Flap Related Complications Requiring Secondary Surgery in a Series of 851 Local Flaps Used for Fingertip Reconstruction.

BACKGROUND: Local flaps are widely used to cover fingertip defects. Errors in design or technical execution of the flap may lead to morbidity and additional surgical procedure. The purpose of this study was to review flap related complications requiring unplanned secondary surgery to characterize preventable issues. METHODS: 851 local flaps were used to reconstruct fingertip defects during a 9-year period. Patients requiring unplanned secondary surgery to address flap related complications were subjected to analysis. RESULTS: 31 of 851 flaps (3.6%) required unplanned secondary surgery because of flap related complications. The most reliable flap was VY advancement flap with only one (0.3%) re-operation. The reverse vascular island flap, cross finger flap, and neurovascular island flap were associated with the comparable number of complications (8.0%; 6.3%; and 3.8% respectively). Total or partial necrosis was the cause for re-operation in 6 patients (0.7%). The typical reason for secondary surgery was inadequate soft tissue cover of the tip with homodigital neurovascular island flap and flexion contracture with reverse vascular island flap. Cross finger flaps were revised because of poor graft take at the donor site, bulky flap or flap necrosis. CONCLUSIONS: Local flaps are reliable operations to cover fingertip defects. Each flap has potential pitfalls, which may be avoided if the surgeon is aware of them.

An analysis of the pull-out strength of 6 suture loop configurations in flexor tendons.

PURPOSE: New, stronger suture materials have been introduced for flexor tendon surgery. The advantage of these materials can be lost if the suture loop pulls out from the tendon. The aim of this study was to compare the ability of various locking loops to grip the tendon. METHODS: We inserted 4 different standard and 2 experimental locking loops with 200-µm nitinol wire into human cadaveric flexor digitorum profundus tendons. The standard loops were: group 1, cruciate; group 2, Pennington modified Kessler; group 3, cross-stitch; and group 4, Lim-Tsai. The experimental loops were: group 5, a composition of Pennington modified Kessler with a cross-stitch loop; and group 6, a locking Kessler type of loop with a superficial transverse component. We loaded the loops until failure. We recorded the pull-out strength and stiffness and documented failure mechanisms during the pull-out test. RESULTS: The cruciate loop had the weakest holding capacity, 20 N, which was significantly less than in groups 2 to 6. The cross-stitch loop, Lim-Tsai loop, and modified Kessler loop performed similarly (36 N, 37 N, and 39 N, respectively). The experimental loops had the highest pull-out strength (group 5, 59 N; and group 6, 60 N, both significantly greater than groups 1 to 4). The mode of failure was pull-out for all of the standard loops and 7 of the experimental loops. Of 20 experimental loops, 13 failed by suture rupture. CONCLUSIONS: The 2 experimental loop configurations demonstrated higher pull-out strength and may have advantages when used with newer and stronger suture materials. The number of the locking components in the loops and the way the tension is transmitted to the tendon fibrils explain the results. CLINICAL RELEVANCE: The loops presented in this study and that grip the tendon better may be useful with new materials that have high tensile strength.

Comparison of the holding capacity of round monofilament, round multifilament, and flat multifilament nitinol suture loops in human cadaveric flexor tendon.

Tendon repairs done with strong suture materials fail by suture pull out. To avoid pull out, suture loop needs to have a strong grip on the tendon. The aim of this study was to determine whether a single suture loop has a better grip of the tendon when multifilament or flat sutures are used compared with a conventional monofilament round suture. A cross-locking or simple grasping suture loop was placed into the distal end of a human cadaveric tendon using nitinol wire sutures in the following configurations: round monofilament (200 µm), round multifilament (4 × 100 µm), and flat multifilament (4 × 30 µm × 445 µm). The mean pull-out strength of the round multifilament (49.4 N) and flat multifilament sutures (50.7 N) were significantly higher than that of the round monofilament nitinol suture (36.5 N) when a locking loop was used. Suture grip can be improved by using a multifilament suture and a locking type of suture configuration.

Bites to the hand: are they more than we can chew?

Animal bites to the hand caused by dogs, cats and humans are common conditions that general practitioners, emergency physicians and hand surgeons encounter in their practice. These bites are prone to infection and represent great cost to the patient in terms of time, money and disability, if not treated optimally from the outset. Other than lacerations to the skin, injuries to the tendons, nerves, bone and joints are commonplace given their proximity to the skin surface in the hand. Optimal treatment of acute animal bites to the hand should include clearance of contamination by surgical debridement, prophylactic antibiotics and tetanus toxoid, as well as staged reconstruction of all damaged tissue, including the skin, once the wound is deemed clean.

Nickel-titanium wire in circumferential suture of a flexor tendon repair: a comparison to polypropylene.

PURPOSE: Nickel-titanium (NiTi) has been proposed as an alternative material for flexor tendon core suture. To our knowledge, its suitability as a circumferential suture of flexor tendon repair has not been investigated before. The purpose of this ex vivo study was to investigate the biomechanical properties of NiTi circumferential repairs and to compare them with commonly used polypropylene. METHODS: Forty porcine flexor tendons were cut and repaired by simple running or interlocking mattress technique using 100 microm NiTi wire or 6-0 polypropylene. RESULTS: The NiTi circumferential repairs showed superior stiffness, gap resistance, and load to failure when compared to polypropylene repairs with both techniques. CONCLUSIONS: Nickel-titanium wire seems to be a potential material for circumferential repair of flexor tendons.

Fingertip injuries.

Fingertip injuries are commonly seen by family and emergency physicians. Many of the cases are simple to treat and do not need specialised treatment by a hand surgeon. However, there are certain conditions where early intervention by a hand surgeon is warranted for better functional and aesthetic outcomes. Common injuries include mallet finger injury, crush injuries to the fingertip with resultant subungual haematoma, nail bed laceration, partial or complete amputation of the fingertips, pulp amputations and fractures of the distal phalanges.

Comparison of forearm and conventional Bier's blocks for manipulation and reduction of distal radius fractures.

Forearm-based Bier's block has been advocated as a useful anaesthesic technique in hand surgery. However, there is limited data comparing forearm blocks with the conventional Bier's block. We conducted a randomised controlled trial (n=30) comparing the two techniques of anaesthesia for manipulation and reduction of closed distal radius fractures in an emergency room setting. Pain scores measured using the Visual Analogue Scale during the procedure were used as the primary outcome assessment. There was no significant difference in pain scores between the forearm and conventional Bier's block (mean VAS 18.4 SD 22.10 versus 33.7 SD 29.6). No major complications were observed in either group. The forearm-based Bier block is an effective alternative to the conventional block.

Common bacterial infections of the hand.

Infections of the hand are commonly encountered in general practice. Delay in diagnosis increases the risk of tissue loss and functional impairment. Staphyloccocal infections are most common, but polymicrobial infections are often seen in immunocompromised patients. In this pictorial essay, important and common conditions are illustrated to demonstrate key points and pitfalls in diagnosis and management.

Flap reconstruction following high pressure injection injuries of the hand: a report of three cases.

High pressure injection injuries are well known to cause significant injury to the hand, with high amputation rates and poor functional outcome. Surgical treatment consists of early aggressive debridement followed by secondary closure. Flap reconstruction is a reconstruction option which can increase the chance of digit salvage, as well as give an acceptable functional and cosmetic result. We review three cases of flap reconstruction following high pressure injection injuries, and discuss their role in the treatment of these injuries.