Sequential Clinical Recovery after Replantation for Complete Finger Amputation in Tamai Zone 1.

Background The clinical results of replantation for an amputated distal finger are functionally acceptable. However, few reports exist regarding sequential clinical postoperative recovery. The purpose of this study was to examine the clinical recovery at every 3 months up to 1 year postoperatively. Methods Nineteen patients (16 patients were men), representing 19 fingers with complete amputation at Tamai's zone 1 and replanted successfully, were included in this study. Total active motion (TAM), grip strength (GS), Semmes-Weinstein monofilament (SW) test result, static two-point discrimination (s2PD), and Disability of the Arm, Shoulder, and Hand (DASH) score questionnaire results were obtained postoperatively at 3, 6, 9, and 12 months. Pulp atrophy and nail deformity were assessed at 12 months postoperatively. Results The postoperative %TAM (compared to the uninjured side, 81.8 ± 18.1 at 3 months vs. 91.5 ± 11.9 at 6 months, p < 0.01), %GS (compared with the uninjured side, 61.3 ± 25.9 at 3 months vs. 78.3 ± 20.4 at 6 months, p = 0.02), s2PD (excellent and good/poor; 7/12 at 3 months vs. 18/1 at 6 months, p < 0.01), and DASH scores (26.1 ± 23.1 at 3 months vs. 12.0 ± 12.9 at 6 months, p < 0.01) recovered significantly from 3 to 6 months but did not change significantly from 6 months onward. The SW test results showed a significant recovery between 3 and 12 months postoperatively (2.83 and 3.61/4.31, 6.65, and undetectable, 1/18 at 3 months vs. 7/12 at 12 months, p = 0.04). The DASH score at 12 months postoperatively was significantly associated with %TAM ( r = -0.64, p < 0.01) and %GS ( r = -0.58, p < 0.01) at 12 months postoperatively and age ( r = 0.52, p = 0.02). Five fingers had pulp atrophy and four fingers had nail deformity. Conclusion This 1-year follow-up study showed the sequential clinical recovery after replantation for complete amputation in Tamai zone 1. Postoperative %TAM, %GS, and the DASH score recovered significantly between 3 and 6 months but significant recovery up to 1 year was not observed.

Reconstruction of a Composite Defect of the Distal Index Finger Using a Chimeric Reverse Flow Second Dorsal Metacarpal Artery Flap: A Case Report.

The reconstruction for mild tissue loss at the distal part of a finger is challenging. We report about a 29-year-old man presenting with traumatic tissue loss at the distal interphalangeal (DIP) joint of the index finger, including skin, bone, and nerve. Reconstruction using two types of flaps was performed. The dorsal skin flap, nourished by the second dorsal metacarpal artery (SDMA) perforator, was elevated. The vascularized second metacarpal bone, nourished by the SDMA, was also elevated. Using the vascular connection between the DMA and the palmar digital artery (PDA), both flaps were raised to the distal part of the finger, and the pivot point was set at the dorsal proximal phalanx. After arthrodesis of the DIP joint with the vascularized second metacarpal bone, the digital nerve was repaired using the cutaneous nerve in the skin flap, and the skin defect was covered using the perforator flap. The postoperative course, including flap survival and bone union, was uneventful. A good indication for the reconstruction of the distal part of a finger with this technique is when the defect sizes of the skin and bone differ and the vascular connection between the SDMA and dorsal branch of PDA is not injured.

Computed Tomography Evaluation of Distal Screw Penetration in Volar Locking Plate Fixation for Intra-Articular Distal Radius Fractures.

PURPOSE: Volar locking plate fixation for distal radius fractures (DRFs) is a technically demanding procedure with a risk of distal screw penetration through the dorsal cortex or the articular surface. This study aimed to investigate the incidence and details of distal screw penetration after volar locking plate fixation for intra-articular DRFs using a CT scan and to evaluate the relationship between the incidence of screw penetration and fracture comminution severity and the clinical complications of screw penetration. METHODS: This was a retrospective case series of 91 adult patients (mean age, 63 years; 27 men) who underwent volar locking plate fixation for intra-articular DRFs from 2015 to 2018. The positioning of the distal screws was evaluated using a postoperative CT scan, and radiological outcomes were compared between the AO C1 and C3 groups. At the final follow-up, tendon rupture and arthritis severity were assessed as clinical complications of dorsal and intra-articular screw penetration. RESULTS: Distal screw penetration was observed in 44 wrists (48%), dorsal cortex screw penetration in 34, intra-articular screw penetration in 13, and both dorsal cortex and intra-articular screw penetration in three. The incidence of intra-articular screw penetration was significantly higher in the C3 group than in the C1 group. No tendon rupture was observed. Multivariable analysis revealed that intra-articular screw penetration was significantly related to high severity of arthritis. CONCLUSIONS: Approximately half of the study patients with intra-articular DRFs had distal screw penetration. The incidence of intra-articular screw penetration was associated with the severity of fracture comminution, and the intra-articular screw penetration was associated with the incidence of early radiocarpal arthritis. Intra-articularly penetrating screws should be replaced as soon as they are discovered, regardless of the length of penetrated screw or absence of patients' subjective symptoms. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Intra-articular fibromembranous septum after intra-articular distal radial fracture: Arthroscopic excision and factors associated with formation of the septum.

BACKGROUND: Intra-articular fibromembranous septum in the radiocarpal joint can cause wrist contracture after distal radial fracture, but the mechanism underlying the formation of the septum is unknown. This study examined the clinical outcomes in patients treated with arthroscopic excision of the septum and the factors associated with formation of the septum in patients with and without a septum. METHODS: Fifty-three patients (22 with septum and 31 without septum) treated for intra-articular distal radial fracture with arthroscopy using a volar locking plate and secondary removal of the plate were included. Clinical outcomes and radiological assessments were analyzed. RESULTS: In patients with a septum, the range of wrist flexion and total wrist arc before the second operation were significantly more limited than in those without a septum (p < 0.01 and p = 0.03, respectively). The improvement rate (improvement in wrist arc divided by the wrist arc of the healthy side) after arthroscopic excision of the septum and plate removal was greater in patients with a septum than in those without a septum (6.1% vs. 2.0%, p = 0.08). The significant factors affecting formation of the septum were the residual articular gap and the height of the midradial ridge on computed tomography images. CONCLUSIONS: Intra-articular fibromembranous septum after surgically treated intra-articular distal radial fracture affects limited range of motion and secondary arthroscopic excision of the septum improves the wrist range of motion. Anatomical reduction and maintenance of the articular fragment, as well as anatomical characteristics might be causes of septum formation.

Artery-Only Fingertip Replantation Distal to the Lunula: A Retrospective Analysis of Clinical Results.

Background: Both arterial and venous repair are crucial for optimal results in digital replantation. However, anastomosis of veins becomes challenging in very distal fingertip amputation. This study aimed to report the clinical results of an artery-only replantation without vein repair for a distal fingertip amputation and to analyze the survival rate and clinical outcomes based on the amputation level. Methods: We performed a retrospective review of 47 digits in 38 patients who had undergone fingertip replantation with a mean follow-up period of 12 months. All patients had complete fingertip amputation distal to the lunula. Only one central artery repair distal to the arch was performed. All patients received the postoperative protocol including external bleeding and anticoagulation therapy. Results: By Ishilawa's classification, 12 digits in subzone I, and 35 digits in subzone II. 31 of the 47 fingertip replantations (66%) were successful, and a significantly higher survival rate was observed in subzone I than in subzone II. The mean total active motion of surviving digits was 86% of normal side. The mean grip strength was 82% of normal side. The sensory recovery according to modified Highet and Saunders' classification was S4, S3+, S3, and S2 in fingers 19, 2, 5 and 3, respectively. Conclusions: 66% of survival rate was achieved in fingertip replantation distal to lunula which including large number of crushing/avulsion injury. The result of comparison for the survival rate based on amputation level, a significantly higher survival rate was observed in subzone I compared to subzone II. Therefore, the artery-only fingertip replantation had a better indication for distal amputation, and an aggressive attempt for venous anastomosis or drainage, including a secondary surgery for proximal amputation could be attributed to a higher success rate.

Replantation for multiple digit amputations: A retrospective analysis of the clinical results.

PURPOSE: Replantation of multidigit amputations is difficult to perform due to severe damage to the digits, prolonged operative time, and ischemia. This study aimed to report the clinical results of multidigit replantation. METHODS: A retrospective case series of 34 digits belonging to 12 consecutive patients who underwent multidigit replantation was conducted. Patients with injury in at least one or more amputated fingers proximal to the insertion of the flexor digitorum superficialis tendon were included. The mean follow-up duration was 18.1 months. The number of amputated digits, mechanism and zone of injury, survival rate, and clinical outcomes, including the range of motion, grip strength, and sensory recovery, at the final follow-up were reviewed and analyzed. RESULTS: The mean number of amputated digits per patient was 2.8. Complete survival was achieved in 27 of 31 digits (87.1%). The mean final percentage of total active motion of injured digits was 47.0%, and the mean percentage of grip strength was 45.9% of the contralateral uninjured side. The comparison between patients with two and three amputated digits showed that there was no significant difference in both survival rates and functional outcomes. CONCLUSIONS: The results showed that both the survival rates and functional outcomes of multidigit replantation were as good as those of single-digit replantation, and there was no significant difference for outcomes between patients with two and three amputated digits. These results suggested that all multidigit replantations should be performed regardless of the number of injured digits or amputation zones.

Ulnar-sided wrist pain due to radial bifurcation of the extensor digiti minimi tendon: A case report and literature review.

Stenosing tenosynovitis of the extensor digiti minimi (EDM) without trauma is very rare. We report a 21-year-old woman who presented with dorsoulnar wrist pain during palmar wrist flexion and soft tissue mass at the site of pain. Ultrasonography and magnetic resonance imaging showed a round mass radial to the EDM tendon. Conservative treatment for 3 months failed to improve the patient's pain levels. Intraoperative findings revealed smaller radial slip of the EDM tendon, and bifurcation of these was under the distal portion of the extensor retinaculum (ER). Surgical release of the ER, resection of the smaller slip of the EDM tendon, and tenosynovectomy were performed. Histological examination showed tenosynovitis. At the final follow-up 1 year postoperatively, she was asymptomatic. A literature review suggested that stenosing tenosynovitis of the EDM tendon might be caused by frequent use of the hand with a background history of bifurcation of the EDM tendon.