Fingertip reconstruction

The Use of the Symani Surgical System® in Emergency Hand Trauma Care

Background: The use of robotic systems for microsurgery has gained popularity in recent years. Despite its drawbacks, such as increased learning time and lack of haptic feedback, robot-assisted microsurgery is beneficial for emergency care due to its reduced risk of tremor and fatigue. The Symani Surgical System® is 1 example of this advanced technology. The device offers a range of possibilities in the field of microsurgery by combining precision and dexterity, revolutionizing microsurgical procedures. This article explores the applications of the Symani in microsurgical procedures in emergency hand trauma care, highlighting its advantages and limitations. Material and Methods: We present the results of 62 anastomoses of blood vessels under .8 mm diameter after hand trauma. 31 anastomoses were conducted using the Symani Surgical System®, and the other 31 were done as a control group in hand-sewn technique. Study Sample: The patient characteristics, including sex, age, and risk factors, were matched. Results: We found no significant differences in the anastomosis surgery length when performed with the Symani (arterial 17.3 ± 1.9 min; venous 11.5 ± 1.3 min) vs the hand-sewn technique (arterial 16.1 ± 1.4 min; venous 10.2 ± 1.8 min). Additionally, the learning curve consistently decreased over time, with the 10th surgery taking 30% (arterial) less time. Conclusion: Our study indicates that robot-assisted microsurgery can help surgeons maintain a relaxed and focused state while producing results comparable to hand-sutured procedures in emergency care.

From Simple to Complex: Preserving and Reconstructing the Traumatized Thumb

Traumatic thumb injuries significantly affect overall hand function and may result in considerable disability. Reconstructing the traumatized thumb requires a detailed preoperative assessment of the defect and evaluation of the patient's social history and medical comorbidities. Reconstructive techniques can be stratified by the level of thumb injury. The goals of thumb reconstruction are to restore length, stability, mobility, and sensibility. This article reviews reconstructive principles and operative techniques for reconstructing the traumatized thumb.

Blood Vessel Injuries of the Fingers: A Clinical Comparison of One- and Two-Arterial Blood Supply

Traumatic finger injuries are very common in emergency medicine. When patients present with finger injuries, there is often damage to the vascular nerve bundles, which requires subsequent reconstruction. It is unknown if repairing a unilaterally injured artery affects patients' recovery in a well-perfused finger. This retrospective cohort study compares the clinical outcomes of 11 patients with one-vessel supply (mean age 48.3 years; 7 males, 4 females) to 14 patients with two-vessel supply (mean age 44.5 years; 8 males, 6 females). The patient outcomes were assessed using patient questionnaires (Disabilities of Arm, Shoulder, and Hand (DASH), European Quality of Life 5 Dimensions 5 Level Version (EQ-5D-5L), and EuroQol visual analog scale (EQ-VAS)) and a clinical examination of hand function and imaging of circulatory efficiency. No significant changes were observed in the DASH, EQ-5D-5L, and EQ-VAS questionnaires. Clinical evaluation of hand function, measured by cold sensitivity, two-point discrimination, pain numerical analog scale, and grip strength also revealed no significant differences between cohorts. Blood flow measurements using thermal imaging revealed no effects on circulation in the affected digit. Collectively, the study finds reconstruction is not absolutely necessary when there is one intact digital artery as it is sufficient for healing and functional outcomes. We recommend finger artery reconstruction when both digital arteries are injured or if an immediate tension-free suture is possible.

Comparison of Treatment Methods of Thumb-Tip Defects With Phalangeal Bone Exposure: Modified Heterodigital Neurovascular Island Flap Versus Free Lateral Great Toe Flap

PURPOSE

Modified heterodigital neurovascular island flaps and free lateral great toe flaps are dependable methods for treating thumb-tip defects with phalangeal bone exposure. We retrospectively analyzed and compared the details and results of the two methods.

METHODS

This retrospective study included 25 patients with thumb injuries with phalangeal bone exposure treated between 2018 and 2021. Patients were categorized as per the following surgical methods: (1) modified heterodigital neurovascular island flap (12 patients, finger flap group) and (2) free lateral great toe flap (13 patients, toe flap group). The Michigan Hand Outcome Questionnaire, aesthetic appearance, Vancouver Scar Scale, Cold Intolerance Severity Score, static 2-point discrimination, Semmes-Weinstein monofilament, and range of motion of the metacarpophalangeal joint of the injured thumb were evaluated and compared. In addition, operation time, hospital stay, return-to-work time, and complications were recorded and compared.

RESULTS

In both groups, the defect was successfully repaired, with no cases of complete necrosis. The 2 groups had similar mean scores in static 2-point discrimination, Semmes-Weinstein monofilament, range of motion, and Michigan Hand Outcome Questionnaire scores. The aesthetic appearance, scarring, and cold tolerance of the toe flap group were better than the finger flap group. The operation time, hospital stay, and return-to-work time in the finger flap group were shorter than the toe flap group. The finger flap group had 2 complications-a superficial infection and 1 case of partial flap necrosis. The toe flap group had 3 complications-a superficial infection, 1 case each of partial flap necrosis, and partial skin graft loss.

CONCLUSION

Both treatments can achieve satisfactory results; however, they each have advantages and disadvantages.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

To Do or Not to Do? Neurorrhaphy in Great Toe Pulp Flap Fingertip Reconstruction

Since its inception, the great toe pulp (GTP) flap has represented a valid therapeutic choice in the reconstruction of defects of the hand. This study illustrates the clinical outcomes of GTP free flaps performed without nerve anastomosis' mainly for fingertip defect reconstruction.

Methods

We performed a retrospective, monocentric cohort study. All patients included in this study presented with fingertip traumatic injury, with tendon or bone exposure; reconstruction with GTP flap, without nerve reconstruction, was performed by the first author (L.T.) from May 2019 to October 2021.

Results

All 37 flaps survived completely. Due to COVID restrictions' we had to send the tests and PROMs to our patients; 28 of them replied. Cold intolerance was reported by 12 patients (moderate in two cases and mild in ten cases). No pain was complained about either in hand or donor site (Visual Analog Score 0, at rest and at movement). Complete range of motion was achieved in 22 of 28 patients. All flaps recovered protective sensitivity. In every section of the Michigan Hand Outcome Questionnaire, all patients expressed a high level of satisfaction based on the reconstruction's function and aesthetics. Regarding the donor site morbidity, no patient complained about gait disturbance.

Conclusions

This study showed that the GTP flap is the optimal choice for fingertip reconstruction, providing excellent functional and aesthetic results with durable and glabrous skin, satisfactory pulp contour, and sensory restoration. These results could be achieved with no need for nerve suture, especially in defects with no injuries proximal to the loss of substance.

Management of Fingertip Injuries: A Survey of Opinions of Surgeons Worldwide

Introduction  Fingertip injuries are common injuries in all ages. There is currently no consensus nor evidence to support the use of any one treatment, with numerous options available for management. The aim is to review the consensus for treatment of fingertip injuries among surgeons worldwide.

Materials and Methods  Nonprobability judgment sampling using purposive method was performed on surgeons ( n = 65) using two digital platforms of the community of practice of hand surgeons. Three illustrative case scenarios were presented to the participants to understand their consensus on treating fingertip injuries, and their choice of treatment for themselves with a similar injury.

Results  This survey demonstrates that there is a wide range of treatment preferences for fingertip injuries for each clinical scenario. In Allen 1 and in crush injuries, most respondents favored healing by secondary intention (66.2 and 92.3%, respectively). In Allen 3 injuries, 72.3% favored surgical intervention. In all clinical scenarios, most surgeons would want their own fingertip injuries treated identically to how they would treat patients with similar fingertip injuries (93.9, 96.9, and 95.4%, respectively). Furthermore, our study demonstrated experience in surgery was not associated with treatment preferences.

Conclusion  Management of fingertip injuries remains controversial, but this study is suggestive that treatment preferences may not be determinant on patient factors, given that all of our respondents are highly functioning individuals who practice microsurgery, but most chose to administer the same treatment to patients as they would to themselves.

Microsurgical Free Tissue Options for Fingertip Reconstruction

Fingertip injuries occur commonly owing to trauma in everyday life. Performing amputation or stump revision for a fingertip injury can make it possible to quickly return to daily life, but causes functional and cosmetic problems. We believe that free flaps are the ideal way to minimize donor site morbidity and provide satisfactory reconstruction. Fingertips have different anatomic characteristics on the dorsum, volar aspect, and pulp, so it is necessary to select the appropriate free flap. Sometimes for larger defects, composite tissue transfer can be considered for reconstruction. This article discusses various free flap options for different fingertip defects.

Evaluation of Pediatric Fingertip Injuries Using Etiology, Demographics and Therapy

Objectives

In this study, 354 pediatric cases were evaluated and treated at the emergency service department due to fingertip injuries in a four years period. The data were studied using etiology, demographics, treatment and complications. This study aims to draw attention to fingertip injuries that are very common in childhood and to help developing preventive strategies.

Methods

Of the 354 patients, 191 were boys and 163 were girls. Their ages ranged from six months to 17 years. These patients were studied concerning sex, injured hand and fingers, injury mechanism, injury zone, selected treatment modalities and complications. All interventions were performed under local anesthesia at the emergency service department. Patients were discharged on the same day.

Results

In our study group, the male patients (54%) were more affected than the girls (46%). It was observed that the right hand (65.3%) was much more vulnerable to the injury than the left hand (34.7%). It was determined that the most injured fingers were middle fingers in the 136 (38.4%) of the patients, followed by the ring finger (33.9%). Injury was most frequent at five years old patient group. The most frequent type of injury was crush type injuries with a rate of 83.3%, and among crush type injuries, the most common mechanism was trapping of fingers in the doors or windows. While many of these injuries required surgical intervention, appropriate patients were treated with wound care and secondary wound healing.

Conclusion

In childhood, hand injuries are quite frequent and fingertip injuries constitute the majority of these entities. These childhood injuries lead to significant functional, aesthetic and psychological sequelae in these patients. The knowledge about the etiology, distribution and mechanisms of these injuries will enable the development of preventive measures in this regard.

Soft Tissue Coverage of the Digits and Hand

There are multiple options available for reconstruction of soft tissue defects of the digits. The main goal of reconstruction is to achieve normal or near-normal mobility. Soft tissue defects can be considered in the following groups: fingertip, nonfingertip, and multiple digits. The choice of reconstruction for fingertip defects depends primarily on the amount of volar skin available. The patient's functional demands and expectations, and the expertise of the surgeon, also determine the reconstructive strategy.

[The semi-occlusive dressing in treating Allen III and IV fingertip injuries as an alternative to local skin flaps]

BACKGROUND

Fingertip injuries are very common in emergency departments. According to the literature, Allen III and IV fingertip injuries should be treated with local skin flaps. Instead, we have treated these kinds of injuries in recent years with a semi-occlusive dressing. The main purpose of this study was to evaluate the outcome after semi-occlusive dressing therapy with respect to soft tissue cover, recovery of sensibility and duration of disability.

METHODS

We retrospectively analysed 77 fingertip injuries (39 Allen I, 25 Allen II, 9 Allen III, 4 Allen IV) from 2008-2011 in 23 women and 54 men who were treated with a semi-occlusive dressing. The mean age was 36 ± 14 years and the mean follow-up was seven months. The bone was not shortened even if the bone was exposed up to the wound level. The primarily occlusive dressing was left as long as possible and was sealed when necessary. Furthermore, the treatment time with the semi-occlusive dressing and the period of disability was recorded. Patient sensitivity recovery was also analysed.

RESULTS

The mean treatment duration was 21 ± 10 days and the mean duration of disability was 30 ± 17 days. The mean duration of disability was 19 ± 8 days for Allen I injuries, 36 ± 16 days for Allen II, 45 ± 20 days for Allen III and 58 ± 7 days for Allen IV. All patients developed satisfactory tissue cover and sensibility recovery. For amputation injuries of Allen III and IV, we recorded a normal light-touch 2‑point discrimination in the Semmes-Weinstein Test in 77 % and diminished in 23 %. There were no complications like tissue infections, neuroma or osteitis. Also, no secondary flap supply was necessary.

CONCLUSIONS

The semi-occlusive dressing is a good therapy for all kind of fingertip injuries, regardless of the amputation level. Even if the bone is exposed up to the wound level, satisfactory soft tissue cover can be achieved.

Digit Tip Regeneration: Merging Regeneration Biology with Regenerative Medicine

Regeneration Biology is the study of organisms with endogenous regenerative abilities, whereas Regenerative Medicine focuses on engineering solutions for human injuries that do not regenerate. While the two fields are fundamentally different in their approach, there is an obvious interface involving mammalian regeneration models. The fingertip is the only part of the human limb that is regeneration-competent and the regenerating mouse digit tip has emerged as a model to study a clinically relevant regenerative response. In this article, we discuss how studies of digit tip regeneration have identified critical components of the regenerative response, and how an understanding of endogenous regeneration can lead to expanding the regenerative capabilities of nonregenerative amputation wounds. Such studies demonstrate that regeneration-incompetent wounds can respond to treatment with individual morphogenetic agents by initiating a multi-tissue response that culminates in structural regeneration. In addition, the healing process of nonregenerative wounds are found to cycle through nonresponsive, responsive and nonresponsive phases, and we call the responsive phase the Regeneration Window. We also find the responsiveness of mature healed amputation wounds can be reactivated by reinjury, thus nonregenerated wounds retain a potential for regeneration. We propose that regeneration-incompetent injuries possess dormant regenerative potential that can be activated by targeted treatment with specific morphogenetic agents. We believe that future Regenerative Medicine-based-therapies should be designed to promote, not replace, regenerative responses. Stem Cells Translational Medicine 2018;7:262-270.

Looking Ahead to Engineering Epimorphic Regeneration of a Human Digit or Limb

Approximately 2 million people have had limb amputations in the United States due to disease or injury, with more than 185,000 new amputations every year. The ability to promote epimorphic regeneration, or the regrowth of a biologically based digit or limb, would radically change the prognosis for amputees. This ambitious goal includes the regrowth of a large number of tissues that need to be properly assembled and patterned to create a fully functional structure. We have yet to even identify, let alone address, all the obstacles along the extended progression that limit epimorphic regeneration in humans. This review aims to present introductory fundamentals in epimorphic regeneration to facilitate design and conduct of research from a tissue engineering and regenerative medicine perspective. We describe the clinical scenario of human digit healing, featuring published reports of regenerative potential. We then broadly delineate the processes of epimorphic regeneration in nonmammalian systems and describe a few mammalian regeneration models. We give particular focus to the murine digit tip, which allows for comparative studies of regeneration-competent and regeneration-incompetent outcomes in the same animal. Finally, we describe a few forward-thinking opportunities for promoting epimorphic regeneration in humans.

Donor-Site Morbidity after Partial Second Toe Pulp Free Flap for Fingertip Reconstruction

BACKGROUND

In this study, we characterize the morbidity at the donor-site of partial second toe pulp free flaps in terms of wound management as well as long-term outcomes.

METHODS

A single-institutional retrospective review was performed for patients who had undergone partial second toe pulp free flap transfer to the fingertip. Patient charts were reviewed for infection, skin necrosis, wound dehiscence, and hematoma for the donor site. Additionally, a questionnaire survey was given to patients who had a follow-up of longer than 1 year to characterize long-term postoperative pain and appearance.

RESULTS

The review identified a total of 246 cases. Early wound complications were significant for wound dehiscence (n=8) and hematoma (n=5) for a wound complication rate of 5.3%. The questionnaire was distributed to 109 patients, and 54 patients completed the survey. Out of these 54 patients, 15 patients continued to have donor-site pain (28%) at a mean follow-up period of 32.4 months. However, the pain intensity was relatively low in the range between 2 to 5, on a 0-10 scale. None of these patients felt this donor-site pain interfered significantly with daily activity, nor did any patient require pain medications of any type. Donor-site appearance was satisfactory to most patients.

CONCLUSIONS

The partial second toe pulp flap was associated with low rates of wound complications and favorable long-term outcomes. Given the functional and aesthetic gain in the recipient finger, donor-site morbidities appear acceptable in this patient population. This study can be helpful in counseling patients regarding donor-site morbidity during the informed consent process.

Reconstruction of the traumatized thumb

BACKGROUND

The goals of thumb reconstruction include the restoration of thumb length, strength, position, stability, mobility, sensibility, and aesthetics. It is a rare event when all of these objectives can be achieved, and prioritization should be based on the goals and functional demands of the patient.

METHODS

In this article, the authors review the most common reconstructive strategies for all types of traumatic thumb defects.

RESULTS

Replantation is approached first as the primary option for most amputations. Nonreplantable injuries are organized using a simple classification adapted from Lister, dividing thumb amputations into four functional categories: soft-tissue deficit with acceptable length, subtotal amputation with borderline length, total amputation with preservation of the carpometacarpal joint, and total amputation with destruction of the carpometacarpal joint. Within each category, relevant microsurgical and nonmicrosurgical reconstructive techniques are discussed, with a focus on appropriate technique selection for a given patient. Evidence and outcomes data are reviewed where available, and case examples from our own experience are provided.

CONCLUSIONS

Given that available options now range from simple gauze dressings to complex microsurgical reconstruction, preservation of reconstructive flexibility is essential and should be facilitated by judicious preservation of intact structures. The divergence of available reconstructive pathways underscores the importance of knowing one's patients, understanding their motivation, and assessing their goals. Only in properly matching the right reconstruction with the right patient will a mutually satisfactory result be achieved.

Resurfacing glabrous skin defects in the hand: the thenar base donor site

Defects of the glabrous skin surfaces of the palm and fingers result from numerous causes including larger fingertip injuries, unhealed burns, and after surgery for diverse pathologies. The qualities of glabrous skin are specifically tailored to the functional requirements of high-shear strength and robustness. Despite these unique properties, graft reconstruction of defects in the glabrous regions of the hand is frequently achieved with skin from nonglabrous donor sites such as the medial forearm. Nonglabrous skin has a poor color and texture match for such applications and is frequently associated with tender and unsightly donor scars. We describe our experiences of harvesting full-thickness grafts from the glabrous skin centered over the proximal flexion crease at the level of the metacarpophalangeal joint of the thumb. We have utilized this site to harvest skin grafts of up to 2 cm in width for the resurfacing of small-sized to medium-sized defects on the palmar surfaces of the hands and fingers in 28 patients under both traumatic and elective circumstances. The skin has an excellent type-match to the defect and is quick and easy to harvest due to its adjacent location to the defect. The donor scar matures quickly, and as it lies along the thumb base crease, it runs along one of the least used contact surfaces, thereby limiting the potential discomfort associated with FTSG harvest sites from other areas. Patient satisfaction with the procedure has been high, and it represents a useful alternative to traditional nonglabrous skin graft donor sites for small-sized to medium-sized defects.

Local and regional flaps for hand coverage

Hand surgeons are frequently challenged by the unique requirements of soft tissue coverage of the hand. Whereas many smaller soft tissue defects without involvement of deep structures are amenable to healing by secondary intention or skin grafting, larger lesions and those with exposed tendon, bone, or joint often require vascularized coverage that allows rapid healing without wound contraction. The purpose of this review was to present an overview of local and regional flaps commonly used for soft tissue reconstruction within the hand.

The anterograde homodigital neurovascular island flap

The value of the human fingertip is incalculable. More than just aesthetic, the fingertip is an instrument through which we navigate our environment and acquire information. All too often, fingertip reconstruction is either not attempted or attempted without adhering to the fundamental principle of "replacing like with like." Through detailed description and case examples, this article highlights the power and utility of the anterograde homodigital neurovascular island flap in fingertip reconstruction. This single-stage flap can reliably resurface large soft tissue defects with sensate glabrous skin.

Fingertip reconstruction using free toe tissue transfer without venous anastomosis

BACKGROUND

This study was designed to introduce the feasibility of toe tissue transfer without venous outflow for fingertip reconstruction.

METHODS

Five cases of fingertip defects were treated successfully with this method. Four cases were traumatic fingertip defects, and one case was a hook-nail deformity. The lateral pulp of a great toe or medioinferior portion of a second toe was used as the donor site. An arterial pedicle was dissected only within the digit and anastomosis was performed within 2 cm around the defect margin. The digital nerve was repaired simultaneously. No additional dissection of the dorsal or volar pulp vein was performed in either the donor or recipient sites. Other surgical procedures were performed following conventional techniques. Postoperative venous congestion was monitored with pulp temperature, color, and degree of tissue oxygen saturation. Venous congestion was decompressed with a needle-puncture method intermittently, but did not require continuous external bleeding for salvage.

RESULTS

Venous congestion was observed in all the flaps, but improved within 3 or 4 days postoperatively. The flap size was from 1.5×1.5 cm(2) to 2.0×3.0 cm(2). The mean surgical time was 2 hours and 20 minutes. A needle puncture was carried out every 2 hours during the first postoperative day, and then every 4 hours thereafter. The amount of blood loss during each puncture procedure was less than 0.2 mL. In the long-term follow-up, no flap atrophy was observed.

CONCLUSIONS

When used properly, the free toe tissue transfer without venous anastomosis method can be a treatment option for small defects on the fingertip area.

Thumb reconstruction

Thumb reconstruction aims to restore the cardinal thumb traits and actions including mobility, stability, sensibility, length, and appearance. The level of thumb loss is divided into thirds: distal (tip to interphalangeal [IP] joint), middle (IP joint to metacarpal neck), and proximal (metacarpal neck to carpometacarpal joint). Distal third reconstruction usually requires only soft tissue restoration. Many options exist for middle third reconstruction, including increasing thumb ray length (metacarpal lengthening, osteoplastic reconstruction, toe transfer) and increasing relative length (phalangization). Proximal third reconstruction is best accomplished with toe transfer, pollicization, or on-top plasty (pollicization of a damaged index finger).

Patient-specific prosthetic fingers by remote collaboration--a case study

The concealment of amputation through prosthesis usage can shield an amputee from social stigma and help improve the emotional healing process especially at the early stages of hand or finger loss. However, the traditional techniques in prosthesis fabrication defy this as the patients need numerous visits to the clinics for measurements, fitting and follow-ups. This paper presents a method for constructing a prosthetic finger through online collaboration with the designer. The main input from the amputee comes from the Computer Tomography (CT) data in the region of the affected and the non-affected fingers. These data are sent over the internet and the prosthesis is constructed using visualization, computer-aided design and manufacturing tools. The finished product is then shipped to the patient. A case study with a single patient having an amputated ring finger at the proximal interphalangeal joint shows that the proposed method has a potential to address the patient's psychosocial concerns and minimize the exposure of the finger loss to the public.