Salvage of Devascularized and Amputated Upper Extremity Digits with Temporary Ectopic Replantation: Our Clinical Series.

BACKGROUND: One of the reasons for unsuccessful replantation is recipient site problems. In cases where proximal stump status cannot be predicted exactly, reamputation may be required depending on the result of infection and tissue necrosis. The ectopic banking method has been defined for this type of injury. In this study, we presented the amputated or devascularized upper extremity digit ectopic banking application results in our clinical practice. METHODS: Nineteen digits (17 patients) banking ectopically were included in the study. All digits ectopically banked in the forearm volar of the non-injured upper limb. Transfers were made after waiting for the appropriate time. Ectopic banking periods, postoperative complications, and other descriptive data were recorded. In the postoperative 6th month, the range of motion (ROM) values of the digits were measured and compared with the ROM values of the same digit on the non-injured extremity.Also, in the postoperative 6th month, a questionnaire with a score of 1-5 was conducted for cosmetic results. RESULTS: The mean follow-up time was 13.6 months. The mean patient age was 39.5 years. The ectopic banking success rate is 94.1% (16/17). The orthotopic/heterotopic transfer success rate is 100% (17/17). Ectopic banking time is, on average, 19.2 days (min 5-max 55). Average cosmetic scale is 3.54. CONCLUSIONS: We think that the results of our study will shed light on surgeons who make ectopic banking applications.

The Roles of Injury Type, Injury Level and Amputation Type in the Need for Revision Surgery after Replantation: Retrospective Clinical Outcome with 296 Finger Replantation.

BACKGROUND: With the development of microsurgical techniques, the replantation survival rate has increased, but in some cases, revision surgery is required. Although there are many studies on replantation survival rate, studies on revision surgery are limited. In this study, we evaluated replantation patients requiring revision surgery in terms of amputation level, injury type, and amputation type (single-multiple). METHODS: This is a retrospective study.Two hundred fifty-six patients (296 fingers) who were operated on for total finger amputation in our hospital between 2013 and 2018 were included in the study. In the postoperative period, revision surgery was required for 24 fingers due to vascular insufficiency. Patients were evaluated in terms of amputation level, injury type, and amputation type. RESULTS: Two hundred sixty-four fingers were saved after primary surgery. Eight fingers failed before they could undergo revision surgery. Revision surgery was performed for 24 fingers. After revision surgery, 19 fingers were saved, and five fingers were failed. There was no significant effect of gender and age in terms of revision (p > 0.05).There was no statistically significant difference in injury level and injury type, but there was a statistically significant difference in terms of amputation type (p < 0.05). CONCLUSION: Despite advanced microsurgery and experience, vascular insufficiency can be observed after replantation. Surgical re-exploration is necessary for salvage.

Low-molecular-weight heparin-associated multiple digital necrosis in a patient as a result of heparin-induced thrombocytopenia syndrome.

Heparin-induced thrombocytopenia syndrome (HITS) is a rare complication of low-molecular-weight heparin (LMWH). It is an autoimmune-mediated side effect of LMWH which is caused by platelet-activating antibodies that recognize platelet factor-4/ heparin complexes. Although HITS often leads to thrombosis in large veins and arteries, it can be presented as microvascular thrombosis. In this article, we report a case of HITS complicated with multiple digital necrosis after administration of LMWH.

Trephine biopsy versus conventional open surgical technique for bone graft harvesting from the olecranon: A retrospective comparison of perioperative outcomes.

OBJECTIVE: This study aimed to compare the perioperative clinical outcomes of trephine biopsy (TB) with the conventional open surgical method (COSM) in bone graft harvesting from the olecranon. METHODS: In this retrospective study, 130 patients who underwent bone graft harvesting from the olecranon using either TB or COSM were included. Patients were then divided into two groups: the COSM group (48 patients; 36 men and 12 women; mean age=32 years; age range=18-52) and the TB group (82 patients; 61 men and 21 women; mean age=34 years; age range=20-62). The mean follow-up was 30 months (range=17-57) in the COSM group and 26.8 months (range=6-48 months) in the TB groups. The two groups were compared in terms of pain intensity, operating time, complication rate, elbow range of motion, and the scar sensitivity of the graft donor site. Pain intensity was measured using the visual analogous scale (VAS) on postoperative days 1 and 15. Other outcome measures were evaluated at the final follow-up. RESULTS: In the TB group, the mean VAS score was 4±1.62 on postoperative day 1 and 1.6±0.76 on postoperative day 15. In the COSM group, the mean VAS score was 7.2±1.38 on postoperative day 1 and 3.1±1.34 on postoperative day 15. The early VAS scores were significantly higher in the COSM group than in the TB group (p<0.05). The mean operating time was 7±1.99 minutes in the TB group and 20±4.51 minutes in the COSM group. Hematoma occurred in one patient from each group, with an incidence of 2.1% in the COSM group and 1.2% in the TB group. There was no significant difference between the two groups regarding elbow range of motion at final follow-up p>0.05). No patient in the TB group showed sensitivity of the scar region, while scar sensitivity occurred in 3 of 48 patients (0.6%) in the COSM group. CONCLUSION: Compared with COSM, TB seems to be a safe technique with similar complication rates. TB can provide shorter operating time, less postoperative pain, and smaller and less sensitive scar compared with COSM. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Perforator artery repair in revascularization of extremity degloving injuries.

INTRODUCTION: This article aims to expand the microsurgical treatment options for extremity degloving injuries with perforator artery repairs of the specific degloved angiosomes in upper and lower extremity. METHODS: Fourteen perforator arteries were repaired in seven patients. Four of them had circumferential degloving and 3 of them have non circumferential degloving injury. All had repair of the perforator arteries of the specific degloved segments. Four patients had additional vein repairs but none of the patients had AV shunts. RESULTS: All perforators provided adequate arterial supply to their specific angiosomes with some necrotic areas in neighboring angiosomes. CONCLUSIONS: Perforator artery repair within the degloved tissues provides a direct arterial supply successfully even if one could not find an intact venous plexus.

Intramedullary Venous Drainage System for Distal Fingertip Replantations.

The number of venous anastomoses performed during fingertip replantation is one of the most important factors affecting the success of replantation. However, because vessel diameters decrease in the zone 1 level, vessel anastomoses, especially vein anastomoses, are technically difficult and, thus, cannot be performed in most cases. Alternative venous drainage methods are crucial when any reliable vein repair is not possible. In the literature, so many artery-only replantation techniques have been defined, such as arteriovenous anastomoses, forming an arteriovenous or venocutaneous fistula, manual milking and massage, puncturing, and external bleeding via a fishmouth incision and using a medical leech. It has been shown that, in distal fingertip replantations, the medullary cavity may also be a good way for venous return. In this study, we introduce an alternative intramedullary venous drainage system we developed to facilitate venous drainage in artery-only fingertip replantations. The results of 24 fingertip replantations distal to the nail fold by using this system are presented with a literature review.

Dorsal approach for vascular repairs in distal finger replantations.

INTRODUCTION: Distal finger replantations are technically difficult operations due to small vessel sizes and narrow field of vision. The results of 25 distal finger replantations performed by dorsal approach are presented. The technical benefits and details of this technique is discussed with a literature review. PATIENTS AND METHODS: Twenty-five distal finger replantations were performed by dorsal approach. In dorsal approach volar skin was repaired first and arterial and venous repairs were performed from dorsal side before bone fixation and nailbed repair. Twenty-one cases were Tamai zone I amputations 4 cases were Tamai zone II amputations. 3 amputations were in children and the other patients were adults. Nine amputations were transverse type and the others were oblique amputations. RESULTS: Twenty-three fingers survived and 2 fingers were lost despite revision surgeries (92% success rate). Dorsal approach provided about 2 times wider exposures compared to the volar approach. Fourteen patients had external bleeding to prevent congestion. Mean duration of external bleeding was 6.8 days (range, 6 - 8 days). Mean hospitalization period was 7.7 days (range, 6 - 10 days). The mean follow up period was 13 months (range, 6 - 28 months). Six patients had nail deformity. Four patients had pulp atrophy. Three patients had restriction of range of motion in distal interphalangeal joint. CONCLUSION: Dorsal approach provides a better exposure of vessel repair sites without tension and helps in technical difficulties of distal finger replantation. All types of distal finger amputations are amenable to dorsal approach for vascular repairs and oblique amputations are ideal ones. © 2016 Wiley Periodicals, Inc. Microsurgery, 2016. © 2015 Wiley Periodicals, Inc. Microsurgery 36:628-636, 2016.

Rehabilitation after successful finger replantation.

OBJECTIVE: The aim of the present study was to assess results of rehabilitation of patients after finger replantation. METHODS: The study examined 160 fingers amputated and replanted at various levels between 2000 and 2013 at the clinic. Mean patient age was 29.4 years. Mean follow-up time was 23 months. Rehabilitation of fingers began between postoperative fourth and eighth week and continued until the 24th week. Range of motion of affected hand, return to daily activities, aesthetic appearance, and patient satisfaction were assessed according to Tamai criteria. RESULTS: Functional results according to Tamai criteria were perfect in 36 patients, good in 54 patients, average in 27 patients, and poor in 18 patients. CONCLUSION: Post-operative rehabilitation of replanted fingers should begin as soon as possible. During the rehabilitation period, physiotherapist, surgeon, and patient must work in close cooperation. Functional results of patients who adjust to the rehabilitation program, home practice, and splint usage are better.

Flexor Tenosynovitis Due to Tuberculosis in Hand and Wrist: Is Tenosynovectomy Imperative?

The treatment of flexor tenosynovitis in the hand and wrist due to tuberculosis is controversial. Although some authors recommend the antituberculous chemotherapy, the others recommend the surgical treatment. In this article, 12 patients with synovial tuberculosis of the flexor aspect of the hand and the wrist were evaluated with respect to diagnosis and treatment modalities. None of the patients had a history of tuberculosis, concomitant disease, immunosuppressive drug use, drug abuse, and human immunodefficiency virus positivity. A chest x-ray and family screening were performed in all of the cases, none had evidence of tuberculosis in the lung. The biopsy, histopathological examination, acid-fast bacillus staining, and BACTEC tuberculosis culture were performed. Antituberculous chemotherapy was initiated in patients diagnosed with tuberculosis by either histological or microbiological examinations. The patients did not undergo any further surgery after biopsy procedures. The lesions regressed totally in all patients after 3 months of treatment. Carpal tunnel syndrome symptoms and signs recruited at five months of treatment. In patients with flexor tuberculosis tenosynovitis, it is possible to achieve good results by applying only medical therapy after a biopsy, and without the need for further surgery.

[Arthroscopic dorsal ligamento capsulodesis results in Geissler grade 2 and 3 scapholunate interosseous ligament injuries]. / Geissler 2. ve 3. derece skafolunat interossöz bag hasarlanmalarinda artroskopik dorsal kapsüloligamentöz onarim sonuçlari.

OBJECTIVES: This study aims to retrospectively evaluate results of arthroscopic dorsal ligamento capsulodesis in Geissler grade 2 and 3 scapholunate ligament injuries. PATIENTS AND METHODS: Thirty-two patients (20 males, 12 females; mean age 30.1 years; range 21 to 42 years) who were performed arthroscopic dorsal ligamento capsulodesis due to Geissler grade 2 and 3 scapholunate ligament injuries between February 2011 and July 2013 were included in this study. Mean duration between the onset of complaints and surgery was 13.7 (range 6-20) months. Joint ranges of motion were compared to wrist motions on the healthy side. Patients were evaluated postoperatively by Mayo Wrist Scoring Test. Pain was assessed by visual analog scale (VAS). RESULTS: Mean follow-up period was 15.12 (range 6-24) months. According to Mayo Wrist Scoring Test, results were excellent in 20 patients, and good in 12 patients. Compared to the healthy extremity, preoperative mean flexion gap range was 2.18° (range 0°-5°), and mean extension gap range was 4.37° (range 0°-15°). Compared to the healthy extremity, postoperative mean flexion gap range was 1.71° (range 0°-5°), and extension gap range was 1.09° (range 0°-10°). Compared to the healthy hand, preoperative and postoperative mean grip strengths were 86% and 94%, respectively. While preoperative VAS score was 6.59 (range 4-9), postoperative VAS score was 1.21 (range 0-6). CONCLUSION: According to the study results, arthroscopic dorsal ligamento capsulodesis is an effective method for the elimination of pain and range of motion limitation, and recovery of grip strength.

[Results of arthroscopic repair of triangular fibrocartilage complex peripheral tears (Palmer type 1B)]. / Triangular fibrokartilaj kompleks periferik (Palmer tip 1B) yirtiklarinda artroskopik tamir sonuçlari.

BACKGROUND: Triangular fibrocartilage complex (TFCC) injury is the major cause of wrist pain on the ulnar side. In this study, treatment outcomes of arthroscopically repaired peripheral TFCC tears (Palmer type 1B) were evaluated retrospectively. METHODS: Thirty-eight patients (30 males, 8 females; mean age 27.6; range 19 to 42 years) with TFCC tears (Palmer type 1B) who were treated arthroscopically between February 2007-July 2012 were evaluated retrospectively. The data were collected by Mayo wrist evaluation form and by preoperative and postoperative visual analogue scale (VAS). RESULTS: The results of the data collected by the Mayo wrist evaluation forms were perfect in 30 patients and good in 8 patients. Preoperative VAS was 6.53 (range: 4.5-8.2) and postoperative VAS was 1.48 (range: 0.3-3.1). DISCUSSION: With the arthroscopic technique, TFCC tears can be repaired with minimal harm and better visualization, and evaluation of all the structures of the wrist can be done. Outside-to-inside suturing technique, which is performed through the portal opened 1 cm inferior to the 6R portal, is the least traumatic technique and does not carry the risk of injury to the superficial branch of the ulnar nerve. With this technique, the complaints of preoperative pain can be eliminated significantly.

Advantages of using volar vein repair in finger replantations.

Providing adequate venous outflow is essential in finger replantation surgeries. For a successful result, the quality and quantity of venous repairs should be adequate to drain arterial inflow. The digital dorsal venous plexus is a reliable source of material for venous repairs. Classically, volar digital veins have been used only when no other alternative was available. However, repairing volar veins to augment venous outflow has a number of technical advantages and gives a greater chance of survival. Increasing the repaired vein:artery ratio also increases the success of replantation. The volar skin, covering the volar vein, is less likely to be avulsed during injury and is also less likely to turn necrotic, than dorsal skin, after the replantation surgery. Primary repair of dorsal veins can be difficult due to tightness ensuing from arthrodesis of the underlying joint in flexion. In multiple finger replantations, repairing the volar veins after arterial repair and continuing to do so for each finger in the same way without changing the position of the hand and surgeon save time. In amputations with tissue loss, the size discrepancy is less for volar veins than for dorsal veins. We present the results of 366 finger replantations after volar vein repairs.

An alternative classification of occupational hand injuries based on etiologic mechanisms: the ECOHI classification.

BACKGROUND: The aim of this study was to construct an alternative classification system for occupational hand injuries based on etiologic mechanisms and to analyze the injury patterns resulting from various mechanisms. METHODS: A retrospective analysis of patients operated between January 2005 and December 2007 in two hand surgery units staffed by a team of hand surgeons was made. The patient files were retrospectively examined, and mechanisms causing the injuries were analyzed. Similar mechanisms were classified in the same groups, and the mechanism of injury was matched with type of injury often caused by this mechanism. In the classification of injuries, the tissues that were injured were taken as a basis for classification. 4120 upper extremity injuries were seen in the study hospitals, and 2188 (53.1%) of them were occupational injuries. There were 2063 males (94.3%) and 125 females (6.7%). The mean age was 28.2 (range: 15-71) years. RESULTS: Examination of the agents causing injury yielded 62 agents. Further examination of these agents showed that the mechanism by which they caused injury was similar in some agents, and these agents were placed in the same groups, which constituted the Etiologic Classification of Hand Injuries (ECOHI) classification. These groups of mechanisms were: cutting-penetrating, cutting-crushing, crushing-penetrating, crushing-compressing, crushing-burning, stinging, avulsing, electrical current, and chemical injuries and miscellaneous burns. The two most common mechanisms were crushing-compressing and cutting-crushing types, constituting 744 (34.0%) and 514 (23.5%) of injuries, respectively. CONCLUSION: We believe that ECOHI is important to form a common language for the classification of etiologic factors.

Ligament reconstruction using the Fulkerson-Watson method to treat chronic isolated distal radioulnar joint instability: short-term results.

OBJECTIVE: Isolated distal radioulnar instability may remain unrecognized during the acute period of trauma as it is difficult to diagnose, and does not become obvious until later when it has become chronic. We present early results in patients who underwent stabilization with extraarticular ligament reconstruction (Fulkerson-Watson reconstruction). METHODS: Four women and 1 man underwent surgery for chronic isolated distal radioulnar joint instability demonstrated in X-rays and magnetic resonance images. Arthroscopy revealed avulsion of the triangular fibrocartilage complex from the point of insertion in 3 patients, and peripheral tears in 2 patients. The peripheral tears were debrided arthroscopically. All patients had an adequate sigmoid notch and therefore underwent ligament reconstruction using the Fulkerson-Watson method. Postoperative evaluations were done with MRI. RESULTS: Mean follow-up was 15.5 months (range 6-26 months). Stability was achieved in all patients. The mean Quick-DASH symptom score decreased from 18.63 (15.90-22.72) to 6.81 (2.27-9.09) after surgery. A mean visual analogue score to assess pain decreased from 7.32 (6.30-8.40) to 1.88 (1.50-2.30) after surgery. Preoperative and postoperative measurements were 26° (passive 44°) and 47° (passive 65°) for active supination, 18° (passive 45°) and 49°(passive 68°) for active pronation, 20° (passive 43°) and 42° (passive 60°) for active wrist flexion,and 38° (passive 52°) and 45° (passive 59°) for active wrist extension. CONCLUSION: Surgical revision of distal radioulnar joint instability using Fulkerson-Watson reconstruction is easier than intraarticular techniques and satisfactorily re-establishes stability, provided that the sigmoid notch is adequate.

Evaluation of patients undergoing removal of glass fragments from injured hands: a retrospective study.

The hand is the body part most frequently injured by broken glass. Glass fragments lodged in soft tissues may result in numerous complications, such as infection, delayed healing, persistent pain, and late injury as a result of migration. Between 2005 and 2010, we removed 46 glass particles from the hands of 26 patients. The injuries were caused by the following: car windows broken during motor vehicle accidents in 11 patients (42%); fragments from broken glasses, dishes, or bottles in 9 (35%); the hand passing through glass in 5 (19%); and a fragment from a broken fluorescent lamp in 1 (4%) patient. Despite the efficacy of plain radiographs in detecting glass fragments, these are sometimes not obtained. Given the relatively low cost, accessibility, and efficacy of radiographs, and the adverse consequences of retained foreign bodies, the objections to obtaining radiographs should be few in diagnosing glass-related injuries of the hand.

Crossover replantation as a salvage procedure following bilateral transhumeral upper limb amputation: a case report.

Cross-over replantation is a salvage option for cases with bilateral extremity amputations where the wound conditions do not enable an orthotopic replantation. Here, we present a 24-year-old patient who applied to our center with bilateral transhumeral amputations. Due to the wound conditions, a cross-over replantation was performed. 24 months after the initial operation, the patient exhibits good protective sensation at the distal levels and function to some degree, whereas the active range of motion is not as promising as previously expected. In this article, we present this case together with its immediate and long-term outcomes and the consequences of the cross-over replantation.

Olecranon bone graft: revisited.

Autogenous bone grafts are frequently in use in the field of reconstructive upper extremity surgery. Cancellous bone grafts are applied to traumatic osseous defects, nonunions, defects after the resection of benign bone tumors, arthrodesis, and osteotomy procedures. Cancellous bone grafts do not only have benefits such as rapid revascularization, but they also have mechanical advantages. Despite the proximity to the primary surgical field, cancellous olecranon grafts have not gained the popularity they deserve in the field of reconstructive hand surgery. In this study, the properties, advantages, and technical details of harvesting cancellous olecranon grafts are discussed.

[Evaluation of long-term results in mutilating hand injuries]. / Agir hasarli el yaralanmalarinda tedavi sonuçlarinin degerlendirmesi.

BACKGROUND: The aim of this study is to report the surgical procedures performed in patients with mutilating hand injuries and evaluate the outcomes of treatment. METHODS: A retrospective evaluation of 130 patients operated between 2000 and 2005 for mutilating hand injuries is presented. Twenty-five of the patients could be followed until the end of rehabilitation. The grip power and ranges of motion in affected joints were determined. Minnesota manipulation speed test and Purdue Pegboard Test were used for evaluation of functional results. RESULTS: Mean range of motion was 64.7% (minimum: 17%, maximum 96%) of the uninjured extremity. Mean grip strength was 52% (15-80%) of the uninjured extremity. Lateral pinch was 66% (25%-81%) of the contralateral hand and the results were 53% (12%-68%) for key pinch and 52% for tripod pinch. Minnesota manipulation speed test showed satisfactory results in 92% of the patients in hand skill, strength and coordination. A decrease in fine motor skills was observed in Purdue Pegboard Test. CONCLUSION: The main treatment purposes in mutilating hand injuries are obtaining an extremity that is useful in daily activities and if possible that facilitates a return to work.

Sensory outcome of fingertip replantations without nerve repair.

The sensory recovery outcomes of fingertip replantations without nerve repair were retrospectively studied. Between 2000 and 2006, 112 fingertip replantations with only arterial repair were carried out in 98 patients. About 76 of the replants survived totally, with a success rate of 67.8%. Evaluation of sensory recovery was possible in 31 patients (38 replantations). Sensory evaluation was made with Semmes-Weinstein, static and dynamic two-point discrimination, and vibration sense tests. Fingertip atrophy, nail deformities, and return to work were also evaluated. According to the Semmes-Weinstein test, 29.0% (11/38) of the fingers had normal sense, 60.5% (23/38) had diminished light touch, 7.9% (3/38) had diminished protective sensation, and 2.6% (1/38) had loss of protective sensation. Mean static and dynamic two-point discriminations were 7.2 mm (3-11 mm), and 4.60 mm (3-6 mm), respectively. Vibratory testing revealed increased vibration in 42.1% of the fingers, decreased vibration in 36.8%, and equal vibration when compared with the non-injured fingers in 21.1%. Atrophy was present in 14 (36.8%) fingers and negatively affected the results. Nail deformities, cold intolerance, return to work, and the effect of sensory education were investigated. Comparison of crush and clean cut injuries did not yield any significant difference in any of the parameters. Patients who received sensory education had significantly better results in sensory testing. The results were classified as excellent, good, and poor based on results of two-point discrimination tests. The outcome was excellent in 18 fingers and good in 20 fingers. Overall, satisfactory sensory recovery was achieved in fingertip replantations without nerve repair.