Reply: Impact of Microsurgery on the Treatment of Ring Avulsion Injuries
The Impact of Microsurgery on the Treatment of Ring Avulsion Injuries
BACKGROUND:Treating ring avulsion injuries continues to challenge the reconstructive hand surgeon. The complex operation draws from plastic surgery and orthopedic surgery principles to provide soft-tissue coverage, skeletal fixation, tendon repair, and neurovascular reconstruction. Furthermore, the application of microsurgical techniques has enabled the revascularization and replantation of completely avulsed fingers. METHODS:A retrospective review of 22 consecutive ring avulsion injuries (seven amputations, five replantations, and 10 revascularizations) from 1987 to 2015 performed by a single senior surgeon (D.T.W.C.) was conducted. RESULTS:Of these 22 ring avulsions, 10 revascularizations, five replantations, and seven amputations (five because of clinical factors, and two because of patient request) were performed. None of the 15 replantations and revascularizations resulted in loss of the ring finger or necrosis of the revascularized tip. CONCLUSIONS:With proper patient selection, appropriate level of injury identification, and meticulous surgical execution, the restoration of form and function to the hand is feasible in ring avulsion injuries. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, IV.
Relative Motion Flexion Splinting for Flexor Tendon Lacerations: Proof of Concept
BACKGROUND:The principle of relative motion has allowed patients to regain a higher degree of hand function, while protecting extensor tendon repairs. The purpose of this study was to determine whether the principle of relative motion could be a viable method to protect a flexor tendon repair. METHODS:Four fresh-frozen cadaver arms were each mounted on a testing apparatus (wrist in 30Â° of extension, metacarpophalangeal [MCP] joints blocked to 70Â°-80Â°). A minimum of 11 N was used to cyclically load the flexor digitorum profundus and extensor digitorum communis tendons to maximum allowable flexion and extension for 25 cycles. Measurements of elongation of the tendons were obtained through the use of differential variable reluctance transducers. Testing was performed in both intact and repaired (single 6-0 nylon suture) middle finger tendons (zone 3) with and without a relative motion flexion splint (RMFS), which placed the affected finger in 15Â° to 25Â° of relative flexion at the MCP joint. RESULTS:In all 4 hands, elongation was restricted to less than 1.3 mm in repaired tendon in the RMFS compared with elongation >2 mm in the nonsplinted condition. Average elongation was 0.86 mm (SD = 0.45). Visual examination of the tendons demonstrated no gapping with the use of the RMFS in any of the hands. All repairs had suture breakage and repair rupture without the RMFS. CONCLUSIONS:This study demonstrates that the RMFS decreases elongation and eliminates tendon-repair gapping after flexion/extension cycling in a cadaver model. It provides proof of concept that the RMFS may be a viable protective mechanism for flexor tendon repairs in zone 3.
Reply: Adipose Tissue-Preserved Skin Graft: Applicability and Long-Term Results
Reply: Adipose Tissue-Preserved Skin Graft: Applicability and Long-Term Results
An Invitation to Explore the Realm of Adipose Tissue Preserved Skin Graft (ATPSG)
Isocitrate dehydrogenase-1 deficiency exacerbates growth defects and metabolic alteration in caenorhabditiselegans induced by glucose 6-phosphate dehydrogenase deficiency [Meeting Abstract]
NADPH is a key reducing equivalent that maintains redox homeostasis and supports reductive biosynthesis. Lack of major NADPH producing enzymes predisposes cells to growth retardation and demise. Inactivation of the NADPH generating enzymes, glucose 6-phosphate dehydrogenase (G6PD), the rate limiting enzyme of the pentose phosphate pathway, and isocitrate dehydrogenase (IDH) has been hypothesized to affect growth and development in the nematode, C. elegans. Toward this end, the G6PD/IDH1 double-deficient C. elegans model was shown to display shrinkage of body size, growth retardation, slow locomotion and impaired molting. Global metabolomic analysis was employed to address whether or not metabolic pathways were altered by NADPH depletion by the G6PD/IDH1 double-deficiency. Principal component analysis (PCA) points to a distinct metabolomic profile of G6PD/IDH1 doubledeficiency. Further metabolomic analysis revealed that NADPH-dependent and glutamate-dependent amino acid biosynthesis were significantly impaired. Consequently, the reduction in amino acids may affect protein synthesis, as indicated by the absence of NAS-37 expression during the molting process. All in all, these findings support the notion that inactivation of G6PD and IDH1 causes growth retardation and molting defects, possibly mediated by impaired amino acid biosynthesis and metabolism in C. elegans
The Impact of Microsurgery on Congenital Hand Anomalies Associated with Amniotic Band Syndrome
Background/UNASSIGNED:Amniotic Band Syndrome is a clinical constellation of congenital anomalies characterized by constricting rings, tissue synechiae and amputation of body parts distal to the constriction bands. Involvement of the hand with loss of multiple digits not only leads to devastating deformities but also loss of functionality. Methods/UNASSIGNED:In this series, utilizing microvascular transfer of the second toe from both feet, along with local tissue reconfiguration, a tetra-digital hand with simile of normal cascade was reconstructed. A consecutive series of eight children with Amniotic Band Syndrome, younger than two years in age operated on by single surgeon over a twenty five year interval was reviewed. Results/UNASSIGNED:There was no flap loss. The hands were sensate with effective simple prehensile function. Conclusion/UNASSIGNED:Application of Microvascular toe-to-hand transfer for well selected, albeit severe hand deformity in Amniotic Band Syndrome is a valid surgical concept.
A Technique for Tripartite Reconstruction of Fingertip Injuries Using the Thenar Flap With Bone and Nail Bed Grafts [Case Report]
Fingertip amputation is the most common amputation encountered by hand surgeons. Treatment decisions are multifactorial, based on mechanism, level of injury, tissue loss, associated injuries, and patient preference, among others. In this article, we present use of the thenar flap in combination with bone graft and split-thickness nail bed graft to address the tripartite loss of distal phalanx, soft tissue, and nail bed. This method allows for a full-length and functional reconstructed fingertip that is aesthetically satisfactory and does not require microsurgical techniques.
Adipose Tissue-Preserved Skin Graft: Applicability and Long-Term Results
BACKGROUND: Composite grafts consisting of adipose tissue and skin have been reported in the literature but have been restricted to areas smaller than 4 to 5 cm. The senior author (D.T.W.C.) has developed a technique of adipose tissue-preserved full-thickness skin grafts for larger areas with success similar to that achieved with conventional full-thickness skin grafts. METHODS: All cases of the senior author involving a full-thickness skin graft were identified and reviewed to identify cases in which adipose tissue-preserved full-thickness skin grafts were used. Indication for skin grafting, anatomical location of recipient and donor sites, size of graft, total number of grafts received by each patient, and percentage take were extracted from patient charts. Graft take was measured between days 5 and 14. RESULTS: A total of 72 adipose tissue-preserved skin grafts on 47 patients were identified from 1994 to 2009, with a median follow-up of 8 years. The size of defect ranged from 0.7 to 210 cm, with a median area of 6 cm (interquartile range, 2.5 to 15 cm). Only six of 72 grafts were found to have less than 100 percent take. The lowest take percentage was 85 percent in a graft with an area of 2.6 cm. There were no graft failures. CONCLUSIONS: This study confirms the proof-of-concept that both larger and distant donor- site adipose tissue-preserved skin grafts are a viable alternative to conventional defatted full-thickness skin grafting. It appears that there is a low complication rate with respect to graft failure or incomplete graft take. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.