Second toe transfer for thumb reconstruction in multiple digit amputations including thumb and basal joint

Amputation of the thumb, including the basal joint, is a disabling injury that leaves limited reconstructive options. Three cases of multiple digit amputation including the thumb and basal joint are presented in which a second toe transfer was used to reconstruct the thumb. All patients have functional pinch with an average pinch strength of 27% of the opposite uninjured extremity. The average grip strength for two patients is 44% of the opposite hand. Average motion of the transfer at the MP, PIP, and DIP is 25 degrees, 37 degrees, and 9 degrees, respectively. Adduction and abduction are obtained, the degree depending on the site of proximal bony fixation. No patient has morbidity at the donor site and all are happy with their reconstruction. In selected cases we feel second toe transfer is an excellent choice to reconstruct the thumb amputated at a proximal level.     

A systematic review of outcomes of revision amputation treatment for fingertip amputations

Purpose

The purpose of this study was to conduct a systematic review of outcomes of fingertip revision amputation for fingertip amputation injuries in the English-language literature to provide best evidence of functional outcomes.

Methods

A MEDLINE literature search was performed to identify studies that met the following criteria: (1) reported primary data; (2) included at least five cases of primary revision amputation treatment following digit amputation injury; (3) reported finger or thumb amputation at or distal to the distal interphalangeal (DIP) joint or interphalangeal (IP) joint, respectively; (4) presented at least one of the following outcomes: static two-point discrimination (2PD), cold intolerance, arc of motion (AOM) of metacarpophalangeal (MCP) joints, proximal interphalangeal joints (PIP), DIP joints, or return-to-work time.

Results

Thirty-eight studies met the inclusion criteria. Twenty-seven studies reported 2PD, 20 studies reported cold intolerance, eight studies reported AOM, and 18 studies reported return-to-work time after revision amputation of fingertip injuries. The mean 2PD was 5.6 mm. On average, 24 % of patients experienced cold intolerance. AOM at the PIP joint was reported in four studies and averaged 94°. DIP joint AOM was presented in four studies and averaged 66°. Thumb MCP and IP joint AOM was presented in three and four studies, respectively. Mean thumb MCP joint AOM was 54° and that of the IP joint was 71°. The mean return-to-work time was 47 days.

Conclusions

On average, fingertip revision amputation can achieve almost normal sensibility and satisfactory motion and patients can expect to return to work on average approximately 7 weeks after surgery.     

Long-term results of trapeziometacarpal silicone arthroplasty

Long-term results of trapeziometacarpal (TMC) joint silicone arthroplasty were evaluated. From 1975 to 1990, 90 TMC joint silicone implants were placed in 85 patients with TMC joint arthritis caused by osteoarthritis and inflammatory arthritis. Sixty-two implants in 58 patients were available for follow-up evaluation averaging 16.4 years (range, 10-25 years) with a 10-year minimum. Patient satisfaction; range of motion; grip, key pinch, and tip pinch strengths; and radiographs were recorded. Eighty-four percent of the thumbs had satisfactory results with good-to-excellent pain relief and function. Grip, key pinch, and tip pinch strengths increased. The number of thumb tips able to touch the palmar base of the small finger increased. Subluxation was apparent in 19% of implants but was not clinically important; however, implant fracture occurred in 6% and required revision. None of the 62 implants had frank silicone synovitis. Silicone arthroplasty seems to be a reliable option for disabling TMC joint arthritis and is associated with a high degree of patient satisfaction.     

Functional outcome after the Moberg advancement flap in the thumb.

A Moberg palmar advancement flap was performed for pulp reconstruction of the thumb in 36 cases. No flap was lost. Eighty-three percent of the defects were closed without additional iatrogenic bony shortening of the thumb. Sensory testing showed normal sensitivity in 74% of the 25 patients studied at a mean of 27 months. Minor restrictions in the active range of motion in the interphalangeal joint were mainly attributable to a loss of hyperextension. No thumb showed a permanent flexion contracture. The flap alone did not result in a reduction in grip strength, but an additional bony amputation resulted in decreased strength of 3-point pinch grip. Seventy-two percent of the patients had no or only mild subjective complaints. The Disabilities of the Arm, Shoulder, and Hand questionnaire, which was used for the first time as a standardized measure to assess functional outcome after this procedure, showed only minor impairment levels (12.4 +/-). Based on these data, the Moberg advancement flap remains the procedure of choice for covering defects of the distal palmar thumb.     

Direct end-to-end repair of flexor pollicis longus tendon lacerations.

Between 1976 and 1986, 38 consecutive acute isolated flexor pollicis longus lacerations were repaired. This study excluded all replanted or mutilated digits and all lacerations with associated fracture. Average follow-up was 26 months. Tendon rehabilitation was standardized. Range of motion and pinch strength were measured postoperatively. Seventy-four percent (28/38) of the flexor pollicis longus injuries occurred in zone II. Neurovascular injury occurred in 82% of the lacerations, and this correlated with the zone of tendon injury. In 21% of the patients (8/38) both digital nerves and arteries were transected. Postoperative thumb interphalangeal motion averaged 35 degrees and key pinch strength was 81% that of the uninjured thumb. One rupture occurred in a child. Laceration of the flexor pollicis longus is likely to involve damage to neurovascular structures, and repair may be necessary. Direct end-to-end repairs within the pulley system do at least as well as delayed tendon reconstruction and do not require additional procedures.     

Thumb reconstruction with a wrap-around free flap according to the level of amputation

In 1980, Morrison and O'Brien reported their experiences with the reconstruction of an amputated thumb using a wrap-around neurovascular free flap from the great toe, but its indication has been limited distal to the metacarpophalangeal (MP) joint (Morrison et al., J Hand Surg 5:575-583, 1980). We have performed 37 wrap-around free flaps from the great toe for the reconstruction of thumbs amputated at distal or proximal to the MP joint and investigated their functional results according to the level of amputation. The amputation was distal and proximal to the MP joint in 25 and 12 cases, respectively. Pinching and grasping power, two-point discrimination, and the amount of opposition to the other fingers were compared to the uninjured hand. Pinching and grasping power were not significantly different according to the level of amputation but the results of two-point discrimination was better in the cases amputated proximal to the MP joint. The opposition of reconstructed thumb to the other fingers was completely possible in all cases amputated distal to the MP joint. In the 12 cases amputated proximal to the MP joint of the thumb, opposition was completely possible in 6 cases in which the iliac bone block was fixated in the position of 30 degrees flexion and 45 degrees internal rotation. However, in the other six cases in the fixation of 30 degrees flexion and 30 degrees internal rotation, the opposition of the reconstructed thumb to the ring and little fingers was impossible in five cases and only to the little finger in one case. In this study, we concluded that amputation proximal to the MP joint is not an absolute contraindication to the wrap-around free flap procedure for thumb reconstruction. However, for a better functional outcome, we recommend iliac bone block fixation in the position of 30 degrees flexion and 45 degrees internal rotation.     

Traumatized index finger pollicization for thumb reconstruction

PURPOSE: When the index finger is injured or severed in conjunction with a traumatic amputation of the thumb, transfer of the injured index finger can restore the important function of the thumb. The purpose of this study is to evaluate the results of the transfer of an injured index finger for traumatic loss of the thumb. METHODS: Seven patients treated by pedicled transfer of a traumatized index finger after amputation to the ipsilateral thumb were reviewed retrospectively. Postoperative evaluations included thumb range of motion, opposition and pinch function, grasp and pinch strength, sensation, a pick-up test, and a patient-rated appearance of the thumb and hand. Vascular patency of the traumatized index finger and thumb was evaluated in each patient prior to thumb reconstruction. RESULTS: After an average of 4 years of follow-up for surviving patients, all had excellent postoperative function and satisfactory results. The period between injury and thumb reconstruction ranged from 5 months to 4 years. All patients were men with a mean age of 43 years. Amputation levels included the metacarpophalangeal joint in 2 patients, the first metacarpal in 2 patients, and the proximal phalanx in 3 patients. All transferred traumatic index fingers survived without complications. CONCLUSIONS: Transfer of the injured index finger to the amputated thumb serves as an excellent adjunct for treatment of traumatic thumb amputations/crush injuries. Consistent results can be obtained while maintaining opposition and protective sensation after this procedure. However, technical demands are great, and initial injuries to the thumb and index finger ultimately determine the final outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.     

Pyrolytic carbon proximal interphalangeal joint arthroplasty: results with minimum two-year follow-up evaluation

PURPOSE: To retrospectively review the surgical technique, postoperative therapy/splinting protocols, and clinical and radiographic outcomes of patients who had pyrolytic carbon proximal interphalangeal (PIP) joint arthroplasty. METHODS: A total of 50 PIP joint replacements in 35 patients were performed with a minimum follow-up period of 27 months. Indications for surgery included pain, decreased range of motion, instability, and/or deformity. The preoperative diagnosis was osteoarthritis in 14, rheumatoid arthritis in 11, and posttraumatic arthritis in 10. There were 20 women and 15 men affected. The average age at the time of surgery was 53 years. The fingers replaced included the index (15), middle (18), ring (10), and small (7). The preoperative arc of motion averaged 40 degrees (0 degrees-60 degrees ), and the pinch and grip measurements averaged 3 and 19 kg, respectively. The preoperative pain scores averaged 6 (scale, of 0-10) on a visual analog space scale. RESULTS: The arc of motion was 47 degrees after surgery, and the average pinch and grip measurements were 4 and 25 kg, respectively. Pain scores improved to 1. At the final follow-up evaluation the overall patient satisfaction was nearly 80%. The results of index finger PIP replacements are compatible with other digits. Fourteen joints (in 14 patients) to date have required additional procedures to improve or maintain joint motion/function or pain; 5 for minor reasons and 9 for major complications. The revision arthroplasty rate was 8%. No infections were noted. Although not medically necessary, 2 patients requested and had an amputation. Radiographic subsidence and subsequent settling (in accordance with Wolff's law) without apparent loosening occurred in 20 joints. CONCLUSIONS: Our 2-year minimum follow-up evaluation of pyrolytic carbon implant arthroplasty showed improved pain relief and good overall patient satisfaction. Twenty-eight percent of patients required a second procedure and 8% required a revision arthroplasty. Radiographs showed gross changes in implant and eventual settling to a stable position in 40% of the joints. A longer follow-up period will help to better determine the efficacy of this implant. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Functional range of motion of the joints of the hand

Active ranges of motion of the joints of the hand are well documented, but there is little data reporting the functional ranges of motion required to perform activities of daily living. Electrogoniometric and standard methods were used to measure both active and functional ranges of motion of the metacarpalphalangeal and interphalangeal joints during 11 activities of daily living. In the fingers, only a small percentage of the active range of motion of the joints was required for functional tasks. Functional flexion postures averaged 61 degrees at the metacarpalphalangeal joint, 60 degrees at the proximal interphalangeal joint, and 39 degrees at the distal interphalangeal joint. In the thumb, functional flexion postures averaged 21 degrees at the metacarpalphalangeal joint and 18 degrees at the interphalangeal joint using only 32% of the available flexion. Active thumb metacarpalphalangeal joint motion was found to be bimodal in the study group.     

Ultrasonographic stress test of the metacarpophalangeal joint of the thumb

The purpose of this study was to evaluate functional ultrasound as a tool for detecting an ulnar collateral ligament injury of the thumb. The feasability of using ultrasound for imaging the thumb joint space was tested in a pilot study, using ultrasound and dissection in 14 cadaveric hand specimens. To test this method clinically, both metacarpophalangeal joints of the thumb in 461 healthy volunteers were examined using ultrasound (11 MHz) under radial stress. The distance between the innominate tubercle of the first metacarpal head to the proximal phalanx was measured. The mean distance between the first metacarpal head and the proximal phalanx (n = 461) was 4.5 mm (standard deviation, 0.65 mm) on the right side and 4.6 mm (standard deviation, 0.61 mm) on the left side. These data were compared with data of 25 patients with an operative diagnosis of rupture of the ulnar collateral ligament of the thumb. The difference in joint space between the injured and uninjured sides was 2.25 mm (standard deviation, 0.46 mm). The metacarpophalangeal joint space can be reproducibly detected on high-frequency ultrasound. An increased gap seen on ultrasound is indicative of a rupture of the ulnar collateral ligament of the thumb.     

Trapeziometacarpal abnormalities in Ehlers-Danlos syndrome

We studied 24 patients with Ehlers-Danlos syndrome with particular attention to the thumb and the trapeziometacarpal joint. The 11 males and 13 females had a mean age of 15.9 years. Symptomatic complaints included pinch, grip and twisting weakness; measurements showed dominant hand strength deficits of 71% for tip pinch, 55% for palmar pinch, 46% for key pinch, and 70% for grip. All finger joint ranges of motion were increased. Sixty-six percent of all the patients had trapeziometacarpal subluxation; 29% had dislocation. Sixteen percent had radiographic evidence of arthritis. Early occupational therapy evaluation and education can help these patients better understand and adapt to their limitations.     

Reconstruction of Amputated Thumb through Lengthening of First Metacarpal

Objective Restoration and/or improvement of pinch and grasp through elongation of the first metacarpal and deepening of the first web space. Indications Functional limitation of thumb, in particular of pinch and grasp after traumatic amputation in zone 2 according to Strickland & Kleinman. Contraindications Inadequate skin and soft tissue coverage of amputation stump. Absence of sensation over stump. Osteoarthritis of trapezometacarpal joint. Osteoporosis. Insufficient compliance and lack of comprehension by patient. Surgical Technique First step: placement of unilateral minifixateur. Posteroradial incision and osteotomy of the first metacarpal. Phase of distraction: continuous distraction starting on day 7, 1 mm per day. Second step: once the desired length has been reached, bridging of the distraction callus with a miniplate and deepening and enlargement of first web space using a local skin flap. Results Between 1998 and 2000, ten patients (nine men, one woman, aged between 15 and 68 years) were treated. The amputation occurred four times in zone 2a and six times in zone 2b. An isolated injury to the thumb was seen nine times, and once one of the other fingers was involved. The desired gain in length was reached in nine patients, it amounted to 31 mm (25–35 mm). Strength of pinch improved by an average of 45% and that of grasp by 55%.     

Long-term functional and subjective results of thumb replantation

The aim of this follow-up study was to evaluate the functional and subjective results after thumb replantation. Twenty-four patients with replantation of the thumb, performed during the period 1992-1997, were reexamined after 6.5 years (range, 4.2-9.1 years post-injury). In 10 cases the amputations were isolated, 14 amputations were combined with other injuries of the hand, 15 amputations resulted from crush/avulsion injuries, and 9 amputations were sharp. Range of motion, grip strength, cutaneous sensibility, and upper-extremity functioning using the DASH questionnaire were determined. A correlation analysis with important variables was performed. Average range-of-motion in the metacarpophalangeal joint was 44 degrees (+/-24.2) and in the interphalangeal joint was 12 degrees (+/-8.4). Grip-strength of the injured hand was 70% (+/-31.4) and pinch strength was 68% (+/-28.7) in comparison to the non-injured hand. DASH-scores correlated with grip-strength, pinch-strength, and cutaneous sensation but no correlation was found between DASH and the level of amputation. Functional results were independent of amputation levels and patient age. Although the results of cutaneous sensibility were only moderate, patients were able to use their thumb to perform work and daily living activities. The majority of patients had returned to their previous occupation.     

Wiederherstellung der Daumenendgelenkbeugung durch Transposition der oberflächlichen Beugesehne des Ringfingers

Objective

Restoration of active thumb flexion at the distal joint.

Indications

Loss of active flexion of the interphalangeal (IP) joint of the thumb if there is a transection of the flexor pollicis longus (FPL) tendon at the tendon channel of the thumb or thenar and direct suture is not possible but the tendon channel is intact, as alternative procedure to a free tendon graft if the transection is proximal to the tendon channel and the muscle of the FPL is contracted/injured or the FPL tendon is unharmed but the FPL muscle is partially or complete paralyzed.

Contraindications

Insufficiency of the FPL tendon channel, impairment of the superficial or deep flexor tendon of the ring finger, limited passive motion of the proximal and distal thumb joints, acute local general infection and non-compliance or incapacity of the patient.

Surgical technique

The surgical technique depends on the necessity of transosseous refixation of the FDS IV at the base of the distal phalanx of the thumb or the possibility of woven sutures through the FPL proximal to the tendon channel. If the tendon channel is intact the distal part of the FPL tendon is shortened to 1 cm, the FDS IV tendon is cut distal to the chiasma of Camper, pulled through the carpal tunnel and moved into the channel of the FPL tendon and fixed transosseously through the base of the distal phalanx of the thumb. If the transection of the FPL tendon is located proximal to the tendon channel and muscle of the FPL is injured, FDS IV tendon will be woven using the Pulvertaft technique through the FPL tendon at the distal forearm.

Postoperative management

Postoperative 6 weeks motion of thumb flexion without resistance in relieved position of the thumb through a thermoplast splint and 6 weeks of functional use of the hand with increasing weight bearing.

Results

In this study 10 patients with FDS IV transposition to reconstruct an isolated rupture of the FPL tendon could be followed for an average of 4.1 years postoperatively. The active range of motion of the IP joint of the thumb averaged 65° (10–100°), 8/10 patients achieved an equal active and passive range of motion of the IP joint of the thumb, in 2 patients some flexion insufficiency remained, 9 patients could reach the fingertip of the small finger with the thumb and 1 patient lacked 3 mm. Contracture of the proximal thumb joint developed in two patients. After removal of the FDS IV tendon two patients developed contracture of the PIP joint of the ring finger. The grip force was reduced to 81?%, lateral grip to 83?% and pinch grip to 77?%. The DASH score averaged 18 (0–31) and 8/10 patients would choose to undergo this surgery again.     

Basal thumb metacarpal osteotomy for trapeziometacarpal osteoarthritis

PURPOSE: To review the subjective and functional results of basal thumb metacarpal osteotomy for the treatment of trapeziometacarpal osteoarthritis. METHODS: Between July 1993 and November 1998, 35 thumb osteotomies without internal fixation were performed on 33 patients in the Christchurch Hospital, New Zealand. Records of 28 thumbs (13 right and 15 left) of 26 patients (17 women and 9 men) were available for review. Patients were reviewed using strength testing and the Michigan Hand Outcomes Questionnaire. RESULTS: The mean age of the 26 patients was 54 years (range, 30-69 years). Of the 28 thumbs, 22 (21 patients) had good or excellent results, 2 fair, one poor. The remaining 3 thumbs (3 patients) required further revision and were classified as failures. The mean follow-up period of the 25 thumbs (24 patients) not requiring revision was 34 months (range, 12-73 months). Good thumb motion was present in all hands with no trapeziometacarpal instability seen. Compared with the normative data, the strengths of key pinch, pulp pinch, and tripod pinch of our patients were significantly lower (22-32% lower), but not the grip strength. Michigan Hand Outcomes Questionnaire scores increased 28 (range, 1-56) points after surgery, with significant improvement especially in pain (+44 points), activities of daily living (one-handed tasks, +41 points), and satisfaction (+35 points). CONCLUSION: Basal thumb metacarpal osteotomy is a straightforward, conservative procedure that should be considered for grades II and III trapeziometacarpal osteoarthritis.     

Reconstruction of the thumb amputation at the carpometacarpal joint level by groin flap and second toe transfer

IntroductionTraumatic loss of thumb at the carpometacarpal (CMC) joint level is very disabling to an individual. Pollicisation is the recommended technique of reconstruction for loss of thumb at this level. On occasions, injury to the rest of the hand or amputation of additional fingers may make pollicisation an impossible option. Microsurgical transfer of second toe is an option in such situations. Although many large series of toe transfers are available in the literature, no series deals exclusively with this subset of patients.Materials and methodsEight patients who had amputation of the thumb at or proximal to the CMC joint level were reconstructed by second toe transfer by us in the period 2002–2011. All had preliminary groin flap cover in the area of the thumb during the acute stage of treatment. Second toe with the metatarsal was transferred for thumb reconstruction after a mean duration of 3 months after flap cover. Patients were assessed for their ability to pinch, hold large objects and opposition achieved by Kapandji score. Average follow up is 4 years and 6 months with a minimum of 1 year.ResultsAll toe transfers survived. They reached their maximum functional potential by 1 year. All patients actively used the reconstructed thumb for day to day activities. Pinch was possible in all patients except two patients who did not have any fingers. Six of them registered grip strength of at least 50% of the opposite hand. When fingers were present, opposition was possible in all patients with Kapandji scores ranging from 5 to 8. Extent of usage was less in patients who did not have good function in other fingers.ConclusionSecond toe transfer is a viable option for reconstruction of thumb loss at or proximal to the CMC joint level. Proper planning of the preliminary flap cover determines the length of the thumb reconstruction. Strategic position of the transferred toe of adequate length and the functional status of the other fingers are important determinants of functional outcome.     

Osteosynthetisch versorgte intraartikuläre Frakturen der Metakarpale-I-Basis

BACKGROUND: Fractures of the thumb metacarpal occur quite frequently at the base. Intra-articular metacarpal base fractures (such as Bennett or Rolando fractures) present treatment challenges and surgical therapy remains controversial. Malunion of these fractures may lead to the development of painful osteoarthrosis at the trapeziometacarpal joint which can seriously impair overall hand function. PATIENTS AND METHODS: In a retrospective analysis, 30 intra-articular fractures (24 Bennett's, three Rolando's and three comminuted fractures) treated between 1994 and 1999 in the Department of Hand, Plastic and Reconstructive Surgery in Ludwigshafen have been reviewed. A total of 25 patients (83%) could be examined clinically and radiologically at an average follow-up of 39 months. The subjective outcome was measured using the DASH-questionnaire. Clinical examination included grip strength and range of motion measurements. RESULTS: Four cases were treated with percutaneous pinning, in 26 cases open reduction with internal fixation was performed. Radiological analysis demonstrated good reduction in 90% of all cases (metacarpal base gap/step-off in articular surface: <1 mm in 63%, between 1-2 mm in 27%, >2 mm in 10%). Twelve patients (48%) were free of symptoms at follow-up. Slight restricted flexion was noted in 11 (44%) patients (75-90% of healthy collateral values), including one patient with moderate opposition deficit (<75% of uninjured value). Three patients (12%) demonstrated weakness in tip pinch and one patient had decreased key pinch compared to the uninjured hand. Overall, good functional results for radial abduction, flexion and opposition as well as good grip strength compared to their uninjured side were found. At follow-up a total of 64% radiological features of trapeziometacarpal arthrosis have been documented. Very low impairment rates in the DASH-scores of all three parts (below 9 points) were measured. There was no correlation between the quality of thumb base restoration and radiological or subjective outcome. CONCLUSION: Exact anatomical restoration of the articular surface may not be essential for obtaining satisfactory functional results.     

Thumb reconstruction with a wraparound free flap according to the level of amputation

We surgically treated 37 thumbs amputated distal or proximal to the metacarpophalangeal (MCP) joint using a wraparound free flap from the great toe for the reconstruction. We studied the functional results of the procedure according to the level of amputation and the fixation angle of the iliac bone block. The cases were divided into 2 groups: group 1, which comprised 25 cases with the level of amputation distal to the MCP joint, and group 2, which comprised 12 cases with the level of amputation at or proximal to the MCP joint. Opposition of the reconstructed thumb to the other fingers was completely possible in all cases in group 1. In group 2 opposition was completely possible in 6 cases in which the iliac bone block was fixated into the position of 30 degrees flexion and 45 degrees internal rotation; in the remaining 6 cases, in which the graft was fixated into the position of 30 degrees flexion and 30 degrees internal rotation, complete opposition of the reconstructed thumb to the ring and little fingers was not possible. We found that amputation of the thumb proximal to the MCP joint is not an absolute contraindication for the wraparound free flap reconstruction. We recommend fixating the iliac bone block into 30 degrees flexion and 45 degrees internal rotation to obtain better functional outcome in cases with amputation at or proximal to the MCP joint.     

Total joint arthroplasty in the treatment of advanced stages of thumb carpometacarpal joint osteoarthritis

PURPOSE: Osteoarthritis of the thumb basal joint is a very common and disabling condition that frequently affects middle-aged women. Many different surgical techniques have been proposed for extensive degenerative arthritis of the first carpometacarpal (CMC) joint. Joint replacement has been an effective treatment of this condition. The purpose of this article is to present the outcome of a total cemented trapeziometacarpal implant in the treatment of more advanced stages of this disease. METHODS: Total joint arthroplasty of the trapeziometacarpal joint was performed on 26 thumbs in 25 patients to treat advanced osteoarthritis (Eaton and Littler stages III and IV) between 1998 and 2003. Indications for surgery after failure of conservative treatment were severe pain, loss of pinch strength, and diminished thumb motion that limited activities of daily living. A trapeziometacarpal joint prosthesis was the implant used in this series. The average follow-up time was 59 months. RESULTS: At the final follow-up evaluation, thumb abduction averaged 60 degrees and thumb opposition to the base of the small finger was present. The average pinch strength was 5.5 kg (85% of nonaffected side). One patient had posttraumatic loosening, which was revised with satisfactory results. Radiographic studies at the final follow-up evaluations did not show signs of atraumatic implant loosening. One patient complained of minimal pain, and the remaining 24 patients were pain free. CONCLUSIONS: In our series, total joint arthroplasty of the thumb CMC joint has proven to be efficacious with improved motion, strength, and pain relief. We currently recommend this technique for the treatment of stage III and early stage IV osteoarthritis of the CMC joint in older patients with low activity demands. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.     

Replantation and revascularization vs. amputation in injured digits

Background

The purpose of this study was to analyze factors associated with the decision to replant or revascularize rather than amputate an injured digit as well as factors associated with successful replantation or revascularization.

Methods

We reviewed 315 complete and subtotal amputations at or proximal to the distal interphalangeal joint in 199 adult patients treated over 10 years. Ninety-three digits were replanted (30 %), 51 were revascularized (16 %), and 171 were amputated (54 %), including 5 attempted replantations. Bivariate and multivariable analyses sought factors associated with replantation vs. amputation, revascularization vs. amputation, and success of replantation or revascularization.

Results

Factors associated with replantation rather than amputation were injury to the left hand, thumb, middle digit, and ring digit, more than one digit affected, and surgeon. Factors associated with revascularization are surgeon and shorter ischemia time. Forty-five replantations (48 %) and 41 revascularizations (80 %) were successful. Successful replantation was associated with the side of injury (left side more likely to survive), zone of injury (distal interphalangeal and interphalangeal joint more likely to survive and proximal phalanx less likely to survive), and shorter ischemia time. Success of revascularization was associated with the mechanism of injury (saw and not crush injury), multiple digits involved, and the surgeon.

Conclusions

The decision to replant, revascularize, or amputate a nonviable digit and the success of replantation and revascularization are related to both injury factors, such as mechanism of injury, affected digit, and zone of injury, and the surgeon.