Primary reconstruction of a degloved hand using multiple toe transfers on a single pedicle and a reversed radial artery flap.

This case study reports one-stage reconstructive surgery on an 18-year-old man who was injured by an industrial roller machine and who presented with a degloved hand. Non-replantable delgloving occurred in all fingers, with the loss of the palmar and part of the dorsal skin. Multiple free contiguous toes were transferred based on a single dorsalis pedis artery pedicle. The artery was anastomosed to a reversed radial artery flap, which was used to cover the palm for primary reconstruction of the degloved hand. Multiple toes were harvested from the same foot, based on a single pedicle, to contain the potential morbidity to one foot, to enable primary reconstruction, and to decrease the length of the operation. The flaps healed well, and the patient demonstrated adequate tripod pinch and key pinch with the transferred toes, with a two-point discrimination of 12 mm at 1-year follow-up. The patient was satisfied with both the appearance and function of the hand and foot.

Replantation of total degloving of the hand: case report.

This article reports a patient who had a total degloving of the hand, caused by a roller injury, up to the distal forearm level. The authors replanted the degloved skin using arteriovenous anastomosis of the radial artery at the wrist to the cephalic vein in the degloved skin in an end-to-side manner. To enhance the survival of the replanted skin, it was deepithelialized and buried in an abdominal pocket created specifically for this purpose. The replanted skin survived, except at the terminal portions of the fingers. The patient had reasonable function and cosmesis after the wound healed. The procedure may be used for the treatment of this rare injury to salvage a cosmetically acceptable and functional hand.

A comparative analysis of the six-strand double-loop flexor tendon repair and three other techniques: a human cadaveric study.

The ideal zone II flexor tendon repair would be easy to perform, cause minimal scarring, and be strong enough to allow early active motion. A 6-strand loop suture technique devised by the senior author (T.M.T.) was studied in vitro. Forty flexor tendons were harvested from fresh-frozen human hands and divided into 4 groups of 10 tendons each. Each group of tendons was repaired with a specific technique: group 1, the modified Kirchmayr (modified Kessler) technique; group 2, the single-loop 2-strand technique described by Tsuge; group 3, Tsai's double-loop 4-strand modification of Tsuge's technique; and group 4, Tsai's double-loop 6-strand modification of Tsuge's technique. Gap resistance of each repair technique was recorded on a computer using a Differential Variable Reluctance Transducer (MicroStrain, Burlington, VT) and on videotape to record first gap formation, 1-mm and 2-mm gap formation, and maximum load. Statistically significant differences between groups were as follows: at first gap formation between the 2-strand and 6-strand loop suture techniques, and at maximum load between the modified Kessler and 4-strand, modified Kessler and 6-strand, 2-strand and 4-strand, and 2-strand and 6-strand loop suture techniques. The 6-strand double-loop suture technique had a higher tensile strength than the other techniques, as measured in this model at each stage in our experiment. The 6-strand double-loop suture technique simplifies flexor tendon repair. It improves the repair's strength and its resistance to gapping without increasing tendon handling or bulk. This increased repair strength allows us to pursue a more aggressive rehabilitation program.

Cubital tunnel release with endoscopic assistance: results of a new technique.

We evaluated the results of cubital tunnel release with endoscopic assistance. The study included 76 patients (85 elbows); 47 women and 29 men. Nine patients had bilateral procedures. Patients were excluded if they had less than 1 year of follow-up, associated pathology at the elbow to account for the nerve compression, or recurrent cubital tunnel syndrome. Before surgery, cases were categorized by stage of cubital tunnel syndrome according to Dellon's classification: 33 (39%) elbows were classified as mild, 35 (41%) moderate, and 17 (20%) severe. Surgical results were assessed according to a modified Bishop rating system. The mean follow-up period was 32 months (range, 12-52 months). Results were excellent in 42% of the elbows, good in 45%, fair in 11%, and poor in 2%. Recurrence occurred in 3 elbows. There were no serious complications. The results of this study support our recommendation of cubital tunnel release with endoscopic assistance as a safe and reliable technique for the treatment of cubital tunnel syndrome, especially in patients with mild to moderate symptoms.

Major replantation versus revision amputation and prosthetic fitting in the upper extremity: a late functional outcomes study.

The functional outcomes of amputated arms that were either replanted or had a prosthesis were compared. In addition, factors that influenced the functional outcome of replants were evaluated. The Carroll test was used to evaluate functional capacity of 22 successful upper extremity replantations at or proximal to the wrist as well as 22 amputees (at similar levels) fitted with a variety of prosthetic devices. The outcome was excellent or good in 8 (36%) replanted limbs. This proportion was statistically higher than those grades in the prosthetic group. When the groups were more closely matched (adults with below elbow injuries), the replantation group had 6 (50%) good or excellent outcomes and the prosthetic group had none. An analysis of covariance of the replantations demonstrated a statistical association between a better outcome in younger patients with more distal injuries. This study indicates that replantation produces superior functional results compared with amputation and a prosthesis.

Free vascularized transfer of the metatarsophalangeal and proximal interphalangeal joints of the second toe for reconstruction of the metacarpophalangeal joints of the thumb and index finger using a single vascular pedicle.

Previously described double-joint transfers from a single toe have required a separate vascular pedicle for each joint transferred. In this case report, however, we describe the use of a single vascular pedicle to perform a free vascularized double-joint transfer of the metatarsophalangeal and proximal interphalangeal joints of a single toe to the metacarpophalangeal joints of the thumb and index finger. Although a pollicization could have restored adequate function to the patient's hand, she desired five digits. Given the increased distance between the metacarpophalangeal joints of the thumb and index finger, an increased interjoint pedicle length was needed. We obtained this by mobilizing the digital vessels away from the joints of the second toe. This involved transecting the tibial digital vascular branches of the proximal interphalangeal joint and the fibular vascular branches of the metatarsophalangeal joint. Based on a single pedicle, the vascularity of the proximal interphalangeal joint was maintained by preserving the distal commissural vessels at the distal phalanx. Advantages of this technique include using a single donor artery and reconstruction of two metacarpal joints with a single toe.

A neurovascular island flap for volar-oblique fingertip amputations. Analysis of long-term results.

A neurovascular island flap has been developed to reconstruct volar-oblique fingertip amputations. This study analyzes the data collected on 16 patients who were treated with this flap and had at least 2 years follow-up. The average active/passive range of motion was 54/55 degrees at the DIP joint, 96/98 degrees at the PIP joint, and 83/83 degrees at the MP joint. Twelve out of 16 flaps (75%) had two-point discrimination better than 10 mm. Moderate and severe problems included cold intolerance (six patients), hypersensitivity (three patients), stiffness (three patients), and numbness (two patients). Out of the 16 patients treated with this technique, 14 were satisfied with their surgical outcome. In experienced hands, this technique is a safe and reliable method with which to reconstruct volar-oblique fingertip amputations.

Outcome of digital nerve injuries in adults.

Evaluations of 67 adults with 90 complete digital nerve injuries were made more than 1 year after surgery. Moving and static two-point discrimination was determined on both lateral aspects of the injured and contralateral uninjured digits. Digits with primary repairs in mild crush or saw injuries had significantly worse two-point discrimination compared with digits that had a primary repair of a simple laceration. Furthermore, in mild crush injuries, digits with primary grafting had significantly better results than those with primary repair. Patients under 40 years of age had better two-point discrimination than those over 40. Some overlap innervation from the uninjured side was noted in two of eight digits tested, since sensation of the injured side was completely lost when the uninjured nerve of that digit was anesthetized. These results support the hypothesis that better recovery is obtained if tension is avoided at the nerve repair site in mild crush or saw injuries.

A new technique for endoscopic carpal tunnel decompression.

A new one-portal technique for endoscopic carpal tunnel release (ECTR) is introduced with its clinical results. The incision is made at the palmar aspect of the hand. A custom-made glass tube with a groove is inserted, and under endoscope observation, a meniscus knife is pushed forward along the groove to release the flexor retinaculum. This new technique has been studied in ten fresh cadaver hands and used in 123 patients' hands. Results of the cadaver study showed that the flexor retinaculum was released completely in all ten hands. No injuries to tendons, nerves, or arteries were noted. In one case the cotton tip was lost from the stick. All clinical releases were performed uneventfully except for three cases of neuropraxia of the digital nerve of the radial side of the ring finger, one laceration of the motor branch of the median nerve, one mild infection, one loss of cotton tip from the cotton swab stick, and one case of chipping of the glass tube. The case with the laceration of the motor branch of the median nerve occurred early in the series and required the conventional open incision to repair the nerve. The cases with loss of cotton from the stick and chipping of the tube also required a conventional incision to remove the cotton and glass chip. Advantages of this one-portal technique with the glass tube include less scar tenderness than with two-portal techniques, decreased risk of injury to the superficial palmar arch and ulnar nerve because of the distal approach, a view of pathology in the carpal tunnel through the glass tube, and confirmation of release of the flexor retinaculum.

Catalytic properties of NAD(P)H:quinone acceptor oxidoreductase: study involving mouse, rat, human, and mouse-rat chimeric enzymes.

NAD(P):quinone acceptor oxidoreductase (quinone reductase) (DT-diaphorase, EC 1.6.99.2) is involved in the process of reductive activation of cytotoxic antitumor quinones and nitrobenzenes. In this study, we initially examined the relative abilities of mouse, rat, and human quinone reductases to reduce two prodrugs, CB 1954 [5-(aziridin-1-yl)-2,4-dinitrobenzamide] and EO9 [5-(1-aziridinyl)-3-(hydroxymethyl)-2-(3-hydroxy-1-propenyl)-1- methyl-1H-indole-4,7-dione]. By using Escherichia coli-expressed quinone reductases and evaluating them under identical conditions, we confirmed previous finding showing that the human enzyme is not as effective as the rat enzyme in reducing CB 1954 and EO9, although the two enzymes have similar NAD(P)H-menadione reductase activities. Interestingly, although the amino acid sequence of mouse quinone reductase is more homologous to that of the rat enzyme, we found that the mouse enzyme behaves similarly to the human enzyme in its ability to reduce these compounds and to generate drug-induced DNA damage. To determine the region of quinone reductase that is responsible for the catalytic differences, two mouse-rat chimeric enzymes were generated. MR-P, a chimeric enzyme that has mouse amino-terminal and rat carboxy-terminal segments of quinone reductase, was shown to have catalytic properties resembling those of rat quinone reductase, and RM-P, a chimeric enzyme that has rat amino-terminal and mouse carboxyl-terminal segments of quinone reductase, was shown to have catalytic properties resembling those of mouse quinone reductase. In addition, MR-P and RM-P were found to be inhibited by flavones with Ki values similar to those for rat and mouse quinone reductases, respectively. Based on these results, we propose that the carboxyl-terminal portion of the enzyme plays an important role in the reduction of cytotoxic drugs and the binding of flavones.

[A clinical and experimental study of dorsiflexed intercalated segmental instability in a scaphoid fracture].

The purpose of this study was to clarify the pathomechanics of dorsiflexed intercalated segmental instability (DISI) in a scaphoid fracture. Twenty two patients with a scaphoid fracture were used for the clinical study. DISI was recognized in 6 patients. There was no statistically significant difference between the DISI(+) group and the DISI(-) group in total ROM, or in grip strength. In the DISI(+) group, however, ROM shifted dorsally (p < 0.05). Clinical factors for DISI were as follows. (1) pseudoarthrosis without treatment: 2 cases; (2) bone union taking place in a humpbacked position: 3 cases; (3) resection of proximal fragment: 1 case. Two fresh cadavers were used for the experimental study. In one cadaver which received simple osteotomy of the scaphoid, DISI was not seen after 216,000 repeated wrist movements (15 times/min., 10 days). In the other cadaver which underwent a volar wedge osteotomy of the scaphoid, the proximal fragment of the scaphoid and the lunate dorsiflexed temporarily under axial compression force immediately after surgery. After 8 days (172,800 repeated movements), static DISI could be seen without axial compression force. These results suggested that a volar bone defect was important for DISI after a scaphoid fracture. When an axial compression force was added, both the proximal fragment of the scaphoid and the lunate could be dorsiflexed in proportion to the volar bone defect due to the linkage between the proximal fragment and the lunate. Loosening in the surrounding tissue occurred gradually during continuous wrist movement and static DISI was finally observed. Therefore, immediate and proper treatment should be recommended to prevent mal-union as well as non-union.

Effect of ischemia and three different perfusion solutions on the rabbit epiphyseal growth plate.

An isolated vascularized knee joint model was used (1) to determine the minimum ischemia time that produced growth retarding damage to the epiphyseal plate and (2) to evaluate whether intra-arterial perfusion could reduce the ischemia damage. Experiment 1 consisted of 31 rabbits in 5 groups: 0, 2,4,6, and 8 hr of warm ischemia produced by clamping the pedicle. Experiment 2 consisted of 18 rabbits in which 10 ml of one of (1) Euro-Collins, (2) University of Wisconsin solution, or (3) heparinized blood were perfused through the joint without ischemia. Experiment 3 consisted of 21 rabbits in which one of the three solutions was perfused for a short period during 6 hr of ischemia. Growth of the tibia was followed radiographically every month over 3 months, and the growth plates were evaluated histologically after sacrifice. Results showed that at least 6 hr of ischemia was needed before longitudinal growth was reduced; less ischemia time caused overgrowth. Histologic damage was found in all animals to some degree. Perfusion alone without ischemia had no detrimental effect on growth or histology. The growth reduction at 6 hr of ischemia was minimized by perfusion with every solution. Heparinized blood was the most effective and Euro-collins was the least effective.

Vascular filling and protein extravasation in three varieties of vascularized venous nerve grafts.

The purpose of this study was to compare the microcirculation perfusion and plasma-protein extravasation in varieties of venous nerve grafts. Venous nerve grafts were created from the left median nerve and brachial vein of the rabbit. The vein was interposed between (a) brachial artery to brachial artery (AVA); or (b) brachial artery to proximal cephalic vein (AVV); or (c) brachial vein to brachial vein (VVV). A standard, vascularized, nerve graft was created in the opposite limb, to serve as a control, and the untouched sciatic nerve served as a second control. Microcirculation perfusion and permeability of endoneurial vessels were evaluated using intravenously-injected albumin labelled with Evans blue dye (EBA) as a fluorescent tracer within 1 hr after surgery. Six hours after surgery, the nerves were removed and evaluated for tracer content and distribution. Extravasation of EBA was extensive in both AVA and AVV forms of the venous nerve graft, suggesting good perfusion but showing significant protein leakage and edema. VVV, on the other hand, had only slight extravasation, comparable to untouched sciatic nerves. Although the number of vessels filled with blood in the VVV was 69 percent of the vascularized nerve graft, the lack of marked extravasation may make it the venous nerve graft of choice.

A transverse skin incision approach for decompression of pronator teres syndrome.

Pronator teres syndrome is a compressive neuropathy of the median nerve in the proximal part of the forearm and distal part of the arm. The outcome of surgical decompression is occasionally unsatisfactory because of a poor scar. We present the use of a transverse skin incision that allows adequate exploration and decompression distally and proximally, beneath the subcutaneous tissue beyond the volar elbow crease.

Microvascular reconstruction of the foot: weight-bearing patterns, gait analysis, and long-term follow-up.

Between 1980 and 1989, 46 free-tissue transfers (32 skin flaps, 14 muscle flaps) were performed in 44 patients for foot reconstruction. Patient age averaged 25.8 years (range 2 to 74 years). Length of follow-up averaged 43 months. Flap survival rate was 96 percent. Debulking was done in 16 skin and 8 muscle flaps. The ulceration rate in 25 patients with weight-bearing flaps was 32 versus 11 percent in 19 patients with non-weight-bearing flaps. Time before ambulation averaged 6.4 months following weight-bearing reconstruction and 4.5 months following non-weight-bearing reconstruction. All patients with either abnormal foot-mat diagrams or major gait abnormalities had significant underlying radiologic foot abnormalities or nerve injuries. We conclude that both skin and muscle free flaps frequently need secondary debulking procedures to improve function. The ulceration rate tends to be higher in weight-bearing flaps than in non-weight-bearing flaps. Underlying bony architecture and nerve function affected weight-bearing patterns and gait more than type of wound coverage.

Regeneration following rejection of peripheral nerve allografts of rats on withdrawal of cyclosporine.

Sequential changes in the sciatic nerve function and morphology were evaluated in transplanted nerve allografts from ACI-RT1a into Lewis RT1I rats after withdrawal of cyclosporine, which had been administered subcutaneously daily (5 mg/kg) for 12 weeks. Experimental groups were established as follows: (1) allograft with cyclosporine (evaluated and sacrificed at 12, 14, 16, 20, 24, and 36 weeks, 10 rats at each week), (2) allograft without cyclosporine (12 and 24 weeks, 10 rats at each week), (3) isograft with cyclosporine (12 and 24 weeks, 6 rats at each week), and (4) isograft without cyclosporine (12 and 24 weeks, 10 rats at each week). Regeneration was evaluated through walking track analysis, electrophysiologic studies, weight of the anterior tibial muscle, and axon counts, diameter, and myelin thickness. Regeneration was observed through 14 weeks after grafting; by 16 weeks, all rats had demonstrated a clear rejection phase, but regeneration indices then recovered quickly by 24 weeks. Electron microscopy of both the graft and distal nerve suggested that both Schwann cells and axons were affected by the rejection phenomenon. Allografts without cyclosporine showed inferior regeneration histologically at 24 weeks. Morphologically, allografts were equivalent to isografts treated with cyclosporine at 24 weeks. Although nerve allografts are rejected after cyclosporine withdrawal, they may still serve as effective nerve conduits.

A modified extensor carpi ulnaris tenodesis with the Darrach procedure.

Fourteen patients with pain and limited forearm rotation were treated with a modified Darrach procedure involving a distally based slip of the extensor carpi ulnaris tendon. Seven patients had Colles' fractures, four had rheumatoid arthritis, and three had primary osteoarthritis of the distal radioulnar joint. Patients were assigned to one of two groups: rheumatoid arthritis or Colles' fracture/osteoarthritis. The average age was 50 years. Follow-up averaged 54 months (range, 12 to 96 months). The average amount of ulnar resection was 10 mm (range, 6 to 20 mm). In the Colles' fracture/osteoarthritic group, average grip strength (a percentage of the uninvolved hand) improved from 26% preoperatively to 74% postoperatively, and in the rheumatoid arthritis group it improved from 67% to 144%. Distal ulnar instability of the dorsal side was not observed on x-ray examination. Patients were satisfied with pain relief, and all returned to their original work.

Thumb replantation: survival factors and re-exploration in 122 cases.

We analyzed 122 cases of replantation following complete amputation of the thumb and correlated various factors with rates of survival. The overall survival rate of thumb replantation was 71%. The type of amputation markedly affected survival rate. In minimally damaged amputations, the time period from injury to the start of surgery was the only significant factor related to survival. Other factors such as age, smoking history, amputation level, the number of vessels reconstructed and the method used did not relate statistically to survival. With avulsion amputations, the survival rate of replantation at and proximal to the MP joint was significantly better than replantation distal to the MP joint. 20 thumbs required re-exploration for vascular compromise; nine of these were salvaged (45%).

Complications and results of scapho-trapezio-trapezoid arthrodesis.

Forty cases of scapho-trapezio-trapezoid (STT) arthrodesis were reviewed. Indications for the procedure included rotatory subluxation of the scaphoid (30 patients) and STT arthrosis (ten patients). Follow-up time averaged 41 months. Ten patients (25%) required 13 additional procedures: operations for nonunion or a fracture of the distal radius after bone harvesting, partial radial styloidectomy, first carpometacarpal joint arthroplasty, and wrist arthrodesis. Complications without surgeries were seen in several cases: pin-tract infection, sympathetic dystrophy, delayed union treated with brace, and radial nerve irritation. Overall, complications were observed in 21 patients (53%), some having more than one complication. Degenerative arthritis at joints surrounding the STT mass was suspected based on roentgenograms in five cases. Twenty-three patients (58%) became pain free or had minimal pain with a limited arc of motion. Twenty of 34 patients (59%) returned to their regular work or the same job, and 27 (68%) reported good to excellent results. Although STT arthrodesis can provide a painless wrist with a limited arc of motion in most patients, complications are frequent.