Syndactylized glabrous flaps for multiple finger palmar defects.

BACKGROUND: Palmar finger or pulp defects require coverage with glabrous tissue to achieve a good match with the lost tissue. The management of multiple finger palmar or pulp defects is challenging because these defects may not always be suitable for local or pedicled flaps. In such situations, syndactylizing free or pedicled flaps can be used. PATIENTS AND METHODS: We evaluated the results of free glabrous flaps syndactylizing across multiple finger defects. The two flaps used were the superficial branch of the radial artery (SUPBRA) flap and hypothenar free flap. Seven syndactylized glabrous free flaps were used to cover the defects in 16 fingers. The functional results and complaints were also assessed. RESULTS: Mean flap size was 14.35 cm2. Six flaps survived. Postoperative evaluation data were obtained for the 13 fingers. All the patients returned to their previous work. All patients had a diminished protective sensation of at least 4.31 according to the SWM test. The mean two-point discrimination score of the patients was 9.9 mm (7-14). One finger had a PIP joint flexion contracture of 30°, no donor-site complaints were observed. CONCLUSION: The advantages of these flaps include single operation site, strong glabrous tissue coverage, low risk of flexion contracture, and adequate tissue size for large defects. Disadvantages include two-stage and complex microsurgical operations, prolonged treatment, and hospital stay.

Long-term outcomes of homodigital neurovascular island flap reconstruction of fingertip injuries in children.

We evaluated the long-term functional and cosmetic results of homodigital neurovascular island flap (NIF) used to reconstruct extensive pulp defects with bone exposure in children. Twenty-three children (mean age 4.8 years, range 1-10 years) with fingertip injuries were reconstructed with a pedicled homodigital NIF and evaluated in terms of sensation quality, cold intolerance, scar formation, nail deformity, range of motion and overall finger length at a mean follow up of 7.8 years (range 2-13). Eleven patients reported cold sensitivity in the operated fingertip, and 15 presented with hook nail deformities at the final follow-up. The total active motion of the injured finger was significantly lower than that of the uninjured side (p < 0.001). NIFs is a safe, reliable reconstructive treatment for fingertip loss in children, but commonly encountered issues in the long term include an extension lag of the interphalangeal joints, hook nail deformities and cold intolerance. Level of evidence: IV.

The results of delayed open reduction and internal fixation in chronic bony mallet finger injuries.

OBJECTIVES: The aim of this study was to evaluate the functional results of delayed open reduction and Kirschner wire (K-wire) fixation procedures in patients with delayed presentation of bony mallet finger. PATIENTS AND METHODS: Between February 2009 and November 2019, a total of 19 patients (15 males, 4 females; median age: 24.8 years; range, 14 to 47 years) who were diagnosed with a delayed bony mallet finger and treated with dorsal block pin, direct pinning, or the umbrella handle technique were retrospectively analyzed. The Crawford criteria were used to evaluate the outcomes. The degrees of range of motion (ROM) were measured by a goniometer. RESULTS: The median time from injury to surgery was 41 (range, 28 to 90) days. The median DIP joint extension limitation was 7.63 (range, 0 to 40) degrees and the median ROM of the DIP joint was 66.3 (range, 20 to 90) degrees. There was no statistically significant difference in the postoperative ROM, compared to the uninjured side (p>0.05). The Crawford score was excellent in 11, good in four, fair in three, and poor in one patient. Bone union was achieved in all patients. CONCLUSION: Delayed open reduction and K-wire fixation of chronic bony mallet finger injuries yield successful functional outcomes with low complication rates. Extension lag can be eliminated in most patients by making the joint surface anatomical. The most optimal method should be selected depending on the size of the fracture fragment.

Reconstruction of mutilating hand injuries by microsurgical free tissue transfers from the foot.

INTRODUCTION: The aim of this study is to present various hand reconstruction methods and provide technical notes regarding the treatment of mutilating hand injuries using free-tissue transfers from the foot and to investigate whether these transfers provide patients with a usable hand or not. PATIENTS AND METHODS: Ninety patients with mutilating hand injuries were included in the study. A total of 101 procedures were performed. Patients were contacted by phone to evaluate their working status and to record any complaints regarding their donor sites. The Quickdash questionnaire was conducted for the 53 patients who could be reached. Operative techniques, secondary procedures, finger survival, and physiotherapy data were noted retrospectively. RESULTS: In 36 patients, a trimmed great toe was transferred to the thumb. Second toe-to-thumb transfers were performed in 8 patients, and second toe-to-finger transfers were performed in 10 patients. In 13 patients, 2 toes from one side were transferred, and in 6 patients, 3 toes were transferred to the hand. Bilateral toe transfers were performed in 9 patients. Eight patients underwent joint transfers, of which 2 involved joint transfers from both feet. The overall finger survival rate for the transfer procedures was 95.04%. The average Quickdash score of the patients who could be reached (n = 53) was 27.49, with 62.3% of the patients being able to use their hands in their previous jobs, and 26.4% needing to change their jobs because of their hand injuries. 41.5% of the patients had no donor site complaints. 47.2% had mild complaints, and 11.3% had major donor site complaints. CONCLUSION: Multiple-toe transfer techniques along with flap coverage options should be considered, and delicate planning is mandatory to achieve at least a basic or acceptable hand. Three toes, including the great toe, can be transferred in a single operation by dissecting both the dorsal and plantar arterial systems. Crush injuries of the dorsal side of the hand may be reconstructed using combined transfers of bones, joints, extensor tendons, and skin. In our series, 88.7% of patients with mutilating hand injuries were able to return to work after we performed tissue transfers from the foot.

Glomus tumors of the nail bed: topographic anatomy and an algorithmic approach based on the topography.

PURPOSE: Glomus tumors are rare vascular pathologies characterized by a triad of symptoms: tenderness, pain and cold intolerance. In the hand they are highly concentrated under the nail bed. In this retrospective study, we aimed to present a topographic map of the location of glomus tumors in the nail bed and a map-based surgical approach algorithm to the subungual glomus tumors. METHODS: We prepared a nail bed map with 6 zones and named these zones as ulnar distal, ulnar proximal, central distal, central proximal, radial distal and radial proximal. With respect to the tumor location and the used surgical approach we retrospectively evaluated the intraoperative photos and the hospital records of patients who were operated between 2008-2019 and had the pathological diagnosis of glomus tumor. The examination records of the postoperative first year were evaluated for each patient retrospectively. A descriptive statistical analysis was performed. In addition we analyzed the described surgical approaches to excise a glomus tumor in the nail bed. The described approaches and the approaches used by us were matched with the localisation of the tumors in this study developing an algorithm for the surgical approach depending on the localisation of the nail bed glomus tumor. RESULTS: Finally 44 patients had inclusion criteria. The distribution of the glomus tumor was as follows: 2 were on ulnar distal (4.5 %), 9 on ulnar proximal (20.5 %), 1 on central distal (2.3 %), 18 on central proximal (40.9 %), 4 on radial distal (9.1 %) and 10 were on the radial proximal zones (22.7 %). 4 lateral approaches, 1 nail sparing and 39 transungual approaches were performed. We had one recurrence in a male patient operated by transungual approach. CONCLUSION: Glomus tumors are mostly located on the central proximal part of the nail bed. Our glomus map and the algorithm we described might be helpful for the selection of the surgical approach for the glomus tumor.

Survival and Comparison of External Bleeding Methods in Artery-Only Distal Finger Replantations.

PURPOSE: If there are no veins available in a distal amputation, an artery-only replantation is performed, and an external bleeding method is commonly used. We conducted a survival analysis in a large series of artery-only replantations and compared 2 different external bleeding methods in artery-only distal replantations: nail matrix or hyponychial area bleeding and pulp skin area bleeding, which we have called the crater method. METHODS: Two hundred twenty-eight artery-only distal finger replantations in 199 patients were included in the study. The replanted digits were divided into 2 groups according to the external bleeding methods. One group (n = 94; 41.2%) included the patients in whom the external bleeding was performed using a traditional nail bed incision and the second group (n = 134; 58.8%) included the patients in whom external bleeding was performed using the crater method. The finger survival rates and postoperative circulatory problems were examined. The impact of the injury mechanism, injury level, and external bleeding method on survival were evaluated. RESULTS: Clinical findings indicating venous insufficiency were observed in 198 (86.8%) replanted fingers. One hundred eighty-two (79.8%) survived, and complete necrosis developed in 46 (20.2%). Viability was maintained in 84% of patients treated with the nail bed bleeding method and 76.9% of patients treated using the crater method. Clean-cut cases had the best results and subzone 3 cases had the worst results. CONCLUSIONS: The artery-only replantation was associated with a 79.8% survival rate. The method of achieving venous outflow did not appear to have an impact on survival. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Clinical outcomes of salvage revision surgery following finger replantation with vascular insufficiency: A retrospective study.

OBJECTIVE: The aim of this study was to analyze the outcomes of revision surgery following replantation of single digital amputations. METHODS: In this study, first, a total of 403 patients (339 male, 64 female; mean age=28 years; age range=1-76) in whom a single finger replantation was performed were retrospectively reviewed, and then 60 patients with arterial or venous insufficiency in whom revision surgery was performed were reanalyzed. The second finger was observed to be the most injured one (32.8%). Injury type was classified as clean cut (25.3%), local crush (38.7), extensive crush (7.9%), and avulsion (28.1%). When taking the levels of injuries of the artery-only finger replantations into account, one finger (0.8%) was nail distal third, 70 fingers (56%) were nail distal third to lunula, 43 fingers (34.4%) were lunula to distal phalanx basis, 10 fingers (8%) were distal interphalangeal (DIP) joint, and one finger (0.8%) was middle phalanx. Operative revision was performed on 60 (14.9%) fingers. The need for operative revision was arterial insufficiency in 37 fingers (61.7%) and venous insufficiency in 23 fingers (38.3%). The average revision time was 43 (range=6-144) hours. While the average elapsed time for artery procedures was 35.3 (range=8-110) hours, the average elapsed time for vein procedures was 47.1 (range=6-144) hours. Finger survival rates were examined. Injury mechanism, amputation level, the number of artery/vein repairs and methods were examined in all patients and revision patients separately. RESULTS: After the replantations, according to survival analysis, while 342 (84.9%) fingers were operated upon successfully, 61 (15.1%) fingers developed necrosis. In the patients with revision surgery, the survival rate was 78.3%. The need for revision was arterial insufficiency in 37 fingers (61.7%) and venous insufficiency in 23 fingers (38.3%). The revision rate was significantly lower than other injury types in clean-cut cases. In terms of levels of injury, no revisions were required from distal to lunula level, and the highest revision rate was observed at the proximal interphalangeal (PIP) joint level. CONCLUSION: The results of the present study have shown that early re-exploration can provide a 78.3% success rate and can increase the survival rate from 67.6% to 84.2% following replantation of single digital amputations. Surgical re-exploration seems to be a reasonable salvage for replanted fingers with vascular insufficiency. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Results of 4-strand modified Kessler core suture and epitendinous interlocking suture followed by modified Kleinert protocol for flexor tendon repairs in Zone 2.

OBJECTIVE: There has been no consensus in literature for the ideal flexor tendon repair technique. The results of zone 2 flexor tendon lacerations repaired primarily by 4 strand Modified Kessler core suture and epitendinous interlocking suture technique followed by Modified Kleinert protocol were investigated. METHODS: 128 fingers of 89 patients who had flexor tendon laceration in zone 2 built the working group. Functional outcomes were evaluated using the Strickland formula. A statistical analysis was made between Strickland scores and some parameters such as age, gender, follow-up time, co-existing injury existence, repair time, single or multiple finger injury, tendon rupture and the effect of FDS injury and repair. RESULTS: Excellent, good, fair, poor results were obtained from 71 (55.5%), 46 (35.9%), 8 (6.3%), 3 (2.3%) fingers, respectively. Time of the repair has a significant effect on the strickland scores. Surgery performed within the first 24 hours following the injury gave better results. 3 fingers (2.3%) had tendon ruptures. Existence of ruptures affected the results significantly. Co-existing injuries were found that they did not have any effect on the results. In the fingers in which both FDP and FDS tendons were lacerated, no significant relationship was found between only FDP repair, both FDP and FDS repair and single FDS slip repair. Additionally no significant relationships between follow-up time, gender, single or multiple finger injury and Strickland scores were observed. 13 fingers (10.1%) had PIP joint contracture above 20°. CONCLUSION: The low rupture rate (2.3%) and 91.4% 'good' and 'excellent' scoring rates in our series support the idea that modified Kessler 4-strand core suture and epitendinous interlocking suture repair combined with modified Kleinert protocol gives satisfactory results. Repair time is one of the most important factors affecting the functional results and surgery should not be delayed if there is an experienced surgeon available. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Techniques and survival incidence for revascularization of degloved fingers.

We report techniques and survival incidence of three subtotally and nine completely degloved fingers in seven patients. We performed end-to-end arterial repairs in seven fingers, vein graft repairs for arteries in two fingers, arteriovenous anastomoses in three fingers. End-to-end vein anastomosis was performed in all fingers. One finger requred re-exploration. Soft tissues in the eight degloved fingers survived completely, two failed completely, and two were partially necrotic. We conclude from our results that following revascularization, the skin from a completely degloved finger skin will survive in approximately two cases out of three. LEVEL OF EVIDENCE: IV.