Effects of external bleeding and hyperbaric oxygen treatment on Tamai zone 1 replantation.

INTRODUCTION: Tamai zone 1 replantation poses a challenge due to the very small size of the vascular structures; often there is no vein for anastomosis. Replantation may have to be done with only an arterial anastomosis. In our study, we aimed to evaluate the success of replantation by combining external bleeding and hyperbaric oxygen treatment (HBOT) in Tamai zone 1 replantation. METHODS: Between January 2017 and October 2021, 17 finger replantation patients who underwent artery-only anastomosis due to Tamai zone 1 amputation received 20 sessions of HBOT with external bleeding after the 24th postoperative hour. Finger viability was assessed at the end of treatment. A retrospective review of outcomes was performed. RESULTS: Seventeen clean-cut finger amputation patients were operated on under digital block anaesthesia with a finger tourniquet. No blood transfusion was required. In one patient, complete necrosis developed and stump closure was performed. Partial necrosis was observed in three patients and healed secondarily. Replantation in the remaining patients was successful. CONCLUSIONS: Vein anastomosis is not always possible in fingertip replantation. In Tamai zone 1 replantation with arteryonly anastomosis, post-operative HBOT with induced external bleeding appeared to shortened the hospital stay and was associated with a high proportion of successful outcomes.

Outcomes of Wide-Awake Flexor Tendon Repairs in 58 Fingers and 9 Thumbs.

PURPOSE: The purpose of this study was to present the outcomes of wide-awake flexor tendon repairs in zones 1 and 2 in a major hand trauma referral center. METHODS: Zone 1 and zone 2 wide-awake flexor tendon repairs performed between August 2018 and March 2020 were analyzed retrospectively. Outcomes were assessed by the original Strickland-Glogovac criteria for fingers and Buck-Gramcko scoring system for thumbs. Further descriptive analysis of the groups according to potential negative factors, such as injury mechanism, concomitant neurovascular injury, and the extent of injury in zone 2, were performed. RESULTS: A total of 94 tendons were repaired in 67 digits (58 fingers, 9 thumbs) of the 61 patients included in the study. Satisfactory results were achieved in 89.6% of the fingers and 77.8% of the thumbs. Intraoperative gapping was corrected after active digital extension-flexion test in 1 patient. Rupture was seen in 1 patient for a rate of 1.5%. The tenolysis indication rate was 5.1% for fingers and 11.1% for thumbs. CONCLUSIONS: In our series, functional outcome scores, tenolysis, and rupture rates remained similar with findings in the literature. The outcome of a flexor tendon repair is influenced by many factors that cannot be controlled intraoperatively. To assess the effect of performing the repair in a wide-awake setting on the outcome, clinical trials with large patient groups are needed. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Clinical Application of Restrictive Brace Combined with Psychological Intervention after Replantation of Severed Fingers in Children.

Objective: After replantation of severed fingers in infants, the utility model patent upper limb restrictive brace-assisted bed rest braking, combined with psychological intervention, can alleviate children's anxiety, so as to reduce the occurrence of vascular crisis. Methods: The study period was from April 2015 to July 2018. In this paper, 30 children with finger injuries in hand surgery in the CIS electronic medical record system of Cangzhou Integrated Traditional Chinese and Western Medicine Hospital were selected as the research objects. Replantation was performed in 30 infants with severed fingers. Among them, 15 cases were applied with the method of aircraft chest arm gypsum splint combined with sedative drug braking and the utility model patented product upper limb restrictive brace fixation-assisted bed rest braking, and the method of psychological intervention was applied at the same time. Results: Among the 15 fingers in the control group, 6 had vascular crisis and 1 in the experimental group. The incidence of vascular crisis in the experimental group was lower, and the difference between the two groups was statistically significant (P < 0.05). The patients were followed up for 9~18 months, with an average of 9.72 ± 1.07 months. In the control group, 15 cases of severed fingers survived, and there were 13 cases of replantation finger necrosis in 2 cases of intractable arterial crisis. In the experimental group, 14 cases of severed fingers survived in 15 cases and there was 1 case of replanted finger necrosis in intractable arterial crisis after operation. There was no significant difference in the survival rate between the two groups (P > 0.05). In addition, the replanted finger function was evaluated. In the control group, 9 cases were excellent, 4 cases were good, and 1 case was fair. In the experimental group, 14 cases were excellent, 1 case was good, and 0 case was fair. The functional evaluation of the experimental group was better than that of the control group, and the difference between the two groups was statistically significant (P < 0.05). Conclusion: For infants after replantation of severed fingers, the application of the utility model patented product upper limb restrictive brace can effectively make up for the insufficient fixation of aircraft chest arm gypsum splint, reduce the occurrence of vascular crisis, and assist children in bed. In addition, the application of psychological intervention can reduce children's postoperative crying and is conducive to children's postoperative recovery.

A rare case of subcutaneous traumatic index finger both extensor tendons rupture. Results of WALANT extensor digiti minimi transfer and literature review.

Traumatic subcutaneous index finger both extensor tendons ruptures are rare injuries. Aim of the present paper is to review the literature about this uncommon lesion and to describe the case of 56 years old woman injured when her hand became stuck under a weight during a wrist hyperflexion movement. Surgical treatment was undertaken after 7 days. An extensor digiti minimi (EDM) tendon transfer and a Pulvertaft tenodesis on the index EDC to middle EDC using wide awake local anesthesia no tourniquet (WALANT) technique was performed. The advantage is to allow immediate visualization of active motion and confirmation of appropriate soft tissue tensioning. In our patient no complications were observed and an early rehabilitation program was started. The patient recovered full function at 2 months and resumed hear heavy labour working activity at 4 months.

Analysis of Anesthesia Effect of Dexmedetomidine in Clinical Operation of Replantation of Severed Finger.

Brachial plexus block commonly used in finger replantation has the advantages of simple operation, small side effects, and stable circulation, but it has inherent problems such as imperfect block range, slow onset of anesthesia, and short maintenance time of anesthesia. In order to explore the reliable clinical anesthesia effect, this paper uses experimental investigation methods to study the effect of dexmedetomidine in clinical surgery of replantation of severed fingers. Moreover, this paper uses comparative test methods, uses statistical methods to process test data, and uses intuitive methods to display test results. Finally, this paper verifies the reliability of dexmedetomidine in replantation of severed finger through comparative analysis and verifies that the anesthesia method proposed in this paper has certain user satisfaction through parameter survey.

Application of WALANT technique for repairing finger skin defect with a random skin flap.

BACKGROUND: Wide-awake local anesthesia no tourniquet (WALANT) technique has emerged among hand surgeons with other indications. Surgeries involving pedicled flap and revascularization are no longer used as contraindications. The present study aimed to evaluate the feasibility and merits of the WALANT technique in random skin flap surgery. METHODS: From May 2018 to March 2019, 12 patients with finger skin defects repaired with random skin flaps were reviewed. Abdominal skin flaps or thoracic skin flaps were used to cover the wound. Both the fingers and the donor sites were anesthetized by the WALANT technique. A 40-mL conventional volume consisted of a mixture of epinephrine and lidocaine. A volume of 5 mL was injected at the distal palmar for nerve block, the other 5 mL was injected around the wound for hemostasis, and the remaining was injected at the donor site of flaps for both analgesia and hemostasis. Baseline data with respect to sex, age, side, type of finger, donor sites, flap size, dosage of anesthetics, usage of finger tourniquet, intraoperative and postoperative pain, hemostasis effect, operation time, Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) score, and hospitalization expense, were collected. RESULTS: All patients tolerated the procedure, and none of them needed sedation. Single finger skin defect in 8 patients and double finger skin defect occurred in 4 patients; 5 patients were repaired by abdominal skin flaps, and 7 patients were repaired by thoracic skin flaps. The good surgical field visibility was 91.7%. All flaps survived adequately, without necrosis, pulling fingers out, and other complications. The average visual analog scale (VAS) score of the maximal pain was 1.1 in fingers vs. 2.1 in donor sites during the operation. On postoperative day one, the average VAS score of the maximal pain in fingers and donor sites was 1.3 and 1.1, respectively. The average hospitalization expense before reimbursement of the whole treatment was 11% less expensive compared to the traditional method. The average QuickDASH score was 9.1. CONCLUSIONS: Under wide-awake anesthesia, patients have the ability to control their injured upper extremities consciously, avoiding the complications due to pulling flap pedicles. With the merits of safety, painlessness, less bleeding, and effectivity, the WALANT technique in random skin flaps is feasible and a reliable alternative to deal with finger skin defect.

WALANT-Epinephrine injection may lead to short term, reversible episodes of critical oxygen saturation in the fingertips.

INTRODUCTION: Although the WALANT technique's long-term safeness has been demonstrated in many studies, there are only few data investigating its short-term effects on tissue perfusion and oxygen levels. It was hypothesized that, temporarily, critical levels of tissue perfusion may occur. METHODS: Seventeen patients, who were scheduled for different procedures in WALANT technique, were injected with 5-7 ml of 1% Articain containing 1:200,000 epinephrine at the finger base. Capillary-venous oxygen saturation, hemoglobin volume in the capillaries, and relative blood flow in the fingertips were recorded once per second by white light spectrometry and laser Doppler flowmetry before, during and after injection for an average of 32 min. RESULTS: Clinically, no persistent tissue malperfusion was observed, and there were no postoperative complications. Capillary-venous oxygen saturation was reduced by ≥ 30% in seven patients. Critical levels of oxygen saturation were detected in four patients during 13 intervals, each lasting for 132.5 s on average. Oxygen saturation returned to noncritical values in all patients by the end of the observation period. Blood flow in the fingertips was reduced by more than 30% in nine patients, but no critical levels were observed, as with the hemoglobin. Three patients demonstrated a reactive increase in blood flow of more than 30% after injection. CONCLUSIONS: Injection of tumescent local anesthesia containing epinephrine into finger base may temporarily cause a substantial reduction in blood flow and lead to critical levels of oxygen saturation in the fingertips. However, this was fully reversible within minutes and does not cause long-term complications.

Effects of ozone autohemotherapy on blood VEGF, TGF-ß and PDGF levels after finger replantation.

BACKGROUND: The study aimed to confirm the important role of ozone autologous blood therapy (autohemotherapy) in promoting successful finger replantation and its possible influence mechanism. METHODS: A total of 150 patients with severed finger replantation admitted to our hospital from March 2018 to March 2019 were selected. Patients were divided into observation group and control group according to different treatment methods. The observation group received additional ozone autologous blood treatment in the control group. We compared the number of white blood cells, visual analogue scale (VAS) scores, and the expression levels of vascular endothelial growth factor (VEGF), transforming growth factor-ß (TGF-ß), and platelet-derived growth factor (PDGF) in the two groups of patients before and after intervention. We also assessed the hospitalization time and survival time of the replanted finger in the two groups, as well as blood flow values (Vbcf). RESULTS: Compared with the observation group on the 1st day after the operation and the control group on the 7th day after the operation, the average white blood cell count of the observation group on the 7th day after the operation was significantly increased (P<0.05), and the VAS score was significantly decreased (P<0.05).48 hours after the operation, the average Vbcf value of the replanted finger was lower than that of the contralateral healthy finger (P<0.05). Compared with the control group, the Vbcf value of the replanted fingers in the observation group was higher, and the hospitalization time and finger survival time were shorter (P<0.05). At 7 days after operation, the serum VEGF, TGF-ß and PDGF levels in the observation group were significantly higher than the 1 day after operation, before the operation and the control group (P<0.05). CONCLUSIONS: Intervention with ozone autohemotherapy after severed finger replantation can significantly increase the number of white blood cells, relieve postoperative pain, and improve the survival rate of the finger body. Ozone autohemotherapy also improves the microcirculation after anastomosis of the severed finger by up-regulating the expression of VEGF, TGF-ß and PDGF in blood.

Leech Therapy Following Digital Replantation and Revascularization.

Venous congestion after digital replantation or revascularization threatens digit survival in the immediate postoperative period. External bloodletting, including leech therapy, provides a central role in salvage of the congested finger. Although there have been previous studies describing the initiation of leech therapy for digits experiencing venous insufficiency, few published articles and no consensus guidelines have discussed the weaning of leeches in the postoperative period. We review the current evidence behind leech therapy and offer a treatment algorithm based on available data and existing leech weaning protocols.

Novel Technique for Toe-to-Hand Transplantation: The Fourth-toe as an Alternative Option for Toe-to-Hand Transplantation for Pediatric Patients.

The first toe-to-hand transplantation was done in 1898 by Nicoladoni. It was a staged procedure and the toe flap was based on a pedicle. With advancement of optical instruments and microsurgeons' skills in 1964 the first microvascular toe-to-hand transplantation on a rhesus monkey was done. The technique's development has not stopped, many authors have modified it to achieve better outcomes for both traumatic and congenital hand defects. The most commonly used toes for transplantation are first, second, and second to third toe block. Well described plantar and dorsal vascular systems for first web space vessels as well as possibility to perform successful perforator anastomosis allows us to improve toe-to-hand transplantation further. There is a paucity of studies on single fourth toe-to-hand transplantation. We performed fourth-toe transplantation for three pediatric patients (mean age, 73 mo) with congenital (n=2) and traumatic (n=1) hand defects. Common plantar digital arteries were used for blood supply to the transplanted toes. No vascular problems occurred, and all transplanted toes survived. Patients and parents are satisfied with functional and esthetic outcomes. Early podometry results show insignificant changes which should not harm the foot in the long-term. We believe the fourth-toe transplantation is a promising method to use to reconstruct congenital or traumatic absence of digits for pediatric population.

Optimal Time Delay of Epinephrine in One-Per-Mil Solution to Visualize Operation Field.

BACKGROUND: This study aimed to find out the optimal time delay of epinephrine in one-per-mil tumescent solution containing 1:1,000,000 epinephrine and 0.2% lidocaine to achieve optimal visualization in hand surgery. MATERIALS AND METHODS: Twelve healthy male subjects who volunteered to join this prospective, randomized, double blind study were selected with convenient sampling technique. The subject's hand and the solution, either the one-per-mil or normal saline solution, were randomly selected. Injections were given to the ring finger's pulp, whereas the oxygen saturation (SpO2) of each finger was measured with Masimo's Radical-7 Pulse Oximeter at 5 min before injection and continuously up to 45 min after injection. The device showed the SpO2 every 2 s. Any value of SpO2 was noted if it stayed the same point for at least 30 s in a row without interruption. The time of the lowest SpO2 was recorded and analyzed. RESULTS: The average of SpO2 after injection in the epinephrine group was 96.5 (95-97), P = 0.002, whereas the normal saline group was 97.5 ± 1.168, P = 0.003. Both were statistically significant compared with their respective baseline values. The average delta SpO2 of the epinephrine group was 3.42 ± 0.996, whereas the normal saline group was 1.50 ± 1.567 (P = 0.001; CI 0.923-2.911). The time to achieve the lowest SpO2 in the epinephrine group was obtained at the average time of 13.90 ± 5.38 min after injection. CONCLUSIONS: The optimal time delay of the epinephrine in the one-per-mil tumescent solution was 13.90 ± 5.38 min after injection.

Quantifying outcomes for leech therapy in digit revascularization and replantation.

We retrospectively reviewed 201 digit replantations or revascularizations that were performed between August 2007 and June 2015. Leeching therapy was used in 48 digits and was more commonly required in replanted digits. In revascularized digits, leeching was used significantly more frequently in avulsion injuries and injuries associated with fractures. Digits that were leeched for more than 4.5 days had significantly higher rates of survival of digits after replantation or revascularization. Leeching was associated with higher incidence of transfusion, higher mean number of transfusions, and longer length of stay. We conclude from this study that leeching is used more frequently after digital replantation than revascularizaion, and in revascularized digits, leeching is used more often in avulsion injury and in patients with fractures. In patients requiring leeching therapy, leaching for more than 4.5 days leads to higher rate of digital survival. Level of evidence: IV.

The success of salvage procedures for failing digital replants: A retrospective cohort study.

BACKGROUND: The success of salvage procedures for failing digital replants (FR) is poorly documented. We sought to evaluate the success of salvage procedures for FR and factors contributing to successes and failures of replants. METHODS: Adult patients who presented to our center between January 1, 2000 and December 31, 2015, suffered ≥1 digital amputation(s), and underwent digital replantation were included. Preoperative, perioperative, and postoperative details were recorded. Digits were monitored postoperatively via nursing and physician assessments. The presumed reason for failure, details, and outcomes of salvage attempts were recorded for FR. Length of hospital stay and complications were also recorded. RESULTS: Fifty-two patients and 83 digits were included. Fifty-two digits (63%) were compromised (arterial ischemia in 15 digits; venous congestion in 37 digits) and 48 digits had salvage therapy. Twenty-one FR (44%) were salvaged via operative (1 of 2; 50%), nonoperative (19 of 43; 44%), and combined (1 of 3; 33%) therapies. FR patients were more likely than those with successful replants to receive a blood transfusion (52 vs. 23%; p = .009) with more transfused units (3.45 ± 3.30 vs. 0.86 ± 0.95; p = .001). Length of stay was prolonged for FR patients (9 [range: 2-22] vs. 7 [range: 3-19] days; p = .039). Ultimately, 59% (49 of 83) of replants were successful, where 25% (21 of 83) were successfully salvaged. CONCLUSION: Nonoperative and operative salvage therapies improve the rate of replant survival. We suggest close postoperative monitoring of all replants and active salvage interventions for compromised replants in the postoperative period.

The Use of Medicinal Leeches for the Treatment of Venous Congestion in Replanted or Revascularized Digits.

PURPOSE: A noteworthy cause of failure in digital replantation is venous insufficiency. External bloodletting with medicinal leeches is a common treatment for venous insufficiency after distal digital replantations. The objective of this study was to evaluate the salvage rate of digits replanted proximal to the distal interphalangeal (DIP) joint that were treated with medicinal leeches for venous congestion. METHODS: We retrospectively reviewed the charts of patients with complete or incomplete digit amputation admitted between January, 2008 and April, 2014. We included all patients with venous congestion in one or more digits replanted or revascularized at the middle or proximal phalangeal level, who were treated with medicinal leeches. Treatment initiation and duration were based on clinical judgment. Demographic, therapy, and surgical data were collected. RESULTS: Of 145 patients with 205 digits that were replanted or revascularized, 25 digits were treated with medicinal leeches for venous congestion. Venous congestion was diagnosed later than 48 hours after operation in 24 of the 25 digits. Of the 25 digits, 11 survived (44.4%) (8 of 22 replanted digits and all 3 revascularized digits). No complications were recorded except for substantial blood loss requiring transfusion in one patient. CONCLUSIONS: External bloodletting with medical leeches might be less effective with late treatment or with a higher volume of congested tissue, as is characteristic of proximal finger replantation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Decision-making and Management of Ulnar Polydactyly of the Newborn: Outcomes and Satisfaction.

BACKGROUND: Polydactyly is the most common congenital hand deformity. There is currently no consensus among pediatricians or hand surgeons regarding optimal management of ulnar (post-axial) type B polydactyly leading to uncertainty in initial treatment decisions for infants with this type of deformity. METHODS: Parents of newborns with type B ulnar polydactyly were enrolled in a prospective, nonrandomized trial from 2010 to 2012. At enrollment they were offered: 1) no treatment, 2) suture ligature, 3) immediate excision under local anesthesia, and 4) delayed excision at four months of age under general anesthesia. After choosing a treatment option, parents were asked to complete an initial survey on their motivation for choosing a particular option, and then additional surveys at one and three month follow-up visits regarding outcomes and satisfaction. RESULTS: Fourteen newborns were enrolled in the study. Eleven patients had bilateral polydactyly for a total of 25 hands involved in the study. With statistical significance, parents chose an immediate bedside excision over all options. No surgical complications were noted and satisfaction scores were 9.8 or higher in all groups. CONCLUSIONS: A majority of parents whose children are born with type B post-axial polydactyly prefer to have the deformity addressed immediately with excision under local anesthesia at the bedside. This can be accomplished safely, with a satisfaction score of 9.8 out of 10 and no appreciable residual deformity. This may reduce emotional distress or embarrassment in parents who would otherwise have to deal with the deformity for at least a four-month period.

Linear Hand Burn Contracture Release under Local Anesthesia without Tourniquet.

The objective of this report is to present a case of hand burn linear contracture release performed under local anesthesia. It also introduces the one-per-mil tumescent solution consisted of 0.2% lidocaine and 1:1.000.000 epinephrine as a local anesthesia formula, which has the potential of providing adequate anesthesia as well as hemostatic effect during surgery of the hand without tourniquet. The surgery was performed on a 19 year-old male patient with multiple thumb and fingers flexion linear contracture for 105 minutes without any obstacle. The patient did not complain any pain and discomfort during the procedure; while bloodless operative field was successfully achieved. At four-month follow up, the patient could fully extend his thumb, middle and ring finger, while the index was limited by 10° at the DIP joint. Overall, the patient was satisfied with the outcome.