Identifying Predictors of Radiographic Distal Phalangeal Nonunion After Fingertip Replantation

PURPOSE

This study aimed to estimate the risk factors for distal phalangeal nonunion in cases involving Kirchner wire fixation after successful fingertip replantation.

METHODS

This study retrospectively analyzed 116 digits of 111 patients, including 74 and 42 digits with replantation in Tamai zones I and II, respectively. Univariate and multivariable analyses were performed to assess the influences of 15 independent variables on nonunion, including age, sex, medical history of diabetes mellitus, history of smoking, injured hand and digit, injury type (clean, blunt, and crush-avulsion), amputation type (complete or incomplete), length of the distal bone fragment (mm), fracture type (simple or comminuted), presence of a bone defect, length of the fracture gap after fixation (mm), number of Kirchner wires used, evidence of venous repair, and the occurrence of pin tract infections after fixation.

RESULTS

At 12 months after replantation, 100 digits showed bony union and 16 (13.8%) digits showed radiographic nonunion or equivalent complications, including 9 digits with asymptomatic nonunion without a secondary operation, 5 that underwent an additional operation for nonunion or a complication, and 2 with distal bone resorption. A multivariable analysis indicated that the postfixation fracture gap was the only significant predictor influencing nonunion (odds ratio, 3.30; 95% confidence interval, 1.92-5.68).

CONCLUSIONS

The extent of the postfixation fracture gap had the greatest influence on preventing distal phalangeal nonunion, indicating the importance of reducing the fracture gap in primary fixation as much as possible.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Painful Proximally Oriented Large Heterotopic Spur Formation in an Active Adult With a Nontraumatic Amputation

Heterotopic ossification (HO) is excess bone growth in soft tissues, typically juxta-articular and interfascicular, with varying incidence. This excess bone growth has been well-documented in cases of traumatic amputation but less frequently observed in cases of nontraumatic amputation. Symptomatic heterotopic ossification usually includes pain during prosthetic use with management involving prosthetic adjustments for comfort. This atypical case highlights a patient with a nontraumatic amputation and a proximal-oriented large spur formation that was not painful with ambulation but with doffing his prosthesis.

Management of partial traumatic hemipelvectomy

Partial traumatic hemipelvectomy is a devastating condition. Although by definition the affected limb is not totally transected from the trunk because of retained soft tissue, the reported mortality rate is actually higher than in complete traumatic hemipelvectomy. Between January 2000 and December 2011, a total of 917 patients were admitted to the authors' institution for pelvic fracture. Seven of these patients met the criteria for partial traumatic hemipelvectomy. All 7 patients had multiple associated injuries and met the criteria for Baskett class IV hypovolemic shock on arrival at the emergency department. The amount of bleeding was the greatest issue, and control of hemorrhage and rapid blood transfusion were the initial goals. Abdominal aorta balloon occlusion, laparotomy and packing, and pelvic external fixation were useful to control bleeding. Two patients died during the initial resuscitation phase. Angiography (digital subtraction or computed tomographic) was performed in 4 patients but did not provide any treatment-altering information. Limb preservation was attempted in 2 patients; both of these patients eventually required hindquarter amputation. One patient died, and the second patient survived after a difficult postoperative course. The best results were obtained in 3 patients who underwent completion of the hindquarter amputation within 24 hours of trauma. All patients became wheelchair dependent, and no patient was able to return to work. Early completion of hindquarter amputation after hemorrhaging has been controlled is recommended in patients with partial traumatic hemipelvectomy. Angiography did not prove useful in decision making.

Organization and activity of the Replantation Service for amputated hands in Poland

A permanent on-call service for hand amputations (Replantation Service) was established in 2010 of the initiative of the Council of Polish Society for Surgery of the Hand. It is run by three qualified hand centres in Trzebnica, Poznań and Szczecin. Organization of this system, rules of activity and spectrum of cases admitted to replantation units was presented. A scheme of referral of amputations was shown and the main problems that appeared during almost three-year activity of the Service were discussed. Medico-legal and ethical implications arising from these problems were shown and organization of replantation service in other European countries was outlined. Establishing of the Replantation Service constituted a significant progress in the organization of the management of upper limb amputations. Thanks to that, over the period of three years, more than 200 patients were saved from severe disability, receiving a chance to regain an amputated limb.

Notable features in composite tissue allografts: value of high-resolution ultrasonography as a first-line imaging modality

PURPOSE

Hand transplantation is challenging, especially with respect to postoperative care. Serious complications including rejection of the transplant are possible. To date, imaging has relied mainly on plain radiography, CT and MRI. High-resolution ultrasound (HRUS) has the potential to be a quick, cost-effective and dynamic alternative at least for the initial assessment of most of these complications. We report on our experience with HRUS in three patients after bilateral hand/forearm transplantation.

MATERIALS AND METHODS

Three male patients with bilateral hand/forearm transplantation after traumatic amputation underwent periodic HRUS and color Doppler assessment. These exams focused especially on the detection of changes at the coaptation sites (nerve/muscle/tendon coaptation) and expected changes in vessels and healing bones in the compound allograft. The HRUS data were compared to available data of other radiological imaging modalities.

RESULTS

Relevant post-transplant changes such as neuromas, arteriovenous fistulas, heterotopic ossifications and scars were specified by HRUS. In addition information on muscle and tendon function was gained by dynamic ultrasound. In most cases no relevant information gain by other modalities was stated.

CONCLUSION

Based on our experience, we recommend sonography as a first-line modality for the follow-up of patients who underwent composite tissue allografting. HRUS allows the reliable and timely diagnosis of relevant complications and the monitoring of postoperative changes and sets the course for therapy or further more invasive imaging.

COMPARISON OF METHODS OF SKELETAL FIXATION FOR SEVERELY INJURED DIGITS

Our objective is to compare the results of three different methods of osteosynthesis used in severely injured digits, namely the K-wire group, the K-wire & Wire-loop group and the Plate & Screws group. The results of 38 patients with 50 severely injured fingers managed between 1994 and 2000 were reviewed. Majority of them had serious injury caused by electric-saw and Zone III was the most common level of injury using Biemer's classification. Using the scoring system of Nakamura and Tamai, excellent and good results were obtained in 59.5% of the patients. The rate of bony complications was different among the three methods of osteosynthesis though the final functional outcomes were comparable. The rate of bony complications in this series was 20.4%, which included non-union (7), migration of K-wires (2) and infection (1). All occurred in K-wire and K-wire & Wire-loop groups. Plate & Screws, therefore, is the preferred method of bony fixation if further operation for non-union is to be avoided. This is more so for the proximal injuries.

Fingertip injuries in children treated in Department of Pediatric Surgery and Oncology in the years 2008-2010

BACKGROUND

Fingertip injuries are the most common hand injuries in children seeking medical advice at trauma care centres. Most cases are treated conservatively and hospitalisation is not necessary. However, surgery under general anaesthesia is often required on account of severity of the injuries and the patients' young age. The aim of the paper is to discuss a series of patients treated in the Department of Paediatric Surgery and Oncology between 2008 and 2010, and present the problems associated with surgical care in fingertip injuries in children.

MATERIAL AND METHODS

A total of 76 children were treated in the Department of Pediatric Surgery and Oncology between 2008 and 2010 because of fingertip injuries. This group is estimated to represent approx. 10% of all patients admitted to the Emergency Unit. Fingertip injuries were treated with situation sutures, V-Y-plasty, suturing back the amputated fingertip and by suturing into thenar skin. Data were extracted from medical files and presented as percentages.

RESULTS

There were 50 boys in the group of 76 children (65.79%). Mean age was 7 years. Most of the patients were children aged 1 to 5 years (36 patients, 47.37%). In 45 children (59%), the right hand was injured. Injury to fingers responsible for the pincer grasp occurred in 29 children (38.16%).

CONCLUSIONS

Fingertip injuries are among the most common injuries in children and preservation of the hand's motor abilities depends on thorough surgical care. Most children with fingertip injuries are treated in Emergency Units and only 10% of patients need surgery under general anaesthesia after hospital admission. A number of surgical techniques can be used in the management of fingertip injuries in children. These techniques represent adaptations of methods used in adults. A model for the evaluation of severity and management of fingertip injuries in children should be established.

[Experience with the treatment of combined open injuries to the upper extremities with affected main arteries]

The paper deals with the principles of management of combined mechanical injuries to the upper extremities with special reference to amputation of their segments based on the 3-year experience with the treatment of 1488 patients including 405 ones with traumatic amputations. Replantation of large and small segments was undertaken in 24 and 76% of the cases respectively. 43% of the patients underwent one-step traumatic amputation of two and more segments. Skin and soft tissue defects occurred in 111 patients including 27 with extensive lesions. 82.4% of the surgical interventions had the desired outcome. An example of successful replantation is described. The results are compared with the literature data.

One case of big-toe re-plantation: a 13-year follow-up and a literature review

In this case of a 3-year-old patient who had a left big-toe amputation through the proximal phalange, re-plantation was performed successfully. Big-toe amputations are not frequent entities, but it should always be re-planted to avoid unsatisfactory aesthetic and functional outcomes. There are just a few reports in literature and their follow-up is very brief compared with our report.

[Successful brachial replantation in a child after a traction-type traumatic amputation]

The article deals with certain aspects of managing patients presenting with extremital bone-and-vascular injuries known for utter severity and a high incidence rate of postoperative complications. Suggested herein, as the authors believe, is an optimal for both the patient and surgeon policy of emergency reconstruction. Emphasis is placed on the necessity to follow a certain sequence while restoring the anatomical structures destroyed. The conclusions drawn include compulsorily considering a possibility to spare the damaged segment, followed by restoring adequate blood circulation and prevention of wound infection, carrying out osteosynthesis with obligatory shortening of the bones, and postponing orthopaedic measures for the remote postoperative period. Also presented in the article is a photograph-illustrated clinical case report of a successful brachial replantation.

Cosmetic amputation of the fourth ray as possible outcome of the traumatic amputation of the ring finger injury: a case report

The aim of this work is to describe a case of traumatic amputation of the fourth finger of the left hand. In its first phase, a treatment which consisted in a disarticulation at the level of the metacarpo-phalangeal joint was carried out; in the second phase, three months after this emergency treatment, a cosmetic amputation of the fourth metacarpal ray was required. Surgery was performed in accordance with the technique described by Bunnell, which consisted in the disarticulation of the fourth metacarpal, together with radial traslation of the fifth ray. Eighteen months after the operation The patient reported the absence of any subjective problems, with complete functional recovery of the hand that had been operated on. By that time she was back at her job; she also was satisfied with the cosmetic results that had been achieved.

Effects of long-term immobilisation on cortical bone mass after traumatic amputation of the phalanges estimated by digital X-ray radiogrammetry

Osteopenia of the cortical and trabecular bone partition is a common finding after immobilisation. Digital X-ray radiogrammetry (DXR) seems to quantify cortical demineralisation caused by circular saw amputation already few days after accident.

INTRODUCTION

The study analyses the extent of demineralisation caused by immobilisation in patients with digital amputation after a circular saw injury, and elucidates the period of time which discloses a significant deprivation of bone mineral density estimated at the metacarpalia II-IV using DXR.

METHODS

Twenty-eight patients with digital amputations underwent measurements of bone mineral density, cortical thickness, bone width and metacarpal index using DXR-technology in a follow-up up to 902 days.

RESULTS

The data showed a significant decline of bone mineral density (-10.47%), the metacarpal index (-4.38%), the bone width (-12.06%) and the cortical thickness (-7.04%) after trauma-related amputation. The cortical demineralisation of the metacarpals could already be revealed in two patients after the second day, according to the amputation of phalanges (-3.65%).

CONCLUSIONS

The inhibition of the periosteal bone formation detected by DXR-technique seems to be a specific finding caused by amputation, which thus differs from normal age-related (i.e., endosteal) bone loss and from demineralisation following acute immobilisation (i.e., trabecular osteopenia).

Heterotopic ossification following traumatic and combat-related amputations. Prevalence, risk factors, and preliminary results of excision

BACKGROUND

Although infrequently reported in amputees previously, heterotopic ossification has proven to be a common and problematic clinical entity in our recent experience in the treatment of traumatic and combat-related amputations related to Operation Enduring Freedom and Operation Iraqi Freedom. The purpose of the present study was to report the prevalence of and risk factors for heterotopic ossification following trauma-related amputation as well as the preliminary results of operative excision.

METHODS

We identified 330 patients with a total of 373 traumatic and combat-related amputations who had been managed at our centers between September 11, 2001 and November 30, 2005. We reviewed the medical records and radiographs of 187 patients with 213 amputations who had adequate radiographic follow-up. Additional analysis was performed for twenty-four patients with twenty-five limbs that required excision of symptomatic lesions. The mechanism and zone of injury, amputation level, timing of excision, use of prophylaxis against recurrence, and other confounding variables were examined. Outcomes were assessed by determining clinical and radiographic recurrence rates, perioperative complications, preoperative and follow-up pain medication requirements, and the ability to be fit with a functional prosthesis.

RESULTS

Heterotopic ossification was present in 134 (63%) of 213 residual limbs, with twenty-five lesions requiring excision. A final amputation level within the zone of injury was a risk factor for both the development and the grade of heterotopic ossification (p < 0.05). A blast mechanism was predictive of occurrence (p < 0.05) but did not correlate with grade. All patients who had been managed with excision were tolerating the prosthetic limb at an average of twelve months of follow-up. Twenty-three limbs demonstrated no evidence of recurrence, and two limbs had development of clinically asymptomatic, radiographically minimal recurrences. Six patients experienced wound-related complications that required reoperation, and two patients required subsequent minor revision surgery. There was a significant decrease in the use of pain medication following surgery (p < 0.05).

CONCLUSIONS

Heterotopic ossification following trauma-related amputation is more common than the literature would suggest, particularly following amputations that are performed within the initial zone of injury and those that are due to blast injuries. Many patients are asymptomatic or can be successfully managed with modification of the prosthesis. For patients with refractory symptoms, surgical excision is associated with low recurrence rates and decreased medication requirements, with acceptable complication rates.

Free Lateral Arm Flap for 1-Stage Reconstruction of Soft Tissue and Composite Defects of the Hand

In this article, the long-term outcomes of hand defects after 1-stage reconstruction with lateral arm flap were retrospectively analyzed in a large series. Between the years 1990 and 2004, 118 traumatic hand defects were reconstructed using lateral arm fasciocutaneous flap (n = 104), lateral arm fascial flap (n = 6), and composite lateral arm flap (n = 8) in Chang Gung Memorial Hospital. There were 22 females and 96 males with an average age of 32.5 +/- 13.3 years. The mean follow-up period was 17 +/- 6.2 months. The overall success rate was 97.5%. The cosmetic outcomes were satisfactory and only 16.1% of the patients required debulking. The functional recovery of the hand contractures secondary to crush injury were generally associated with poor results. In the composite flap group, reconstruction of the extensor tendons with triceps tendon yielded limitation in tendon excursion and poor functional results. However, complete bone healing without complication was uniformly detected in all cases. Lateral arm fasciocutaneous flap endured secondary interventions well and no complications regarding wound healing was encountered.

The first case of primary metacarpal V restoration with titanium mesh and cancellous bone graft

Any references of use of the titanium mesh in hand reconstruction could not be found. A case of primary metacarpal reconstruction after severe hand trauma with a help of cage made of titanium mesh and cancellous iliac bone graft is presented.

[Inner amputation of an upper extremity with impaired cerebral perfusion and lethal outcome]

An inner amputation of the upper extremity is understood to be a rupture of the arm's vascular nerve bundle as well as the shoulder's and scapular's stabilizing muscles and fibrous joints without damage to the dermal soft tissue sheath. This injury is a rare and grave incident which mostly occurs within the scope of a high-energy trauma and in cases of polytraumatized patients in combination with additional life-threatening injuries. In the literature this is referred to by the terms scapulothoracic dissociation (SD) and closed forequarter amputation--the entity of SD was first described by Oreck et al. in 1984. Traction of the upper extremity leads to the rupture of the m. pectoralis major, m. pectoralis minor, the musculi rhomboidei, the m. levator scapulae, the m. latissimus dorsi as well as the m. trapezius. Furthermore the traction causes acromioclavicular or sternoclavicular bursting of the joints or a displaced clavicle fracture. Among the more than 50 cases depicted until now, 94% of the patients exhibit a neurological (plexus) and 80% a vascular lesion, thus corresponding to a genuine inner amputation. The prognosis for this injury is consistently poor: 10% of the patients die, in 52% an nonfunctional extremity remains, and in 21% a untimely amputation has to be performed. The observed complication of cerebral hypoperfusion caused by increasing pressure in the neck compartment, which ultimately leads to the death of the patient, has, as far as we know, not yet been specified and emphasizes the gravity and the magnitude as well as the necessity of rapid diagnosis and appropriate therapy of this infrequent injury.

[The results of digital replantations at the level of the distal interphalangeal joint and the distal phalanx]

OBJECTIVES

We retrospectively evaluated replantations performed for distal amputations.

METHODS

The study included 82 patients (75 males, 7 females; mean age 29 years; range 10 to 52 years) who underwent replantations distal to the distal interphalangeal joint for a total of 98 amputations. According to the Tamai classification, there were 58 zone 1 and 40 zone 2 amputations. Local digital anesthesia was used in 77 patients (93.9%). Arterial anastomosis was accomplished after bone fixation, and venous anastomosis and nerve repair were performed whenever possible. When venous anastomosis was not possible or in case of venous insufficiency, venous decompression was performed with heparinized gauze placed on the bleeding nail matrix. Functional results and the degree of patients' satisfaction with the cosmetic outcome were evaluated. The mean follow-up was 16 months (range 3 to 46 months).

RESULTS

Replantation was successful in 60 amputations (61.2%) and unsuccessful in 38 cases (38.8%). In successful cases, cosmetic results were satisfactory due to the preservation of the nail and finger length. Functional results were satisfactory in cases in which the distal interphalangeal joint could be preserved. Replantations for zone 1 amputations (74.1%) yielded better results than those performed for zone 2 amputations (42.5%).

CONCLUSION

Despite technical difficulties, replantations for distal finger amputations can provide satisfactory functional and cosmetic results.

[Improved fixation of finger prostheses by means of intramedullary titanium anchors and magnets]

BACKGROUND

A small series of patients with traumatic amputation of fingers have undergone treatment with a new technique using endomedullar osseointegrated titanium implant device that magnetically holds the finger prosthesis.

METHODS

A two-stage reconstruction procedure with endomedullar osseointegrated titanium implants was performed to attach a finger prosthesis to the proximal, middle and distal phalanx. The first stage included implantation of the titanium fixture into the medullary cavity canal of the phalanx. After a 2-month rest period to allow the fixture to firmly osseointegrate with the phalanx of the bone, a skin-penetrating titan-magnetic abutment was placed on top of the fixture, to which the prosthesis was firmly attached.

RESULTS

Good stability could be achieved using an endomedullar osseointegrated prosthesis. Easy handling is possible with the magnetic connection between finger and prosthesis. In the clinical use were no complications observed. We observed no infections and no problems with the soft tissue.

CONCLUSIONS

The combination of osseointegrated titanium implants and magnetics for finger prosthetics provides several advantages. Such as stable fixation of the prosthetic finger to the bone, restoration of some sensory feedback with better osseoperception as well as an excellent cosmetic result.

Effect of Body Armor on Simulated Landmine Blasts to Cadaveric Legs

BACKGROUND

Antipersonnel landmine protective footwear relies on blast deflection or on exaggerated standoff between the foot and the explosive. Neither design has been tested for clinical effectiveness.

METHODS

4 cadaveric lower extremities--3 fitted with a Koflach boot incorporating TABRE (Technology for Attenuating Blast Related Energy) were subjected to controlled blast with charges of up to 100 g trinitrotoluene (TNT). The blasts were recorded by a digital recording system. All legs were X-rayed and underwent computed tomography scanning before and after testing.

RESULTS

TABRE-protected limbs directly subjected to the blast hyperextended at the knee during firing. Injuries showed a pattern of open tibial fractures (Gustilo grade I, II), of multiple calcaneal (Sanders Type III, IV), and fibular fractures and of the tibial plateau, but showed no traumatic amputation.

CONCLUSIONS

Development of protective footwear against landmine blast is feasible. From medium mines up to charges of 100 g TNT limb salvage may be possible.

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.

Bilateral hand transplantation: bone healing under immunosuppression with tacrolimus, mycophenolate mofetil, and prednisolone

PURPOSE

Little is known about bone healing after composite tissue transplantation that requires pharmacologic immunosuppression. Bone integration and callus development were assessed in bilateral hand transplantation.

METHODS

In this study the course of callus development and callus maturation were assessed by color Doppler sonography and radiography in a double hand transplant and compared with forearm replantation.

RESULTS

After hand transplantation, ingrowth of small vessels at the bone junction was observed at week 3, calcified callus became visible at month 4, and bone union was completed at month 11. A similar time course of bone integration was observed after replantation. Plating offered sufficient stability. A recipient periostal flap is thought to have improved blood supply and favored development and induction of callus.

CONCLUSIONS

Bone healing after hand transplantation under immunosuppression with tacrolimus, mycophenolate mofetil, and prednisolone is identical to that after forearm replantation.