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.

[Advantages of blocking intramedullary osteosynthesis in treatment of patients with fractures of the forearm bones]

The blocking intramedullary osteosynthesis (BIO) of the forearm bones possesses quite a number of advantages in comparison with the bone and transosseous methods. The BIO allows the restoration of the anatomy and biomechanics of the forearm, it shortens the term of disability and restores the function of the extremity in proximate terms. The BIO of the forearm bones consists of great number of nuances, each of them is really important. It is necessary to have the X-ray unit with electron-optical image for the intraoperative monitoring of operation stages and to follow the well-defined algorithm of technology of performing BIO of the forearm bones with special reference to all possible features of anatomy.

[Perforator flap in the middle segment of posterolateral forearm for dorsal defects at the lower forearm]

OBJECTIVE

To discuss the feasibility of perforator flaps in the middle segment of posterolateral forearm for dorsal defects at the lower forearm.

METHODS

30 specimens of adult upper limbs, perfused with red latex, were dissected. The course, origin, distribution and branches of major perforator artery in the middle segment of posterolateral forearm were observed and measured. 8 cases with dorsal defects at the lower forearm were treated with the perforator flaps.

RESULTS

All the 8 flaps survived completely with primary healing. The patients were followed up for 2-28 months with good flap texture, color and appearance.

CONCLUSIONS

The perforator flap in the middle segment of posterolateral forearm has constant and rich blood supply which is originated from the main artery. It is suitable for defects at the dorsal side of lower forearm.

Fashioning reversed axial pattern forearm tissues in different challenging conditions of the forearm territory as a reliable substitute for free tissue transfer

AIM

Traumatic tissue defects, chronic ulcerations, burn contractures and post-oncological excisions are the main problems affecting the hand and forearm areas. This work addresses the question of whether reversed axial island flaps from the forearm area could be applicable to any form of soft tissue defects in the territory of the forearm, and whether they could be considered reliable substitutes for free tissue transfer.

METHOD

Thirteen patients who sought surgical treatment for soft tissue defects of the hand, wrist, and distal forearm regions were included in this evaluation report. The patients complained of four different etiologies, and their resultant tissue defects were managed by reversed radial forearm flap in eight cases and by the ulnar variety of the reversed forearm flap in another five cases. Selection of the flap option depended on the site of the pathology, size and thickness of the resultant defect, special needs of the defect, vascular limitations, and the like-tissue reconstruction objective.

RESULTS

All flaps survived well with no complications. Both donor and recipient sites healed successfully. The selected flaps were ideal in their specific application. Harvesting reversed forearm flaps does not require high surgical skills or special equipment, venous congestion is less significant than with free flaps, and the patients do not need intensive immediate postoperative care and supervision.

CONCLUSION

This is an easy and reliable technique requiring short operating time, and initiation of early physiotherapy is permitted, making forearm flaps reliable substitutes for free flap applications with all the associated complications.

Free tissue transfer in hand surgery--essential step in hand transplantation

INTRODUCTION

The development of microsurgery allowed huge advancements in the reconstructive surgery of the upper limb. The use of free digital transfer started a true revolution for the reconstruction of the mutilated, functionally compromised hand, with multiple amputations. Slowly, surgeons started using free tissue transfers in other reconstructive procedures of the hand, forearm and arm. This way they avoided amputating a limb and they realized quality reconstructions in a single surgical step in cases in which classical methods did not apply. We shouldn't neglect to mention that free tissue transfers, along with hand replantation, represent an important step for microsurgery centers in preparing the hand transplant.

MATERIAL AND METHODS

There have been 48 cases of free tissue transfers of the upper limb in the Plastic Surgery Department of the "Bagdasar-Arseni" Emergency Hospital between 2000 and 2010, of which 18 free digital transfers, 11 free tissue transfers of the hand, 15 transfers of the forearm and 4 of the arm.

RESULTS AND DISCUSSION

Of the total 48 cases we studied, 4 have been total failures and 6 cases presented partial necrosis of the transferred tissue, all of which have been managed with ulterior corrective procedures. We used free tissue transfer in cases where there was no other surgical option and also in cases where other methods applied, but free tissue transfer provided a superior quality solution.

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.

Bites to the hand: are they more than we can chew?

Animal bites to the hand caused by dogs, cats and humans are common conditions that general practitioners, emergency physicians and hand surgeons encounter in their practice. These bites are prone to infection and represent great cost to the patient in terms of time, money and disability, if not treated optimally from the outset. Other than lacerations to the skin, injuries to the tendons, nerves, bone and joints are commonplace given their proximity to the skin surface in the hand. Optimal treatment of acute animal bites to the hand should include clearance of contamination by surgical debridement, prophylactic antibiotics and tetanus toxoid, as well as staged reconstruction of all damaged tissue, including the skin, once the wound is deemed clean.

MR intensity measurements of nondenervated muscle in patients following severe forearm trauma

Fluid increases resulting in higher MRI signal intensities in T(2) -weighted and short tau inversion recovery (STIR) sequences can be used to diagnose nerve injury. By comparing the signal intensities over time, MRI may become a new method for monitoring the healing process. Muscle edema is assessed by comparing the signal intensity of affected muscle with that of nonaffected muscle. However, in severe forearm trauma, the signal of nondenervated muscle may also be increased by wound edema, thus masking the effect of denervation. Hence, the purpose of this study was to investigate the influence of wound edema on muscle signal intensity in 29 consecutive patients examined on a 1.5-T MRI scanner at 1, 3, 6, 9 and 12 months after severe forearm trauma. The long-term course of wound edema and the influence of wound distance were thus investigated using a standardized imaging, calibration and post-processing protocol. The signal intensities of nondenervated intrinsic hand muscles were measured in the affected and contralateral sides. Muscle signal intensities were increased on the trauma side at 1 and 3 months (18% and 7.4%, respectively; p < 0.001) and normalized thereafter. In the contralateral hand, no significant signal changes were seen. No relationship was found between wound distance and the severity of wound edema. This study shows that wound edema influences muscle signal intensity comparisons in patients with forearm trauma. When comparing denervated muscle with nondenervated muscle, an additional scan of the contralateral side is indicated during the first 6 months after trauma to assess the extent of wound edema. After 6 months, the ipsilateral side can be used for muscle signal intensity comparisons.

Radius-only intramedullary nailing for both-bones diaphyseal forearm fractures in children

Both-bones diaphyseal forearm fractures are common injuries in the paediatric age group and are potentially unstable. Both-bones intramedullary nailing for these fractures is a minimally invasive procedure that maintains alignment, and promotes rapid bony healing. Good results have also been shown with single-bone fixation. We report our experience in treating these common injuries with radius-only intramedullary nailing in 29 children. The clinical notes and radiographs were reviewed retrospectively. There were 9 girls and 20 boys; the mean age at the time of operation was 9 years (range: 5 to 17 years). Closed reduction was achieved in 21 patients, while eight patients required open reduction. Mean duration of follow-up was 6.8 months (range: 4 to 12 months). All fractures achieved clinical and radiological union at 6-8 weeks. Radius-only intramedullary nailing is a sufficient and effective option in treating both bones paediatric forearm displaced unstable type AO 22-A3 fractures, with excellent functional outcome and union rates.

The practice of plastic surgery in emergency trauma surgery: a retrospective glance at 10,732 patients

BACKGROUND

The number of patients applying to the emergency Plastic and Reconstructive Surgery outpatient clinic varies considerably depending on the sociocultural profiles of societies. Due to the abundance of anatomic regions comprising the targets of this field of specialization, plastic surgery is continuously gaining in importance in emergency traumatology.

METHODS

In this study, 10,732 patients admitted to the outpatient clinic of Emergency Plastic Surgery in Şişli Etfal Training and Research Hospital were evaluated retrospectively regarding etiology, sex, age distribution, injury characteristics, and treatment.

RESULTS

While 64% of all patients had forearm and hand injuries, 28% had maxillofacial injuries, and 8% had tissue defects. There was a male: female ratio of 4: 1, and the mean age of all patients was 22.9 years. The mean age of patients (males 81%) admitted with upper extremity injuries was 22.3 years. Most of the upper extremity injuries were due to glassware cuts (33%). The mean age of patients admitted with maxillofacial trauma was 23.2 years. Among the patients with head-and-neck injuries, the most frequent cause of trauma was traffic accidents (38%).

CONCLUSION

Regarding the frequency and characteristics of the patients treated, we suggest that plastic surgery shows a progressively increasing significance and widening field of practice in emergency traumatology and, as no similar study currently exists, ours will contribute significantly to the literature.

Management of fractures in adolescents

There are well-established treatment standards for adults who sustain fractures; however, these treatment standards are not always applicable when treating adolescents with similar fractures because of the presence of physes. Fractures in adolescents are treated by pediatric orthopaedic surgeons, adult orthopaedic traumatologists, or general orthopaedic surgeons. It is imperative that the principles of fracture management are well defined and discussed in both the pediatric and adult orthopaedic community. Controversial topics include the youngest age at which an adolescent can be treated as an adult and acceptable fracture reduction criteria. The general principles of managing fractures in adolescents regarding classification, treatment options, complications, and estimating skeletal age should be understood by the treating physician.

Oblique pedicled paraumbilical perforator-based flap for reconstruction of complex proximal and mid-forearm defects: a report of two cases

Reconstruction of complex proximal and mid-forearm wounds can be challenging. Free tissue transfer might not be feasible in certain patients or at institutions lacking microsurgical expertise and equipment. Traditional pedicled flaps are either insufficient in length to reach more proximal forearm defects or are used sparingly due to donor site complications and extremity stiffness. We present a novel technique to reconstruct forearm defects using the oblique pedicled paraumbilical perforator (PUP) based flap. This flap is simple to harvest, has low donor site morbidity, and allows elbow and shoulder range of motion during the interval between flap transfer and pedicle division.

First Polish forearm transplantation - final report (outcome after 4 years)

BACKGROUND

Hand transplantation (HTx) presents an exceptional reconstructive solution for hand amputees. Relatively few patients qualify for such an operation - generally healthy patients suffering from a serious disturbance of body integrity.

CASE REPORT

We present a patient 48 months after unilateral transplantation of an allogenic forearm. Clinical course, laboratory results, function of the graft, and quality of life of the patient are analyzed. These findings are compared with those achieved by 2 other patients - recipients of allograft forearm transplanted on the same zone in Lyon 2002, and Louisville 2001. The patient suffered no post-transplantation infections, had 1 episode of rejection - I degrees . Except for mild diabetes, no disturbances of internal organs were observed. Total active motions of fingers (TAM) equaled 53% of fingers of unaffected hand. The functional evaluation by SF 36 is 53; by DASH - 92; Chen's score system rates our patient as II (good); CFSS score system - 84 points (excellent result). His functional result is similar to that achieved by 2 others mid-forearm recipients.

CONCLUSIONS

The upper limb transplant performed on a functionally unfavorable zone of the mid-forearm has greatly increased patient's quality of life.

[Non-vascularized fibular graft as salvage technique for forearm reconstruction]

Authors report a case of a reconstruction of a large bone defect in the forearm with a free fibular graft occurring a good incorporation of the graft. Authors discuss the interest of fibula graft in reconstruction of large bone defect of the forearm.

Delayed successful free fibula flap for treatment of complex arm gunshot wound--a case report

More than 25% of unintentional gunshot injuries and more than 15% of intentional gunshot injuries involve extremities. In these patients, early acute multidisciplinary treatment is essential and critical to achieve a satisfactory mobility and composite wounds repair. We hereby report a logistic delayed successful treatment of a complex arm gunshot wound with a free fibula flap. The significance of this case report is related to the necessity of emphasising the organised and multidisciplinary approach required to cure these patients in the proper way from a surgical and medical point of view.

Reconstruction of posttraumatic disorders of the forearm

Forearm rotation is crucial for full upper extremity mobility. The two-bone unit with its proximal and distal radioulnar joints should be considered as a single bicondylar articulation. After a traumatic bony forearm injury, surgical treatment for complications, such as deformity, bone loss, or failed fracture healing is challenging because complete return of forearm rotation can be difficult to achieve. It is important to be aware of methods for assessing and managing posttraumatic forearm bony complications, including preoperative assessment and osteotomy techniques for malunited fractures. The vascularized fibular transplant also has been proven as an effective treatment method. Although nonunion of forearm fractures is uncommon, it can prove problematic; therefore, it is beneficial to review options for surgical management.

Osteopetrosis--a challenge for the orthopaedic surgeon

Osteopetrosis (OP) is a rare heterogeneous group of inherited skeletal dysplasias characterised by osteoclast dysfunction, impaired bone resorption and poor bone remodelling. Three groups can be categorised on the basis of clinical findings. These include neurological symptoms, haematological abnormalities and renal tubular acidosis in the first group. Increased bone density, osteomyelitis and frequent fractures are the clinical findings in the second group, and the third group have normal life expectancy but may develop cranial nerve compression and osteomyelitis. Fractures in patients with OP are common and require appropriate pre-, peri- and postoperative management. The long bones are most frequently affected, fractures of the femoral neck and proximal (upper third) shaft being particularly common. This case report proposes possible operative fracture treatment in a patient with OP and highlights the potential perioperative pitfalls in this rare surgical population.

[Application of pedicled muscular flaps of brachioradialis in repairing wounds at proximal forearm resulted]

OBJECTIVE

To explore the clinical effects of pedicled muscular flaps of brachioradialis in repairing wounds at proximal forearm resulted from hot crush injury.

METHODS

From February 2003 to December 2008, 5 wounds at proximal forearm resulted from hot crush injury were repaired with pedicled muscular flaps of brachioradialis. The size of muscular flaps ranged from 6 cm x 4 cm - 9 cm x 5 cm. The wounds at donor sites were closed directly or by free skin grafts.

RESULTS

All the muscular flaps of brachioradialis were survived completely. 4 patients were followed up for 3 to 36 months. The cosmetic and functional results were satisfactory both in recipient areas and in donor sites.

CONCLUSIONS

Pedicled muscular flap of brachioradialis can not only repair wounds at proximal forearm resulted from hot crush injury, but also repair extensor muscle defects. It is an ideal method and is very practical.

[Repair of large skin defect of forearm and hand using bilateral groin flaps and abdominal flaps]

OBJECTIVE

To investigate an operative method of repairing large skin defect of the forearm and the hand.

METHODS

From July 2003 to September 2008, 11 patients with large skin defect of the forearm and the hand were repaired using bilateral groin flaps in complex with abdominal flaps, including 7 males and 4 females aged 17-55 years old (average 33.5 years old). Among the 11 cases, 5 were caused by carding machine and 4 by traffic accident, and the interval between injury and operation was 90 minutes to 6 hours (average 3.5 hours); 2 cases suffered from severe cicatricial contracture deformity in the late stage of burn injury, and the interval between injury and operation was 7 months and 19 months, respectively. The size of skin defect ranged from 42 cm x 12 cm to 60 cm x 16 cm. The flaps harvested during operation was 45.0 cm x 10.5 cm - 62.0 cm x 18.0 cm in size. Pedicle division of the combined flaps was performed 4 weeks after operation. The donor site wound was repaired by direct suturing in 7 cases and by free skin grafting in 4 cases.

RESULTS

All flaps survived. All incisions healed by first intention. The donor site wound all healed by first intention. Skin graft all survived. All patients were followed up for 2 months to 3 years. The flaps were soft in texture, full in contour, and normal in color. Sensory recovery of the flaps was evaluated according to the Criteria of UK Medical Research Council (1954), 4 cases were in grade S1, 6 in grade S2, and 1 in grade S3. Hand function was assessed by the Criteria of Chinese Hand Surgery Society, 7 cases were graded as excellent, 2 as good, 2 as poor, and the excellent and good rate was 81.8%.

CONCLUSION

Combined use of bilateral groin flaps and abdominal flap is an effective approach to repair large skin defect of the forearm and the hand due to its simple operative procedure and satisfying effect.

Free peroneal perforator-based sural neurofasciocutaneous flaps for reconstruction of hand and forearm

BACKGROUND

Sural neurofasciocutaneous flap has been popularly used as an excellent option for the coverage of soft tissue defects in the lower third of leg, ankle and foot, but its free transplantation has been rarely reported. The objective of our work was to investigate the operative technique and clinical results of repairing the soft tissue defects of hand and forearm with free peroneal perforator-based sural neurofasciocutaneous flap.

METHODS

Between May 2006 and March 2007, 10 patients including 7 men and 3 women were treated. Their ages ranged from 22 to 51 years. They presented to emergency with large soft tissue defects of 16 cm x 7 cm to 24 cm x 10 cm in size in hand and forearm after injured by motor vehicle accidents (2 cases) or crushed by machine (8 cases). Thorough debridements and primary treatments to associated tendon ruptures or bone fractures were performed on emergency. And free peroneal perforator-based sural neurofasciocutaneous flaps were transplanted when the wound areas were stable at 5 to 7 days after emergency treatment. The flaps were designed along the axis of the sural nerve according to the shape and size of the soft tissue defects, with the peroneal perforator above the lateral malleolus as the pedicle and along with a part of the peroneal artery for vascular anastomosis. Then the flaps were harvested to repair the recipient sites with the peroneal artery anastomosed to the radial (or ulnar) artery and the peroneal veins to one of the radial (or ulnar) veins and the cephalic vein respectively. The flap sizes ranged from 18 cm x 8 cm to 25 cm x 12 cm. The donor areas were closed by skin grafts.

RESULTS

All of the 10 flaps survived after surgeries. Marginal necrosis occurred in only 2 cases. The skin grafts survived entirely in the donor sites, and no obvious influence on the donor legs was observed. All of the transplanted flaps presented favourable contours and good functions at 9 to 12 months' follow-up.

CONCLUSIONS

Peroneal perforator-based sural neurofasciocutaneous flap has favourable appearance, constant vascular pedicle, reliable blood supply, large size of elevation, and minimal influence on the donor site. The free transplantation of this flap offers a satisfactory alternative for repairing the large soft tissue defects of forearm and hand.

Impairment and employment issues after nerve repair in the hand and forearm

PURPOSE

To evaluate retrospectively subjective impairments, experienced disabilities, job and leisure restrictions and job changes in patients at least 2 years after repair of a peripheral nerve injury in the forearm, wrist or hand.

METHODS

Between January 1,997 and January 2,000, 125 patients were treated surgically for a peripheral nerve injury in the hand and forearm at the Department of Plastic Surgery of a University Hospital. Sixty-one patients met the inclusion criteria. Using a questionnaire the ability to return to work (RTW), the possible consequences on Activities of Daily Life (ADL) and Instrumental Activities of Daily Life (IADL), job, hobby and housekeeping related disabilities and subjective pain were assessed.

RESULTS

Forty of the 61 included patients returned the questionnaire. As a result of the injury, seven patients (19%) were not able to return to their own job and eight patients (20%) needed to quit or change their hobbies. Mean Time Off Work (TOW) was significantly longer (p=0.024) in non-digital nerve lesions (21.4 weeks) as compared to digital nerve lesions (9.5 weeks).

CONCLUSIONS

From this study it was concluded that digital nerve lesions have little consequence on the ability to return to work and the time off work. However, the patients' hobbies are significantly affected. At least 2 years after the injury, the effects on ADL and IADL are minor.