No change in O2 saturation but measurable difference in thenar flexor power after radial artery harvest.

OBJECTIVES: Objective measures of morbidity will be required to establish the radial artery (RA) as a viable long term alternative to saphenous vein. The RA is the dominant arterial supply to the thenar musculature. We hypothesised that RA harvest should decrease O2 saturation and thenar muscle power. METHODS: RA was harvested from non-dominant (ND) limbs only (left n = 58, right n = 21). Oximeter values of O2 saturation were taken from the thumb of the dominant (D) and non-dominant (ND) limb pre and post operatively. A syringe filled with 25 cc of air is emptied against a one way valve connected to a pressure generator MX 100 by MEDEX, Inc, Ohio, USA. Three measures of thenar flexor power (TFP) were taken and mean values obtained in the ND and D limbs. RESULTS: O2 saturation ranged from 92 to 98% in the thumb of the ND limbs 24 h post RA harvest. The values for TFP (mean +/- SD) were 1246 +/- 246 mmHg (ND) and 1240 +/- 258 mmHg (D) pre-operatively and 1216 +/- 250 (ND) and 1259 +/- 233 (D) post operatively. The changes in TFP between the ND and D limbs (37.0 +/- 60.6 ND and 1.86 +/- 65.9 D) were significant for the D against the ND limb (P < 0.001). This reduction in TFP for the harvested limb was also found when considering handedness (28.0 +/- 24.2 and 40.3 +/- 69.2 for the left and right handed patients respectively). CONCLUSION: Our findings confirm the hypothesis that there are objective differences in TFP pre and post RA harvest at 3 months. Further studies are required to assess the clinical significance and persistence of the loss of TFP.     

Wrist arthrodesis with intercalated iliac crest graft in mutilans rheumatoid arthritis

In mutilans rheumatoid arthritis (RA) patients with major wrist destruction, wrist arthrodesis is recommended. This type of arthrodesis needs carpal reconstruction and stable fixation. The goal of this study was to assess the functional and anatomical outcomes of an iliac crest graft and internal fixation with two medullary pins. Six wrists in three patients suffering from RA were reviewed clinically and radiologically at an average follow-up of 25 months. We assessed the fusion of the iliac graft with the radius and the metacarpus, the preoperative and postoperative carpal height, and the bone stock in front of the thumb. All the patients had improved functionally. The iliac graft fused with the radius in all cases and fused with the metacarpus in 5 out of 6 cases; the non-union occurred in the wrist where only one pin was used. Restoration of carpal height was associated with improvements in hand function. The bone stock was sufficient to allow implantation of a trapezial cup during a total arthroplasty of the thumb trapeziometacarpal (TMC) joint. No major complications occurred. An iliac graft and two pins through the 2nd and 3rd metacarpals were used to reconstruct the carpal height and to obtain wrist fusion. Internal fixation with only one pin is not recommended. Functional improvement can be attributed to the normal tension within the extrinsic flexors and extensors of fingers and thumb being restored because the carpal height was restored. A secondary TMC arthroplasty is theoretically possible.     

桡动脉在65岁以上老年患者冠状动脉旁路移植术中的应用效果

目的 探讨桡动脉在65岁以上老年患者冠状动脉旁路移植术(CABG)中的应用效果.方法 2000年1月至2007年3月利用桡动脉对322例65岁以上老年冠状动脉心脏病患者实施CABG,观察围手术期情况和术后远期效果.结果 共取桡动脉344支,300例患者取单侧桡动脉,22例患者取双侧桡动脉.322例CABG中,远端吻合口共有974个,平均每例远端吻合口(3.0±0.4)个,平均每例桡动脉远端吻合口(1.1±0.4)个.桡动脉桥单纯端侧吻合321次,序贯吻合7次,利用桡动脉行T型桥或Y型桥16次.桡动脉近端直接吻合于主动脉328次,吻合于左胸廓内动脉9次,吻合于大隐静脉7次.桡动脉远端吻合于右冠状动脉系统234次,钝缘支95次,对角支/中间支22次.仅13例桡动脉取材处出现一过性感觉异常.围手术期无心肌梗死发生.住院期间7例患者(2.2%)死亡.平均随访(46.5±6.7)个月(12～81个月),患者全部存活.73例患者术后复查冠状动脉造影,复查时间为术后(47.5±11.2)个月(22-73个月),结果示桡动脉桥均通畅.结论 在老年CABG患者中选用桡动脉是安全有效的.     

Management of thumb hypoplasia

This chapter emphasizes the dilemma of salvage and reconstruction of the congenitally aplastic or hypoplastic thumb without normal cerebrocortical representation for prehensile grasp and pinch. The philosophy of reconstruction of the congenitally anomalous thumb is clearly divergent from thumb reconstruction following trauma. It is difficult to advise parents who seek surgical correction of the severely deficient thumb ray that amputation is the procedure of choice, to be followed by transfer of an otherwise normal digit to become a functional thumb unit. The psychological impact of these recommendations may be devastating to parents. Informed understanding of the likely progressive development of index-middle finger scissoring, pronation of the index ray with spontaneous broadening of the pulp, and the deteriorating use of an existing hypoplastic thumb may make the decision for ablation easier for parents. It is critical that these decisions be made through careful education and understanding, considering always the overall grasp-and-pinch capability of the hand as a whole. Reconstruction of the aplastic or hypoplastic thumb is an exciting and challenging area of hand surgery. The rewards are improvement in grasp and pinch either by functional integration of the reconstructed part, or by complete replacement of the deficient thumb by tissue from adjacent or distant donor sites. Success is measured not only in terms of cosmetic appearance, but as enhanced capacity of the child's hand in all activities of daily living (Fig. 39A and B).     

Thumb reconstruction by the wrap-around method

Reconstruction of a thumb amputated distal to the metacarpophalangeal joint can be accomplished by the "wrap-around" procedure. The operative procedure calls for an iliac crest graft to replace the bone of the amputated thumb. A flap from the great toe with innervation and circulation intact, including the toenail as well as sensory nerve, is wrapped around an iliac crest graft in a single-stage reconstruction of the thumb. This procedure allows a nice aesthetic result; the nail is transferred, sensibility is restored to the amputated thumb through the transferred neurovascularly intact flap, and the procedure is done at a single sitting. Results to date have been excellent in ten patients.     

Atrophy of the thumb web space in rheumatoid arthritis: clinical and electrodiagnostic studies

One hundred and twenty definite or classical rheumatoid arthritis (RA) patients with an average duration of the disease of 12.1 years were studied. Sixty-two patients had distinct atrophy of the first dorsal interosseous of the hand without definite signs of carpal, cubital, or ulnar tunnel syndrome (group A); 43 patients showed neither distinct atrophy nor sensory disturbance of either hand (group B). Other patients had sensory and/or motor disturbances due to carpal, cubital, or ulnar tunnel syndrome and other neuropathies. Electrodiagnostic examinations revealed that there were differences in the distal latency to the first dorsal interosseous muscle from the wrist between 24 group-A patients and 14 normal controls (P less than 0.05), and between the group-A patients and 12 group-B patients (P less than 0.1). The results of this study indicate that some RA patients with atrophy of the thumb web space may have compression neuropathy of the most distal branches of the ulnar nerve.     

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.     

Treatment of the triphalangeal thumb

Triphalangeal thumb is a thumb with 3 phalanges and has an estimated incidence of 1 in 25,000 live births. Clinical presentation of triphalangeal thumb can vary considerably. Most strikingly is the long finger-like thumb with clinodactyly, in the same plane as the fingers and may or may not present with an extra thumb. Anatomically, the extra phalanx can have different shapes, from wedge to rectangular. Furthermore, the involved joints, ligaments, muscles, and tendons of the first ray, from distal interphalangeal joint to radiocarpal joint, can be hypoplastic, malformed, or absent with varying degrees of stiffness or instability. Also, the first web can be insufficient, and radial polydactyly as well as other hand deformities can be present. The aim of surgical treatment is to try to reconstruct or correct the anatomic difference and at the same time provide a more acceptable appearance. In our series, depending on the malformation, operations varied from removal of the delta phalanx with ligament reconstruction to multiple osteotomies and rebalancing as well as pollicization. Complications are mostly related to structures that have not been reconstructed or corrected during operation. Results in these often complex cases can be rewarding if the surgeon has sufficient knowledge of the underlying anatomic differences.     

Reconstruction of traumatic absence of the thumb in the adult by pollicization.

Amputation of the thumb is a severe handicap. In an emergency situation, thumb amputation must be treated by means of reimplantation when possible. If reimplantation cannot be performed or fails, several methods of thumb reconstruction can be used according to various factors. These include the number of surviving fingers and the level of the thumb amputation. Pollicization is the first choice for amputations proximal to the metacarpophalangeal joint when four and even three fingers are present. It is the easiest and safest operation that supplies the best results both from the motor and sensory points of view. Pollicization can be done even in an emergency situation in selected patients. The index finger is preferred because it can be pollicized without palmar scar or tendons, vessels, or nerves crossing over. If a damaged finger is present, it is preferred to the index finger to leave one more sound finger; a damaged finger can frequently be used, because the thumb is shorter than the other fingers, and although its mobility is very important at the trapeziometacarpal joint, it is less important at the metacarpophalangeal and interphalangeal joint levels. It is preferable to take as much second metacarpal bone as necessary to place the transferred second metacarpophalangeal joint at the position of the thumb metacarpophalangeal joint so that the tendons of the index interosseous muscles can be sutured to the intrinsic muscles of the thumb. According to this concept, the distal phalanx of the transferred finger should be amputated. In this manner, the new thumb will have a normal size, only two phalanges, only one extrinsic flexor, and normal insertion of the muscles of the thumb.     

Atrophy of the thumb web space in rheumatoid arthritis: Clinical and electrodiagnostic studies

Summary One hundred and twenty definite or classical rheumatoid arthritis (RA) patients with an average duration of the disease of 12.1 years were studied. Sixty-two patients had distinct atrophy of the first dorsal interosseous of the hand without definite signs of carpal, cubital, or ulnar tunnel syndrome (group A); 43 patients showed neither distinct atrophy nor sensory disturbance of either hand (group B). Other patients had sensory and/or motor disturbances due to carpal, cubital, or ulnar tunnel syndrome and other neuropathies. Electrodiagnostic examinations revealed that there were differences in the distal latency to the first dorsal interosseous muscle from the wrist between 24 group-A patients and 14 normal controls (P < 0.05), and between the group-A patients and 12 group-B patients (P < 0.1). The results of this study indicate that some RA patients with atrophy of the thumb web space may have compression neuropathy of the most distal branches of the ulnar nerve.     

Effective use of portions of the supernumerary digit to correct polydactyly of the thumb

The purpose of surgery for polydactyly of the thumb is to ablate the supernumerary digit and to reconstruct a thumb with adequate function that approximates normal size and shape. A further aim is to prevent the occurrence of deformity in the future. To achieve these goals, one good thumb is reconstructed using portions from the supernumerary digit as follows: To increase the diameter of the reconstructed thumb, a skin flap is formed from the supernumerary digit. A portion of the joint from the supernumerary digit is used to correct joint deviation in the reconstructed thumb. The collateral ligament and abductor muscle are detached from the supernumerary digit with the bone fragment into which they are inserted, and transplanted together with the bone fragment into the reconstructed thumb. Osseous tissue to be used in open wedge osteotomy to correct longitudinal deviation is obtained from the phalanx of the supernumerary digit.     

Nail flaps for microsurgical aesthetic reconstruction of thumb and donor site of great toe

Abstract We describe a case of mutual transpositional transfers of toe and thumb in an attempt to restore the aesthetic appearance of the thumb with a deformity of the nail. The reconstructed thumb with the skin-nail flap from the great toe gave an excellent result both aesthetically and functionally, and the nail grew normally. The donor site of the great toe that was covered with the skin-nail flap from the thumb healed satisfactorily. This is another option for donor site management, the results of which are good, but the indications are under discussion.     

Triphalangeal Thumb with Polydactyly: An Alternative Surgical Method

Triphalangeal thumb (TPT) is congenital hand anomaly which a thumb consists of three phalanges. Thumb appearance can differ widely; the thumb can be longer than usual or it can be deviated in the radio-ulnar plane. Thumb strength and function can be significantly diminished. The goals of surgical treatment are to reduce the elongated thumb length, establish normal thumb function, maintain a stable joint and improve thumb position if necessary. In general, surgical treatment is performed for improvement of thumb function. The case presented here had a TPT with pre-axial polydactyly. The TPT was well developed but it had no movement at the proximal or distal interphalangeal joints. The rudimentary thumb had a well-developed and functioning interphalangeal (IP) joint. So as an alternative surgical technique we planned to transfer the functioning IP joint of rudimentary thumb to the TPT.     

Thumb metacarpal lengthening

Over a period of 35 years, 92 patients have been treated: 70 adults and 22 children age 8 to 14. The metacarpal lengthening obtained varied from 2 to 4.5 cm with an average of 3.5 cm, or equal to the length of a thumb proximal phalanx. In one third of the adult patients, due to delayed spontaneous ossification, the interfragmental space was bridged by a bone graft taken from the iliac crest. Late follow-up of 21 patients made 10 to 14 years after the treatment showed good function of the thumb with a normal pattern of skin sensibility. The lack of trophic changes in the distal part of the reconstructed thumb is due to the interposition type of bone lengthening, that is, the new bone structure is placed into the bone middle and not superimposed on the bone stump end, as is done in other methods of thumb reconstruction. The metacarpal lengthening procedure has the following drawbacks: (1) the full treatment course lasts several months; (2) the reconstructed thumb has neither joint nor nail. Advantages of the method are: (1) reconstruction of the thumb is done by using the available stump tissue resources; (2) the reconstructed thumb is covered by its own, normally innervated skin.     

Nail flaps for microsurgical aesthetic reconstruction of thumb and donor site of great toe

Abstract

We describe a case of mutual transpositional transfers of toe and thumb in an attempt to restore the aesthetic appearance of the thumb with a deformity of the nail. The reconstructed thumb with the skin-nail flap from the great toe gave an excellent result both aesthetically and functionally, and the nail grew normally. The donor site of the great toe that was covered with the skin-nail flap from the thumb healed satisfactorily. This is another option for donor site management, the results of which are good, but the indications are under discussion.     

Three-phalangeal thumbs

Many teratogenic mechanisms converge to create a three-phalangeal thumb: duplication, fusion and deletion. Fine observation of the position of growth centres and of associated hand malformations suggests that the intermediate delta phalanx of the three-phalangeal thumb results of the fusion of a three-phalanx ray with a two-phalanx thumb. The ulnar or radial side of the deviation is determined by the radial or ulnar position of this three-phalangeal ray fusing with the thumb. An opposable three-phalangeal thumb ulnarly deviated with a radial intermediate delta phalanx is the result of the fusion of a duplicated Wassel VII type thumb composed by a radial three-phalangeal ray and an ulnar two-phalangeal ray. In split hands, the three-phalangeal thumb is most often radially deviated because it presumably results from the fusion of a radial two phalanx thumb with the index, deleted in this fusion. The aligned opposable three-phalangeal thumb is quite uncommon and is probably the result of a fusion of two Wassel VII-type duplicated three-phalangeal rays. Conversely, the five-fingered hand or non-opposable three-phalangeal thumb, usually has no deviation and could result of a thumb deletion associated to an index duplication. This understanding of three-phalangeal thumbs makes usual classifications obsolete, but explains the various pathologic associations found in literature and in our own series. Treatment varies with age and takes in account all fundamental aspects of this congenital hand anomaly: the extraphalanx, the clinodactyly due to a delta phalanx, the thumb duplication or the absence of opposable thumb.     

Triphalangies du pouce

Many teratogenic mechanisms converge to create a three-phalangeal thumb: duplication, fusion and deletion. Fine observation of the position of growth centres and of associated hand malformations suggests that the intermediate delta phalanx of the three-phalangeal thumb results of the fusion of a three-phalanx ray with a two-phalanx thumb. The ulnar or radial side of the deviation is determined by the radial or ulnar position of this three-phalangeal ray fusing with the thumb. An opposable three-phalangeal thumb ulnarly deviated with a radial intermediate delta phalanx is the result of the fusion of a duplicated Wassel VII type thumb composed by a radial three-phalangeal ray and an ulnar two-phalangeal ray. In split hands, the three-phalangeal thumb is most often radially deviated because it presumably results from the fusion of a radial two phalanx thumb with the index, deleted in this fusion. The aligned opposable three-phalangeal thumb is quite uncommon and is probably the result of a fusion of two Wassel VII-type duplicated three-phalangeal rays. Conversely, the five-fingered hand or non-opposable three-phalangeal thumb, usually has no deviation and could result of a thumb deletion associated to an index duplication. This understanding of three-phalangeal thumbs makes usual classifications obsolete, but explains the various pathologic associations found in literature and in our own series. Treatment varies with age and takes in account all fundamental aspects of this congenital hand anomaly: the extraphalanx, the clinodactyly due to a delta phalanx, the thumb duplication or the absence of opposable thumb.     

An investigation of the digital nerves of the thumb

With the use of a stereoscopic microscope, observations were made on the course of the proper digital nerve of the thumb on ten upper limbs in adult cadavers. By observation from the dorsal side after removal of the bone, it was possible to clearly see the ramification of the digital nerve from the subcutaneous tissue to the dermis. Ramification from the palm to the level of the interphalangeal joint was segmental. The digital nerve of the thumb trifurcates from the proximal site of the distal palmar thumb crease into the main, medial, and lateral branches. The main branch is thick and extends from the center of the pulp toward the fingertip. Ramification at the pulp of the thumb is of a radiating rather than segmental type, and its control can be considered as spotty or intermittent. Distribution of pacinian corpuscles is dense in the subcutaneous tissue of the distal palmar thumb crease. These observations are of clinical importance not only for avoidance of injury to the digital nerve in surgical procedures such as the incision and drainage for felon and the trigger thumb release but also for precise repair of the digital nerve in the reconstructive surgery of the thumb.     

指动脉双叶皮瓣修复拇指皮肤套状缺损

目的：探讨应用指动脉双叶皮瓣修复拇指套状缺损的可行性.方法：自2007年1月至2012年12月,对45例拇指套状缺损患者采用指动脉双叶皮瓣修复治疗.男39例,女6例;年龄19～46岁,平均32岁.平甲根平面的掌侧皮肤和甲床缺损18例,拇指末节皮肤套脱19例,整个拇指皮肤套脱8例.根据拇指皮肤缺损情况,分别于中指尺侧和环指桡侧设计皮瓣的2个叶,以中环间的指总动脉及其向中指及环指的2个指固有动脉为血管蒂,皮瓣携带指固有神经,将皮瓣转位后瓦合覆盖拇指外露指骨.皮瓣供区用全层皮片植皮,观察皮瓣的外观、质地、颜色和耐磨性,植皮区外观、颜色和凹陷,皮瓣的感觉,手指活动等.结果：所有患者皮瓣及植皮区组织全部成活,完成随访43例,平均随访25个月.失访2例,皮瓣色泽及质地与健侧拇指指腹相近,两点辨别觉平均（4.2±0.3） mm.植皮区,皮肤颜色略深于周围皮肤.结论：应用指动脉双叶皮瓣修复拇指套状缺损是风险小、成功率高、修复效果较理想的手术方式.