PurposeComplex injuries of the hand with finger amputation can result in important functional impairment. If the amputated fingers cannot be replanted, the developed sequelae should be further evaluated. Sometimes, in the presence of a few remaining local vascular resources, the use of the flow-through technique can help in solving the problem. MethodsThis study retrospectively reviews 4 cases who underwent single or multiple fingers reconstruction with toe transfers by using true flow-through or flow-through conduit flaps. A thorough description of the two methods is done, and the quality of the regained functionality of the hand is presented. ResultsAll the patients were males, aged between 21 and 45 (median age 31.75). One of them injured the left dominant hand, and the other three their right dominant hand. The median time between the accident and reconstructive surgery was 14.5 months (range, 3 months-36 months). All the initial lesions were work-related trauma. One patient had severe sequela after forearm compartment syndrome and amputation of the thumb and fifth finger; one patient had a metacarpal hand, one patient had amputation of two fingers (2nd and 4th); and one patient had three fingers amputated (2nd, 3rd, and 4th). In the first patient, a true flow-through flap and a second toe transfer was done, and in the other three patients multiple toe transfers by using the flow-through conduit technique were used. A good functionality of the reconstructed hand was obtained in all the patients. ConclusionsToe transfer remains one of the best methods in the reconstruction of hands with missing fingers. The use of both true flow-through flap and flow-through conduit methods are very useful, especially in cases with few vascular resources.

PurposeThe indications for distal scaphoid excision are limited to localized wrist arthritis surrounding the scaphoid as a result of scaphoid nonunion advanced collapse or scapho-trapezio-trapezoid (STT) joint arthritis. The procedure historically has led to relief of symptoms and improvement in strength. Our aim was to examine the outcomes of this procedure in patients with scaphoid fracture nonunion. MethodsThis is a single-center retrospective case series of 12 consecutive patients who underwent distal scaphoid excision after scaphoid fracture nonunion. Patients were divided into two groups based on nonunion chronicity: chronic (more than a year) and non-chronic (less than a year). Clinical and radiographic data were examined using descriptive statistics. ResultsOur cohort consisted of 12 patients, 10 men (83%) and 2 women (17%), with a mean age 37.6±13.6 years. Eight patients had a chronic scaphoid fracture nonunion (6 had a neglected scaphoid fracture and 2 had a nonunion after scaphoid open reduction and internal fixation (ORIF) with bone graft) and 4 patients had non-chronic fracture non-union (2 had failed cast treatment and 2 had nonunion after scaphoid ORIF with bone graft). Pre-operatively, all patients complained of pain and 4 had numbness (all in chronic group). After an average 21 weeks post-operatively, 7 patients (58%) reported continued pain. Two patients reported ulnar side pain, one underwent arthroscopic synovectomy. All patients who started with normal radiolunate angle continued to have normal angle, whereas patients who had DISI prior to surgery persisted after surgery except for a patient who underwent midcarpal fusion and had their radiolunate angle corrected. ConclusionsDistal scaphoid excision is an effective procedure for carefully selected patients with periscaphoid wrist arthrosis. Patients with recent scaphoid fracture that failed treatment may also be treated with distal scaphoid resection.

BackgroundThe integration of artificial intelligence and machine learning technologies into the medical field has brought about remarkable advancements, particularly in the domain of clinical decision support systems. However, it is uncertain how they will perform as clinical decision makers. MethodsThis prospective cohort study evaluates the potential of incorporating ChatGPT-4 plus into the management of subcapital fifth metacarpal fractures. The treatment recommendations provided by ChatGPT-4 plus were compared with those of two control groups; the attending clinic plastic surgeon and independent expert panel. The primary outcome measures, operative or conservative, were compared between groups. Intra-class correlation of 0.61 infers moderate reliability in the consistency of recommended management plans across all groups. ResultsKey predictors for opting for operative management, regardless of the decision-maker, included clinical signs of scissoring, extension deficit, and radiographic evidence of intra-articular extension. ConclusionThese findings support the potential for AI applications in enhancing diagnostic and treatment decisions

Surgeons across all subspecialties had to adapt to the COVID-19 pandemic to triage patients and steward hospital resources. Hand surgeons found themselves in a unique position to move some hospital-based procedures to a clinic-based setting, which has now impacted their post-pandemic practices. Performing procedures in the clinic using the wide-awake local anesthesia no tourniquet technique is interestingly similar to minor-surgeries traditionally carried out in a general surgery clinic. By abstracting institutional case volumes from orthopedic, hand, and general surgery departments from 2019 to 2022, we identified trends that further support the potential for clinic-based procedures in hand surgery. This communication provides a foundation to compare cost and surgical indications for wide-awake local anesthesia across surgical disciplines.

PurposeThe purpose of this study was to determine the clinical results of carpal tunnel release using ultrasound guidance (CTR-US) at a minimum of 2 years post-procedure. MethodsThe study consisted of 102 patients (162 hands) treated with CTR-US by the same physician between June 2017 and October 2020 for whom minimum 2-year follow-up data were available. Questionnaires were sent to gather long-term information, with additional phone calls for clarification if needed. Outcomes included Boston Carpal Tunnel Questionnaire symptom severity (BCTQ-SSS) and functional status (BCTQ-FSS) scores, Quick Disabilities of the Arm, Shoulder, and Hand (QDASH) scores, global satisfaction scores, and subsequent surgeries. ResultsThe 102 patients included 68 females and 34 males with a mean age of 56.9 years at the time of surgery. Fifty-five (53.9%) patients had simultaneous bilateral procedures, 42 (41.2%) had unilateral procedures, and 5 (4.9%) had staged bilateral procedures. Significant improvements in BCTQ-SSS, BCTQ-FSS, and QDASH scores persisted at a mean final follow-up of 46 months (range 2-6 years). At final follow-up, 91.2% of patients reported satisfaction with the procedure. No outcomes were significantly different between those treated with simultaneous bilateral versus unilateral procedures. No revision surgeries were reported. ConclusionsCTR-US is a safe and effective procedure that results in significant improvements that persist up to 6 years post-procedure. Long-term results of simultaneous bilateral and unilateral procedures are similar. Level of EvidenceIV therapeutic

PurposeThe placement of multi-strand sutures during flexor tendon repair is complex and challenging. We developed a new, simpler nine-strand suture, which we term the Tajima nines. The Tajima nines repair method is a new odd-numbered strand tendon technique. MethodsFourteen porcine flexor tendons were transected and repaired using the Tajima nines repair method, without placement of peripheral sutures. This technique is a modification of the Lim and Tsai repair method; it uses a 4-0 monofilament nylon, three-strand line, and two needles. The repaired tendons were tested for linear, noncyclic, load-to-failure tensile strength. The initial gap, 2-mm gap-formation force, and ultimate strength were measured. ResultsThe initial gap-formation force was 27.9 ± 7.5 newtons (N), the 2-mm gap-formation force was 39.2 ± 4.7 N, and the ultimate strength was 76.7 ± 17.2 N. Eight, three, and three of the fourteen tendons repaired using the Tajima nines method demonstrated failure because of thread breakage, knot failure, and suture pull-out, respectively. ConclusionsThis biomechanical study demonstrated that Tajima nines repair was associated with particularly high initial tension at the repair site; there were minor variations in the initial load and 2-mm gap-formation load. Our results suggest that Tajima nines repair with peripheral suturing allows the repaired flexor tendon to tolerate the stresses encountered during early active mobilization. Clinical RelevanceThis simple nine-strand technique will be particularly useful for inexperienced surgeons who perform early active mobilization after primary flexor tendon repair, because the technique is a modification of the Lim and Tsai repair method using a triple strand instead of a double strand.