Reconstruction of nail bed and fingertip defects with free nail flap / 中国医师杂志

Objective:To explore the application value of free nail flaps in reconstruction of nail bed and fingertip defect.Methods:From January 2018 to June 2020, nine patients with free nail flap transplantation to treat fingertip injuries in Lishui People′s Hospital were included in this study. According to the Allen classification, 6 patients were characterized as type Ⅱ and 3 were characterized as type Ⅲ. Evaluation was based on the patients′ medical records and follow-up, including postoperative healing of recipient and donor sites, two-point discrimination, the Chinese Medical Association Hand Surgery Society′s evaluation of the function of severed finger replantation, and Michigan Hand Outcomes Questionnaire (MHQ) and Foot Function Index (FFI).Results:All patients successfully completed the operation, the operation time was 3.0-5.0 h (average 4.1 h), the intraoperative blood loss was 100-250 ml (average 178 ml), and the follow-up time was 12-40 months (average 25 months). The nails and flaps of all patients survived with primary healing. No complications were observed after surgery. The appearance of the reconstructed finger of 9 patients was similar to that of the uninfected side; the flap two-point discrimination was 5.0-7.5 mm; the replantation score and MHQ results were satisfactory. The toenail of the donor site grew well, and no deformity or pain with walking was noted.Conclusions:The free toenail flap was used to treat fingertip defects, with satisfactory clinical results in repairing tissue defects, reconstructing nail bed and maintaining finger length.

Fixation of Mallet Fractures Using a Modified Hook Plate Technique: A Prospective Case Series of 17 Patients / Fixação de fraturas em martelo com técnica de placa de gancho modificada: Uma série de casos prospectivos de 17 pacientes

Abstract Objective Various modalities have been suggested to manage mallet fractures; however, inappropriate treatment can lead to extension lag, a swan neck deformity, or arthritis of the distal interphalangeal joint (DIPJ). The current study aimed to evaluate the results (functional, radiological, and complications) of open reduction and internal fixation (ORIF) of mallet fractures using low-cost hook plates fabricated from low-profile titanium mini plates. Methods A prospective case series of 17 consecutive patients (average age of 32.3 years) with mallet fractures (six were Wehbe Type IB and 11 were Wehbe Type MB). Eleven (64.7%) were males. The affected hand was dominant in all patients, and the affected digit was the index in 6 (35.3%), the ring in 5 (29.4%), the small in 3 (17.65%), and the middle in 3 (17.65%) patients. The same fellowship-trained hand surgeon performed all surgeries. Results The average operative time was 37.65 minutes. After an average follow-up of 10.94 months (range 6-27), the average DIPJ motion was 50º º (range 20º-70º), the extensor lag was noted in 4 (23.5%) patients, and complications were reported in 6 (35.29%) patients. According to Crawford criteria, 6 (35.3%) patients achieved excellent results, 7 (41.2%) achieved good results, and 4 (23.5%) achieved fair results. Conclusion The modified hook plate technique for fixation of mallet fractures is a beneficiai, economical, yet demanding technique that adequately provides stable fixation to allow early DIPJ motion with acceptable functional outcomes.

Resumo Objetivo Diversas modalidades têm sido sugeridas para o tratamento de fraturas em martelo; no entanto, o tratamento inadequado pode causar retardo de extensão, deformidade em pescoço de cisne ou artrite da articulação interfalangiana distal (AIFD). Este estudo teve como objetivo avaliar os desfechos (funcionais, radiológicos e complicações) da redução aberta e fixação interna (RAFI) das fraturas em martelo com placas de gancho de baixo custo fabricadas com mini placas de titânio de baixo perfil. Métodos Série de casos prospectivos de 17 pacientes consecutivos (idade média de 32,3 anos) com fraturas em martelo (seis do tipo IB e 11 do tipo IIB de Wehbe). Onze (64,7%) pacientes eram do sexo masculino. A mão acometida era a dominante em todos os pacientes, com acometimento do dedo indicador em seis (35,3%), anelar em cinco (29,4%), mínimo em três (17,65%) e médio em três (17,65%) pacientes. O mesmo cirurgião de mão experiente realizou todas as cirurgias. Resultados O tempo operatório médio foi de 37,65 minutos. Após um acompanhamento médio de 10,94 meses (intervalo de 6 a 27), observou-se movimento médio da AIFD de 50º (intervalo de 20º a 70º), retardo de extensão em quatro (23,5%) pacientes e complicações em seis (35,29%) pacientes. De acordo com os critérios de Crawford, os desfechos foram excelentes em seis (35,3%), bons em sete (41,2%) e regulares em quatro (23,5%) pacientes. Conclusão A técnica da placa de gancho modificada para fixação de fraturas em martelo é benéfica e econômica, mas exigente; permite fixação estável e adequada para permitir a movimentação precoce da AIFD com desfechos funcionais aceitáveis.

Comparative Analysis of a Modified Secondary Healing Protocol for Fingertip Amputations and Non-microsurgical Reconstruction Techniques / Análise comparativa de um protocolo de cicatrização secundária modificado para amputações das pontas dos dedos e técnicas de reconstrução não microcirúrgicas

Abstract Objective To describe and compare the results obtained with a secondary healing protocol for fingertip amputations and their relationship to injury severity according to the Allen classification. Methods Medical records of 127 fingertip injuries were revised, and a retrospective, comparative, analytical study the amputations treated conservatively was performed. Injury characteristics, healing time, and complications were described and analyzed. Results Between April 2017 and May 2019, 127 fingertip injuries were treated conservatively. The average age of the sample was of 28.33 years. The average healing time was of 4.31 weeks. The complications during the follow-up were observed in 18.9% (n= 24) of the cases, but none require revision treatment. A statistically significant relationship between the development of complications and treatment revision according to the Allen classification was not found (p ≥ 0.05). Conclusion The proposed secondary healing protocol has shown to be safe and effective in types 1 to 3 fingertip amputations in the Allen classification, and it should be included as a therapeutic option even in injuries of greater extension than those that have traditionally been limited to.

Resumo Objetivo Descrever e comparar os resultados obtidos com um protocolo de cicatrização secundária para amputações das pontas dos dedos e sua relação com a gravidade da lesão de acordo com a classificação de Allen. Métodos Foram revisados os prontuários clínicos de 127 lesões nas pontas dos dedos, e realizou-se um estudo retrospectivo, comparativo e analítico das amputações tratadas de forma conservadora. Foram descritas e analisadas as características da lesão, o tempo de cicatrização, e as complicações. Resultados Entre abril de 2017 e maio de 2019, foram tratadas de forma conservadora 127 lesões nas pontas dos dedos. A idade média da amostra era de 28,33 anos. O tempo médio de cicatrização foi de 4,31 semanas. As complicações apresentadas durante o acompanhamento afetaram 18,9% (n = 24) dos casos, porém nenhum exigiu tratamento de revisão. Não foi encontrada relação estatisticamente significativa entre o desenvolvimento das complicações e a revisão do tratamento de acordo com a classificação de Allen (p ≥ 0,05). Conclusão O protocolo de cicatrização secundária proposto mostrou-se seguro e eficaz nas amputações das pontas dos dedos conforme os tipos de 1 a 3 da classificação de Allen, e deve ser incluída como opção terapêutica mesmo em lesões de maior extensão do que aquelas tradicionalmente limitadas.

Clinical application of 3d printing technology for preoperative planning of thumb reconstruction / Aplicação clínica da tecnologia de impressão 3d para planejamento pré-operatório de reconstrução de polegar

ABSTRACT Objective: This study aimed to explore the clinical application of preoperative precise design for 3D printing and thumb reconstruction, which could help manage the patients with thumb defect and achieve better function and appearance. Methods: This was a retrospective study of 20 patients who underwent the surgery of harvesting toe transplant and thumb reconstruction between January 2015 and December 2016. The 3D model of the thumb defect was created and printed. The dimensions of skin and bones from donor site were precisely designed as reference for surgical operation. The surgery was performed according to the model. Results: Perfect repair of defects was achieved with satisfying appearance and function. The reconstructed thumbs all survived (survival rate of 100%). Follow-up was 3-9 months. The maximum dorsiflexion was 8-30° and the maximum flexion was 38-58°. The two-point sensory discrimination was 9-11 mm. In total, 17 patients reposted "Excellent" satisfaction and three "Good", each for the reconstructed thumb and hand function, respectively. The satisfaction rate was 85%. Conclusion: Preoperative digital design and 3D printing according to the donor and recipient sites allowed a tailored operation. The operation was more precise, the appearance of the reconstructed thumb was good. Level of Evidence II, Retrospective Study.

RESUMO Objetivo: Este estudo explorou a aplicação clínica do desenho pré-operatório preciso para impressão 3D e reconstrução do polegar, para ajudar no controle e melhorar função e aparência. Métodos: Estudo retrospectivo de 20 pacientes submetidos à cirurgia de colheita de transplante de dedo do pé e reconstrução do polegar entre janeiro de 2015 e dezembro de 2016. O modelo 3D do defeito do polegar foi confeccionado e impresso. As dimensões da pele e dos ossos da área doadora foram precisamente projetadas como referência para a operação cirúrgica, realizada de acordo com o modelo. Resultados: O reparo perfeito foi alcançado com aparência e função satisfatórias. Todos os polegares reconstruídos sobreviveram (taxa de sobrevivência de 100%). O acompanhamento foi de 3-9 meses. A dorsiflexão máxima foi de 8-30° e a flexão máxima foi de 38-58°. A discriminação sensorial de dois pontos foi de 9-11 mm. No total, 17 pacientes reportaram índice "Excelente" e três índice "Bom" cada para a função reconstruída do polegar e da mão, respectivamente. O índice de satisfação foi de 85%. Conclusão: O design digital pré-operatório e a impressão 3D de acordo com os locais doador e receptor permitiram uma operação customizada. A operação foi mais precisa, com bom aspecto. Nível de Evidência II, Estudo Retrospectivo.

Tratamento da unha em gancho com a técnica de Bakhach: estudo retrospectivo / Treatment of hook nails using the Bakhach's technique: a retrospective study

Introdução: a causa da unha em gancho é o trauma do hiponíquio. A lâmina ungueal se apresenta com hipercurvatura longitudinal de concavidade volar, causando perda funcional, comprometimento estético e dor. Objetivo: avaliar os resultados na pesquisa de 20 prontuários de pacientes submetidos a cirurgias de correções de unhas em gancho de etiologias traumáticas. Métodos: estudo retrospectivo transversal epidemiológico, de 2010 a 2018, de prontuários de pacientes submetidos à técnica cirúrgica de Bakhach, no ambulatório de Cirurgia da Mão do Hospital do Servidor Público Municipal de São Paulo. Resultados: 20 dedos acometidos. Sete vítimas de acidente com objetos cortantes, cinco com máquinas tipo prensa, cinco com portas, um com janela, um com motocicleta e um por mordida de cachorro. O dedo com maior incidência foi o médio (12 casos); seguido do indicador (cinco casos) e do anelar (três casos). A queixa principal foi estética (11); dor (seis) e funcional (três). Todos tiveram amputações digitais distais transversas do tipo II e foram submetidos a tratamento cirúrgico. A cirurgia de reconstrução ocorreu entre quatro e 25 meses pós-trauma. Conclusão: 15 ficaram satisfeitos, embora dois destes tenham relatado dor: um na articulação interfalângica distal e o outro no hiponíquio. O acompanhamento variou de seis meses a dois anos.

Introduction: The cause of the hook nail is the trauma of the hyponychium. The nail plate presents longitudinal hypercurvature of volar concavity, causing functional loss, aesthetics concerns, and pain. Objective: To evaluate the research results of 20 medical records of patients submitted to hook nail correction surgeries of traumatic etiologies. Methods: Epidemiological, cross-sectional, retrospective study of patients' medical records who were submitted to Bakhach's surgical technique, from 2010 to 2018, in the Hand Surgery Outpatient Clinic of the Hospital do Servidor Público Municipal de São Paulo. Results: We analyzed 20 affected fingers: 7 were victims of accidents with sharp objects, 5 with press machines, 5 with doors, 1 with window, 1 with motorcycle, and 1 due to a dog bite. The finger with the highest incidence was the middle finger (n=12), followed by the index finger (n=5), and ring finger (n=3). The main complaint was aesthetics (n=11); pain (n=6), and functional (n=3). All cases had type II distal digital transverse amputations and underwent surgical treatment. The reconstruction surgery occurred between 4 and 25 months after the trauma. Conclusion: 15 patients were satisfied and two felt pain: one in the distal interphalangeal joint and the other in the hyponychium. The follow-up ranged from 6 months to 2 years

In Vitro Biomechanical Study on the Figure-of-Eight and Kessler Sutures in Swine Flexor Tendons / Estudo biomecânico in vitro das suturas em oito e de Kessler de tendões flexores de porcos

Abstract Objective To evaluate the biomechanical properties of the "figure-of-eight" and Kessler suture techniques for tendons. Methods Flexor tendons of porcine fingers were divided into two groups with triple central "figure of eight" sutures (six passages) and Kessler sutures (two passages) associated with simple and continuous peripheral sutures, and submitted to continuous longitudinal mechanical tests, to obtain the mechanical properties of maximum load and energy at maximum load. Results The mean maximum load and energy at maximum load in the "figure-of-8" suture were of 63.4 N and 217.3 N.mm respectively; in the Kessler suture, the values were of 34.19 N and 100.9 N.mm respectively. The statistical analysis indicated that the "figure-of-eight" suture is mechanically superior to the Kessler technique. Conclusion Under the conditions of this experiment and in the flexor tendon of porcine fingers, the triple "figure-of-eight" suture (six passages) is more resistant than the Kessler suture (two passages). The "figure-of-eight" suture with six passages enables active movement in the immediate rehabilitation of the flexor tendon repair of the finger, with little risk of rupture or suture spacing.

Resumo Objetivo Avaliar as propriedades biomecânicas dos pontos de sutura tendinosa em "oito" e de Kessler. Métodos Tendões flexores dos dedos de membros superiores de porcos foram divididos em dois grupos com suturas triplas centrais em "oito" (seis passagens) e de Kessler (duas passagens) associadas a suturas periféricas contínuas simples, e submetidos a ensaios mecânicos longitudinais contínuos, obtendo-se as propriedades mecânicas de carga máxima e de energia na carga máxima. Resultados As médias da carga máxima e da energia na carga máxima na sutura em "8" foram de 63,4 N e 217,3 Nmm, respectivamente; na sutura de Kessler, os valores foram de 34,19 N e 100,9 Nmm, respectivamente. A análise estatística indicou que o ponto em "oito" é superior mecanicamente ao ponto de Kessler. Conclusões Nas condições deste experimento e no tendão flexor de dedo de membro superior de porcos, o triplo ponto em "oito" (seis passagens) é mais resistente do que o ponto de Kessler (duas passagens). O triplo ponto em "oito", com seis passagens, permite movimentação ativa na reabilitação imediata de reparo de tendão flexor de dedo de membro superior com pouco risco de ruptura ou espaçamento na sutura.

Caso Clínico: Fractura expuesta grave del dedo índice. Cirugía de rescate con colgajo adipofascial vascularizado homodigital reverso / Case report: Severe index finger open fracture. Surgical rescue with homodigital vascularized adipofascial reverse flap.

INTRODUCCIÓN: Los traumas de mano tienen una alta incidencia alrededor del mundo y representan alrededor del 30% de todos los accidentes y visitas a servicios de urgencias, siendo las lesiones de la punta del dedo un subtipo común de trauma de mano. El manejo inicial y la elección del tratamiento adecuado son importantes, el principal objetivo es la cobertura de tejidos para así evitar amputaciones innecesarias, prevenir complicaciones y pérdida de funcionalidad. CASO CLÍNICO: Paciente masculino de 32 años que sufrió trauma por aplastamiento en mano derecha que produce herida con pérdida de tejido en falanges distales de segundo y tercer dedo y amputación traumática parcial de falange distal del segundo dedo. EVOLUCIÓN: Se realizó técnica quirúrgica de colgajo adipofascial vascularizado homodigital reverso en segundo dedo y manejo conservador de fractura, sin complicaciones. Se llevó un control semanal por 2 meses con resultados funcionales, biológicos y estéticos favorables. El tercer dedo se trató con limpieza quirúrgica y colocación de vendaje suboclusivo con evolución favorable. CONCLUSIÓN: El colgajo adipofascial dorsal homodigital reverso tiene varias ventajas sobre otros tipos de colgajos más convencionales; es una técnica simple, segura y confiable, con buenos resultados postquirúrgicos en cuando a funcionalidad, estética y recuperación, requiere de un solo tiempo quirúrgico y brinda la cobertura necesaria de los tejidos expuestos tanto óseos como blandos, con mínima morbilidad del sitio donante.(au)

BACKGROUND: Hand trauma has a high incidence worldwide, it accounts nearly 30% of all trauma and medical visits to emergency rooms, fingertip injuries are the most common among hand trauma. The initial management and the proper choice of treatment are important, the main objective is to achieve adequate tissue coverage, in order to avoid unnecessary amputation, prevent complications and functionality loss. CASE REPORT: A 32-year-old male patient presented with crush trauma on right hand resulting in injuries with tissue loss on the fingertips of the second and third finger and traumatic partial amputation of the distal phalanx of the second finger. EVOLUTION: Surgical technique of homodigital vascularized adipofascial reverse flap was performed in second finger and the fracture was managed conservatively, without complications. A weekly follow up was carried out for 2 months with favorable functional, biological and aesthetic results. The third finger was treated with surgical irrigation and debridement and placement of a sub-occlusive bandage, with favorable outcome. CONCLUSION: Homodigital adipofascial reverse dorsal flap has advantages over other types of conventional flaps; it is a simpler, safe and reliable technique, with good postsurgical outcomes in terms of functionality, aesthetics and recovery, needing only one intervention and offering the appropriate coverage to exposed bone and soft tissue, with minimal repercussions on the donor site.(au)

Interobserver Analysis of Albertoni Classification for Mallet Finger, Using Plain Radiography: Importance of the Goniometer / Análise interobservador da classificação das lesões em dedo em martelo segundo Albertoni, utilizando-se radiografias simples: Importância do uso do goniômetro

Abstract Objectives The objective of the present study is to evaluate the intraobserver and interobserver reliability of the Albertoni classification for mallet finger. Evaluation of goniometer device application is also an objective. Methods A total of 10 lateral radiographs of patients with mallet finger were selected and measured by 60 orthopedic surgeons with and without the use of goniometer. Results The intra- and interobserver reliability coefficients found were high. With the use of a goniometer, the interobserver reliability coefficient was even higher, but without statistical relevance. Conclusion The Albertoni classification showed high intraobserver and interobserver reliability in assessing mallet finger lesions, and the goniometer is dispensable for this purpose.

Resumo Objetivos Quantificar o grau de concordância intra- e interobservador da classificação Albertoni e avaliar a importância do uso do goniômetro na diferenciação do grau da lesão. Métodos Foram selecionados 10 casos de dedo em martelo, os quais foram avaliados por 60 examinadores. Resultados A concordância interobservador sem o uso do goniômetro foi elevada. Com o uso do goniômetro, obteve-se um "kappa" ainda maior, porém sem relevância estatística. Conclusão A Classificação de Albertoni possui elevada concordância intra- e interobservador, e o uso do goniômetro se mostrou dispensável para classificar.

Nail bed defect reconstruction using a thenar fascial flap and subsequent nail bed grafting

BACKGROUND: Full-thickness nail bed defects with significant exposure of the distal phalanx are typically challenging to reconstruct. We describe a novel method of nail bed defect reconstruction using a thenar fascial flap combined with nail bed grafting. METHODS: Full-thickness nail bed defects were reconstructed in a 2-stage operation involving the placement of a thenar fascial flap and subsequent nail bed grafting. A proximally-based skin flap was designed on the thenar eminence. The flap was elevated distally to proximally, and the fascial layer covering the thenar muscle was dissected proximally to distally. The skin flap was then closed and the dissected fascial flap was turned over (proximal to distal) and inset onto the defect. The finger was immobilized for 2 weeks, and the flap was dressed with wet and ointment dressings. After 2 weeks, the flap was divided and covered with a split-thickness nail bed graft from the great toe. Subsequent nail growth was evaluated on follow-up. RESULTS: Nine patients (9 fingers) treated with the novel procedure were evaluated at follow-up examinations. Complete flap survival was noted in all cases, and all nail bed grafts took successfully. Five outcomes (55.6%) were graded as excellent, three (33.3%) as very good, and one (11.1%) as fair. No donor site morbidities of the thenar area or great toe were observed. CONCLUSIONS: When used in combination with a nail bed graft, the thenar fascial flap provides an excellent means of nail bed reconstruction.

Thompson procedure for chronic mallet finger with tendon defect / 中华创伤骨科杂志

Objective To evaluate the Thompson procedure in the treatment of chronic mallet finger with tendon defect.Methods From July 2014 to October 2016,9 cases of chronic mallet finger with tendon defect were treated by Thompson procedure at Department of Hand Surgery,Wuhan Puai Hospital.They were 4 males and 5 females,aged from 25 to 56 years (average,36 years).Their disorder was on the left side in 3 cases and on the right side in 6 ones,involving 2 index fingers,3 middle fingers,3 ring fingers and one little finger.The ranges of motion (ROM) for distal and proximal interphalangeal joints were measured after operation.Operative complications were observed and recorded.Dargan functional assessment was used to evaluate the outcomes at the final follow-up.Results All the 9 patients were followed up for 5 to 36 months (average,16.5months).The wounds healed primarily without such complications as infection,skin breakage,abnormal fingertip sensation or nail deformity.All cases of mallet finger malformation were corrected.About 10 weeks after operation,one case presented with mild mallet finger malformation which was completely corrected after active fixation for 8 weeks.The Dargan assessment at the final follow-up showed 8 excellent and one good cases.Conclusion Thompson procedure can lead to satisfactory outcomes and limited complications in the treatment of chronic mallet finger with tendon defect.

Treatment of fingertip injuries by specialists in hand surgery in brazil / Tratamento de lesões da ponta dos dedos por especialistas em cirurgia da mão no brasil

ABSTRACT Objective: To verify if there is consensus about the treatment of each type of injury or amputation of the fingertips, and if there is a statistical difference among the treatment options according to the surgeon's length of time in the hand surgery specialty. Methods: A cross-sectional survey was conducted during the 37th Brazilian Congress of Hand Surgery, when one hundred and twenty questionnaires were randomly distributed. Observing the inclusion and exclusion criteria, ninety completed questionnaires were included. The answers were submitted to descriptive and inferential analysis with a significance level of p <0.05. Results: This study showed agreement of 63.3% for the treatment with statistical difference for dorsal oblique injury less than 1 cm with bone exposure for the VY advancement flap alternative; 46.7% for volar tip oblique injury with bone exposure less than 1 cm for the Cross Finger alternative; 47.8% for oblique thumb volar injury greater than 1 cm with no bone exposure to the Moberg alternative; 54.4% for thumb pulp injury up to 2.5 cm with bone exposure to the Moberg alternative with proximal release, and 92.2% for antibiotic use, for the "cephalexin" alternative. Conclusion: There is no consensus regarding the treatment of most types of fingertip lesions, with agreement of 45.4%. When we subdivided by time group of specialty in hand surgery, there was an increase in agreement to 54.5% of the questions per subgroup. Further comparative studies are needed to assess the consensus among surgeons regarding the treatment of fingertip injury. Level of Evidence III; Cross-sectional survey.

RESUMO Objetivo: Verificar se há consenso sobre o tratamento de cada tipo de lesão ou amputação da ponta do dedo e se há diferença estatística entre as opções de tratamento de acordo com o tempo em que o cirurgião atua na especialidade de cirurgia da mão. Métodos: Pesquisa transversal realizada durante o 37° Congresso Brasileiro de Cirurgia da Mão, quando foram distribuídos cento e vinte questionários de forma aleatória. Observando-se os critérios de inclusão e exclusão, noventa questionários respondidos foram incluídos. As respostas foram submetidas a análise descritiva e inferencial com índice de significância de p < 0,05. Resultados: Este estudo apresentou concordância no tratamento com diferença estatística para lesão oblíqua dorsal menor que 1 cm com exposição óssea para a alternativa de retalho de avanço VY com 63,3%; lesão oblíqua volar com exposição óssea menor que 1 cm para a alternativa Cross Finger com 46,7%; lesão oblíqua volar do polegar maior de 1 cm sem exposição óssea para a alternativa Moberg com 47,8%; lesão da polpa do polegar com até 2,5 cm com exposição óssea para a alternativa Moberg com liberação proximal com 54,4% e uso de antibióticos para a alternativa "cefalexina" com 92,2%. Conclusão: Não há consenso quanto ao tratamento da maioria dos tipos de lesão da ponta do dedo, sendo que houve concordância em 45,4%. Quando subdividimos por grupo de tempo de especialização em cirurgia de mão, verificou-se aumento da concordância para 54,5% das questões por subgrupo. Há necessidade de realização de novos estudos comparativos para avaliarmos o consenso entre os cirurgiões com relação ao tratamento da lesão das pontas dos dedos. Nível de evidência III; Pesquisa transversal.

Repair of soft tissue defects of the fingers with medial plantar venous flap

SUMMARY OBJECTIVE To report the surgical procedures and efficacy of using medial plantar venous flap for the repair of soft tissue defects of the fingers. Methods From March 2010 to April 2012, medial plantar venous flaps were harvested to repair the wounds of 31 fingers in 29 cases. Among them, there were 13 middle fingers with defects at the tips in 11 cases, 7 fingers with defects in the dorsal part in 7 cases, and 11 fingers with defects in the finger pulp in 11 cases. The size of the defects ranged from 1.2cm×1.5 cm to 2.5cm × 3.5cm. Medial plantar venous flaps of 1.5cm × 2cm - 3×4 cm were harvested. Full-thickness skin grafts were adopted for the donor areas. RESULTS All 31 flaps survived, except for 1 flap with arterial crisis and 2 cases with venous crisis. These conditions were timely corrected by secondary anastomosis of artery and vein and the flaps survived. The wounds and the donor areas achieved healing by the first intention. All grafted skins survived. Postoperative follow-up was conducted for 26 fingers in 24 cases for 4-12 months, excluding 5 cases with lost follow-up. The dorsal part of the damaged fingers had normal morphology, and the skin color and texture were similar to those of the normal skin. After the repair of defects in the fingertip and pulp, fingerprints appeared, and the protective sensation was restored. CONCLUSION The soft tissue defects of the fingers can be satisfactorily repaired with medial plantar venous flap, and little damage is caused to the donor area. This method is proven effective for the repair of soft tissue defects of the fingers.

RESUMO OBJETIVO Relatar os procedimentos cirúrgicos e a eficácia do uso de retalhos plantares mediais venosos para reparo de defeitos de tecidos moles dos dedos. METODOLOGIA De março de 2010 a abril de 2012, foram colhidos retalhos plantares mediais venosos para reparar ferimentos de 31 dedos em 29 casos. Entre eles, 13 dedos médios com defeitos nas pontas em 11 casos, 7 dedos com defeitos na parte dorsal em 7 casos e 11 dedos com defeitos na polpa digital em 11 casos. O tamanho dos defeitos variava de 1,2 cm × 1,5 cm a 2,5 cm × 3,5 cm. Foram colhidos retalhos plantares mediais venosos de 1,5 cm × 2 cm a 3 cm × 4 cm. Foram adotados enxertos de pele de espessura total na área doadora. RESULTADOS Todos os 31 retalhos sobreviveram, com exceção de 1 retalho com crise arterial e 2 casos com crise venosa. Esses problemas foram corrigidos a tempo com anastomoses secundárias das artérias e veias e os retalhos sobreviveram. Os ferimentos e áreas doadoras atingiram cicatrização por primeira intenção. Todos os enxertos de pele sobreviveram. Foi realizado acompanhamento pós-operatório em de 26 dedos em 24 casos por 4 a 12 meses, sendo que dos casos tratados 5 não tiveram acompanhamento. As partes dorsais dos dedos lesionados apresentaram morfologia normal, com cor e textura da pele muito similares a da pele normal. Após o reparo dos defeitos nas pontas e polpas digitais, impressões digitais apareceram e a sensação protetora foi restaurada. CONCLUSÃO Os defeitos de tecido mole dos dedos podem ser reparados de forma satisfatória com retalhos plantares mediais venosos, com poucos danos à área doadora. Este método mostrou se eficaz para o reparo de defeitos de tecido mole dos dedos.

Evaluation of interobserver agreement in Albertoni's classification for mallet finger / Avaliação de concordância interobservador da classificação de Albertoni para dedo em martelo

ABSTRACT Objective: To measure the reliability of Albertoni's classification for mallet finger. Methods: Agreement study. Forty-three radiographs of patients with mallet finger were assessed by 19 responders (12 hand surgeons and seven residents). Injuries were classified by Albertoni's classification. For agreement comparison, lesions were grouped as: (A) tendon avulsion; (B) avulsion fracture; (C) fracture of the dorsal lip; and (D) physis injury-and subgroups (each group divided into two subgroups). Agreement was assessed by Fleiss's modification for kappa statistics. Results: Agreement was excellent for Group A (k = 0.95 (0.93-0.97)) and remained good when separated into A1 and A2. Group B was moderate (k = 0.42 (0.39-0.44)) and poor when separated into B1 and B2. In the Group C, agreement was good (k = 0.72 (0.70-0.74)), but when separated into C1 and C2, it became moderate. Group D was always poor (k = 0.16 (0.14-0.19)). The general agreement was moderate, with (k = 0.57 (0.56-0.58)). Conclusion: Albertoni's classification evaluated for interobserver agreement is considered a reproducible classification by the method used in the research.

RESUMO Objetivo: Avaliar a reprodutibilidade da classificação de Albertoni para dedo em martelo. Métodos: Foi feita uma avaliação por meio de questionário no qual foram avaliadas 43 radiografias em perfil da articulação interfalângica distal de dedos da mão, com lesão tipo dedo em martelo. Todas as lesões foram caracterizadas pela classificação de Albertoni, por 19 entrevistados (12 cirurgiões de mão e sete residentes). Foi então avaliada a concordância com o coeficiente Kappa generalizado, separadas por grupos - (A) avulsão tendínea; (B) fratura avulsão; (C) fratura do lábio dorsal e (D) lesão fisária - e por subgrupos (cada grupo dividido em 1 e 2). Resultados: A concordância foi excelente para o grupo A (k = 0,95 [0,93-0,97]) e manteve-se boa quando separados em A1 e A2. No grupo B, a concordância foi moderada (k = 0,42 [0,39-0,44]), e foi ruim quando separada em B1 e B2. No grupo C, a concordância foi boa (k = 0,72 [0,70-0,74]), mas quando separada em C1 e C2 se tornou moderada. No grupo D foi sempre ruim (k = 0,16 [0,14-0,19]). A concordância geral foi moderada (k = 0,57 [0,56-0,58]). Conclusão: Pela avaliação da concordância geral, a classificação de Albertoni é considerada reprodutível pelo método usado na pesquisa.

Research progress in treatment methods for fingertip defects / 中华创伤杂志

Fingertip soft tissue defects are common,and there are various injury types and repair methods.Because of the special anatomy and functional requirements of the hand,it is particularly important to choose the appropriate treatment in order to achieve ideal appearance and function outcomes.Clinically,the treatment strategy depends on multiple factors including the type of fingertip defect,the patient,and the doctor.Therefore,the author retrieved 39 research articles after literature search in CNKI and Pubmed using relevant key terms.Based on the review of articles,the author recommended and introduced seven commonly used therapeutic methods and their effects (closed or semi-closed dressing change,fingertip replantation,advanced skin flap,palmar rotation flap,free toe pulp flap,free transverse wrist crease flap,and free venous flap) in order to help clinicians improve their understanding about fingertip defect repair as well as choose appropriate methods.

Clinical study of early application of toe flap to repair thumb damaged electrical burns / 中国医师杂志

Objective To study the surgery effect on early application of toe flap to repair thumb severe electric bum.Methods From July 2007 to October 2017,a total of 25 cases of thumb severe electric burn were repaired by thumb toe flap grafting.The function of the finger after operation was evaluated comprehensively,and the effect of 72 hours before and after the injury was compared.Results All the flaps survived and the finger function was excellent.The excellent and good rate of 25 cases was 72％.The excellent and good rate of 72 hours before and after injury were 85.7％ and 54.5％ respectively.5 cases had bad wound complications after operation.1 cases were operated within 72 hours after injury,and 4 cases were operated after 72 hours.Conclusions The early application of toe flap to repair severe electric bum thumb can maximize the recovery of function of the thumb.The earlier the operation,the fewer complications,the better the repair effect.

Clinical study of propacetamol and dezocine for the prevention and treatment of vascular crisis in preemptive analgesia after digit replantation / 中国医师杂志

Objective To explore the clinical effect of propacetamol and dezocine for the prevention and treatment of vascular crisis in the preemptive analgesia after digit replantation.Methods 85 cases of patients treated with digit replantation were selected for the study and divided into the propacetamol group (n =45) and the dezocine group (n =40) according to the different postoperative preemptive analgesic method.The two groups were given with propacetamol or dezocine and fentanyl and ondansetron patient-controlled intravenous analgesia (PCIA) respectively.The analgesic and sedative effects were observed between the two groups,and the occurrence of vascular embolism and vascular crisis and the survival rate of rcplantation were counted.Results There was no significant difference between the two groups in the visual analogue pain score (VAS) at 3 hours after operation (P ＜0.05).The VAS scores of the two groups were significantly increased at 6 h and 24 h after operation while the VAS score was significantly decreased at 48 h after operation (P ＜ 0.05),and the VAS scores were significantly lower in the propacetamol group than those in the dezocine group at 6 h,24h and 48 h after operation (P ＜ 0.05).The difference of the Ramsay sedation scores distribution at 3 hours after operation was statistically significant between the two groups (P ＜ 0.05),and the sedative effect was more satisfactory in the propacetamol group.Within 48 h after operation,PCI effective times/actual sub values of the propacetamol group were significantly higher than the dezocine group (P ＜0.05).The incidence rates of postoperative vascular thrombosis and arterial or venous crisis were 4.44％,6.67％ and 6.67％ respectively in the propacetamol group,which were significantly lower than those in the dezocine group with 20.00％,22.50％ and 27.50％ (P ＜ 0.05).The survival rate of digit replantation,digit replantation at 6 months after treatment were 97.78％,85.00％ which was higher than that of the dezocine group with 91.11％,75.00％ (P ＜ 0.05).Conclusions Compared with dezocine,propacetamol can attain the ideal analgesic and sedative effects and improve the survival rate of replantation,which has a significant role in the prevention and treatment of vascular crisis in the adjuvant treatment of postoperative analgesia in digit replantation.

Repair of fingertip defect with free second toe tibial flap anastomosed by the dorsal nerve of the toe / 中华整形外科杂志

Objective@#To report the operation methods and clinical effects of repairing finger tip defect with the free tibial dorsal nerve flap of the second toe.@*Methods@#13 patients with finger tip defects were repaired by the tibial dorsal nerve flap of the second toe. The area of finger tip defect was 2.5 cm×1.5 cm-1.3 cm×1.0 cm, and the area of cutting flap was 2.7 cm×1.7 cm-1.5 cm×1.1 cm. All donor site defects on the second toe were covered with full-thickness skin graft.@*Results@#There were 13 cases in this group, and all the flaps and skin grafts were survived. Postoperative follow-up ranged from 6 to 18 months, with an average of 13 months. The appearance of the fingers was satisfied and the sensory recovery was good. Two-point discrimination of the flaps returned to 7-13 mm, with an average of 9 mm. According to the total active move(TAM)scale, results were excellent in 11 fingers, good in 1 finger, and fair in 1 finger. The donor site skin graft was well healed, the second toe pulp was full, and the two-point discrimination of the toe pulps were 6-10 mm, with an average of 8 mm.@*Conclusions@#Compared to the traditional method of repairing finger tip defect with the tibial inherent nerve flap of the second toe, our new method can reduce the damage to the donor site, and we can repair finger tip defect as well as the traditional one at the same time. So it was a better operative method to repair finger tip defect with the tibial dorsal nerve flap of the second toe.

Anatomy research and clinical application of reverse dorsoradial thumb flap of different rotation point in repairing defect of thumb / 中华显微外科杂志

Objective To investigate a anatomy research and clinic application of defect of thumb by reverse dorsoradial thumb flap of different rotation point.Methods The origin,course,distribution and vascular chain of the first metacarpal dorsoradial artery of thumb from 11 adult cadaveric hand specimens perfused by red latex were explored from September,2012 to December,2016.There were 3 different rotation points:the proximal of the metacarpophalangeal joint,proximal basal of the first proximal phalanx and distal of the first proximal phalanx.Each could be used as reverse flow flap to repair the defect of thumb.Results The first metacarpal dorsoradial artery of thumb originated from the radial artery and the initial diameter was (0.68±0.26) mm,diagonally across the extensor pollicis brevis tendon and then along the radialis part and terminated in the proximal of the first proximal phalanx of the vascular chain.There was a constant communicating branch among the proximal metacarpophalangeal joint,proximal basal of the first proximal phalanx and digital arterial dorsal branch.All the proximal of the metacarpophalangeal joint 4.3 mm to 10.2 mm and proximal basal of the first proximal phalanx 4.9 mm to 7.2 mm could be used as the rotation point of the flap.The flap of the first promixal phalanx blood supply was based on the vascular chain of neurocutaneous.There was a constant dorsal branch of the pollical artery,which was 8.6 mm to 10.3 mm far from the interphalangeal joint,could be used as the rotation point of the flap.Twenty-four cases with soft tissue defects of thumb were repaired by reverse dorsoradial flap.The flap size ranged from 2.0 cm×1.5 cm to 3.5 cm×2.8 cm.The follow-up period was 3 months to 12 months,protective sensations were restored,and skin flap two-point discrimination were 9.0 mm to 12.0 mm.The appearance of the thumbs was satisfactory.Conclusion Different rotation point of reverse dorsoradial flap can successfully repair the defect of thumb.The operation has advantages of simple,reliable blood supply,high success rate and is an ideal option for reconstruction the defect of thumb.

Reconstruction of adjacent large finger pulps with the modified sensate free proximal ulnar artery perforator flap / 中华显微外科杂志

Objective To study the surgical techniques and the clinical curative ettect of the reconstruction of adjacent large finger pulps with the modified sensate free proximal ulnar artery perforator flap.Methods From February,2013 to May,2016,20 fingers in 10 patients with adjacent large finger pulp defects crossing the DIP joint were reconstructed by the modified senate free proximal ulnar artery perforator flap.All the pulps of every patient were recovered by 1 flap in the first stage and the artificial syndactyly of two digits was divided in 7 weeks after the flap transfer in the second stage.In order to reconstruct the sensation of two pulps in each patient,firstly both of the proximal and distal ends of the cutaneous nerve in flaps were dissected and anastomosed with the most lateral and medial palmar digital nerves of two adjacent fingers respectively,which were divided into 2 groups.Secondly the cutaneous nerve in the middle part of flap was cut and the two ends were anastomosed with the other two palmar digital nerves in the second surgery.There were 8 fingers in 4 patients with the index and middle finger pulp defects,12 fingers in 6 patients with the middle and ring finger defects.The flap size was from 5.0 cm×3.5 cm to 5.5 cm×4.0 cm,and the perforator artery was anastomosed with the palmar digital artery in 6 cases and with the joint branch of digital artery in 4 cases.Results Nine flaps survived uneventfully except the venous congestion was found in 1 flap which was salvaged successfully by acupuncture bleeding.Also,no congestion or ischemia of all the 20 pulp flaps occurred right after releasing the artificial syndactyly.The time of followed-up was from 11 months to 32 months with the average of 17 months after the second surgery.The static two point discrimination of the 2 groups of the sensate pulp flap was (7.3 ± 1.2) mm and (8.6 ±2.4) mm respectively.There was no significant difference between groups (P ＞ 0.05).These 20 pulp flaps were also assessed by the Semmes-Weinstein monofilament test with the result of diminished light touch in 14 pulps and diminished protective touch in 6 pulps.The total active motion in all 20 fingers was (248.0±4.5) °.No patients suffered cold intolerance and local pain but 1 had hypersensitiveness in the pulp flap.Conclusion The modified sensate free proximal ulnar arte~ perforator flap is a practical alternative for the reconstruction of two large adjacent pulps with satisfactory functional and aesthetic outcomes.

Blood bridge venous flap to repair finger wound with proper palmar digital artery defect / 中华显微外科杂志

Objective To explore the application and clinical effect of blood bridge venous flap in finger wound with proper palmar digital artery defect. Methods From February,2007 to September,2016,11 cases of fin-ger wound with artery defect were repaired with forearm vein free flap by the way of bridging blood vessels. The time from injury to surgery was 1.5 to 6 hours(average 2.5 hours).Vascular defect length was 1.4 to 3.4 cm(average 2.3 cm). 8 cases were bridged the unilateral digital artery and 3 cases were bridged the both side. The area of skin flap was 1.5 cm × 2.0 cm to 2.2 cm × 3.5 cm and the donor site was sutured directly. Results One case appeared necrosis in marginal part and healed after dressing change. The other flaps and finger survived and the incisions healed well.All the 11 cases were followed up after operation. The follow-up time ranged from 6 to 20 months, aver-aged 10 months. The color and texture were well,the sensation of temperature, pain and tactile were recovered, and the flap had good contour. According to TAM system evaluation method: 6 cases got excellent results,4 cases were good,1 case was poor. The donor site only had a linear scar and the flexion and extension of wrist were not limited. Conclusion Flow bridging venous flap can reconstruct the finger blood and repair the wound simultaneously. To the finger with nerve or tendon defect,bridged with the cutaneous nerve or palmaris longus tendon can also get satisfactory result.