Identifying Predictors of Radiographic Distal Phalangeal Nonunion After Fingertip Replantation

PURPOSE

This study aimed to estimate the risk factors for distal phalangeal nonunion in cases involving Kirchner wire fixation after successful fingertip replantation.

METHODS

This study retrospectively analyzed 116 digits of 111 patients, including 74 and 42 digits with replantation in Tamai zones I and II, respectively. Univariate and multivariable analyses were performed to assess the influences of 15 independent variables on nonunion, including age, sex, medical history of diabetes mellitus, history of smoking, injured hand and digit, injury type (clean, blunt, and crush-avulsion), amputation type (complete or incomplete), length of the distal bone fragment (mm), fracture type (simple or comminuted), presence of a bone defect, length of the fracture gap after fixation (mm), number of Kirchner wires used, evidence of venous repair, and the occurrence of pin tract infections after fixation.

RESULTS

At 12 months after replantation, 100 digits showed bony union and 16 (13.8%) digits showed radiographic nonunion or equivalent complications, including 9 digits with asymptomatic nonunion without a secondary operation, 5 that underwent an additional operation for nonunion or a complication, and 2 with distal bone resorption. A multivariable analysis indicated that the postfixation fracture gap was the only significant predictor influencing nonunion (odds ratio, 3.30; 95% confidence interval, 1.92-5.68).

CONCLUSIONS

The extent of the postfixation fracture gap had the greatest influence on preventing distal phalangeal nonunion, indicating the importance of reducing the fracture gap in primary fixation as much as possible.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Painful Proximally Oriented Large Heterotopic Spur Formation in an Active Adult With a Nontraumatic Amputation

Heterotopic ossification (HO) is excess bone growth in soft tissues, typically juxta-articular and interfascicular, with varying incidence. This excess bone growth has been well-documented in cases of traumatic amputation but less frequently observed in cases of nontraumatic amputation. Symptomatic heterotopic ossification usually includes pain during prosthetic use with management involving prosthetic adjustments for comfort. This atypical case highlights a patient with a nontraumatic amputation and a proximal-oriented large spur formation that was not painful with ambulation but with doffing his prosthesis.

Management of partial traumatic hemipelvectomy

Partial traumatic hemipelvectomy is a devastating condition. Although by definition the affected limb is not totally transected from the trunk because of retained soft tissue, the reported mortality rate is actually higher than in complete traumatic hemipelvectomy. Between January 2000 and December 2011, a total of 917 patients were admitted to the authors' institution for pelvic fracture. Seven of these patients met the criteria for partial traumatic hemipelvectomy. All 7 patients had multiple associated injuries and met the criteria for Baskett class IV hypovolemic shock on arrival at the emergency department. The amount of bleeding was the greatest issue, and control of hemorrhage and rapid blood transfusion were the initial goals. Abdominal aorta balloon occlusion, laparotomy and packing, and pelvic external fixation were useful to control bleeding. Two patients died during the initial resuscitation phase. Angiography (digital subtraction or computed tomographic) was performed in 4 patients but did not provide any treatment-altering information. Limb preservation was attempted in 2 patients; both of these patients eventually required hindquarter amputation. One patient died, and the second patient survived after a difficult postoperative course. The best results were obtained in 3 patients who underwent completion of the hindquarter amputation within 24 hours of trauma. All patients became wheelchair dependent, and no patient was able to return to work. Early completion of hindquarter amputation after hemorrhaging has been controlled is recommended in patients with partial traumatic hemipelvectomy. Angiography did not prove useful in decision making.

Organization and activity of the Replantation Service for amputated hands in Poland

A permanent on-call service for hand amputations (Replantation Service) was established in 2010 of the initiative of the Council of Polish Society for Surgery of the Hand. It is run by three qualified hand centres in Trzebnica, Poznań and Szczecin. Organization of this system, rules of activity and spectrum of cases admitted to replantation units was presented. A scheme of referral of amputations was shown and the main problems that appeared during almost three-year activity of the Service were discussed. Medico-legal and ethical implications arising from these problems were shown and organization of replantation service in other European countries was outlined. Establishing of the Replantation Service constituted a significant progress in the organization of the management of upper limb amputations. Thanks to that, over the period of three years, more than 200 patients were saved from severe disability, receiving a chance to regain an amputated limb.

Notable features in composite tissue allografts: value of high-resolution ultrasonography as a first-line imaging modality

PURPOSE

Hand transplantation is challenging, especially with respect to postoperative care. Serious complications including rejection of the transplant are possible. To date, imaging has relied mainly on plain radiography, CT and MRI. High-resolution ultrasound (HRUS) has the potential to be a quick, cost-effective and dynamic alternative at least for the initial assessment of most of these complications. We report on our experience with HRUS in three patients after bilateral hand/forearm transplantation.

MATERIALS AND METHODS

Three male patients with bilateral hand/forearm transplantation after traumatic amputation underwent periodic HRUS and color Doppler assessment. These exams focused especially on the detection of changes at the coaptation sites (nerve/muscle/tendon coaptation) and expected changes in vessels and healing bones in the compound allograft. The HRUS data were compared to available data of other radiological imaging modalities.

RESULTS

Relevant post-transplant changes such as neuromas, arteriovenous fistulas, heterotopic ossifications and scars were specified by HRUS. In addition information on muscle and tendon function was gained by dynamic ultrasound. In most cases no relevant information gain by other modalities was stated.

CONCLUSION

Based on our experience, we recommend sonography as a first-line modality for the follow-up of patients who underwent composite tissue allografting. HRUS allows the reliable and timely diagnosis of relevant complications and the monitoring of postoperative changes and sets the course for therapy or further more invasive imaging.

COMPARISON OF METHODS OF SKELETAL FIXATION FOR SEVERELY INJURED DIGITS

Our objective is to compare the results of three different methods of osteosynthesis used in severely injured digits, namely the K-wire group, the K-wire & Wire-loop group and the Plate & Screws group. The results of 38 patients with 50 severely injured fingers managed between 1994 and 2000 were reviewed. Majority of them had serious injury caused by electric-saw and Zone III was the most common level of injury using Biemer's classification. Using the scoring system of Nakamura and Tamai, excellent and good results were obtained in 59.5% of the patients. The rate of bony complications was different among the three methods of osteosynthesis though the final functional outcomes were comparable. The rate of bony complications in this series was 20.4%, which included non-union (7), migration of K-wires (2) and infection (1). All occurred in K-wire and K-wire & Wire-loop groups. Plate & Screws, therefore, is the preferred method of bony fixation if further operation for non-union is to be avoided. This is more so for the proximal injuries.

Fingertip injuries in children treated in Department of Pediatric Surgery and Oncology in the years 2008-2010

BACKGROUND

Fingertip injuries are the most common hand injuries in children seeking medical advice at trauma care centres. Most cases are treated conservatively and hospitalisation is not necessary. However, surgery under general anaesthesia is often required on account of severity of the injuries and the patients' young age. The aim of the paper is to discuss a series of patients treated in the Department of Paediatric Surgery and Oncology between 2008 and 2010, and present the problems associated with surgical care in fingertip injuries in children.

MATERIAL AND METHODS

A total of 76 children were treated in the Department of Pediatric Surgery and Oncology between 2008 and 2010 because of fingertip injuries. This group is estimated to represent approx. 10% of all patients admitted to the Emergency Unit. Fingertip injuries were treated with situation sutures, V-Y-plasty, suturing back the amputated fingertip and by suturing into thenar skin. Data were extracted from medical files and presented as percentages.

RESULTS

There were 50 boys in the group of 76 children (65.79%). Mean age was 7 years. Most of the patients were children aged 1 to 5 years (36 patients, 47.37%). In 45 children (59%), the right hand was injured. Injury to fingers responsible for the pincer grasp occurred in 29 children (38.16%).

CONCLUSIONS

Fingertip injuries are among the most common injuries in children and preservation of the hand's motor abilities depends on thorough surgical care. Most children with fingertip injuries are treated in Emergency Units and only 10% of patients need surgery under general anaesthesia after hospital admission. A number of surgical techniques can be used in the management of fingertip injuries in children. These techniques represent adaptations of methods used in adults. A model for the evaluation of severity and management of fingertip injuries in children should be established.

[Experience with the treatment of combined open injuries to the upper extremities with affected main arteries]

The paper deals with the principles of management of combined mechanical injuries to the upper extremities with special reference to amputation of their segments based on the 3-year experience with the treatment of 1488 patients including 405 ones with traumatic amputations. Replantation of large and small segments was undertaken in 24 and 76% of the cases respectively. 43% of the patients underwent one-step traumatic amputation of two and more segments. Skin and soft tissue defects occurred in 111 patients including 27 with extensive lesions. 82.4% of the surgical interventions had the desired outcome. An example of successful replantation is described. The results are compared with the literature data.

One case of big-toe re-plantation: a 13-year follow-up and a literature review

In this case of a 3-year-old patient who had a left big-toe amputation through the proximal phalange, re-plantation was performed successfully. Big-toe amputations are not frequent entities, but it should always be re-planted to avoid unsatisfactory aesthetic and functional outcomes. There are just a few reports in literature and their follow-up is very brief compared with our report.

[Successful brachial replantation in a child after a traction-type traumatic amputation]

The article deals with certain aspects of managing patients presenting with extremital bone-and-vascular injuries known for utter severity and a high incidence rate of postoperative complications. Suggested herein, as the authors believe, is an optimal for both the patient and surgeon policy of emergency reconstruction. Emphasis is placed on the necessity to follow a certain sequence while restoring the anatomical structures destroyed. The conclusions drawn include compulsorily considering a possibility to spare the damaged segment, followed by restoring adequate blood circulation and prevention of wound infection, carrying out osteosynthesis with obligatory shortening of the bones, and postponing orthopaedic measures for the remote postoperative period. Also presented in the article is a photograph-illustrated clinical case report of a successful brachial replantation.

Cosmetic amputation of the fourth ray as possible outcome of the traumatic amputation of the ring finger injury: a case report

The aim of this work is to describe a case of traumatic amputation of the fourth finger of the left hand. In its first phase, a treatment which consisted in a disarticulation at the level of the metacarpo-phalangeal joint was carried out; in the second phase, three months after this emergency treatment, a cosmetic amputation of the fourth metacarpal ray was required. Surgery was performed in accordance with the technique described by Bunnell, which consisted in the disarticulation of the fourth metacarpal, together with radial traslation of the fifth ray. Eighteen months after the operation The patient reported the absence of any subjective problems, with complete functional recovery of the hand that had been operated on. By that time she was back at her job; she also was satisfied with the cosmetic results that had been achieved.

Effects of long-term immobilisation on cortical bone mass after traumatic amputation of the phalanges estimated by digital X-ray radiogrammetry

Osteopenia of the cortical and trabecular bone partition is a common finding after immobilisation. Digital X-ray radiogrammetry (DXR) seems to quantify cortical demineralisation caused by circular saw amputation already few days after accident.

INTRODUCTION

The study analyses the extent of demineralisation caused by immobilisation in patients with digital amputation after a circular saw injury, and elucidates the period of time which discloses a significant deprivation of bone mineral density estimated at the metacarpalia II-IV using DXR.

METHODS

Twenty-eight patients with digital amputations underwent measurements of bone mineral density, cortical thickness, bone width and metacarpal index using DXR-technology in a follow-up up to 902 days.

RESULTS

The data showed a significant decline of bone mineral density (-10.47%), the metacarpal index (-4.38%), the bone width (-12.06%) and the cortical thickness (-7.04%) after trauma-related amputation. The cortical demineralisation of the metacarpals could already be revealed in two patients after the second day, according to the amputation of phalanges (-3.65%).

CONCLUSIONS

The inhibition of the periosteal bone formation detected by DXR-technique seems to be a specific finding caused by amputation, which thus differs from normal age-related (i.e., endosteal) bone loss and from demineralisation following acute immobilisation (i.e., trabecular osteopenia).

Heterotopic ossification following traumatic and combat-related amputations. Prevalence, risk factors, and preliminary results of excision

BACKGROUND

Although infrequently reported in amputees previously, heterotopic ossification has proven to be a common and problematic clinical entity in our recent experience in the treatment of traumatic and combat-related amputations related to Operation Enduring Freedom and Operation Iraqi Freedom. The purpose of the present study was to report the prevalence of and risk factors for heterotopic ossification following trauma-related amputation as well as the preliminary results of operative excision.

METHODS

We identified 330 patients with a total of 373 traumatic and combat-related amputations who had been managed at our centers between September 11, 2001 and November 30, 2005. We reviewed the medical records and radiographs of 187 patients with 213 amputations who had adequate radiographic follow-up. Additional analysis was performed for twenty-four patients with twenty-five limbs that required excision of symptomatic lesions. The mechanism and zone of injury, amputation level, timing of excision, use of prophylaxis against recurrence, and other confounding variables were examined. Outcomes were assessed by determining clinical and radiographic recurrence rates, perioperative complications, preoperative and follow-up pain medication requirements, and the ability to be fit with a functional prosthesis.

RESULTS

Heterotopic ossification was present in 134 (63%) of 213 residual limbs, with twenty-five lesions requiring excision. A final amputation level within the zone of injury was a risk factor for both the development and the grade of heterotopic ossification (p < 0.05). A blast mechanism was predictive of occurrence (p < 0.05) but did not correlate with grade. All patients who had been managed with excision were tolerating the prosthetic limb at an average of twelve months of follow-up. Twenty-three limbs demonstrated no evidence of recurrence, and two limbs had development of clinically asymptomatic, radiographically minimal recurrences. Six patients experienced wound-related complications that required reoperation, and two patients required subsequent minor revision surgery. There was a significant decrease in the use of pain medication following surgery (p < 0.05).

CONCLUSIONS

Heterotopic ossification following trauma-related amputation is more common than the literature would suggest, particularly following amputations that are performed within the initial zone of injury and those that are due to blast injuries. Many patients are asymptomatic or can be successfully managed with modification of the prosthesis. For patients with refractory symptoms, surgical excision is associated with low recurrence rates and decreased medication requirements, with acceptable complication rates.

Free Lateral Arm Flap for 1-Stage Reconstruction of Soft Tissue and Composite Defects of the Hand

In this article, the long-term outcomes of hand defects after 1-stage reconstruction with lateral arm flap were retrospectively analyzed in a large series. Between the years 1990 and 2004, 118 traumatic hand defects were reconstructed using lateral arm fasciocutaneous flap (n = 104), lateral arm fascial flap (n = 6), and composite lateral arm flap (n = 8) in Chang Gung Memorial Hospital. There were 22 females and 96 males with an average age of 32.5 +/- 13.3 years. The mean follow-up period was 17 +/- 6.2 months. The overall success rate was 97.5%. The cosmetic outcomes were satisfactory and only 16.1% of the patients required debulking. The functional recovery of the hand contractures secondary to crush injury were generally associated with poor results. In the composite flap group, reconstruction of the extensor tendons with triceps tendon yielded limitation in tendon excursion and poor functional results. However, complete bone healing without complication was uniformly detected in all cases. Lateral arm fasciocutaneous flap endured secondary interventions well and no complications regarding wound healing was encountered.

The first case of primary metacarpal V restoration with titanium mesh and cancellous bone graft

Any references of use of the titanium mesh in hand reconstruction could not be found. A case of primary metacarpal reconstruction after severe hand trauma with a help of cage made of titanium mesh and cancellous iliac bone graft is presented.

[Inner amputation of an upper extremity with impaired cerebral perfusion and lethal outcome]

An inner amputation of the upper extremity is understood to be a rupture of the arm's vascular nerve bundle as well as the shoulder's and scapular's stabilizing muscles and fibrous joints without damage to the dermal soft tissue sheath. This injury is a rare and grave incident which mostly occurs within the scope of a high-energy trauma and in cases of polytraumatized patients in combination with additional life-threatening injuries. In the literature this is referred to by the terms scapulothoracic dissociation (SD) and closed forequarter amputation--the entity of SD was first described by Oreck et al. in 1984. Traction of the upper extremity leads to the rupture of the m. pectoralis major, m. pectoralis minor, the musculi rhomboidei, the m. levator scapulae, the m. latissimus dorsi as well as the m. trapezius. Furthermore the traction causes acromioclavicular or sternoclavicular bursting of the joints or a displaced clavicle fracture. Among the more than 50 cases depicted until now, 94% of the patients exhibit a neurological (plexus) and 80% a vascular lesion, thus corresponding to a genuine inner amputation. The prognosis for this injury is consistently poor: 10% of the patients die, in 52% an nonfunctional extremity remains, and in 21% a untimely amputation has to be performed. The observed complication of cerebral hypoperfusion caused by increasing pressure in the neck compartment, which ultimately leads to the death of the patient, has, as far as we know, not yet been specified and emphasizes the gravity and the magnitude as well as the necessity of rapid diagnosis and appropriate therapy of this infrequent injury.

[The results of digital replantations at the level of the distal interphalangeal joint and the distal phalanx]

OBJECTIVES

We retrospectively evaluated replantations performed for distal amputations.

METHODS

The study included 82 patients (75 males, 7 females; mean age 29 years; range 10 to 52 years) who underwent replantations distal to the distal interphalangeal joint for a total of 98 amputations. According to the Tamai classification, there were 58 zone 1 and 40 zone 2 amputations. Local digital anesthesia was used in 77 patients (93.9%). Arterial anastomosis was accomplished after bone fixation, and venous anastomosis and nerve repair were performed whenever possible. When venous anastomosis was not possible or in case of venous insufficiency, venous decompression was performed with heparinized gauze placed on the bleeding nail matrix. Functional results and the degree of patients' satisfaction with the cosmetic outcome were evaluated. The mean follow-up was 16 months (range 3 to 46 months).

RESULTS

Replantation was successful in 60 amputations (61.2%) and unsuccessful in 38 cases (38.8%). In successful cases, cosmetic results were satisfactory due to the preservation of the nail and finger length. Functional results were satisfactory in cases in which the distal interphalangeal joint could be preserved. Replantations for zone 1 amputations (74.1%) yielded better results than those performed for zone 2 amputations (42.5%).

CONCLUSION

Despite technical difficulties, replantations for distal finger amputations can provide satisfactory functional and cosmetic results.

[Improved fixation of finger prostheses by means of intramedullary titanium anchors and magnets]

BACKGROUND

A small series of patients with traumatic amputation of fingers have undergone treatment with a new technique using endomedullar osseointegrated titanium implant device that magnetically holds the finger prosthesis.

METHODS

A two-stage reconstruction procedure with endomedullar osseointegrated titanium implants was performed to attach a finger prosthesis to the proximal, middle and distal phalanx. The first stage included implantation of the titanium fixture into the medullary cavity canal of the phalanx. After a 2-month rest period to allow the fixture to firmly osseointegrate with the phalanx of the bone, a skin-penetrating titan-magnetic abutment was placed on top of the fixture, to which the prosthesis was firmly attached.

RESULTS

Good stability could be achieved using an endomedullar osseointegrated prosthesis. Easy handling is possible with the magnetic connection between finger and prosthesis. In the clinical use were no complications observed. We observed no infections and no problems with the soft tissue.

CONCLUSIONS

The combination of osseointegrated titanium implants and magnetics for finger prosthetics provides several advantages. Such as stable fixation of the prosthetic finger to the bone, restoration of some sensory feedback with better osseoperception as well as an excellent cosmetic result.

Effect of Body Armor on Simulated Landmine Blasts to Cadaveric Legs

BACKGROUND

Antipersonnel landmine protective footwear relies on blast deflection or on exaggerated standoff between the foot and the explosive. Neither design has been tested for clinical effectiveness.

METHODS

4 cadaveric lower extremities--3 fitted with a Koflach boot incorporating TABRE (Technology for Attenuating Blast Related Energy) were subjected to controlled blast with charges of up to 100 g trinitrotoluene (TNT). The blasts were recorded by a digital recording system. All legs were X-rayed and underwent computed tomography scanning before and after testing.

RESULTS

TABRE-protected limbs directly subjected to the blast hyperextended at the knee during firing. Injuries showed a pattern of open tibial fractures (Gustilo grade I, II), of multiple calcaneal (Sanders Type III, IV), and fibular fractures and of the tibial plateau, but showed no traumatic amputation.

CONCLUSIONS

Development of protective footwear against landmine blast is feasible. From medium mines up to charges of 100 g TNT limb salvage may be possible.

Distal fingertip replantation without skeletal fixation

The replantation of fingertip amputation (through the nail bed) requires repair of the artery and vein on the palmar side. These structures are present in different planes, with the artery being deeper and the veins superficial. The authors believe that vascular repair in such cases is facilitated by stabilization of the amputated part by nail-bed repair alone. This provides a certain degree of flexibility, which allows for easier placement of clamps in the limited space available. Although Kirschner wires were not used for bony fixation, bony union was achieved in all five cases in which this technique was used.

Bilateral hand transplantation: bone healing under immunosuppression with tacrolimus, mycophenolate mofetil, and prednisolone

PURPOSE

Little is known about bone healing after composite tissue transplantation that requires pharmacologic immunosuppression. Bone integration and callus development were assessed in bilateral hand transplantation.

METHODS

In this study the course of callus development and callus maturation were assessed by color Doppler sonography and radiography in a double hand transplant and compared with forearm replantation.

RESULTS

After hand transplantation, ingrowth of small vessels at the bone junction was observed at week 3, calcified callus became visible at month 4, and bone union was completed at month 11. A similar time course of bone integration was observed after replantation. Plating offered sufficient stability. A recipient periostal flap is thought to have improved blood supply and favored development and induction of callus.

CONCLUSIONS

Bone healing after hand transplantation under immunosuppression with tacrolimus, mycophenolate mofetil, and prednisolone is identical to that after forearm replantation.

Free Dorsoulnar Perforator Flap Transfers for the Reconstruction of Severely Injured Digits

The aim of this study was to investigate the feasibility of transferring the free dorsoulnar perforator flap nourished by the cutaneous perforator branched dorsoulnar artery to reconstruct severely injured fingers under upper arm anesthesia. Between April of 2001 and April of 2002, 13 free dorsoulnar perforator flaps were used in 13 patients. There were 11 men and two women ranging in age from 18 to 64 years, with an average age of 38 years. The affected fingers were one thumb, four index fingers, five middle fingers, two ring fingers, and one little finger. All cases were performed under upper arm anesthesia combined with intravenous local anesthesia. The operative time ranged from 103 to 140 minutes, with an average time of 120 minutes. The flap size ranged from 1 x 3 to 3 x 4 cm, and was transferred from the same forearm of the injured finger. All donor sites were closed primarily without a skin graft. The aim of reconstruction for fingers was to repair a traumatic defect (five cases), partial necrosis following replantation (two cases), and soft-tissue defects resulting from resection of a scar (three cases) and to revascularize ischemic fingers (three cases). All flaps survived completely. After repair of the flow-through circulation of the common digital artery and ischemic finger, a postoperative angiogram showed the vascular patency and hypervascularity of the reconstructed fingers, and the patients' complaints were reduced. The free dorsoulnar perforator flap under regional anesthesia is first reported; it may become one valuable option as a very small flap for the treatment of repairing intercalated or segmental defects as a flow-through flap for soft-tissue defects and ischemic fingers.

Primary use of the index finger for reconstruction of amputated thumbs

Seven cases of primary reconstruction of traumatic amputation of the thumb using the index finger are reported. In six cases, the reconstruction was done using an injured index finger, while in one case where the amputation of the thumb was through the carpometacarpal joint, an intact index finger was primarily pollicised. This reduces cost of treatment, hospitalisation period and allows earlier rehabilitation without a period of a 'no thumb experience'. We have followed all the patients for a minimum period of 2 years and all of them have excellent functional results. We believe that pollicisation of a normal index finger, if thumb amputation is through the carpometacarpal joint or an injured index finger at the time of initial management of a severely traumatised hand with thumb amputation is an excellent technique for thumb reconstruction.

[Lengthening of the phalanges by callus distraction in traumatic amputations of the fingers]

OBJECTIVES

We evaluated the results of lengthening of the phalanges by callus distraction in traumatic amputations of the fingers.

METHODS

We treated traumatic amputations of 16 fingers of 13 male patients (mean age 27.7 years; range 12 to 43 years) by callotasis of the phalanges. Callus distraction was performed with a rate of 1 mm/day using a unilateral dynamic external fixation device. The mean follow-up period was 42 months (range 12 to 80 months).

RESULTS

The mean lengthening was 24 mm (range 18 to 26 mm) and 21 mm (range 18 to 26 mm) for the thumbs and the other fingers, respectively. The achieved thumb length provided adequate depth and width of the first web space and enabled functional improvement in the ability of gripping, and pulp-to-pulp and pulp-to-side pinching. In the absence of flexor pollicis longus, the mean strength of the thumbs was 7 kg (range 5 to 9 kg), amounting to 65% of the normal side. Lengthening of the other fingers resulted in improved functioning of the hand. The mean healing index (number of months per centimetre of lengthening) was 1.7 months/cm (range 1.6 to 2.1 months/cm) and 1.6 months/cm (range 1.4 to 1.9 months/cm) in the thumbs and the other fingers, respectively. Pin tract infections were observed in four phalanges.

CONCLUSION

Callotasis of the proximal phalanx of the thumb is an effective reconstruction method to compensate for the loss of distal phalanx and to alleviate functional problems due to shortness. It may also be applied to the phalanges of the other fingers in patients who do not accept ray resection with or without transposition.

[Complications after distal finger injuries]

Injuries of the fingertips are often but not always of a simple, easily healing kind. If there are complications they are induced by the severity of the trauma itself or because the patient himself or the physician treating the injury is misjudging its severity. This leads to an inadequate therapy, which may very well be the cause of a dramatic development, ending in loss of function of the injured hand if it comes to the worst. By the means of some selected examples the pitfalls in the treatment of fingertip injuries shall be pointed out.

[Simultaneous reimplantation of both lower legs--5-year follow-up (case report)]

We are reporting the case of a 29 year old male in whom we performed successful reimplantaton of both lower legs following trauma inflicted by a railroad boxcar. Five years after this accident, the patient's walk is almost normal and both deep sensitivity and two point discrimination on the soles of his feet are sufficient. The patient can walk, run and stand very well on one leg, both on even and on uneven ground.He returned to his job with the railroad 8 months after his accident. Originally the patient was employed as a railroad workman, and is now an office employee. His private life is normal and he enjoys hiking and dancing. In our opinion, sufficient function of the tibial nerve in the reconstructed extremity is important for clinically satisfactory long-term results. Both the Mangled Extremity Severity Score (MESS) and the NISSSA are helpful in making the decision on whether to primarily amputate or reconstruct Gustillo IIIC cases. Good long-term results as well as general cost reduction are achievable following reconstruction of extremities. Amputation of an extremity can be predicted with 100% certainty when MESS is 9 or more. Primary shortening and secondary lengthening of an extremity is a good method of treating Gustillo III C fractures.

[Finger reconstruction by microvascular second toe-to-finger transplantation in patients with traumatic loss of all fingers]

PURPOSE

To assess the utility of second toe-to-finger transplantation with neurovascular reconstruction in patients with loss of all four digits.

METHOD

Analysis of 24 toe-to-finger transplantations in 18 patients regarding over-all survival, complications and secondary procedures, sensibility, function, foot symptoms, and patient satisfaction. The original metacarpophalangeal joint was preserved in 50 % of the transplantations. In six patients, a second transplantation was performed.

RESULTS

A mean follow-up of 5.8 years was available in 94 % of the patients. 92 % of the transplanted toes survived, in 38 % of the cases complications occurred followed by a secondary procedure. Two-point-sensibility was present in 62 % of the transplantations, the largest range of motion of ca. 50 degrees was obtained in the metacarpophalangeal joint. An increase in the range of motion could be achieved by preservation of the original finger joint. The mean extension lag was 37 degrees independent of the preservation of the metacarpophalangeal joint. Foot symptoms were mild in four patients, in two cases severe donor-site-problems were observed. Cold intolerance was present in 47 % of the transferred toes. Overall patient satisfaction was high with 83 % of the patients confirming their decision to undergo operative treatment.

CONCLUSION

Second toe-to-finger transplantation is indicated in patients with traumatic loss of all digits. By this method, a great functional gain could be achieved as well as a high level of satisfaction. The rate of complications and possible foot symptoms should be considered. The preservation of the original metacarpophalangeal joint seems to be of importance for the function of the transplanted toe.

Functional latissimus dorsi island pedicle musculocutaneous flap to restore elbow flexion in replantation or revascularisation of above-elbow amputations

Two total and one subtotal above-elbow amputations had replantation or revascularization for their severely damaged upper extremities followed by functional latissimus dorsi island pedicle musculocutaneous flap to restore elbow flexion. The mean follow-up was 68 months (range: 14 to 121 months). At final follow-up examinations, the patients had sufficient range-of-motion of their elbows with good strength. Restoring elbow function eliminates one of the most important limiting factors for above-elbow replantations. Functional latissimus dorsi island pedicle musculocutaneous flap is very reliable, has minimal donor-site morbidity and offers a wider choice when deciding about arm replantation in the upper arm region by providing a chance of restoring functions.

[Late results following avulsion injuries of the thumb]

Out of the 127 amputated thumbs replanted at our unit during the last 15 years, there were 27 avulsion injuries. The average age of the 24 male patients was 33 years, that of the three female patients was 34 years. 70 % of the injuries were occupational accidents. Among the 27 patients, 21 had a complete and six an incomplete avulsion of the thumb. The level of avulsion-amputation was at the MP-joint ten times, between MP and IP joint ten times and at the IP-joint seven times. The healing rate of the subtotally avulsed thumbs was 100 %, that of the completely amputated thumbs 36 %. The most important post-operative complications observed were venous and secondary arterial thrombosis, whereby most of them occurred within the first 24 hours after replantation. The duration of ischaemia had a significant influence on the healing rate. In 80 % of the cases reconstruction of nerves have been carried out secondarily. A two-point discrimination was achieved in two cases only. The osteosynthesis was done almost exclusively with K-wires. Ten of 19 patients had to change their profession, while nine of them were able to return to their previous jobs, which in these cases were pre-dominantly white collar jobs. Another patient went for early retirement (he was a painter). All 19 patients followed-up had a range of movement of their saddle joints which was sufficient for the needs of most of the activities of daily life. Stiffness of the MP and IP joints was a common finding but had little functional impact, as it has been reported by other authors previously. We conclude from the results presented that in cases of avulsion injury of the thumb replantation is a procedure with significant chances of success.

[Reposition flap techniques in fingertip amputations: 6 cases]

PURPOSE OF THE STUDY

The purpose of this study was to evaluate an alternative procedure for amputations distal to the distal interphalangeal joint: the reposition flap.

MATERIALS AND METHODS

The reposition flap was used for 6 patients who underwent fingertip amputations in an emergency setting. Pulp was excised on the amputated segment and the remaining bone and nail bed were reattached to the proximal stump with a Kirschner wire. The pulp was reconstructed with a local advancement and sensitive flap. The patients were aged 18 to 44 years and had been victims of work accidents. All refused finger shortening.

RESULTS

The fingers showed good scarring and good trophicity. Two-point discrimination was 6 mm. Bony fusion was constant but all distal interphalangeal joints remained stiff. Cosmetic results were correct except for two cases of claw nail formation.

DISCUSSION

Fingertip amputations have been widely reported. Methods have varied from directed scarring to partial toe transfer. These situations present two types of challenge: insensitivity of the volar aspect or an overly sensitive pulp; cosmetic presentation and function of the dorsal aspect due to the complex role of the nail. Distal reimplantation remains the best technique, but the reposition flap offers an interesting alternative in case of failure or for patients who do not accept finger shortening. The advantage of the reposition flap is that it preserves finger length and the nail. Work stoppage and intolerance to cold can be an inconvenience due to the long time required for wound healing.

[Timing of soft tissue reconstruction in severe crush injury of the upper extremity]

Complex injuries of the distal forearm and the hand by industrial machines often require extensive reconstructive procedures. Crush injuries with soft tissue damage extending over the limits of visible injury require a special approach. Large soft tissue defects often have to be covered by extensive flap procedures. The optimum point of time for plastic reconstruction is an essential question and represents a controversial issue in the literature. To be able to compare different patient cohorts in the future, we classify crush injuries into five clinically relevant categories. In the course of this review article, three different cases of severe crush injuries of the upper extremity are representatively discussed. Two patients were reconstructed in a secondary procedure, one patient in the acute phase. Definite coverage of soft tissue defects in severe crush injuries should be performed secondarily after 5-7 days since the extent of damage in this special form of trauma can often only be judged after a few days and the reconstruction of bones, vessels and tendons is completed.

A continuum between scapulothoracic dissociation and traumatic forequarter amputation: a review of the literature

Both traumatic forequarter amputation and scapulothoracic dissociation are rare and life-threatening injuries. We present the case of a 31-year old woman who was ejected from a car after a motor vehicle accident and sustained an apparent partial forequarter amputation. Upon examination her injury was found to share many characteristics with a scapulothoracic dissociation injury. With both injuries mortality is high and prompt diagnosis and treatment imperative. By viewing scapulothoracic dissociation and forequarter amputation as a continuum faster recognition and appropriate treatment may be implemented for these devastating injuries.

Metacarpal and phalangeal lengthening by callus distraction

Twelve metacarpals and two phalanges in 14 patients (nine males and five females) were lengthened between August 1992 and March 1999 by the callus distraction technique using a small external fixator (Orthofix). The indications were traumatic amputation (10 cases), aplasia (three cases) and hypoplasia owing to premature epiphyseal closure of the metacarpal (one case). All patients were reviewed with a median follow-up time of 39 (range, 9-88) months. The median age of the patients was 15 (range, 4-39) years. The median lengthening was 21 (range, 13-34) mm which was a median of 82% (range, 38-162) of the original bone length. The median times for callus distraction and consolidation were 4.5 and 7.5 weeks respectively. All except one patient tolerated the procedure well and were satisfied with the results. Functional improvement was seen in 13 out of 14 patients, but non-union was observed in one patient.

[Callus distraction of the first metacarpal bone for thumb reconstruction after traumatic amputation]

From 1990 to 1997, callus distraction of the first metacarpal bone was performed on 34 patients with a traumatic amputation of the thumb, if replantation was not possible. After a period of 7 +/- 11 months (range, 1-48), a corticotomy and continuous distraction with an external fixator was carried out. Of the patients, 31 (91%) were reviewed after treatment. The follow-up period range was 41 +/- 32 months. With this method, the average lengthening of the thumb was 78% in comparison to the uninjured side. Complications were rupture of the callus in one case, four patients suffered a superficial wound infection, and seven patients showed pin tract infection without osteitis. At follow-up examination, 20 patients (64.5%) showed excellent, 9 (29%) good and 2 patients (6.5%) unsatisfying results.

[Expanded pedicled forearm flap for reconstruction of multiple finger amputations]

Soft-tissue injuries of the hand frequently require flap coverage to preserve structures damaged at the time of injury or to facilitate later reconstruction. The radial forearm flap makes local tissue readily available and offers a simple method of reconstruction. Secondary augmentation of the skin flap by means of tissue expansion appears to be a useful alternative to improve the possibilities of reconstruction. This case report describes a primary reconstruction of a hand with multiple finger amputations using both techniques: Forearm flap and tissue expansion.

[Proximal amputation injuries of the thumb including the radial half of the hand. Case reports]

The primary treatment of proximal amputations of the thumb and radial half of the hand is of particular importance, if the primary functions of a basic hand are to be restored. It is of utmost importance, that such treatment be carried out by a highly experienced reconstructive surgeon, since the transplantation or transposition of blood vessels, nerves, tendons and skin and soft-tissue flaps may be necessary. Five case reports illustrate the fundamental principles of primary and secondary reconstruction of the hand.

Distraction-lengthening of digital rays using a small external fixator

We present 19 ray lengthenings in 14 patients done with a small external fixator. In six cases the thumb was lengthened and in the other 13 cases, other digital rays. The most frequent reason for lengthening was an amputation sustained in a work accident. All the lengthenings were done by an osteotomy and subsequent gradual distraction with a small external fixator. The mean lengthening achieved was 20 mm (range, 0-32). An iliac-crest graft was needed in nine cases, corrective osteotomy in five cases and a deepening of the web in the six cases of thumb lengthening. In five cases an additional technique was needed to achieve bony consolidation. We have analysed the functional results and the ability to perform activities of daily living and resume employment. Although most of the patients had multiples injuries, the results have been very favourable, achieving a very high level of patient satisfaction.

[Primary shortening--secondary lengthening. A new treatment concept for reconstruction of extensive soft tissue and bone injuries after 3rd degree open fracture and amputation of the lower leg]

The main problem in major limb replantation--especially of the lower extremity--is an extensive bone- and soft-tissue loss. The traditional replantation concept tries to preserve the initial limb length; only a small shortening is accepted. To avoid a more extensive shortening, often insufficient debridement at the time of replantation is carried out. After successful revascularisation, bone and soft-tissue defects will be reconstructed according to the principles of staged reconstruction. Especially segmental nerve defects of more than one major peripheral nerve and severe skin and muscle loss necessitate extensive secondary grafting procedures. This often leads to a prolonged hospitalisation and a high complication rate. In 1951, Lorenz Böhler described the deliberate extremity shortening as a method of therapy in segmental combined bone-soft-tissue defects of the extremities. No additional surgical procedure were necessary to treat the soft tissue defect. A functional but shortened extremity was the result. With Ilizarov's principle of callus distraction he proved in an extensive experimental and clinical study the possibility to lengthen extremities without functional damage up to 20 cm. A new reconstruction concept--"concept of primary shortening with secondary limb lengthening"--for the treatment of amputation and/or amputation-like injuries was created by combining both principles mentioned above. At the time of replantation (reconstruction), deliberate shortening is carried out in order to reduce soft-tissue and/or bone defect or to enable primary nerve repair. Moreover, the aggressive debridement leads to a reduction of the local complication risk (wound healing disturbance, infection) and the potential systemic complications (crush-syndrome, ischemia-reperfusion-syndrome) after revascularisation of a large tissue bloc. Six to twelve months after replantation, secondary limb lengthening is started using an external or internal (= programmable intramedullary nail) distraction device. Since 1985, twelve patients (six macroamputations and six third-degree open fractures of the lower leg) have been treated using the "concept of primary shortening with secondary limb lengthening". Indications, operative technique, and results are shown and discussed, comparing this new concept to the traditional "concept of staged length-reconstruction" with extensive free tissue reconstruction and secondary nerve grafting.

[Complex trauma of the hand]

The hand is very exposed to injuries in the daily man's work. The multiple functions of the hand are based on vitality, sensibility, motor function and stability. In severe hand injuries the functional results of the repair are often very poor. In a complex injury of the hand we are faced with the damage of the soft tissue and bone and the loss of vitality and function of the hand. The cause of hand injuries are mainly a crush trauma or the rotating saw. Basically, we recommend an extended primary repair. After the radical debridement we have to reconstruct the damaged structures. We start doing the osteosynthesis and stabilization of the joints. Thereafter, suturing of extensor and flexor tendons. Then, we do the microsurgical reconstructions of vessels and nerves. In case tendons and bones are exposed we have to cover the defect with a pedicled or a free flap. In a long ischemic time we have to change our concept and do the reconstruction of the vessels first. Our results in vitality and sensibility are listed. In the result of a complex hand injury each single functional restoration is very important. Therefore, it is necessary that severe hand injuries are treated at well established centres for hand surgery.

Reimplantation of the upper limb after tear lesion: long-term results

Reimplantation revascularization of the upper limb proximal to the elbow represents an absolute indication in specific conditions. In the young subject, in good general conditions with a clean amputation (guillotine-like caused by a circular saw), the limb preserved in ideal conditions, indications for reimplantation are supported by the expectations of good functional recovery. When amputation is due to avulsion tear the possibility of anatomical and functional success is influenced by the complexity of vascular and nervous lesions. Thus, indications for reimplantation must be made by carefully evaluating each individual case.