Long-term results of major upper extremity replantations.

We analyzed the long-term functional outcome in patients with major upper extremity replantations. Two patients had amputations proximal to the elbow joint, two had elbow disarticulations and five patients had amputations at the forearm. The mean age was 24 and the mean follow-up time was 18 years. Six patients have undergone secondary operations. The mean grip strength was restored to 34% of the contralateral extremity. Protective sensation was restored in all patients. According to Chen's functional recovery scale, five patients had excellent, two had good, and two had fair results. Grip strength, two-point discrimination, ranges of motion and Chen's scale did not improve after 5 years. However, Semmes-Weinstein monofilament testing and cold intolerance continued to improve up to 10 and 12 years, respectively. Replantation of an upper extremity proximal to the wrist joint satisfactorily restored the upper extremity function.

Replantation of thumb avulsion injuries.

PURPOSE: To point out detailed technical considerations and tactical modifications within the experience of 59 replantations of thumb avulsion injuries, to clarify the indications of replantation, and to evaluate the long-term results. PATIENTS AND METHODS: Seventy-two thumb avulsions of 510 thumb amputations were treated at our centre between 1986 - 2002. Sixty-two of them were male and 10 were female. The average age of the patients was 27 years. Fifty-nine avulsed thumbs were replanted, and 13 were considered as "not replantable" and operated using other reconstructive procedures. Since the main goal of thumb replantation is survival with sensitivity and good function, all the injured tissues were repaired or primarily reconstructed. As a main principle, we always aimed for a one-stage reconstruction including vein grafts for the arterial injury, direct vein repair or vein transfer to establish venous outflow, tendon transfers to restore movement, and nerve transfer to restore sensation. RESULTS: Overall survival rate was 84.7 %. The average follow-up time was 65.2 months. 80 percent of the patients returned to their original work within an average of 4 months after replantation. The patients were generally satisfied with the outcome and ability to use their thumb. The average range of movement of the interphalangeal joint was 75 % of the normal side. On average, key pinch strength was 65 % of contralateral hand. Two-point discrimination was less than 10 mm in 60 % of the cases. Semmes-Weinstein monofilament testing evaluation showed 2.83 in 35 patients, 3.61 in 20, and 6.68 in 4 patients. CONCLUSIONS: In replantation of avulsion amputation of the thumb, functional success depends on repair or reconstruction of all damaged tissues, if necessary, using nerve transfers and tendon transfers. If these could be done primarily as a one-stage reconstruction, the costs would be less, the patients would return to their work when the one-stage treatment and rehabilitation is finished, and would also eliminate the technical difficulties encountered in secondary reconstructions.

Toe-to-hand transfers: more than 20 years follow-up of five post-traumatic cases.

In post-traumatic losses of the thumb and fingers, reconstruction can be performed with success using various combinations of toe transfers. In this study, we have presented second toe and combined toe transfers which have been followed up for more than 20 years. Second toe transfer was used in four patients for reconstruction of the thumb. Combined second and third toe transfer was performed in two patients with a metacarpal hand for finger reconstruction. Long-term follow-up results show that patients with toe-to-hand transfers have acceptable adaptation to the reconstructed hand and good hand function. Toe transfer should be individually planned and carefully executed to obtain optimal results and minimal disability in the donor foot.

Brachioradialis re-routing for the restoration of active supination and correction of forearm pronation deformity in cerebral palsy.

A brachioradialis muscle rerouting procedure was used to restore active supination in five children with cerebral palsy and a pronation deformity. Following release and lengthening of the pronator quadratus and pronator teres muscles, respectively, the brachioradialis tendon was divided as a Z plasty and the distal part of the tendon was passed through the interosseous space in a dorsal to palmar direction, and then sutured to its proximal end. The procedure resulted in a gain of 81 degrees of active supination.

Restoration of sensibility in irreparable ulnar and median nerve lesions with use of sensory nerve transfer: long-term follow-up of 20 cases.

A prospective study was conducted to evaluate patient outcomes following sensory nerve transfer. Twenty patients with irreparable ulnar or median nerve lesions underwent the procedure. Nerve involvement was bilateral in 5 cases. The mean age of the patients at the time of surgery was 29 years. The mean paralysis time and the average length of follow-up were 59 and 78 months, respectively. Eighteen of 20 patients attended a sensory re-education program after surgery. Outcome was assessed objectively by functional sensory recovery testing and by the British Medical Research Council standards. Subjective outcome was assessed by a questionnaire. Two-point discrimination of less than 10 mm was achieved in 15 of 25 hands. The mean functional sensory recovery score was 83. Eighteen of 20 patients reported that the function of their hands improved after the procedure. Good or excellent results were associated with immediate transfer of the nerve, young age, and patients' attendance to the sensory re-education program after surgery. No differences were found between the recovery of ulnar and median nerves. Based on these results we suggest that sensory nerve transfer is a simple and reliable way of restoring sensibility to the hand with favorably comparable results over conventional nerve grafting in selected cases.

[Proximal amputation injuries of the thumb including the radial half of the hand. Case reports]. / Proximale Amputationsverletzungen des Daumens einschliesslich der radialen Handhälfte. Fallbeschreibungen.

The primary treatment of proximal amputations of the thumb and radial half of the hand is of particular importance, if the primary functions of a basic hand are to be restored. It is of utmost importance, that such treatment be carried out by a highly experienced reconstructive surgeon, since the transplantation or transposition of blood vessels, nerves, tendons and skin and soft-tissue flaps may be necessary. Five case reports illustrate the fundamental principles of primary and secondary reconstruction of the hand.

Comparison between sensitive and nonsensitive free flaps in reconstruction of the heel and plantar area.

In this study, 12 cases of reconstruction of the heel and plantar area since 1982 are reviewed. Six nonsensate muscle free flaps and six sensate fasciocutaneous flaps were used, respectively. Categories assessed were the time interval for return to daily living activities, sensation to light touch, pinprick, Semmes-Weinstein monofilament test of the reconstructed area for sensory evaluation; and results of pedograms (maximal pressure, pressure distribution, and total contact area of the plantar surface). Follow-up periods were between 2 and 14 years, with an average of 6 years. Better sensory results and early return to daily living activities were observed in the sensate flap group, but the defects were smaller in this group. Despite the slightly longer time to return to daily living activities and worse sensory results, long-term follow-up showed that patients with nonsensate flaps had no difficulty in performing living activities if they continued to be careful and to use some kind of protective shoes. The results of the pedogram analyses were similar between the two groups with regard to total contact area of the reconstructed foot in relation to the healthy foot. Pressure values of the reconstructed areas in sensate flaps were found to be close to pressure values in the same weight areas of the normal foot. The differences between pressure values of the sensate and nonsensate flaps were statistically significant (p < 0.001). Therefore, in reconstruction of the weight-bearing surface of the foot, each case should be evaluated individually. The reconstructive method should be chosen according to the location and soft-tissue requirements of the defect.

The effects of cortisone on liver blood flow in experimental hemorrhagic shock: using a new simplified radioisotope clearance method to measure liver blood flow.

Liver blood flow was measured in the dog under control and hemorrhagic shock conditions by the 133Xe clearance method. 133Xe was administered first into the portal vein and its clearance from the liver recorded, and then directly into the liver tissue and another clearance curve was obtained. The resuts were compared. We have also investigated the effects of corticosteroids, given in pharmacologic doses, on liver blood flow in hemorrhagic shock. We have shown that the difference between the results of tissue injection and those of portal injection of 133Xe was not significant (p greater than 1.10). Hemodynamic studies indicated that the liver blood flow is decreased, the liver venous resistance and portal venous pressures are increased in dogs in hemorrhagic shock, and that hydrocortisone, with the blood pressure and the bleedout volume held constant in the experimental model, lowers the liver venous resistance and raises the liver blood flow significantly (p less than 0.05) at various stages of hemorrhagic shock.