Replantation and revascularization of the digits in a community microsurgical practice.

One-hundred and twenty-seven digits in Verdan zones I and II, and 24 thumbs in 106 patients were reviewed from 1979 to 1995. Patients were all followed for a minimum of 5 months to assess early results and complications, and to determine if a short course (minimum 3 days) of dextran 40 anticoagulation adversely affected digit survival. The total survival rate was 88 percent. Digits with only a single artery and vein repaired had a significantly higher rate of failure (p > .05). Index and small fingers also showed a trend toward lower survival. Vein grafts were used in 22 percent of cases. No vascular problems were noted after 5 days. Variables not affecting survival were: presence of a joint fusion, type of fixation, level of injury, number of digits, mechanism of injury, and use of vein grafts. The average hospital stay for the group was 6.5 days (+/-SD 3.3). No complications were seen with dextran use. A total of 51 complications were seen overall and the non-union rate was 10 percent. Community-based replantation and revascularization can be performed with early results equivalent to prior published studies. Complications are to be expected and demand expeditious treatment. Functional recovery of severed digits remains the benchmark for success in these injuries, however, lost digits never work.

Fracture subluxation of proximal interphalangeal joint treated by palmar plate advancement.

A modified technique of palmar plate advancement (PPA) was used to treat certain patients, most with failed previous treatment, with fracture subluxation of the proximal interphalangeal joint. The modification of the original technique consisted of using two sutures to attach the palmar plate and tying them deep to the skin on the dorsum. This allowed consistent maintenance of reduction, and there were no infections. The results of 11 of 23 patients who were treated with this technique and followed from 2 to 9 years postoperatively are reported. The indications for PPA in this injury are discussed.

Distal ulnar head shortening for treatment of triangular fibrocartilage complex tears with ulna positive variance.

Patients with a tear of the horizontal part of the triangular fibrocartilage complex and ulna plus variance were treated by excision of the distal part of the ulnar head. Three of the seven consecutive patients also had lunotriquetral ligament injuries and had fusions of that joint. Six of the seven patients had either complete relief or marked improvement of symptoms at the distal radioulnar joint. When ulnar shortening is indicated, ulnar head shortening should be considered.

The groin flap in reparative surgery of the hand.

The historical literature of the use of axial vascular pattern flaps from the hypogastric and iliofemoral regions in reparative surgery of the hand is concisely reviewed. Thirty-six iliofemoral (groin) flaps were utilized for delayed primary resurfacing and secondary reconstruction of defects of the hand and forearm. Two flaps (6 percent) were complicated by partial necrosis. We caution against the immediate resurfacing (within 24 hours of injury) of acute crushed hand wounds by distant flaps. The immediate application of a healthy flap on a soiled or crushed wound invites complications of local tissue necrosis, infection, and subsequent loss of the flap. When distant flaps are indicated for coverage of acute hand wounds, delayed primary coverage following complete removal of all nonviable tissue is a safe and reliable regimen. It is advantageous to design the serviceable portion of the flap on the distal area of the vascular territory of the groin flap. Thoughtful yet "radical" defatting can be performed on the lateral portion of the groin flap territory. Constructed in this way, the long medial base of the groin flap allows freedom for movement at the wrist and metacarpophalangeal and interphalangeal joints, thus decreasing edema and stiffness. In the management of soft-tissue defects in the hand requiring distant flap coverage, we choose to utilize the conventional groin flap in preference to the microvascular free flap when both techniques will deliver equal results.

Anatomical basis for repair of ulnar and median nerves in the distal part of the forearm by group fascicular suture and nerve-grafting.

The topography of the intraneural fascicular groups must be understood if the treatment of acute lacerations of the major nerves in the forearm is to be successful. Most lacerations in the upper extremity occur at the wrist and in the distal half of the forearm. With microsurgical longitudinal dissections and serial sections, we studied the intraneural topography of the fascicular groups of the median and ulnar nerves utilizing forty-five fresh frozen or refrigerated specimens. We devised a new technique of light photography to demonstrate the distinct boundaries of the fascicular groups. The intraneural fascicular groups provide the anatomical basis for the recommended surgical techniques of group fascicular repair and nerve-grafting.

Forearm replantation--long-term functional results.

The replantation of amputated extremities is justified only by the ultimate good function and appearance of the replanted part. This paper is a critical review of our clinical experience with forearm replantation and revascularization in 6 patients over the past ten years. All replanted parts survived. The long-term functional results of the forearm replants are analyzed. Return of function depends on nerve regeneration. The functional outcome in the first patient was unsatisfactory due to poor motor and sensory return. Specific attention directed to careful primary neurorrhaphy in subsequent cases yielded favorable results. We believe that two factors in particular are central in achieving good functional results in forearm replantation--careful repair of the severed major peripheral nerves, and postoperative hand rehabilitation programs.

Surgical correction of thumb deformity in arthrogryposis multiplex congenita.

Four patients underwent surgical correction of five thumb deformities due to arthrogryposis. Although varying degrees of deformity were present, all exhibited adduction contracture, laxity of the ulnar collateral ligament at the metacarpophalangeal joint and absence of the abductor pollicis brevis. Techniques for release of the adduction contracture included Z-plasties or a local flap. Four thumbs had simultaneous opponensplasties performed and repair of the ulnar collateral ligament of the metacarpophalangeal joint. The patients have now been followed for an average of twenty-eight months (range 1 1/2 to 3 years). Parents and patients have been pleased with the results.

External fixator use in comminuted gunshot fractures of the proximal phalanx.

Comminuted low velocity gunshot fractures of the proximal phalanx were stabilized with an external fixator in 15 patients. This device was found to be useful. It allowed healing of the fracture in good alignment in 13 patients. And motion of the metacarpophalangeal joint was preserved.

Deep fasciitis of the biceps region.

An infection of the biceps fascia, later myositis, and spreading to the pectoralis is described in six patients. The majority were synergistic infections with an anaerobic Peptococcus, Eikenella, or Bacteroides and an aerobic Streptococcus. Five of the patients were drug abusers. Excision of the biceps and portions of the pectoralis major was necessary in four patients.

Eikenella corrodens in human bites.

Eikenella corrodens, a gram negative rod, was cultured in about one third of 24 patients with human bite wounds. The organism was sensitive to penicillin but not to methicillin. Clinically the infections in which Eikenella corrodens were found were not different from other infections. Because of the variety of possible pathogens in human bite infections, we start the patients on a broad spectrum antibiotic while awaiting the results of the culture and sensitivity. However, antibiotics alone are not sufficient treatment in HBI; 20 of 24 patients in this series required surgical drainage. Surgical treatment consists of thorough exploration, exteriorization and excision of devitalized tissues. Complications were more frequent in sutured wounds, or when surgical drainage was delayed.

Fracture-dislocation of the radiocarpal joint.

In five patients with fracture-dislocation of a radiocarpal joint, the wrist injury was severe and associated with injuries to other systems. Typically there was neurovascular impairment and closed reduction was performed as soon as possible to relieve pressure to tension on vessels and nerves. Fracture of the radial and ulnar styloid processes, fracture of the dorsal rim of the radial articular surface, and a multitude of carpal and intercarpal injuries were present in all cases. Early open reduction, internal fixation of the fractures, and repair of all torn ligaments appeared to be the treatment of choice.