Result of arm-level upper-limb transplantation in two recipients at 19- and 30-month follow-up.

BACKGROUND: Arm transplantation (ATx) is a novelty in the field of upper-limb transplantation, with only 7 procedures performed world-wide. CASE REPORT: In this paper we report on early results of unilateral arm transplantation recipients. Patient 1, a 30-year-old man, examined 30 months post-transplant, is able to actively flex the elbow, has 160 degree of ROM in the fingers of the grafted limb, and scored 92 points in the DASH questionnaire and 62 points in the Comprehensive Functional Score System (CFSS). The post-transplant period was complicated with 1 acute rejection episode due to CMV infection, and delayed bony union. Patient 2, a 55-year-old woman, examined 19 months post-transplant, is able to actively flex the elbow, has 180 degree of ROM in the fingers of the grafted limb, and scored 89 points in the DASH questionnaire and 64 points in the Comprehensive Functional Score System (CFSS). CONCLUSIONS: The post-transplant period was complicated with a delayed bony union. The ATx seems to be a valuable reconstructive therapeutic modality.

Quality of life-oriented evaluation of late functional results of hand replantation.

BACKGROUND: Forearm amputation in different zones via a similar mechanism in a group of patients of similar age is associated with different possibilities of functional recovery. The degree of postoperative recovery of function is invariably partial compared to pre-amputation function; this kind of trauma inevitably leads to disability. The patients adapt to their new circumstances to a different extent. That is why a quality of life evaluation should be included in the assessment of replantation outcomes. The aim of the study was to evaluate functional outcomes in patients after replantation at the metacarpal, wrist and mid-forearm level with regard to the quality of life of this patients. MATERIAL AND METHODS: Thirty patients (29 men, 1 woman) of an average age of 41 years who had had replantation or revascularization surgery of an upper limb at different levels took part in a randomized study. The patients were divided into 3 groups depending on the level of amputation: metacarpal, wrist, mid-forearm, with 10 patients in each group. Amputations had been done by a circular saw (21) or via a guillotine mechanism (9). The patients were evaluated on average 4.2 years postoperatively. The following parameters were assessed: total range of active motion (the long finger with the greatest range of motion was assessed) (TAM), grip strength, and sensation; patients performed the Nakamura-Tamai test (modified). Overall functional outcomes were assessed according to Chen's classification. The quality of life (QoL) was measured with the SF-36 questionnaire (0-136 points). The correlation of functional and QoL results was assessed by Spearman's non-parametric test. RESULTS: Average TAM was: 167 degrees in metacarpal, 174 degrees in wrist, 114 degrees in mid-forearm group; grip strength was 0.7 N, 0.9 N and 0.6 N respectively. All patients had at least protective sensation, whereas a 2PD of less then 10 mm was present in 4 patients in the metacarpal group, and 6 patients in the wrist group. In Chen's classification 5 patients in metacarpal group were rated as grade I and II, compared to 7 in the wrist group, and 2 in the forearm group. QoL scores were 98.9, 104 and 82 respectively. A strong QoL-function correlation was confirmed in the wrist and forearm groups (0.73 - 0.81 respectively), and in the metacarpal group it was weak (0.43). CONCLUSION: The quality of life of patients of the designated groups was correlated with their functional results.

Patient rehabilitation following hand transplantation at forearm distal third level.

The results of hand transplantations in terms of both graft survival (49/52, i.e. 94.3%) and hand function recovery are very inspiring. The degree of functional recovery is similar to that achieved after hand replantation at the same level. With regard to function recovery, the most favorable level of replantation seems to be the distal third of the forearm, with 75% of hand transplantations performed at this level. The aim of this paper was to present the process of limb rehabilitation following a hand transplantation at the level of the forearm's distal third. The recipient, a 29-year-old male, lost his right dominant hand 6 years before the operation in a drum flaker accident. The donor was a 52-year-old female. The limb was transplanted in a standard manner, with an uneventful postoperative period. The multidirectional rehabilitation focused on motor and sensory function as well as the recipient's psychological status. First passive finger movements were introduced on postoperative day 2, followed by assisted active movements from day 21 post-transplant onwards, and from day 28 we implemented exercises with an outrigger extension splint. Favorable hand position positioning was ensured by changing ortheses frequently. Motor rehabilitation relied on Perfetti's visual-motor training (from d 28 p-op.) together with continuous passive motion (Artromot F device). We also used electrical stimulation of the nerve trunks and intrinsic muscles of the hand as well as discrimination exercises of tactile sensation. The rehabilitation process was very similar to the one we use in patients after limb replantation. We assessed the motor and sensory functions of the grafted limb as very good despite diminished muscle strength, which does not affect the general functional result. The recipient adapted perfectly to living with a transplanted limb. The outcomes achieved by the hand transplant recipient confirm the need of early and multidirectional rehabilitation.

[Bilateral transversal humeral defect accompanied by defects of lower limbs--an attempt of improvement of upper limb's function by a reconstructive procedure, a case illustration]. / Obustronny ubytek poprzeczny ramion wspólistniejacy z niedorozwojem konczyn dolnych --próba poprawy funkcji konczyny górnej poprzez operacje rekonstrukcyjna, ilustracja przypadku.

Motor system is the most common localization of congenital defects. Disturbances of limb formation resulting in a total defect of a limb fragment are most difficult to treat. Transversal defects within the arm are usually unilateral and rarely accompanied by other congenital mutilations. The exceptional case is presented of a child with bilateral humeral transversal defect accompanied by transversal defect of a right thigh, and bilateral hip joint dysplasion. The etiology of the mutilation is unknown. The child was able to move on a wheel-chair as well as thanks to well innervated arm-stumps and a single foot to perform many activities of daily life, although some of them with a serious difficulty. The commonly stated decision was taken to operate the child aiming at improvement of limb's function. That was achieved by a reconstructive procedure creating a pincer-like enlargement of arm-stump's ending. Arm lengthening seems to be necessary in the near future.

[New possibilities of hand rehabilitation based on CPM protocol by means of a device Artromot-F]. / Nowe mozliwosci usprawniania reki metoda ciaglych ruchów biernych (CPM) za pomoca urzadzenia Artromot-F.

Continuous passive motion exercised by special devices called artromot is a well-known method of lower limb rehabilitation. It is seldom used for mobilisation of large joints of upper limb like shoulder, elbow or wrist joint. Until recently this method could not be applied for mobilisation of smaller hand joints because of lack of suitable device. The newest device--Artromot-F belonging to the group of CMP-device seems to meet such requirements. The paper presents it's application.

Modified Colzi method in the management of established Volkmann contracture--the experience of Trzebnica Limb Replantation Center (preliminary report).

BACKGROUND: "The terrible disability of irreversible ischaemic flexion contracture of the metacarpi and digits known as Volkmann's contracture can be avoided in the vast majority of cases, but never completely cured" (M. Koszla). A modification of Colzi's forgotten technique for the treatment of Volkmann's contracture is presented together with our treatment outcomes. MATERIAL AND METHOD: The Colzi procedure was performed in 15 patients aged: 3-54 years with Buck-Gramcko grade III, III/IV and IV Volkmann's contractures. Time between injury and surgery ranged from 4.5 months to 21 years. The main manoeuvre to reduce the contracture was two-level shortening osteotomy in the proximal and distal thirds of the radius and ulna. Osteosynthesis was performed by Rush intramedullary nailing. RESULTS AND CONCLUSIONS: A very good range of mobility (from 17 degrees preop. to 56 degrees postop.), force (0.73 preop.- 7.6 kg postop.) and contracture correction (183 degrees preop. - 27 degrees postop.) was achieved. Complications in the form of delayed union or secondary fractures occurred in 4/15 patients, and were managed by prolonged immobilisation and decortication with bone grafting. The modified Colzi procedure proved its value as a universal, easy, minimally invasive and safe method of treatment of Volkmann's contracture regardless of patient age, duration of illness, previous therapy, and stage of contracture.

[Second-toe transfer on forearm stump as an alternative to Krukenberg's operation--case illustration]. / Transfer II palca stopy na kikut przedramienia sposobem Vilkkiego jako alternatywa operacji metoda Krukenberga--ilustracja przypadku.

The result of gripping ability reconstruction by Vilkki's method in a patient after a total wrist amputation is presented. The achieved range of motion makes possible gripping of objects of 3.5 cm in diameter; patient's hand function improved which depicts the drop of 8 points according to DASH questionnaire. The patient is highly satisfied with this result.

Zone 1 extensor tendon lesions: current treatment methods and a review of literature.

The treatment options for the soft-tissue mallet finger, both acute and chronic, continue to generate a certain degree of controversy. Priority should always be given to conservative management of these injuries. This translates into a 6-to-8-week period of uninterrupted immobilization of the DIP joint with an external splint. Splinting has been shown to be highly effective and safe for both acute and chronic lesions. Even in the presence of an open injury, the value of splinting should be appreciated by the practitioner. The conversion of an acute closed, soft-tissue injury to an open one is to be discouraged,due to unacceptable complication rates. When surgery is contemplated, in a selected group of patients, the first option advocated by most authors is the placement of a trans-articular Kirschner wire at the DIP joint and/or conjoint tendon advancement. If external splinting fails in an acute injury, an argument can certainly be made for a second trial of conservative management. It has been found that some patients will not tolerate a second period of immobilization, and in most such cases surgery is offered. In summary, mallet injuries are best treated using closed, nonoperative techniques. The period of time after injury for which this conservative treatment can be prolonged and still be effective is being extended, and the absolute outside time limit remains unknown. Surgical treatment should be reserved for mallet fractures, and in such cases Bunnel's pull-out suture is recommended. Finger rehabilitation is an indispensable part of any method of treatment.

[Assessment of results of opponensplasty by transfer of flexor digitorum superfitcialis tendon of the ring finger]. / Wyniki odtwarzania opozycji kciuka za pomoca transferu sciegna zginacza powierzchownego palca obraczkowego.

This study is the review of 16 hands in the same number of patients (15 men, 1 female) in whom ring finger flexor digitorum superficialis opponensplasty was performed. The patients were operated on during the period of 6 years. The lack of thumb opposition was a result of traumatic nerve leasions (5 median, 11 median and ulnar). The operation was performed 7.2 months (on average) after the nerve reconstruction. The outcome was assessed by scoring the finger to which the thumb could obtain a pinch grip (Kapandji's test), measuring the gap between thumb and little finger MCP joints, the patient's satisfaction. The sensitivity on the pulps of ring and little finger were also tested. Two patients were reoperated for loosening the transferred tendon, two patients developed minor dysfunction of the donor finger. The results were evaluated 41 weeks after an operation. As a result of the operation the "opposition gap" was diminished by 22 mm on average; the patients scoring by Kapandji's test was improved by 2 points. Eight patients assessed the improvement of the hand function as excellent, six as good, two were dissatisfied with the result.

Rehabilitation of fingers after flexor tendon lesions qualified for secondary reconstruction, using Kleinert's dynamic splinting method.

Background. Primary reconstruction of flexor tendons lesions resulting from serious hand mutilations is not always possible. This causes problems in the rehabilitation of finger joints that are unable to perform active flexion. There is no generally accepted approach to such cases. The authors used a dynamic splinting regimen to treat fingers with unrepaired flexor tendons qualified for secondary reconstruction. Material and methods. Our research involved 39 patients treated in the Department Limb Replantation at St. Jadwiga's Hospital in Trzebnica, Poland, who had been referred for flexor tendon repair (from 1 to 3) in secondary reconstruction. The time from the primary operation ranged from 10 to 14 weeks. There were 27 men and 12 women, ranging in age from 19 to 60 years (ave. 39.5), divided into two groups. 24 patients (group I) had their fingers mobilized by dynamic splinting method, while in 14 patients (group II) no specific regimen of rehabilitation applied: the patients mobilized their fingers with their unimpaired hand. Results. The loss of total passive motion of finger joints was up to 75.65 degrees (~29%) greater in group II. Conclusions. The method applied is very effective in maintaining a wide range of passive motion in finger joints, which is essential for secondary flexor tendon reconstruction.

The application of nerve block in early post-operative rehabilitation after tenolysis of the flexor tendon.

Background. Satisfactory outcome after flexor and extensor tenolysis depends on post-operative hand rehabilitation, but the accompanying pain presents a serious obstacle. The aim of our paper was to evaluate the effectiveness of a specific blockade of the distal segments of the median or ulnar nerve in post-tenolysis rehabilitation. Material and methods. During the period 2002-2004 we operated 11 patients (mean age 31, range 17-44) with tenolysis of the flexor tendon (19 tendons). During surgery an epidural catheter was placed in the wrist proximal to an ulnar or median nerve. Bupivacaine was applied through the catheter 3-4 times daily to anesthetize a specific region of the hand. The day after surgery the patients started hand rehabilitation. The active range of motion (ARM) was measured: 1) before surgery, 2) after tenolysis but before bupivacaine, 3) after nerve blockade, 4) ca. 12 weeks after surgery. Pain during exercises before and after the application of bupivacaine was evaluated using a 10-point visual pain scale (VAS). Results. The catheters were removed 5-8 days after surgery (earlier in one case due to inflammation). Apart from 2 ruptured tendons (10.5%) no other complications were observed. The experimental technique produced a 3-point reduction on the VAS. The average increase in ARM after application of the anesthetic was 17.2 degrees . Surgery resulted in an increase in ARM to 74.5 degrees , an average of 73% when measured ca. 12 weeks after surgery. Conclusion. The method of selective post-operative nerve blockade enables more effective hand rehabilitation after tenolysis of the flexor tendon.