Efficacy of novel, three jaw adventitia holding microclamps compared to Acland microclamps in patients undergoing end-to-end microvascular anastomosis: A randomized control trial.

OBJECTIVE: To evaluate the efficacy of three jaw adventitia holding (TADH) microclamps in end-to-end microvascular anastomosis. BACKGROUND: Acland clamps, though highly efficacious, require a steep learning curve and are associated with complications such as back walling and incomplete bites. METHODS: A single center, parallel group, 30-patient randomized clinical trial was conducted with a 1:1 allocation ratio in Acland and TADH microclamp groups. Primary outcome was time taken for microvascular anastomosis in terms of arterial and venous clamping and suturing time. Secondary outcomes included ease of use, need for clamp flipping and adventitia trimming, and need for assistance and flap survival. RESULTS: TADH microclamps were found to be beneficial when compared to Acland microclamps in end-to-end microvascular anastomosis, in terms of artery clamp time (19.07 ± 3.751 min, 95% CI 10.058-17.942, p < 0.001), artery suture time (15.87 ± 3.357 min, 95% CI 10.660-17.206, p < 0.001), vein clamp time (21.50 ± 3.849 min, 95% CI 12.131-19.469, p < 0.001), and vein suture time (16.58 ± 3.147 min, 95% CI 13.232-20.368, p < 0.001). The TADH microclamps did not require flipping to enable suturing of the posterior walls of the vessel. Statistically significant difference was found in surgeon-reported ease of use with TADH microclamps (Chi-square value 9.867, p < 0.001). Statistically significant difference was found in relation to the need for assistance with TADH microclamps (Chi-square value 19.286, p < 0.001). CONCLUSION: This study found TADH microclamps to be faster, easier to use, and clinically efficacious in reducing the anastomosis time compared to those of the Acland clamps.

A Prospective Trial Comparing Outcomes at 11 Months of a Standard Cross-Finger Flap versus a Laterally Based Thenar Flap for Fingertip Reconstruction.

Background: The standard cross-finger flap (CFF) and laterally based thenar flap (LTF) are the time-tested modalities of fingertip reconstruction. We were unable to find any studies that have compared these two flaps for fingertip reconstruction. The aim of this study is compare the outcomes of these two flaps at 11 months after fingertip reconstruction. Methods: This is a prospective study of 40 patients with fingertip amputation who underwent reconstruction with either a standard CFF or an LTF. Data with regards to the patient, the injury, treatment and complications were recorded. Patients were followed up weekly for the first 6 weeks and at 3, 6, 9 and 12 months thereafter. Outcome measures assessed at final follow-up included passive range of motion, two-point discrimination, cold intolerance, patient aesthetic satisfaction with the flap, assessment of donor scar and psychosocial benefit. Results: Fingertip reconstruction was done with 23 CFFs and 17 thenar flaps. Partial necrosis was noted in three thenar flaps. The mean follow-up period was 11 months. The sensory recovery and aesthetic satisfaction with the flap were greater in thenar flap group. There were no differences between the two flaps in the other outcome measures. Conclusions: Sensory recovery and aesthetic outcomes were better in thenar flaps compared to a CFF. However, thenar flap were associated with a greater incidence of partial flap loss. Level of Evidence: Level III (Therapeutic).

Fingertip Amputation Reconstruction with VY Advancement Flap: Literature Review and Comparative Analysis of Atasoy and Kutler Flaps.

BACKGROUND: Many different flaps had been described to cover exposed bone in fingertip amputations and injuries. The variants of VY advancement flap, by far the simplest, had proven to render good functional and aesthetic outcome. We aimed to revisit and compare the various VY advancement flaps in fingertip reconstruction. METHODS: PubMed [MEDLINE] database was searched for VY advancement flap in fingertip reconstruction. Demographic and outcome data were extracted from relevant studies and comparative analysis was made. Patients with fingertip amputations undergoing reconstruction by either Kutler of Atasoy flaps in our institute, were assessed for sensory recovery, cold intolerance, joint's range of motion, and aesthetic outcomes and results were analysed. RESULTS: Among the 744 articles, 32 citations went full text review and were included, while data of 13 articles were tabulated. Weighted mean of 2PD in Kutler and Atasoy estimated to be 6 and 7.5 mm respectively. Hook nail deformity was in 29% and 35%, pain was present in 71% and 30% patients, in Kutler and Atasoy flaps respectively. Forty fingertips with Allen type II/III were reconstructed. Sensory outcomes of Atasoy flap and Kutler flaps were better than the previous study results. Four patients had cold intolerance. All patients achieved satisfactory aesthetic outcome. CONCLUSION: Over time, VY advancement flap have been successfully used for reconstruction of Allen type II-IV fingertip amputations, as suggested by the good sensory, functional and aesthetic outcomes.

Finger pulp reconstruction with thenar flap: Aesthetic and functional outcome.

PURPOSE: Fingertip injuries are common in industrial production activities as well as in domestic work. Loss of pulp hampers daily life activities. Functional and aesthetic aspects are important in fingertip reconstruction. The bone is usually exposed along with soft tissue loss. Therefore to reconstruct the pulp flap with adequate bulk is required. METHODS: We reported a case series of 12 patients with the injury over the volar aspect of distal phalanx of the index or middle finger. In all cases, laterally based thenar flap was chosen. The flap donor site was closed primarily in most of cases, while 4 patients required skin graft. The flap was detached between 2-3 weeks. Functional assessment was done using static and dynamic 2-point discrimination and range of motion at each joint. The aesthetic outcome was assessed through questionnaire. The results were analyzed using the unpaired t-test (SPSS version 21). RESULTS: Partial necrosis occurred in 2 cases while rest of flaps survived successfully. Static 2-point discrimination ranged from 6-10 mm, mean 8.6 mm; and dynamic 2-point discrimination ranged from 8-10 mm, mean 8.9 mm. The mean satisfaction score was (4.0 ± 0.55). CONCLUSION: Thenar flap is a good choice for reconstruction of the finger pulp as it provides the bulk with good functional and aesthetic outcome.

Two-staged reverse sural flap: a versatile flap with consistent results in the soft tissue reconstruction of distal leg and heel defects-an institutional experience.

BACKGROUND: Reverse sural flap (RSF) is commonly used for soft tissue reconstruction of distal leg and heel defects. The classic method of flap transfer is the single-staged cutaneous islanded reverse sural flap (SS-RSF). This method is associated with variable flap complications notably the venous congestion. The other form of flap transfer is the two-stage reverse sural flap (TS-RSF), in which the pedicle of the flap is exteriorized in the first stage. Flap division and re-inset are done in the second stage. The aim of this paper is to review the flap outcomes and complications among the SS-RSF and TS-RSF reconstruction of soft tissue defects in the distal leg and heel. METHODS: This is a retrospective chart review of RSF being operated in a tertiary care hospital. The duration of study was 1.5 years. Twelve RSFs (6 SS-RSF, 6 TS-RSF) were done for soft tissue defects in the distal leg and heel. Wounds of various etiologies (traumatic, chronic, non-healing ulcers) were reviewed. Trauma was the most common etiology with 8 out of 12 (66.7%) patients. Large wounds, donor site damage and patients with peripheral vascular disease were excluded from the study. RESULTS: Five out of six (83.3%) of TS-RSF healed uneventfully. However, 3 out of 6 (50%) of SS-RSF had partial flap necrosis. All complicated flaps healed well subsequently. No donor site complication was found in any of our patients. CONCLUSION: Pedicle exteriorization in TS-RSF eliminates the element of venous congestion and eventually flaps necrosis. Less technical expertise and minimal morbidity are additional advantages of TS-RSF. LEVEL OF EVIDENCE: Level IV, therapeutic study.