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Long-term recovery following surgical treatment for ulnar artery occlusion
long-term Recovery Following Surgical Treatment for Ulnar Artery Occlusion Neal 6. Zimmerman, MD, Sheryl ltkin Zimmerman, PhD, Michael A. McClinton, MD, E. F. Shaw Wilgis, MD, Cherry 1. Koontz, PT, Jane Wallace Buehner BSN, Baltimore, MD Fourteen
patients
measurements or reconstruction brachial tion
surgically
(DBI)
for arterial
artery
treated
by arterial
without
of the eight reconstructed reconstruction it was
group,
negative
presurgical Complaints
DBI change
in the resection
in the small, group.
were
cold
intolerance
intolerance at follow-up
were ring,
Eleven
over half continued
and contact groups
at follow-up
than
0.7,
treated
Ulnar artery thrombosis has acquired the name hammer syndrome” due to its frequent occurrence among laborers who use the palm of the hand as a hammer. ‘-4 In Guyon’s canal, the ulnar artery is relatively immobile and protected by fascial supports. After emerging, it runs superficially across the hypothenar musculature for a distance of approximately 2.0 cm. Here, it is protected only by subcutaneous tissue and the scant muscle fibers of From the Raymond M. Curtis Hand Center, The Union Memorial Hospital. Baltimore, MD. Received for publication Dec. 17, 1992; accepted for publication Aug. 10. 1993. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Neal B. Zimmerman, MD, Greater Chesapeake Hand Specialists PA, 1400 Front Avenue, Suite 100, Lu-
ligation
resection
improvement
pain on a regular different
In the
whereas from
their
basis. Reports
following between
Surg 1994;19A:
evalua-
values.
was positive,
improvement
were Seven
by Doppler
fingers
(J Hand
patients
resection.
and index
also showed
to the
of the occluded
arterial
evaluation
indicated
pressure
Eight
to preoperative
patients
The digital
to 0.7 was an indica-
compared
to experience
evaluation.
with
pressure
blood
appropriate.
were not significantly
LLhypothenar
therville. MI) 21093.
of digital
blood between
segment.
of less than or equal
considered
and six patients
Digital
the choice
of the occluded
the ratio
A DBI value was
occlusion. guide
ulnar arteries were patent at follow-up
of pain and cold
and reconstruction
resection
If the DBI was greater
obtained
status, although
of environmental
artery helped
by calculating
reconstruction
reconstruction
DBI measurements
for ulnar
following
pressure.
reconstruction.
segment
tion.
artery
was derived
brachial
arterial
treated
pre- and intraoperatively
of the ulnar
index
simultaneous
were
obtained
surgery.
the resection
17-21.)
the palmaris brevis muscle, rendering it vulnerable to compressive injury.5 Repeated contusion or trauma to the hypothenar eminence forces the ulnar artery against the hook of the hamate, possibly damaging the arterial intima with resultant thrombosis. Ulnar artery thrombosis often is noted first as pain in the hypothenar eminence associated with a tender mass corresponding to the thrombosed vessel. Pallor and cold intolerance typically are noted in the ulnar digits. Treatment is initiated by protection during cold exposure and administration of calciumchannel blocking agents to combat vasospasm.’ The goal of surgical treatment is to increase arterial inflow to the affected digits. Flow can be augmented by either reconstruction of the thrombosed segment or by surgical sympathectomy. Resection of the thrombosed arterial segment constitutes a local sympathectomy, possibly by division of the terminal branches of the nerve of Henle, which is thought to The Journal of Hand
Surgery
17
18
Zimmerman
et al. / Ulnar
Artery
Occlusion
conduct a majority of the sympathetic fibers to the ulnar artery.7 Removal of this nidus for sympathetically driven excessive vascular tone in the hand may significantly increase digital blood flow. Vascular testing was used in 14 patients to guide the choice between arterial reconstruction and resection. This study was designed to assess residual symptoms in these patients and to compare current digital blood pressure to analogous measurements obtained at the time of surgery.
Materials and Methods Patients with suspected ulnar artery occlusion undergo pneumoplethysmography and Doppler examination to evaluate flow through the ulnar artery and to measure individual digital blood pressures. The digital blood pressures obtained are divided by the concurrent ipsilatera! brachial pressure to yield the digital brachia! index (DBI). Preoperative DBI values less than 0.7 suggest that arterial reconstruction may be required to provide adequate arterial inflow to the digits. Conversely, if the preoperative DBl value is greater than 0.7, digital flow is likely to be adequate without reconstruction. Pneumoplethysmography of the affected digits and at least one radial digit or the thumb following complete surgical exposure and isolation of the ulnar artery provide intraoperative baseline values. The ulnar artery segment then is resected and microvascular clamps are applied to the ends of the remaining vessel. The tourniquet is deflated again, and digital blood pressure measurements are repeated. Values
Table 1. Comparison
of Preoperative
of the DBI guide the intraoperative choice between resection and reconstruction. Care must be taken to ensure that the ambient temperature of the operating room is controlled and the tissues are not allowed to desiccate. Additionally, axillary block anesthesia is beneficial to diminish proximal sympathetic influence. If arterial reconstruction is necessary, it is crucial that the damaged arterial segment be resected back to normal intima. Usually a vein graft, often terminally bifurcated, is required to ensure a tension-free repair. The proximal arterial clamp is released prior to anastamosis to ascertain adequate pulsatile flow. If vigorous flow is not obtained, usual measures including further proximal resection, topical vasodilators, and adventitial removal are implemented. Postoperatively, antibiotics are administered for the first 24 hours, low molecular weight dextran is administered for 72 hours, and 325 mg aspirin is prescribed daily for 6 months. The study group includes 14 patients who were surgically treated for ulnar artery occlusion. They were evaluated with noninvasive vascular testing and interviewed at an average of 45 months (range, IS-84 months) following surgery. The study protoco! was approved by the institutional review board and informed consent was obtained from al! participants. The group was composed of 12 men and 2 women, with an mean age of 47 years (range, 3 l-72 years). One half of the study group indicated that they were exposed to vibrational tools in the workplace, and 6 of 14 patients indicated that they regularly used their hands as hammers prior to surgery.
and Postoperative
Digital Brachial Index (DBI)* Change in DBI
Follow-up (months) 42 84 33 46 39 68 30 18 69 51 18 20 71 45
Patent al Follow~p NA
Ring Finger Small Finger Procedure -Patient 1 Resection unknown - 1.0 2 Resection NA - .82 0 3 Resection NA -.06 -.03 4 Resection NA - .02 +.25 5 Resection NA -.16 0 6 Resection NA + .07 -.02 7 Reconstruction Yes + .Ol unknown 8 Reconstruction Yes + .25 unknown 9 Reconstruction Yes +.12 + .43 10 Reconstruction Yes -.20 - .03 11 Reconstruction Yes + .09 +.27 12 Reconstruction Yes +.06 + .30 13 Reconstruction Yes - .lO + .05 14 Reconstruction No -.16 +.11 -____ * DBI is determined by dividing the digital blood pressure by the concurrent brachial blood pressure.
Index
Finger
- 1.0 -.64 +.20 - .23 -.07 -.19 -.18 +.11 +.66 +.14 + .14 0 +.24 -.12
The Journal of Hand Surgery / Vol.
19A No.
1 lanuary 1994
19
Small
Ring
I
-0.35
I
I
I
I
I
I
I
I
-0.25
-0.20
I I
-0.30
-0.15
-0.10
I
I I
-0.5
0.00
I
I
I
I
I I
0 10
0.15
0.05
0.:
Mean DBI Change Figure 1. Average
change
in the DBl
value per tinger
All but three patients were active smokers at the time of surgery; the three nonsmokers claimed to have quit smoking recently. Eight patients underwent arterial reconstruction, including reversed interpositional vein grafts (n = 6) and direct end-toend anastamoses (n = 2). Six patients underwent resection of the occluded segment and ligation of the vessel ends. Results Seven of the eight reconstructed ulnar arteries were patent by Doppler evaluation at follow-up evaluation. Digital pressure measurements were obtained, and DBI values were calculated for each digit. Follow-up DBI values were compared to presurgical values, and change scores were calculated for the small, ring, and index fingers (Table I. Fig. I). The greatest difference between treatment groups was noted in the index finger. These data were evaluated utilizing two-tailed l-tests and analysis of variance. The differences in DBI measurements between and within the treatment groups for
preoperative
versus postoperative.
the small and ring fingers were not statistically significant, although the difference in the index finger between resection and reconstruction groups approached significance (p = .056). As shown in Table 2. patients remained symptomatic following surgery. although improvement from their presurgical state was apparent. Seven of the patients reported continued pain in their operated hand 3 or more days a week, four of whom had daily pain. The remaining patients reported pain much less frequently or not at all. It is important to note that all patients reported daily pain prior to surgery. When asked to compare the pain in their hands to their presurgical status, I I indicated improvement over their preoperative condition. Prior to surgery. 5 patients had functional limitations that “caused outcries” or prevented completion of all daily activities. In contrast, at follow-upevaluation. no patients reported such severe disability (Table 3). All patients had environmental cold intolerance preopera-
Table 3. Functional
Limitations
Due to Pain
HCfiUY, .GlQJ:c,r:\ Table 2. Patients’ Reports of Pain Frequency Bqfiw
Daily 3-6 days/week 1-2 days/week l-3 days/month
S/rtpr-~
Ajier
Swgrrl\
14
4
0 0 0 0
3 0 3 3
Pain Does Not
Interfere
With Activities Pain Interferes With Activities Pain Prevents Activities Pain Prevents Activities and Causes “Outcries” Pain Prevents All Activities
A.jiCV s//,ger\
I
I
I
x
3 3
5 0
1
0
20
Zimmerman
et al. / Ulnar
Artery
Occlusion
tively compared to 12 at follow-up evaluation. Likewise, eight patients had preoperative contact cold intolerance compared to five at follow-up evaluation.
Discussion This study investigated the clinical outcome of patients surgically treated for ulnar artery occlusion by either arterial resection or reconstruction. Preoperative and intraoperative digital blood pressure measurements were used as criteria to guide the choice between these two options. Rothkopf et al.8 employed intraoperative plethysmography in a similar manner. Their indication for arterial reconstruction was the presence of a flat or blunted digital wave form following resection and tourniquet release. Our criterion differs in that the actual digital pressure measurements were utilized rather than the qualitative appearance of the waveform. We chose the DBI value of 0.7 as the point at which digital pressure is inadequate and arterial reconstruction advisable. Our choice of this value was influenced by the report of Gelberman et al.9 on a group of patients with replanted digits. They noted that all patients in which the digital pulse pressure was less than 75% of the contralateral side had severe cold intolerance.’ We also noted the study of Gross et al. who reported forearm claudication in their patients with a segmental pressure of 63% or less of the contralateral side.‘” Our DBI value is midway between these two figures. Doppler examination demonstrated that seven of the eight reconstructed arteries were patent at reevaluation. Similarly, Mehlhoff and Wood veingrafted eight patients with chronic ulnar artery occlusion. At a minimum follow-up period of 1 year, seven of their eight vein grafts were patent.” Koman and Urbaniak employed several techniques to assess the need for arterial reconstruction. Relative contraindications for vein grafting included the presence of pulsatile back-flow from the distal arterial stump, normal digital blood pressure waveforms on plethysmography, and elevated arterial backflow pressure. They reported patency in 12 of their 17 patients.‘* DBI change scores were calculated to assess alterations in digital blood pressure following surgery. Patients undergoing resection exhibited primarily negative change scores, while arterial reconstruction patients had largely positive change scores. While statistically insignificant, these differences may relate to the regional sympathectomy accomplished by the arterial resection. The removal of the nidus for sympathetically mediated excess vascular
tone may exert its strongest effect in the vicinity of the resection, decreasing with distance. Comparison of the DBI in the index finger for the resection and reconstruction group was most marked among the fingers measured. Assuming that the sympathectomy effect is similar in the index finger in these two groups, the difference in blood flow may be explained by an increase in radial artery flow. In contrast, an increase in ulnar artery flow would most likely increase pressure in the small finger pressure as well. We did not observe this increase. Possibly, the presence of a complete superticial arch in this two-vessel system facilitates augmented radial artery inflow. The entire group reported continued symptoms after surgery, but patient satisfaction was high. Differences in self-reported symptoms were not statistically significant between groups, nor were trends apparent in symptomatology or stratification for either group. Although differences in DBI changes between groups were noted, they may be spurious due to extraneous variables that could impact on the validity and reliability of these measurements (e.g., ambient temperature of the operating room, continued digital vasospasm due to humoral factors, emboli in the digital vessels). In consideration of these variables and the small sample size, this study warrants replication. Larger samples also would permit a more rigorous examination of the relationship between DBI change and symptoms and satisfaction following arterial reconstruction and resection. The authors thank Melissa Reuland for her assistance in data collection.
References JJ, Bell JL. Hypothenar hammer syndrome: posttraumatic digital ischemia. Surgery 1970; 68: 1122-g. Ettien JT, Allen JT, Vargas C. Hypothenar hammer syndrome. South Med J 1981;74:491-2. Foster DR, Cameron DC. Hypothenar hammer syndrome. Br J Radio1 1981;54:995-6. Vayssairat M, Debure C, Cormier JM, Bruneval P, Laurian C, Juillet Y. Hypothenar hammer syndrome: seventeen cases with long-term follow-up. J Vast Surg 1987;5:838-43. Porubsky CL, Brown SI, Urbaniak JR. Ulnar artery thrombosis: a sports-related injury. Am J Sports Med 1986;14:170-5. Fisher MM, Snart AG. Nifedipine in ulnar artery occlusion. Angiology 1984;35:320-3. McCabe SJ, Kleinert JM . The nerve of HenlC . J Hand Surg 1990;15A:784-8. Rothkopf DM, Bryan DJ, Cuadros CL, May JW. Surgical management of ulnar artery aneurysms. J Hand Surg 1990;15A:891-7.
I. Conn J, Bergan
2. 3. 4.
5.
6. 7. 8.
The Journal
9. Gelberman RH, Urbaniak JR, Bright DS, Levin LS. Digital sensibility following replantation. J Hand Surg 1978;3:313-9. 10. Gross WS, Flanigan DP, Kraft RO, Stanley JC. Chronic upper extremity arterial insufficiency. Arch Surg 1978;113:419-23.
of Hand
Surgery
i Vol. 19A No. 1 january
1994
21
11. Mehlhoff TL, Wood MB. Ulnar artery thrombosis and the role of interpositional vein grafting: patency with microsurgical technique. J Hand Surg 199 I : 16A: 274-8. 12. Koman LA, Urbaniak JR. Ulnar artery thrombosis. Hand Clin 1985;1:311-5.
patients
measurements or reconstruction brachial tion
surgically
(DBI)
for arterial
artery
treated
by arterial
without
of the eight reconstructed reconstruction it was
group,
negative
presurgical Complaints
DBI change
in the resection
in the small, group.
were
cold
intolerance
intolerance at follow-up
were ring,
Eleven
over half continued
and contact groups
at follow-up
than
0.7,
treated
Ulnar artery thrombosis has acquired the name hammer syndrome” due to its frequent occurrence among laborers who use the palm of the hand as a hammer. ‘-4 In Guyon’s canal, the ulnar artery is relatively immobile and protected by fascial supports. After emerging, it runs superficially across the hypothenar musculature for a distance of approximately 2.0 cm. Here, it is protected only by subcutaneous tissue and the scant muscle fibers of From the Raymond M. Curtis Hand Center, The Union Memorial Hospital. Baltimore, MD. Received for publication Dec. 17, 1992; accepted for publication Aug. 10. 1993. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Neal B. Zimmerman, MD, Greater Chesapeake Hand Specialists PA, 1400 Front Avenue, Suite 100, Lu-
ligation
resection
improvement
pain on a regular different
In the
whereas from
their
basis. Reports
following between
Surg 1994;19A:
evalua-
values.
was positive,
improvement
were Seven
by Doppler
fingers
(J Hand
patients
resection.
and index
also showed
to the
of the occluded
arterial
evaluation
indicated
pressure
Eight
to preoperative
patients
The digital
to 0.7 was an indica-
compared
to experience
evaluation.
with
pressure
blood
appropriate.
were not significantly
LLhypothenar
therville. MI) 21093.
of digital
blood between
segment.
of less than or equal
considered
and six patients
Digital
the choice
of the occluded
the ratio
A DBI value was
occlusion. guide
ulnar arteries were patent at follow-up
of pain and cold
and reconstruction
resection
If the DBI was greater
obtained
status, although
of environmental
artery helped
by calculating
reconstruction
reconstruction
DBI measurements
for ulnar
following
pressure.
reconstruction.
segment
tion.
artery
was derived
brachial
arterial
treated
pre- and intraoperatively
of the ulnar
index
simultaneous
were
obtained
surgery.
the resection
17-21.)
the palmaris brevis muscle, rendering it vulnerable to compressive injury.5 Repeated contusion or trauma to the hypothenar eminence forces the ulnar artery against the hook of the hamate, possibly damaging the arterial intima with resultant thrombosis. Ulnar artery thrombosis often is noted first as pain in the hypothenar eminence associated with a tender mass corresponding to the thrombosed vessel. Pallor and cold intolerance typically are noted in the ulnar digits. Treatment is initiated by protection during cold exposure and administration of calciumchannel blocking agents to combat vasospasm.’ The goal of surgical treatment is to increase arterial inflow to the affected digits. Flow can be augmented by either reconstruction of the thrombosed segment or by surgical sympathectomy. Resection of the thrombosed arterial segment constitutes a local sympathectomy, possibly by division of the terminal branches of the nerve of Henle, which is thought to The Journal of Hand
Surgery
17
18
Zimmerman
et al. / Ulnar
Artery
Occlusion
conduct a majority of the sympathetic fibers to the ulnar artery.7 Removal of this nidus for sympathetically driven excessive vascular tone in the hand may significantly increase digital blood flow. Vascular testing was used in 14 patients to guide the choice between arterial reconstruction and resection. This study was designed to assess residual symptoms in these patients and to compare current digital blood pressure to analogous measurements obtained at the time of surgery.
Materials and Methods Patients with suspected ulnar artery occlusion undergo pneumoplethysmography and Doppler examination to evaluate flow through the ulnar artery and to measure individual digital blood pressures. The digital blood pressures obtained are divided by the concurrent ipsilatera! brachial pressure to yield the digital brachia! index (DBI). Preoperative DBI values less than 0.7 suggest that arterial reconstruction may be required to provide adequate arterial inflow to the digits. Conversely, if the preoperative DBl value is greater than 0.7, digital flow is likely to be adequate without reconstruction. Pneumoplethysmography of the affected digits and at least one radial digit or the thumb following complete surgical exposure and isolation of the ulnar artery provide intraoperative baseline values. The ulnar artery segment then is resected and microvascular clamps are applied to the ends of the remaining vessel. The tourniquet is deflated again, and digital blood pressure measurements are repeated. Values
Table 1. Comparison
of Preoperative
of the DBI guide the intraoperative choice between resection and reconstruction. Care must be taken to ensure that the ambient temperature of the operating room is controlled and the tissues are not allowed to desiccate. Additionally, axillary block anesthesia is beneficial to diminish proximal sympathetic influence. If arterial reconstruction is necessary, it is crucial that the damaged arterial segment be resected back to normal intima. Usually a vein graft, often terminally bifurcated, is required to ensure a tension-free repair. The proximal arterial clamp is released prior to anastamosis to ascertain adequate pulsatile flow. If vigorous flow is not obtained, usual measures including further proximal resection, topical vasodilators, and adventitial removal are implemented. Postoperatively, antibiotics are administered for the first 24 hours, low molecular weight dextran is administered for 72 hours, and 325 mg aspirin is prescribed daily for 6 months. The study group includes 14 patients who were surgically treated for ulnar artery occlusion. They were evaluated with noninvasive vascular testing and interviewed at an average of 45 months (range, IS-84 months) following surgery. The study protoco! was approved by the institutional review board and informed consent was obtained from al! participants. The group was composed of 12 men and 2 women, with an mean age of 47 years (range, 3 l-72 years). One half of the study group indicated that they were exposed to vibrational tools in the workplace, and 6 of 14 patients indicated that they regularly used their hands as hammers prior to surgery.
and Postoperative
Digital Brachial Index (DBI)* Change in DBI
Follow-up (months) 42 84 33 46 39 68 30 18 69 51 18 20 71 45
Patent al Follow~p NA
Ring Finger Small Finger Procedure -Patient 1 Resection unknown - 1.0 2 Resection NA - .82 0 3 Resection NA -.06 -.03 4 Resection NA - .02 +.25 5 Resection NA -.16 0 6 Resection NA + .07 -.02 7 Reconstruction Yes + .Ol unknown 8 Reconstruction Yes + .25 unknown 9 Reconstruction Yes +.12 + .43 10 Reconstruction Yes -.20 - .03 11 Reconstruction Yes + .09 +.27 12 Reconstruction Yes +.06 + .30 13 Reconstruction Yes - .lO + .05 14 Reconstruction No -.16 +.11 -____ * DBI is determined by dividing the digital blood pressure by the concurrent brachial blood pressure.
Index
Finger
- 1.0 -.64 +.20 - .23 -.07 -.19 -.18 +.11 +.66 +.14 + .14 0 +.24 -.12
The Journal of Hand Surgery / Vol.
19A No.
1 lanuary 1994
19
Small
Ring
I
-0.35
I
I
I
I
I
I
I
I
-0.25
-0.20
I I
-0.30
-0.15
-0.10
I
I I
-0.5
0.00
I
I
I
I
I I
0 10
0.15
0.05
0.:
Mean DBI Change Figure 1. Average
change
in the DBl
value per tinger
All but three patients were active smokers at the time of surgery; the three nonsmokers claimed to have quit smoking recently. Eight patients underwent arterial reconstruction, including reversed interpositional vein grafts (n = 6) and direct end-toend anastamoses (n = 2). Six patients underwent resection of the occluded segment and ligation of the vessel ends. Results Seven of the eight reconstructed ulnar arteries were patent by Doppler evaluation at follow-up evaluation. Digital pressure measurements were obtained, and DBI values were calculated for each digit. Follow-up DBI values were compared to presurgical values, and change scores were calculated for the small, ring, and index fingers (Table I. Fig. I). The greatest difference between treatment groups was noted in the index finger. These data were evaluated utilizing two-tailed l-tests and analysis of variance. The differences in DBI measurements between and within the treatment groups for
preoperative
versus postoperative.
the small and ring fingers were not statistically significant, although the difference in the index finger between resection and reconstruction groups approached significance (p = .056). As shown in Table 2. patients remained symptomatic following surgery. although improvement from their presurgical state was apparent. Seven of the patients reported continued pain in their operated hand 3 or more days a week, four of whom had daily pain. The remaining patients reported pain much less frequently or not at all. It is important to note that all patients reported daily pain prior to surgery. When asked to compare the pain in their hands to their presurgical status, I I indicated improvement over their preoperative condition. Prior to surgery. 5 patients had functional limitations that “caused outcries” or prevented completion of all daily activities. In contrast, at follow-upevaluation. no patients reported such severe disability (Table 3). All patients had environmental cold intolerance preopera-
Table 3. Functional
Limitations
Due to Pain
HCfiUY, .GlQJ:c,r:\ Table 2. Patients’ Reports of Pain Frequency Bqfiw
Daily 3-6 days/week 1-2 days/week l-3 days/month
S/rtpr-~
Ajier
Swgrrl\
14
4
0 0 0 0
3 0 3 3
Pain Does Not
Interfere
With Activities Pain Interferes With Activities Pain Prevents Activities Pain Prevents Activities and Causes “Outcries” Pain Prevents All Activities
A.jiCV s//,ger\
I
I
I
x
3 3
5 0
1
0
20
Zimmerman
et al. / Ulnar
Artery
Occlusion
tively compared to 12 at follow-up evaluation. Likewise, eight patients had preoperative contact cold intolerance compared to five at follow-up evaluation.
Discussion This study investigated the clinical outcome of patients surgically treated for ulnar artery occlusion by either arterial resection or reconstruction. Preoperative and intraoperative digital blood pressure measurements were used as criteria to guide the choice between these two options. Rothkopf et al.8 employed intraoperative plethysmography in a similar manner. Their indication for arterial reconstruction was the presence of a flat or blunted digital wave form following resection and tourniquet release. Our criterion differs in that the actual digital pressure measurements were utilized rather than the qualitative appearance of the waveform. We chose the DBI value of 0.7 as the point at which digital pressure is inadequate and arterial reconstruction advisable. Our choice of this value was influenced by the report of Gelberman et al.9 on a group of patients with replanted digits. They noted that all patients in which the digital pulse pressure was less than 75% of the contralateral side had severe cold intolerance.’ We also noted the study of Gross et al. who reported forearm claudication in their patients with a segmental pressure of 63% or less of the contralateral side.‘” Our DBI value is midway between these two figures. Doppler examination demonstrated that seven of the eight reconstructed arteries were patent at reevaluation. Similarly, Mehlhoff and Wood veingrafted eight patients with chronic ulnar artery occlusion. At a minimum follow-up period of 1 year, seven of their eight vein grafts were patent.” Koman and Urbaniak employed several techniques to assess the need for arterial reconstruction. Relative contraindications for vein grafting included the presence of pulsatile back-flow from the distal arterial stump, normal digital blood pressure waveforms on plethysmography, and elevated arterial backflow pressure. They reported patency in 12 of their 17 patients.‘* DBI change scores were calculated to assess alterations in digital blood pressure following surgery. Patients undergoing resection exhibited primarily negative change scores, while arterial reconstruction patients had largely positive change scores. While statistically insignificant, these differences may relate to the regional sympathectomy accomplished by the arterial resection. The removal of the nidus for sympathetically mediated excess vascular
tone may exert its strongest effect in the vicinity of the resection, decreasing with distance. Comparison of the DBI in the index finger for the resection and reconstruction group was most marked among the fingers measured. Assuming that the sympathectomy effect is similar in the index finger in these two groups, the difference in blood flow may be explained by an increase in radial artery flow. In contrast, an increase in ulnar artery flow would most likely increase pressure in the small finger pressure as well. We did not observe this increase. Possibly, the presence of a complete superticial arch in this two-vessel system facilitates augmented radial artery inflow. The entire group reported continued symptoms after surgery, but patient satisfaction was high. Differences in self-reported symptoms were not statistically significant between groups, nor were trends apparent in symptomatology or stratification for either group. Although differences in DBI changes between groups were noted, they may be spurious due to extraneous variables that could impact on the validity and reliability of these measurements (e.g., ambient temperature of the operating room, continued digital vasospasm due to humoral factors, emboli in the digital vessels). In consideration of these variables and the small sample size, this study warrants replication. Larger samples also would permit a more rigorous examination of the relationship between DBI change and symptoms and satisfaction following arterial reconstruction and resection. The authors thank Melissa Reuland for her assistance in data collection.
References JJ, Bell JL. Hypothenar hammer syndrome: posttraumatic digital ischemia. Surgery 1970; 68: 1122-g. Ettien JT, Allen JT, Vargas C. Hypothenar hammer syndrome. South Med J 1981;74:491-2. Foster DR, Cameron DC. Hypothenar hammer syndrome. Br J Radio1 1981;54:995-6. Vayssairat M, Debure C, Cormier JM, Bruneval P, Laurian C, Juillet Y. Hypothenar hammer syndrome: seventeen cases with long-term follow-up. J Vast Surg 1987;5:838-43. Porubsky CL, Brown SI, Urbaniak JR. Ulnar artery thrombosis: a sports-related injury. Am J Sports Med 1986;14:170-5. Fisher MM, Snart AG. Nifedipine in ulnar artery occlusion. Angiology 1984;35:320-3. McCabe SJ, Kleinert JM . The nerve of HenlC . J Hand Surg 1990;15A:784-8. Rothkopf DM, Bryan DJ, Cuadros CL, May JW. Surgical management of ulnar artery aneurysms. J Hand Surg 1990;15A:891-7.
I. Conn J, Bergan
2. 3. 4.
5.
6. 7. 8.
The Journal
9. Gelberman RH, Urbaniak JR, Bright DS, Levin LS. Digital sensibility following replantation. J Hand Surg 1978;3:313-9. 10. Gross WS, Flanigan DP, Kraft RO, Stanley JC. Chronic upper extremity arterial insufficiency. Arch Surg 1978;113:419-23.
of Hand
Surgery
i Vol. 19A No. 1 january
1994
21
11. Mehlhoff TL, Wood MB. Ulnar artery thrombosis and the role of interpositional vein grafting: patency with microsurgical technique. J Hand Surg 199 I : 16A: 274-8. 12. Koman LA, Urbaniak JR. Ulnar artery thrombosis. Hand Clin 1985;1:311-5.