Trigger Finger Release With Stepwise Preservation of the A1 Pulley: A Functional Pulley-Preserving Technique

The first annular (A1) pulley is an important structure of the hand, providing a biomechanical support to the metacarpophalangeal joint and maintaining joint stability and flexor tendon alignment. Albeit uncommon, disruption of this pulley can result in dislocation or ulnar drift of the digit, particularly pronounced in patients with rheumatoid arthritis. Despite this, the A1 pulley is commonly divided without reconstruction in trigger finger. Several annular pulley reconstructive techniques have been developed to preserve its function. However, development of recurrent triggering has been observed due to fibrosis, largely due to inadequate release of the pulley. We have developed a technique to increase the volume within the flexor sheath while preserving the A1 pulley by way of stepwise lengthening. This has enabled an increase in the diameter of the pulley to 4 times its original size. A prospective study was performed comprising 10 trigger finger releases with stepwise lengthening of the A1 pulley. In all patients, there were no complications, and good hand function was achieved with no recurrence of triggering at 6 weeks of follow-up. This technique can thus safely achieve trigger release without sacrifice of the function of the A1 pulley.     

The vascular basis of the hemi-hamate osteochondral free flap. Part 2: surgical anatomy and clinical application

Purpose

The free vascularised hemi-hamate flap combines the utility of providing a small osteochondral portion of hamate for reconstruction, while providing a means of vascularisation to preserve articular cartilage after transfer. In Part 1 of this series, we highlighted the vascular approaches to such a technique. The current study investigates the bony architecture of the hamate, with particular emphasis on its utility for a range of osteochondral defects in the hand.

Methods

A morphometric assessment of the hamate as a potential osteochondral flap donor site for resurfacing digital phalangeal heads (either total or unicondylar) and/or bases was thus undertaken. This anatomic study was undertaken using in vivo imaging performed for a range of clinical indications, with computed tomographic angiography (CTA) and digital subtraction angiography (DSA) of the upper limb included. Bony and vascular measurements and relationships were recorded and assessed both quantitatively and qualitatively. A clinical case is presented, highlighting the application of these measurements.

Results

The mean digital artery diameter was 0.7 mm with a mean distance between digital artery and interphalangeal joint surface (i.e. pedicle length) of 1.18 mm. Mean hamate dimensions comprised a transverse width 16.62 mm, lateral width of 14.29 mm and ridge height of 1.43 mm. Measurements of the phalangeal bases, condyles and total phalangeal heads were recorded, and the optimal hamate harvest approaches demonstrated. Despite perceived differences, in all cases there was statistical similarity demonstrated between the fragments.

Conclusion

The hemi-hamate osteochondral flap can be applied to a range of osteochondral defects in the hand and may offer new options to the hand surgeon.     

The Pfannenstiel scar and its implications in DIEP flap harvest: a clinical anatomic study

Background

Despite the utility of the deep inferior epigastric artery perforator (DIEP) flap, the presence of abdominal wall scars can limit flap perfusion. Pfannnstiel scars are among the most common abdominal scars, during which undermining at either a subfascial or suprafascial level can damage perforators. There is an anecdotal belief that raising a DIEP flap in the presence of a Pfannenstiel scar may be less reliable due to vascular disruption.

Methods

A clinical prospective analysis of retrospectively recorded imaging from 150 patients (300 hemi-abdominal walls) was undertaken. Preoperative imaging, with two computer software programmes used to reconstruct three dimensional (3-D) volume-rendered images and analyse vasculature, was used to accurately identify and measure perforators.

Results

A total of 959 perforators were identified, with 319 perforators identified in the ‘Pfannenstiel scar’ group and 640 perforators in the ‘no abdominal scar’ group. All patients, except for one patient with a Pfannenstiel scar, had one or more perforators that were larger than 1.0 mm in diameter. There were no differences in the number of DIEA perforators (6.81 vs 6.22, p?=?0.2819); however, perforators of the ‘Pfannenstiel scar’ group were of larger mean diameter than the ‘no abdominal scar’ group (0.96 vs 0.85 mm (p?=?0.0027).

Conclusions

The presence of a Pfannenstiel scar is associated with larger perforator size than controls and no diminution in overall perforator number. As such, a Pfannenstiel scar may in fact aid DIEP flap harvest, a finding consistent with anecdotal outcomes.Level of Evidence: Level III, risk / prognostic study.

     

Outcomes of contemporary management of gangrenous and non-gangrenous acute cholecystitis

BackgroundGangrenous cholecystitis (GC) is considered a more severe form of acute cholecystitis. The risk factors associated with this condition and its impact on morbidity and mortality compared with those of non-gangrenous acute cholecystitis (NGAC) are poorly defined and based largely on findings from older studies.MethodsPatients with histologically confirmed acute cholecystitis treated in specialized units in a tertiary hospital between 2005 and 2010 were identified from a prospectively maintained database. Data were reviewed retrospectively and patients with GC were compared with those with NGAC.ResultsA total of 184 patients with NGAC and 106 with GC were identified. The risk factors associated with GC included older age (69 years vs. 57 years; P= 0.001), diabetes (19% vs. 10%; P= 0.049), temperature of >38 °C (36% vs. 16%; P < 0.001), tachycardia (31% vs. 15%; P= 0.002), detection of muscle rigidity on examination (27% vs. 12%; P= 0.01) and greater elevations in white cell count (WCC) (13.4 × 10⁹/l vs. 10.7 × 10⁹/l; P < 0.001), C-reactive protein (CRP) (94 mg/l vs. 17 mg/l; P= 0.001), bilirubin (19 µmol/l vs. 17 µmol/l; P= 0.029), urea (5.3 mmol/l vs. 4.7 mmol/l; P= 0.016) and creatinine (82 µmol/l vs. 74 µmol/l; P= 0.001). The time from admission to operation in days was greater in the GC group (median = 1 day, range: 0–14 days vs. median = 1 day, range: 0–10 days; P= 0.029). There was no overall difference in complication rates between the GC and NGAC groups (22% vs. 14%; P= 0.102). There was a lower incidence of common bile duct stones in the GC group (5% vs. 13%; P= 0.017). Gangrenous cholecystitis was associated with increased mortality (4% vs. 0%; P= 0.017), but this was not an independent risk factor on multivariate analysis.ConclusionsGangrenous cholecystitis has certain clinical features and associated laboratory findings that may help to differentiate it from NGAC. It is not associated with an overall increase in complications when treated in a specialized unit.Case series which identifies patients at risk of having gangrenous cholecystitis when presenting with acute gallstone disease     

The vascular basis of the hemi-hamate osteochondral free flap. Part 1: vascular anatomy and clinical correlation

Purpose

The treatment of comminuted fractures of the proximal interphalangeal joint is highly challenging due to the complexities of joint bio-mechanics and stability. The hemi-hamate osteochondral auto-graft has been popularised in this role, able to replace articular loss and restore joint stability. Recent evaluation of their long-term follow-up however has shown the early development of osteoarthritis and potential early cartilage loss, which may be due to the non-vascularised nature of the graft. We offer a new technique that maintains vascularisation of the transferred hamate fragment, and investigate the anatomical vascular basis for the technique.

Methods

Dissection and angiographic studies of ten cadaveric specimens were undertaken, exploring the vascular anatomy of the dorsal hamate. A clinical case of hemi-hamate osteochondral free flap is presented, including preoperative, intraoperative and postoperative investigation of the relevant vasculature.

Results

Cadaveric studies demonstrated dorsal vascular supply to the hamate from the central of three dorsal carpal arches. The arch was supplied by the dorsal branch of the ulnar artery. Multiple supracapsular veins are present for use in flap venous drainage. This vascular pattern was found to be constant. A clinical case of hemi-hamate osteochondral free flap harvest demonstrated the same vascular anatomy intraoperatively. The digital artery was used as a recipient for microvascular anastomosis. Postoperative computed tomographic angiography and nuclear bone scan confirmed flap perfusion.

Conclusions

The hemi-hamate osteochondral flap has a reliable anatomical vascular basis, and is clinically feasible as a technique for early vascularisation of the osteochondral fragment to sustain the transferred articular cartilage.