Free Dorsoulnar Perforator Flap Transfers for the Reconstruction of Severely Injured Digits

The aim of this study was to investigate the feasibility of transferring the free dorsoulnar perforator flap nourished by the cutaneous perforator branched dorsoulnar artery to reconstruct severely injured fingers under upper arm anesthesia. Between April of 2001 and April of 2002, 13 free dorsoulnar perforator flaps were used in 13 patients. There were 11 men and two women ranging in age from 18 to 64 years, with an average age of 38 years. The affected fingers were one thumb, four index fingers, five middle fingers, two ring fingers, and one little finger. All cases were performed under upper arm anesthesia combined with intravenous local anesthesia. The operative time ranged from 103 to 140 minutes, with an average time of 120 minutes. The flap size ranged from 1 x 3 to 3 x 4 cm, and was transferred from the same forearm of the injured finger. All donor sites were closed primarily without a skin graft. The aim of reconstruction for fingers was to repair a traumatic defect (five cases), partial necrosis following replantation (two cases), and soft-tissue defects resulting from resection of a scar (three cases) and to revascularize ischemic fingers (three cases). All flaps survived completely. After repair of the flow-through circulation of the common digital artery and ischemic finger, a postoperative angiogram showed the vascular patency and hypervascularity of the reconstructed fingers, and the patients' complaints were reduced. The free dorsoulnar perforator flap under regional anesthesia is first reported; it may become one valuable option as a very small flap for the treatment of repairing intercalated or segmental defects as a flow-through flap for soft-tissue defects and ischemic fingers.

Primary use of the index finger for reconstruction of amputated thumbs

Seven cases of primary reconstruction of traumatic amputation of the thumb using the index finger are reported. In six cases, the reconstruction was done using an injured index finger, while in one case where the amputation of the thumb was through the carpometacarpal joint, an intact index finger was primarily pollicised. This reduces cost of treatment, hospitalisation period and allows earlier rehabilitation without a period of a 'no thumb experience'. We have followed all the patients for a minimum period of 2 years and all of them have excellent functional results. We believe that pollicisation of a normal index finger, if thumb amputation is through the carpometacarpal joint or an injured index finger at the time of initial management of a severely traumatised hand with thumb amputation is an excellent technique for thumb reconstruction.

[Lengthening of the phalanges by callus distraction in traumatic amputations of the fingers]

OBJECTIVES

We evaluated the results of lengthening of the phalanges by callus distraction in traumatic amputations of the fingers.

METHODS

We treated traumatic amputations of 16 fingers of 13 male patients (mean age 27.7 years; range 12 to 43 years) by callotasis of the phalanges. Callus distraction was performed with a rate of 1 mm/day using a unilateral dynamic external fixation device. The mean follow-up period was 42 months (range 12 to 80 months).

RESULTS

The mean lengthening was 24 mm (range 18 to 26 mm) and 21 mm (range 18 to 26 mm) for the thumbs and the other fingers, respectively. The achieved thumb length provided adequate depth and width of the first web space and enabled functional improvement in the ability of gripping, and pulp-to-pulp and pulp-to-side pinching. In the absence of flexor pollicis longus, the mean strength of the thumbs was 7 kg (range 5 to 9 kg), amounting to 65% of the normal side. Lengthening of the other fingers resulted in improved functioning of the hand. The mean healing index (number of months per centimetre of lengthening) was 1.7 months/cm (range 1.6 to 2.1 months/cm) and 1.6 months/cm (range 1.4 to 1.9 months/cm) in the thumbs and the other fingers, respectively. Pin tract infections were observed in four phalanges.

CONCLUSION

Callotasis of the proximal phalanx of the thumb is an effective reconstruction method to compensate for the loss of distal phalanx and to alleviate functional problems due to shortness. It may also be applied to the phalanges of the other fingers in patients who do not accept ray resection with or without transposition.

[Complications after distal finger injuries]

Injuries of the fingertips are often but not always of a simple, easily healing kind. If there are complications they are induced by the severity of the trauma itself or because the patient himself or the physician treating the injury is misjudging its severity. This leads to an inadequate therapy, which may very well be the cause of a dramatic development, ending in loss of function of the injured hand if it comes to the worst. By the means of some selected examples the pitfalls in the treatment of fingertip injuries shall be pointed out.

[Simultaneous reimplantation of both lower legs--5-year follow-up (case report)]

We are reporting the case of a 29 year old male in whom we performed successful reimplantaton of both lower legs following trauma inflicted by a railroad boxcar. Five years after this accident, the patient's walk is almost normal and both deep sensitivity and two point discrimination on the soles of his feet are sufficient. The patient can walk, run and stand very well on one leg, both on even and on uneven ground.He returned to his job with the railroad 8 months after his accident. Originally the patient was employed as a railroad workman, and is now an office employee. His private life is normal and he enjoys hiking and dancing. In our opinion, sufficient function of the tibial nerve in the reconstructed extremity is important for clinically satisfactory long-term results. Both the Mangled Extremity Severity Score (MESS) and the NISSSA are helpful in making the decision on whether to primarily amputate or reconstruct Gustillo IIIC cases. Good long-term results as well as general cost reduction are achievable following reconstruction of extremities. Amputation of an extremity can be predicted with 100% certainty when MESS is 9 or more. Primary shortening and secondary lengthening of an extremity is a good method of treating Gustillo III C fractures.

[Finger reconstruction by microvascular second toe-to-finger transplantation in patients with traumatic loss of all fingers]

PURPOSE

To assess the utility of second toe-to-finger transplantation with neurovascular reconstruction in patients with loss of all four digits.

METHOD

Analysis of 24 toe-to-finger transplantations in 18 patients regarding over-all survival, complications and secondary procedures, sensibility, function, foot symptoms, and patient satisfaction. The original metacarpophalangeal joint was preserved in 50 % of the transplantations. In six patients, a second transplantation was performed.

RESULTS

A mean follow-up of 5.8 years was available in 94 % of the patients. 92 % of the transplanted toes survived, in 38 % of the cases complications occurred followed by a secondary procedure. Two-point-sensibility was present in 62 % of the transplantations, the largest range of motion of ca. 50 degrees was obtained in the metacarpophalangeal joint. An increase in the range of motion could be achieved by preservation of the original finger joint. The mean extension lag was 37 degrees independent of the preservation of the metacarpophalangeal joint. Foot symptoms were mild in four patients, in two cases severe donor-site-problems were observed. Cold intolerance was present in 47 % of the transferred toes. Overall patient satisfaction was high with 83 % of the patients confirming their decision to undergo operative treatment.

CONCLUSION

Second toe-to-finger transplantation is indicated in patients with traumatic loss of all digits. By this method, a great functional gain could be achieved as well as a high level of satisfaction. The rate of complications and possible foot symptoms should be considered. The preservation of the original metacarpophalangeal joint seems to be of importance for the function of the transplanted toe.

Functional latissimus dorsi island pedicle musculocutaneous flap to restore elbow flexion in replantation or revascularisation of above-elbow amputations

Two total and one subtotal above-elbow amputations had replantation or revascularization for their severely damaged upper extremities followed by functional latissimus dorsi island pedicle musculocutaneous flap to restore elbow flexion. The mean follow-up was 68 months (range: 14 to 121 months). At final follow-up examinations, the patients had sufficient range-of-motion of their elbows with good strength. Restoring elbow function eliminates one of the most important limiting factors for above-elbow replantations. Functional latissimus dorsi island pedicle musculocutaneous flap is very reliable, has minimal donor-site morbidity and offers a wider choice when deciding about arm replantation in the upper arm region by providing a chance of restoring functions.

[Late results following avulsion injuries of the thumb]

Out of the 127 amputated thumbs replanted at our unit during the last 15 years, there were 27 avulsion injuries. The average age of the 24 male patients was 33 years, that of the three female patients was 34 years. 70 % of the injuries were occupational accidents. Among the 27 patients, 21 had a complete and six an incomplete avulsion of the thumb. The level of avulsion-amputation was at the MP-joint ten times, between MP and IP joint ten times and at the IP-joint seven times. The healing rate of the subtotally avulsed thumbs was 100 %, that of the completely amputated thumbs 36 %. The most important post-operative complications observed were venous and secondary arterial thrombosis, whereby most of them occurred within the first 24 hours after replantation. The duration of ischaemia had a significant influence on the healing rate. In 80 % of the cases reconstruction of nerves have been carried out secondarily. A two-point discrimination was achieved in two cases only. The osteosynthesis was done almost exclusively with K-wires. Ten of 19 patients had to change their profession, while nine of them were able to return to their previous jobs, which in these cases were pre-dominantly white collar jobs. Another patient went for early retirement (he was a painter). All 19 patients followed-up had a range of movement of their saddle joints which was sufficient for the needs of most of the activities of daily life. Stiffness of the MP and IP joints was a common finding but had little functional impact, as it has been reported by other authors previously. We conclude from the results presented that in cases of avulsion injury of the thumb replantation is a procedure with significant chances of success.

[Reposition flap techniques in fingertip amputations: 6 cases]

PURPOSE OF THE STUDY

The purpose of this study was to evaluate an alternative procedure for amputations distal to the distal interphalangeal joint: the reposition flap.

MATERIALS AND METHODS

The reposition flap was used for 6 patients who underwent fingertip amputations in an emergency setting. Pulp was excised on the amputated segment and the remaining bone and nail bed were reattached to the proximal stump with a Kirschner wire. The pulp was reconstructed with a local advancement and sensitive flap. The patients were aged 18 to 44 years and had been victims of work accidents. All refused finger shortening.

RESULTS

The fingers showed good scarring and good trophicity. Two-point discrimination was 6 mm. Bony fusion was constant but all distal interphalangeal joints remained stiff. Cosmetic results were correct except for two cases of claw nail formation.

DISCUSSION

Fingertip amputations have been widely reported. Methods have varied from directed scarring to partial toe transfer. These situations present two types of challenge: insensitivity of the volar aspect or an overly sensitive pulp; cosmetic presentation and function of the dorsal aspect due to the complex role of the nail. Distal reimplantation remains the best technique, but the reposition flap offers an interesting alternative in case of failure or for patients who do not accept finger shortening. The advantage of the reposition flap is that it preserves finger length and the nail. Work stoppage and intolerance to cold can be an inconvenience due to the long time required for wound healing.

[Timing of soft tissue reconstruction in severe crush injury of the upper extremity]

Complex injuries of the distal forearm and the hand by industrial machines often require extensive reconstructive procedures. Crush injuries with soft tissue damage extending over the limits of visible injury require a special approach. Large soft tissue defects often have to be covered by extensive flap procedures. The optimum point of time for plastic reconstruction is an essential question and represents a controversial issue in the literature. To be able to compare different patient cohorts in the future, we classify crush injuries into five clinically relevant categories. In the course of this review article, three different cases of severe crush injuries of the upper extremity are representatively discussed. Two patients were reconstructed in a secondary procedure, one patient in the acute phase. Definite coverage of soft tissue defects in severe crush injuries should be performed secondarily after 5-7 days since the extent of damage in this special form of trauma can often only be judged after a few days and the reconstruction of bones, vessels and tendons is completed.

A continuum between scapulothoracic dissociation and traumatic forequarter amputation: a review of the literature

Both traumatic forequarter amputation and scapulothoracic dissociation are rare and life-threatening injuries. We present the case of a 31-year old woman who was ejected from a car after a motor vehicle accident and sustained an apparent partial forequarter amputation. Upon examination her injury was found to share many characteristics with a scapulothoracic dissociation injury. With both injuries mortality is high and prompt diagnosis and treatment imperative. By viewing scapulothoracic dissociation and forequarter amputation as a continuum faster recognition and appropriate treatment may be implemented for these devastating injuries.

Metacarpal and phalangeal lengthening by callus distraction

Twelve metacarpals and two phalanges in 14 patients (nine males and five females) were lengthened between August 1992 and March 1999 by the callus distraction technique using a small external fixator (Orthofix). The indications were traumatic amputation (10 cases), aplasia (three cases) and hypoplasia owing to premature epiphyseal closure of the metacarpal (one case). All patients were reviewed with a median follow-up time of 39 (range, 9-88) months. The median age of the patients was 15 (range, 4-39) years. The median lengthening was 21 (range, 13-34) mm which was a median of 82% (range, 38-162) of the original bone length. The median times for callus distraction and consolidation were 4.5 and 7.5 weeks respectively. All except one patient tolerated the procedure well and were satisfied with the results. Functional improvement was seen in 13 out of 14 patients, but non-union was observed in one patient.

[Callus distraction of the first metacarpal bone for thumb reconstruction after traumatic amputation]

From 1990 to 1997, callus distraction of the first metacarpal bone was performed on 34 patients with a traumatic amputation of the thumb, if replantation was not possible. After a period of 7 +/- 11 months (range, 1-48), a corticotomy and continuous distraction with an external fixator was carried out. Of the patients, 31 (91%) were reviewed after treatment. The follow-up period range was 41 +/- 32 months. With this method, the average lengthening of the thumb was 78% in comparison to the uninjured side. Complications were rupture of the callus in one case, four patients suffered a superficial wound infection, and seven patients showed pin tract infection without osteitis. At follow-up examination, 20 patients (64.5%) showed excellent, 9 (29%) good and 2 patients (6.5%) unsatisfying results.

[Expanded pedicled forearm flap for reconstruction of multiple finger amputations]

Soft-tissue injuries of the hand frequently require flap coverage to preserve structures damaged at the time of injury or to facilitate later reconstruction. The radial forearm flap makes local tissue readily available and offers a simple method of reconstruction. Secondary augmentation of the skin flap by means of tissue expansion appears to be a useful alternative to improve the possibilities of reconstruction. This case report describes a primary reconstruction of a hand with multiple finger amputations using both techniques: Forearm flap and tissue expansion.

[Proximal amputation injuries of the thumb including the radial half of the hand. Case reports]

The primary treatment of proximal amputations of the thumb and radial half of the hand is of particular importance, if the primary functions of a basic hand are to be restored. It is of utmost importance, that such treatment be carried out by a highly experienced reconstructive surgeon, since the transplantation or transposition of blood vessels, nerves, tendons and skin and soft-tissue flaps may be necessary. Five case reports illustrate the fundamental principles of primary and secondary reconstruction of the hand.

Distraction-lengthening of digital rays using a small external fixator

We present 19 ray lengthenings in 14 patients done with a small external fixator. In six cases the thumb was lengthened and in the other 13 cases, other digital rays. The most frequent reason for lengthening was an amputation sustained in a work accident. All the lengthenings were done by an osteotomy and subsequent gradual distraction with a small external fixator. The mean lengthening achieved was 20 mm (range, 0-32). An iliac-crest graft was needed in nine cases, corrective osteotomy in five cases and a deepening of the web in the six cases of thumb lengthening. In five cases an additional technique was needed to achieve bony consolidation. We have analysed the functional results and the ability to perform activities of daily living and resume employment. Although most of the patients had multiples injuries, the results have been very favourable, achieving a very high level of patient satisfaction.

[Primary shortening--secondary lengthening. A new treatment concept for reconstruction of extensive soft tissue and bone injuries after 3rd degree open fracture and amputation of the lower leg]

The main problem in major limb replantation--especially of the lower extremity--is an extensive bone- and soft-tissue loss. The traditional replantation concept tries to preserve the initial limb length; only a small shortening is accepted. To avoid a more extensive shortening, often insufficient debridement at the time of replantation is carried out. After successful revascularisation, bone and soft-tissue defects will be reconstructed according to the principles of staged reconstruction. Especially segmental nerve defects of more than one major peripheral nerve and severe skin and muscle loss necessitate extensive secondary grafting procedures. This often leads to a prolonged hospitalisation and a high complication rate. In 1951, Lorenz Böhler described the deliberate extremity shortening as a method of therapy in segmental combined bone-soft-tissue defects of the extremities. No additional surgical procedure were necessary to treat the soft tissue defect. A functional but shortened extremity was the result. With Ilizarov's principle of callus distraction he proved in an extensive experimental and clinical study the possibility to lengthen extremities without functional damage up to 20 cm. A new reconstruction concept--"concept of primary shortening with secondary limb lengthening"--for the treatment of amputation and/or amputation-like injuries was created by combining both principles mentioned above. At the time of replantation (reconstruction), deliberate shortening is carried out in order to reduce soft-tissue and/or bone defect or to enable primary nerve repair. Moreover, the aggressive debridement leads to a reduction of the local complication risk (wound healing disturbance, infection) and the potential systemic complications (crush-syndrome, ischemia-reperfusion-syndrome) after revascularisation of a large tissue bloc. Six to twelve months after replantation, secondary limb lengthening is started using an external or internal (= programmable intramedullary nail) distraction device. Since 1985, twelve patients (six macroamputations and six third-degree open fractures of the lower leg) have been treated using the "concept of primary shortening with secondary limb lengthening". Indications, operative technique, and results are shown and discussed, comparing this new concept to the traditional "concept of staged length-reconstruction" with extensive free tissue reconstruction and secondary nerve grafting.

[Complex trauma of the hand]

The hand is very exposed to injuries in the daily man's work. The multiple functions of the hand are based on vitality, sensibility, motor function and stability. In severe hand injuries the functional results of the repair are often very poor. In a complex injury of the hand we are faced with the damage of the soft tissue and bone and the loss of vitality and function of the hand. The cause of hand injuries are mainly a crush trauma or the rotating saw. Basically, we recommend an extended primary repair. After the radical debridement we have to reconstruct the damaged structures. We start doing the osteosynthesis and stabilization of the joints. Thereafter, suturing of extensor and flexor tendons. Then, we do the microsurgical reconstructions of vessels and nerves. In case tendons and bones are exposed we have to cover the defect with a pedicled or a free flap. In a long ischemic time we have to change our concept and do the reconstruction of the vessels first. Our results in vitality and sensibility are listed. In the result of a complex hand injury each single functional restoration is very important. Therefore, it is necessary that severe hand injuries are treated at well established centres for hand surgery.

Reimplantation of the upper limb after tear lesion: long-term results

Reimplantation revascularization of the upper limb proximal to the elbow represents an absolute indication in specific conditions. In the young subject, in good general conditions with a clean amputation (guillotine-like caused by a circular saw), the limb preserved in ideal conditions, indications for reimplantation are supported by the expectations of good functional recovery. When amputation is due to avulsion tear the possibility of anatomical and functional success is influenced by the complexity of vascular and nervous lesions. Thus, indications for reimplantation must be made by carefully evaluating each individual case.