Repair of thumb defect by using the toenail flap: biomechanical analysis of donor foot-a retrospective cohort study.

BACKGROUND: The thumb accounts for 50% of the total hand function. This study reports the functional outcomes and complications of people with traumatic thumb amputations who underwent toe-to-thumb reconstruction. METHODS: From January 2013 to January 2018, 29 patients with second-degree thumb defect underwent thumb reconstruction with distal phalangeal braided toenail flap. The footscan foot pressure gait analysis system was used to measure the index changes of the same foot before and after 1, 3 and 6 months. The contact area, peak pressure, impulse value, contact time of each gait phase, centre of gravity coordinate and foot balance were analysed statistically. RESULTS: Twenty-nine cases of thumb reconstruction recovered well. After following up for 6-15 months, the appearance of the reconstructed thumb was close to normal, and the sensation was restored to S3+. The two-point discrimination was 6-8 mm, and the function of the thumb was good. The function of the donor foot was well restored, and no skin ulceration, pain and claudication were noted during walking. Compared with that before the operation, the biomechanical indices of the donor foot were basically restored to normal 6 months after the operation. Only the stress and impulse values of the third metatarsal head were significantly increased, forming a stress concentration area centred on the third metatarsal head. CONCLUSIONS: This study confirmed that the toenail flap with distal phalangeal bone restored the second-degree thumb defect without destroying the main functional structure of the sole. The biomechanical indices of the donor foot were basically restored to normal 6 months after the operation. Only the stress concentration area centred on the third metatarsal head, and the pain on the forefoot was induced after the operation. Discomfort, callus formation, metatarsal fasciitis, etc., can lead to fatigue fracture of the third metatarsal bone in severe cases, which requires further follow-up and observation. TRIAL REGISTRATION: Clinicaltrials.gov , NCT03879941; registered on 10 March 2019, retrospectively.

Complications of high volume circumcision: glans amputation in adolescents; a case report.

BACKGROUND: The past four years has seen a rapid roll-out of male medical circumcision services in South Africa in response to clinical trials showing circumcision prevents HIV acquisition in heterosexual men. Clinics conduct substantial numbers of circumcisions per day. We report three cases of glans amputation in adolescents attending high volume clinics where modified Models of Optimising Volume and Efficiency (MOVE) are implemented. CASE PRESENTATIONS: Three cases of glans amputation in young healthy men that presented for voluntary medical male circumcision. The procedures were performed by highly experienced medical officers in two cases. All these cases shared characteristics: younger males with immature genitalia, forceps guided circumcision, and likely operator fatigue. Voluntary male medical circumcision programs should include regular monitoring and evaluation and training of operators to ensure high quality surgical techniques such as working in clean areas and taking frequent breaks. CONCLUSION: Circumcision is a relatively simple medical procedure, however regular training and quality control in high volume Male Medical Circumcision sites is essential to prevent rare catastrophic adverse events.

Traumatized index finger pollicization for thumb reconstruction-A case report.

When the index finger is injured or severed with a traumatic thumb amputation, transfer of the injured index finger can restore the function of the thumb. The purpose of this study was to evaluate the result of the transfer of an injured index finger for the traumatic loss of the thumb. A patient had a traumatic amputation at the first metacarpal level with the bone defect of the second metacarpal and proximal part of index finger. She was treated with a pedicled transfer of the injured index finger to the ipsilateral thumb. Postoperative evaluations included thumb range of motion, opposition and pinch function, grasp and pinch strength, sensation, and a patient-rated appearance of the thumb and hand. In result, the blood supply of the transferred traumatic index fingers was normal, and the transferred index fingers survived without complications. The range of motion of the first metacarpophalangeal joint and interphalangeal joint was almost the same as that of a normal thumb. The opposition and pinch function of the thumb was also normal. The patient is able to complete activities of daily living with the new thumb. Nevertheless, the sensation has not yet been completely restored. In conclusion, it is feasible to treat traumatic thumb amputation with the transfer of injured index finger.

A Uniquely Abnormal Stool Specimen: A Case Report.

BACKGROUND: Autoamputation of the appendix is a condition associated with the Ladd's procedure, a pediatric surgical technique for correction of intestinal malrotation. A 4-year-old male patient with a history of a Ladd's procedure performed as a newborn was brought in by his mother for "passing intestine" just prior to arrival. She reported that for several weeks her son had intermittent, crampy abdominal pain that resolved after the unusual-appearing bowel movement. After reviewing an image of the bowel movement, and in consultation with pediatric surgery, it was concluded that the patient had passed a devascularized appendix in his stool immediately prior to arrival. CASE REPORT: A 4-year-old boy with a past medical history of heterotaxy syndrome (inversion of the thoraco-abdominal organs), a double outlet right ventricle, and Ladd's procedure presented to the Emergency Department (ED) after "passing intestine" in his stool. Close examination of the photo demonstrated a tubular structure with taenia, consistent with an appendix. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Autoamputation of the appendix is an uncommon presentation in the ED. Passing a devascularized appendix is a benign condition and can present with weeks of intermittent abdominal pain that resolves with passage of appendix in the stool. Remnants of the appendix can remain within the intestinal lumen years after the Ladd's procedure. Emergency physicians with a general awareness of this rare phenomenon can confidently make the diagnosis and reassure worried parents.

Metacarpal-Like Hand: Classification and Treatment Guidelines for Microsurgical Reconstruction with Toe Transplantation.

The metacarpal-like hand is a severe hand injury, never addressed before. It describes a hand that has lost a significant degree of prehension through a wide array of amputations, involving all digits proximal to the functional length except in one finger or in two digits, including the thumb. The thumb condition can be used to differentiate between two types. In type I, the thumb is intact or amputated at or distal to the interphalangeal joint (functional length); therefore, the reconstruction is focused mainly on fingers. In type II, the thumb is amputated proximal to the interphalangeal joint; therefore, the reconstruction is focused on both the thumb and fingers. Thumb amputation level, integrity of the first basal joint, and functionality of the thenar muscles can be used to subdivide type II. Functional reconstruction should consider the patient's desire and vocational needs. The finger left with adequate functional length is assessed for its location, level of amputation, and joint motion, especially the proximal interphalangeal joint. The goal is to use the reliable techniques of toe-to-hand surgery to reconstruct more opposable units, at least two fingers, whether adjacent to each other or not, and the thumb, when needed, to achieve a functionally and aesthetically better hand instead of a functionally adequate hand, with a more acceptable to ideally natural hand cascade. Strategic, individualized toe transfer(s) is the key element in fulfilling the goals of this operation whether single or multiple toes are transplanted.

Gamma oscillations in the somatosensory thalamus of a patient with a phantom limb: case report.

The amputation of an extremity is commonly followed by phantom sensations that are perceived to originate from the missing limb. The mechanism underlying the generation of these sensations is still not clear although the development of abnormal oscillatory bursting in thalamic neurons may be involved. The theory of thalamocortical dysrhythmia implicates gamma oscillations in phantom pathophysiology although this rhythm has not been previously observed in the phantom limb thalamus. In this study, the authors report the novel observation of widespread 38-Hz gamma oscillatory activity in spike and local field potential recordings obtained from the ventral caudal somatosensory nucleus of the thalamus (Vc) of a phantom limb patient undergoing deep brain stimulation (DBS) surgery. Interestingly, microstimulation near tonically firing cells in the Vc resulted in high-frequency, gamma oscillatory discharges coincident with phantom sensations reported by the patient. Recordings from the somatosensory thalamus of comparator groups (essential tremor and pain) did not reveal the presence of gamma oscillatory activity.

Traumatic penile amputation: a case report.

BACKGROUND: Traumatic amputation of the penis is a rare surgical emergency. Although repair techniques have been well described in literature, failure of replantation and its causes are poorly understood and reported. Herein, we report the case of a 9 year old boy who underwent replantation of his amputated penis with delayed failure of the surgery, along with a discussion of recent advances in the management of this condition. CASE  PRESENTATION: A 9-year-old boy was referred to our hospital for traumatic amputation of the penis. Papaverine aided microsurgical replantation of the severed part was performed, but by 48 h, the glans became discoloured and necrosis set in by 4 days. Unfortunately, by day 12 two thirds of the re-implanted penis was lost along with overlying skin. CONCLUSION: Replantation of an amputated penis in a pediatric patient is a daunting task even for experienced surgeons. The vasodilatory effect of papaverine for vascular anastomosis is well described, but the use of a paediatric cannula for identification and instillation of papaverine into penile vasculature, has not been described for the repair of penile amputation. Despite its apparent failure, we believe this technique may be valuable to surgeons who might encounter this rare event in their surgical practice, especially in resource limited settings like ours.

Long-term outcome following upper extremity replantation after major traumatic amputation.

BACKGROUND: Amputations in general and amputations of upper extremities, in particular, have a major impact on patients' lives. There are only a few long-term follow-up reports of patients after macro-replantation. We present our findings in contrast with the existing literature. METHODS: Sixteen patients with traumatic macro-amputation of an upper extremity were eligible for inclusion in this study. Altogether, the patients underwent replantation in 3 institutions between 1983 and 2011. RESULTS: Twelve male and four female patients with an average age at injury of 40.6 years (range, 14-61 years) were included in this study. The mean follow-up period was 13.5 years (range, 4.4-32.6 years; SD, 5.7 years). The mean disabilities of the arm, shoulder and hand (DASH) outcome measure was 41 (range, 5.2-94.8; SD, 18.2), functional independence measurement (FIM) was 125 (range, 120-126; SD, 1.8). Chen I representing very good function was accounted in six, Chen II representing good function in eight, Chen III (fair) in one and Chen IV (bad function) in one patient. CONCLUSIONS: We found that while the majority of the included patients exhibited good or very good function of the extremity, none of the replanted appendages regained normal levels of functionality. In addition, all participants were very satisfied with their outcomes. Positive long-term results with high rates of subjective satisfaction are possible after replantation of upper extremities.

Gait rehabilitation for a patient with an osseointegrated prosthesis following transfemoral amputation.

BACKGROUND: In patients with a transfemoral amputation socket-related problems are associated with reduced prosthetic use, activity, and quality of life. Furthermore, gait asymmetries are present that may explain secondary complaints. Bone-anchored prostheses (BAPs) may help these patients. Two types of BAP are available, screw and press-fit implants. Rehabilitation following surgery for a press-fit BAP is poorly described. PURPOSE: To describe a rehabilitation program designed to minimize compensation strategies and increase activity using a case-report of an active, 70-year-old man with a traumatic transfemoral amputation who had used a socket prosthesis for 52 years and received a press-fit BAP [Endo-Exo Femoral Prosthesis - EEFP]. INTERVENTION: A 13-week physiotherapy program. OUTCOMES: Outcomes were assessed before surgery, at the end of rehabilitation, and six-month and one-year follow-ups. After rehabilitation gait had improved, the patient had more arm movement, more pelvic shift, less hip rotation during swing phase on the prosthetic side, and absence of vaulting on the sound side. Isometric hip abductor strength was 15% higher on the sound side and 16% higher on the prosthetic side, and walking distance increased from 200 m to 1500 m. At the six-month follow-up, the patient had lower back complications and reduced hip abductor strength and walking distance. At one-year follow-up, walking distance had recovered to 1000 m and gait pattern had improved again, with yielding and absence of terminal impact on the prosthetic side. CONCLUSION: The described rehabilitation program may be an effective method of improving gait in patients with an EEFP even after long-term socket usage.

Lawnmowers Versus Children: The Devastation Continues.

BACKGROUND: Accidents with lawnmowers can cause mutilating injuries to children. Safety guidelines regarding the use of lawnmowers were promoted by professional organizations beginning in 2001. The Pennsylvania Trauma Systems Foundation maintains a database including all admissions to accredited Levels 1 to 4 trauma centers in the state. The annual rates of admission for children in our state and the severity of injuries subsequent to introduction of safety guidelines have not been reported, to our knowledge. Ride-on lawnmowers have been associated with more severe injuries in children. QUESTIONS/PURPOSES: We asked: (1) What was the incidence of hospital admissions for children with lawnmower-related injuries during 2002 to 2013 and did the incidence vary by age? (2) What was the severity of injuries and did the severity vary by age? (3) How often did these injuries result in amputation? (4) What types of lawnmowers were involved? METHODS: This was a retrospective study using a statewide trauma registry. We queried the Pennsylvania Trauma Outcome Study database for children 0 to 17 years old admitted to trauma centers in Pennsylvania between January 2002 and January 2014 with injuries resulting from lawnmower-related accidents. All accredited Levels 1 to 4 trauma centers in the state are required to submit their data to the Pennsylvania Trauma Systems Foundation which maintains the Pennsylvania Trauma Outcome Study database. Demographic information, Injury Severity Scores, International Classification of Diseases procedure codes, and injury location codes were recorded. Type of lawnmower was determined from the narratives and was identified in 60% (119/199) of patients. Traumatic and surgical amputations performed during the index hospitalization were included in the analysis. Information on later surgeries was not available. Subjects were stratified by age: 0 to 6, 7 to 12, and 13 to 17 years old. RESULTS: The incidence of lawnmower injuries in Pennsylvania was a median five of 100,000 children (range, 4-12/100,000) during the study period. The median age was 6 years (range, 1-17 years). The median Injury Severity Score was 4 (range, 1-75). Children 0 to 6 years old had higher median Injury Severity Scores (median, 8; range, 1-75) compared with those 13-17 years old (median, 4; range, 1-20; difference of the medians, 4; p < 0.001). A total of 53% of the patients (106/199) underwent at least one amputation. There were 83 amputations in or of the foot, 18 in the leg, 14 in the hand, and three in the arm. Ride-on lawnmowers accounted for 92% (110/119) of mowers identified by type. CONCLUSIONS: The incidence of serious injuries to children owing to lawnmower-related trauma did not change during the 12-year study period. If children younger than 6 years had not been near the lawnmower and those younger than 12 years had not been operating one, at least 69% of the accidents might have been prevented. We recommend annual publicity campaigns during spring to remind the public of the dangers of lawnmowers to children. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Traumatic amputations in children and adolescents: A demographic study from a tertiary care center in Northern India.

PURPOSE: To determine the demographic pattern, level, mechanism of traumatic amputation in children and adolescent age group and to compare findings with other studies. METHODS: Patients aged less than 18 years with traumatic amputation attending Department of Physical Medicine and Rehabilitation, King George's Medical University, Lucknow, India between July 2013 and January 2016 were enrolled and their demographic characteristics were analyzed. RESULTS: Fifty-three patients were included aged less than 18 years when injured. Mean age of the population studied was 9.89 ± 4.13 with male to females ratio of 3:2. Majority (69.81%) of traumatic amputations involved lower limb. Most common level was unilateral transtibial (35.85%), followed by transfemoral (16.98%). In upper limb, most common type was transradial. RTA followed by train accidents was most common mechanism of traumatic amputation. 8 patients needed revision surgery. 52.8% patients of acquired amputations complained of phantom sensation and 37.74% phantom pain. CONCLUSIONS: This study aims to visualize the current scenario and the data generated could be possibly helpful in planning policies and programs at institutional as well as at higher levels for prevention, treatment and distribution of resource to the young amputee population, to ensure their better health care and also opportunities in life.

Surgical Technique Utilizing Suture-Button Device for Central Metacarpal Ray Resection.

Certain technical demands must be overcome in order to accomplish the goals of creating a functional hand when performing a central digital ray resection of the hand. One of the biggest challenges is maintaining metacarpal gap closure and in such a way that the metacarpals are balanced and not rotated. Inadequate closure of the defect created between the metacarpals by a central ray resection will produce a persistent gap between the remaining fingers as well as the potential for malalignment. Current techniques are fraught with difficulty and have frequently proven inadequate. We describe a technique for performing a central ray resection without the worry of nonunion, malunion, or increase in gap. With the development of newer fixation devices, we have been able to perform central ray resection while optimally closing the gap, controlling rotation, and providing good hand function.

Pain Phenotypes and Associated Clinical Risk Factors Following Traumatic Amputation: Results from Veterans Integrated Pain Evaluation Research (VIPER).

OBJECTIVE: To define clinical phenotypes of postamputation pain and identify markers of risk for the development of chronic pain. DESIGN: Cross-sectional study of military service members enrolled 3-18 months after traumatic amputation injury. SETTING: Military Medical Center. SUBJECTS: 124 recent active duty military service members. METHODS: Study subjects completed multiple pain and psychometric questionnaires to assess the qualities of phantom and residual limb pain. Medical records were reviewed to determine the presence/absence of a regional catheter near the time of injury. Subtypes of residual limb pain (somatic, neuroma, and complex regional pain syndrome) were additionally analyzed and associated with clinical risk factors. RESULTS: A majority of enrolled patients (64.5%) reported clinically significant pain (pain score ≥ 3 averaged over previous week). 61% experienced residual limb pain and 58% experienced phantom pain. When analysis of pain subtypes was performed in those with residual limb pain, we found evidence of a sensitized neuroma in 48.7%, somatic pain in 40.8%, and complex regional pain syndrome in 19.7% of individuals. The presence of clinically significant neuropathic residual limb pain was associated with symptoms of PTSD and depression. Neuropathic pain of any severity was associated with symptoms of all four assessed clinical risk factors: depression, PTSD, catastrophizing, and the absence of regional analgesia catheter. CONCLUSIONS: Most military service members in this cohort suffered both phantom and residual limb pain following amputation. Neuroma was a common cause of neuropathic pain in this group. Associated risk factors for significant neuropathic pain included PTSD and depression. PTSD, depression, catastrophizing, and the absence of a regional analgesia catheter were associated with neuropathic pain of any severity.

Digit Replantation The First 50 Years.

Since the first successful digit replantation by Japanese surgeons Komatsu and Tamai, the past half century has seen the field of digit replantation in the USA experience exponential growth followed by a steady decline in volume of cases and percentage of successful viable digits. The initial enthusiasm and technical progress of digital replantation has been tempered by mediocre functional outcomes, rising healthcare costs, and limited healthcare resources. The history and approach to digit replantation is reviewed and highlights the likely push toward the development of regional replant centers staffed by highly skilled teams to improve the functional outcomes following these complex procedures. More than 50 years have passed since the first successful digit replantation by Komatsu and Tamai who replanted a sharply amputated thumb in a 28-year-old male at the metacarpal-phalangeal joint level in a 4.5 hour procedure. Two arteries and 2 veins were anastomosed using 8-0 monofilament nylon and 7-0 braided silk suture. The patient remained in the hospital for 40 days and did not return to work for 4 months. News of this triumph of microvascular skill was heralded throughout the world as the first successful replantation of a completely amputated digit. Over the past half century, the field of digit replantation in the USA experienced exponential growth followed by a steady decline in volume of cases and percentage of successful viable digits. The initial enthusiasm and technical progress of digital replantation has been tempered by mediocre functional outcomes, rising healthcare costs, and limited healthcare resources. In the next 50 years, it is possible that the majority of digit replantation procedures in the USA may be performed in tertiary centers or regional replant centers by highly skilled teams.

Postoperative care in finger replantation: our case-load and review of the literature.

OBJECTIVE: Technical success of a finger replantation depends on several factors such as surgical procedure, type of injury, number of segments amputated, amputation level and individual patient factors. Among early complications that can occur in this type of surgery the onset of venous or arterial thrombosis is the most dreaded. Local irrigating solutions, oral and intravenous anticoagulants, thrombolytic agents, plasma expanders, vasodilating, and antiaggregant drugs are routinely used in patients undergoing microvascular procedures, but currently there is only a non-standardized practice based on anecdotal personal experience. MATERIALS AND METHODS: The aim of our study is to review selected literature relating to perioperative therapy in microsurgical digital replantation. We also report our case-load of 16 patients with finger avulsion describing our particular protocol for postoperative anticoagulation and restoration of fluid and electrolyte balance. RESULTS: Following our daily pharmacological protocol, the postoperative course of the replanted fingers was uneventful. The survival rate for finger replantations performed was 100% (n = 16) with no need for surgical revisions. CONCLUSIONS: The association Dextran-40/Heparin/fluids in the proposed standardized pro-weight pharmacological protocol is an optimal postoperative prophylactic/therapeutic plan to reduce the incidence of endovascular thrombosis after replantation, so ensuring high rate of success in microvascular surgery.

Heterotopic Procedures in Mutilating Hand Injuries: A Synopsis of Essential Reconstructive Tools.

BACKGROUND: In the complex and challenging treatment of a mutilating hand injury, any available resources need to be primarily recruited. Besides direct digital replantation, the tissue of the nonreplantable "spare parts" could often be "recycled," and also some replantable or injured structures could be "redistributed" in a more functional individualized pattern, irrespective of their initial origin. METHODS: Ten patients, six male and four female, were treated for multidigital mutilating injury with various "heterotopic" procedures. Immediate digital heterotopic replantations were performed in seven patients. In one case, the bone and skin of a nonreplantable digital part were used as grafts in the reconstruction of a metacarpal bone and the overlying skin defect. A neurovascular fillet flap from a nonreplantable finger for the reconstruction of the webspace and a pollicization of an injured index were undertaken in two further cases. Another patient underwent pedicled transfer of the proximal interphalangeal joint and metacarpal bone of an impaired index to the middle finger. RESULTS: Sensate prehensile function was restored in 100 percent of the cases, and the ability for tripod pinch and more subtle tasks was restored in 90 percent. The minimum of two long fingers and a thumb was restored in every case, and the patients judged the appearance of their hands as "acceptable." CONCLUSION: In the reconstruction of a mutilating hand injury, besides and beyond the straightforward microsurgery, the various heterotopic procedures are essential reconstructive tools that can enhance the versatility of the hand surgeon when pursuing a better outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

[Experience in treatment of combined osteovascular limb injuries in children].

The article is dedicated to one of the currently important problems of present-day traumatology and angiosurgery, i. e. possibility of performing primary reconstructive operations in children with complete and incomplete amputations, open and closed bone fractures in the conditions of circulatory impairment. The authors share their experience in treatment of 92 patients presenting with such injuries, describing the main indications for carrying out repair operations, and drawing appropriate conclusions. The main stages of reconstructions are demonstrated by a series of clinical examples.

Surgical revision for stump problems after traumatic above-ankle amputations of the lower extremity.

BACKGROUND: Stump problems (SPs) secondary to traumatic lower limb amputation had a crucial influence on amputees' ability to return to living and work. The purpose of this study was to investigate the surgical management strategies of the SPs after above-ankle amputation of the lower limb secondary to trauma. METHOD: A cohort of clinical cases, who were troubled by SPs after above-ankle amputation following trauma, had undergone revision surgery of the stump and was analyzed retrospectively. Various factors were noted like sex, unilateral or bilateral, amputation type, and causes of trauma. Different SPs like excess soft tissue (where a considerable amount of soft tissue interposed between the rigid elements which hindered the fitting of a prosthesis), scar, ulcers, neuromas, and bone spurs were taken as dependent variables. The relationship between factors and SPs was analyzed. RESULTS: A total of 80 stumps were treated surgically. The frequency of excess soft tissue in above-knee amputation cases was higher than that in below-knee amputation (p = 0.007). Bone spur occurred more frequently in the unilateral amputation than in bilateral ones (p = 0.018). There was a significant difference in the ADL scores between admission and discharge (p = 0.000). CONCLUSION: Stump problems secondary to traumatic lower limb amputation had crucial influence on amputees' ability to return to living and work, appropriate evaluation and timely surgical revision showed excellent results.

[Management of peripheral injuries of the finger]. / Management peripherer Verletzungen der Finger.

The treatment of acute peripheral finger injuries is part of the daily routine of surgeons in emergency departments. This article presents the most common forms of peripheral finger injuries and the specific diagnostic and therapeutic aspects. The injuries include incision and tear injuries, injuries to the nailbed, distal extensor tendon injuries, severed flexor tendons of the distal joint, bite injuries, high-pressure injection injuries and amputation injuries of the distal phalanx of fingers. For the latter, the form, level and height of the amputation are decisive for therapy. Soft tissue defects on the extensor and flexor side of the finger are also common for emergency surgeons. The basic principles of the initial management of peripheral soft tissue injuries of the hand involve the reconstruction of tendons and nerves and soft tissue coverage. Pathogenic organisms are detectable in more than 80 % of bite wounds so that prophylaxis and therapy of infections are of special importance. An adjuvant antibiotic therapy is necessary for infections as well as for high-pressure injection injuries. It is also important for the treating physician to recognize when a hand surgeon must be involved.