1/74. Fingertip reconstruction with flaps and nail bed grafts.We retrospectively reviewed the cases of 14 fingertips reconstructed with a combination of local or regional flaps and nail bed grafts, some of which were placed wholly or partially over a de-epithelialized flap. Most of the fingertips sustained a crushing injury and were reconstructed at the time of the injury. Soft tissue coverage was provided by palmar V-Y flaps in 6 cases, thenar flaps in 4, lateral V-Y flaps in 2, a Moberg flap in 1, and a cross-finger flap in 1. Split toenail bed grafts were used in 6 cases, full-thickness nail bed grafts from the amputated part in 6, and split nail bed grafts from the injured digit in 2. There was 1 partial graft loss and 1 partial flap loss. The remaining cases had completely successful grafts and good soft tissue healing. Subsequent nail growth and adherence were good in all but the 1 digit requiring secondary composite grafting.- - - - - - - - - - ranking = 1keywords = soft (Clic here for more details about this article) |
2/74. Management of farm-related injuries to the upper extremity.This article familiarizes physicians with common farm equipment that can cause devastating hand injuries. The focus is on farm-related injuries to the hand and stresses the degree of soft tissue injuries, discusses avulsion injuries, and acute management principles. Types of injuries, their pathophysiology, case reports, and treatments also are reviewed. This article also stresses how these injuries differ from the urban trauma patient.- - - - - - - - - - ranking = 1keywords = soft (Clic here for more details about this article) |
3/74. Local recombinant tissue plasminogen activator (rt-PA) thrombolytic therapy in microvascular surgery.Vascular thrombosis remains a dreaded complication of any microvascular procedure, be it composite tissue transfer or replantation of amputated limbs or parts. Despite the tremendous advances in microvascular-related technologies and the accumulated surgical skills, failures caused by occlusion of anastomosed vessels remain a continuous source of frustration to all microsurgeons alike. Several anticoagulation and antiplatelet protocols have been proposed to be used in conjunction with microvascular surgery. More recently, thrombolytic drugs such as urokinase, streptokinase, and thrombolysin have been introduced, yet their systemic effect on hemostasis remains an undesirable side effect. We present our experience with local intra-arterial, intravenous, and soft-tissue injection of recombinant tissue plasminogen activator rt-PA in replantation surgery in three consecutive patients. Arterial thrombi are managed by intra-arterial rt-PA infusion with the catheter placed proximal to the arterial anastomosis. Venous thrombi are best lysed by infusing rt-PA in an engorged vein of the replanted limb. In replanted digits, direct intravenous infusion is not possible. In such situations, injection of rt-PA in the pulp soft tissues may result in successful salvage. We believe this agent also has a role in microvascular composite tissue transfer in preventing free flap failures as well as in salvaging failing flaps.- - - - - - - - - - ranking = 2keywords = soft (Clic here for more details about this article) |
4/74. Reverse neurocutaneous radial artery island flap salvage of a rodeo thumb degloving injury in a nine-year-old.A unique case of thumb salvage in a nine-year-old boy with degloving from a roping injury is presented. Immediate replantation was performed, but the part subsequently underwent arterial thrombosis and the soft-tissue unit was lost. Secondary resurfacing of the digit was achieved with a reverse island neurocutaneous radial artery island flap.- - - - - - - - - - ranking = 1keywords = soft (Clic here for more details about this article) |
5/74. Use of the microvascular finger fillet flap.This paper reports the authors' experience with the use of microvascular flaps, elevated from severely injured fingers to cover soft-tissue defects of other digits. Two clinical cases are presented and pertinent literature is reviewed.- - - - - - - - - - ranking = 1keywords = soft (Clic here for more details about this article) |
6/74. A case report of total finger joint replacement arthroplasty after traumatic amputation.INTRODUCTION: Joint reconstruction following trauma at the proximal interphalangeal or metacarpophalangeal levels remain a difficult problem in hand surgery. Function of the injured finger depends on the mobility and stability at these joints. In fingers amputated at these levels with joint destruction, the hand surgeon can perform either an arthrodesis or a replacement arthroplasty (either as an emergency or as a secondary procedure). arthrodesis will give a stable pain-free joint, but at the cost of sacrificing mobility and even cosmesis. CLINICAL PICTURE: We report a case of traumatic amputation through the proximal interphalangeal joint (PIPJ) of the right middle finger. arthrodesis of the PIPJ in extension using Kirschner wires was performed following replantation due to extensive periarticular soft tissue loss, so as to enable repair and healing of the extensor mechanism. This results in poor cosmesis and stiffness of finger interfering with function three months after surgery. TREATMENT AND OUTCOME: A prosthetic total joint replacement of PIPJ was performed as a secondary procedure. Satisfactory hand function and finger movement ensued two years after the procedure, with no loosening or infection of the implant. CONCLUSION: Total interphalangeal joint arthroplasty is a useful secondary procedure, after the initial replantation, for finger amputation with periarticular soft tissue loss.- - - - - - - - - - ranking = 2keywords = soft (Clic here for more details about this article) |
7/74. A reverse ulnar hypothenar flap for finger reconstruction.A reverse-flow island flap from the hypothenar eminence of the hand was applied in 11 patients to treat palmar skin defects, amputation injuries, or flexion contractures of the little finger. There were three female and eight male patients, and their ages at the time of surgery averaged 46 years. A 3 x 1.5 to 5 X 2 cm fasciocutaneous flap from the ulnar aspect of the hypothenar eminence, which was located over the abductor digiti minimi muscle, was designed and transferred in a retrograde fashion to cover the skin and soft-tissue defects of the little finger. The flap was based on the ulnar palmar digital artery of the little finger and in three patients was sensated by the dorsal branch of the ulnar nerve or by branches of the ulnar palmar digital nerve of the little finger. Follow-up periods averaged 42 months. The postoperative course was uneventful for all patients, and all of the flaps survived without complications. The donor site was closed primarily in all cases, and no patient complained of significant donor-site problems. Satisfactory sensory reinnervation was achieved in patients who underwent sensory flap transfer, as indicated by 5 mm of moving two-point discrimination. A reverse island flap from the hypothenar eminence is easily elevated, contains durable fasciocutaneous structures, and has a good color and texture match to the finger pulp. This flap is a good alternative for reconstruction of palmar skin and soft-tissue defects of the little finger.- - - - - - - - - - ranking = 2keywords = soft (Clic here for more details about this article) |
8/74. Use of the distally-based radial forearm flap supplied by the dorsal carpal arch, or palmar carpal arch, or both, in mutilating injuries. Two case report.The distally-based radial forearm flap is safe, easy, and versatile as a regional, one-stage procedure to reconstruct soft tissue defects of the hand. However, there is a general perception that the deep and superficial palmar arches have to be intact to raise a distally-based radial forearm flap. We successfully used two flaps supplied by the dorsal carpal arch, or the palmar carpal arch, or both, despite the fact that the deep and the superficial palmar arches were damaged in mutilating injuries.- - - - - - - - - - ranking = 1keywords = soft (Clic here for more details about this article) |
9/74. replantation of large segments in children.If one looks at the final results obtained in children, one should conclude that replantation of large segments is more often indicated in children than in adult patients. Nevertheless, the more common components of crush or avulsion and the frequent severe associated lesions must restrain the surgeon's enthusiasm when indicating replantation of a large segment in children. The possible dramatic consequences of a late revascularization syndrome can be easily foreseen as an outcome of replantation of a large segment in children. Moreover, the problem of growth must be faced from the start, programming secondary surgery either for soft tissue assessment (skin retraction treatments, tendon lengthening, muscle sliding) or for bone lengthening. The final outcome being a functional arm, special care has to be taken in nerve repair integrated with possible secondary tendon transfers to compensate the functional deficit. With all these limitations in indications, care in emergency, and correct timing and planning for secondary surgery, the final functional results of macroreplantations in children will certainly be improved.- - - - - - - - - - ranking = 1keywords = soft (Clic here for more details about this article) |
10/74. A new strategy of fingertip reattachment: sequential use of microsurgical technique and pocketing of composite graft.Many methods have been used to reattach amputated fingertips. Of these methods, microsurgery has been accepted as the procedure of choice because the defining characteristic of a microsurgically replanted finger is that its surival in the recipient bed is predicated on functioning intravascular circulation. Although considerable progress has been made in the techniques for microvascular replantation of amputated fingers, the replantation of an amputated fingertip is difficult because digital arteries branch into small arteries. This is in addition to digital veins that run from both sides of the nail bed to the median dorsal sides, which are difficult to separate from the immobile soft tissue. Furthermore, even with the most technically skilled microsurgeon, replantation failure often occurs, especially in severe injury cases. Therefore, the technique is not the only protection against failure, and a new strategy of fingertip reattachment is needed. From March of 1997 to December of 1999, 12 fingers of 11 patients with zone 1 or zone 2 fingertip amputations that were reattached microsurgically but were compromised were deepithelialized, reattached, and then inserted into the abdominal pocket. All had been complete amputations with crushing injuries. Approximately 3 weeks later, the fingers were depocketed and covered with a skin graft. Of the 12 fingers, 7 survived completely and 3 had partial necrosis on less than one-third the volume of the amputated part. The complete survival rate was approximately 58 percent. The results of the above 10 fingers were satisfactory from both functional and cosmetic aspects. The authors believe that this high success rate was achieved because the deepithelialized finger pulp was placed in direct contact with the deep abdominal fascia, which was equipped with plentiful vascularity, not subcutaneous fat. In addition, the pocketing was performed promptly before necrosis of the compromised fingertip occurred. From the results of this study, it is clear that this new method is useful and can raise the survival rate of an amputated fingertip.- - - - - - - - - - ranking = 1keywords = soft (Clic here for more details about this article) |
| | Next -> |