Staged Tendon Repair to Improve Range of Motion in Tamai Zone 4 Replantation: Two Case Reports.

Tamai zone 4 replantation, defined as the replantation at a level proximal to the flexor digitorum superficialis' insertion and distal to where the common digital artery branches into the proper digital artery, has poor functional results because making orthosis and rehabilitation protocols that protect the bone and the flexor and extensor tendons simultaneously difficult. Two cases of Tamai zone 4 replantation are presented: one case of an index finger replantation at the proximal phalanx and a case of ring finger replantation at the proximal interphalangeal joint. The author did not repair the flexor tendon intentionally in the primary replantation and performed two-stage flexor tendon reconstruction later. The total active motions (TAMs) at the last follow-up were 215 and 180 degrees, respectively, with the latter distal interphalangeal joint being an arthrodesis. Both cases had no extension lag in the proximal interphalangeal joint. These results were much better than those in previous reports, in which the mean TAM was 133 degrees or less. The good results appeared to be mainly due to the reasonable and clear postoperative rehabilitation protocols made by the proposed procedure. This procedure may be useful for obtaining reproducible functional results even in Tamai zone 4 replantation.

Easy and Simple Techniques to Reconstruct Natural Nailfold with the Wrap-around Flap for Finger Reconstruction.

The wrap-around flap (WAF) has become a popular approach to thumb reconstruction because the results are functionally and cosmetically excellent. By modifying to a partial toenail transfer, the WAF can also be used for finger reconstruction. However, performing cosmetically superior finger reconstruction is a significant challenge because it is difficult to reconstruct the natural nailfold by partial nail transplantation, although partial nail transplantation is required to reconstruct a narrow fingernail. One side of the reconstructed lateral nailfold tends to be a missing nail margin, and one side of the proximal nailfold angle tends to be retracted. Based on the rationale that loss of the lateral nailfold volume due to the postoperative tension of the volar flap would result in a missing nail margin, the volume of the lateral nailfold was maintained with a single thread that was passed from the nail to the volar flap. Additionally, half of the proximal nailfold from the nail plate was elevated to advance it forward. The results indicated that a cosmetically natural nailfold was achieved with the WAF approach to finger reconstruction. These easy and simple techniques enable reconstruction of a cosmetically natural nailfold using WAF for finger reconstruction.

Evaluation of sensation in volume reduction techniques of a wrap-around flap.

PURPOSE: Because the subcutaneous tissue of the great toe is thicker than that of the finger, the reconstructed finger tends to have bulging pulp when reconstructing with wrap-around flap (WAF) surgery. Secondary pulp plasty and thinning of the WAF are used to solve this cosmetic problem. This study aimed to examine the effect of these surgical techniques on sensation. METHODS: A single-center retrospective study was conducted on posttraumatic patients who underwent digit reconstruction by WAF procedure by the same surgeon from February 2014 to June 2019. WAF cases were divided into three groups: a conventional WAF Group (A), a secondary pulp plasty (B), and a thin WAF Group (C). The Semmes-Weinstein monofilament test (SWMT) and two-point discrimination were used for examination. RESULTS: All flaps survived; no cases developed partial flap necrosis. The sensation at the last follow-up in each group was good, achieving 4.31 (diminished protective sensation) or better in SWMT. The median SWMTs at the last follow-up were 4.08, 3.61, and 3.42 in Groups A, B, and C, respectively. Groups A and C showed a significant difference (p = .01). No significant differences were observed between groups A and B (p = .20) or between Groups B and C (p = .40). Static two-point discriminations (s2PDs) at the last follow-up were 14 ± 2.9 mm, 13 ± 3.7 mm, and 14 ± 1.5 mm in Groups A, B, and C, respectively. Moving two-point discriminations (m2PDs) at the last follow-up were 13 ± 4.5 mm, 12 ± 3.6 mm, and 14 ± 1.7 mm in Groups A, B, and C, respectively. Both s2PD and m2PD did not differ significantly (p = .37 and .47, respectively). CONCLUSIONS: Secondary pulp plasty and thinning of WAF for finger reconstruction did not impact sensation.

Is Antithrombotic Therapy Necessary Following Replantation of an Amputated Digit?

BACKGROUND: Antithrombotic therapy following replantation remains controversial, and the survival of replanted digits is affected by various other factors, such as the state of vascular damage and the surgeon's level of skill. The present study's aim is to obtain clinical evidence for postoperative antithrombotic therapy in replantation, with antithrombotic therapy being the only variable. METHODS: This was a single-center retrospective study of patients who underwent replantation of a completely amputated digit by the same surgeon. The subject sample included 17 patients/19 digits (group A) in whom heparin and prostaglandin E1 (PGE1) were used postoperatively during a 1-year period, 19 patients/22 digits (group B) in whom heparin was not used postoperatively but PGE1 was used for a 1-year period, and 16 patients/19 digits (group C) in whom neither heparin not PGE1 were used postoperatively for a 1-year period. RESULTS: Patient background and surgical procedure were not significantly different among groups, and only the postoperative use of heparin and/or PGE1 showed differences. Incidence of arterial occlusion, venous occlusion, or vascular spasm were not significantly different among groups (arterial occlusion: 1 digit in group A, 2 in group B, and two in group C, p = 1; venous occlusion: 1 digit in group A, 2 in group B, and three in group C, p = 0.67; vascular spasm: 1 digit in group A, 2 in group B, and one in group C, p = 1). Postoperative bleeding was significantly more common in the group using heparin (7 patients in group A, 0 in group B, and zero in group C, p < 0.001). CONCLUSIONS: These results suggest that heparin and PGE1 administration do not improve impaired blood flow following replantation. Considering the potential complications, heparin and PGE1 following replantation do not seem necessary.