Management of complex tissue injuries and replantation across the world

Management of complex tissue injuries and provision of replantation services calls for the availability of a dedicated team with high skill levels and good infrastructure. Centres of excellence which provide consistent good care exist in many parts of the world, but large populations are still left uncovered. In the developed world, the reduced exposure to such injuries, lesser training opportunities and poor reimbursement for the efforts put in are the problems. In the developing countries, lack of awareness of the possibilities, inadequate transport systems and infrastructure are the problems. In both systems the cornerstone for improvement will be the availability of well trained surgeons who will deliver consistent good results. Public education and developing a team around the surgeon will improve the results in developing countries. Collaboration with good units with high volume load in the developing countries will be beneficial for training and maintainance of the required skill levels in the developed world.     

The VO2 slow component: relationship between plasma ammonia and EMG activity

PURPOSE: An increased recruitment of type II muscle fibers has been suggested as a major cause of the slow component of O(2) uptake (VO(2)) kinetics. Furthermore, the rise in plasma ammonia (NH(3)) during high-intensity exercise, where a slow component is observed, has been associated with the activation of type II muscle fibers. Therefore, the purpose of this study was to examine the relationship between the VO(2) slow component, plasma NH3 concentration, and electromyography (EMG) responses during constant-load cycling. METHODS: Eight healthy adults (mean age +/- SEM: 21.4 +/- 1.0 yr) performed 7 min of heavy constant-load exercise. The breath-by-breath VO(2) response was characterized using a two-term exponential model. Plasma NH(3) concentration was measured at rest, following 3 min of unloaded cycling and at 3 and 7 min of constant-load exercise. Surface EMG activity of the right vastus lateralis muscle was measured during the final 10 s of every minute of exercise. RESULTS: The amplitude of the slow component was 561 +/- 52 mL.min(-1), and occurred 132 +/- 11 s following the onset of constant-load exercise. Plasma NH(3) concentration increased significantly from 3 to 7 min of constant-load exercise by 32.2 +/- 2.9 micromol.L(-1). The rise in plasma NH(3) concentration correlated significantly with the amplitude of the slow component (r = 0.79, P < 0.05). The mean power frequency of the EMG increased significantly while the integrated EMG/VO(2) ratio remained constant over the duration of the slow component. CONCLUSION: The rise in NH(3) concentration and the amplitude and spectral components of the EMG are consistent with a progressive increase in the recruitment of type II muscle fibers during the slow component phase of exercise.     

Functional evaluation of a great toe transfer and the osteoplastic technique for thumb reconstruction in the same individual

Since the popularization of microvascular toe transfer, there has been a tendency to relegate osteoplastic reconstruction techniques for the thumb to history. A case is presented which shows that a successful and well-planned osteoplastic thumb reconstruction can match microsurgical reconstruction in all functional activities. Cosmetically, the toe transfer is the better reconstructive option but it may cause significant donor site morbidity.     

A Unique Case of Replantation of Previously Replanted Fingers

Replantation of digital amputations is now the accepted standard of care. However, rarely will a replantation surgeon be presented with amputated fingers which have been previously replanted. In our literature search, we could find only one publication where a replanted thumb suffered amputation and was successfully replanted again. We report the technical challenges and the outcome of replanting two fingers which suffered amputation 40 months after the initial replantation and were successfully replanted again. Replantation was critical since the amputated fingers were the only two complete fingers in that hand which had initially suffered a four-finger amputation. The second-time replantation of previously replanted fingers is reported to allay the concern of the reconstructive surgeon when faced with this unique situation of “repeat amputation of the replanted finger.” Second-time replantation is feasible and is associated with high-patient satisfaction. Replantation must be attempted especially in the event of multiple digit amputations.     

Outcomes and Disability After Massive Proximal Upper Extremity Reconstruction in a Resource-Limited Setting

Background

At Ganga Hospital in Coimbatore, India, a unique approach is applied to treat massive upper limb injuries. However, long-term outcomes of complex reconstruction performed in the resource-limited setting are not known. This hinders understanding of outcomes and disability from these injuries and prevents systematically addressing care delivery around upper extremity trauma in the developing world. This project aims to analyze the details of the unique Ganga Hospital reconstruction experience and use patient-reported outcome measures for the first time in this patient population to evaluate post-injury recovery and disability .

Methods

Forty-six patients were evaluated 6 months or more after massive proximal upper extremity reconstruction at Ganga Hospital. Patients completed functional tests, Jebsen–Taylor test (JTT), and patient-reported outcomes (PROs)—Michigan Hand Questionnaire (MHQ), Disability of Arm, Shoulder, and Hand questionnaire (DASH), and Short-Form 36 (SF-36). Correlations between metrics were assessed with Pearson’s correlation coefficients. Linear regression modeling evaluated associations between severity, reconstruction, and outcomes.

Results

MHQ and DASH results correlated with functional test performance, JTT performance, and SF-36 scores (Pearson’s coefficients all ≥0.33, p ≤ 0.05). In this cohort, mean MHQ score was 79 ± 15 and mean DASH score was 13 ± 15, which are not significantly different than scores for long-term outcomes after other complex upper extremity procedures. The following factors predicted PROs and functional performance after reconstruction: extent of soft tissue reconstruction, multi-segmental ulna fractures, median nerve injury, and ability for patients to return to work and maintain their job after injury.

Conclusions

Complex proximal upper extremity salvage can be performed in the resource-limited setting with excellent long-term functional and patient-reported outcomes. PRO questionnaires are useful for reporting outcomes that correlate to functional and sensory testing and may be used to assess post-traumatic disability.