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High arm-level replantations in children: late results
SESSION7 More than ten variants of the flaps have been used for reconstruction of extensive defects of the upper extremities. However in most cases the following types of flaps have been used: radial forearm flaps, digital and metacarpal island flaps, fibularosteo-septo-cutaneus flaps, ilium bone flap, gracilis and latissimus dorsi muscle flaps. The radial forearm flap had been used in some cases as a composite flap, including vascularized tendon graft, nerve, fascial tissue and muscular components. We worked out a method of increasing the size of the radial forearm flap based on the septal construction of the blood supply of the flap. In two cases we used the radial forearm flap for creation of a thumb with good functional result. In some cases free vascular fibular epiphysial bone flap was used for radiocarpal and shoulder joint formation. The reconstruction had been used in conjunction with the Ilizarov device. Muscle flaps were usually used for restoration of hand function.
Replantation of degloved skin: A feasible solution R. Adani, C. Castagnetti, L. Castagnini, R. Busa, A. Caroli
Modena, Italy Degloving injury of the hand is still one of the most difficult problems in reconstructive surgery. Generally the pure degloving injury leaves the underlying anatomical structures (tendons, bones and joints) intact. The aim of treatment should be coverage with pliable, sensitive and cosmetically similar skin. Various surgical methods (island or free flaps) have been adopted in the past years without solving the problems entirely. In 1981, Watson and McGregor suggested that "with increasing experience in microsurgical techniques it may not be long before replacement of degloved skin becomes a feasible solution of this difficult problem".
35 damaged irreversibly by the trauma. Coverage obtained in this way offers the best cosmetic results and allows early mobilization and good recovery of joint motion. Reestablishing sensibility is more difficult. It is not always possible to suture the digital nerves damaged by the injury, and even when neurorraphy is performed the results are often unsatisfactory.
Twenty-three years of replantations G. A. Brunelli, A. Vigasio, G. R. Brunelli
Brescia, Italy After the first replantation in Italy which we performed in Brescia in 1973, we have done more than 800 replantations for total or sub-total amputations. By experience we have now restricted indications and improved our technique and have obtained an increased average survival and number of good results. General indications have slightly changed since the beginning: old age is no longer a contraindication since biological age is more important. Time of ischaemia is very important in macro replantations: if it has been longer than 6 hours at room temperature, operation is generally not performed. In selected cases muscle excision may diminish the risks of ischaemia as well as those due to tissue crushing. Fingers can always be replanted even after 24 hours. The thumb has always to be replanted using neurovascular pedicles from neighbouring fingers if necessary. If thumb replantation is not possible we immediately do pollicization of the index finger or replantation of another amputated finger in place of the thumb. We often use parts of amputated fingers, which cannot be replanted, to improve replantation. Isolated amputations of the index (and ring finger) in the adult is not an indication unless the patient is a pianist or a top-model. In distal digital amputations we perform replantation in the thumb but in long fingers we use distal replantations or, alternatively, different types of flaps. As regards big segments, in selected cases with short ischaemia time we will do replantation at shoulder, arm and elbow levels. Especially at the elbow we have obtained very satisfying results for the patients.
Objective We report our results (cosmetic appearance, ROM, recovery of sensibility) in the treatment of degloved hand and fingers by microsurgical replantation of the avulsed skin.
High arm-level replantations in children: late results
Methods
M. Solinc
Between 1988 and 1995, nine patients with degloving injuries of the hand and fingers were treated by replantation of the degloved skin layer. The injury involved the thumb in three patients, the ring finger ~n three, the little finger in one and multiple fingers in two patients. Successful complete revascularization was obtained in eight patients. In one patient with multiple degloving injury of the finger, revascularization was achieved only in the middle finger. Deferred thumb reconstruction was carried out by a free flap from the foot.
Ljubljana, Slovenia
Results With a mean follow-up of 28 months, good cosmetic appearance and protective-to-light touch sensation was obtained in all cases with excellent recovery of range of motion of digital joints.
Conclusions Revascularization of the degloved skin does represent the best solution and must be attempted early, when the vessels are not
We evaluated three children 3 to 5 years of age who underwent major limb replantation between 1982 and 1986 at the University department of plastic surgery in Ljubljana. All injuries were high arm-level amputations, two of them caused by a driving belt and one by a train. Replantation was performed 3 to 5 hours after the amputation. The operation took 5 to 6 hours. Bone shortening was the rule (mean 5 cm) and plates were used for fixation, in all cases we sutured the brachial artery, three veins and three main nerves. No vein or nerve grafts were required. The skin was closed primarily. All three replantations were successful. In the postoperative treatment dynamic splintage, physiotherapy and compresive bandage were used. Patients later underwent additional procedures - functional tendon and muscle transfer (3•3 cases). The subjective evaluation revealed that all the patients were satisfied by the appearance of the replanted limb and they were
36
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.
Replantation of degloved skin: A feasible solution R. Adani, C. Castagnetti, L. Castagnini, R. Busa, A. Caroli
Modena, Italy Degloving injury of the hand is still one of the most difficult problems in reconstructive surgery. Generally the pure degloving injury leaves the underlying anatomical structures (tendons, bones and joints) intact. The aim of treatment should be coverage with pliable, sensitive and cosmetically similar skin. Various surgical methods (island or free flaps) have been adopted in the past years without solving the problems entirely. In 1981, Watson and McGregor suggested that "with increasing experience in microsurgical techniques it may not be long before replacement of degloved skin becomes a feasible solution of this difficult problem".
35 damaged irreversibly by the trauma. Coverage obtained in this way offers the best cosmetic results and allows early mobilization and good recovery of joint motion. Reestablishing sensibility is more difficult. It is not always possible to suture the digital nerves damaged by the injury, and even when neurorraphy is performed the results are often unsatisfactory.
Twenty-three years of replantations G. A. Brunelli, A. Vigasio, G. R. Brunelli
Brescia, Italy After the first replantation in Italy which we performed in Brescia in 1973, we have done more than 800 replantations for total or sub-total amputations. By experience we have now restricted indications and improved our technique and have obtained an increased average survival and number of good results. General indications have slightly changed since the beginning: old age is no longer a contraindication since biological age is more important. Time of ischaemia is very important in macro replantations: if it has been longer than 6 hours at room temperature, operation is generally not performed. In selected cases muscle excision may diminish the risks of ischaemia as well as those due to tissue crushing. Fingers can always be replanted even after 24 hours. The thumb has always to be replanted using neurovascular pedicles from neighbouring fingers if necessary. If thumb replantation is not possible we immediately do pollicization of the index finger or replantation of another amputated finger in place of the thumb. We often use parts of amputated fingers, which cannot be replanted, to improve replantation. Isolated amputations of the index (and ring finger) in the adult is not an indication unless the patient is a pianist or a top-model. In distal digital amputations we perform replantation in the thumb but in long fingers we use distal replantations or, alternatively, different types of flaps. As regards big segments, in selected cases with short ischaemia time we will do replantation at shoulder, arm and elbow levels. Especially at the elbow we have obtained very satisfying results for the patients.
Objective We report our results (cosmetic appearance, ROM, recovery of sensibility) in the treatment of degloved hand and fingers by microsurgical replantation of the avulsed skin.
High arm-level replantations in children: late results
Methods
M. Solinc
Between 1988 and 1995, nine patients with degloving injuries of the hand and fingers were treated by replantation of the degloved skin layer. The injury involved the thumb in three patients, the ring finger ~n three, the little finger in one and multiple fingers in two patients. Successful complete revascularization was obtained in eight patients. In one patient with multiple degloving injury of the finger, revascularization was achieved only in the middle finger. Deferred thumb reconstruction was carried out by a free flap from the foot.
Ljubljana, Slovenia
Results With a mean follow-up of 28 months, good cosmetic appearance and protective-to-light touch sensation was obtained in all cases with excellent recovery of range of motion of digital joints.
Conclusions Revascularization of the degloved skin does represent the best solution and must be attempted early, when the vessels are not
We evaluated three children 3 to 5 years of age who underwent major limb replantation between 1982 and 1986 at the University department of plastic surgery in Ljubljana. All injuries were high arm-level amputations, two of them caused by a driving belt and one by a train. Replantation was performed 3 to 5 hours after the amputation. The operation took 5 to 6 hours. Bone shortening was the rule (mean 5 cm) and plates were used for fixation, in all cases we sutured the brachial artery, three veins and three main nerves. No vein or nerve grafts were required. The skin was closed primarily. All three replantations were successful. In the postoperative treatment dynamic splintage, physiotherapy and compresive bandage were used. Patients later underwent additional procedures - functional tendon and muscle transfer (3•3 cases). The subjective evaluation revealed that all the patients were satisfied by the appearance of the replanted limb and they were
36
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.