injury or for primary thumb construction in cases of congenital thumb hypoplasia. Given the complexity of this operation, intimate familiarity with the involved anatomy and surgical principles is key to successful surgical outcomes. In this Video Plus article, the authors present a step-by-step approach to pollicization in case of Blauth type IIIB thumb hypoplasia., (Copyright © 2020 by the American Society of Plastic Surgeons.)

Background: Burn injuries commonly affect the hand, and the development of adduction contractures of the first web space is frequent and deleterious, both functionally and aesthetically. Many corrective techniques and algorithmic approaches have been described to treat this problem, but there is no consensus on the optimal management., Methods: A retrospective review at a single high-volume pediatric burn center was undertaken to evaluate the clinical course of these patients. All pediatric patients undergoing initial release of burn scar contracture of the first web space from 2005 through 2015 were included in a retrospective cohort study., Results: The authors identified 40 patients with 57 burned hands. The initial approach to management was variable. Z-plasty or other local flap was the first technique used in 28 hands (49 percent), split-thickness skin graft in 19 hands (33 percent), full-thickness skin graft in seven hands (12 percent), groin flaps in two hands (4 percent), and a reverse radial forearm flap in one hand (2 percent). The mean numbers of total reconstructive procedures per hand including the initial procedure were as follows: groin flap, 4.0; full-thickness skin graft, 3.1; split-thickness skin graft, 2.1; Z-plasty, 1.4; and reverse radial forearm flap, 1.0., Conclusions: Successful reconstruction of the first web space must be addressed in the context of the entire hand. It is the authors' preference to use split-thickness skin grafting whenever a skin deficiency is present-only then should leading edge contractures be addressed with Z-plasty. Based on their experience, the authors recommend five principles that are essential to successfully treat postburn contractures of the first web space., Clinical Question/level of Evidence: Therapeutic, III.

Background: Trigger finger, or stenosing tenosynovitis, is one of the most common conditions affecting the hand, yet its pathophysiology remains poorly understood, and genetic association studies of trigger finger are lacking. The purpose of this study was to identify single-nucleotide polymorphisms associated with trigger finger through a genomewide approach., Methods: The authors performed a case-control genomewide association study in the Partners HealthCare Biobank. Single-nucleotide polymorphism- and gene-based association analyses were carried out after quality control, imputation, and filtering., Results: Among 942 trigger finger cases and 24,472 controls, the authors tested 7,846,471 single-nucleotide polymorphisms for association with trigger finger. In the single-nucleotide polymorphism-based analysis, a single locus on chromosome 13 corresponding to KLHL1 met the genomewide significance threshold (lead single-nucleotide polymorphism rs59988404; OR, 1.74; 95 percent CI, 1.47 to 2.07; p = 1.99 × 10). After mapping, gene-based analysis demonstrated a significant association with POLE2 (p = 7.53 × 10) on chromosome 14. Among trigger finger cases, rs59988404 genotype was significantly associated with the total number of trigger finger procedures performed (p = 0.026)., Conclusions: In the first reported genomewide association study of trigger finger, the authors report significant associations of KLHL1 and POLE2 with risk of trigger finger. The authors' results may help to elucidate the pathophysiology of trigger finger and facilitate an individualized, precision-medicine treatment approach., Clinical Question/level of Evidence: Risk, III.

Background: Local health care facilities are often unequipped to treat complex upper extremity injuries, and patients are therefore transferred to designated trauma centers. This study describes the characteristics of patients transferred to a Level I trauma center for hand and upper extremity injuries and to investigate the accuracy of the provided diagnosis at the time of referral., Methods: Adult patients transferred from outside facilities to the authors' Level I trauma center by means of direct contract with the on-call fellow for the care of hand and upper extremity injuries were identified. Patient- and injury-related information was prospectively collected at the time of referral before patient transfer, and again following diagnostic evaluation by a hand surgeon at the authors' institution., Results: Sixty-three patients were transferred to the authors' hand surgery service from outside facilities after direct contact with the on-call fellow. Most patients were referred by emergency medicine physicians [n = 47 (76 percent)], followed by midlevel emergency department providers (physician assistant or nurse practitioner) [n = 12 (19 percent)] or hand surgeons [n = 3 (5 percent)]. Six patients were transferred directly from a Level I trauma center. Twenty-one transferred patients (33 percent) had an inaccurate diagnosis at the time of referral. Factors associated with an inaccurate diagnosis included trauma level of the referring hospital and diagnoses of infection or dysvascularity., Conclusions: The diagnostic accuracy for hand injuries transferred from outside facilities by means of provider-to-provider communication is imperfect, and some injuries are misdiagnosed. Hand surgeons should continue to improve the triage and transfer process for patients with acute hand surgery injuries., Clinical Question/level of Evidence: Diagnostic, IV.

Background: Many surgical techniques are used to treat symptomatic neuroma, but options are limited for digital neuromas because of a paucity of soft-tissue coverage and/or the absence of the terminal nerve end. The authors assessed factors that influence patient-reported outcomes after surgery for symptomatic digital neuroma., Methods: The authors retrospectively identified 29 patients with 33 symptomatic digital neuromas that were treated surgically. Patients completed the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity and Pain Interference scales, a numeric rating scale for pain, and the PROMIS Depression scale at a median follow-up of 7.6 years postoperatively (range, 3.2 to 16.8 years). Surgical treatment for neuroma included excision with nerve repair/reconstruction (n =13; 39 percent), neuroma excision alone (n =10; 30 percent), and excision and implantation (n =10; 30 percent). Multivariable linear regression was performed to identify the factors that independently influenced patient-reported outcomes., Results: The mean postoperative PROMIS Upper Extremity score was 45.2 ± 11.2, the mean Pain Interference score was 54.3 ± 10.7, and the mean numeric rating scale pain score was 3 (interquartile range, 1 to 5). Compared with other treatment techniques, neuroma excision with nerve repair/reconstruction was associated with lower numeric rating scale pain scores; lower Pain Interference scores, corresponding to less daily impact of pain; and higher Upper Extremity scores, reflecting better upper extremity function. Older age and higher Depression scores were associated with lower Upper Extremity scores and higher Pain Interference scores. Smoking was associated with higher Pain Interference and numeric rating scale pain scores., Conclusions: Neuroma excision followed by nerve repair/reconstruction resulted in better outcomes compared with neuroma excision alone with or without implantation. Patient age and psychosocial factors influenced patient-reported outcomes., Clinical Question/level of Evidence: Risk, III.

Background: Patients undergoing abdominal wall reconstruction are at increased risk of postoperative respiratory failure. Understanding the epidemiology of this complication may guide preventive efforts., Methods: The authors performed a population-based retrospective cohort study of adults undergoing elective abdominal wall reconstruction (ventral hernia repair with component separation) in the United States from 2004 through 2011 using the Nationwide Inpatient Sample., Results: Of 2283 patients undergoing elective abdominal wall reconstruction, 57 percent were women, with a median age of 57 years, median hospital stay of 5 days, and mean total cost of $23,730. Postoperative respiratory failure occurred in 212 patients (9.3 percent), 164 patients (7.2 percent) were discharged to a skilled nursing facility, and 18 patients (0.8 percent) died. On multivariate analysis, age, male sex, congestive heart failure, lung disease, obesity, and obstructive sleep apnea were independently associated with increased risk of respiratory failure. Respiratory failure was associated with significantly increased risk of death and discharge to a skilled nursing facility as well as significantly increased total cost and hospital length of stay., Conclusions: Respiratory failure is an uncommon but devastating complication of abdominal wall reconstruction. The authors report clinical risk factors that may facilitate perioperative risk-reduction strategies to improve outcomes of elective abdominal wall reconstruction., Clinical Question/level of Evidence: Risk, III.

Background: The pathophysiology of hypertrophic scarring is unknown in part because of the lack of a robust animal model. Although the red Duroc pig has emerged as a promising in vivo model, the cellular mechanisms underlying Duroc scarring are unknown, and the size and cost of Duroc pigs are obstacles to their use. Given the central role of the dermal fibroblast in scarring, the authors hypothesized that dermal fibroblasts from the Duroc pig exhibit intrinsic differences in key aspects of the fibroblast response to injury compared with those from the Yorkshire pig, a same-species control that heals normally., Methods: Duroc and Yorkshire dermal fibroblasts were isolated from uninjured dorsal skin. Actin stress fibers and focal adhesions were visualized by immunocytochemistry and transmission electron microscopy. Cell migration was measured using a scratch wound-closure assay. Contractile function was assessed by collagen gel contraction. Expression of scarring-related genes was determined by quantitative real-time reverse-transcriptase polymerase chain reaction, and transforming growth factor (TGF)-β1 protein expression was determined by Western blotting., Results: Duroc dermal fibroblasts display increased adhesion-complex formation, impaired migration, enhanced collagen contraction, and profibrotic gene and protein expression profiles compared with Yorkshire fibroblasts at baseline. In addition, Duroc fibroblasts overexpressed TGF-β1 and were less responsive to exogenous TGF-β1., Conclusions: Duroc dermal fibroblasts have inherent myofibroblastic differentiation that may account for the pathologic scarring in these animals. The authors' data further validate the Duroc model and support Duroc fibroblast cell culture as a simple, inexpensive, reproducible, and biologically tractable in vitro model for the study of fibroproliferative scarring.