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PubMed2001

[Dorsal dislocation of the proximal interphalangeal joints of the finger. Results after static and functional treatment].

In a follow-up examination of 30 patients who had sustained dorsal dislocations of the PIP joint, the results of two conservative therapy regimens, either immobilisation or early motion were investigated. In Group A, 15 patients were treated by closed reduction and immobilisation with a forearm cast for four weeks. Nine patients showed normal range of motion, whereas a limitation of extension of ten degrees and more was seen in six cases. All PIP joints were stable. Nine patients were satisfied. Three patients complained of a limitation of extension, two of a limitation of extension and pain and one of swelling. In Group B, 15 patients were treated by dorsal block splinting of the PIP joint following reposition. The finger was released in extension with daily active exercise of the PIP joint. Only two of 15 patients showed limitation of extension, whereas 13 cases showed normal range of motion. Instability of one collateral ligament was seen in two cases. Palmar instability did not occur. Eleven patients were satisfied. One patient complained of instability, pain and lack of extension, one of pain in combination with instability, one of pain and one of swelling of the joint.

Adult↗
PubMed2002

Arterialized venous free flaps for soft-tissue reconstruction of digits: a 40-case series.

When there is not sufficient local tissue available for reconstruction of one or multiple digital defects, distant flap reconstructions are required. Available thin flaps with defined arterial inflow and venous outflow are limited and require the sacrifice of an arterial pedicle. In addition, a functional limitation can occur at the donor site. During the last decades, experimental and clinical attempts have been made in using venous flaps, based just on the venous network for in- and outflow. A 40-case series of arterialized venous free flaps in soft-tissue reconstruction of the digits and hand is presented. Neovessel formation induced by an intact venous plexus within the flap proved clinically to be the survival mechanism. Postoperative congestion was present in all flaps and subsided within 14 days; 92 percent of all flaps eventually survived. In 57.5 percent of cases, total flap survival was observed; in 17.5 percent of flaps, a superficial epidermolysis occurred, not requiring further surgery; in 17.5 percent of flaps, a full-thickness skin necrosis developed, requiring grafting (minor complication); in 7.5 percent of reconstructions, total flap necrosis was observed. Thus, in the authors' experience, when conventional local flaps are not available, arterialized venous free flaps proved to be a successful solution for soft-tissue reconstruction in digits and hands. The authors present the main indications and advantages of arterialized venous free flaps, emphasizing the essential technical steps and the most frequent pitfalls in treatment.

Adolescent↗
PubMedDate not supplied

[Finger replantation in a 3-year-old child].

In this case report, we present a three year old boy who suffered an amputation of his left index finger at the level of the nail base (proximal zone I) caused by a scissor cut. Following referral to a center with hand surgical and pediatric care, successful replantation was achieved and postoperative pediatric care ensured finger perfusion. Three months postop, the reconstructed finger was in normal daily use with full function. Our success encourages for initial replantation of digits in infants in any case and irrespective of the level of amputation. Optimal results in these patients can only be achieved by interdisciplinary care of hand surgeons and pediatricians.

Age Factors↗
PubMed2003

Early compensatory sensory re-education.

After a neurorrhaphy, there will be a distal disconnection between the cortex and skin receptors, along with interruption of sensibility information. This report demonstrates the efficacy of a new sensory re-education program for achieving optimal sensation in a relatively short time. Between 1999 and 2001, in the authors' Hand Rehabilitation Department, 11 patients with previous neurorrhaphy were subjected to a program of early "compensatory sensory re-education." Lesions were caused by clean cut. There were 13 primary digital nerve procedures, 12 at the distal palmar MP level, and one at the radial dorsal branch of the index (just after emerging from the common digital nerve). The technique of compensatory sensory re-education was based on a previous, but modified, sensory re-education method. In order to evaluate the results in the compensatory sensory re-education series described, additional tests for evaluation of achieved functional sensibility were used. The authors' best results were achieved in a maximum of 8 weeks (4-8 weeks), much less time than with the original method (1-2 years). Using the British classification, it was possible to compare the achieved levels of sensibility and the time required for optimal results. The different methods of sensibility re-education may be similar, but with the authors' compensatory sensory re-education method, substantial time is saved.

Adolescent↗
PubMed2005

Distal fingertip replantation without skeletal fixation.

The replantation of fingertip amputation (through the nail bed) requires repair of the artery and vein on the palmar side. These structures are present in different planes, with the artery being deeper and the veins superficial. The authors believe that vascular repair in such cases is facilitated by stabilization of the amputated part by nail-bed repair alone. This provides a certain degree of flexibility, which allows for easier placement of clamps in the limited space available. Although Kirschner wires were not used for bony fixation, bony union was achieved in all five cases in which this technique was used.

Amputation, Traumatic↗
PubMed2006

Results of replantation of amputated fingertips in 450 patients.

Over a 15-year period (August, 1988 to May 2003), the authors have carried out 510 replantations of amputated fingertips distal to the nail base (zone I) in 450 patients, with a high overall survival rate (92 percent), using combinations of arterial and venous anastomoses without any alternative methods such as "pocketing." Replantations that anastomosed only one artery (25 digits) had a success rate of 68 percent, one artery and one vein (115 digits) had a success rate of 82 percent, one artery and two veins (240 digits) had a success rate of 95 percent and more than two artery and vein anastomoses (130 digits), had a success rate of 99 percent. The follow-up period ranged from 3 months to 14 years and 432 patients were followed-up more than 6 months. In these latter patients, the average two-point discrimination was 7 mm.

Adolescent↗
PubMed2006

Free dorsal middle phalangeal finger flap.

Three patients underwent finger reconstruction using free dorsal middle phalangeal finger flaps (DMF flaps). All flaps survived. The free DMF flap relies on blood flow from the dorsal branches of the digital artery and is harvested from the skin on the dorsum of the middle phalanx. The digital artery gives rise to four dorsal branches; two in the middle and two in the proximal phalangeal regions. The flap is based on the dorsal branch of the digital artery that passes near the center of the phalanx. The characteristic feature of the free DMF flap is that the dorsal cutaneous veins are used as drainage vessels. Unlike island flaps, blood congestion does not occur after free DMF flap surgery. Sensibility of the free flap may be obtained by inclusion of the dorsal branches of the digital nerves in the flap pedicle. Loss of the digital artery at the donor site can be circumvented with venous grafting. Surgery under brachial plexus block is an advantage of this flap. The free DMF flap is a useful technique for skin and soft-tissue defects.

Adult↗
PubMed1999

Intravenous bolus infusion of heparin for circulatory insufficiency after finger replantation.

When heparin 2,500 to 5,000 U was administered by intravenous bolus infusion to 13 fingers that had developed arterial thrombosis after replantation, complete survival was achieved in seven of 13 fingers. If fingers demonstrating partial necrosis were included, survival was obtained in 11 of 13 fingers. In nine fingers in which survival was obtained and follow-up observation was possible, sensory recovery was favorable, and there was no limitation in the use of the affected fingers, although mild atrophy of the pulp and nail deformity were noted in fingers with partial necrosis. Using a model of arterial thrombosis created in the carotid arteries of Sprague-Dawley rats, the authors investigated how the intravenous bolus infusion of heparin affected thrombolysis. During the early phase of arterial thrombosis when the thrombus is fragile, the intravenous bolus of heparin affected the balance between coagulation and fibrinolysis, facilitating the thrombolytic process, and increasing the rate of recanalization of the occluded arteries. Since an intravenous bolus injection of heparin is an easy procedure, without the risk of any severe side effects, this method should be considered in such cases of arterial thrombosis, with attention paid to the general condition of the patient.

Adolescent↗
PubMed1999

Effect of hyperbaric oxygen therapy as a monitoring technique for digital replantation survival.

There have been few clinical reports of successful replantation assisted with hyperbaric oxygen (HBO) therapy. In order to improve replant survival, the author has used HBO in ten digital replantations of crush, avulsion, and degloving amputations. Seven of ten replants survived and the other three failed. The failed three digits demonstrated remarkable color changes during HBO therapy. No color changes were observed in six of the seven surviving digits under HBO. The remaining digit showed a slight color difference between pre- and post-therapy. It appears that hyperbaric oxygen is potentially effective in distinguishing "uneventful" replants in which color does not change during HBO therapy, while hyperbaric oxygen could not salvage those "congestion to necrosis" replants in which the color became bright vermilion under hyperbaric oxygen therapy. The difference in digital color reaction to hyperbaric oxygen may be helpful in early decisions to employ salvaging procedures.

Adult↗
PubMed1999

Use of the microvascular finger fillet flap.

This paper reports the authors' experience with the use of microvascular flaps, elevated from severely injured fingers to cover soft-tissue defects of other digits. Two clinical cases are presented and pertinent literature is reviewed.

Adult↗
PubMed1998

Vascularized partial first metatarsal transfer for the treatment of phalangeal osteomyelitis.

The author reports the salvage of the index finger in a patient with extensive osteomyelitis of the proximal phalanx. Salvage was achieved by a staged reconstruction, using external fixation combined with aggressive debridement, and an antibiotic/methylmethacrylate spacer, followed by a vascularized bone flap from the first metatarsal. Union was achieved with an excellent functional outcome of 205 degrees of total active motion. The literature addressing the management of osteomyelitis in this particular location is incomplete. This author believes that loss of a large portion of the diaphysis is difficult to treat by conventional bone grafting because of the poorly vascularized bed following extensive infection. The case reported is unique because of the choice of donor site. Vascularized bone grafting is suggested as offering the best chance for success, and the donor-site material can be easily tailored to fit the phalangeal defects.

Adult↗
PubMed1998

Flow-through vascularized toe-joint transfer for reconstruction of segmental loss of an amputated finger.

A segmental finger defect was reconstructed in a 46-year-old woman with a free flow-through vascularized toe-joint, including the proximal interphalangeal joint, the plantar digital nerve, and tendons of the second toe. The advantages of this composite flap are: (1) The segmental loss of the finger can be easily reconstructed to achieve a normal anatomic structure. (2) Excellent cosmesis is achieved, compared with conventional flaps such as the groin flap. (3) The distal segment of the donor toe can be preserved. (4) The transected digital arteries of the amputated finger can be simultaneously reconstructed with a flow-through arterial interposition. (5) The digital nerve can be repaired with a vascularized plantar digital nerve graft.

Female↗
PubMed1995

An easy method of vascular anastomosis for replantation of fingertips.

Many cases of successful replantation of fingertips have been reported; however, it still remains difficult for an inexperienced surgeon to anastomose very small vessels (especially veins of the fingertip) because their walls and lumina cannot be clearly defined. The authors report a simple method which is useful for anastomosis of small vessels. A colored silicone background is cut into a small, thread-like segment, and both ends are tapered. This segment is then introduced into the vessel lumen to serve as a vascular stent. The silicone vascular stent makes it easy to identify the vessel lumen and then to suture the vessel edges. It also prevents a through-stitch, the most common cause of anastomosis failure with small vessels. The silicone vascular stent is removed before the last suture is tied. This technique has been used for suturing small veins in the finger pulp or small arteries in zone I, and it will be most helpful for the inexperienced microsurgeon.

Amputation, Traumatic↗
PubMed1994

Clinical evaluation and temperature monitoring in predicting viability in replantations.

Experiences with temperature and clinical monitoring in a series of 111 patients with 188 revascularized digits were reviewed. Criteria for abnormal temperature monitoring were defined. Monitoring of only clinical parameters showed a sensitivity of 1.00 and specificity of .97, but this technique was time-consuming and required experienced interpretation of subtle clinical changes. Temperature monitoring gave a sensitivity of 1.00, while the specificity was only .61. Drops in temperature were frequently not associated with vascular problems. Review of digits with abnormal clinical or temperature monitoring showed five patterns of abnormality. The first three groups had either abnormal clinical or temperature monitoring, but all fingers survived without reexploration. The fourth and fifth groups showed abnormalities in both clinical and temperature monitoring; all but one finger were found to be nonviable. Combined clinical and temperature monitoring was highly effective in early prediction of vascular compromise, with a sensitivity of 1.00 and a specificity of .99. The authors recommend the use of temperature monitoring. If a temperature drop occurs, monitoring of the clinical parameters can then be done. If both temperature and clinical monitoring yield abnormal results after a specified time, intervention should be carried out.

Body Temperature↗
PubMed1994

Spiral oblique retinacular ligament (SORL) mallet correction in a finger with a proximal interphalangeal joint transferred from a toe.

The use of a spiral oblique retinacular ligament (SORL) reconstruction is reported in a middle finger that had previously undergone reconstruction of the proximal interphalangeal (PIP) joint, using a free, vascularized, second-toe PIP joint transfer. The SORL procedure was applied for the reconstruction of the terminal tendon. A satisfactory postoperative range of joint mobility and stability was achieved.

Adult↗
PubMed1993

Correlation between number of anastomosed vessels and survival rate in finger replantation.

In replantation surgery, an attempt is made to repair as many vessels as possible. However, operative procedures might be simplified to reduce the operative time and the number of personnel required. In an attempt to determine the essential number of vascular anastomoses in finger replantation, the correlation between the number of anastomosed vessels and survival rates was examined in 216 replanted fingers that had been completely amputated. Digits with two arteries repaired had higher survival rates than those with only one artery repaired; however, there was no significant difference between survival rates and the number of arterial anastomoses in any of the zones. The number of anastomosed veins was well-correlated statistically with the survival rate. In Zone I (distal to the lunula), there was no significant difference in the survival rates between no venous anastomosis and one to two venous anastomoses. A statistically significant difference between the survival rates with one venous anastomosis and two or three venous anastomoses was observed only in Zone III (middle phalangeal region). These results support the following conclusions: 1) The essential amount of arterial repair appears to be one arterial anastomosis. 2) The essential venous repair appears to be no veins in Zone I, one vein in Zone II (lunula to distal interphalangeal joint), two veins in Zone III, and one vein in Zone IV (proximal phalangeal region).

Amputation, Traumatic↗
PubMed1993

The sticker-type temperature indicator in digital replantation: simplified application.

A sticker-type skin-surface temperature indicator, commercially available in Japan, has been utilized to monitor temperature changes in replanted digits. In clinical application, the authors evaluated several shortcomings in some of these devices. For example, the 10-mm diameter indicator is too small for numbers to be seen clearly. The 18-mm diameter indicator is too large to patch onto the finger pulp. To improve this device, the authors used only the number 33 from the 18-mm diameter indicator and applied it to several study subjects. Judgments about the circulatory status of the replanted digit can be made on the basis of the indicator color. The 18-mm diameter indicator, now modified to use only the number 33, is in common use for all the authors' digital replantation cases. Clinicians' ability to see critical temperature changes has been markedly improved, even under poor lighting conditions.

Adult↗