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.

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.

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 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.

[Late results of replantations in tip amputations of the thumb]. / Basparmak distal uç amputasyonlarinda replantasyon uygulamalarinin geç dönem sonuçlari.

OBJECTIVES: We retrospectively evaluated replantations performed for Tamai type 1 thumb amputations. METHODS: The study included 14 patients (12 males, 2 females; mean age 28 years; range 14 to 40 years) whose replanted thumbs survived following replantation for Tamai type 1 amputations in the distal nail fold of the thumb. Central digital artery anastomosis was performed in all the cases. Four patients with an appropriate vein had a single volar vein anastomosis. Nerve repair could be possible in only three patients. Sensory evaluations were made with the Semmes-Weinstein monofilament test, static and moving two-point discrimination tests, and vibration test. In addition, patients were evaluated with respect to atrophy in the replanted part, nail-bed deformities, and cold intolerance. The mean follow-up period was 11 months (range 6 to 48 months). RESULTS: The Semmes-Weinstein test was green (range 2.83 to 3.22) in five patients (35.7%), blue (range 3.22 to 3.61) in eight patients (57.1%), and purple (range 3.84 to 4.31) in one patient (7.1%). The mean static and moving two-point discrimination test results were 6.9 mm (range 3 to 10 mm) and 4.5 mm (range 3 to 6 mm), respectively. Compared to the intact fingers, vibration was increased in six thumbs (42.9%), decreased in six thumbs, and the same in two thumbs (14.3%). Atrophy of the replanted parts was observed in five patients (35.7%). Three patients (21.4%) complained about cold intolerance, and three patients had nail-bed deformities. The mean time to return to work was 3.2 months (range 2 to 6 months). CONCLUSION: Despite technical difficulties, thumb replantations yield good functional and aesthetic results. Sensory recovery is sufficient even after tip replantations without nerve repair.

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.

[Treatment algorithm in synovial tuberculosis of the hand and wrist: a report of three cases]. / El ve el bilegi yerlesimli sinovyal tüberkülozda tedavi plani: Uç olgu sunumu.

Three patients with synovial tuberculosis are presented. Involvement was in the hand in one patient, and in the wrist in two patients. None of the patients had pulmonary tuberculosis or a family history of tuberculosis. Tuberculosis treatment was initiated only after histologic verification. The cultures remained negative. The patients received a 12-month course of multidrug chemotherapy for tuberculosis, resulting in symptomatic improvement and healing. There were no recurrences during a follow-up period of 16 to 26 months. Our clinical observations showed that tuberculosis tenosynovitis benefited well from antituberculosis chemotherapy.

[The results of digital replantations at the level of the distal interphalangeal joint and the distal phalanx]. / Distal interfalangeal eklem ve distal falanks seviyesindeki replantasyon sonuçlari.

OBJECTIVES: We retrospectively evaluated replantations performed for distal amputations. METHODS: The study included 82 patients (75 males, 7 females; mean age 29 years; range 10 to 52 years) who underwent replantations distal to the distal interphalangeal joint for a total of 98 amputations. According to the Tamai classification, there were 58 zone 1 and 40 zone 2 amputations. Local digital anesthesia was used in 77 patients (93.9%). Arterial anastomosis was accomplished after bone fixation, and venous anastomosis and nerve repair were performed whenever possible. When venous anastomosis was not possible or in case of venous insufficiency, venous decompression was performed with heparinized gauze placed on the bleeding nail matrix. Functional results and the degree of patients' satisfaction with the cosmetic outcome were evaluated. The mean follow-up was 16 months (range 3 to 46 months). RESULTS: Replantation was successful in 60 amputations (61.2%) and unsuccessful in 38 cases (38.8%). In successful cases, cosmetic results were satisfactory due to the preservation of the nail and finger length. Functional results were satisfactory in cases in which the distal interphalangeal joint could be preserved. Replantations for zone 1 amputations (74.1%) yielded better results than those performed for zone 2 amputations (42.5%). CONCLUSION: Despite technical difficulties, replantations for distal finger amputations can provide satisfactory functional and cosmetic results.

[Single-stage flexor tendoplasty in the treatment of flexor tendon injuries]. / Fleksör tendon yaralanmalarinda tek seansli fleksör tendoplasti.

OBJECTIVES: We evaluated tendon reconstruction with one-stage tendon grafting in flexor tendon injuries in which primary repair was not considered because of delay in treatment or of inappropriate circumstances on the part of the wound and the patient. METHODS: Thirty-seven patients (29 males, 8 females; mean age 20.5 years; range 4 to 52 years) underwent single-stage flexor tendoplasty involving 41 fingers. Twenty-eight patients had zone II injuries. The mean duration from trauma to surgery was one month (range 3 to 6 weeks). Tendon grafts were obtained from the palmaris longus in 26 repairs, flexor digitorum superficialis in 14 repairs, and flexor carpi radialis in one repair. Early passive rehabilitation was administered after surgery. Improvement in the flexion motion was calculated using the Strickland formula. The results were compared with respect to the tendon graft used, associated nerve injuries, and the age of the patients (equal to or below 10 years/above 10 years). The mean follow-up was 35 months (range 4 to 83 months). RESULTS: Functional results were excellent in 12 fingers (29.3%), good in 13 fingers (31.7%), moderate in 14 fingers (34.2%), and poor in two fingers (4.9%). Overall, the mean total active movement was 57% (range 22 to 88%). No significant differences were found between the functional results with respect to the tendon graft used, associated nerve injuries, and the age of the patients (ANOVA, p>0.05). CONCLUSION: Single-stage flexor tendoplasty seems to be an appropriate choice of treatment for flexor tendon injuries where local wound conditions and decreased tendon length prevent primary repair, provided that the pulley system remains intact.

[Flexor tendoplasty with a tendon prosthesis for zone II flexor tendon injuries]. / Zone II fleksör tendon yaralanmalarinda tendon protezi ile fleksör tendoplasti uygulamalarimiz.

OBJECTIVES: We evaluated two-staged flexor tendoplasty with tendon prosthesis in patients with flexor tendon injuries in which conventional tendon grafting would fail to yield an acceptable result. METHODS: We performed flexor tendoplasty with tendon prosthesis in 37 hands of 31 patients (24 males, 7 females; mean age 23 years; range 4-46 years). Twenty-six patients had penetrating injuries, four had occupational injuries, and one patient had an electric burn. Preoperatively, all patients were evaluated according to the Boyes' classification. At the first stage, a silicone prosthesis, 4-6 mm in diameter was placed according to the patient's age and the recipient bed; after 3 to 5 months, silicone prosthesis was removed and flexor tendoplasty with a tendon graft was performed. The results were calculated according to the Strickland's formula. The mean follow-up period after the second operation was 37 months (range 12-80 months). RESULTS: The results were excellent in 11 hands (Strickland 75-100%), good in 15 hands (50-74%), moderate in nine hands (25-49%), and poor in two hands (0-24%), with a mean of 58%. Tenolysis was performed in seven patients at least four months after the second stage. Removal of the tendon prosthesis was required in one patient because of infection. CONCLUSION: Satisfactory results can be obtained with two-staged flexor tendoplasty with a tendon prosthesis in patients with joint injuries restricting finger movements, digital nerve injuries causing trophic changes in the finger, and multiple tissue injuries.