Evaluation outcome of replanted digits using the DASH score: review of 38 patients.

The ultimate usefulness of replanted fingers is related to the adequacy of nerve, tendon and bone repair. Thirty-eight patients with successful replantation of the thumb, a single finger or after multiple digital amputations were followed up clinically. The subjective disability after finger replantation was evaluated by means of the DASH score, and the presence of cold intolerance was assessed. The subjective outcome of the achieved replantation reached an overall DASH score of 12.3. Patients after thumb replantation reached a score of 10.0, after a single finger replantation DASH 11.2 and after multiple finger amputations and replantation of at least one finger, DASH 16.1. Cold intolerance was subjectively found in 86.7% of all hands with replanted fingers without a correlation to the patients DASH scores. The patient's evaluation of their limb function after replanted digits by means of the DASH score, when combined with an objective external assessment, represents a valuable comparative tool.

A variant of Cenani-Lenz syndactyly (CLS): review of the literature and attempt of classification.

An oligodactylous variant of Cenani-Lenz syndactyly and its surgical treatment is presented. The deformity is believed to be of autosomal recessive inheritance and caused by a disordered axial and longitudinal differentiation of the upper and lower extremities. The classical form is mainly characterised by a complete syndactyly of the hands. Malformations may also affect the bones of the forearm and, to a lesser extent, the lower limbs. We analysed clinical features and compared them with those previously described. According to our research of literature and our clinical findings there seem to exist two grossly different clinical phenotypes: spoon hand type and oligodactyly type. Typical constant clinical features such as carpal, metacarpal and digital synostoses, disorganisation of carpal bones, reduction of digital rays and syndactyly of toes are found in the reported cases. Inconstant features such as radio-ulnar synostosis, brachymesomelia, metatarsal synostoses and reduction of metatarsal rays may be present. In our case, successful bilateral digital ray individualisation and tendon transfers were performed to construct a grip function of the grossly deformed hands.

[Technical refinements in planning and surgical therapy of pectus carinatum]. / Technische Neuerungen in der Planung und Therapie der Kielbrust-Deformität. Volume-rendering-CT und resorbierbare Osteosynthesematerialien.

From 1998 to 2002 ten patients underwent surgical correction of pectus carinatum using a new diagnostic preoperative three-dimensional volume rendering mode computed tomography. Particularly the deformed rib cartilages can now also be visualized, which allows exact preoperative planning of the extent of cartilage resection and localization of required sternum osteotomies. This additional information results in a focused surgical approach and hence minimizes scars. As an additional innovation, resorbable plates and screws were used for refixation of the osteotomized parts of the sternum. For postoperative thorax immobilization and hypertrophic scar circumvention, a special keel chest brace was applied in all patients for 6-8 weeks. No complications occurred in any case, and all patients were very content with the aesthetic results achieved.

[Free microvascular transplantation of parts of the great toe for thumb reconstruction]. / Die mikrochirurgische Daumenrekonstruktion mittels partieller Grosszehentransplantation.

PURPOSE/BACKGROUND: A reconstructed thumb has to fulfil the function of opposition, pinch-grip, stability, sufficient length, sufficient sensibility, and painlessness. Next to pollicisation, these requirements can only be met satisfactory by the microvascular free great toe-to-hand transplantation. The goal of a thumb reconstruction is a compromise between an optimal functional and aesthetic outcome and a minimal morbidity of the donor site. METHOD AND CLINICAL MATERIAL: Depending on the extent of the traumatic thumb defect, not only the fibular part of the ipsilateral great toe but also its adjacent soft tissue and the first web space may be integrated into the vascularized transplant. The distal phalanx is reduced in width on its tibial side to integrate the second digital nerve to the transplant. The rest of the great toe is covered with the remaining sensible tibial flap. RESULTS: From 1993 to 1998, five male patients have been operated with the described method of partial great toe transfer and an additional deepening of the first web space. All reconstructions passed without complications. All patients present with a protective sensibility and a dynamic two-point discrimination between 8 and 15 mm. The average strength of the reconstructed thumb was 79 %, the strength of pinch-grip 90 % of the healthy thumb. CONCLUSION: Thumb reconstruction after traumatic amputation distal to the metacarpophalangeal joint can in our hands optimally be managed with free microvascular anastomosed parts of the great toe and its adjacent soft tissues.

Small free vascularized iliac crest bone grafts in reconstruction of the scaphoid bone: a retrospective study in 60 cases.

Carpal instability may result in progressive degenerative arthritis of the wrist. The surgical goal of the reconstruction of scaphoid nonunion is to achieve bone union and to restore the scaphoid. Many procedures are described to treat scaphoid nonunion for different indications. This retrospective study reports on the anatomical fundamentals, the operative procedure, and the results of 60 patients (21 with recalcitrant scaphoid nonunion that lasted longer than 4 years, 26 with an avascular pole fragment, and 13 with scaphoid nonunion after previous surgery) who were treated by a small free vascularized iliac crest bone graft. All 60 patients have routinely been followed up clinically and with magnetic resonance imaging. Union was achieved in 91.7 percent by improvement of stability and the compromised vascularity of the scaphoid. The bone flap loss rate and persisting nonunion was 8.3 percent, leading to progressive arthritis and carpal collapse. Complaints concerning discomforts caused by the scar were heard from 40.1 percent of the patients, and 31.7 percent complained of discomforts caused by the bony deformity. Bone deformations on the donor site were detected radiologically in 63.3 percent of the patients. In 31.7 percent, an impairment of the lateral femoral cutaneous nerve was noted. Reconstruction of the scaphoid by means of implantation of a vascularized iliac bone graft proved efficient to treat avascular recalcitrant scaphoid nonunion and pseudarthrosis with avascular proximal pole fragments.

The lateral arm flap.

The authors contend that the conventional flap (LAF) and the ELAF should be considered among the best choices of all possible fasciocutaneous flaps for head and neck reconstruction. Easy and quick dissection under tourniquet, design variability, and potential sensory innervation make these flaps superior to other fasciocutaneous flaps. The ELAF provides the same pliable, thin fasciocutaneous tissue and a longer pedicle than the RFF. In contrast to the RFF, the donor site can be closed primarily and heals with an acceptable scar without any functional deficit. The authors therefore strongly recommend clinical application of these flaps in head and neck reconstruction.

Radial nerve palsy associated with humeral shaft fracture: evaluation with US--initial experience.

PURPOSE: To determine the feasibility of using ultrasonography (US) for evaluation of a radial nerve injury associated with humeral shaft fracture. MATERIALS AND METHODS: In a prospective study, 11 consecutive patients with sensorimotor radial deficiency after distal humeral fracture were evaluated with conventional radiography, US, electroneurography, and electromyography. Surgical repair of the fracture and nerve inspection were performed in five patients. The remaining six patients were successfully treated conservatively. The US appearance of the radial nerve was studied in 10 healthy volunteers and in the noninjured arm of the 11 patients for comparison. RESULTS: In five patients, US findings of a severely damaged radial nerve were confirmed at surgical nerve inspection. In one patient, the nerve was entrapped between fragments. One patient had a complete nerve dissection, one had a lacerated nerve from a loose compression plate, and one had a nerve riding on the edge of a bone fragment. In the fifth patient who underwent surgical inspection, the nerve was buried in the callus. In the six patients treated conservatively, US showed continuity of the nerve. CONCLUSION: US may be useful for accurate evaluation of the radial nerve in patients with nerve palsy associated with humeral shaft fracture.

A case of mirror hand deformity with a 17-year postoperative follow up. Case report.

We present a case of a boy with a congenital upper-extremity malformation, including aplasia of the radius, double ulna, aplasia of the thumb, and polydactyly with a 17-year postoperative follow-up. The whole extremity, particularly the upper arm and shoulder girdle were hypoplastic. There was restriction of movement of the elbow and a flexion contracture of the wrist. At an age of 2 years he had three hypoplastic fingers resected and pollicisation of the third accessory finger. The thenar was reconstructed by interosseous muscle transfers and the flexion contracture corrected by a flexor tendon transfer. Preoperative electromyographic studies showed that he had two ulnar nerves with cross-innervation of the median nerve. Further improvements (including tendon transfer of the flexor carpi radialis) were made 16 years after the primary operation. At the age of 18 years the patient has satisfactory function of his left hand.

Transpositional replantation of digits. Case reports.

Heterotopic or transpositional replantation of digits is technically feasible with results similar to those of conventional replantation procedures. Occasionally in multiple digital amputations not all the digits may be replanted in their correct place as a result of complex injuries proximal to the amputation zone or severe damage to important fingers. In these circumstances the amputated digits that are in the best condition as regards undamaged tissue are used for replantation. The primary priority is an optimal functional outcome and the secondary priority the cosmetic outcome. Amputated long digits will always be used to substitute for a non-replantable thumb rather than to replace a long finger. We present 13 cases of successful transpositional digit or joint replantations in traumatic amputations of more than one digit.

[Iatrogenic lesion of the accessory nerve in cervical lymph node biopsy]. / Iatrogene Läsion des Nervus accessorius bei der cervicalen Lymphknotenbiopsie.

The majority of lesions of the spinal accessory nerve occur as an iatrogenic injury after lymph node biopsy in the posterior cervical triangle (trigonum colli laterale). In most cases the accessory nerve palsy is not recognised immediately after the injury. Therefore surgical repair is often performed too late to regain sufficient function of the paralytic trapezius muscle. Later than 6 months after the injury, reconstruction seems to be hopeless. However, "timely" reconstructions often have poor results. Exact knowledge of anatomy, postoperative check of the trapezius muscle and, if an accessory nerve injury has occurred, early reconstructive procedures (neurolysis, reconstruction of nerve continuity) may on the one hand prevent iatrogenic lesions of the nerve and on the other hand improve the reconstructive result. A series of 6 patients with an injury of the spinal accessory nerve after lymph node biopsy is reported. In 2 cases primary coaptation, in 3 cases interpositional nerve grafting and in 1 case neurotization was performed. Clinical recovery was achieved in 3 of the 6 cases.

Free flap reconstruction of the foot.

Free flap reconstruction of the foot has been widely performed in the last 20 years, but choice of a free transferred substitute for the soft tissue of the particular defect remains controversial. The authors present a series of 77 free flaps to the foot performed in 68 patients during October 1976 and September 1997. Long-term follow-up ranged from 12 months to 18 years (median, 44.4 months). Seventy-three flaps were transferred successfully (95%). The indications for a specific flap depended on the localization and extension of the foot defect. In weight-bearing areas the authors favored the use of a muscle flap covered with a split-thickness skin graft; the latissimus dorsi muscle was used primarily. This study shows a lower ulceration rate in muscle flaps covered with split-thickness skin grafts than in fasciocutaneous flaps in weight-bearing areas (27% vs. 60%). In nonweight-bearing areas, fasciocutaneous flaps were the best choice. In this series, the lateral arm flap was applied most often. The authors recommend free fascial flaps (serratus fascial flap or radial forearm fascial flap) covered by split- or full-thickness skin grafts for coverage of the malleolar region as well as coverage of exposed tendons of nonweight-bearing regions. Proper tailoring of the flap and postoperative care are very important to maintain a result without ulceration, as is avoiding having the suture line cross a weight-bearing area. Tactile sensation does not seem to be essential.

One-stage reconstruction of defects in the hypopharyngeal region with free flaps.

Despite the almost universal poor prognosis, the reconstruction of combined cervical skin and hypopharyngeal defects after extensive resection of tumour should maintain optimal quality of life. From 1992 to 1996 we treated 10 patients with combined skin and hypopharyngeal defects with five fasciocutaneous free flaps, three myocutaneous latissimus dorsi free flaps, one myocutaneous VRAM (vertical rectus abdominis muscle) free flap and one free radial forearm flap. None of our flaps failed. The complications that required revision (one arterial bleeding, one arterial thrombosis, two fistula formations, one superficial wound dehiscence, one haematoma) occurred mainly in those patients having secondary reconstructions. After primary extensive oncological resection of these tumours reconstruction should be done in one stage. The primary reconstruction should provide sufficient pharyngeal lining, a satisfactory covering of cervical soft-tissue, and adequate functional rehabilitation. We have reviewed our experience and conclusions about the advantages, disadvantages, and current indications for different free flaps in the reconstruction of combined hypopharyngeal, cervico-oesophageal, and cervical skin defects.

The lateral arm flap: review of 72 cases and technical refinements.

Between 1985 and 1995, 72 free lateral arm flaps (LAFs) were transferred in 68 patients. The main purpose of the reported study was to demonstrate a comprehensive follow-up and essential technical refinements: extension of the flap, shaping of a custom-designed flap, the "emergency" free flap, and sensible nerve coaptation. The effect of nerve coaptation vs. no nerve coaptation was investigated by measuring objective and subjective grades of sensibility at the recipient site. The outcomes of sensory flap reinnervation showed no significant advantages of one over the other technique. The second intention was to clarify discrepant anatomic descriptions concerning the nomenclature of the supplying blood vessels. Current anatomic investigations revealed that the main blood supply derives from the posterior radial collateral artery (anastomosing with the interosseous recurrent artery); blood supply via the anterior radial recurrent artery (anastomosing with the radial recurrent artery) has a secondary importance.

Free innervated latissimus dorsi muscle flap for reconstruction of full-thickness abdominal wall defects.

Full-thickness abdominal wall defects continue to be a challenge for the reconstructive surgeon. The most frequently used reconstructive techniques are transfer of a pedicled, local abdominal flap or a distant flap from the thigh region. The purpose of this paper is to present a new approach to full-thickness abdominal wall reconstruction using an innervated free latissimus dorsi musculocutaneous flap. Four patients with large full-thickness abdominal wall defects underwent reconstruction with a free innervated latissimus dorsi muscle flap. In two patients, staged abdominal wall reconstruction was performed. Primary closure was first obtained with a skin graft. During the subsequent definitive reconstruction (with an innervated free latissimus dorsi muscle flap), this skin graft was not excised. Instead, deep dermabrasion of the skin graft was performed, leaving a residual dermal layer. This layer was then covered with a free innervated latissimus dorsi muscle flap. In these two cases, there was no need for the use of a prosthetic mesh. A single stage reconstruction was performed in the other two cases. After abdominal wall sarcoma resection, Prolene mesh was placed and subsequently covered with a free innervated latissimus dorsi muscle flap. There were no free flap failures. The average time of surgery was 4 hours, 50 minutes. The average hospital stay was 14 days. No significant complications occurred except for one donor site seroma. No hernias have occurred postoperatively. The mean follow-up was 21 months. Postoperatively, electromyographic testing was performed regularly in all patients to document reinnervation of the latissimus dorsi muscle flap. With reinnervation and intensive muscle training, the transplanted latissimus dorsi muscle offers enough contractile capacity and strength to adequately replace the function of the missing abdominal wall muscles. In complicated staged reconstructions, dermabrasion of the temporary skin graft allows for the use of a residual dermal layer as a fascia-like substitute to aid in the restoration of structural integrity. The combination of the dermal layer with an innervated free latissimus dorsi muscle provides a strong, vascularized fascial repair as well as an overlying vascularized soft-tissue coverage. In conclusion, adequate functional dynamic reconstruction of full-thickness abdominal wall defects is possible using an innervated free latissimus dorsi muscle flap. The reinnervated latissimus dorsi muscle is suitable for reconstitution of the missing functional and anatomic components of complex abdominal wall defects.

Reconstruction of a complex hypopharyngeal cervical defect with a single latissimus dorsi free flap.

Large, complex hypopharyngeal defects that include mucosa and cervical skin, and that result from debridement of orocutaneous fistulas secondary to failed repairs of laryngectomy defects, are difficult to treat, especially when previous irradiation has damaged adjacent tissues. We have found that such defects can be repaired sufficiently in one stage using a latissimus dorsi musculocutaneous free flap. The wound is debrided until only healthy tissue remains. The skin paddle of the free flap is then used to reconstruct the hypopharyngeal mucosal defect, whereas the muscular portion serves to cover any cervical tissue that remains exposed. A split-thickness skin graft is then placed over the muscle to complete the repair. The resulting reconstruction is free of excess bulk, has no radiation damage, is well vascularized, and has an acceptable appearance.

[Dynamic and functional abdominal wall stabilization, reconstruction of extensive abdominal wall defects]. / Dynamische und funktionelle Bauchdeckenstabilisierung, Wiederherstellung von ausgedehnten Bauchwanddefekten.

The aim of any abdominal wall reconstruction is maximal functional stability and adequate soft tissue coverage. The anatomy, elevation and clinical application of the myofascial tensor fasciae latae transposition flap and of the microvascular musculocutaneous latissimus dorsi free flap are presented. Repairing extensive fascial defects and recurrent hernias with the tensor fasciae latae transposition flap provides strong, dynamic, and functional reconstruction of fascial continuity to prevent a further recurrence. Adequate functional and aesthetic repair of a full-thickness abdominal wall defect can be optimally managed by the innervated microsurgical latissimus dorsi free flap.