Process of Obtaining Social Consensus and 3-Year Functional Outcomes of the First Hand Allotransplantation in Korea

Background@#On February 2, 2017, the surgical team of ten board-certified hand specialists of W Hospital in Korea successfully performed the nation's first hand transplantation at Yeungnam University Medical Center (YUMC). This paper reports on the legal, financial, and cultural hurdles that were overcome to open the way for hand transplantation and its functional outcomes at 36 months after the operation. @*Methods@#W Hospital formed a memorandum of understanding with Daegu city and YUMC to comply with government regulations regarding hand transplantation. Campaigns were initiated in the media to increase public awareness and understanding. With the city's financial and legal support and the university's medical cooperation, a surgical team performed a left distal forearm hand transplantation from a brain-dead 48-year-old man to a 35-year-old left-handed man. @*Results@#With this successful allotransplantation, the Korean Act on Organ Transplantation has now been amended to include hand transplantation. Korean national health insurance has also begun covering hand transplantation. Functional outcome at 36 months after the operation showed satisfactory progress in both motor and sensory functions. The disabilities of the arm, shoulder, and hand score were 23. The final Hand Transplantation Score was 90 points. Functional brain magnetic resonance imaging shows significant cortical reorganization of the corticospinal tract, and reinnervation of intrinsic muscle is observed. @*Conclusions@#Hand transplantation at the distal forearm shows very satisfactory outcomes in functional, aesthetical, and psychological aspects. Legal and financial barriers against hand transplantation have long been the most burdensome issues. Despite this momentous success, there have been no other clinical applications of vascularized composite allotransplantation due to the limited acceptance by Korean doctors and people. Further public education campaigns for vascularized composite allotransplantation are needed to increase awareness and acceptance.

Immediate Nail Lengthening with the Eponychial Folding Procedure in Acute Finger Tip Injury

PURPOSE: We present the clinical results and operative method of the immediate eponychium of nail fold set back for lengthening of nails caused by acute fingertip injuries. METHODS: The research was conducted with a total of 172 patients during the period from January 2014 to June 2016. The operation method was performed in a way to fold down the two sides of the nail eponychium and had suture. A survey of the patients' subjective satisfaction was conducted and the relative nail length was compared before and after the operation as well as the nail length of the uninjured contralateral finger. The mean follow-up period was 18.2 weeks. RESULTS: In all cases, the operation time was under 3 minutes. There were no specific complications such as nail eponychium's necrosis or congestion. The new nail did not have any additional deformation. On average, the extended nail length was 3.2 mm. Compared with preoperation, the average extension ratio of the nail length was 48%, even with 75% of nail length recovery in comparison with the uninjured contralateral finger. The subjective self-satisfaction score was 92.5 on average. The satisfaction score was higher for patients who had greater remnant nail length. CONCLUSION: Immediate nail lengthening with the eponychial folding is a simple, safe and useful method with high subjective satisfaction in aesthetics for the patients with acute fingertip injuries.

Primary Ring Flexor Digitorum Superficialis Transfer with Open Carpal Tunnel Release in Extreme Carpal Tunnel Syndrome

PURPOSE: To analyze the clinical outcome for primary ring flexor digitorum superficialis transfer with open carpal tunnel release in extreme carpal tunnel syndrome. METHODS: Ring flexor digitorum superficialis transfer with open release of the transverse carpal ligament was performed on 23 patients who were diagnosed with extreme carpal tunnel syndrome between September 2008 and August 2013. All patients had visibly severe atrophies, with no sign of compound muscle action potential (CMAP) of abductor pollicis brevis from electromyography. They wanted simultaneous reconstruction of the function of the hand as well as recovery of the numbness. We evaluated the clinical results using key-pinch, hand grip abilities, disability of the arm, shoulder and hand (DASH) scores, Kapandji scores. RESULTS: Key-pinch and hand grip abilities had no significant difference after the surgery compared with before, but DASH scores were significantly different, averaging 18.6 after, compared with 39.8 before surgery. And Kapandji scores increased significantly from 4.8 before, to 9.3 after the surgery. Numbness and pain in hands were also markedly improved with a different score on VAS each. CONCLUSION: Primary ring flexor digitorum superficialis opponensplasty with open carpal tunnel release is a very practical and useful way of treating extreme carpal tunnel syndrome in thenar weakness.

Efficiency of Vein Repair for Distally Based Avulsion Flap Injury of the Hand and Forearm

PURPOSE: The purpose was to evaluate the efficiency of vein repair on flap survival in distally based avulsion flap injury of the hand and forearm. METHODS: Sixteen cases of distally based avulsion flap injury larger than 30 cm2 in size of the hand and forearm in which vein repair was done were enrolled. All had a avulsion injury by rolling machine. To survive the flap, extensive debridement was done to reduce the size of distally based flap injury as little as possible. Thereafter, an average of 1.4 vein were repaired. Postoperatively, hyberbaric oxygen therapy was performed for 2 weeks. The flap survival was assessed at three weeks after operation. RESULTS: When comparing the size of distally based avulsion flap injury and flaps that survived after operation, excellent results were observed in 12 cases, and good results in 4 cases. Additional operation was required including split thickness skin graft in 4 cases. A reverse island fasciocutaneous flap was performed in one case, and elbow joint arthrolysis was performed in another one. CONCLUSION: Treatment of distally based avulsion flap injury of the hand and forearm using vein repair lead to relatively satisfying results in flap survival by allowing earlier motion of the joint, providing favorable functional results.

Modified Bilhaut-Cloquet Procedure for Convergent Type IV of Duplicated Thumb

PURPOSE: The authors applied modified Bilhaut-Cloquet procedure to convergent type of Wassel type IV duplicated thumb. In order to avoid secondary Z-deformity and dysfunction of the reconstructed thumb, the authors modified operative techniques of Bilhaut-Clopuet procedure. METHODS: Fourteen patients received Bilhaut-Cloquet procedures to correct duplicated thumbs from October 2008 to May 2013. Five patients were balanced type and nine patients were unbalanced type. Mean age at the operation was 20.1 month-old (range, 12-52 month-old). Angular deformity, joint stability, range of joint motion and cosmetic outcome were estimated based on Tada score. Postoperative subjective satisfaction score of the parents was evaluated using a 100-points scale. RESULTS: Mean subjective satisfaction score was 75 points at 28 months after the operation. Radiologic study showed bony union of proximal phalangeal bone and stable joint in all patients. Mean range of motion was 20 degrees in interphalangeal joint and 73 degrees in metacarpophalangeal joint. Based on Tada score, the results were good in ten patients (72%), fair in two (14%) and poor in two (14%). Seven patients who were able to follow up for a long term showed no significant difference in length of proximal and distal phalangeal bones compared to the opposite thumb. CONCLUSION: Modified Bilhaut-Cloquet procedure can be applied not only to balanced type of convergent Wassel type IV duplicated thumb, but also to unbalanced type, that focused on functional reconstruction and cosmetic improvement.

Anatomical Distribution of Branches of the Medial Antebrachial Cutaneous Nerve during Cubital Tunnel Surgery

PURPOSE: The purpose of this prospective study is to examine the anatomical variations of the branches of the medial antebrachial cutaneous nerve in Koreans encountered during cubital tunnel surgery. METHODS: Ninety two patients with cubital tunnel syndrome were treated with a standard approach from December 2008 to July 2012. The position of the branches of medial antebrachial cutaneous nerve was evaluated based on the medial humeral epicondyle with the elbows fully extended. RESULTS: At least one medial antebrachial cutaneous nerve branch was found during the surgeries in all patients. The average number of crossing medial antebrachial cutaneous nerve branches per patient was 1.6. Thirty-eight percent of the cases showed that the medial cutaneous nerve branches cross proximal to the medial humeral epicondyle within 1 cm. Eighty-two percent showed that the medial antebrachial cutaneous nerve branches cross distal to the medial humeral epicondyle within 1.9 cm. CONCLUSION: When using standard approach during cubital tunnel surgery, more than one medial forearm cutaneous nerve is found. Therefore, understanding the general position of medial antebrachial cutaneous nerve branches helps avoid iatrogenic damage to this nerve during cubital tunnel surgery.

Suspended Replantation in Complete Amputations of the Hand and Finger

PURPOSE: We report the results of replantations which was intentionally delayed for a certain period of time in patients with an amputation of multiple digits, both hands or the single digit presented at night. MATERIALS AND METHODS: Two staged intentianlly delayed replantations were performed in twenty patients. Three patients had amputations of four or more fingers, two had bilateral hand amputations and fifteen had a single digit amputation. RESULTS: The mean warm ischemic time was 3 hours and 58 minutes. The mean cold ischemic time was 2 hours and 36 minutes for the first operation, and 15 hours and 13 minutes for the second operation. Twenty digits out of 28 digits (85%) survived completely. At the mean follow-up of months, functional results according to Chen's criteria were rated as excellent in six patients, good in eight, and fair in five. CONCLUSION: When the patients had multiple finger amputations, bilateral hand amputations or presented late at night, intentional delay of the replantation also provide satisfactory outcomes.

Dupuytren's Contracture Release with Straight Line Incision and Multiple Z-plasty

PURPOSE: To report the results of patients with a Dupuytren's contracture treated with fasciectomy combined with straight line incision and multiple Z-plasty. MATERIALS AND METHODS: We performed retrospective study on 33 hands in 28 patients who had a Dupuytren's contracture between March 2006 to July 2009. Patients were males and the average age was 62-year-old ranging from 50 to 75. There were 15 single and 18 multiple digits involvement. Operation involved fasciectomy using straight skin incision combined with multiple Z-plasty. Postoperative assessment was based on the Honner's classification and range of motion of the involved fingers. RESULTS: According to Honner's classification, the clinical results were excellent in 19 cases, good in 11 and fair in 3. No complication was found except three patients who complained of pain for 6 months after the surgery. The mean range of motion of the involved fingers was 120degrees preoperatively and it increased to 205degrees postoperatively. Cold intolerance lasted for about 6 months in 5 patients but improved spontaneously. CONCLUSION: In patients with a Dupuytren's contracture, fasciectomy with a straight midline incision and multiple Z-plasty provides satisfactory recovery of finger motions.

Reconstruction of Soft Tissue Defects in the Finger using Arterialized Venous Free Flaps

PURPOSE: To report the clinical results of the use of arterialized venous free flaps in reconstruction in soft tissue defects of the finger and to extend indications for the use of such flaps based on the clinical experiences of the authors. Materials and METHODS: Eighteen patients who underwent arterialized venous free flaps for finger reconstruction, between May 2007 and July 2009 were reviewed retrospectively. The mean flap size was 4.7x3.2 cm. The donor site was the ipsilateral volar aspect of the distal forearm in all cases. There were 8 cases of venous skin flaps, 5 cases of neurocutaneous flaps, 4 cases of tendocutaneous flaps, 1 case of innervated tendocutaneous flap. The vascuality of recipient beds was good except in 4 cases (partial devascuality in 2, more than 50% avascuality (bone cement) in 2). RESULTS: All flaps were survived. The mean number of included veins was 2.27 per flap. Mean static two-point discrimination was 10.5 mm in neurocutaneous flaps. In 3 of 5 cases where tendocutaneous flaps were used, active ROM at the PIP joint was 60 degrees, 30 degrees at the DIP joint and 40 degrees at the IP joint of thumb. There were no specific complications except partial necrosis in 3 cases. CONCLUSIONS: An arterialized venous free flap is a useful procedure for single-stage reconstruction in soft tissue or combined defect of the finger; we consider that this technique could be applied to fingers despite avascular recipient beds if the periphery of recipient bed vascularity is good.

Flexor Tendon Entrapment at the Malunited Base Fracture of the Proximal Phalanx of the Finger in Child : A Case Report

The proximal phalangeal base is the most commonly fractured hand bone in children. Such fractures are rarely reported to be irreducible as a consequence of flexor tendon entrapment. A 12-year-old male sustained a malunited base fracture of the proximal phalanx of the small finger on the right hand and was unable to flex the finger. 6 weeks ago he was treated with closed reduction and percutaneous K-wire fixation, at another hospital. In a subsequent operation, it was found that the flexor tendon was entrapped at the fracture site. Flexor tenolysis and realignment of the fracture and internal fixation with K-wires were performed. The patient could perform his work without discomfort in his hand and a normal range of motion was possible in the small finger 12 months after the operation.

Entrapment of Superficial Peroneal Nerve (A Case Report) / 대한족부족관절학회지

We experienced a case of an athlete with a painful mass on the distal peroneal musculature after sports activity, and diagnosed as the entrapment syndrome of superficial peroneal nerve. We treated the case with the mini-open and subcutaneous fasciotomy to release the entrapped peroneal nerve. We report the case with a review of the literature.

Treatment of Tibial Shaft Fractures in Children Using K-wires Fixation

PURPOSE: To report the effectiveness of Kirschner wire fixation for the treatment of unstable tibial shaft fractures in children. MATERIALS AND METHODS: We analyzed 15 cases of pediatric tibial shaft fractures treated at our hospital with fixation using K-wire and followed up for more than 1 year from July 1998 to January 2002. The subjects included 11 boys and 4 girls. The ages ranged from 3 to 10 years at the time of injury, with the average age being 7.9 years. We examined the presence of angulation, leg length discrepancy, joint motion limitation, and complications. RESULTS: Bony fusion was obtained in all patients by an average of postoperative 9.5 weeks. At the time of last follow-up (by an average of postoperative 1 year and 4 months), anterior and posterior radiographs showed an average of 4.2degree angulation, and lateral radiographs showed an average of 4.4degree angulation. The affected leg was extended by an average of 3.7 mm compared to the opposite leg according to Bell-Thompson's radiographs. As for complications, infection was developed around the pin in 3 cases but treated with the administration of oral antibiotics and sterilization around the site without progressing to deep infection. We could not observe joint motion limitation, pain and difficulties related with discrepancy in leg length. CONCLUSION: We concluded that fixation using K-wire for children with tibial shaft fractures was a safe and effective method of surgery that could be performed easily, did not require secondary surgery to remove the wire, and showed sufficient stability after fixation.