Ray Resection Research Articles

Utility of synthetic electrospun fiber matrix in general surgery: From head to toe

BackgroundTo highlight the role of a novel synthetic electrospun fiber matrix in the treatment of high-risk wounds across a range of etiologies. MethodsThis was a retrospective study of patients at a single institution who underwent complex wound care treatment with at least 1 application of the electrospun fiber matrix from January 2021 to December 2022. Information regarding patient demographics, wound size and etiologies, pertinent medical history, and treatment outcomes was collected. ResultsTwenty-one patients with 24 complex wounds who received synthetic electrospun fiber matrix treatment were identified. Nineteen patients (22 wounds) met the inclusion criteria for analysis. Patient mean age was 63.58 ± 15.20 (range 34–90) years. A wide range of wound etiologies was represented, including transmetatarsal amputation secondary to frostbite (n = 1), post-Mohs defect (n = 2), acute trauma (n = 3), surgical dehiscence (n = 3), infected implanted medical device (n = 2), chronic ulcers (n = 3), partial ray resection (n = 1), pilonidal cyst (n = 1), rattlesnake bite (n = 1), necrotizing soft-tissue infection (n = 1), and others (n = 2). A total of 17 of 19 (89.5%) patients were observed to meet their individual clinical goals after application of the wound matrix. Wound ages ranged from 1 to 429 days before initial synthetic electrospun fiber matrix application. ConclusionThe synthetic nature of the matrix limits the risk of inflammatory response and is well tolerated, which demonstrates initial proof of concept of synthetic electrospun fiber matrix treatment in a variety of complex wounds. The positive results observed across this mixed etiology surgical analysis should be replicated in future controlled, single-etiology studies to further confirm the utility of the electrospun fiber matrix in the surgical setting.

A Prospective Comparative Study of Ray Resection versus Amputation through Proximal Phalanx for Nonviable Digits of Upper Limb

Abstract Background Finger amputations aim at preserving function and optimizing cosmesis. The crucial decision here is whether to preserve a stump or to do a ray amputation. The present study aimed to compare the functional outcome and postoperative quality of life after ray amputation or amputation through the proximal phalanx. Methods A prospective study was conducted from January 2019 to June 2020 in patients requiring single-finger amputation through the proximal phalanx or metacarpal. Patients were divided into two groups; Group A: amputation through the proximal phalanx and Group B: ray amputation of the finger. The following functional parameters were assessed: grip strength, hand circumference, palmar volume, and webspace span. The Michigan Hand Outcomes Questionnaire (MHQ) score was employed to score hand function and aesthesis at 6 months in both hands. Results Thirty patients were enrolled. Findings in 26 patients (52 hands) were subjected to further analysis, 12 in Group A and 14 in Group B. Patients in both groups lost grip strength significantly compared with their contralateral normal hands (29.22 ± 14.88 [Group A] and 34.57 ± 19.12 [Group B]); however, it was statistically nonsignificant between the two groups. There was reduced mean palmar circumference in both groups' involved hands, but the decrease in circumference was statistically significant, only for Group B. Group B patients scored better in all the six subscales of the MHQ; however, only the Aesthetics score was significantly superior. The operated hand's webspace span increased significantly with respect to the normal contralateral web by a mean of 4.55 mm. Conclusion The study concluded that both the surgical options for the level of amputation should be discussed with the patients in detail, taking into account their occupational and personal requirements. Our study findings will help to objectively counsel the patients regarding expectations in functional and aesthetic outcomes following either technique.

Anatomy, evolution, and clinical aspects of the superextended-intercompartmental-supraretinacular artery perforator flap (SISAP-flap): A proof of concept

BackgroundExtended soft tissue defects of the fingers—irrespective of their origin—are challenging to treat. In cases of missing amputates or crush injuries, the options are often limited to further amputation, ray resection, or free tissue transplantation. The SISAP-flap was developed to add an extra option to treat finger avulsion injuries or otherwise extended soft tissue finger defects. MethodsCadaveric SISAP-flaps were individually dissected, tested for arterial perfusion using red ink and radiopaque dye, and transposed into artificially created same-size defects. After introducing this flap in the clinic, which was partially successful in the first patient, we modified the flap to its definite design. ResultsAverage cadaver flap size ranges between 11 cm and 22 cm in length, allowing dorsal wrapping of the flap over the fingertip and way back to the palmar metacarpophalangeal-joint. The flap is based on the distal web space perforator, which is commonly used by a dorsal metacarpal artery flap and supercharged using an intercompartmental, supraretinacular artery. Donor sites were closed primarily with little tension. Application of the flap in the clinic resulted in satisfactory functional and esthetic outcomes. ConclusionThe SISAP-flap is a new option for the reconstruction of extended finger defects and should be added to the reconstructive surgeon’s armamentarium of pedicled flaps, providing relatively short operating times and promising clinical outcomes.

Ray resection in pediatric population after trauma injuries.

The aim of this study is to assess the functional, emotional, and social adaptation of pediatric patients submitted to a hand ray resection to treat a traumatic hand injury. Retrospective study of pediatric patients undergoing hand ray resection, in the period 2013-2022, performed in two hospital institutions. Inclusion criteria: age less than 18 years, primary/secondary resection due to traumatic etiology and follow-up time of more than 1 year. Data concerning demographic information, lesion location, traumatic mechanism and surgical description were collected. Functional outcomes (QuickDASH Score), social and emotional integration (PEDSQL) and satisfaction were evaluated. Seven patients were included, with male predominance (n = 4) and the right side was the most affected (n = 5). Median age at the time of surgery was 10 years (2-15). Primary ray resection, without previous revascularization, was performed in three patients. Secondary ray resection was performed in four patients. Three patients with an unsuccessful revascularization procedure attempt another patient with a sequela with severe deformity. All patients presented a good adaptation to daily living activities, with good pinch and grip function. The median follow-up was 4 years (min:1; max:9). The scores were collected on six out of seven patients. Median QuickDASH score of 14 (min:11; max:22), and PEDSQL[physical] of 95.31 (min:78.13; max:100) and PEDSQL[social] of 93.47 (min:66.3; max:100). Hand ray resection is a rare procedure in pediatric age and usually difficult for patients and parents to accept. However, it is a useful and safe technique that allows for an improvement in overall hand function and psychosocial readaptation in specific and selected cases. Level of evidence: Level of evidence IV - case series.

Should we resect more proximally? Outcomes of toe amputation versus ray resection in patients with infected diabetic ulcers and osteomyelitis. A preliminary study and new treatment algorithm

BackgroundThe treatment of severe diabetic toe infection complicated with osteomyelitis is often surgical. The decision on the level of amputation, when required, is difficult. Very few articles reported comparative outcomes between toe amputation and ray resection, and only in relation to the hallux. The aim of this preliminary report is to record the results of these procedures when performed on all toes. MethodsThis is a comparative retrospective study where the charts of a continuous series of 44 patients (48 procedures) with diabetic forefoot infection were analyzed. Only cases of severe infection with confirmed osteomyelitis were included. Two groups were compared based on the level of amputation: the toe amputation group (at and distal to the metatarsophalangeal joint) and the ray resection group (distal to tarsometatarsal joint). The primary outcomes were defined as osteomyelitis recurrence and re-amputation. ResultsOutcome comparison between toe amputation and ray resection; 47.3 % vs. 51.7 % had a recurrence of their osteomyelitis (p = 0.8), 36.8 % vs. 34.5 % had a re-amputation (p = 0.02). Re-amputation was needed in 25 % of cases following hallux/first ray index procedure while the same was required in 39 % of cases following lateral toes/rays index procedures (p = 0.4). Both primary outcomes were correlated to CDK, smoking and creatinine level. ConclusionsBone infection recurrence and re-amputation are highly prevalent in patients undergoing initial amputation for severe diabetic toe infection. A more aggressive approach in the form of a more proximal level of index amputation might be needed when treating severe toe infections with osteomyelitis in patients with diabetes.

Outcomes of Hallux Amputation Versus Partial First Ray Resection in People with Non-Healing Diabetic Foot Ulcers: A Pragmatic Observational Cohort Study.

There are few data comparing outcomes after hallux amputation or partial first ray resection after diabetic foot ulcer (DFU). In a similar context, the choice to perform one of these two surgeries is attributable to clinician preference based on experience and characteristics of the patient and the DFU. Therefore, the purpose of this study was to determine the more definitive surgery between hallux amputation and partial first ray resection. We abstracted data from a cohort of 70 patients followed for a 1-year postoperative period to support clinical practice. We also attempted to identify patient characteristics leading to these outcomes. Our results suggested no statistical difference between the type of surgery and outcomes such as recurrence of DFU and amputation at 3, 6, and 12 months or death. However, there was a statistically significantly increased likelihood of re-ulceration for patients with CAD who underwent hallux amputation (p = 0.02). There was also a significantly increased likelihood of re-ulceration for people with depression or a history when the partial ray resection was performed (p = 0.02). Patients with prior amputation showed a higher probability of undergoing another re-amputation with partial ray resection (p = 0.01). Although the trends that emerge from this project are limited to what is observed in this statistical context, where the number of patients included and the number of total observations per outcome were limited, it highlights interesting data for future research to inform clinical decisions to support best practices for the benefit of patients.

Ring Avulsion Injuries: About Three Cases And Review of the Literature

Ring avulsions are rare and represent a wide variety of soft tissue and bone injuries, ranging from circumferential lacerations with or without vascular involvement to complete amputations. Treatment options are variable and depend on the injury pattern as well as functional and aesthetic requirements. We hereby report three cases of ring avulsions in three young males; all classified Urbaniak III, two treated with a revision amputation and the other with intrapalmar ray resection. In last follow-up of 12 months, the three patients were satisfied with cosmetic as well as functional results.

Amputationen an den Fingern und der Hand

Revision amputation, ray amputation and narrowing of the hand can be indicated for pathological alterations of fingers and thumbs due to traumatic, inflammatory or vascular causes but also for functional deficits regarding mobility, sensibility, perfusion, and/or pain. Surgical amputation is considered if reconstructive options are no longer possible, not desired and are no longer meaningful with respect to effort and risks. Patients need to be informed about the expected deficits in function and esthetic appearance due to the amputation in advance. On the other hand, surgical amputations represent a good treatment option, for which the duration of treatment and scope are well estimated. Therefore, they are good options for patients with comorbidities, with concerns about extensive reconstructive surgery and with limited compliance. It is essential to respect anatomical and functional aspects to guarantee favorable surgical results and avoid complications, which might compromise the function of the hand beyond that which is unavoidable. The most frequent complications after creating a stump or ray resection are persistent pain, unstable skin and soft tissue conditions, mobility disorders, disturbing stumps without function, uncontrolled growth of nail remnants and recurrent inflammation.

The management of mirror foot polydactyly: A case report.

BackgroundMirror foot or mirror image duplication of the foot is an extreme form and very rare congenital anomaly. There are limited management recommendations, and most cases are treated before walking age. We present the clinical findings, surgical treatment, and results of a rare case of mirror foot polydactyly.Case presentationA five-month-old girl with bilateral mirror foot was referred to our orthopaedic department. She was born full-term by the caesarian section and there was no family history of similar skeletal abnormalities and no history of drug or radiation exposure during gestation. The child had eight toes on the right foot and seven toes on the left with fully developed metatarsal, proximal, middle, and distal phalanges. Radiographs confirmed the diagnosis of mirror foot with a full complement of normal lateral toes and three additional complete rays medial to the right foot and two additional complete rays medial to the left foot. The patient underwent ray resection and concurrent reconstruction of the medial arch of the foot. A medial longitudinal incision was used to excised the right medial three rays and left medial two rays. The target of this surgical intervention was for aesthetic or cosmetic reasons and enabling the patient to allow shoe wear.ConclusionMirror-foot abnormalities are distinctly uncommon entities and represent extreme forms of congenital duplication of the preaxial polydactyly spectrum. Treatment on age of five-month-old with medial longitudinal incision had a satisfying clinical and radiological results.

Knotless Webspace Reconstruction Technique for Central Metacarpal Ray Resections.

Ray amputations of the hand are procedures performed for traumatic injuries, infection, neoplasm, and certain deformities. When performed for the central digits, the gap created between the remaining digits can significantly impact hand function. Multiple deep transverse metacarpal ligament reconstruction techniques and bone transposition have been described to address this issue. The purpose of this case series is to describe a novel technique utilizing a knotless suture anchor reconstruction of the deep transverse metacarpal ligament after central digit ray amputation. We present a novel knotless suture anchor reconstruction technique through a single incision which allowed for an immediate range of motion. We present 2 cases where this technique was utilized with satisfactory cosmetic and functional outcomes. Knotless webspace reconstruction for central metacarpal ray resection reconstruction is technically simple and allowed for immediate motion with satisfactory cosmetic and functional patient outcomes. Level of Evidence: Level IV-therapeutic.

CHONDROSARCOMAS OF THE HAND: A REPORT OF THREE CASES

Chondrosarcoma of the hand is very rare. We report three observations of chondrosarcoma of the hand, which enable us to make a review of its pathology. The follow-up was up to 2 years.There were two women and one man with an average age of 48 years old (30, 85 and 31). The localisation was phalangeal in two cases and metacarpal in one case, one case followed for chondroma. The three cases were central. X-rays were characterized by the presence of lytic areas with calcifications and in one case, we showed a calcification in the peripheral tissue. Histological diagnosis was made by biopsy (grade 2 in two cases and grade 1 in one case). Treatment consisted of amputation of the finger in two cases. In the case of metacarpal localization, wide resection of concerned ray. The patients showed no local recurrence and no metastatic spread after 2 years.The chondrosarcoma in the hand may due to malignant change in a pre-existing chondroma. He is the most common malignant bone tumor of the hand. This shows that the diagnosis of a chondrosarcoma can only be made in the synopsis of the radiological, histological and clinical findings.The metastasis of hand chondrosarcomas is very rare but has been described. With regard to the local recurrence rate, the data in the literature varies between 11% and 50%. Conservative treatment is difficult due to the small size of the hand, which allows easy spread of the tumor from compartment to compartment.Despite the low metastatic potential of chondrosarcomas of the hand in comparison with other sites, ray resection or digital amputation is recommended to avoid local recurrence. In cases with only local excision, close follow-up is recommended.

Ray Resection for Recurrent Invasive Squamous Cell Carcinoma: A Case Report

Squamous cell carcinoma is the most common tumor of the hand. This malignancy requires unique treatment considerations; the surgeon and patient must balance retention of maximal functional capacity of the hand and minimization of the risk of recurrence and metastasis. Digital-sparing and digital-sacrificing therapies should be considered. Chance for cure, recurrence and metastasis risk, cosmetic concerns, and functional concerns should be addressed on a case-by-case basis. We report a case of a fifty-three-year-old man with cutaneous squamous cell carcinoma of his non-dominant hand. Ulceration and rapid growth of a long-standing lesion of the dorsal hand prompted evaluation and treatment. Over the course of a year, three separate surgeries including digital amputations and metacarpal resections were required to manage this recurrent and invasive malignancy. Seven years post-operatively, our patient retained a full, painless range of motion arc of the left thumb and ability to grip utilizing a functional brace. Treatment of squamous cell carcinoma of the hand is not always straightforward. High rates of local recurrence require negative margins and diligent postoperative surveillance. Digital sparing therapy should be considered to minimize functional impairment and maximize cosmesis. However, aggressive treatment and amputation must be considered for advanced disease and if pursued, should focus on maximization of functional capacity as one of the treatment goals.

Tenoarthrolysis after flexor tendon injuries

Normal function of the fingers and thumb depends on properly gliding flexor tendons and afree range of motion of the involved joints. This normal gliding function may be inhibited by adhesions due to damage of the tendon, tendon sheath and adjacent tissue. When digital function is still limited despite a long-term course of hand therapy and there are no signs of further improvement, surgical intervention should be considered. There are no absolute indications for tenoathrolysis of the flexor tendons. With respect to complications, such as secondary tendon rupture, loss of annular pulleys and scar formation, it is part of astepwise reconstructive concept including further procedures, such as staged flexor tendon reconstruction. Important preconditions for tenoathrolysis are motivation of the patient, the possibility of readily available and frequent postoperative follow-up hand therapy, healed fractures and osteotomy, mature soft tissue, intact tendons and gliding tissue. Preoperatively, amaximum passive range of motion of the involved joints should be achieved. During the operative procedure all adhesive tissue surrounding the tendon within and outside the tendon sheath is consistently resected preserving the annular pulleys as far as possible. Therefore, extensive approaches, arthrolysis, dissolution of unfavorable scar tissue, resection of scarred lumbrical muscles and annular pulley reconstruction are frequently necessary. Salvage procedures, such as arthrodesis, amputation, ray resection or multistage flexor tendon reconstruction are recommended in failed cases and should be considered even preoperatively. In order to retain the intraoperative functional improvement hand therapy for at least 3-6months should follow.

Factors associated with secondary ray amputation after initial finger amputation at the traumatic level

Objectives: To assess if surgeon specialty, demographics or injury-related variables are related to a second operation to convert a finger amputation at the level of injury to a ray amputation. Methods: We identified 869 patients that had a finger (non-thumb) amputation at the level of injury over a period between 2000 and 2015. Bivariable analyses were used to identify factors associated with a second operation for ray amputation. Results: Eighteen patients had secondary ray amputation (2.1%), 8 for stiffness and contracture, 5 for pain, and 5 for necrosis of the stump. Factors associated with secondary ray amputation include central finger, amputation at a more proximal part of the finger, and other injured fingers that were not amputated. Conclusion: A second operation for ray resection is uncommon after major trauma, more likely proximal and central, and usually for pain or dysfunction, in patients treated by both plastic surgery and orthopedic surgery trained hand surgeons.

Outcome of Ray Resection as Definitive Treatment in Forefoot Infection or Ischemia: A Cohort Study

Ray resection is frequently performed in cases of infection or ischemia, but the literature is scarce concerning its outcome as a definitive treatment. In this retrospective cohort study, we reviewed our cohort with transmetatarsal ray resection with a mean follow-up of 36.3 months. Reulcerations, transfer ulcers, and reamputations were determined. Risk factor analysis for revision surgery was conducted. Among 185 patients, 71 (38.4%) had revision surgery within a mean of 1.4 ± 2.6 years (range 2 days to 12.9 years), 22 (11.9%) had major amputations, 49 (26.5%) had minor amputations, 11 (5.9%) had same-ray reulceration, 40 (21.6%) had transfer ulceration, and 2 (1.1%) had both reulceration and transfer ulceration. Occurrence of a postoperative ulcer was statistically significantly associated with revision surgery (p < .01). In conclusion, metatarsal ray resection is a reasonable treatment option in cases of forefoot ischemia or infection to prevent major amputation but fails in 11.9%, and reulceration is associated with further revisions, making ulcer prevention paramount.

A Novel Approach to Ray Resection of the Hand

Ray resections have been a viable treatment option for patients with tumors, trauma, infection, vascular insufficiency, or other abnormalities of the hand since the procedure was described in the 1920s. The creation of a functional hand after central ray resection presents unique technical challenges: insufficient closure of the gap between the metacarpals bordering the resected ray can produce an enlarged space between remaining digits and potentially cause digital malrotation, both of which negatively affect hand function. The goal is to make the space between resulting fingers as close to normal as possible. A number of procedures were described to address this issue, but unfortunately, they can be technically onerous and may require prolonged immobilization, the use of internal hardware, or the use of temporary hardware requiring removal.We describe a technique for amputation of the affected ray at the proximal metacarpal metadiaphyseal flare and a concomitant closing wedge osteotomy to allow superior gap closure between the residual fingers while maintaining the structure of the carpus and alignment of the hand. This improves functional and aesthetic outcomes after central ray resection of the hand.

Indications, functional results and patient satisfaction after isolated second ray resection following traumatic injury: A retrospective review of 25 patients

Amputation of the second ray is a surgical treatment option when reconstruction and/or reimplantation fail. The aim of our study was to review the outcomes after transmetacarpal resection of the second ray following a post-traumatic injury and to assess indications, functional outcomes, and patient satisfaction. Between January 2003 and December 2013, 25 patients (6 women and 19 men with a mean age of 51 years) underwent transmetacarpal resection of their second ray after a post-traumatic injury. Sixteen patients were right-handed and 9 were left-handed. Injuries involved the dominant hand in 14 cases (60%). In order to differentiate patients with preserved index finger length preoperatively from those with a shorter, amputated index finger stump, patients were divided into 2 groups. Group 1 included those with an “intact finger” and Group 2 included patients with an “amputated stump”. Data collection, including patient satisfaction and functional outcomes, was performed at 83 months postoperative on average. Average length of follow-up was 7.0±1.0 years (range 5–12 years). Group 1 (intact finger) and 2 (amputated stump) included 15 and 10 patients, respectively. Six patients (24%) had primary ray amputation and 19 (76%) had secondary ray amputation. No surgical revision was necessary. In Group 1, the indications were purely functional in all but two cases, whereas aesthetic indications played a role in all patients in Group 2. The average total time off work was 3 months. There was no difference between Group 1 and 2 (P>0.05). However, patients with primary ray resection averaged 10 weeks of lost work compared to 17 weeks for secondary amputation. There was no functional difference between Groups 1 and 2. Scores for cosmetic appearance and patient satisfaction were higher in Group 2. In certain specific situations after complex hand trauma, transmetacarpal amputation of the second ray is indicated as soon as possible, in order to reduce the time off work. Patient satisfaction following this surgical procedure is high, especially in groups with amputated stumps. A 30% decrease in pinch and grip strength is the rule. No secondary surgery is normally required.

Extended ray resection for sarcoma of the hand: long-term survival and functional results.

In this retrospective study, we analysed the long-term oncological and functional results after extended ray resection for sarcoma of the hand. Recurrence-free and overall survivals were calculated using the Kaplan-Meier method. The function of the operated hand was assessed with the Michigan Hand Questionnaire and compared with the contralateral side. Extended ray resection was performed in 25 out of 168 consecutive patients with soft-tissue and bony sarcomas of the hand. The overall 5- and 10-year, disease-specific survival rates were 86% and 81%, respectively. Local recurrences were observed in two patients. The Michigan Hand Questionnaire score for the affected hand at follow-up in nine patients was 82 points versus 95 for the healthy contralateral hands. We conclude that extended ray resection of osseous sarcomas breaking through the bone into the soft tissue or for soft tissue sarcomas invading bone is a preferable alternative to hand ablation when excision can be achieved with tumour-free margins. Level of evidence: III.

Single ray amputation in traumatic injury of the hand: review of literature.

Background and aim of the work: Ring avulsion are relatively common hand lesions and are associated with significant disability, especially in hand-workers. The treatment choice is still debatable. We sought to conduct a detailed systematic review in attempt to collate evidence on functional, cosmetic and patient-reported outcomes (PROs) following ray amputation for the management of traumatic hand injury and ring avulsion injury. Methods: Using the PubMed database we made a systematic search for articles regarding single ray amputation after traumatic hand lesion. Nine articles met our including criteria and were analysed. Results: Most of the included studies suggest that for those worse cases ray amputation still represent a good option. Indeed ray resection can eliminate the gap, remove a cumbersome or painful digit and guarantes better cosmesis but reduces grip and pinch strength (from 15% to 30%) and decreased palm width. Conclusions: Different surgical techniques are available, almost all of them results in a loss of strength but ensure good both functional and cosmetic results. (www.actabiomedica.it)

Surgical Management of Diabetic Neuropathy Foot Complications.

Background: Diabetic foot complications result from the association between peripheral vascular disease, neuropathy and a precarious healing process. Peripheral neuropathy observed in diabetics affects all components of the nervous system, contributing to the occurrence of leg ulcers, musculoskeletal changes, resulting in severe deformities. The clinical manifestation of these complications ranges from simple lesions to complex entities threatening the loss of pelvic limb or even life (1,2). Methods: In our surgery department, a significant number of patients with diabetic foot lesions are hospitalized and treated annually, 40% having clinical manifestations of diabetic neuropathy associated. In 2017, a total of 448 patients were hospitalized for complications of diabetes. We performed a retrospective analysis of 150 consecutive patients who underwent surgery for neuropathic diabetic foot lesions. Results: The analyzed patients had a favorable postoperative progression, benefiting from distal perfusion. Ray resection was the preferred surgical intervention. Major amputation was performed in 10% of cases with extensive gangrene and sepsis, amputation of the calf being preferred in all situations. Conclusions: The management of these patients is delicate, often multidisciplinary approach being necessary. A well-managed therapeutic attitude can make the difference between preserving or losing the pelvic limb.