Sensory recovery in replanted digits and transplanted toes: a review

A review of replanted digits has indicated that excellent sensory function can be recovered in replants that are distal, in which the mechanism of injury has been a sharp cut, in which the patient's age is young, and in cases where the patient receives postoperative sensory re-education. It appears that poor sensory recovery in replanted digits is most directly attributable to crush or avulsion type injuries and lack of sensory re-education in the postoperative period. The level of sensory recovery in toe-to-thumb transfers appears to be better than in the donor toe and better than in replanted digits. The explanation for this most likely lies in the sharp "mechanism of injury" in the toe-to-thumb transfer and in the "extra" postoperative rehabilitation such cases receive. Future improvements in recovery of sensation in replanted digits may come from increased use of nerve grafting in those digits that have been crushed or avulsed, and by instituting routine sensory re-education in the postoperative period.     

Sensory recovery following digital replantation

The recovery of sensibility following digital replantation is essential in the restoration of hand function. We reviewed 12 series of digital replantations between 1977 and 1989. Three hundred sixty-seven fingers and 87 thumbs were successfully replanted. Mean age was 32.5 years. Mean follow-up was 33.5 months. Mean static two-point discrimination (S2PD) was 9.3 mm in clean thumbs vs. 12.1 mm in crush/avulsion thumb replantations. Mean S2PD was 8 mm in clean finger vs. 15 mm in crush/avulsion finger replantations. Overall mean S2PD was 11 mm in thumb and 12 mm in finger replantations. Sixty-one percent of replanted thumbs and 54% of replanted fingers regained useful S2PD (less than 15 mm or greater than or equal to S3 +). Factors that influenced digital sensibility following replantation included patient's age, level and mechanism of injury, digital blood flow, cold intolerance, and postoperative sensory reeducation. Recovery of sensibility in the replanted digit is comparable to simple nerve repair and to nerve grafting techniques. Further emphasis should be on elucidating the mechanism of cold intolerance, which was a significant complaint for most replanted digits. The universal practice of postoperative sensory reeducation will continue to improve digital sensibility following replantation.     

Sensory recovery after median nerve grafting.

Fourteen patients were evaluated prospectively after median nerve grafts. Twelve male and two female patients with a mean age of 41 years were included. Mean time since surgery was 4 years. Detailed sensory evaluations were completed. Statistical evaluation analyzed relationships between object identification, sensory tests, and graft length. According to the S-0 to S-4 grading system, 11 patients were considered to be S-3+ or greater. Recovery of moving two-point discrimination of 2 to 3 mm. was achieved by 50% of the patients. Strong correlations were found between object identification and static two-point discrimination, moving two-point discrimination, and graft length. Cutaneous pressure threshold and vibration threshold correlated weakly with object identification.     

Lesser toes proximal interphalangeal joint fusion in rigid claw toes

Rigid claw toes are a common complaint. Multiple procedures have been described for solving this condition, but fusion remains the most common, with reproducible results. Various methods to fuse the proximal interphalangeal joint and different stabilization methods have been proposed and used. In this article, the various alternatives are summarized and the authors' preferred technique is explained.     

Trigger toes

We report a case of bilateral trigger toes. The clinical presentation is similar to that experienced by patients with trigger finger. A history of painful and at times audible clicking of the toes should alert the clinician to the diagnosis. Conventional radiography, ultrasonography and magnetic resonance imaging were unhelpful in establishing a diagnosis. Surgical release of the flexor tendon sheath at the level of the medial malleolus effected complete cure.     

Open flexor tenotomy for hammer toes and curly toes in childhood

Sixty-two children were reviewed between 3 and 14 years (average 9.8 years) after flexor tenotomy for curly toes or hammer toes. No patients were aware of loss of flexor power in the toes. In only 5% of 188 toes was the operation unsuccessful. When the cause of failure was identifiable it proved to be that the scar crossed one or more flexor creases. None of the operated toes had an abnormally extended posture; only one toe was stiff and this resulted from tethering by a scar. It is concluded that open flexor tenotomy is an effective method for correcting curly toes and hammer toes in childhood. Pre-operative assessment must demonstrate that the resting length of the flexor tendons is unduly short, and that this shortening is the only cause of the deformity.     

Sensory recovery in melolabial flaps used for oral cavity reconstruction.

Current literature advocates the use of complex reinnervated free flaps to re-establish oral sensation after resection of oral cavity cancers. It has been demonstrated that noninnervated flaps can also re-establish sensation. We assessed the return of sensation in local melolabial flaps used in oral reconstruction. Seven patients underwent sensory testing at intervals from 12 to 18 months after surgery. The ability to distinguish differences in temperature was present in all patients. Spontaneous return of sensitivity to touch was documented by clinical testing in 71% of the patients. Less return of sensation was seen in flaps used for defects of the buccal mucosa relative to the floor of mouth. We conclude that spontaneous return of flap sensation does occur with local melolabial flaps. Given the simplicity of these procedures, melolabial flaps represent a reasonable alternative in floor-of-mouth reconstruction for selected patients.     

Flexor tendon lengthening for hammer toes and curly toes in paediatric patients

The purpose of this retrospective study was to evaluate the outcome of flexor tendon lengthening performed for hammer toes or curly toes in children, after a mean follow up of 31 months. Specific attention was given to postoperative active flexion of the toe. The deformity improved in all patients, but less in the fourth and fifth toe. Active flexion returned and strength was recovered in all patients. We think that open flexor tendon lengthening for hammer and curly toes is a safe and reliable procedure. We recommend a transverse skin incision, Z-lengthening of the flexor digitorum longus in hammer toes and an associated tenotomy of the flexor digitorum brevis in curly toes.     

Sensory recovery following decellularized nerve allograft transplantation for digital nerve repair

Abstract

This study reported preliminary clinical experience of using decelluarised nerve allograft material for repair of digital nerve defect in five hand injury patients. From October 2009 to July 2010, five patients with traumatic nerve defect were treated with nerve repair using AxoGen® nerve allograft (AxoGen Inc, Alachua, FL) in California Hospital Medical Center. All patients were followed at least for 12 months, and sensory recovery and signs of infection or rejection were documented by a hand therapist. Average two-point discrimination was 6 mm, and average Semmes-Weinstein Monofilaments test was 4.31. No wound infections or signs of rejections were observed at wound site. All patients reported sensory improvement during the follow-up period after operation. It is believed that decellularised nerve allografts may provide a readily available option for repair of segmental nerve defect.     

Strapping of curly toes in children

This is a retrospective review of 49 children with curly toes treated by strapping; 24 children (44 toes) presented for review. The strapping produced improvement in 68% of toes while strapping was maintained, but there was a statistically significant loss of correction once strapping was stopped. There was some sustained improvement in the shape of the toes compared with the natural history, but not sufficient to warrant its use for this minor congenital deformity. Treatment should be reserved for the more severely deformed toe, as this may cause symptoms in later life, and the author recommends open flexor tenotomy.     

Claw toes after tibial fracture in children

Purpose  

The development of claw toe deformity following fracture of the tibia in children has not been described in our review of the literature. We report on the management of the acquired claw toe deformity after tibia fracture in five children.