Precision grip function after hand replantation and digital nerve injury.

Understanding how the loss of digital sensibility affects manual dexterity could have important implications for rehabilitation after hand injury. We investigated precision grip function during lifting tasks in seven patients after hand replantation, in five after single digital nerve injury and in four volunteers subjected to digital anaesthesia. Using their affected hand, all participants could successfully lift test objects with parallel and vertical grip surfaces and they all reliably increased the grip force with increasing object weight (0.11-0.55 kg). However, the grip forces used were frequently significantly higher than those applied by the unaffected hand. This was partly due to participants compensating for loss of sensibility with high grip force safety margins against slips, and partly related to misalignments of the fingertips on the grasp surfaces. The latter was most prominent after hand replantation. In a second series of lifting experiments we changed the shape of the grip surfaces in order to investigate the participants' ability to adapt grip forces based on tactile recognition of object shape. An important finding from this series was that in patients with poor clinical outcomes, the contralateral unaffected hand tended to mirror the abnormal grasp patterns of the injured hand. This suggests that control strategies developed for the impaired hand can influence the control of the contralateral uninjured hand.     

Selection of grip function in double free gracilis transfer procedures after complete paralysis of the brachial plexus

Double free gracilis transfer (DFGT) procedures introduced by Doi et al have resulted in significant improvement in maintaining functional prehensile hand after total brachial plexus injury (TBPI). However, not all patients with satisfactory recovery of finger motion could improve their prehensile function. The use of reconstructed hand in daily activities was examined retrospectively to plan individual grip function, depending on the patient's own demand.Thirty patients who had had reconstruction with DFGT procedures were evaluated retrospectively according to total active motion (TAM), power grip, hook grip, and pinch function. Power grip was evaluated by holding a bottle and hook grip by lifting a weight. Only 11 patients (36%) had very light pulp-to-pulp pinch, 11 (36%) had power grip, and 25 (83%) had hook grip. The mean weight that could be carried by hook grip was 1.3 kg. The mean TAM was 43 degrees. Pain sensation was the only encouraging sensation recovery, radiating to the chest.Fine movements of the hand like pinching require well-developed exquisite control of movements. TBPI patients have the contralateral normal limb, which they always prefer, only using their reconstructed hand when the activity requires both hands, such as when holding a bottle to open its cap or lifting bags when the contralateral normal hand is already engaged. For performance of these actions, hook grip and power grip are the useful prehensile hand functions that can be obtained after DFGT. Selection of grip functions should be done according to patient needs, and the late-stage reconstructive hand operations should be decided according to preferred grip function.     

Multiple toe transfer and sensory free flap use after a traumatic amputation of multiple digits. Surgery done in a single setting: A case study

Crush avulsion injuries to the hand with concomitant traumatic amputation of multiple digits can be a devastating injury to the patient. These injuries have multiple issues occurring under emergency conditions. When feasible, replantation of the multiple digits is optimal, but in many cases, it is not possible. Because of the crushing force on the digits, they are not viable candidates for replantation. The usual course of treatment for these patients is a two stage procedure, usually involving a groin flap. Here, we present the case of a patient who had a left hand skin avulsion of the whole palm and P1 of index, long, ring and small fingers. The left index finger had a complete amputation at the P2 level, the long, ring and small fingers all had complete amputations at the P1 level. This injury was dealt with by a left foot second and third toe transplant, a sensory free flap from the left big toe and a fourth toe microvascular free transfer to the left hand. The remainder of the defect was managed with a 10 × 14 cm reversed radial forearm flap and a combination of full and split thickness skin grafts. The procedure was performed in a single operation, obviating the need for a second surgery. This procedure optimized the patient's outcome during a single setting, making it an ideal choice in an emergency setting. © 2011 Wiley‐Liss, Inc. Microsurgery, 2011.     

足趾移植术手功能重建的进展

先天发生或者创伤导致的多个手指的缺失,都会给手的功能和外形带来严重影响,如果缺失指中包括拇指在内,情况就更严重。缺失手指的再造,可以达到重建和改善残手功能的目的。再造的方法不一而足,但以足趾移植再造最为理想。这是因为足趾和手指相比,在外形和结构上均十分接近,所以足趾是各国学者公认的再造手指的最理想材料。用显微外科技术移植自体足趾再造的拇指和手指,能够达到患者最能接受的外形和最大程度的功能恢复〔１,２〕。　　事实上,早在１８９７年,显微外科技术还没有问世,Ｎｉｃｏｌａｄｏｎ就用分期手术的方法,将足…     

第二足趾延长塑形再造二～四指

目的 改善第2足趾再造手指的长度及外观，探讨一种更为理想的手指再造方式。方法 应用携带双翼状跖背侧皮瓣及部分跖骨的第2足趾，联合Mu趾腓侧条形岛状复合组织瓣反转镶嵌再造手指共5例8指。结果 应用此方法再造手指，其长度、粗细接近正常，外形及功能良好。对足的外观及功能无明显影响。结论 克服了传统的第2足趾再造手指令人尴尬的短小外观，是一种较理想的手指再造方法。     

Hand reconstruction by microsurgical free toe transfer

Reconstruction of complex hand mutilations with multi-digital or thumb amputations are best treated with microsurgical toe transfers. We present the results of the first 15 cases operated by the first author, of which 12 are thumb reconstructions (6 great toe and 6 second toe transfers) and 3 long fingers reconstructions with combined second and third toe transfers. There were no microsurgical complications. Cortical integration and functional integration was achieved for all transferred toes, with discriminatory sensibility (m2PD between 5 and 13 mm) and active mobility range between 30 and 60 degrees.     

Coverage of big toe defects after wrap-around flap transfer with a free soleus perforator flap

In thumb reconstruction, a wrap-around flap transfer from the big toe gives excellent results aesthetically and functionally; however, there may be some problems at the donor site, such as delayed wound healing and skin ulceration. In 10 patients, a free soleus perforator flap was used for immediate coverage of defects of the big toe with wrap-around flap procedures. Eight flaps survived completely, and the time required for wound healing was less than 1 month. Two flaps developed partial necrosis and required additional skin grafts. The average follow-up period was 46 months. There were no patients requiring defatting of the flaps. There were no patient complaints, such as postoperative skin erosion or ulceration. All patients were satisfied with the outcome. A free soleus perforator flap is an available method for covering defects of the big toe after wrap-around flap transfer.     

Robot-assisted free toe pulp transfer: feasibility study

The current tendency of microsurgery is heading toward supermicrosurgery and microsurgery assisted by robotics. The aim of this work was to study the feasibility of a free hallux hemipulp transfer with a surgical robot in a cadaveric model. We used a human body. The intervention was realized by a Da Vinci SI? robot (Intuitive Surgical?, Sunnyvale, CA) in two stages: first taking off the medial hallux hemipulp, then transferring the hallux hemipulp to the radial thumb hemipulp. The intervention lasted 1 hour 59 minutes, exclusively with the Da Vinci SI? robot, without any interruption or outside intervention. Despite the absence of sensory feedback and an intervention 25% longer than in conventional microsurgery, we have demonstrated the feasibility of free hallux hemipulp transfer with a surgical robot. In the future, it is likely that the added benefits of the robot (physiological tremor suppression, user-friendly ergonomics, ultraprecise control of the instruments) will make the robot an indispensable tool for the surgeon.     

Microsurgical free toe pulp transfer for digital reconstruction

Posttraumatic fingertip reconstruction with a free toe pulp neurovascular flap, first described in 1979, has not been frequently reported. We present our results with 8 free transfers of the toe pulp and demonstrate the successful restoration of a well-padded and sensitive fingertip. All patients, studied with a follow-up of up to 20 months, recovered a discriminative sensibility of the thumb and main fingers, with a stationary two-point discrimination test between 5 and 12 mm and a moving two-point discrimination test between 4 and 8 mm. In spite of the good results obtained, we believe this procedure must be chosen only in certain circumstances. We present the indications and the contraindications for this digital reconstruction.     

足趾和/或(足母)甲瓣移植再造手指

目的总结120例164指足趾和/或甲瓣移植再造手指全部获得成活的临床经验.方法自1989年以来,共采用足趾和/或甲瓣移植再造手指120例164指,单个拇指再造58例,双拇指再造5例,2～4指单指再造24例,多指再造33例.其中2指再造28例,3指再造4例,4指再造1例.结果3例术后发生血管危象,经及时处理均得以纠正,所有手术全部一期完成并全部获得存活.结论1.明确趾蹼分型,尤其是明确第一跖骨背动脉和第一趾底动脉在趾蹼的交通情况,是确定采用第一跖骨背动脉系统,还是采用跖底动脉系统或其他第二套供血系统的首要依据.并将趾蹼间血管按交通支情况分为3型：Ⅰ型：交通支口径＞0.5mm;Ⅱ型交通支口径＜0.5mm;Ⅲ型：无交通支.2.以第一跖骨底动脉系统作为第二套供血系统更安全.3.在条件允许的情况下采用趾-指动脉吻合是避免第一跖骨背动脉或趾蹼血管解剖变异风险的最好选择.     

Resurfacing of the donor defect with a second toe plantar flag flap after free first toe pulp flap.

A second toe plantar flap was attached to the donor site after a free first toe pulp flap. Twenty-two days postoperatively, the wound had almost healed. Although the whole defect is impossible to cover with this flap, partial resurfacing will reduce the healing time and morbidity from recurrent ulceration.     

Mu趾腓侧皮瓣嵌入第二足趾改形法再造拇手指

目的 研究第二足趾改形方法，使再造后的手指外形更美观。方法 切取第二足趾的同时游离并切取带翼状组织瓣的Mu趾腓侧皮瓣，将Mu趾腓侧皮瓣嵌入第二足趾跖侧，Mu趾腓侧皮瓣上的翼状组织瓣嵌入第二足趾中部两侧皮下。结果 再造36例46指全部成活，嵌入的Mu趾腓侧皮瓣也全部成活，术后随访6-24个月，再造的拇指及2-4指（第二足趾）的外形，较传统的第二足趾移植有了不同程度的改善。结论 Mu趾腓侧皮瓣嵌入第二足趾，能较好地改变第二足趾外形，使之更接近正常的拇指与手指。     

趾腓侧皮瓣嵌入第二足趾改形法再造拇手指

目的　研究第二足趾改形方法 ,使再造后的手指外形更美观。方法　切取第二足趾的同时游离并切取带翼状组织瓣的趾腓侧皮瓣 ,将趾腓侧皮瓣嵌入第二足趾跖侧 ,趾腓侧皮瓣上的翼状组织瓣嵌入第二足趾中部两侧皮下。结果　再造 3 6例 46指全部成活 ,嵌入的趾腓侧皮瓣也全部成活。术后随访 6～ 2 4个月 ,再造的拇指及 2～ 4指 (第二足趾 )的外形 ,较传统的第二足趾移植有了不同程度的改善。结论　趾腓侧皮瓣嵌入第二足趾 ,能较好地改变第二足趾外形 ,使之更接近正常的拇指与手指     

一趾提供两组复合组织再造两手指的临床应用

目的 探讨利用一趾提供两组复合组织再造两手指的应用.方法 2001年1月-2009年2月,对11例手部多处复合组织缺损患者,采用第2趾提供两组复合组织进行再造两个手指.结果 再造11例共22块复合组织均成活.其中2例3块复合组织术后出现血管危象,经手术探查解除,组织块成活.术后随访3个月～3年,平均20个月.再造手指功能及外观良好.结论 一趾提供两组复合组织再造两手指,可使患手功能获得良好的恢复.