Donald H. Lalonde

Wide-awake Flexor Tendon Repair and Early Tendon Mobilization in Zones 1 and 2

The wide-awake approach to flexor tendon repair has decreased our rupture and tenolysis rates and permitted us to get consistently good results in cooperative patients. The wide-awake surgery allows the repair of gaps of the surgical repair site revealed with intraoperative active movement testing of the repair We are now doing midrange active movement after primary tendon repair. After tenolysis, full-range active motion is possible even before skin closure. We no longer perform flexor tendon repair with the tourniquet, sedation, and muscle paralysis of general or block (Bier or axillary) anesthesia.

IFSSH Flexor Tendon Committee report 2014: from the IFSSH Flexor Tendon Committee (Chairman: Jin Bo Tang).

Hand surgeons continue to search for the best surgical flexor tendon repair and treatment of the tendon sheaths and pulleys, and they are attempting to establish postoperative regimens that fit diverse clinical needs. It is the purpose of this report to present the current views, methods, and suggestions of six senior hand surgeons from six different countries — all experienced in tendon repair and reconstruction. Although certainly there is common ground, the report presents provocative views and approaches. The report reflects an update in the views of the committee. We hope that it is helpful to surgeons and therapists in treating flexor tendon injuries.

Achieving the optimal epinephrine effect in wide awake hand surgery using local anesthesia without a tourniquet

BackgroundIn our experience, for all surgeries in the hand, the optimal epinephrine effect from local anesthesia—producing maximal vasoconstriction and visualization—is achieved by waiting significantly longer than the traditionally quoted 7xa0min from the time of injection.MethodsIn this prospective comparative study, healthy patients undergoing unilateral carpal tunnel surgery waited either 7xa0min or roughly 30xa0min, between the time of injection of 1xa0% lidocaine with 1:100,000 epinephrine and the time of incision. A standardized incision was made through dermis and into the subcutaneous tissue followed by exactly 60xa0s of measuring the quantity of blood loss using sterile micropipettes.ResultsThere was a statistically significant reduction in the mean quantity of bleeding in the group that waited roughly 30xa0min after injection and before incision compared to the group that waited only 7xa0min (95xa0% confidence intervals of 0.06u2009+u2009−0.03xa0ml/cm of incision, compared to 0.17u2009+u2009−0.08xa0ml/cm, respectively) (Pu2009=u20090.03).ConclusionsWaiting roughly 30xa0min after injection of local anesthesia with epinephrine as oppose to the traditionally taught 7 min, achieves an optimal epinephrine effect and vasoconstriction. In the hand, this will result in roughly a threefold reduction in bleeding—making wide awake local anesthesia without tourniquet (WALANT) possible. This knowledge has allowed our team to expand the hand procedures that we can offer using WALANT. The benefits of WALANT hand surgery include reduced cost and waste, improved patient safety, and the ability to perform active intraoperative movement examinations.

Secondary healing of fingertip amputations: a review

Most literature on fingertips reviews new surgical techniques of coverage while many surgeons prefer the results of secondary healing. This article reviews the current best evidence and concepts about secondary healing in fingertip injuries.

Internal Pedicle Shaping to Improve Aesthetic Results in Reduction Mammaplasty

Reduction mammaplasty has been performed using various techniques to achieve reduction in breast volume and to enhance aesthetic shape. The conventional inverted T-scar method is the most widely used technique in breast reduction because of its predictability and versatility.1 Nonetheless, newer surgical techniques have been developed to optimize outcome while minimizing associated complications. Pedicle types include inferior, central, superior, lateral, and bipedicle, all of which maintain the blood supply and innervation to the nipple-areola complex.2–6 Cosmetically acceptable placement of scars, although debated, has also been emphasized through additional technical modifications, including short scar periareolar inferior pedicle reduction mammaplasty, vertical mammaplasty without inframammary scar, or no vertical scar breast reduction.7–10 A common problem resulting from inferior pedicle reduction mammaplasty is amorphous breast shape and inadequate breast projection. After resection of the medial, central, and lateral breast using the traditional inferior pedicle technique, the pedicle tends to be loose and mobile, lacking any significant form or shape. With this technique, the breast shape depends solely on the skin envelope, which may not provide adequate projection. Any shape achieved is dependent in part on tension created by the apposition of the lateral flaps. Mathes et al. reported a technique of folding the inferior dermal breast flap and suturing it to the chest wall to increase projection and avoid the flat breast appearance.11 Lalonde et al. also described the use of breastshaping sutures to improve breast shape and projection in their “no vertical scar breast reduction.”8 We describe our technique of using internal absorbable sutures in inferior pedicle reduction mammaplasty to contour the pedicle for enhanced breast projection and shape. In addition, it decreases closure tension of the lateral flaps, as breast shape is in part created by shaping the central pedicle.

Commentaries on Clinical results of releasing the entire A2 pulley after flexor tendon repair in zone 2C. K. Moriya, T. Yoshizu, N. Tsubokawa, H. Narisawa, K. Hara and Y. Maki. J Hand Surg Eur. 2016, 41: 822-28.

In the 1970s, Boyes pointed out the problem of flexor tendon repairs sticking under the A2 pulley, the tightest part of the sheath (Boyes and Stark, 1971). This article is too small to define how we move forward to avoid this problem in zone 2C and the authors apply too much science to their small study. However, it is important. In 1994, Professor Tang showed better results for simple Zone 2C flexor tendon injuries when only the flexor digitorum profundus (FDP) was repaired (Tang, 1994). In 1998, we could not corroborate this for simple flexor tendon divisions in our work and, for a time, I believed that flexor digitorum superficialis (FDS) tendon sacrifice was only necessary under circumstances likely to result in significant oedema in the distal palm. More recently, I have come round to Professor Tang’s view that FDP repair only is wise for any injury under the A2 pulley as an acknowledgement of the reality: (i) that the complex anatomy below the A2 pulley of the FDS tendon wrapping itself around the FDP tendon makes a double pulley; (ii) that the sutured tendon is inevitably thicker than the original; and (iii) that most flexor tendon repairs are done, worldwide, by surgeons with less skill than the best of senior hand surgeons who may obtain ideal repair of both tendons in this area. The expertise to achieve free tendon movement after repair of both FDS and FDP tendons in zone 2C with partial divisions of the A2 pulley, even up to removal of twothirds of its length, may not be always be present. This article suggests a simpler, but not new, policy of complete A2 division. Yet again, we must acknowledge the research work of Savage (1990), who showed that division of the A2 pulley caused no significant change to function, provided the remainder of the sheath, including the A1 pulley, remained intact. In addition, earlier surgeons who, believing in healing by extrinsic adhesions, were no respecters of the pulleys, as shown in the writings of Mason (1940): ‘ The sheath is just large enough for its contents and provides scarcely enough space for repair of one tendon. The fibrous sheath is excised for a distance of about 1/4 inch above and below the suture line’; and Verdan (1958): ‘The sheath is excised over a distance of about 2 to 3 cm; the amount of sheath to be resected was determined by estimating the physiological gliding amplitude at this level’.

Carpal tunnel syndrome and workers’ compensation: A cross-Canada comparison

Carpal tunnel syndrome (CTS) is the source of substantial workers compensation claims in industrialized countries. Its pathogenesis, however, continues to be questioned. The purpose of the present study was to assess the attitudes of Canadian plastic surgeons toward Workers Compensation Board (WCB)-supported claims for CTS and to assess patterns of resource allocation across Canada. Sixty-seven plastic surgeons were asked to read a clinical scenario and respond whether they would support a WCB claim for CTS. Provincial WCB offices were contacted and asked to provide statistics surrounding CTS claims for 1997 to 2001. Fifty-eight per cent (39 of 67) of surgeons surveyed felt that CTS should be covered as a WCB claim, while 42% (28 of 67) felt that it should not be covered by WCB. In British Columbia, 50% (six of 12) of surgeons were in support of the claim compared to 92% (11 of 12) of those from Alberta, 55% (17 of 31) of those from the Central Provinces and 42% (five of 12) of those from the Maritime Provinces. Trends of resource allocation and number of CTS claims per year are presented for the individual provinces for 1997 to 2001. An extensive literature review revealed that there is minimal to no evidence to support the view that CTS should be a compensated claim. As defined by the WCB of Canada, a compensated claim is one that arises out of, and in the course of, employment and that results from causes and conditions peculiar to the trade, occupation or industry. The ambiguity in the beliefs of Canadian plastic surgeons in supporting CTS as a WCB claim reflects a situation where many of the decisions to cover CTS as a WCB claim are not evidence based.