Custom 3D-printed finger proximal phalanx as salvage of limb function after aggressive recurrence of giant cell tumour.

Giant cell tumours (GCT) of the finger phalanges are extremely rare but have a high rate of recurrence. This report details the case of a GCT of the proximal phalanx of the fourth finger in a 64-year-old man. The patient was initially subjected to systemic neoadjuvant denosumab treatment, and subsequent aggressive curettage, sparing of the articular joints, local cryotherapy and autologous intercalary fibular bone graft. Finger function after surgery was considered satisfactory, despite limited proximal interphalangeal (PIP) joint motion. Aggressive local GCT recurrence was noted at the 32-month follow-up, with entire articular and diaphyseal phalangeal destruction. The patient refused amputation and, after analysing several reconstruction options, he was treated by entire en bloc resection and reconstruction employing a 3D-printed custom titanium implant. At the 24-month follow-up, the patient is free of disease and pain, and has a stable finger, good metacarpal-phalangeal joint motion, fusion of the PIP joint, a good Musculoskeletal Tumour Society score, and functional ability.

Tissue engineering a human phalanx.

A principal purpose of tissue engineering is the augmentation, repair or replacement of diseased or injured human tissue. This study was undertaken to determine whether human biopsies as a cell source could be utilized for successful engineering of human phalanges consisting of both bone and cartilage. This paper reports the use of cadaveric human chondrocytes and periosteum as a model for the development of phalanx constructs. Two factors, osteogenic protein-1 [OP-1/bone morphogenetic protein-7 (BMP7)], alone or combined with insulin-like growth factor (IGF-1), were examined for their potential enhancement of chondrocytes and their secreted extracellular matrices. Design of the study included culture of chondrocytes and periosteum on biodegradable polyglycolic acid (PGA) and poly-l-lactic acid (PLLA)-poly-ε-caprolactone (PCL) scaffolds and subsequent implantation in athymic nu/nu (nude) mice for 5, 20, 40 and 60 weeks. Engineered constructs retrieved from mice were characterized with regard to genotype and phenotype as a function of developmental (implantation) time. Assessments included gross observation, X-ray radiography or microcomputed tomography, histology and gene expression. The resulting data showed that human cell-scaffold constructs could be successfully developed over 60 weeks, despite variability in donor age. Cartilage formation of the distal phalanx models enhanced with both OP-1 and IGF-1 yielded more cells and extracellular matrix (collagen and proteoglycans) than control chondrocytes without added factors. Summary data demonstrated that human distal phalanx models utilizing cadaveric chondrocytes and periosteum were successfully fabricated and OP-1 and OP-1/IGF-1 accelerated construct development and mineralization. The results suggest that similar engineering and transplantation of human autologous tissues in patients are clinically feasible. Copyright © 2016 John Wiley & Sons, Ltd.

Trauma complexo da mão parte II: lesão óssea, amputação e reimplante, perda de substância dos dedos, lesão da polpa digital e lesão ungueal / Complex trauma of the hand, part II: bone injury, amputation and replantation, loss of fi nger substance, digital pulp injury and nail injury

O trauma da mão representa uma das lesões que com maior frequência pode deixar sequelas funcionais importantes. A idade mais afetada é a economicamente ativa. Valorizamos o conhecimento adequado do primeiro atendimento e do manejo das lesões mais frequentes na mão traumatizada. Nesta segunda parte, serão abordados os fundamentos e conceitos considerados como essenciais na lesão óssea, amputações e reimplantes, perda de substância na mão, lesão da polpa digital e do complexo ungueal. Procuramos orientar a conduta dos médicos nas diversas situações clínico-cirúrgicas para diminuir o grau de complicações e sequelas (AU)

Hand trauma is one of the injuries that can most often leave important functional sequelae. The most affected age group is economically active people. We appreciate proper knowledge of the initial treatment and management of the most common injuries in the traumatized hand. In this second part we address the fundamentals and concepts considered essential in bone injury, amputation and replantation, loss of substance in the hand, and injuries of digital pulp and ungual complex. We aim to guide the conduct of physicians in different clinical and surgical situations to reduce the degree of complications and sequelae (AU)

Treatment of a type 3B hypoplastic thumb using extra phalanges from the contralateral duplicated thumb: case report.

A boy was born with a right duplicated thumb (Wassel type 6) and a left radial club hand (type 3) associated with a hypoplastic thumb (type 3B). He underwent surgical centralization of the left wrist when he was 13 months old. At age 38 months, he underwent reconstruction of the carpometacarpal joint of the hypoplastic left thumb. This procedure involved transplantation of the radial ray of the right duplicated thumb to the base of the left thumb. When he was 6 years old, the patient underwent an abductor digiti minimi muscle transfer to create opposition for the left thumb and deepening of the first web. At the final follow-up, he could grasp items in the first web space and pick up small items between the thumb and other digits of the left hand. The treatment represents a method of using otherwise discarded tissues for effective reconstruction.

Anatomic basis of ulnar index metacarpal reverse flow vascularized bone graft for index distal bone loss.

Well-known advantages of vascularized bone grafts led us to determine the anatomical basis of a metacarpal vascularized bone graft to find a solution for distal index bone loss. Seventeen adult human hands from fresh cadavers were dissected and analyzed. For each hand, we studied the second dorsal metacarpal artery, the ulnar dorsal proper digital artery of index, and the ulnar palmar proper digital artery of the index. Location, diameters, origins, and anastomoses were observed, and at the end, the vascularised bone graft was raised. The second dorsal metacarpal artery was present in all hands, always arising from the dorsal carpal arch with a 1-mm mean diameter. The ulnar dorsal proper digital artery of index was isolated on all dissections, with a subcutaneous location on the ulno-dorsal side of the proximal phalanx. The mean diameter of ulnar dorsal proper digital artery at the level of index proximal phalanx was 0.4 mm. We found anastomotic branches between the ulnar dorsal and palmar proper digital artery of index at the level of the proximal phalanx which permitted us to elevate a vascularised bone graft. We succeeded in removing the graft in all specimens. Its pivot point was always more distal than the middle of the proximal phalanx. The arc of rotation allowed the graft to reach the distal phalanx in 80% of the cases. This anatomical study has demonstrated the theoretical possibility of a reversed pedicled bone graft taken from the ulnar neck of the second metacarpal. This graft brings the following benefits: (a) the use of a minor vascular axis, (b) a surgical technique with a dorsal approach allowing the elevation and the use of the graft at the same time. It can be used on the index for failures of DIP joint arthrodesis, huge chondroma, or traumatology.

Is the rabbit knee a suitable model for the human interphalangeal and metacarphophalangeal joints of the hand?

OBJECTIVES: The purpose of this study was to assess the suitability of the rabbit knee as a small joint model for the human interphalangeal and metacarphophalangeal joints of the hand. METHODS: The proximal joint surface areas of 47 middle phalanges, the proximal and distal joint surface areas of 90 proximal phalanges, and the distal joint surface areas of 42 metacarpals of various human cadavers were calculated and compared with the distal femoral and proximal tibial joint surface areas of 20 knee of 10 New Zealand white rabbits by a photogrammetric method. RESULTS: The mean joint surface area of the rabbit proximal tibia was larger than the proximal joint surface area of the middle phalanx, the distal joint surface area of the proximal phalanx, the proximal joint surface area of the proximal phalanx, and the distal joint surface area of the metacarpal. The mean joint surface area of the rabbit distal femur was larger than that of the middle phalanx, but similar to the proximal joint surface area of the proximal phalanx, and that of the distal metacarpal and distal proximal phalanx. CONCLUSION: The rabbit knee is not suitable model for the human interphalangeal and metacarphophalangeal joints of the hand. There is still a lack of an appropriate animal model for the small joints of the hand.

Transplantation of amputated bony phalanges as a salvage thumb reconstruction method - a preliminary report.

BACKGROUND: Every traumatic amputation of the thumb is an indication for an attempt of replantation. Due to local state of the wound not every case qualifies for this procedure. Such patients may be offered a multi-step salvage reconstruction of the amputated finger; the first step consists of an emergency implantation of the bony phalanx under the skin of the abdominal wall. The osseous graft was covered with skin using a pedicled tubular flap or a "cutaneous pocket". The aim of this paper was to evaluate the effectiveness of this reconstructive method. MATERIAL AND METHODS: Over a period of four years, we operated on 24 patients (22 males, 2 females) aged 17 - 56 years (mean 31.3 yrs); trauma affected the dominant hand in 16 cases (66%); 17 patients (71%) lost their thumbs at the level of IP joint ; in the remaining 7 cases (29%) the amputation was at the level of the MCP joint. In 3 cases with concomitant amputation of the 2nd and 3rd fingers, the grafted structure was the bony phalanx of the index finger. The grafted phalanx, its soft tissues pared off, was joined with the proximal phalanx or the 1st metacarpal bone with two K-wires and then covered with a pedicled tubular flap or implanted to a cutaneous pocket preformed from the abdominal wall. The flap and the "pocket" were cut away on average after 30.2 days. The cutaneous plasty of the finger was performed on average after 11.3 weeks; the sensory island was transferred according to Littler in 18 patients on average 22.2 weeks after the amputation. The evaluation included: osteosynthesis, mobility of the finger (Kapandji's test), pinch-grip strength, touch sensation (filament and discriminatory, temperature sensitivity), esthetics of the finger, and the employment status of the patients. RESULTS: Failure of losing the graft occurred in 3 patients (12%) and was due to an infection unresponsive to treatment and developing on necrotic flaps. Five patients (21%) developed marginal necrosis within the fragments of the cut off flaps requiring cutaneous plasty; an inflammation of the recipient site occurred in 5 cases (21%). 18 patients (75%) of the patients turned up for the distant follow-up on average 13.2 months after the accident (range 11 - 28 mths). 16 patients (89%) had good bone union; in 2 cases the distal part of the graft had been resorbed. All of the patients were able to touch the pseudo-ball of the thumb with the 5th finger. The strength of the pinch-grip on average reached 3.3 kG (range 1.8 - 6.2 kG), which equals to 55% (range 36 - 78%) of the uninjured hand. Touch sensation was satisfactory in 16 patients (89%) (blue filament), reduced in 2 (11%); 6 patients (33%) showed two-point discrimination in the range of 10 to 15 mm. The esthetical result of the thumb was assessed as good in 13 (72%) and satisfactory in 5 patients (28%). Fifteen patients (83%), 9 blue collar workers and 6 farmers, continued with their occupations. CONCLUSION: The autograft of the amputated phalanx is a valuable reconstructive method for a selected group of patients.

[Forward homodigital ulnaris artery flap coverage for bone and nail bed graft in thumb fingertip amputation].

OBJECTIVE: To approach a new procedure of microsurgery to repair thumb fingertip amputation with forward homodigital ulnaris artery flap coverage for bone and nail bed graft. METHODS: From March 2005 to October 2007, 6 cases of amputated thumb fingertip (6 fingers) were treated, including 4 males and 2 females and aging 23-63 years. Six patients' (3 crush injuries, 2 cut injuries and 1 other injury) amputated level was at nail root (2 cases), mid-nail (3 cases), and the distal one third of nail bed (1 case). The time from injury to surgery was 3-10 hours, they were treated with forward homodigital ulnaris artery flap coverage for bone and nail bed graft. The flaps size ranged from 1.5 cm x 1.4 cm to 2.0 cm x 1.4 cm. RESULTS: All flaps survived. Wound healed in one-stage in 5 cases, and healed in second stage in 1 case because of swelling. All skin grafting at donor site survived in one-stage. All patients were followed up for 6-8 months. The appearance of flaps were good, and the two-point discrimination was 5-6 mm. Bone graft were healed, the healing time was 4-5 weeks. All finger nails were smooth and flat without pain. CONCLUSION: When there was no indication of replantation in thumb fingertip amputation, establishing the functional and esthetic construction can be retained with forward homodigital ulnaris artery flap coverage for bone and nail bed graft.

The use of vascularized phalanx for the first metacarpal bone defect in a mutilating hand injury. Case report.

In this case report, the use of middle phalanx of index finger for reconstruction bone defect of the first metacarpal is described. The reasons for this kind of usage and 1-year follow-up of the patient are discussed. During the follow-up, a pseudoarthrosis was observed in the repaired first ray. And this may be considered as a useful complication, when there is stiffness in the carpometacarpal joint. It may be a result of a stiff joint or vice versa.