[Results of 46 digital replantations. With a minimal follow-up of one year]. / Résultats de 46 replantations digitales. A un an de recul minimum.

Forty six digital replantations were analysed with a minimum follow-up of one year. The mechanism of the injury and the level of the amputation were systematically analysed to asses the objective (mobility, sensitivity, prehension), and the subjective results (pain, vasomotor dysfunction, satisfaction). The replantations were typically in the long fingers in young men (index and middle fingers at the level of the middle phalanx) by work or industrial accident (complete section or digital crushing). Seventeen replantations (37%) were secondarily amputated. Arterial thrombosis was the main cause of amputation in 94% of the cases and had occurred in 50% of the cases by the forty eight postoperative hour. An early revascularization procedure was attempted in ten cases (21%). Among these ten revascularizations procedures, we noted eight failures (80%). During the first six postoperative weeks, the complications of the replantations were skeletal displacements, tendon ruptures and joint subluxations. After six weeks, the complications were joint stiffness (26%), sensory deficits (19.5%), severe cold intolerance (13%), vasomotor dysfunction (10%) with stiffness of the proximal interphalangeal joints in 60% of the cases. We noted other complications such as neuroma of distal stump, cutaneous retraction and deformation of the fingers. Finally, only nine digital replantations (19.5%) evolved favourably with complete restoration of sensorimotor function without any complication. The best results were obtained from amputations of the middle finger with the mechanism of section being a circular saw (40%).

[Failure of upper limb macro-implantations: surgery and outcome. 11 cases]. / Echec des macroréimplantations du membre supérieur: chirurgie et devenir. A propos de 11 cas.

The failure of macro-implantation of the upper limb must not be considered as the end of a therapeutic method, but instead as a step in the functional rehabilitation of the upper limb. From a group of 24 patients that have been operated with a macro-implantation of the upper limb, we have seen 11 patients for who the reimplantation had failed. We have studied the surgical procedure of those failures, the mid-term evolution (prosthesis and operations), and a long-term evolution with the functional future of those patients. A surgical procedure with latissimus dorsi flap was necessary in six cases, in one hand to maintain a sufficient length of the stump for prosthesis and the other hand to preserve the articulation of the elbow. Nine patients on 11 were able to be "apparated" by a myoelectric prosthesis for the amputation below the elbow (seven cases), by prosthesis for the amputation above the elbow (two cases). On a long period of time (average time 51 months) only four patients had a permanent use of their prosthesis (myoelectric type). For us, the functional rehabilitation of the upper limb need two important elements: first a good quality of the stump with a sufficient length, and second an important motivation from the patient to live with his "new hand".

[Acute digital ischemia: a microsurgical emergency]. / L'ischémie digitale aiguë: une urgence microchirurgicale.

The authors are reporting their experience about the treatment of the acute finger ischemia concerning 14 patients. Twelve men and two women were concerned. The average age was 39 years old (18 to 65 years old). The acute finger ischemia was caused by emboli released by an ulnar aneurysm in nine cases and consecutive to an atrial fibrillation in five cases. The angiography was realized each time systemically in the emergency context. The medical or surgical etiological treatment was associated each time an emboli was found on the digital arteries. A microsurgical dissection of the digital collateral arteries permitted to perform a thrombectomy. The transversal arteriotomies were closed after collateral arteries were washed. The most proximal emboli were accessible to an extraction with a Fogarty's probe up to the superficial palmar arcade. An anticoagulant treatment was conducted in the early postoperative period. Considering this aggressive treatment, no secondary amputation was necessary up to today. The average follow-up was five years. This method has no indication for the chronic digital ischemias (diabetes, Buerger's disease) and for infectious or auto-immune arteriopathy.

[Secondary reconstruction of stumps above the elbow. Five cases]. / Reconstruction secondaire des moignons d'amputation au-dessus du coude. A propos de cinq cas cliniques.

The authors report a serie of five patients with five stumps above the elbow who needed a secondary reconstruction to allow or facilitate a prosthesis. They used in the first case an expansion of the latissimus dorsi flap and of the axillary and prepectoral region in order to free the stump of the humerus sutured on the thorax. In the second case, a free parascapular flap covered an unstable scar of the clavicula after a scapulothoracic amputation. In the third case, the transfer of a free flap of fibula associated with a pedicled latissimus dorsi flap had allowed the elongation of the stump of the humerus. In the two last cases, a latissimus dorsi flap pedicled in one and free in the second one had allowed to preserved the length of the humerus for prosthesis. The technical choices are eclectic and different in every case. The purpose is to obtain an efficient trophicity and a thickness that can support the prosthesis and if possible a stump long enough to improve the adaptation of the prosthesis. The five operated patients were able to be apparated, reducing in this way their daily functional difficulties.

[Qualitative retrospective study comparing 43 advanced-rotated flaps to 19 island type Venkataswami-Subramanian flaps]. / Etude qualitative rétrospective comparant 43 lambeaux d'avancement-rotation à 19 lambeaux en îlot type Venkataswami-Subramanian.

OBJECTIVE: In case of a fingertip trauma, the surgeon'aim is to give the finger a good function, that means a fingertip with good sensibility and trophicity. The purpose of this study was to follow-up three different types of flaps used for fingertip reconstruction, and to analyse their sensibility and functional results. METHOD: 62 fingertip-flaps performed in 60 patients were included in this series. Patients were mainly males (45-60), adults (42-60), middle age (mean age = 40), right-handed (55-60) and home-injured (32-60). The dominant side was injured more often (43-60), by section (27-60) or crush (25-60). Patients were reviewed by the same investigator. Various types of flaps were used: 31 Atasoy flaps, 19 neurovascular island unipedicled flaps and 12 Hueston flaps. Sensory results were evaluated using static and moving two-point discrimination tests, and pain and hot-cold discrimination. Esthetic and functional results were also evaluated. RESULTS: The tactile sensibility was good or excellent in 63% of flaps and the nail looked good in 70% of flaps. Among all flaps, the Atasoy flap obtained the best results. DISCUSSION: This study showed the good quality of Atasoy and Hueston flaps in fingertip reconstruction. Neurovascular island flaps gave poor results without taking in account the severity of initial trauma.

[Macroreimplantation of the upper limb. Results in 24 cases]. / Les macroréimplantations du membre supérieur. Résultats à propos de 24 observations.

The authors present a retrospective study of 24 cases of macroreimplantations of the upper limb operated between 1985 and 1995. The upper limb survival rate was 54%. The prognosis was better for sections distal to the middle third of the forearm. The cause of early failure was arterial thrombosis and that of later failures was muscle necrosis, responsible for infections and venous thromboses. The functional results are analysed as a function of the type of amputation. Sections outside of muscle zones or with nervous continuity have a more favourable prognosis. 33% of reimplantations obtained a good or excellent result according to Chen's criteria. Poor functional results are nevertheless associated with a number of positive points: protection sensitivity, useful elbow, psychological satisfaction of limb preservation.

[Emergency reconstruction using partial transfer of toes. Apropos of 6 cases]. / La reconstruction digitale en urgence utilisant les transferts partiels d'orteil. A propos de 6 cas.

The authors report on 6 cases for which an emergency toe partial transfer was performed for the reconstruction of a thumb or long finger digital segment. In most cases, toe pulp transfer was involved, but also partial composite pulp-bone-nail transfers. Such technique, whose indications seldom apply in an emergency, gives better results than conventional techniques (such as homo- and hetero-digital flaps or distant flaps).

[The strategy of the finger bank]. / Stratégie du doigt banque.

The authors present 40 cases of multidigital amputations with a "bank-finger" reconstruction. They use of flaps, tendons, nerves grafts .... from the injured finger. Moreover, they propose a guide in the use of heterotopic implantations, in emergency and in secondary. The indications of the digital translocation is discussed about the priority finger and the localisation of the others fingers to be reimplanted. They make mention of the rare possibility of temporary ectopic implantation.

[Reconstruction of the long fingers using toe transfers]. / La reconstruction des doigts longs par transfert d'orteils.

The authors review 29 toes transfers on 24 patients with injury of long fingers between 1985 and 1990. The series contains 16 complete toes and 13 partial toes transfers. The results, inconvenience and indications are discussed.

[Forum: reconstruction of the traumatic thumb. Pollicization in the traumatic thumb reconstruction]. / Forum: la reconstruction du pouce traumatique. Les pollicisations dans la reconstruction du pouce traumatique.

The authors present a technical review of 25 pollicisations and define the indications based on their own experience. Pollicisation remains a good solution to restore the function of the adult thumb after injury sparing functional integrity and enhancing the value of stumps.

[Forum: reconstruction of the traumatic thumb. Toe as a donor site for reconstruction of the thumb]. / Forum: la reconstruction du pouce traumatique. L'orteil: site donneur pour la reconstruction du pouce.

One method of reconstruction of the thumb consists of microsurgical transfer of a toe. After a brief anatomical and technical review, the authors describe the various possibilities of thumb reconstruction using toe transfer: transfer of the 2nd toe, transfer of the great toe, partial toe transfers. Traumatic amputations must be distinguished from congenital amputations in terms of the indications for toe transfers. The indication for toe transfer in a case of traumatic amputation may be based on the level of amputation.

[The value of pollicization in the reconstruction of thumb injuries in adults. Observations apropos of 15 cases]. / Intérêt de la pollicisation dans la reconstruction du pouce traumatique de l'adulte. Réflexions à propos de quinze cas.

Pollicisation remains a good solution to restore the function of the adult thumb after injury. This technique requires a good knowledge of plastic hand surgery to perform an emergency or secondary reconstruction, sparing the functional integrity and enhancing the value of the stumps. The authors report their own experience of 15 cases treated between 1985-1990.

[Management of digital ischemia. 5 cases]. / Conduite à tenir devant une ischémie digitale. A propos de cinq cas.

Ischaemic fingers, a rare, generally chronic disease, may sometimes be acute, requiring emergency surgical treatment. Five cases are reported: 3 acute and 2 chronic. The 3 cases of acute ischaemia occurred in the context of cardiac arrhythmias in 2 cases and an aneurysm of the ulnar artery in 1 case. Treatment consisted of 2 thrombectomies with microsurgical digital sympathectomy thrombectomies with microsurgical digital sympathectomy and resection of the aneurysm. Complete clinical and functional recovery was obtained in these three cases. The 2 cases of chronic ischaemia were due to diabetes and Buerger's disease. In both cases, medical treatment was followed by thoracic sympathectomy with secondary resection of necrotic tissue as required. In conclusion, the prognosis in the acute cases depends on the rapidity of correction of the arterial obstruction associated with digital sympathectomy. In the case of chronic ischaemia, the clinical course depends on the efficacy of medico-surgical treatment and the severity of the underlying disease.

[Hyperbaric oxygen therapy in the treatment of wounds, in plastic and reconstructive surgery]. / L'oxygénothérapie hyperbare dans le traitement des plaies, en chirurgie plastique et reconstructive.

After recalling the mechanism of action of hyperbaric oxygen (HBO) on healing processes, the authors review the principal indications for this technique in plastic and reconstructive surgery, such as crush injuries and acute post-traumatic ischemia of the limbs, skin flaps and skin grafts, when there is a risk of their not taking, and burns. They stress the importance of strict, stratified therapeutic protocols with control of the hyperoxygenation induced by HBO. In the authors' experience, transcutaneous measurements of the partial pressure of oxygen under the hyperbaric atmosphere is a very useful method with a predictive value to determine the indications for treatment with HBO and to monitor its effects.

[Review of 30 digital ring avulsions]. / Revue de trente arrachements digitaux par mécanisme de bague.

Thirty cases of digital avulsions caused by a ring have were reviewed after a period of eighteen months. The average age of the patients was 30 years, ranging from 5 to 60 years. Fourteen vascular survivals were obtained. In this series the ring finger was the most frequently affected one (21 cases). In 20 cases, the people involved were long distance lorry drivers. The operating techniques were direct micro arterial and venous anastomosis in 2 cases, and isolated arterial bypass grafts in 6 cases, combined arterial and venous bypass graft in 18 cases. No surviving finger was amputated, but 3 patients, including 2 women, asked the amputation of an unsightly stump. This series confirms the extreme seriousness of digital avulsion caused by rings and the value of a microsurgical treatment of vascular lesions by anastomosis or by arterial and venous bypass grafts from stage 2 onwards.

[Spontaneous rupture of the flexor tendon of the hand disclosing the presence of Recklinghausen's disease]. / Rupture spontanée d'un tendon fléchisseur de la main révélatrice d'une localisation de la maladie de Recklinghausen.

Seemingly spontaneous subcutaneous ruptures of the flexor tendons of the hand are not frequently encountered. The case studied is that of a young man whose deep flexor tendon of the third finger snapped during a slight effort. The histological and immunohistochemical analysis led to the conclusion that there was localization of an intra-tendinous neurofibroma, which would seem to be a so-far undescribed phenomenon. The patient presented neurofibromas elsewhere and had pigmented spots on the body, which enabled Von Recklinghausen's disease to be diagnosed.

[The value of the free external brachial flap in surgery of the hand]. / Intérêt du lambeau brachial externe libre en chirurgie de la main.

The lateral brachial flap is a septo-cutaneous flap raised from the lateral surface of the arm. It is a thin and reliable flap with a neurovascular pedicle and its donor site can be self-closing in the case of small flaps. The authors report six cases of closure of hand defects by means of this flap, including one case of emergency repair. Due to its simplicity, the lateral brachial flap now constitutes one of the alternatives for cover of hand defects and its pedicled version may be useful cover of the elbow region.