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Digital sympathectomy in systemic sclerosis
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using their hands in all activities. Objective evaluation revealed that sensation and function of the digits recovered in less than 2 years (3/3 cases). Wrist and elbow function was diminished because of poor radial nerve recovery. The difference in the length of the replanted arm compared with the nonoperated arm was less than 3 cm. Patients had a two-point discrimination of less tham 15 mm (3/3 cases). The average grip strength was reduced by 10 to 20')0. From our experience we conclude that high arm-level replantations in children should be performed since they offer good functional and cosmetic results.
Digital sympathectomy in systemic sclerosis N. J. G o d d a r d , C. Black
London, UK Digital sympathectomy is thought to promote improved blood flow in the digital arteries by interrupting the sympathetic vasoconstrictor nerves and also by removal of the external constrictive cuff of peri-adventitial fibrosis from around the arteries - a so called decompression arteriolysis. Over the past 5 years 132 patients with SSC involving over 400 digits have undergone digital sympathectomy in our unit. The technique is a modification of that described by Wilgis (1981) and Egloff (1983). Our preference is to perform a relatively limited sympathectomy operating only on the affected digits rather than the more extensive operations as described by Jones (1987) and O'Brien (1992). Our results suggest that digital sympathectomy promotes the healing of ulcers (after 25 years in one case), provides pain relief, diminishes the symptoms of cold intolerance, and reduces the severity if not the frequency of attacks of Raynaud's phenomenon. The results at 5 years are undoubtedly encouraging with no major complications and a low rate of recurrent ulceration (5% at 3 years).
Microvascular mechanical anastomoses in hand reconstruction: a 3-year experience M. L a n z e t t a , R. N o l l i
Milano, Italy This paper presents the results of a clinical series of patients over a 3-year period who had mechanical microvascular repair of arteries or veins during reconstructive procedures of the hand and upper limb. This included 41 patients (47 anastomosis), with an age range from 18 to 76 years. They required either a replantation/revascularization of the hand or a free flap transfer, following trauma or tumour excision. In some cases the mechanical device assisted in placing an interpositional synthetic micrograft in the arterial system. There were 39 arterial and two venous anastomoses. 25 vascular repairs were done at the level of the superficial palmar arch or distal to it. We used the 3M Precise Microvascular Anastomotic System to perform mostly 1 mm diameter anastomoses, with some 1.5 or 2.0 mm anastomoses performed at the wrist level or more proximally. The time needed to complete a single anastomosis averaged 6 minutes. Systemic anticoagulant therapy was used in only one patient. The follow-up was between 6 months and 3
THE J O U R N A L O F H A N D SURGERY VOL. 22B SUPPLEMENT 1
years. A simple digital Allen test was used to assess patency of the vascular repairs when a contralateral uninjured artery was present. In case of a critical anastomosis (which meant that if the device thrombosed, then arterial in-flow or venous drainage would be compromised and would lead to loss of viability of the part), patency of the device was obvious if the postoperative period was uneventful in terms of tissue survival. At long term, patency of the anastomotic devices and quality of the blood flow were evaluated in each patient by serial Doppler Ultrasound investigations. Colour doppler and spectral doppler analysis provided a qualitative and quantitative assessment of flow presence and direction. In selected cases, angiography was performed. Position and tight ring-to-ring fit of the device were also evaluated by radiological examinations at different intervals. In all cases, the device was patent immediately after removing the vascular clamps and at closure of the wound. No early thromboses were observed in the post-operative period, and all operations were successful with regard to tissue survival and wound healing. Clinical results demonstrated that all "critical" repairs, where tissue viability was dependent on the anastomosis, were patent. Two of the 41 patients were lost to follow-up. In 38 of the remaining 39 patients (41 repairs) serial Doppler Ultrasound investigations showed patency of the device and adequate blood flow. In the selected cases, angiography performed in addition to the Doppler Ultrasound investigations confirmed patency of the device. The occluded repair involved an ulnar artery at the wrist level which was grafted with a synthetic microvascular prosthesis No foreign body reaction was noted in the series. This study shows that the 3M PMAS can be a safe and reliable microvascular anastomotic device even when used in very distal vessels like digital arteries, with a diameter of 0.7 mm. Its major drawback compared to conventional techniques is that a much longer dissected segment of vessel is required to perform a safe anastomosis, and this is not always possible especially in distal vessels.
The sensory and functional potential of the foucher Flap ("kite flap") in reconstruction of important "tactile" zones of the hand G. Germann, H. Schepler
Ludwigshafen, Germany Introduction Reconstruction of complex defects including restoration of sensation is of the utmost importance in the thumb. An alternative to the traditional Littler neurovascular island flap is the neurovascular island flap based on the first dorsal metacarpal artery (Foucher or "kite flap"), which can be transferred as a pedicle or a microvascular free flap. Sensitivity is usually measured by static or dynamic two point discrimination. Little data is available about donor site morbidity, digital function or more complex sensitivity evaluations.
Material and methods Nine patients were evaluated for: 1. Sensitivity (Semmes-Weinstein monofilaments, and sharp/blunt discrimination of donor and recipient site); 2. Subjective perception (cosmesis, dual location phenomenon, "feeling", mobility). 3. Function (various forms of grip, active range of motion) with the Dexter R computer system.
using their hands in all activities. Objective evaluation revealed that sensation and function of the digits recovered in less than 2 years (3/3 cases). Wrist and elbow function was diminished because of poor radial nerve recovery. The difference in the length of the replanted arm compared with the nonoperated arm was less than 3 cm. Patients had a two-point discrimination of less tham 15 mm (3/3 cases). The average grip strength was reduced by 10 to 20')0. From our experience we conclude that high arm-level replantations in children should be performed since they offer good functional and cosmetic results.
Digital sympathectomy in systemic sclerosis N. J. G o d d a r d , C. Black
London, UK Digital sympathectomy is thought to promote improved blood flow in the digital arteries by interrupting the sympathetic vasoconstrictor nerves and also by removal of the external constrictive cuff of peri-adventitial fibrosis from around the arteries - a so called decompression arteriolysis. Over the past 5 years 132 patients with SSC involving over 400 digits have undergone digital sympathectomy in our unit. The technique is a modification of that described by Wilgis (1981) and Egloff (1983). Our preference is to perform a relatively limited sympathectomy operating only on the affected digits rather than the more extensive operations as described by Jones (1987) and O'Brien (1992). Our results suggest that digital sympathectomy promotes the healing of ulcers (after 25 years in one case), provides pain relief, diminishes the symptoms of cold intolerance, and reduces the severity if not the frequency of attacks of Raynaud's phenomenon. The results at 5 years are undoubtedly encouraging with no major complications and a low rate of recurrent ulceration (5% at 3 years).
Microvascular mechanical anastomoses in hand reconstruction: a 3-year experience M. L a n z e t t a , R. N o l l i
Milano, Italy This paper presents the results of a clinical series of patients over a 3-year period who had mechanical microvascular repair of arteries or veins during reconstructive procedures of the hand and upper limb. This included 41 patients (47 anastomosis), with an age range from 18 to 76 years. They required either a replantation/revascularization of the hand or a free flap transfer, following trauma or tumour excision. In some cases the mechanical device assisted in placing an interpositional synthetic micrograft in the arterial system. There were 39 arterial and two venous anastomoses. 25 vascular repairs were done at the level of the superficial palmar arch or distal to it. We used the 3M Precise Microvascular Anastomotic System to perform mostly 1 mm diameter anastomoses, with some 1.5 or 2.0 mm anastomoses performed at the wrist level or more proximally. The time needed to complete a single anastomosis averaged 6 minutes. Systemic anticoagulant therapy was used in only one patient. The follow-up was between 6 months and 3
THE J O U R N A L O F H A N D SURGERY VOL. 22B SUPPLEMENT 1
years. A simple digital Allen test was used to assess patency of the vascular repairs when a contralateral uninjured artery was present. In case of a critical anastomosis (which meant that if the device thrombosed, then arterial in-flow or venous drainage would be compromised and would lead to loss of viability of the part), patency of the device was obvious if the postoperative period was uneventful in terms of tissue survival. At long term, patency of the anastomotic devices and quality of the blood flow were evaluated in each patient by serial Doppler Ultrasound investigations. Colour doppler and spectral doppler analysis provided a qualitative and quantitative assessment of flow presence and direction. In selected cases, angiography was performed. Position and tight ring-to-ring fit of the device were also evaluated by radiological examinations at different intervals. In all cases, the device was patent immediately after removing the vascular clamps and at closure of the wound. No early thromboses were observed in the post-operative period, and all operations were successful with regard to tissue survival and wound healing. Clinical results demonstrated that all "critical" repairs, where tissue viability was dependent on the anastomosis, were patent. Two of the 41 patients were lost to follow-up. In 38 of the remaining 39 patients (41 repairs) serial Doppler Ultrasound investigations showed patency of the device and adequate blood flow. In the selected cases, angiography performed in addition to the Doppler Ultrasound investigations confirmed patency of the device. The occluded repair involved an ulnar artery at the wrist level which was grafted with a synthetic microvascular prosthesis No foreign body reaction was noted in the series. This study shows that the 3M PMAS can be a safe and reliable microvascular anastomotic device even when used in very distal vessels like digital arteries, with a diameter of 0.7 mm. Its major drawback compared to conventional techniques is that a much longer dissected segment of vessel is required to perform a safe anastomosis, and this is not always possible especially in distal vessels.
The sensory and functional potential of the foucher Flap ("kite flap") in reconstruction of important "tactile" zones of the hand G. Germann, H. Schepler
Ludwigshafen, Germany Introduction Reconstruction of complex defects including restoration of sensation is of the utmost importance in the thumb. An alternative to the traditional Littler neurovascular island flap is the neurovascular island flap based on the first dorsal metacarpal artery (Foucher or "kite flap"), which can be transferred as a pedicle or a microvascular free flap. Sensitivity is usually measured by static or dynamic two point discrimination. Little data is available about donor site morbidity, digital function or more complex sensitivity evaluations.
Material and methods Nine patients were evaluated for: 1. Sensitivity (Semmes-Weinstein monofilaments, and sharp/blunt discrimination of donor and recipient site); 2. Subjective perception (cosmesis, dual location phenomenon, "feeling", mobility). 3. Function (various forms of grip, active range of motion) with the Dexter R computer system.