Extending the limits of fingertip composite grafting with moist-exposed dressing

We introduced the concept of moist wound healing to extend the limits of fingertip composite grafting. In this retrospective study, we assessed the success of fingertip composite grafting with moist-exposed ointment dressing, which has been shown to maintain adequate moisture for optimal healing by frequent ointment application without the need for a secondary overlying dressing. We reviewed the outcome of composite graft replacement of 60 amputated fingertips in 56 consecutive patients over a period of 3 years and 3 months. Forty-two fingertips had survived completely and 18 had failed. Twelve of 15 fingers among patients younger than 15 years of age and 30 of 45 fingers among those 16 years of age and older had survived completely. We believe that our use of antibiotic ointment to maintain a moist environment was an important factor in improving the survival of composite grafts.     

One-stage Integra coverage for fingertip injuries

Background

We hypothesize that one-stage Integra skin coverage is an effective treatment modality for the treatment of fingertip defects.

Methods

Nine patients who sustained fingertip injuries were treated with one-stage Integra coverage. In all cases, Integra was placed directly on bone. Static two-point discrimination and the Semmes–Weinstein Monofilament Test (SWMFT) were used to determine the sensations of the affected and opposite unaffected digit. The QuickDASH, Cold Intolerance Symptom Severity (CISS), visual analog scale (VAS), and a 0–10-point pain scale were administered to assess patient function, satisfaction, and pain levels.

Results

The mean age was 53.1 years (39–61). There were 8 males and 1 female. The average area covered was 2.3 cm² (1.0–3.2). The mean follow-up duration was 16 months (8–46). The median QuickDASH, CISS score, VAS patient satisfaction, and 0–10 pain score were 9.1 (2.3–40.9), 18 (4–30), 10 (most satisfied) (7–10), and 0 (0–3), respectively. Five patients were evaluated for their digital sensory perception. The mean static two-point discrimination was 9.6 mm for the affected digit and 4.6 mm for the opposite unaffected digit. The median SWMFT was 4.31 for the affected digit and 3.61 for the opposite unaffected digit.

Conclusion

For small soft tissue and bone defects involving the fingertip, the use of Integra without further skin grafting appears to be effective, avoids the morbidity of the donor site, and avoids a second surgery. Despite mild sensory deficits, patients were satisfied with the results and fully functional during short-term follow-up.     

Secondary healing of fingertip amputations: a review

Most literature on fingertips reviews new surgical techniques of coverage while many surgeons prefer the results of secondary healing. This article reviews the current best evidence and concepts about secondary healing in fingertip injuries.     

Modification of VY flap to preserve fingertip contour

Background

VY flap is a reliable treatment for fingertip amputation injuries. Insetting the flap to replicate fingertip contour can be challenging with the conventional method of using sutures. We propose a modification of inset technique with K-wire to simplify contouring during flap inset.

Methods

Seven patients underwent VY flap reconstruction with the modified inset technique for fingertip defects ranging from 10 × 15 to 20 × 15 mm. The flaps were advanced between 6 and 10 mm and inset with K-wires. The donor site is allowed to heal by secondary intention. At 6 months, static two-point discrimination, sensitivity, and flap appearance were assessed.

Results

All flaps healed uneventfully, and each patient returned to work between 8 and 10 weeks. Fingertip and nail contour were satisfactory in every case.

Conclusion

This modification simplified contouring during flap inset and provided a viable alternative to flap inset and contour adjustment.     

特殊性手指末节及指尖离断再植的临床分析

目的回顾性分析特殊手指末节及指尖再植的临床效果.方法对于手指末节及指尖特殊断指再植,尽可能多的吻合血管或吻合1条动脉及1条静脉或吻合1条动脉加拔甲、小切口放血滴肝素处理等方法,恢复断指血循环.结果本组42例56指,成活50指,失败6指,成活率89.3%,成活患指功能及外形接近正常,病人对疗效满意.结论手指末节及指尖离断再植技术要求高,在充分认识伤情的基础上,慎重选择适应证的同时,高质量的血管吻合技术及对血管损伤的有效处理,可以大大提高再植的成活率.     

A novel technique for distal fingertip replantation: Polypropylene suture guided interpositional vein graft

Abstract

Background: Despite current advances in microsurgery, fingertip replantation is still controversial, mainly due to its difficulty and cost. The purpose of this study is to describe a new technique of interposition vein graft guided by polypropylene suture in distal fingertip replantation. Methods: A total of eight consecutive Tamai zone 1 fingertip replantations performed by the same author were included. All replantations were performed using interposition vein graft guided by polypropylene suture. This technique involved a vein graft of ～ 2 cm, with appropriate calibration, obtained from the volar part of the forearm and a 2-0 polyprolene suture passed through the interposition vein graft. Then, a polypropylene suture guide carrying the vein graft was inserted into the artery. The anastomosis was easily performed with the aid of 10-0 or 11-0 nylon in a bloodless medium and without encountering the posterior wall problem. Results: Average surgery time was 2.5 hours (range = 2–3 hours). Among eight Tamai zone 1 replantations, six were successful (75%). There were two replantations lost because of arterial failure. Conclusion: This technique may ease fingertip replantations and increase the success rate for Tamai zone 1 injuries.     

Composite grafting for distal digital amputation with respect to injury type and amputation level

Abstract

Purpose. This study evaluated the composite graft survival rate in distal digital amputations with respect to injury type and amputation level. Methods. Twenty-seven patients with complete fingertip amputations (32 digits) distal to the distal interphalangeal joint who were treated by composite grafting from January 2010 to February 2012 were enrolled. Injury type was classified as clean-cut, blunt-cut, or crush-avulsion. Amputation level was classified according to Ishikawa’s classification: subzones I–IV. Graft survival was categorised as complete, partial, or no survival. Results. The graft was more likely to exhibit complete survival in clean-cut injuries (50%) than in blunt-cut (10%) or crush-avulsion injuries (12.5%). However, when complete and partial survival were combined, there was no significant difference among injury types (clean-cut = 83.3%, blunt-cut = 70.0%; crush-avulsion = 68.8%). Composite grafting in sub-zone I provided good results (complete survival = 50%; partial survival = 50.0%; no survival = 0%). When complete and partial survival were combined, there was no significant difference with respect to amputation level except sub-zone I (II = 70.6%; III = 66.7%; IV = 60%). In sub-zone II, clean-cut injuries exhibited better graft survival than blunt-cut or crush-avulsion injuries. In sub-zones III and IV, no complete graft survival was observed. Conclusion. In conclusion, all types of injuries in sub-zone I and clean-cut injuries in sub-zone II are candidates for composite grafting. Blunt-cut and crush-avulsion injuries in sub-zone II are marginal candidates for composite grafting. Any type of injury in sub-zone III or IV is contraindicated for composite grafting and should be treated by microanastomosis.     

Lessons for adult fingertip regeneration: glimpses from basic research

Understanding the mechanisms involved in limb and finger regeneration holds promise for improving current treatment therapies. Recent animal studies have improved our understanding of the limb regeneration process markedly. Improved sophistication in experimentation has allowed results that partly reveal the cells of origin in fingertip regeneration in mouse models, which implicates a tissue-resident progenitor cell population. The impressive regeneration of amputated salamander limbs has been shown to work through an evolutionarily divergent mechanism and may not be open to direct translational approaches in mammals. In addition, researchers are beginning to understand the complexity of the interrelated mechanisms of axis determinants in chick embryo limb development. In this article, we review lessons to be learned from these divergent experiments, to understand fingertip regeneration in humans.     

Screening for blunt cerebrovascular injuries in pediatric trauma patients

BackgroundAdult imaging for blunt cerebrovascular injuries (BCVI) is based on the Denver and Memphis screening criteria where CT angiogram (CTA) is performed for any one of the criteria being positive. These guidelines have been extrapolated to the pediatric population. We hypothesize that the current adult criteria applied to pediatrics lead to unnecessary CTA in pediatric trauma patients.Study designAt our center, a 9-year retrospective study revealed that strict adherence to the Denver and Memphis criteria would have resulted in 332 unnecessary CTAs out of 2795 trauma patients with only 0.3% positive for BCVI. We also conducted a retrospective chart review of 776,355 pediatric trauma patients in the National Trauma Data Bank (NTDB) from 2007 to 2014. Data collection included children between ages 0 and 18, ICD-9 search for blunt cerebrovascular injury, and ICD-9 codes that applied to both Denver and Memphis criteria.ResultsOf 776,355 pediatric trauma activations, 81,294 pediatric patients in the NTDB fit the Denver/Memphis criteria for screening CTA neck or angiography based on ICD-9 codes, while only 2136 patients suffered BCVI. Strict utilization of the Denver/Memphis criteria would have led to a negative CTA in 79,158 (97.4%) patients. Multivariate regression analysis indicates that patients with skull base fracture, cervical spine fractures, cervical spine fracture with cervical cord injury, traumatic jugular venous injury, and cranial nerve injury should be considered part of the screening criteria for BCVI.ConclusionOur study suggests the Denver and Memphis criteria are inadequate screening criteria for CTA looking for BCVI in the pediatric blunt trauma population. New criteria are needed to adequately indicate the need for CT angiography in the pediatric trauma population.Level of evidenceIV.     

Dorsally extended digital island flap for repairing soft tissue injury of the fingertip

Background

The digital triangular island flap is one of the most useful types of flap for repairing soft-tissue loss at the fingertip, because it is sensate and has glabrous skin. However, this type of flap has several disadvantages, including limited length of advancement and limited flap size.

Methods

We have developed a new type of dorsally extended digital island flap to extend the reach of the digital triangular island flap. This dorsally extended portion, 15 mm in width and 20 mm in length, is based on the dorsal branch of the digital artery at the distal phalanx level. This island flap has a longer reach than the conventional digital island flap and can transfer larger amounts of soft tissue to the injured fingertip. Sixteen patients with fingertip amputation were treated using this flap.

Results

All of the flaps survived. The dorsally extended digital island flap could repair pulp tissue losses up to 30 mm in length in oblique volar injury. In transverse injury, a new fingertip could be produced with this flap in a single stage. We successfully covered the exposed bone without shortening the digital bone of the fingertip using our extended flap. No claw nail deformity occurred and no flexion contracture remained in any of the cases.

Conclusion

Use of a dorsally extended digital island flap is recommended for repairing fingertip injury in cases with defect sizes ranging from 10 to 30 mm in length and also in both oblique volar and transverse injuries. This flap is more versatile for repair of fingertip injury than the conventional digital island flap.     

拇指指尖离断再植

目的 介绍拇指指尖离断再植的临床经验。方法 采用改良逆行再植方法，用三种血运重建的方式对105例拇指指尖离断进行再植。结果 再植105例，成活四例，成活率94.2％，术后手指外形和长度与健指相似，两点辨别觉3～6mm，指甲生长良好。结论 熟悉拇指指尖血管分布规律及再植特点，可以明显缩短再植时间，提高再植成功率。     

指甲延长术在指尖损伤中的临床应用

目的总结指甲延长术在指尖损伤中的临床应用经验。方法用这种方法对8例（拇指3例,食指4例,中指1例）指尖损伤的患者进行了指甲延长术。在距甲根皮缘0.5～0.6cm处,去除一块矩形皮肤,勿损伤皮下血管网,其高度0.2～0.3cm,宽度与甲相等,将“U”形皮瓣向近端柔和推剥并缝合。结果1例术后供区发生表浅感染,经交换敷料逐渐愈合。所有甲延长的手指术后经过顺利,随访7个月～2年（平均13个月）,指甲外形较好,取得较满意的临床效果。结论在指尖损伤中应用指甲延长术,可延长指甲2～3mm,改善了手指的外形,没有发生甲生长畸形,是一种简单有效的指甲延长手术方法。     

Outcome of free digital artery perforator flap transfer for reconstruction of fingertip defects

Background:

Fingertip defect can be treated with many flaps such as random pattern abdominal flap, retrograde digital artery island flap, V-Y advancement flap, etc. However, swelling in the fingertip, dysfunction of sensation, flexion and extension contracture or injury in the hemi-artery of the finger usually occurs during the recovery phase. Recently, digital artery perforator flaps have been used for fingertip reconstructions. With the development of super microsurgery techniques, free flaps can be more effective for sensory recovery and durability of the fingertip.

Materials and Methods:

Six cases (six fingers) of fingertip defects were treated with free digital artery perforator flaps of appropriate size and shape from the proximal phalanx. During surgery, the superficial veins at the edge of flap were used as reflux vessels and the branches of the intrinsic nerve and dorsal digital nerve toward the flap were used as sensory nerves. The proximal segment of the digital artery (cutaneous branches) towards the flap was cut off to form the pedicled free flap. The fingertips were reconstructed with the free flap by anastomosing the cutaneous branches of digital artery in the flap with the distal branch or trunk of the digital artery, the flap nerve with the nerve stump and the veins of the flap with the digital artery accompanying veins or the superficial veins in the recipient site.

Results:

Six flaps survived with successful skin grafting. Patients were followed up for 6-9 months. The appearance and texture of the flaps was satisfactory. The feeling within the six fingers recovered to S4 level (BMRC scale) and the two point discrimination was 3-8 mm.

Conclusion:

Free digital artery perforator flap is suitable for repairing fingertip defect, with good texture, fine fingertip sensation and without sacrificing the branch of the digital artery or nerve.     

游离同侧前臂穿支皮瓣修复指端缺损

目的：分析探讨游离同侧前臂穿支皮瓣修复指端缺损的临床经验。方法自2011年6月至2014年6月,本科采用游离同侧前臂穿支皮瓣修复17例(18指)患者指端缺损,采用中华医学会手外科学会上肢部分功能评分试用标准等评定疗效。结果其中14个皮瓣顺利成活。2个骨间背侧穿支皮瓣、1个尺动脉穿支皮瓣、1个桡动脉穿支皮瓣在术后24 h内出现静脉危象。视循环危象具体情况分别采用拆除皮瓣部分缝线,皮瓣小切口放血,皮瓣按摩等方法处理,未行手术血管探查。2个皮瓣存活、1个部分坏死、1个全部坏死,全部坏死病例改用邻指皮瓣修复。患者均获得3.0~12.0个月随访,平均随访5.8个月。皮瓣色泽红润、质地柔软、外观自然、不臃肿,与周围皮肤接近。指端饱满,外形良好。两点辨别觉8~12 mm,无严重触痛。患指各关节活动基本正常,无关节坚硬。患者对指端感觉及伤指外形均较为满意,能适应正常的工作与生活。按中华医学会手外科学会上肢部分功能评定试用标准评定：优12指,良4指,可2指,优良率88.9%。结论游离同侧前臂穿支皮瓣移植修复指端缺损,皮瓣供区、受区位于同一上肢、同一术野。患者仅需在一侧臂丛神经阻滞麻醉下即可接受手术,可在止血带控制下进行无血、无创操作。手术操作简单、麻醉方便,成功率高。手术不破坏手背及手指组织,不损伤主干血管,损伤小。但是,手术需要较高显微外科技术,有一定的皮瓣坏死率,手术风险较高。     

复合移植物股-远端动脉旁路术(附8例报道)

目的：初步报道和评价复合材料移植物行膝下动脉旁路术挽救缺血肢体的结果。方法：８例缺乏合适自体静脉的病人应用复合移植物行膝下动脉旁路术,复合移植物近侧段为人造血管（ＰＴＦＥ）,远侧段为自体静脉,自体静脉跨越膝关节,术后应用节段性动脉压测定（踝／肱指数）、双功彩超和动脉ＤＳＡ检查进行随访。结果：所有病人术后症状明显改善,静息痛消失,平均踝肱指数由术前的０．２１提高到０．６７,术后平均随访时间约１年,随访期间双功彩超和动脉造影检查显示移植物通畅,１例病人术后２个月因移植物血栓形成,经再次手术后症状缓解。结论：当肢体面临严重缺血需行膝下动脉旁路术而又缺乏可供移植的自体静脉时,复合移植物旁路术提供了一种有效的方法。