Lorenzo Rocchi

Articular ganglia of the volar aspect of the wrist: arthroscopic resection compared with open excision. A prospective randomised study

Our aim was to compare two methods of treatment of ganglia on the volar aspect of the wrist (the open excision done through a longitudinal volar skin incision and the arthroscopic resection through two or three dorsal ports), to see if arthroscopy could reduce the risks of operating in this area and the time to healing. Twenty radiocarpal and five midcarpal volar ganglia were operated on by open approach and an equivalent group was treated by arthroscopy. Fifteen radiocarpal and five midcarpal ganglia were treated with good results in the open group and 18 radiocarpal and one midcarpal ganglia in the arthroscopic group (no visible or palpable ganglion, a full range of active wrist movement, grip strength equal to preoperatively, no pain, and a cosmetically acceptable scar). In the open group there were four injuries to a branch of the radial artery, two cases of partial stiffness of the wrist associated with a painful scar, one case of neuropraxia, and one recurrence (all of which were among the 20 radiocarpal ganglia). In the arthroscopic group there was one case of neuropraxia, one injury to a branch of the radial artery, and three recurrences (three of the complications were among the five midcarpal ganglia). The mean functional recovery time was equal to 15 (6) days in the open group and 6 (2) days in the arthroscopic group. The mean time lost from work was equal to 23 (11) days in the open group and 10 (5) days in the arthroscopic group. Our results suggest that arthroscopic resection is a reasonable alternative to open excision in treating radiocarpal volar ganglia because it has less postoperative morbidity and a better cosmetic result. Midcarpal volar ganglia, however, should still be treated by open operation.

In vivo regeneration of rat sciatic nerve in a double‐halved stitch‐less guide: A pilot‐study

It is about 20 years that tubular nerve guides have been introduced into clinical practice as a reliable alternative to autograft, in gaps not‐longer‐than 20 mm, bringing the advantage of avoiding donor site sacrifice and morbidity. There are limitations in the application of tubular guides. First, tubular structure in itself makes surgical implantation difficult; second, stitch sutures required to secure the guide may represent a site of unfavorable fibroblastic reaction; third, maximum length and diameter of the guide correlate with the occurrence of a poorer central vascularization of regenerated nerve. We report on the in vivo testing of a new concept of nerve‐guide (named NeuroBox) which is double‐halved, not‐degradable, rigid, and does not require any stitch to be held in place, employing acrylate glue instead. Five male Wistar rats had the new guide implanted in a 4‐mm sciatic nerve defect; two guides incorporated a surface constituted of microtrenches aligned longitudinally. Further five rats had the 4‐mm gap left without repair. Contralateral intact nerves were used as controls. After 2 months, nerve regeneration occurred in all animals treated by the NeuroBox; fine blood vessels were well represented. There was no regeneration in the un‐treated animals. Even if the limited number of animals does not allow to draw definitive conclusions, some result can be highlighted: an easy surgical technique was associated with the box‐shaped guide and acrylate glue was easily applied; an adequate intraneural vascularization was found concurrently with the regeneration of the nerve and no adverse fibroblastic proliferation was present.

A more detailed mechanism to explain the “bands of Fontana” in peripheral nerves

In 1779, Fontana identified transverse and oblique bands along peripheral nerves. Subsequent studies pointed alternatively to endoneural or perineural components as the cause. Our aim was to clarify these conflicting findings.

Flexor tendon injuries of the hand treated with TenoFixTM: mid-term results

BackgroundRecently, the Teno FixTM device has been detailed in the literature. Conventional stranded cruciate repair requires splinting to protect the sutures from excessive loading, and then, active motion is strongly limited leading to a possible incomplete functional recovery.Materials and methodsThe authors report on their experience in treating 21 patients presenting primary flexor tendon injuries within the digital sheath in zone 2, in all fingers (including the thumb), at an average follow-up of 16 (range: 6-16) months.ResultsThere were, according to Strickland and Glogovac criteria: 12 excellent; 6 good; 3 fair.ConclusionsThis new device is practical clinically and can effect strong tendon repairs that withstand early active finger motion, but the best indication is to treat only selected cases of sharp flexor tendon lesions in zone 2. Using this technique it is possible to achieve a quick functional recovery and early return to work.

Reconstruction of the Distal Finger with Partial Second Toe Transfers by Means of an Exteriorised Pedicle

This study reports the outcome of a series of ten microsurgical fingertip reconstructions with partial toe transfers in which the vascular pedicle was exteriorised and subsequently excised after the transfer had become established. The aim of this technique was to provide better aesthetic and functional outcomes. The technique was successful and without complication in nine of the ten patients who had excellent functional and aesthetic outcomes. Arterial thrombosis resulted in partial necrosis of the fingertip in the other case.

Peripheral nerve regeneration inside collagen-based artificial nerve guides in humans

Purpose Nerve gap injuries may be associated with lesions in other structures, like tendons or bones; in these cases, it is common to plan a second surgery to improve functional recovery. Since macroscopic observations of nerve regeneration in humans are rare, we exploited these second surgeries for the purpose of studying nerve regeneration in humans. Methods We assessed the clinical outcomes of 50 implants of collagen-based nerve guides in the upper limb. We performed a second look at 20, assessing macroscopically both nerve regeneration and collagen degradation. Results and Conclusions Pain was never recorded in these patients. An adequate sensory recovery took place whenever nerve regeneration was found inside the guide. Motor recovery seemed to occur only when the gap lesion was shorter than 10 mm. The degree of degradation appeared to be variable and was not directly correlated with time; we hypothesize that it could be associated with the site of implantation. Such a large number of second looks in humans has never been previously reported in the literature.

Abductor pollicis longus hemitendon looping around the first intermetacarpal ligament as interposition following trapeziectomy: a one-year follow-up study.

BACKGROUND Trapeziectomy and ligament reconstructions are favoured by surgeons concerned that telescoping of the thumb may reduce its function. However, theoretically ligamentoplasties are at risk to develop tendinosis or tendon rupture or trigger a complex regional pain syndrome type 1. HYPOTHESIS Authors tested the looping of a slip from the abductor pollicis longus (APL) tendon around the first intermetacarpal ligament. They intended to use a surgical treatment which does not require bone tunnelling or looping around a tendon. Their results support the hypothesis that this new technique is a valid addition among treatments for carpometacarpal arthritis. PATIENTS AND METHODS Forty-two patients were followed up to one year. Each patient had subjective assessment for: pain; function (DASH score); overall satisfaction. An objective assessment was used for: first web span angle; abduction and opposition; key pinch; grip strength. Tests were performed prior to surgery, then at three, six and 12 months. X-ray films were taken to monitor thumb height. RESULTS A substantial improvement in all these parameters was measured in all patients. X-ray films showed the mantainance of a physiological heigth after one year. We recorded one complication of keloid and two of temporary dysesthesia but no case of tendinosis, delayed rupture, or CRPS 1. Mean operative time was 27 minutes. DISCUSSION Simplification and search for a technique which avoids the looping around a tendon is why the authors undertook this study. Advantages are the small number of required steps, short time of surgery and comfortable postoperative rehab regimen for the patient. The technique provides a distal anchoring point (without bone tunnelling). It is quite respectful of anatomy and physiology, in minimizing the re-routing of functioning tendons. We propose it as an effective procedure both to expand the armamentarium for treating the thumb carpometacarpal joint osteoarthritis and/or to simplify the ligamentoplasties already in use.

A discussion on the limits of carbon-fibres reinforced polymers prompted by a case of destruent synovitis in the wrist

Carbon-fibre-reinforced polymers (CFRP) are composite materials. They consist of two phases: an isotropic matrix and an anisotropic reinforcement. The isotropic matrix is a polymer whose mechanical properties are the same in any direction in the 3-D space. The anisotropic reinforcement is a fibre which provides strength and rigidity along its direction. The three-dimensional lay-out of the fibres and the fibres/polymer ratio define the material properties of any composite artefact. Composite materials are largely applied in aerospace and car industry, where an accurate modelling of the possible strains and stresses endured by the artefact is possible. The more complex is the geometry and load-cycle of an artefact, the more difficult (and expensive) will be the design and production by composites. Application of CFRP artefacts in humans has been promoted in Orthopaedic and Trauma Surgery. A prominent advantage is their X-ray transparency which helps in assessing proper reduction of fractures and radiological healing at follow-up. Literature documents the biocompatibility of materials used, namely carbon fibres and poly-ether thermoplastics, like poly-ether–ether–ketone (PEEK) and poly-ether–immide (PEI). These materials do not promote any relevant inflammatory reaction by themselves and, actually, the interface with living tissues is the matrix polymer alone, since the carbon fibres should remain deeply embedded. PEEK is a widely employed material in Spinal Surgery; PEI was tested in the past for bone application [1]. In papers on CFRP it was sporadically noted that, sometimes, carbon fibres can be exposed to a direct contact with soft or hard tissues. In this case an inflammatory reaction may ensue because of the fibre geometry, regardless of the biologically inert character of the material [2,3]. This response is the long-time known inflammatory reaction to fibres which causes, for example, Asbestosis (from asbestos fibres). A properly designed and accurately implanted composite artefact should not expose its fibres during or after surgery: however this may happen. We had the chance to document a case of severe destruent synovitis in a distal radius fracture treated by a CFRP wrist plate. A white Caucasian woman of 64 years of age came to our attention 11 months after surgery for a right distal radial fracture. She had a CFRP plate in place (CarboFix Orthopaedics Ltd., Israel). A painful swelling was evident on the volar wrist 3 months after surgery, and it kept worsening. After 4 months she was unable to flex the thumb and soon afterwards she experienced inability in flexing the index finger and DIP joint of the third finger (Fig. 1: top left). She had normal active MCP flexion (thanks to intrinsic muscles); no instrumental evidence of neurological disorders; no laboratory evidence of Rheumatoid Disease. An ultrasound examination showed a massive sinovytis.

Osteoid Osteoma of the Distal Fibula: a Case Report of a Very Rare Location Treatment

Osteoid Osteoma (OO) is a very common small benign osteoblastic tumor. It represents 10% of all bone benign lesions, and is usually localized to the proximal metadiaphysis of the femur. We report the case of an OO localized in the distal inner metadiaphysis of the fibula. To our knowledge this is the first report in literature. We performed enbloc resection because of the deep localization of the lesion, which was not reachable by minimally invasive procedures. At 6 months follow-up bone stock reconstitution was observed, and no relapse occurred at 1 year. Plain X-rays are generally sufficient to make a diagnosis. When radiological findings are not suggestive, computed tomography and bone scan represent second level examinations. Minimally invasive procedures represent a promising and valuable treatment, but open surgery shall be still taken in account when the location is not easy to reach and/or it is in proximity to neurovascular structures.