Correlation of volumetric flow rate and skin blood flow with cold intolerance in digital replantation

Transplantation of a free fillet flap from discarded fingers for repair of a finger pulp skin defect: a case report

Background

Replantation represents a treatment option for patients with severed finger pulps. However, in some cases, replantation is a challenging task.

Case presentation

We report a successful case of finger pulp reconstruction of the ring finger using free flaps from a nonreplantable index finger in a spare-parts procedure. A 43-year-old worker accidentally injured the index, middle and ring fingers of his left hand on a machine turntable. The severed index and middle fingers and the distal pulp of the ring finger could not be replanted in situ due to extensive contusion of blood vessels and soft tissues. After vascular and nerve anastomosis, a free skin flap isolated from the nonreplantable index finger was transplanted to the wound of the distal pulpal defect of the ring finger. The flap survived completely postoperatively. Six months after the operation, only a slight deformity of the ring finger was observed. Moreover, sensation of the digit recovered well.

Conclusions

Spare-part surgery is a surgical approach that effectively saves and utilizes tissue that would otherwise be discarded in cases of severe limb trauma. This idea may be applied to treatment of severe injuries to multiple fingers. Additionally, in the process of tissue transplantation and repair, attention should be given to protecting the tissue in the recipient area to avoid damage to the original undamaged tissue structure, which can adversely affect healing and recovery of the tissue.

Is microsurgical experience essential in Zone II flexor tendon injuries?

OBJECTIVES

This study aims to investigate whether microsurgical experience was necessary for the treatment of Zone II flexor tendon injuries.

PATIENTS AND METHODS

Between October 2018 and October 2021, a total of 73 Zone II flexor tendon injuries in 71 patients (53 males, 18 females; mean age: 39.6±12.1 years; range, 21 to 57 years) who underwent surgical intervention in our center were retrospectively analyzed. All patients in the study had flexor digitorum profundus (FDP) tendon injury. The clinical outcomes of patients with digital artery injury, nerve injury or phalanx fracture accompanying FDP tendon injury were evaluated separately according to the American Society for Surgery of the Hand (ASSH) scores. The scores of multiple injuries accompanying FDP tendon injury in patients with FDP+flexor digitorum superficialis (FDS)+digital nerve injury and FDP+FDS+digital artery+nerve injury were evaluated.

RESULTS

The mean ASSH score was 69.4±28.2 in the group with FDP tendon injury accompanying digital nerve injury and 62.9±19.7 in the group with FDP tendon injury and digital artery injury. The clinical outcomes were significantly lower in patients with digital nerve injury and digital artery injury respectively, compared to patients without accompanying injuries (p=0.029 and p=0.012, respectively). The lowest mean score (45.3±10.2) was in patients with fracture accompanying FDP tendon injury and ASSH score was significantly lower than in patients without fracture (p<0.001).

CONCLUSION

Zone II flexor tendon injuries are frequently accompanied by digital artery or nerve injuries, which usually require microsurgical repair. If left untreated, treatment outcome may be poor. Surgical centers and departments undertaking the treatment of flexor tendon injuries should be able to perform microsurgery.

The incidence and severity of the cold intolerance after reverse homodigital dorsoradial flap for coverage of thumb tissue defect

BACKGROUND

The reverse homodigital dorsoradial flap (RHDF) has been an optional treatment for thumb soft tissue defects. The current study aims to investigate the incidence and severity of cold intolerance after the use of the RHDF for thumb soft tissue reconstruction.

METHODS

49 patients with thumb soft-tissue defects treated with RHDF from 2010 to 2018 were included with the mean follow-up time of 36 (range, 14-61) months. The assessment of sensory recovery in the flap, the Cold Intolerance Symptom Severity (CISS) questionnaire, symptoms triggering temperature grade, and natural history of the symptoms were included in the final follow-up.

RESULTS

35 out of 49 patients (71.4%) reported cold intolerance. The mean CISS score of 35 cases was 28 (range 3-72) points. The mean age of the intolerance group was significantly older than that of the non-cold intolerance group. The incidence of cold intolerance in the dorsum was significantly lower than in the pulp and tip. Significantly positive correlations were presented between CISS scores and temperature grades of symptoms triggered. Seven patients were with partial recovery while 6 patients were with complete recovery from negative symptoms. 22 patients reported no change in terms of the symptoms.

CONCLUSIONS

Cold intolerance is a common complication after the RHDF for thumb tissue reconstruction, especially in the elderly population. Cold intolerance following RHDF warrants more attention for surgeons to describe the patient expect after the procedure.

Treatment of cold intolerance following finger pulp amputations: a case comparison between immediate finger replantation and delayed pulp and digital arterial arch reconstruction with flow-through free hypothenar flap

We report a unique case of cold intolerance following identical fingertip amputations of two fingers on the same hand. The index finger was replanted and the middle finger was reconstructed with a free flow-through hypothenar perforator flap to anatomically restore the digital arterial arch circulation and successfully treat cold intolerance.

A comparative study of lateral and palmar venous anastomosis in Ishikawa zone Ⅱ fingertip replantation

PURPOSE

Venous anastomosis is the key procedure for Ishikawa zone Ⅱ fingertip replantation. Both palmar and lateral veins provide efficient venous drainage. This study compared the clinical effects between these venous anastomoses for fingertip replantation.

METHODS

In 2016-2018, 61 patients underwent Ishikawa zone Ⅱ fingertip replantation with venous anastomosis (28 and 33 cases with palmar and lateral anastomoses, respectively). Retrospective comparative analyses evaluated surgical technique and function, including operative time; rates of finger survival, venous congestion, and infection; sensation; joint motion; cold intolerance symptom severity (CISS), Disabilities of the Arm, Shoulder, and Hand (DASH), and Vancouver scar scores; and chronic regional pain syndrome (CRPS) rates.

RESULTS

There were 33 patients with lateral vein anastomosis and 28 patients with palmar vein anastomosis. The average patient follow-up was 18.2 months. The survival rates did not differ significantly between groups (87.8% (29/33) vs. 85.7% (24/28), p > 0.05); however, the operative time was shorter in the lateral vein group than in the palmar vein group (78.57 ± 7.08 min vs. 67.88 ± 5.77 min, p < 0.05). Venous congestion and infection rates did not differ significantly between groups (p > 0.05). The replanted finger function, including joint motion, sensation, DASH scores, Vancouver scar scores, and CRPS rates, did not differ significantly between groups (p > 0.05). However, the CISS score was higher in the palmar vein group than in the lateral vein group (44.39 ± 5.16 vs. 38.09 ± 4.49, p < 0.05).

CONCLUSIONS

Venous anastomosis with either palmar or lateral veins showed high survival rates and good function in fingertip replantation. The lateral vein had a shorter operative time and benefit to arterial revision and was especially suitable for patients with finger pulp damage.

The fate of delayed revascularization for neglected vascular injury of incompletely amputated digits and hands

We report the fate of neglected vascular injury in cases of incomplete amputation of the digits and hand after delayed revascularization. Twelve patients underwent primary bone fixation, tendon or skin repair for hand injuries without vessel repair despite ischaemic findings. There was discoloration or necrosis of the fingertips during follow-up examination and the patients were referred to us for treatment. The mean warm ischaemic time was 53 hours (range 17-120). Delayed revascularization was performed with end-to-end anastomosis of the digital arteries in eight and vein graft in four cases. Digital nerves were repaired in four cases and flexor tendons in two cases. Of the 12 cases, eight cases showed complete survival. However, in four patients, complete necrosis of the fingers occurred, with one finger surviving partially. Revision amputation was performed in the four cases where necrosis occurred. We conclude that neglected vascular injury associated with incomplete amputation of digits and hands can be overcome in some patients by delayed revascularization even after prolonged warm ischaemic time. Level of evidence: IV.