Replantation of degloved skin of the hand

Harnessing the Degloved Palm in Crush Injury Management

Degloving injuries of the upper limbs, common in industrial settings, pose significant reconstructive challenges. The injury's severity dictates the approach, from primary closure and skin grafting to complex free tissue transfer. Proper preparation of both the wound bed and degloved tissue is crucial, as the degloved tissue can serve as an effective biological dressing. Furthermore, salvaging this tissue and preparing it as a full-thickness skin graft can lead to good graft take-up and healing. This case report presents a 23-year-old male who sustained a severe crush and degloving injury to his right hand from heavy machinery. Using meticulous debridement and careful preparation of the degloved tissue, we achieved optimal wound management and coverage. This case highlights the critical role of preparation technique in achieving successful outcomes and underscores the potential benefits of using the degloved tissue prior to complex reconstructive scenarios, offering valuable insights for clinical practice.

A Useful Technique for Templating the Reverse Radial Forearm Flap (RFF) for Thumb Degloving Injuries

Degloving injuries of the thumb pose a significant challenge as replantation is usually unsuccessful. A 60-year-old man was transferred to "Queen Victoria Hospital NHS Trust" four hours after having his left thumb completely avulsed at metacarpophalangeal level. The anastomosis repeatedly failed during urgent replantation and a distally based pedicled RFF was utilized. To achieve accurate flap design, we used the amputated part as a template for the missing tissue. After a longitudinal cut exposing the inner surface, the thumb was placed flat on top of a clean gauze package which was used as a paper template for the skin paddle; the flap was subsequently sutured without tension. Since the circumferential soft tissue envelope is three-dimensional, accurate designing of the flap on the forearm is vital. We propose a useful technique using the amputated part to enable a precise estimation of the tissue requirements to reduce potential complications related to flap inset.

Replantation using groin flap in thirty-four years old male with traumatic total degloving of little finger: A case report

INTRODUCTION AND IMPORTANCE

Degloving injuries of the hand or fingers have a devastating presentation which challenges a surgeon to conduct reconstruction in order to resurface the naked finger and recover its function. The gold standard treatment for degloving injuries is using skin grafting and flap. The pedicle of groin flap is based on superficial circumflex iliac artery. It is one of standard flaps used in reconstruction of degloving fingers. In this study, we use groin flap for reconstruction of traumatic total degloving little finger.

PRESENTATION OF CASE

This is a case of 34-years old man with total degloving of his left little finger because stuck inside running cutting machine in a clothes factory. The patient was then brought to the Hasan Sadikin General Hospital. The patient underwent thorough debridement, preparation of the donor site, and groin flap. After a week, the wound was in good condition with no signs of infection.

CLINICAL DISCUSSION

The groin or skin flap is pedicled and vascularized by superficial circumflex artery. It can be considered as an option for treatment of single finger degloving wound because of its compliant nature and vascularization reliability. Despite this, it often results in bulky appearance which needs to be reconstructed later.

THE CONCLUSION

Groin flaps are an appropriate method in managing degloving little fingers and are still cosmetically acceptable.

Combined great toe dorsal nail-skin flap and medial plantar flap for one-stage reconstruction of degloved finger

BACKGROUND

Historically, the degloved finger with the total loss of nail and skin had been resurfaced with an expanded great toe wrap-around flap transfer for better outcomes. The purpose of this study aims to present our experience with a related modified design, with total preservation of a weight-bearing plantar skin.

METHOD

From April 2016 to September 2019, nine fingers (5 index and 4 middle fingers) in nine cases, with skin loss to the base of the proximal phalangeal or metacarpophalangeal (MCP) joint level, were reconstructed with combined great toe dorsal nail-skin flap and medial plantar artery perforator (MPAP) flap. The dorsal great toe donor was covered with a thin groin flap, and the medial plantar site was covered with a full-thickness skin graft. The cutaneous nerves were preserved within both flaps. Standardized assessment of outcome in terms of sensory, functional, and esthetic performance of the reconstructed fingers was completed.

RESULTS

Flap survival was achieved in all cases. The contour of the reconstructed digits was comparable with the contralateral one. The fingers were available for a mean follow-up of 28 months (ranged, 22-39 months). The mean dimension of the great toe dorsal nail-skin flap was 8.5 × 4.0 cm (ranged, 6.5 × 3.5-11.0 × 4.5 cm). The average size of the MPAP flap was 6.5 × 4.5 cm (ranged, 5.0 × 3.5-8.0 × 5.5 cm). At the last follow-up, the functional and aesthetic consequences were satisfactory, as well as the restored sensory.

CONCLUSION

Reconstruction of degloved fingers with the great toe dorsal nail-skin flap combined MPAP flap, preserving a plantar weight-bearing area, results in excellent contour and functional outcome. Donor-site morbidity in the foot was minimal.

Revascularization of a Circumferential Hand and Forearm Degloving Injury Using an Arteriovenous Shunt

Major upper-extremity degloving injuries with distal dysvascularity are rare and challenging surgical problems. When these degloving injuries occur over nonexpendable regions, such as the glabrous skin of the palm and digits, revascularization or replantation may be the treatment of choice. Because the degloved skin flap is often separated in the suprafascial plane, direct arterial repair may be impossible. We present a rare case of circumferential degloving of the hand and forearm with distal dysvascularity, treated successfully with revascularization with arterial anastomosis, venous anastomosis, and arteriovenous shunt creation. The patient required reoperation for partial flap loss and ligation of the arteriovenous fistula. At final follow-up 16 months after the injuries, she showed independence in activities, reported good functional use of the hand, and worked full-time at her original occupation.

Clinical Outcomes in Ring Avulsion Fingers and Systematic Review of the Literature

Ring avulsions continue to be a challenge in reconstructive surgery. We conducted a retrospective study and reviewed all Urbaniak-Kay type IV degloving injuries replanted at our institution between 2011 and 2018. A systematic review of the literature was also conducted to assess the survival rates, functional, and sensibility outcomes. The results of our systematic review outline a survival rate of 79.50% (101/127). With 1 artery being repaired, 79% of the fingers survived, a value that increased to 87.50% when 2 arteries were anastomosed (P = 0.484). Statistically significant differences (P < 0.001) were found when comparing the survival rates of the fingers with 2 or more veins repaired (87%) with those with only 1 vein anastomosed (51.90%). In terms of nerve reconstruction, there was a significant difference (P < 0.001) with the 2-point discrimination test in favor of the reconstructed group when nerve reparation was done (10.80 mm ± 2.95 mm) versus when digital nerves were not repaired (15.25 mm ± 0.50 mm). Fingers after secondary procedures did not obtain better mobility. The mean total active motion in nonreoperated fingers was 221 degrees (195-270 degrees), whereas the total active motion in the cases who received secondary surgeries was 152 degrees (110-195 degrees), with statistically significant differences (P = 0.02). Therefore, we recommend attempting replantation of degloved fingers. All efforts must be done to carry out 2 vein anastomoses, and our results strongly recommend attempting at least some kind of nerve reconstruction. Secondary surgeries should be reserved for selected cases only, because of the extensive scarring in this kind of injuries. Early mobilization protocols must be encouraged to achieve a good functional result.

Hyperoxygenated solution improves tissue viability in an avulsion injury flap model

BACKGROUND

Management of avulsion injuries remains a challenge due to necrosis. The aim of the present study is to create an experimental model reproducing an avulsion injury and investigate the effects of hyperoxygenated solution (HOS), a method of oxygen delivery that has been widely used in the therapy of ischaemia-hypoxia diseases, on avulsion injury flap survival in rats.

METHODS

Forty male rats were divided into four groups (n = 10 each). Dorsal random pattern flaps measuring 3 × 9 cm, including the panniculus carnosus, were elevated and run over by the skin avulsion model machine, and the flaps were then sutured into their original places. The sham+HOS and avulsion+HOS groups received intravenous HOS (20 ml/kg) each day for 7 days after the operation. The sham+saline and avulsion+saline groups received intravenous saline solution (20 ml/kg) each day for 7 days after the operation. Percutaneous O₂ pressure (TcpO₂) measurement_, serial examinations of skin flap blood perfusion, skin flap survival evaluation and histopathology were performed to assess the efficacy of HOS on avulsion injury.

RESULTS

Compared to the avulsion+saline groups, TcpO₂ was significantly higher in the avulsion+HOS groups at 15, 30 and 60 min after infusion (P < 0.05). The blood perfusion of flaps in the avulsion+HOS group was higher than in the avulsion+saline group (P < 0.05). The survival rate was higher in the avulsion+HOS group than in the avulsion+saline group (P < 0.05), and the histopathology assays supported the data.

CONCLUSION

We succeeded in developing an avulsion injury model and demonstrated that HOS could improve the survival of the avulsion injury flaps in rats by effectively increasing the local oxygen content and blood perfusion and ameliorating inflammatory damage.

Compressed Fixation Combined with Vacuum-Assisted Closure for Treating Acute Injury of the Heel Fat Pad

Background

Treating acute injury of the heel fat pad is different from treating common soft tissue damage. Due to the paucity of literature on the topic, we described our initial experience treating acute injury of the heel fat pad to determine the ideal treatment method.

Material/Methods

A total of 53 patients with acute injury of the heel fat pad admitted to our hospital were selected for the study and were randomly divided into 2 groups: the compressed fixation combined with vacuum-assisted closure group and the only reimplanted and sewn group. Twenty-seven of the heel fat pads were compressed and fixed using a flat, hard piece of plastic and hollow screws; then, they were covered with a vacuum-assisted closure device. The other 27 were only sewn without tension. The clinical results were evaluated according to the American Orthopedic Foot and Ankle Society hindfoot score and the British Medical Research Council function evaluation criteria

Results

In the compressed fixation combined with vacuum-assisted closure group, flaps of 12 feet with retrograde avulsion injury survived successfully. Partial flap necrosis occurred in 8 feet. Seven feet underwent repair using the neurocutaneous vascular resupinated island flap. Results were excellent or good for 74% of patients according to the AOFS. However, in the only reimplanted and sewn group, results were excellent or good for 44% of patients according to the AOFS.

Conclusions

Compressed fixation with vacuum-assisted closure is effective for treating acute injury of the heel fat pad, with high success rates and good utility.

Successful repair of total hand degloving injury by avulsed skin in situ replantation through vascular transplantation: a case report

A 35-year-old man presenting with right-sided total hand skin degloving injury due to crushing of printing machine was reported in this study. The superficial vein of forearm was transplanted intraoperatively to reconstruct the blood supply, and the avulsed skin was replanted in situ. The patient was followed-up for 2 years, and satisfactory results and functional recovery were achieved.

Techniques and survival incidence for revascularization of degloved fingers

We report techniques and survival incidence of three subtotally and nine completely degloved fingers in seven patients. We performed end-to-end arterial repairs in seven fingers, vein graft repairs for arteries in two fingers, arteriovenous anastomoses in three fingers. End-to-end vein anastomosis was performed in all fingers. One finger requred re-exploration. Soft tissues in the eight degloved fingers survived completely, two failed completely, and two were partially necrotic. We conclude from our results that following revascularization, the skin from a completely degloved finger skin will survive in approximately two cases out of three.

LEVEL OF EVIDENCE

IV.

Microsurgical thumb repair and reconstruction

In this article, we review microsurgical reconstructive techniques available to treat thumb amputation at different levels based on our experience. We reference techniques used by other surgeons and identify the most suitable technique for different clinical situations. Indications and techniques for microsurgical partial or composite transfer of the great or second toe for thumb reconstruction are summarized. Different microsurgical transfer techniques suggest a great freedom of surgical choices. However, the choices are considerably restricted if all functional and cosmetic requirements are to be met. We recommend individualized surgical design and reconstruction because each case of thumb amputation is unique.

The use of pedicled abdominal flaps for coverage of acute bilateral circumferential degloving injuries of the hand

Reconstruction of bilateral soft tissue defects in hand and distal third of the forearm, is a challenge for any reconstructive surgeon. When there is circumferential skin loss affecting the whole hand and fingers as in major degloving injuries, the extent of tissue required for reconstruction narrows down the choice of flaps. When the injury affects both hands the magnitude of the problem becomes compounded. There is no report in the literature of free skin flaps to cover circumferential degloving injuries in both hands. We are presenting the technical considerations and outcome of pedicled abdominal flaps used for immediate coverage of circumferential degloving injuries of both hands.

Teletriage for patients with traumatic finger injury directing emergency medical transportation services to appropriate hospitals: a pilot project in Nagoya City, Japan

INTRODUCTION

Emergency medical technicians in Japan have experienced difficulties in identifying hospitals that will accept patients with severe finger injuries. We developed and managed a system named Interactive Teletriage using mobile phone photos to aid efficient patient transportation. The aim of this study was to investigate features related to the transportation of patients with severe finger injuries and to evaluate the feasibility of this system.

MATERIALS AND METHODS

We prospectively analysed data from the medical association of Aichi Prefecture and the Nagoya City Fire Department in Japan. We investigated features related to the transportation of 474 patients with severe finger injuries in Nagoya from 2010 to 2013: 100 in 2010, 134 in 2011, 125 in 2012, and 115 in 2013. We began using Teletriage in August 2011 and compared the periods before and after its implementation.

RESULTS

The time of injury showed two different peaks from 09:00 to 11:00h and at 13:00h. The number of patients injured during each weekday was generally the same, while cases on Saturdays and Sundays reflected 70% and 47% of the weekday average, respectively. Of the 474 patients, 395 (83%) were accepted to hospitals after 3 or fewer requests for admission: 160 of 202 (79.2%) before and 235 of 272 (86.4%) after Teletriage, constituting a significant increase (p=0.039). Furthermore, the number of patients who required 4 or more requests significantly decreased after implementation of Teletriage (p=0.039): 42 patients (20.8%) before and 37 (13.6%) after Teletriage. Our data showed that as the number of requests until final determination increased, the transportation period increased. Furthermore, the mean transportation period significantly decreased from 22.3min before to 18.1min after Teletriage (p=0.021). As the number of requests until final determination increased, the proportion of patients transported to Level I and II hospitals decreased; conversely, the proportion of patients transported to Level III, IV, and V hospitals increased.

CONCLUSIONS

Our results indicated that the implementation of Teletriage has the potential to ease the problem of emergency medical transportation for those with severe finger injuries.

Successful repair of flayed tissue in a degloving injury of the hand by arteriovenous anastomosis

We report the case of a 43-year-old man who had a degloving injury of the left hand from a printer machine. There was no response to a pin prick test over the peripheral portion of the degloved skin, so a branch of a digital artery was selected for anastomosis to a subcutaneous vein, which resulted in survival of the degloved tissue with no signs of congestion. Postoperative care and rehabilitation were straightforward, and functional results.were satisfactory.

Effect of hyperbaric oxygen therapy on healing in an experimental model of degloving injury in tails of nicotine-treated rats

The aim of this study was to investigate the effect of hyperbaric oxygen (HBO) therapy on healing in an experimental model of a degloving injury of the tails of nicotine-treated rats. Thirty-two male Sprague-Dawley rats were randomized to four groups (n = 8): nicotine (group 1); HBO (group 2); nicotine + HBO (group 3); and control (group 4). The mean length of the necrotic parts of the tails at the degloving injury site was significantly higher in group 1 compared with groups 2, 3, and 4, and was significantly lower in group 2 compared with groups 1, 3, and 4. The mean histopathological stage of ulcers at the degloving injury site was statistically significantly higher (more severe) in group 1 compared with groups 2, 3, and 4, and was statistically significantly lower in group 2 compared with groups 1, 3, and 4. It appears that the negative effects of nicotine on wound healing in degloving injuries are negated by the positive effects of immediate HBO therapy.

Results of replantation of 33 ring avulsion amputations

PURPOSE

Despite microsurgical advances, it is still difficult to achieve satisfactory functional results in cases of replantations following complete ring avulsion amputations. Our aim is to report the experience we have collected since the early 1990s in the treatment of this type of injury.

METHODS

We replanted 33 fingers on 33 patients (age, 15-54 y) with complete ring avulsion amputation injuries. Twenty-eight amputations were distal to the insertion of the flexor digitorum superficialis, and 5 were complete degloving injuries with intact tendons. Vascular transpositions and vein grafts were used, and in all cases, only 1 of the digital nerves was repaired.

RESULTS

The 29 successful cases were tracked over an average follow-up of 89 months. The average total active motion of the reconstructed finger was 185°. Sensibility evaluated by static 2-point discrimination varied from 9 to 15 mm and by moving 2-point discrimination from 8 to 15 mm. Five patients complained of cold intolerance.

CONCLUSIONS

Resection of the avulsed digital artery and vein is the most crucial part of the procedure.Vessels reconstruction can be performed using various methods, but vessel transfers from the middle finger appear to be the most reliable solution. The outcome of the cases demonstrates that replantation should be attempted.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Replantation of a circumferentially degloved ring finger by venous arterializations

Treatment of ring degloving injuries of the finger is one of the most demanding problems in hand surgery. Replantation has been advocated as the best solution if the vessels belonging to the degloved skin are not irreversibly destroyed. We present a case involving a ring finger with circumferentially avulsed skin. Debridement under microscopy showed that the peeled skin did not retain any arteries, but did have various superficial veins of good caliber. The neurovascular bundles of the finger remained in situ and did not appear to be disrupted. The degloved finger survived uneventfully by venous arterialization, retaining excellent function and appearance.

Replantation of a degloved hand with added arteriovenous anastomoses: report of two cases

Revascularization of the degloved skin is generally accepted as the best option for the management of totally degloved hands. Nevertheless, the selection of vessels for anastomoses is usually difficult in this situation, and insufficient perfusion of the degloved hand skin is common after arterial repair. We present 2 cases of patients who sustained totally degloved hand injuries. Favorable outcomes of replantation were achieved with added arteriovenous anastomoses between the dorsal veins of the degloved hand skin and the digital arteries.

Microsurgical Replantation of a Small Segment of Thumb Volar Skin

This report presents a case of microsurgical replantation of a volar skin segment of the thumb. In a 24-year-old patient, a heavy object falling over the dominant thumb resulted in a crush-avulsion injury of a pure skin segment measuring 4 x 2 cm. Examination revealed that the distal fingertip as well as the bone-tendon structures remained intact. Exploration demonstrated that both neurovascular bundles were included in the avulsed skin segment. Microsurgical replantation was achieved successfully, repairing the radial digital artery at both ends with vein grafts as well as anastomosing a palmar vein. Both digital nerves were coapted proximally and distally. An excellent functional and cosmetic result was accomplished with a good sensory recovery. The authors conclude that microsurgical replantation should be attempted in cases of more proximal pure skin avulsions, even if the injury spares distal fingertip tissue or bone-tendon units. In such cases, replantation is superior to any other method of reconstruction. Liberal use of vein grafts is crucial to achieve success.

Long-term results of replantation for complete ring avulsion amputations

Ring avulsion injuries have long presented complex management problems. Despite microsurgical advances, it is difficult to achieve good functional results in complete degloving injuries or amputations, and their management remains somewhat controversial. Ten patients with class IV injuries according to Kay's classification were treated from 1986 to 2000. In this study the authors subdivided class IV injuries into those with amputation distal to the insertion of the flexor digitorum superficialis tendon (class IVd, 5 cases); those with amputation proximal to the insertion of the flexor digitorum superficialis tendon (class IVp, 3 cases); and complete degloving injuries leaving the tendons intact (class IVi, 2 cases). Replantation was done in class IVi and class IVd injuries, and 6 cases were revascularized successfully. In all these patients range of motion was complete at the metacarpal and proximal interphalangeal joints, but reestablishing sensibility was more difficult. Patients with class IVp injuries were treated by surgical amputation of the digit. Modifications of Kay's classification system based on anatomic injury is more predictive of functional outcome for completely amputated ring avulsion injuries. The authors conclude that complete ring avulsion amputations are salvageable, with acceptable functional results in select patients.

Surgical treatment of chronic gluteal hidradenitis suppurativa: reused skin graft technique

BACKGROUND

The treatment of chronic lesions in hidradenitis suppurativa (HS) remains a challenge for dermatologists. In most cases, wide surgical excision of the affected skin reduces the recurrence rate to a minimum. Split-thickness skin grafts have usually been applied to resurface large postoperative defects. OBJECTIVE. : The aim of this study is to introduce an alternative method of skin grafting, called "reused" or "recycled" skin graft, for the reconstruction of the large skin defect with chronic gluteal HS.

METHODS

The study consisted of six patients (two females and four males) with gluteal HS. After a wide en bloc excision, the wound was immediately recovered with meshed-skin graft, made from the resected skin itself. Thus, the sacrifice of the skin donor is spared. The drum dermatome (Padgett-Hood) is suitable to take the split-skin graft from the resected skin of the affected buttock. The thickness of grafts was set between 12/1,000 and 20/1,000 inches, and all grafts were meshed with 1.5 times the expansion. The skin grafts were secured in place on the wound and a tie-over dressing was applied.

RESULTS

Postoperative complications were usually minor ones, such as hematoma, discharge, and small areas of graft skin necrosis (less than 1 cm2), although one patient developed a 3 x 4 cm2 graft necrosis and wound infection. The follow-up period after surgery ranged from 8 to 36 months. No patient experienced any functional disabilities or recurrence during follow-up years.

CONCLUSION

When the epidermal involvement remains mild to moderate, this reused skin graft technique is an alternative choice to resurface the surgical defect of gluteal HS. It is superior to the conventional procedure, which requires fresh skin donor site.

Ring avulsion replantation by extended debridement of the avulsed digital artery and interposition with long venous grafts

Ring avulsion replantation is a technically challenging procedure with a very low success rate. Because the zone of arterial injury is more extensive than what it appears to be in such avulsion amputations, a technique was developed to debride the avulsed digital artery for a long distance, extending well into the digital pulp, thereby creating healthy arterial ends to be bridged by one or two segments of long venous grafts. Using this technical approach, 7 patients with complete amputations of ring avulsion injury (Urbaniak's class III) were operated. In all amputations the bone was disrupted at the distal interphalangeal level (except in 1 patient) and the soft tissues at the proximal phalanx level, with the proximal interphalangeal joint and the flexor digitorum superficialis tendons being intact. Results indicated that replantation was successful in all patients. However, 2 patients presented with unusually late arterial failure 28 and 30 days after surgery respectively. Although one of these cases was salvaged by reoperation, the other case (followed by conservative management) demonstrated partial distal necrosis. Therefore, the ultimate success rate in this series was 85% in the long term. At follow-up, sensibility was protective in all patients, with an average static two-point discrimination of 7.8 mm (range, 6-14 mm). The total active motion of the replanted digits was 194 deg on average (range, 155-205 deg) without loss of function of the proximal interphalangeal joint except in 2 patients who had late vascular problems. The authors conclude that microsurgical replantation of completely amputated ring avulsion injuries with an intact proximal interphalangeal joint and flexor digitorum superficialis tendon, is a worthwhile procedure that results in good functional and aesthetic results. Furthermore, using an aggressive approach for debridement of the avulsed digital artery, as described in this article, an experienced microsurgeon can replant successfully nearly all cases. However, one should be cautious in the follow-up of such patients, because late arterial failure may be encountered, as was observed in 2 patients in this series. The authors suggest immediate reoperation in such unusual circumstances.

The use of a thin abdominal flap in degloving finger injuries

Three multiple-finger degloving injuries were successfully resurfaced with thin abdominal flaps. This method offers immediate total wound coverage in multiple-finger degloving injuries.

Salvage of completely degloved finger with a posterior interosseous free flap

The use of a free posterior interosseous skin flap should be considered in a single digit degloving injury, especially when replantation of the avulsed skin or the use of skin from the second toe, transferred as a composite-tissue flap, is not feasible. The flap is thin and pliable. It allows early mobilisation with good recovery of joint motion and attains protective sensation of the finger.