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Distal replantation
456
The Journal of HAND SURGERY
Letters to the editor
pseudotendon and a normal tendon. Both have fibrocytes, collagen fibers, and blood vessels that are aligned parallel to the line of muscle tension. However, the two are easily separated when one stains and looks for elastic tissue. The pseudotendon is void of any elastic fibers for its entire length, other than that area surrounding the blood vessels." Furthermore, the last line of that paragraph adds a second clinical distinction: 'The glistening white tendon fibers that are evident intraoperatively on the surface of a normal tendon and that project prominently from a cut tendon end are totally lacking in the pseudotendon." For Dr. Khan's theory that what we found was "normal tendon with posttraumatic changes" to be correct it would mean that the inflammatory process at the injury site would have to affect the entire uninvolve~ segment of proximal tendon, thus, making it devoid of its normal elastic content and normal tendon fiber organization. One possibility might be that our stain was ineffective in showing elastic tissue. However, there was a clear demarcation of elastic fibers surrounding the blood vessels within the pseudotendon, as well as at the recoiled portion of the proximal and distal tendon stumps. Dr. Khan further suggests that our clinical observations were due to the tendons being "pregnant (increased metabolic activity) ." We are unaware of the normal gestation period of a tendon, but for his statement to be true, it would have to be greater than 2 years. This was the length of time from tendon rupture to our surgical intervention in case 3. Regarding the tensile strength, we based our assumption on the histologic and clinical similarities of a pseudotendon, with the tissues located at the tendon gap of a primary tendon repair. References to the fact that this tissue is less resilient and has a decreased breaking strength were provided in the original article. The readers should have a clear understanding that anisotropic scar does not equal tendon. If Dr. Khan feels more comfortable in calling a pseudotendon, a tendon gap, and scar tissue in general "a pregnant tendon," "pregnant tendon gap," or "pregnant tissue," he should not advocate this to others. To summarize our findings, we are not seeing a normal tendon with posttraumatic changes; nor are we seeing a tendon regenerated by primary tendon healing over such a great distance. What we have observed is the reconstitution of a divided, recoiled tendon by scar tissue that has both' clinical and histologic differences from a normal tendon. Michael I . Kulick, M.D. 450 Sutter St. San Francisco, CA 94108
Distal replantation To the Editor: I read with great interest the article by Y. Yamano l entitled' 'Replantation of the Amputated Distal Part of the Finger," in which the author presented a series of 87 replantations with five failures and seven partial necroses. It would have been interesting had the author given some details regarding what proportion had an anastomosis of a dorsal vein, a palmar vein, or no venous anastomosis. Contrary to what the author states that no article has yet been published on attempted replantations in zones I and II, there have been several publications on this topic during the last 6 years. In addition to our own article,2 series have been published in France by J. J. Comtet and J. Baudet. 3 We have proposed an alternative to the author's method of continuous drip of warm saline with heparin in 1978 at the Groupe d' Avancement de la Microchirurgie meeting under the title, "Un vieux remMe dans un pot neuf" (A New Use For an Old Remedy).4 Our method consists of the application of leeches, which allows venous drainage. Because of the injection of hirudin, an anticoagulant produced by the leech (at least as effective as heparin), oozing is maintained for 1 or 2 hours after falling of the leech. This prevents local vascular network thrombosis. We have also stressed that use of this method for 5 days permits successful replantations at so-called "very distal" level (distal to the distal interphalangeal joint). Identical results have been published by J. Baudet. Finally, an important point to be noted is that the largest artery used for the anastomosis distal to the arcade is constantly found in the midline (and not laterally). We have been struck by the speed and simplicity of this type of operation that allows a rapid return to work, with the mean time off work in our series of 96 cases being 2 months. G. Foucher, M.D . 4, Blvd. duPresident-Edwards (Bd de I'Orangerie) 67000 Strasbourg France
REFERENCES I. Yamano Y: Replantation of the amputated distal part of the finger. J HAND SURG lOA:21l-7, 1985 2. Foucher G, Henderson HR, Maneaud M, Merle M, Braun FM: Distal digital replantation one of the best indications for microsurgery. Int J Microsurg 3:263-70, 1981 3. Baudet J: Distal replantation. Paper presented at"the International Society for Reconstructive Microsurgery, New York, June 19-23, 1983 4. Foucher G: Un vieux remede dans un pot neuf: la sangsue en microchirugie. Communication a la Vieme Rencontre
Vol. IIA, No.3 May 1986
Intemationale de Microchirurgie GAM, Marseille, May 14-17,1980
Reply To the Editor: I regret that I missed Dr. Foucher's paper; however, my meaning was not that I could not find any such articles, but simply that I did not find any papers concerning replantation of the fingertip (especially zone I), in which surgery was attempted in every patient encountered. Several articles describe selected cases of replantation, all of which report good function, but it is not possible to make reference to all of them. We have been doing fingertip replantations for more than 10 years and reported our results in 1976 in a Japanese journal. Making a fish mouth in the fingertip and allowing continuous bleeding have been carried out
Letters to the editor
457
for nearly 10 years in Japan. As anyone can see, this method is only a modification of the drip method and certainly is not a method that I invented on my own. The arteries in zone I run centrally as Dr. Foucher emphasizes. It hardly seems necessary to state this fact in the text, however, since the position is made quite clear in Fig. 2. Finally, I would like to add that I have had the pleasure of reading his paper, but regardless of the fact that the blood vessels were sutured together, it does not appear that the rate of success was much better than that achieved with the Werber method. Yoshiki Yamano, M.D. Department of Orthopedic Surgery Kawasaki Medical School Kurashiki, Okayama 701-01, Japan
The Journal of HAND SURGERY
Letters to the editor
pseudotendon and a normal tendon. Both have fibrocytes, collagen fibers, and blood vessels that are aligned parallel to the line of muscle tension. However, the two are easily separated when one stains and looks for elastic tissue. The pseudotendon is void of any elastic fibers for its entire length, other than that area surrounding the blood vessels." Furthermore, the last line of that paragraph adds a second clinical distinction: 'The glistening white tendon fibers that are evident intraoperatively on the surface of a normal tendon and that project prominently from a cut tendon end are totally lacking in the pseudotendon." For Dr. Khan's theory that what we found was "normal tendon with posttraumatic changes" to be correct it would mean that the inflammatory process at the injury site would have to affect the entire uninvolve~ segment of proximal tendon, thus, making it devoid of its normal elastic content and normal tendon fiber organization. One possibility might be that our stain was ineffective in showing elastic tissue. However, there was a clear demarcation of elastic fibers surrounding the blood vessels within the pseudotendon, as well as at the recoiled portion of the proximal and distal tendon stumps. Dr. Khan further suggests that our clinical observations were due to the tendons being "pregnant (increased metabolic activity) ." We are unaware of the normal gestation period of a tendon, but for his statement to be true, it would have to be greater than 2 years. This was the length of time from tendon rupture to our surgical intervention in case 3. Regarding the tensile strength, we based our assumption on the histologic and clinical similarities of a pseudotendon, with the tissues located at the tendon gap of a primary tendon repair. References to the fact that this tissue is less resilient and has a decreased breaking strength were provided in the original article. The readers should have a clear understanding that anisotropic scar does not equal tendon. If Dr. Khan feels more comfortable in calling a pseudotendon, a tendon gap, and scar tissue in general "a pregnant tendon," "pregnant tendon gap," or "pregnant tissue," he should not advocate this to others. To summarize our findings, we are not seeing a normal tendon with posttraumatic changes; nor are we seeing a tendon regenerated by primary tendon healing over such a great distance. What we have observed is the reconstitution of a divided, recoiled tendon by scar tissue that has both' clinical and histologic differences from a normal tendon. Michael I . Kulick, M.D. 450 Sutter St. San Francisco, CA 94108
Distal replantation To the Editor: I read with great interest the article by Y. Yamano l entitled' 'Replantation of the Amputated Distal Part of the Finger," in which the author presented a series of 87 replantations with five failures and seven partial necroses. It would have been interesting had the author given some details regarding what proportion had an anastomosis of a dorsal vein, a palmar vein, or no venous anastomosis. Contrary to what the author states that no article has yet been published on attempted replantations in zones I and II, there have been several publications on this topic during the last 6 years. In addition to our own article,2 series have been published in France by J. J. Comtet and J. Baudet. 3 We have proposed an alternative to the author's method of continuous drip of warm saline with heparin in 1978 at the Groupe d' Avancement de la Microchirurgie meeting under the title, "Un vieux remMe dans un pot neuf" (A New Use For an Old Remedy).4 Our method consists of the application of leeches, which allows venous drainage. Because of the injection of hirudin, an anticoagulant produced by the leech (at least as effective as heparin), oozing is maintained for 1 or 2 hours after falling of the leech. This prevents local vascular network thrombosis. We have also stressed that use of this method for 5 days permits successful replantations at so-called "very distal" level (distal to the distal interphalangeal joint). Identical results have been published by J. Baudet. Finally, an important point to be noted is that the largest artery used for the anastomosis distal to the arcade is constantly found in the midline (and not laterally). We have been struck by the speed and simplicity of this type of operation that allows a rapid return to work, with the mean time off work in our series of 96 cases being 2 months. G. Foucher, M.D . 4, Blvd. duPresident-Edwards (Bd de I'Orangerie) 67000 Strasbourg France
REFERENCES I. Yamano Y: Replantation of the amputated distal part of the finger. J HAND SURG lOA:21l-7, 1985 2. Foucher G, Henderson HR, Maneaud M, Merle M, Braun FM: Distal digital replantation one of the best indications for microsurgery. Int J Microsurg 3:263-70, 1981 3. Baudet J: Distal replantation. Paper presented at"the International Society for Reconstructive Microsurgery, New York, June 19-23, 1983 4. Foucher G: Un vieux remede dans un pot neuf: la sangsue en microchirugie. Communication a la Vieme Rencontre
Vol. IIA, No.3 May 1986
Intemationale de Microchirurgie GAM, Marseille, May 14-17,1980
Reply To the Editor: I regret that I missed Dr. Foucher's paper; however, my meaning was not that I could not find any such articles, but simply that I did not find any papers concerning replantation of the fingertip (especially zone I), in which surgery was attempted in every patient encountered. Several articles describe selected cases of replantation, all of which report good function, but it is not possible to make reference to all of them. We have been doing fingertip replantations for more than 10 years and reported our results in 1976 in a Japanese journal. Making a fish mouth in the fingertip and allowing continuous bleeding have been carried out
Letters to the editor
457
for nearly 10 years in Japan. As anyone can see, this method is only a modification of the drip method and certainly is not a method that I invented on my own. The arteries in zone I run centrally as Dr. Foucher emphasizes. It hardly seems necessary to state this fact in the text, however, since the position is made quite clear in Fig. 2. Finally, I would like to add that I have had the pleasure of reading his paper, but regardless of the fact that the blood vessels were sutured together, it does not appear that the rate of success was much better than that achieved with the Werber method. Yoshiki Yamano, M.D. Department of Orthopedic Surgery Kawasaki Medical School Kurashiki, Okayama 701-01, Japan