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Lee JE, Kim S, Kwon J, Lee YH. V advancement eversion flap for fingertip injury: Preventing ischemia and hook-nail deformity. JPRAS Open 2024; 40:175-184. [PMID: 38558878 PMCID: PMC10978456 DOI: 10.1016/j.jpra.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 02/24/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction Traumatic fingertip amputation is the most common type of upper extremity injuries. The V-Y advancement flap is a reliable method for reconstructing fingertip defects, but it is associated with complications such as hook-nail deformity and suture site ischemia. Here, we describe our modifications to V-Y advancement flap technique, termed as "V advancement eversion flap" and review the outcomes of this procedure in 21 patients with fingertip amputation. Methods This was a retrospective review of 21 consecutive patients with fingertip injury who were treated surgically using the V advancement eversion flap technique at a single trauma center between 2006 and 2019. We analyzed the age, injury location and mechanism, Allen classification, injury geometry, and objective and subjective clinical outcomes. Results Twenty-three fingertip amputations with defect sizes greater than 1.0 cm2 from the tip to lunula were included in this study. The mean age of the patients was 43.6 years (range, 24-65 years). The average follow-up period was 20 months (range, 12-37 months). The average wound healing time (apparent epithelization) was 29.4 days (range, 14-41 days). At the final follow-up, all flaps had healed uneventfully without noticeable hook-nail deformity. In the static two-point discrimination test, the mean value was 4.61 mm in the injured finger. Patient ratings of the outcomes were "excellent" in 18 and "good" in 5 cases. Conclusion The V advancement eversion flap technique, when properly designed and executed in fingertip amputation cases, can minimize morbidity and result in successful wound healing without flap necrosis and hook-nail deformity.
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Affiliation(s)
- Jung Eun Lee
- Department of Orthopedic Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Sihun Kim
- Department of Orthopedic Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Jieun Kwon
- Department of Orthopedic Surgery, Ehwa Womans University College of Medicine, Ehwa Womans University Mokdong Hospital, Seoul, Korea
| | - Young Ho Lee
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
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Zhang YF, Xing CM, Chen QZ, Gong YP. Reverse dorsolateral proximal phalangeal island flap: Long-term results. HAND SURGERY & REHABILITATION 2024; 43:101680. [PMID: 38431045 DOI: 10.1016/j.hansur.2024.101680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVES This study aims to present long-term follow-up results of the reverse dorsolateral proximal phalangeal island flap designed for reconstruction of large fingertip and pulp defects. METHODS We examined 18 patients who underwent reverse dorsolateral proximal phalangeal island flap surgery to address ≥2.5 cm fingertip and pulp defects. Mean follow-up was 84.4 months. Sensitivity assessments were conducted using the Semmes-Weinstein monofilament and 2-point discrimination tests. Additionally, we evaluated finger joint active range of motion, complications and cold intolerance. RESULTS Mild venous congestion was observed in 5 flaps. Significant differences were observed in 2-point discrimination and Semmes-Weinstein monofilament tests between the injured and contralateral sides, specifically in the flaps, the dorsal side of the middle phalanx, and the donor site. The flap's mean static 2-point discrimination was 8.3 mm. Restricted distal interphalangeal joint extension was observed in 2 cases. Total active motion with the flap was good or excellent in the injured fingers, but with a significant difference between injured and contralateral fingers. Additionally, 42% of the injured fingers exhibited hook nail deformity, and 2 patients reported cold intolerance. Despite these issues, most patients has high scores for the appearance and satisfaction aspects of the Michigan Hand Outcomes Questionnaire. CONCLUSION In moderate or larger fingertip defects, the reverse dorsolateral proximal phalangeal island flap serves as an alternative for reconstructing both fingertip and pulp issues. However, this option involves sacrificing some sensation in the dorsum of the middle phalangeal finger and the donor area. LEVEL OF EVIDENCE IV, therapeutic study.
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Affiliation(s)
- Yang Fan Zhang
- Department of Orthopedic Surgery, Jingmen Central Hospital, Jingmen, Hubei, 448000, PR China; Department of Hand Surgery, Hand Surgery Research Center, Affiliated Hospital of Nantong University, Jiangsu, 226001, PR China
| | | | - Qing Zhong Chen
- Department of Hand Surgery, Hand Surgery Research Center, Affiliated Hospital of Nantong University, Jiangsu, 226001, PR China.
| | - Yan Pei Gong
- Department of Hand Surgery, Hand Surgery Research Center, Affiliated Hospital of Nantong University, Jiangsu, 226001, PR China
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Jordan JA, Polmear MM, Wells ME, Dunn JC. Traumatic Finger Amputation in the U.S. Military. Mil Med 2024; 189:321-325. [PMID: 36519500 DOI: 10.1093/milmed/usac390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/24/2022] [Accepted: 11/19/2022] [Indexed: 01/31/2024] Open
Abstract
INTRODUCTION Finger amputations can lead to loss of work time and suboptimal function, particularly in the active duty military. There is a paucity of epidemiologic and outcome data for these injuries. The purposes of this study are to define key demographic data pertaining to transphalangeal finger amputations in the U.S. Military and to assess epidemiological data to define risk factors for medical readiness following finger injuries. MATERIALS AND METHODS This was a retrospective review of the military electronic medical record of encounters between 2016 and 2019 with traumatic transphalangeal amputation ICD 10 codes S68.5 (thumb) and S68.6 (finger). Primary outcomes included median military occupational activity limitation length, ability to return to duty, and medical separation from the military. RESULTS A total of 235 patients were included in the final dataset. 221 (94.0%) of these service members were able to return to full duty, although 14 (6.0%) underwent medical separation from the military because of their finger injuries. The median limited duty timeline was 6 weeks. Significant risk factors identified that led to increased rates of medical separation were the use of tobacco (odds ratio [OR] of 5.53, 95% CI 1.21-25.29), junior enlisted status (OR of 5.51, 95% CI 1.67-18.17), and thumb or index finger involvement (OR of 3.50, 95% CI 1.13-10.83). CONCLUSIONS Within a physically high-demand population, traumatic finger amputation can limit duties and may lead to medical separation from service. Traumatic finger amputations are common and often require 6 weeks of restricted short-term disability, particularly in a tobacco-using, young, physically active cohort.
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Affiliation(s)
- James A Jordan
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, TX 79918, USA
| | - Michael M Polmear
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, TX 79918, USA
| | - Matthew E Wells
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, TX 79918, USA
| | - John C Dunn
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, TX 79918, USA
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Tsumura T, Matsumoto T, Imanaka T, Ito H. Digital skin defect management: Hand and wrist volar flap solutions. J Orthop Sci 2023:S0949-2658(23)00323-8. [PMID: 38007299 DOI: 10.1016/j.jos.2023.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/31/2023] [Accepted: 11/12/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND Selecting the optimal flap for managing digit skin defects is challenging, particularly for inexperienced surgeons, given the numerous reconstructive options and insufficient evidence supporting one flap type's superiority over another. This retrospective study introduces four efficacious hand flaps to address volar skin defects and transverse and oblique cuts, examines the optimal flap advancement distance, and discusses effective management. METHODS Patients with digit skin defects who underwent flap surgery between 2009 and 2022 were included. Fifty-four patients treated with oblique triangular, volar VY advancement (unilateral and bilateral pedicled volar VY advancement flaps for fingers and thumbs, respectively), reverse homodigital island, and radial artery superficial palmar branch flaps were included. We evaluated the flap advancement distance, flap length, range of motion, complications, and Semmes-Weinstein monofilament test and Disabilities of the Arm, Shoulder, and Hand questionnaire results. RESULTS The median flap advancement distances for triangular oblique (19 patients), unilateral (11 patients), and bilateral pedicled (5 patients) volar VY advancement flaps were 1.3, 1.8, and 2.0 cm, respectively. The flap lengths for the reverse digital island (8 patients) and radial artery superficial palmar branch (11 patients) flaps were 2.4 and 5.0 cm, respectively. Five, three, and one cases of proximal interphalangeal flexion contractures of ≥ -20° were observed in the VY advancement, reverse digital island, and radial artery superficial palmar branch flaps, respectively. One unilateral VY advancement flap case caused severe numbness and neuroma. All complication cases featured >15 and > 20 mm defect lengths on the fingers and thumb, respectively. CONCLUSIONS To minimize sensory disruption and contractures, we recommend oblique triangular and unilateral pedicle volar VY advancement flaps for finger skin defects up to 12 mm and defects sized 12-15 mm, respectively. Advancement flaps are unsuitable for >15 and > 20-25 mm defects on the fingers and thumb, respectively.
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Affiliation(s)
- Takuya Tsumura
- Department of Orthopedic Surgery, Kurashiki Central Hospital, Kurashiki, Japan.
| | - Taiichi Matsumoto
- Department of Orthopedic Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Toshihide Imanaka
- Department of Orthopedic Surgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Hiromu Ito
- Department of Orthopedic Surgery, Kurashiki Central Hospital, Kurashiki, Japan
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Rautio S, Paukkunen A, Jokihaara J. A Prospective Follow-up Study of Fingertip Amputation Treatment With Semi-occlusive Dressing. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5407. [PMID: 38025609 PMCID: PMC10653577 DOI: 10.1097/gox.0000000000005407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 09/28/2023] [Indexed: 12/01/2023]
Abstract
Background The aim of this prospective cohort was to evaluate the conservative treatment of fingertip amputation with exposed bone, with a semi-occlusive dressing. Methods Ten patients with an amputation distal to the distal interphalangeal joint were treated via secondary healing under a semi-occlusive film dressing. We followed up the patients weekly until the fingertip had healed, then a final clinical visit at 6 months, and a patient-reported outcome assessment at 2 years after the injury. Results All 10 patients completed the 6-month clinical follow-up, and seven patients completed the final patient-rated outcome assessments at 2 years. There were no complications during the study period, all the patients were satisfied with the results, and all answered "fully agree" on choosing the same treatment method again in a similar injury. Conclusion Our results show that conservative treatment of fingertip amputation is feasible and can provide good results.
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Affiliation(s)
- Sanni Rautio
- From Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Antti Paukkunen
- Department of Hand Surgery, Tampere University Hospital, Tampere, Finland
| | - Jarkko Jokihaara
- From Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Hand Surgery, Tampere University Hospital, Tampere, Finland
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Uzel K, Çelik V, Abacı YH, Eskandari MM. Outcomes of antegrade homodigital neurovascular island flap in fingertip amputations. J Orthop Sci 2023:S0949-2658(23)00251-8. [PMID: 37839979 DOI: 10.1016/j.jos.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/26/2023] [Accepted: 08/09/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Antegrade homodigital neurovascular island flap (AHIF) is one of the methods used in fingertip amputations to cover the defect area, preserve finger length and obtain a painless and sensitive fingertip. The aim of this study was to evaluate the functional and sensory outcomes in patients who underwent AHIF for fingertip amputation and to analyze the relationship between patient satisfaction and outcome measures. METHODS Twenty patients with a mean age of 37 (18-63) years were analyzed retrospectively. The patients were evaluated in terms of hook nail development, active interphalangeal joint movements, cold intolerance, and sensory function of the flap covered area. Static two-point discrimination test and Semmes Weinstein monofilament test were performed for sensory evaluation. RESULTS All flaps survived completely at the end of follow-up (mean, 36 months; range 11-64 months). Five patients had cold intolerance and two had hook nails. In total, proximal interphalangeal or distal interphalangeal joint flexion contracture developed in 25 % of the patients. The mean static two-point discrimination score was 4.6 ± 1.6 (2-8) and Semmes-Weinstein monofilament test score was 3.48 ± 0.6 (2.44-4.17). Subjective satisfaction levels of the patients were found to be high and did not show a statistical relationship with the measured clinical outcome parameters (p > 0.05). CONCLUSIONS Since AHIF contains a solid and continuous neurovascular pedicle, the probability of necrosis and loss of sensation is low in AHIF. In addition, the graft need of the donor area is not high. Its disadvantage is the rate of restriction of joint movements. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Kadir Uzel
- University of Medipol, School of Medicine, Department of Orthopaedics and Traumatology, İstanbul, Turkey.
| | | | | | - Metin Manouchehr Eskandari
- University of Mersin, School of Medicine, Department of Orthopaedics and Traumatology, Division of Hand Surgery, Mersin, Turkey.
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Kim KH, Ko IC, Kim H, Lim SY. Preserving finger length in a patient with symmetric digital gangrene under local anesthesia: A case report. World J Clin Cases 2023; 11:6640-6645. [PMID: 37900227 PMCID: PMC10601016 DOI: 10.12998/wjcc.v11.i27.6640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/09/2023] [Accepted: 08/31/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Case reports of symmetric digital gangrene resulting from high-dose vasopressors use in patients with alcoholic ketoacidosis, leading to cardiac arrest, are rare. To date, no specific treatment method for autolysis or surgical amputation or guidelines for determining the level of amputation have been established. CASE SUMMARY In this case report, we describe a treatment method that effectively preserved the function of fingers by surgical treatment under local anesthesia with a minimum operative time, while also preserving finger length to the maximum possible extent. CONCLUSION Our approach may contribute to improved postoperative quality of life by preserving finger length.
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Affiliation(s)
- Keun Hyung Kim
- Department of Plastic and Reconstructive Surgery, Konyang University Medical Center, Konyang University of College of Medicine, Daejeon 35365, South Korea
| | - In Chang Ko
- Department of Plastic and Reconstructive Surgery, Konyang University Medical Center, Konyang University of College of Medicine, Daejeon 35365, South Korea
| | - Hoon Kim
- Department of Plastic and Reconstructive Surgery, Konyang University Medical Center, Konyang University of College of Medicine, Daejeon 35365, South Korea
| | - Soo Yeon Lim
- Department of Plastic and Reconstructive Surgery, Konyang University Hospital, Konyang University of College of Medicine, Myunggok Medical Research Center, Daejeon 35365, South Korea
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Park SO, Kim DK, Ahn HC, Kim YH. Fingertip coverage with uni-pedicled volar rotational advancement flap with large Z-plasty: a report on 112 cases. J Orthop Surg Res 2023; 18:553. [PMID: 37525140 PMCID: PMC10391884 DOI: 10.1186/s13018-023-04047-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 07/25/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Simple and safe fingertip reconstruction methods involve the use of local neurovascular islands flaps that can preserve functional length and sensitivity, and reconstruction with skin of the same texture. However, techniques involving flaps have numerous drawbacks and do not satisfy all the requirements for fingertip reconstruction. A particular problem is the persistence of contracture deformity due to lack of full flap advancement. We present a new technique using uni-pedicled volar rotational advancement flap with large Z-plasty, and describe the results of long-term follow-up. METHODS From October 1993 to December 2009, 112 fingers of 98 patients were covered with uni-pedicled volar rotational advancement flap with large Z-plasty after sustaining various types of injuries or finger pulp avulsion. A longitudinal incision was made along the lateral border of the digit and a large neurovascular volar flap was elevated just above the pulleys and flexor tendon sheath. To release tension, a large Z-plasty was applied at the metacarpophalangeal joint or interphalangeal joint crease. The final patient outcomes were reviewed retrospectively. RESULTS All fingertip injuries were treated without flap necrosis. Partial wound dehiscence was observed in two patients and average static two-point discrimination was 5.2 mm. There were no postoperative contracture deformities, joint stiffness, paresthesia, or hypersensitivity. Most patients were left with acceptable scarring and were free of postoperative pain and cold intolerance during the long-term follow-up. CONCLUSIONS Our novel technique provides durable, completely sensate, and well-vascularized coverage of the fingertip with minimal discomfort to patients.
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Affiliation(s)
- Seong Oh Park
- Department of Plastic and Reconstructive Surgery, Hanyang University College of Medicine, 222 Wangsimniro, Seongdong-gu, Seoul, 04763, Korea.
| | - Dae Kwan Kim
- Department of Plastic and Reconstructive Surgery, Hanyang University College of Medicine, 222 Wangsimniro, Seongdong-gu, Seoul, 04763, Korea
| | - Hee Chang Ahn
- Department of Plastic and Reconstructive Surgery, CHA University Bundang Medical Center, Seongnam-si, Gyeonggi-do, Korea
| | - Youn Hwan Kim
- Department of Plastic and Reconstructive Surgery, Hanyang University College of Medicine, 222 Wangsimniro, Seongdong-gu, Seoul, 04763, Korea
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Chen K, Yang S, Cheng Y, Xiang W, Zhang J, Shen J, Tang C. Reverse homodigital artery versus reverse dorsal homodigital island flaps for fingertip defect repair: A meta-analysis. J Plast Reconstr Aesthet Surg 2023; 82:237-246. [PMID: 37201315 DOI: 10.1016/j.bjps.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 02/17/2023] [Accepted: 04/11/2023] [Indexed: 05/20/2023]
Abstract
PURPOSE This review aimed to systematically and comprehensively compare the effectiveness and applicability of reverse homodigital artery island flaps (RHAIF) and reverse dorsal homodigital island flaps (RDHIF) to treat fingertip defects. METHODS A comprehensive search was conducted in multiple databases for studies that compared RHAIF versus RDHIF for treating fingertip defects with no language restrictions from inception until July 31, 2022. A meta-analysis was performed using RevMan 5.4 software. RESULTS A total of 14 articles were retrieved, comprising 484 patients (509 fingers) in the RHAIF group and 453 patients (484 fingers) in the RDHIF group. The pooled estimates suggested that patients treated with RHAIF experienced more donor-side complications and less postoperative venous crisis than patients in the RDHIF group. On the other hand, no significant differences were found in operative time, flap necrosis, static 2-point discrimination, moving two-point discrimination, total active motion, satisfaction rates and sensory recovery grade (S3+ to S4) between the RHAIF and RDHIF groups. CONCLUSIONS No difference in effectiveness was found between the two surgical procedures for treating fingertip defects. Accordingly, the selection of the optimal approach should be based on the functional requirements of the patient and the surgeon's expertize.
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Affiliation(s)
- Keyi Chen
- Department of Hand and Wrist Surgery, Sichuan Province Orthopaedic Hospital, Chengdu, Sichuan 610000, China.
| | - Shun Yang
- Department of Hand and Wrist Surgery, Sichuan Province Orthopaedic Hospital, Chengdu, Sichuan 610000, China.
| | - Yabo Cheng
- Department of Hand and Wrist Surgery, Sichuan Province Orthopaedic Hospital, Chengdu, Sichuan 610000, China.
| | - Wang Xiang
- Department of Hand and Wrist Surgery, Sichuan Province Orthopaedic Hospital, Chengdu, Sichuan 610000, China.
| | - Jing Zhang
- Department of Hand and Wrist Surgery, Sichuan Province Orthopaedic Hospital, Chengdu, Sichuan 610000, China.
| | - Jingshou Shen
- Department of Hand and Wrist Surgery, Sichuan Province Orthopaedic Hospital, Chengdu, Sichuan 610000, China.
| | - Chenxi Tang
- Department of Hand and Wrist Surgery, Sichuan Province Orthopaedic Hospital, Chengdu, Sichuan 610000, China.
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Lee HJ, Deslivia MF, Kholinne E, Rhyu IJ, Lee SJ, Jeon IH. Topographical Analysis of Pacinian Corpuscle in the Pulp of Human Cadaver Finger Tip Pulp: A Pilot Cadaver Study. J Hand Surg Asian Pac Vol 2023; 28:377-381. [PMID: 37501544 DOI: 10.1142/s2424835523500455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Background: The human hand is a specialised organ for fine motion and sensation and has a relatively large representation in the homunculus. The pathway of sensation starts from information sent by mechanoreceptors in the hand. This study reports the topography of the Pacinian corpuscle in the fingertips of a human cadaver. Methods: All 10 digits from both hands of a fresh-frozen cadaver were examined. Glabrous skin distal to the distal interphalangeal joint was harvested superficial to the periosteum including fat and subcutaneous tissue. The glabrous skin were divided into 10 sections that included five distal and five proximal sections. Modified gold chloride staining was performed. Sectioned specimens were observed under a light microscope and the density of Pacinian corpuscles was determined in each segment. The density of the corpuscles was compared between the radial/ulnar and proximal/distal segments and also between digits from the right hand versus those from the left hand. Results: Pacinian corpuscles were observed only in the subcutaneous tissue. There was no significant difference in density of the corpuscles between the distal and proximal segments or between the right and left hands. There was a statistically significant greater density of Pacinian corpuscles on the radial segments of all digits except the thumb. Conclusions: There is a greater density of Pacinian corpuscles on the radial side of the human fingertip in all digits except the thumb.
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Affiliation(s)
- Hyun-Joo Lee
- Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
- Medical Device and Robot Institute, Kyungpook National University, Daegu, Korea
| | - Maria Florencia Deslivia
- Orthopaedics and Traumatology Department, Udayana University, Sanglah Hospital, Denpasar, Bali, Indonesia
| | - Erica Kholinne
- Faculty of Medicine, Universitas Trisakti, Department of Orthopaedic Surgery, St. Carolus Hospital, Jakarta, Indonesia
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Im Joo Rhyu
- Department of Anatomy, Korea University College of Medicine, Songpa-Gu, Seoul, Korea
| | - Suk-Joong Lee
- Department of Orthopedic Surgery, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - In-Ho Jeon
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea
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11
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Petrella G, Della Rosa N, Adani R. P3 Flap: Technique for Fingertip Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5002. [PMID: 37360232 PMCID: PMC10287140 DOI: 10.1097/gox.0000000000005002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 03/29/2023] [Indexed: 06/28/2023]
Abstract
Fingertip amputations represent an important spectrum of injuries, and most are avulsions or crush trauma. There is no consensus about one single standard treatment, and a wide number of techniques are available. The authors present the P3 flap as an option for covering fingertip defects with bone exposure, avoiding painful scars in the pulp area, without a donor site. This study included 12 fingertips with amputated segment not available for replantation. Volar oblique fingertip defects and transverse amputations with bone exposure, not more proximal than Hirase Zone IIB, were included. Defects were less than 2 cm. The patients were followed up for an average of 6 months. The aesthetic and functional outcomes and fingertip discrimination recovery were evaluated at 6 months by the static two-point discrimination (2-PD) test and DASH score (quick version). The average postoperative 2-PD test at 6 months was 5.9 mm (range from 5 to 8 mm). The mean healing time of the fingertip was 4 weeks. Nail deformity was reported in three cases with level IIB of amputation. None of the P3 flaps failed, and local infection was not reported. The average DASH score at 6 months was 1.1. The mean time to return to work was 38 days (range from 30 to 53). The P3 flap proposed in this study demonstrates a reliable single-stage technique, performed under local anesthesia, for fingertip defect reconstruction, avoiding skin incision and scars in the pulp region and preserving digital length and nail bed.
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Affiliation(s)
- Giovanna Petrella
- From the Department of Hand Surgery and Microsurgery, University Hospital Policlinico of Modena, Modena, Italy
| | - Norman Della Rosa
- From the Department of Hand Surgery and Microsurgery, University Hospital Policlinico of Modena, Modena, Italy
| | - Roberto Adani
- From the Department of Hand Surgery and Microsurgery, University Hospital Policlinico of Modena, Modena, Italy
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12
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Kholinne E, Santosa C, Anestessia IJ, Muchtar. Reconstruction of multiple fingertip crush injuries with full-thickness skin grafting. BMJ Case Rep 2023; 16:e253446. [PMID: 37185247 PMCID: PMC10151856 DOI: 10.1136/bcr-2022-253446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
Fingertip crush injuries are commonly encountered as a result of workplace accidents causing significant morbidity. The primary goal of reconstruction is to restore function and sensibility, as well as a faster return to work. We reported a patient with multiple fingertip injuries presented 5 days following the initial injury. Copious irrigation and excisional debridement were performed, followed by a full-thickness skin graft harvested from the volar wrist. At the 4-month follow-up, all of the reconstructed fingertips achieved good functionality without any pain or sensory impairment. The length was well preserved and static two-point discrimination was comparable with the contralateral side. Full-thickness skin grafts may provide an excellent alternative reconstruction option in the management of multiple fingertip crush injuries.
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Affiliation(s)
- Erica Kholinne
- Faculty of Medicine, Universitas Trisakti, Jakarta, Indonesia
- Orthopedic Surgery, St. Carolus Hospital, Jakarta, Indonesia
| | - Claudia Santosa
- Orthopedic Surgery, St. Carolus Hospital, Jakarta, Indonesia
| | | | - Muchtar
- Faculty of Medicine, Universitas Trisakti, Jakarta, Indonesia
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Soraya AAD, Bellynda M, Tiflani AL, Aretnaningtyas G, Yarso KY. Delayed primary intention with full-thickness skin graft in distal interphalangeal injury: A rare case report. Int J Surg Case Rep 2023; 106:108155. [PMID: 37087936 PMCID: PMC10149338 DOI: 10.1016/j.ijscr.2023.108155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/15/2023] [Accepted: 03/17/2023] [Indexed: 04/25/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE The fingertip injury is the most common in the hand area. In this regard, skin grafting can be considered to preserve sensation, due to its functional importance, particularly for distal tip injuries. A full-thickness skin graft (FTSG) results in excellent function after engraftment and should be considered in reconstructing functionally and aesthetically important areas. Moreover, a thorough understanding of FTSG is required for a surgeon to have an excellent outcome. CASE PRESENTATION A 38-year-old man had the third fingertip injury of his right hand after being crushed by a mill. Physical examination revealed exposed bone distal to DIP, with intact periosteum and nail plate, negative active bleeding, and negative contaminants. There was no tendon or soft tissue left above the periosteum. In addition, an X-ray of the right manus revealed no fracture. The wound was applied with hydrogel and petroleum gauze to maintain hydration. A wound toilet was performed, followed by the closure of the wound with full-thickness skin grafting (FTSG). Follow-up was done in the first week and the fourth week after the procedure, as they showed good aesthetic results with satisfactory function. The sensory recovery showed normal result for touch and vibration. Meanwhile, sharp pain and warmth object sensation were minimally diminished. CLINICAL DISCUSSION A literature review concludes that FTSGs are generally unreliable in cases with over poorly vascularized beds, and FTSG will only work with no serious blood supply issues. Therefore, severe fingertip injury was reconstructed by the graft. CONCLUSION This procedure showed excellent graft survival with no additional surgical injury of the normal finger, satisfactory functional and aesthetic outcomes, and no need for secondary debulking procedures. Potential disadvantages consisted of insufficient volume of soft tissue and graft hyperpigmentation. However, delayed primary wound closure by FTSG may be an option for treating full-thickness finger defects with bone or tendon exposure.
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Affiliation(s)
| | - Monica Bellynda
- Resident of General Surgery, Sebelas Maret University, Moewardi Hospital, Surakarta, Indonesia
| | - Achmad Luthfi Tiflani
- Resident of General Surgery, Sebelas Maret University, Moewardi Hospital, Surakarta, Indonesia
| | - Galuh Aretnaningtyas
- Plastic and Reconstructive Surgery Division, Department of Surgery, Sebelas Maret University, Moewardi Hospital, Surakarta, Indonesia
| | - Kristanto Yuli Yarso
- Oncology Surgery Division, Department of Surgery, Sebelas Maret University, Moewardi Hospital, Surakarta, Indonesia.
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Cevik K, Arik A, Eskandari MM. Outcomes of bipedicle V-Y 'cup' flap for repair of volar oblique fingertip amputations. J Hand Surg Eur Vol 2023; 48:144-149. [PMID: 36205049 DOI: 10.1177/17531934221127860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We used bipedicle V-Y 'cup' flaps to reconstruct 13 consecutive volar oblique fingertip amputations encountered in a nearly 2-year period. All flaps survived completely with no bone protuberance, scarring or neuroma evident at the end of follow-up (mean, 7 months; range 4-13 months). Two of the 13 patients had moderate or severe tenderness, three had moderate or severe cold intolerance and two had noticeable hook nails. There were no significant (≥10°) flexion contracture in the interphalangeal joints. The mean static two-point discrimination score was 4 mm (range 3-6) and the modal Semmes-Weinstein monofilament test score was 3.6 g (range 3.2-4.2). All patients were satisfied with their surgical outcomes. The bipedicle V-Y 'cup' flap provides good results in terms of fingertip contour, padding and sensation, and has a low complication rate when used to treat volar oblique fingertip amputations.Level of evidence: IV.
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Affiliation(s)
- Kadir Cevik
- Department of Hand Surgery, Dışkapı Y. Beyazıt Training and Research Hospital, Ankara, Turkey
| | - Atilla Arik
- Department of Hand Surgery, Muğla S. Koçman University Hospital, Muğla, Turkey
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Ma J, Ding Y, Xu L, Zou H, Wu J, Shen L, Xing C, Liu Y, Zhou Z, Zhan J. Repair of fingertip defect with reverse digital artery island flap and repair of donor site with digital dorsal advancement flap. Front Surg 2023; 10:1127356. [PMID: 37123544 PMCID: PMC10130516 DOI: 10.3389/fsurg.2023.1127356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/28/2023] [Indexed: 05/02/2023] Open
Abstract
Objective The reverse digital artery island flap (RDAF) is widely used in repairing fingertip skin defects based on its good appearance and practicability. However, the donor area of the flap needs skin grafting, which can lead to complications. This retrospective study explored the clinical application of digital dorsal advance flap (DDAF) in repairing the donor site of the reverse digital artery island flap. Method From June 2019 to February 2022, 17 patients with a soft tissue defect of the finger had been restored with the reverse digital artery island flap, and at the same time, the donor area was repaired with digital dorsal advance flap (DDAF). The sensitivity, the active range of motion (ROM) and patient satisfaction were assessed after the operation. Results All flaps survived completely without skin grafting with only one linear scar. The sensory and motor functions of all patients recovered well. Assessment based on the Michigan Hand Outcomes Questionnaire (MHQ) showed satisfactory functional recovery for all patients. Conclusions Reconstruction using RDAF combined with DDAF represents an effective alternative for repairing fingertip skin defects.
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Affiliation(s)
- Junwei Ma
- Hand Surgery Department, Central Hospital Affiliated to Shenyang Medical Collage, Shenyang, China
- Department of Orthopedic Surgery, First Affiliated Hospital, China Medical University, Shenyang, China
- Correspondence: Junwei Ma Jie Zhan
| | - Yunqi Ding
- Department of Gynaecology, Shenyang Women's and Children's Hospital, Shenyang, China
| | - Lina Xu
- Operating Room, Central Hospital Affiliated to Shenyang Medical Collage, Shenyang, China
| | - Haibo Zou
- Department of Anesthesiology, Central Hospital Affiliated to Shenyang Medical Collage, Shenyang, China
| | - Jinsheng Wu
- Hand Surgery Department, Central Hospital Affiliated to Shenyang Medical Collage, Shenyang, China
| | - Lin Shen
- Hand Surgery Department, Central Hospital Affiliated to Shenyang Medical Collage, Shenyang, China
| | - Changtai Xing
- Hand Surgery Department, Central Hospital Affiliated to Shenyang Medical Collage, Shenyang, China
| | - Yue Liu
- Hand Surgery Department, Central Hospital Affiliated to Shenyang Medical Collage, Shenyang, China
| | - Zehui Zhou
- Hand Surgery Department, Central Hospital Affiliated to Shenyang Medical Collage, Shenyang, China
| | - Jie Zhan
- Hand Surgery Department, Central Hospital Affiliated to Shenyang Medical Collage, Shenyang, China
- Correspondence: Junwei Ma Jie Zhan
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The Efficacy of Subdermal Pocket Procedure in Fingertip Replantation With Composite Graft. Ann Plast Surg 2022; 90:S89-S94. [PMID: 36729843 DOI: 10.1097/sap.0000000000003351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Microsurgical replantation of fingertip amputation is sometimes difficult because of a lack of available vessels. Composite grafting is an alternative method for nonvascularized replantation, but it has a limited success rate. The subdermal pocket (SDP) procedure is proposed to increase the survival of composite graft. AIM AND OBJECTIVES We aimed to compare the success rate of the composite graft used in fingertip replantation with or without application of the SDP procedure. PATIENTS AND METHODS From 2000 to 2020, 29 fingertip amputations (28 complete amputations, 1 near-complete amputation) from 28 patients were included. Five of the fingertip amputations were classified as Ishikawa zone Ib and 24 as Ishikawa zone II. Seventeen fingers underwent replantation with composite graft plus SDP procedure, whereas the remaining 12 fingers received replantation with composite graft only. RESULTS The overall success rate was 70.59% (12 of 17) in the SDP group and 41.67% (5 of 12) in the composite graft-only group (P = 0.119; odds ratio, 3.36). In the subgroup of Ishikawa zone II fingertip amputations, the success rate was 66.67% (10 of 15) in the SDP group and 22.22% (2 of 9) in the composite graft-only group (P = 0.035; odds ratio, 7.0). CONCLUSIONS The SDP procedure could increase the success rate of fingertip replantation with composite graft, especially for Ishikawa zone II amputations.
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17
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To Do or Not to Do? Neurorrhaphy in Great Toe Pulp Flap Fingertip Reconstruction. Plast Reconstr Surg Glob Open 2022; 10:e4539. [PMID: 36203734 PMCID: PMC9529029 DOI: 10.1097/gox.0000000000004539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/29/2022] [Indexed: 11/26/2022]
Abstract
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.
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Modified Mini-Keystone Flaps for Coverage of Tiny Volar Pulp Defects of the Fingertips in Cases with Missing Amputation Skin Stumps: A Retrospective Study. J Clin Med 2022; 11:jcm11123394. [PMID: 35743460 PMCID: PMC9225022 DOI: 10.3390/jcm11123394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/30/2022] [Accepted: 06/11/2022] [Indexed: 02/01/2023] Open
Abstract
This study aimed to demonstrate the expanding versatility of keystone flap reconstruction in fingertips. Fifteen patients who underwent the modified mini-keystone flap reconstruction for tiny volar pulp defects of the fingertip between September 2020 and February 2021 were included in this study (average age: 43.4 ± 13.52 years, range: 19–61 years). Patient data were retrospectively collected from their medical records. The two-point discrimination test was used to evaluate the degree of sensory recovery. All defects were successfully covered with the modified mini-keystone flap. The defect sizes ranged from 0.5 cm × 1 cm to 1.2 cm × 2.0 cm, and the flap sizes ranged from 0.7 cm × 1.5 cm to 1.5 cm × 3.0 cm. Although one patient showed a small distal margin maceration, all flaps survived fully. The overall outcomes were favorable at the mean follow-up period of 5.73 ± 0.79 months. We suggest that the modified mini-keystone flap technique is a promising alternative modality for covering tiny volar pulp defects of the fingertip, with few complications and favorable outcomes.
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Chakraborty SS, Dixit PK, Kala PC, Sahu RK, Katrolia D, K S. A Prospective Trial Comparing Outcomes at 11 Months of a Standard Cross-Finger Flap versus a Laterally Based Thenar Flap for Fingertip Reconstruction. J Hand Surg Asian Pac Vol 2022; 27:49-56. [PMID: 35135424 DOI: 10.1142/s2424835522500187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: The standard cross-finger flap (CFF) and laterally based thenar flap (LTF) are the time-tested modalities of fingertip reconstruction. We were unable to find any studies that have compared these two flaps for fingertip reconstruction. The aim of this study is compare the outcomes of these two flaps at 11 months after fingertip reconstruction. Methods: This is a prospective study of 40 patients with fingertip amputation who underwent reconstruction with either a standard CFF or an LTF. Data with regards to the patient, the injury, treatment and complications were recorded. Patients were followed up weekly for the first 6 weeks and at 3, 6, 9 and 12 months thereafter. Outcome measures assessed at final follow-up included passive range of motion, two-point discrimination, cold intolerance, patient aesthetic satisfaction with the flap, assessment of donor scar and psychosocial benefit. Results: Fingertip reconstruction was done with 23 CFFs and 17 thenar flaps. Partial necrosis was noted in three thenar flaps. The mean follow-up period was 11 months. The sensory recovery and aesthetic satisfaction with the flap were greater in thenar flap group. There were no differences between the two flaps in the other outcome measures. Conclusions: Sensory recovery and aesthetic outcomes were better in thenar flaps compared to a CFF. However, thenar flap were associated with a greater incidence of partial flap loss. Level of Evidence: Level III (Therapeutic).
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Affiliation(s)
| | - Pawan Kumar Dixit
- Department of Plastic Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Prakash Chandra Kala
- Department of Plastic Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Ranjit Kumar Sahu
- Department of Plastic Surgery, All India Institute of Medical Sciences, Sijua, Patrapada, Bhubaneswar, Odisha, India
| | - Deepti Katrolia
- Department of Plastic Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Suresh K
- Department of Plastic Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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20
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Hao R, Huo Y, Wang H, Liu W. The Clinical Effect of Digital Dorsal Fascial Island Flap Combined With Crossfinger Flap for Repairing Distal Degloving Injury and Sensory Reconstruction. Front Surg 2022; 8:732597. [PMID: 35111803 PMCID: PMC8801504 DOI: 10.3389/fsurg.2021.732597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 12/15/2021] [Indexed: 11/13/2022] Open
Abstract
BackgroundTo explore the clinical effect of digital dorsal fascial island flap combined with crossfinger flap to repair distal degloving injury and sensory reconstruction.MethodsA total of 19 patients with distal fingertip degloving injuries treated with digital dorsal fascial island flap combined with crossfinger flap in our hospital from April 2018 to August 2020 were retrospectively included. Semmes–Weinstein (SW) monofilament and static two-point discrimination (S-2PD) tests, active range-of-motion (ROM) of the fingers, cold intolerance, visual analog scale (VAS) score patient complications, and patient satisfaction were evaluated.ResultsFive cases with post-operative flap blisters were treated at the time of dressing changes until successful scab formation. Three cases with post-operative arterial crisis of finger arterial dorsal branch vessel were relieved after suture removal and tension reduction. All other skin flaps and skin grafts survived. Nineteen patients received follow-up between 3 and 26 months (average 14.6 months). The active ROM of metacarpophalangeal (MCP) and interphalangeal (IP) joints of the injured fingers were satisfactory.ConclusionThe digital dorsal fascial island flap combined with the crossfinger flap for repairing the distal degloving injury of the distal segment of the finger is a good surgical method, which is simple and easy to operate, can repair a large area of soft tissue defect, and obtain a satisfactory effect.
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21
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Arik A, Cevik K, Özcanyüz B. Clinical outcomes of the oblique V-Y advancement pulp flap for repair of lateral fingertip injuries. J Hand Surg Eur Vol 2021; 46:865-872. [PMID: 34018872 DOI: 10.1177/17531934211015858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We report the use of obliquely oriented V-Y advancement pulp flaps to reconstruct 17 consecutive, lateral oblique fingertip traumatic defects over a 2-year period. All flaps survived completely with no bone protuberance, prominent scar or neuroma evident at an average follow-up of 11 months (range 7 to 19). Although there was no incidence of severe hook nail deformities, there were two patients who had residual mild hook nails, two with pulp/nail asymmetries and one with an ingrown nail. The mean static two-point discrimination was 3.9 mm (range 2 to 8) and the mean Semmes-Weinstein monofilament test score 3.6 g (range 2.44 to 4.56). No correlation was found between the flap obliquity angle and sensory test results. We recommend the obliquely oriented V-Y pulp flap as a reliable reconstructive option for the cover of lateral oblique fingertip defects.Level of evidence: IV.
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Affiliation(s)
- Atilla Arik
- Department of Orthopaedics and Traumatology, Adana City Training and Research Hospital, Adana, Turkey
| | - Kadir Cevik
- Department of Orthopaedics and Traumatology, Mersin University Hospital, Mersin, Turkey
| | - Burç Özcanyüz
- Department of Orthopaedics and Traumatology, Adana City Training and Research Hospital, Adana, Turkey
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22
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Yano K, Kaneshiro Y, Ishiko M, Hyun S, Sakanaka H. Reconstruction of a Composite Defect of the Distal Index Finger Using a Chimeric Reverse Flow Second Dorsal Metacarpal Artery Flap: A Case Report. J Hand Microsurg 2021; 15:148-151. [PMID: 37020614 PMCID: PMC10069996 DOI: 10.1055/s-0041-1731938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
AbstractThe reconstruction for mild tissue loss at the distal part of a finger is challenging. We report about a 29-year-old man presenting with traumatic tissue loss at the distal interphalangeal (DIP) joint of the index finger, including skin, bone, and nerve. Reconstruction using two types of flaps was performed. The dorsal skin flap, nourished by the second dorsal metacarpal artery (SDMA) perforator, was elevated. The vascularized second metacarpal bone, nourished by the SDMA, was also elevated. Using the vascular connection between the DMA and the palmar digital artery (PDA), both flaps were raised to the distal part of the finger, and the pivot point was set at the dorsal proximal phalanx. After arthrodesis of the DIP joint with the vascularized second metacarpal bone, the digital nerve was repaired using the cutaneous nerve in the skin flap, and the skin defect was covered using the perforator flap. The postoperative course, including flap survival and bone union, was uneventful. A good indication for the reconstruction of the distal part of a finger with this technique is when the defect sizes of the skin and bone differ and the vascular connection between the SDMA and dorsal branch of PDA is not injured.
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Affiliation(s)
- Koichi Yano
- Department of Orthopaedic Surgery, Seikeikai Hospital, Sakai-ku, Sakai City, Osaka, Japan
| | - Yasunori Kaneshiro
- Department of Orthopaedic Surgery, Seikeikai Hospital, Sakai-ku, Sakai City, Osaka, Japan
| | - Megumi Ishiko
- Department of Orthopaedic Surgery, Seikeikai Hospital, Sakai-ku, Sakai City, Osaka, Japan
| | - Seungho Hyun
- Department of Orthopaedic Surgery, Seikeikai Hospital, Sakai-ku, Sakai City, Osaka, Japan
| | - Hideki Sakanaka
- Department of Orthopaedic Surgery, Seikeikai Hospital, Sakai-ku, Sakai City, Osaka, Japan
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23
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Gupta S, Goil P, Mohammad A, Escandón JM. Workhorse flaps for distal digital reconstruction: an algorithmic approach to surgical decision-making. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01840-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Means KR, Saunders RJ. Understanding and Measuring Long-Term Outcomes of Fingertip and Nail Bed Injuries and Treatments. Hand Clin 2021; 37:125-153. [PMID: 33198913 DOI: 10.1016/j.hcl.2020.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
There are many outcome measures to choose from when caring for or studying fingertip and nail bed trauma and treatments. This article outlines general outcome measures principles as well as guidelines on choosing, implementing, and interpreting specific tools for these injuries. It also presents recent results from the literature for many of these measures, which can help learners, educators, and researchers by providing a clinical knowledge base and aiding study design.
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Affiliation(s)
- Kenneth R Means
- The Curtis National Hand Center @ MedStar Union Memorial Hospital, Baltimore, MD, USA.
| | - Rebecca J Saunders
- The Curtis National Hand Center @ MedStar Union Memorial Hospital, Baltimore, MD, USA
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Abstract
Following a fingertip amputation, if vessels are present and of adequate condition, microsurgical replantation is the preferred technique for management. Composite grafting has a limited role in the management of fingertip amputations due to its unreliable nature but can be an option when an amputated fingertip is not replantable and the patient desires restoration of fingertip length and aesthetics. When composite grafting is selected as the treatment of choice for a particular patient, there are methods of optimizing the chances of graft revascularization and survival, including early grafting, graft cooling, and a moist wound healing environment.
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Affiliation(s)
- Kate Elzinga
- Section of Plastic Surgery, University of Calgary, South Health Campus, 4448 Front Street Southeast, Calgary, Alberta T3M 1M4, Canada.
| | - Kevin C Chung
- Section of Plastic Surgery, The University of Michigan Medical School, The University of Michigan Health System, 1500 East Medical Center Drive, 2130 Taubman Center, SPC 5340, Ann Arbor, MI 48109-0340, USA
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Abstract
Fingertip injuries in the military are common and often hinder the fighting force and support personnel. Injuries range from small subungual hematomas to proximal finger amputations. Treatment modalities are dictated by injury patterns, anatomic considerations, and the need to return to duty. Nail bed injuries should be repaired when possible and exposed bone or tendon is treated with appropriate soft tissue coverage. If soft tissue coverage is unobtainable, revision amputation should be performed with attention given to maintaining as much finger length as possible. Antibiotics may not be required, however they are often utilized in the deployed setting.
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Affiliation(s)
- Matthew E Wells
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, 5005 North Piedras Street, El Paso, TX 79902, USA; Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, 4801 Alberta Avenue, El Paso, TX 79905, USA.
| | - John P Scanaliato
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, 5005 North Piedras Street, El Paso, TX 79902, USA; Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, 4801 Alberta Avenue, El Paso, TX 79905, USA
| | - Nicholas A Kusnezov
- Department of Orthopaedic Surgery, Blanchfield Army Community Hospital, 650 Joel Drive, Fort Campbell, KY 42223, USA
| | - Leon J Nesti
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA; Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - John C Dunn
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, 5005 North Piedras Street, El Paso, TX 79902, USA; Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Modified Oblique Triangular Neurovascular Island Flap Technique to Prevent the Development of Hooked Nail Deformity. Tech Hand Up Extrem Surg 2020; 25:201-205. [PMID: 33370085 DOI: 10.1097/bth.0000000000000333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hooked fingernail deformity can develop after any type of fingertip amputation. A more proximal amputation is associated with a higher probability of developing hooked fingernails. Proximal fingertip amputations with very short remaining nail beds are recommended for revision amputation with nail bed ablation. This procedure eliminates the possibility that the patient may have a functional nail. When the nail matrix is still retained, an oblique triangular neurovascular island flap may preserve the nail and digit length. At our institution, the modified oblique triangular neurovascular island flap is routinely used for patients who underwent fingertip amputation with a retained nail bed. These modifications may aid in preventing the development of hooked nail deformity and creating a round pulp contour without the need for fixation, composite grafts, or distant soft tissue transfer.
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V-Y advancement flaps belong in the orthopaedic resident’s emergency department armamentarium: a case report of two patients. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Potential of Tissue-Engineered and Artificial Dermis Grafts for Fingertip Reconstruction. Plast Reconstr Surg 2020; 146:1082-1095. [PMID: 32915527 DOI: 10.1097/prs.0000000000007258] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Management of skin and soft-tissue defects of the fingertips is functionally and aesthetically important, but controversial, especially when bones are exposed. Recent advances in wound healing technology allow the use of cells or biological dermis. The authors studied the clinical efficacy of tissue-engineered dermis grafts and artificial dermis grafts versus immediate reconstructive procedures, such as the reverse digital artery island flap, in treating bone-exposed fingertip defects. METHODS One hundred eighty-two patients with bone-exposed fingertip defects treated with tissue-engineered dermis grafts (n = 71), artificial dermis grafts (n = 23), or reverse digital artery island flaps (n = 88) were included in this retrospective cohort study. Surgical time, duration of hospitalization, total cost, success rate, healing time, sensory recovery, range of motion, scar quality, and patient satisfaction were compared. RESULTS No tissue-engineered or artificial dermis graft exhibited graft rejection or failure, whereas there was one partial loss and one total loss after reverse digital artery island flap surgery. Tissue-engineered dermis grafts were superior in scar quality, and artificial dermis grafts had shorter surgical times and lower surgical costs; both groups demonstrated superior results in postoperative range of motion and sensory recovery in two-point discrimination tests and shorter hospitalization, compared with the reverse digital artery island flap group. The reverse digital artery island flap had shorter complete closure time and less postoperative tingling sensation. There were no differences in overall patient satisfaction among the groups. CONCLUSIONS Tissue-engineered and artificial dermis grafts may be promising alternatives for fingertip reconstruction. In particular, tissue-engineered dermis grafts may deliver superior functional results, including recovery of sensory discomfort and aesthetic results in terms of scar quality over artificial dermis grafts. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Evaluation of Pediatric Fingertip Injuries Using Etiology, Demographics and Therapy. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2020; 54:306-312. [PMID: 33312028 PMCID: PMC7729728 DOI: 10.14744/semb.2018.82788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 07/26/2018] [Indexed: 11/20/2022]
Abstract
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.
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Volar Neurovascular Advancement Flap With an All Neural Branch-preserving Technique. Tech Hand Up Extrem Surg 2020; 25:63-68. [PMID: 32694408 DOI: 10.1097/bth.0000000000000306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Several fingertip reconstruction options exist, among which, the use of a volar advancement flap or local transposition flap is a simple and effective technique for reconstructing the volar pulp with the same skin texture. To advance the flap, we have to release the tethering structure and sometimes include the neural branches. We describe a concept of an all neural branch-preserving technique to harvest a volar flap. We demonstrate this technique on an anatomic specimen and 1 case with delicate surgical tips. We performed this technique in 16 patients, and the mean follow-up period was 28.4 months. The mean range of motion of the distal interphalangeal joint was 70.3 degrees, and that of the proximal interphalangeal joint was 101.9 degrees. The mean static 2-point discrimination of the volar pulp was 4.8 mm. This technique could be applied on the volar advancement flap with a better sensation recovery.
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A Novel Surgical Technique for Resuspension of Digital Pulp Tissue after Degloving Injuries. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 7:e2600. [PMID: 32537317 PMCID: PMC7288873 DOI: 10.1097/gox.0000000000002600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 10/31/2019] [Indexed: 11/26/2022]
Abstract
Adherence of pulp tissue to the underlying distal phalanx is required for fundamental actions including grip, proprioception, and fine motor skills. Disruption of the fibrous septa causes sliding between the distal phalanx and overlying soft tissues, hindering basic hand function. The authors present a novel surgical technique in which the fibrous pulp septa are resuspended to the distal phalanx with bone anchors and sclerosing agents after a closed degloving injury.
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Kawaiah A, Thakur M, Garg S, Kawasmi SH, Hassan A. Fingertip Injuries and Amputations: A Review of the Literature. Cureus 2020; 12:e8291. [PMID: 32601565 PMCID: PMC7317129 DOI: 10.7759/cureus.8291] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The fingertip is defined as the part of the digit distal to the insertion of the extensor and flexor tendons on the distal phalanx. Devastating injuries to the hand occur every year that lead fingertip amputations in thousands of people. The highest incidence rates are usually seen in children less than five years old and in adults over the age of 65. There are various presentations of injury that may end up with post-traumatic fingertip amputation, including lacerations, avulsions, and crush injuries. The fingertip is vital for sensation, as it has a high concentration of sensory receptors, and hence the restoration of sensation is the most important focus of treatment. The three main goals of treatment are the restoration of sensation and durability in the tip and assuring proper bone support to allow for nail growth. Many complications can arise after fingertip amputation, including delayed wound healing, nail deformities with poor aesthetics, hypersensitivity, residual pain, cold intolerance, scar retraction, flexion contractures, chronic ulceration, infection, and flap loss. The objective of this study is to provide an overview of the anatomy of the fingertip, the presentation of fingertip injuries and their management, and complications that might arise after surgery.
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Affiliation(s)
- Abdal Kawaiah
- Orthopaedics, Xavier University School of Medicine, Oranjestad, ABW
| | - Mala Thakur
- Internal Medicine, Xavier University School of Medicine, Oranjestad, ABW
| | - Stuti Garg
- Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, USA
| | | | - Abbas Hassan
- Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, USA
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Ayhan E, Çevik K, Çelik V, Eskandari MM. Patient satisfaction after innervated digital artery perforator flap for fingertip injuries. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2020; 54:269-275. [PMID: 32544063 DOI: 10.5152/j.aott.2020.03.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the results of the innervated digital artery perforator (IDAP) flap and to analyze the relationship between patient satisfaction and outcome measures. METHODS A total of 17 fingertips of 15 patients (14 men and one woman; mean age: 47.2 (26-62) years) were included in this retrospective study. Patients' injured finger and defect type were recorded. At the last follow-up, the static two-point discrimination (s2PD) test, Semmes Weinstein monofilament (SWM) test, and range of motion of the affected finger were analyzed. We interviewed patients to determine hand dominance, cold intolerance, and their satisfaction with the result. We performed correlation and logistic regression analyses between patient satisfaction and outcome measures. RESULTS The mean follow-up period was 13.8 (7-18) months. The mean range of motion was 77.3±3.5 (70-80) degrees for the distal interphalangeal joints of affected fingers. The mean s2PD was 6.4 (3-10) mm, and the SWM records ranged from 2.83 to 4.93 monofilament markings. Cold intolerance was noted in seven fingers (41%). Patient satisfaction was negatively correlated with cold intolerance, and cold intolerance decreased as the follow-up period extended. CONCLUSION IDAP flap satisfies both patient and surgeon, with the only significant problem being cold intolerance, regarding which patients must be informed. Although cold intolerance is hard to treat, fortunately, it generally improves with time. LEVEL OF EVIDENCE Level IV, Therapeutic study.
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Affiliation(s)
- Egemen Ayhan
- Division of Hand Surgery, Department of Orthopaedics and Traumatology, University of Health Sciences Turkey, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara, Turkey
| | - Kadir Çevik
- Department of Orthopaedics and Traumatology, Mersin University, School of Medicine, Mersin, Turkey
| | - Velat Çelik
- Clinic of Hand Surgery, İskenderun State Hospital, Hatay, Turkey
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Abstract
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.
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Affiliation(s)
- Soumen Das De
- Department of Hand & Reconstructive Microsurgery, National University Health System, Tower Block, Level 11, 1E Kent Ridge Road, Singapore 119228.
| | - Sandeep J Sebastin
- Department of Hand & Reconstructive Microsurgery, National University Health System, Tower Block, Level 11, 1E Kent Ridge Road, Singapore 119228
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Hu YG, Zeng Q, Wan GQ, Li XL. What are the advantages of occlusive dressings for treating fingertip amputations? HAND SURGERY & REHABILITATION 2020; 39:139-140. [PMID: 31982594 DOI: 10.1016/j.hansur.2019.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 11/28/2019] [Accepted: 12/05/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Y-G Hu
- Department of Plastic Surgery, Jiangxi Provincial People's Hospital, 152, Ai Guo road, 330006 Nanchang, Jiangxi, People's Republic of China.
| | - Q Zeng
- Department of Plastic Surgery, Jiangxi Provincial People's Hospital, 152, Ai Guo road, 330006 Nanchang, Jiangxi, People's Republic of China
| | - G-Q Wan
- Department of Plastic Surgery, Jiangxi Provincial People's Hospital, 152, Ai Guo road, 330006 Nanchang, Jiangxi, People's Republic of China
| | - X-L Li
- Department of Plastic Surgery, Jiangxi Provincial People's Hospital, 152, Ai Guo road, 330006 Nanchang, Jiangxi, People's Republic of China.
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Ince B, Cem Yildirim ME, Dadaci M, Yarar S. A New Technique in Tamai Zone 1 Reconstruction: Reverse Dorsal Terminal Vein Flap (Hat Flap). J Hand Microsurg 2019; 11:140-145. [PMID: 31814665 DOI: 10.1055/s-0039-1683949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 02/01/2019] [Indexed: 10/27/2022] Open
Abstract
Introduction The aim of this study was to determine usability of the reverse dorsal terminal vein flap (hat flap) in the reconstruction of Tamai zone 1 defects. Materials and Methods A total of 31 patients with fingertip amputation in Tamai zone 1 defect in the finger operated upon between 2014 and 2016 were included in this study. Flaps were designed from the proximal end of the nail bed to the middle phalanx according to the defect size. After passing through the skin, the proximal parts of the dorsal vein and branches were knotted. The flap was harvested by preserving the paratenon and dorsal digital terminal vein. Then, the flap was rotated and the defect was closed. Results A total of 32 patients were included in this study. The average size of the defects was 2 × 2.2 cm. Loss of epidermis in five patients and partial flap loss in two patients were observed (7/32, 21.8%), but total flap loss was not observed in any patient. Conclusion The reverse flow terminal dorsal vein-based pedicle flaps can be used as a viable surgical technique in the reconstruction of Tamai zone 1 amputations. Level of Evidence This is a Level IV study.
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Affiliation(s)
- Bilsev Ince
- Department of Plastic, Reconstructive and Aesthetic Surgery, Necmettin Erbakan University, School of the Medicine, Konya, Turkey
| | - Mehmet Emin Cem Yildirim
- Department of Plastic, Reconstructive and Aesthetic Surgery, Necmettin Erbakan University, School of the Medicine, Konya, Turkey
| | - Mehmet Dadaci
- Department of Plastic, Reconstructive and Aesthetic Surgery, Necmettin Erbakan University, School of the Medicine, Konya, Turkey
| | - Serhat Yarar
- Konya Numuna Hospital, Plastic Reconstructive and Aesthetic Surgery Clinic, Konya, Turkey
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Wang KL, Zhang ZQ, Buckwalter JA, Yang Y. Supermicrosurgery in fingertip defects-split tibial flap of the second toe to reconstruct multiple fingertip defects: A case report. World J Clin Cases 2019; 7:2562-2566. [PMID: 31559293 PMCID: PMC6745310 DOI: 10.12998/wjcc.v7.i17.2562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/27/2019] [Accepted: 07/20/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Injuries to multiple fingertips pose a significant treatment dilemma. Numerous reconstructive options exist, all with the ultimate goal of restoring function and sensibility to the injured fingertips.
CASE SUMMARY A 24-year-old male suffered injury to multiple fingertips of the right hand, resulting in exposed distal phalanges of the middle, ring, and small fingers. The amputated distal stumps were not possible for replantation. Free flap coverage was selected in order to achieve better functional outcome. The fingertip defects were covered by performing a right second toe split tibial flap using local anesthesia at the harvest site and brachial plexus nerve block for the right upper extremity. At 6-month follow-up, all three of the reconstructed fingertips had some preserved nail growth, Semmes-Weinstein Monofilaments testing was equal to the contralateral side and the Static Two-Point Discrimination were comparable to the contralateral side.
CONCLUSION This report provides a novel reconstructive option for the management of multiple fingertip injuries and demonstrates the utility of supermicrosurgery in management of these injuries.
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Affiliation(s)
- Ke-Lie Wang
- Department of Microsurgery and Hand Surgery, the Longgang Orthopedics Hospital of Shenzhen, Shenzhen 518116, Guangdong Province, China
| | - Zi-Qing Zhang
- Department of Microsurgery and Hand Surgery, the Longgang Orthopedics Hospital of Shenzhen, Shenzhen 518116, Guangdong Province, China
| | - Joseph A Buckwalter
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA 52240, United States
| | - Yi Yang
- Department of Microsurgery and Orthopedic Trauma, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, Guangdong Province, China
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Güleç A, Özdemir A, Durgut F, Yildirim A, Acar MA. Comparison of Innervated Digital Artery Perforator Flap Versus Homodigital Reverse Flow Flap Techniques for Fingertip Reconstruction. J Hand Surg Am 2019; 44:801.e1-801.e6. [PMID: 30581055 DOI: 10.1016/j.jhsa.2018.11.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 10/01/2018] [Accepted: 11/06/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study was to investigate and compare outcomes of 2 different flap techniques for fingertip reconstruction: innervated digital artery perforator (IDAP) flap and homodigital reverse-flow flap. METHODS Medical records of 33 patients who underwent fingertip reconstruction either with an IDAP flap (15 patients) or with a homodigital reverse-flow flap (18 patients), between 2014 and 2016, were evaluated retrospectively. In both study groups, full-thickness skin grafts harvested from the proximal/volar side of the forearm were used to cover the flap donor site. Flap survival, venous congestion, cold intolerance, static 2-point discrimination, flap size, duration of surgery, time to return to work, proximal and distal interphalangeal joint range of motion, Disability of the Arm, Shoulder, and Hand questionnaire scores, and follow-up time were evaluated. RESULTS All the major outcomes, including flap survival, cold intolerance, static 2-point discrimination, flap size, time to return to work, range of motion values for proximal and distal interphalangeal joints, Disability of the Arm, Shoulder, and Hand questionnaire scores, and follow-up time, were similar between the 2 flap methods. Mean duration of surgery was shorter in the IDAP flap group. Marginal flap necrosis occurred in 1 IDAP flap, and there was complete survival of the remainder of the flap after debridement. Temporary venous congestion was seen in 3 IDAP flaps, all of which resolved with nonsurgical measures. CONCLUSIONS Similar success rates and satisfactory outcomes were achieved with IDAP flap and reverse-flow flap techniques used for fingertip reconstruction. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Ali Güleç
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Selçuk University, Konya, Turkey.
| | - Ali Özdemir
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Selçuk University, Konya, Turkey
| | - Fatih Durgut
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Selçuk University, Konya, Turkey
| | - Ahmet Yildirim
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Selçuk University, Konya, Turkey
| | - Mehmet Ali Acar
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Selçuk University, Konya, Turkey
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Extended thenar flap for two adjacent fingertip amputations. J Plast Reconstr Aesthet Surg 2019; 73:65-71. [PMID: 31477494 DOI: 10.1016/j.bjps.2019.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 05/29/2019] [Accepted: 07/27/2019] [Indexed: 01/15/2023]
Abstract
The thenar flap is a well-described technique, but reports about its use in patients with multiple fingertip injuries are limited. This study aims to introduce a surgical technique of using an extended thenar flap for two adjacent fingertip amputations and to evaluate the clinical outcomes and related complications. From October 2013 to October 2016, 12 patients (24 fingers) underwent soft tissue reconstruction of two adjacent fingers with an extended thenar flap. At the last follow-up, the patients were assessed for cold intolerance in the reconstructed fingers; two-point discrimination (2PD); range of motion (ROM); functional outcomes using the quick disabilities of the arm, shoulder, and hand (DASH) score; functional and appearance outcomes using the Michigan Hand Outcome Questionnaire (MHQ); and time taken to return to work. The mean follow-up time was 13.5 (range: 12-16) months. All flaps survived. The mean total active ROM in flexion measured at the last follow-up was 255° (range: 245°-260°). Objective sensibility in the flaps was ascertained as an average static 2PD of 6.9 (range: 3-10) mm. The mean quick DASH score was 3.3 (range: 0-9.1). The mean MHQ score was 93.8 (range: 88-100). All patients returned to work within 6.2 weeks on average. There were no complications. The extended thenar flap technique is a good alternative for simultaneous coverage of small-to-large defects in two adjacent fingertips.
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Composite grafts for fingertip amputations: A systematic review protocol. Int J Surg Protoc 2019; 16:1-4. [PMID: 31897441 PMCID: PMC6921220 DOI: 10.1016/j.isjp.2019.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 04/05/2019] [Accepted: 05/21/2019] [Indexed: 11/20/2022] Open
Abstract
Background There is much debate in the hand surgery literature as to the management of fingertip amputations. Much research continues to be published in this area. Methods of reattachment include microsurgical and non-microsurgical (composite graft) replantation. The role of composite grafts lacks clarity in terms of outcomes, success rates and complications. Hence there is a need for an evidence synthesis, which can guide patient selection, the consent process and determine graft survival rates and functional outcomes to optimise patient outcomes. Methods Search of the databases OVID MEDLINE, PubMed, EMBASE, SCOPUS, The Cochrane Library and clinical trial registries from inception using terms "fingertip" "digital tip" "digit" "finger" "thumb" "amputation" "replantation" "reattachment" "reimplantation" and "composite graft" as key terms with "AND" selected as a Boolean operator, limited to humans will be conducted by two independent researchers. The patient population will include adults and children. Studies will be included if they report: (1) primary data; (2) outcomes of 'composite grafts' or 'nonmicrosurgical replantations'; (3) graft survival, (4) 5 or more cases. Articles will be excluded if surgical techniques involve: (1) composite graft pocketing, or (2) microsurgical replantation or (3) additional flaps (pulp or local). Full exclusion and inclusion criteria are described within this protocol. Data extraction will include; demographic details, patient comorbidities, amputation nature and level, functional, and aesthetic outcomes, complications and need for secondary procedures. All data extracted will be cross-checked, and discrepancies resolved through consensus. Dissemination This review will be published in a peer-reviewed journal and will be presented at national and international conferences to inform the practice of other clinicians.
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Expanded Utilization of the Digital Atasoy Flap. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 6:e2049. [PMID: 30656123 PMCID: PMC6326594 DOI: 10.1097/gox.0000000000002049] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 10/12/2018] [Indexed: 11/25/2022]
Abstract
Background The Atasoy, or Kleinert flap, is well-known to hand surgeons. This triangular volar V-Y flap is frequently used for reconstruction of fingertip amputations with exposed bone. It is indicated in transverse amputations or in dorsal oblique amputations, providing replacement of an area of skin and subcutaneous tissues with sensibility. Originally, this flap was not recommended for use in volar oblique amputations (greater volar tissue loss). With the described modifications and recommendations, modest volar oblique amputations can be closed in a single stage, obviating a 2-stage procedure. Methods With the described technical modifications, modest volar oblique amputations can be closed. An injury that previously may have required a 2-stage procedure can be closed in a single stage. Results The elevation of the flap was originally described as a dissection at the volar periosteum from a distal approach. This distal dissection is no longer recommended, as it does not create advancement. Beasley indicated the need for division of the vertical fibrous septa proximally for flap mobilization. This technique description emphasizes the importance of this division of the fibrous septa rather than stretching. Careful treatment of the remaining bone is stressed. Coverage of the nail bed is not recommended.
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Abi-Chahla ML, Alet JM, Fabre T, Pelissier P. Treatment of defects in the tip and palmar surface of the fingers. HAND SURGERY & REHABILITATION 2018; 37:4-11. [DOI: 10.1016/j.hansur.2017.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 11/04/2017] [Accepted: 11/08/2017] [Indexed: 11/30/2022]
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Sindhu K, DeFroda SF, Harris AP, Gil JA. Management of partial fingertip amputation in adults: Operative and non operative treatment. Injury 2017; 48:2643-2649. [PMID: 29100662 DOI: 10.1016/j.injury.2017.10.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 10/28/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Hand and finger injuries account for approximately 4.8 million visits to emergency departments each year. These injuries can cause a great deal of distress for both patients and providers and are often initially encountered in urgent care clinics, community hospitals, and level one trauma centers. Tip amputation injuries vary widely in mechanism, ranging from sharp lacerations to crush injuries that present with varying degrees of contamination. The severity of damage to soft tissue, bone, arteries and nerves is dependent upon the mechanism and guides treatment decision-making. The management algorithm can oftentimes be complex, as a wide variety of providers, including orthopedists, general surgeons, plastic surgeons and emergency physicians, may care for these injuries, depending on location and local culture. We review the common mechanisms for tip amputation and the optimal treatment in adults, based on the severity of the injury, degree of wound contamination, and the facilities available to the provider. METHODS Pubmed was searched using text words for articles related to management of fingertip injuries in adults. Bibliographies of matching articles were searched for additional relevant articles, which were then also reviewed. 107 articles were reviewed in total, and 61 were deemed relevant for inclusion. All clinical studies and reviews were included. Particular attention was paid to articles published within the past 15 years. RESULTS In the United States, up to 90% of fingertip amputations are treated with non-replant techniques. In comparison, the majority of amputations in Asian countries are replanted due to moral values and importance of body integrity. Tip amputation injuries can be managed with local debridement, complex reconstruction, or simply with irrigation and application of a sterile dressing. CONCLUSION In the United States, most fingertip amputations in adults are treated with non-replant techniques. However, the precise management of a fingertip injury in adults depends on the degree of injury itself, and a number of operative and non-operative techniques may be successfully employed.
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Affiliation(s)
- Kunal Sindhu
- Department of Medicine, Mount Sinai Beth Israel, New York, NY 10003, United States
| | - Steven F DeFroda
- Department of Orthopaedic Surgery, Brown University, Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 0290, United States.
| | - Andrew P Harris
- Department of Orthopaedic Surgery, Brown University, Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 0290, United States
| | - Joseph A Gil
- Department of Orthopaedic Surgery, Brown University, Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 0290, United States
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Qin H, Xia J, Hu B, Wang H, Xu L, Wang Y. [Repair of thumb defects with modified radial dorsal fasciocutaneous flap of thumb]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2017; 31:841-844. [PMID: 29798530 DOI: 10.7507/1002-1892.201703053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To investigate the operative method of repairing soft tissue defect of the thumb with modified radial dorsal fasciocutaneous flap and its effectiveness. Methods Between June 2015 and December 2016, 15 patients with volar or dorsal defects of the thumb were treated with modified radial dorsal fasciocutaneous flaps which distal pedicles were cut off. Of 15 cases, 11 were male and 4 were female, aged 35-70 years (mean, 46 years). The causes of injury included crush injury in 12 cases and avulsion injury in 3 cases. Because all patients had volar or dorsal defects of the thumb which were accompanied by tendon or bone exposure, they had no condition or desire to replant. There were 12 cases of volar defect of thumb and 3 cases of dorsal defect. The area of defects ranged from 2.0 cm×1.2 cm to 3.0 cm×2.5 cm. The time between injury and operation was 16 hours to 2 days (mean, 30.4 hours). The radial dorsal fascio-cutaneous flaps of 2.3 cm×1.5 cm to 3.3 cm×2.8 cm in size were adopted to repair defects. The donor sites were directly sutured. Results All flaps survived, and no severe swelling or tension blister occurred. The donor sites and wounds healed by first intention. All patients were followed up 3-12 months (mean, 6 months). The color and texture of the grafted flaps were similar to those of normal skin, with no bloated appearance. According to total active motion standard at last follow-up, the finger function was excellent in 8 cases and good in 7 cases. Conclusion Modified radial dorsal fasciocutaneous flap of the thumb is a reliable flap with easy dissection and less trauma in repair of soft tissue defects of the thumbs, and satisfactory clinical outcome can be obtained.
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Affiliation(s)
- Hongjiu Qin
- Department of Hand and Foot Surgery, Yijishan Hospital of Wannan Medical Collage, Wuhu Anhui, 241001, P.R.China
| | - Jiang Xia
- Department of Hand and Foot Surgery, Yijishan Hospital of Wannan Medical Collage, Wuhu Anhui, 241001,
| | - Bin Hu
- Department of Hand and Foot Surgery, Yijishan Hospital of Wannan Medical Collage, Wuhu Anhui, 241001, P.R.China
| | - Haisheng Wang
- Department of Hand and Foot Surgery, Yijishan Hospital of Wannan Medical Collage, Wuhu Anhui, 241001, P.R.China
| | - Lei Xu
- Department of Hand and Foot Surgery, Yijishan Hospital of Wannan Medical Collage, Wuhu Anhui, 241001, P.R.China
| | - Yinze Wang
- Department of Hand and Foot Surgery, Yijishan Hospital of Wannan Medical Collage, Wuhu Anhui, 241001, P.R.China
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Germann G, Rudolf KD, Levin SL, Hrabowski M. Fingertip and Thumb Tip Wounds: Changing Algorithms for Sensation, Aesthetics, and Function. J Hand Surg Am 2017; 42:274-284. [PMID: 28372640 DOI: 10.1016/j.jhsa.2017.01.022] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 01/26/2017] [Indexed: 02/02/2023]
Abstract
Management of fingertip and thumb tip injuries has recently undergone substantial changes. The time-proven traditional armamentarium of local flaps has been expanded and replaced by a wide variety of flaps. Simultaneous with the development of new flaps, the conservative treatment of fingertip and thumb tip injuries with semiocclusive dressings has also become a more acceptable treatment for these injuries. The excellent results with respect to restoring contour, sensibility of the pulp, and aesthetics of the finger justify this more tedious and time-consuming treatment of fingertip and thumb tip injuries. This article gives an update of the most commonly used flaps and the semiocclusive dressing treatments of fingertip and thumb tip injuries.
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Affiliation(s)
- Günter Germann
- Ethianum for Clinic Plastic, Hand and Reconstructive Surgery, University of Heidelberg, Heidelberg, Germany.
| | - Klaus D Rudolf
- Ethianum for Clinic Plastic, Hand and Reconstructive Surgery, University of Heidelberg, Heidelberg, Germany
| | - Scott L Levin
- Ethianum for Clinic Plastic, Hand and Reconstructive Surgery, University of Heidelberg, Heidelberg, Germany
| | - Manuel Hrabowski
- Ethianum for Clinic Plastic, Hand and Reconstructive Surgery, University of Heidelberg, Heidelberg, Germany
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Paediatric fingertip composite grafts: Do they all go black? J Plast Reconstr Aesthet Surg 2017; 70:173-177. [DOI: 10.1016/j.bjps.2016.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 11/02/2016] [Accepted: 11/04/2016] [Indexed: 11/23/2022]
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Reconstruction of two fingertip amputations using a double thenar flap and comparison of outcomes of surgery using a single thenar flap. Injury 2017; 48:481-485. [PMID: 28057323 DOI: 10.1016/j.injury.2016.12.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 12/10/2016] [Accepted: 12/26/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Although thenar flap for single fingertip amputation is a common and popular surgical technique, double thenar flap technique for patients with two fingertip amputations has rarely been reported in the literature. The purpose of this case-control study was to introduce the double thenar technique and compare the clinical outcomes between single thenar flap and double thenar flap surgical treatments. METHODS From January 2005 to December 2014, 92 patients with single fingertip amputations were treated with thenar flap (Group I) and 28 patients with two fingertip amputations were treated with double thenar flap (Group II). These 120 patients were followed-up for a minimum of 12 months postoperatively. At the latest follow-up, the two groups were assessed for pain, cold intolerance in the reconstructed finger, functional outcomes by Chen's criteria, and subjective patient satisfaction. RESULTS At the final follow-up, all flaps in both groups had survived. No flap failure occurred. There was no significant difference in cold intolerance (p=0.783), donor site pain (p=0.728), fingertip pain (p=1.000), or paresthesia (p=0.514) between the two groups. A total of 100 (83.3%) patients were completely or fairly satisfied. There was no significant difference in satisfaction between the two groups (p=0.801). According to the Chen criteria, 102 (85%) patients had excellent or good results. CONCLUSION This study demonstrated that the double thenar flap technique used for patients with two fingertip amputations produced complete survival with functional outcomes comparable to those of the single thenar flap technique at the last follow-up.
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Abstract
The management strategy proposed herein for fingertip amputations advocates secondary healing with preservation of appearance as well as function. Conservative healing is more likely to result in a sensate, nontender, and cosmetically acceptable fingertip compared to surgical management in many clinical scenarios. This manuscript examines in detail the extent of fingertip injury and defines the relationship of injury to final fingertip outcome. A classification is presented, which allows adequate initial counseling regarding prognosis, and predicts the need for secondary corrective surgery.
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