Functioning Free Muscle Transplantation to Restore Finger Movement for Sequalae of Volkmann Ischemic Contracture.

Volkmann ischemic contracture (VIC) is a devastating condition that results from neglected compartment syndrome, which leads to prolonged ischemia, irreversible tissue necrosis, and various degrees of muscle and nerve damage, causing serious motor and sensory functional implications for the limb and a spectrum of diseases associated with worsening deformities. A thorough understanding of the anatomy and VIC pathophysiology is needed to plan an appropriate strategy. Functioning free muscle transplantation (FFMT) can restore finger movement in a paralyzed limb but requires a three-staged approach to maximize the benefits of FFMT, leading to meaningful finger extrinsic function.

Ultrasonography-guided percutaneous release of A3 pulley of the fifth finger to treat trigger finger: Description of the technique, with reference to a specific case.

Trigger finger causes pain and a persistent functional limitation of the hand, which can lead to permanent blockage of the flexor tendon. Ultrasonography-guided percutaneous release has been widely reported as a successful technique for trigger finger involving the A1 pulley. This article describes for the first time the use of this technique in an unusual location, the A3 pulley of the fifth finger. A 71-year-old patient presented with a 3-month history of pain and blockage in the fifth finger of the right hand and was diagnosed with a grade III trigger finger, according to the Froimson scale. We performed an ultrasonography-guided percutaneous release technique on the A3 pulley to release the flexor tendon of the fifth finger. Ultrasonography-guided percutaneous polectomy to treat trigger finger in the A1 pulley is an effective alternative treatment to surgery and even has certain advantages over it. The anatomical similarity between the A1 and A3 pulleys was the key factor that supported the use of this technique in this clinical case. Based on past experience in similar cases, we conclude that ultrasonography-guided percutaneous polectomy of the A3 pulley of the fifth finger was a surgical technique which could lead to a satisfactory outcome in the treatment of this condition.

Application of Digital Artery Transposition in the Replantation of Severed Fingers with Vessel Defects and its Influence on Nerve Function and Joint Function Recovery.

OBJECTIVE: To investigate the application of digital artery transposition in replanting severed fingers with vascular defects and its impact on nerve and joint function recovery. METHODS: 200 patients who received replantation of severed fingers were randomly divided into artery transposition group (n = 100) and vein transplantation group (n = 100). The digital artery transposition technique was used in the artery transposition group, and the autologous vein bridging technique was used in the vein transplantation group. The clinical efficacy and survival rate of severed fingers were compared between the two groups. RESULTS: The clinical excellent and good rate in artery transposition group was significantly higher than that in vein transplantation group (P < 0.05). CONCLUSION: The transposition of digital artery is effective and safe in replantation of severed fingers with vascular defects.

Challenges and Solutions in Prosthetic Fitting of Digits after Flap Reconstruction.

Surgical reconstruction can restore length and function, but cannot adequately resolve the problem of disfigurement. Prosthetic fitting can play a complementary role in enhancing the aesthetic outcomes post reconstruction. However, complex reconstruction involving flaps coupled with the surgical imperative for limb length preservation can lead to outcomes where the reconstructed stumps are challenging to fit with prosthesis. This article describes how prosthetic fitting was tackled in a case of a triple-digit amputation after reconstruction that presented with finger stumps that were bulky, long and stiff in extension contracture, compounded by the presence of substantive scar tissues. We discuss major prosthesis modifications that were unconventional but necessary to enable fitting, the techniques involved, as well as the aesthetic and functional considerations behind the modifications. The results showed that enhanced aesthetic appearance, together with a marginal improvement in hand function, was achieved post-prosthetically, meeting the patient's and the clinical team's fitting objective. Level of Evidence: Level V (Therapeutic).

Options for Restoring Finger Extension in Mangled Forearm Injuries.

Restoration of finger extension in mutilating hand injuries is crucial for restoring prehension and independent use of the hand. Patients often express desire to restore finger extension once finger flexion is achieved. However, the extensive forearm injury precludes use of any of conventional donors like the wrist or finger flexors for transfer to restore finger extension. Two patients with sequelae of mangled forearm injuries, underwent biceps and long head of triceps transfer to the finger extensors to improve opening up of the fingers. We discuss the treatment considerations while planning these transfers and provide the technical details, rehabilitation and outcome of these patients. Both the patients expressed dramatic improvement of their hand function and were satisfied with the outcome. Biceps and long head of triceps could serve as an effective second-line donor for restoration of finger extension when the conventional donors are not available. Level of Evidence: Level V (Therapeutic).

Distal fingertip replantation: indications, strategy and postoperative management.

Distal fingertip replantation is associated with being a technically demanding procedure and dubious outcomes, although it is now performed more frequently across the world. However, the technique and outcomes remain controversial with disagreement among replantation surgeons due to lack of consensus about the indications, intraoperative strategy and postoperative regimes. In this article, we asked six experienced hand surgeons several pertinent questions that every replantation surgeon performing distal fingertip replantation would face in their clinical practice. The article summarizes their responses, which might provide valuable insight to every replantation surgeon in different parts of their career while managing these injuries.

Rare Median Nerve and Digital Nerve Tumor Resection and Distal Nerve Transfers: A Report of 2 Cases.

CASES: We present 2 cases of median nerve reconstruction using distal nerve transfers after resection of unusual benign median nerve tumors. Critical sensation was restored in case 1 by transferring the fourth common digital nerve to first web digital nerves. Thumb opposition was regained by transferring the abductor digiti minimi ulnar motor nerve branch to the recurrent median motor nerve branch. Critical sensation was restored in case 2 by transferring the long finger ulnar digital nerve to the index finger radial digital nerve. CONCLUSION: Distal nerve transfers, even with short grafts, are reliable median nerve deficit treatments, sparing the need for larger autologous nerve grafts and late tendon opponensplasties.

Reversed distal laterodigital adipofascial flap for nail-bed reconstruction.

BACKGROUND: Lesions of the distal phalanges of the fingers frequently involve the nail bed. There are few therapeutic options for nail-bed reconstruction and they often lead to painful scars and onychodystrophy. We present our experience with the distal adipofascial laterodigital reverse flap. METHODS: Fifteen patients (average age 46.33 years, range 28-73) with tumors or traumatic injuries (crush injuries, nail avulsion, and partial fingertip amputations) of the nail bed, underwent digital reconstruction through the distal adipofascial laterodigital reverse flap from June 2018 to August 2019. The size of the fingertip defect covered with the flap was ranged between 1.1 × 1.1 and 1.6 × 1.2 cm (average size 1.4 × 1.2 cm). The flap was harvested enrolling subcutaneous tissue from the lateral aspect of the middle and distal phalanx from the less damaged side. RESULTS: The average size of the harvested flaps was 1.3 × 1.2 cm (range 1.1 × 1.0 to 1.4 × 1.1 cm). All adipofascial flaps survived entirely and the nail bed healed in all patients, with an average healing time of 21 days and a subsequent regrowth of the nail. The follow up ranged from 6 to 12 months, with a mean of 7 months. CONCLUSIONS: The distal reverse adipofascial flap provides a very versatile and reliable coverage of the distal finger and its nail bed. It is a rapid and reproducible surgical procedure with poor morbidity for the donor site. LEVEL OF EVIDENCE: IV.

Mini-Shaped Kiss Flap Design for Palmar and Digital Soft-Tissue Resurfacing.

BACKGROUND: Although palmar and digital soft-tissue resurfacing with intrinsic flaps may provide functional and aesthetic reconstruction, the donor site may result in a tight closure or need for a skin graft once the flap is raised. In this series, the "mini-shaped kiss flap" was used to increase the resurfacing efficiency and preserve hand function. METHODS: The mini-shaped kiss flaps, based on common palmar digital arteries (eg, princeps pollicis artery and ulnar palmar digital artery), were developed for the resurfacing of distal or proximal finger areas. The tiny skin paddles were "kissed" together and transferred as pedicled in proposed dimensions and shape. The flap size, donor/recipient site, perforator source, whether free or pedicled, surgical outcome, and donor-site morbidity were evaluated. RESULTS: Twenty mini-shaped kiss flaps were harvested for the purpose of palmar and digital resurfacing. The flap sizes varied from 3 × 1.2 cm to 5 × 2 cm. All 19 patients, aged 6 to 52 years (mean, 35 years), achieved successful reconstruction without major complications after 6- to 12-month follow-up. CONCLUSIONS: The mini-shaped kiss flap technique exhibited favorable surgical outcomes with excellent color and texture match to the recipient sites. The reverse midpalm, thenar, and hypothenar island flap can be raised at the cost of an unnoticeable linear scar with minimized functional compromise in the donor area. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Fingertip Replantation: Surgical Technique, Tips, and Tricks.

SUMMARY: Replantation of fingertip amputations restores the original tissue and is the ideal treatment to provide the best aesthetic and functional outcome. However, successful fingertip replantation is considered challenging because it requires supermicrosurgery techniques. This article provides a detailed surgical technique for fingertip replantation and the authors' preferences and recommendations. In the authors' experience, the most important factors for successful fingertip replantation are meticulous vascular dissection, reliable arterial repair, and venous anastomosis to avoid postoperative venous congestion. Proximal arterial dissection until pulsatile bleeding is encountered avoids the zone of vascular injury, and is particularly important in crush or avulsion amputations. Distal arterial dissection is performed until undamaged intima is identified. The authors believe anastomosis to the central artery is reliable even in a Tamai zone II amputation. When an arterial defect is present, the authors recommend using a vein graft to anastomose to the central artery. In addition, the authors highly recommend at least one venous anastomosis to avoid postoperative venous congestion. In Tamai zone I, available veins can be found on the palmar side of the pulp. It is important to search directly below the dermis and remove adipose tissue around the vessels to secure space for anastomosis. The authors consider nerve suture in Tamai zone I and II replantations inessential, because spontaneous sensory recovery can be expected. Postoperative management of venous congestion, spasm in artery, and arterial thrombosis are as important as surgery.

Reconstruction of finger contracture with an expanded first dorsal metacarpal artery perforator flap: A case report.

Volar finger contractures can be challenging for plastic surgeons. The dorsal metacarpal artery perforator (DMCAP) flap is frequently used to cover bones, tendons, and neurovascular structures in the dorsum of the hand after trauma and burns as an alternative to grafts and free flaps. We aimed to report volar finger defect reconstruction with expanded DMCAP flap. A 9-year-old male patient applied to our clinic with the complaint of inability to open the second finger of the left hand after an electrical burn that caused proximal and distal interphalangeal joints flexion contractures. Reconstruction was planned for the patient with a two-session expanded first DMCAP flap. A 16 mL 5 × 3 cm tissue expander was placed in the prepared area from the vertical incision in the first session. The tissue expander was inflated with 4 mL of isotonic solution. The DMCA area was enlarged 6 weeks later by giving 22 mL of isotonic solution. After the pedicle dissection, the 9 × 3 cm DMCAP flap was elevated by dissection over the paratenon. With 180° of rotation, the left-hand second finger was adapted to the 6 × 2 cm defect area on the volar face. The flap donor site was closed primarily. The operation was terminated by placing the hand on a protective splint. There were no complications in the flap in the postoperative 6 months. The patient was referred to the physical therapy and rehabilitation department. As a result, an expanded DMCAP flap may cover volar tissue defects up to the distal phalanx. This report may present the first case in which volar finger contracture reconstruction was performed with an expanded first DMCAP flap after an electrical burn in a pediatric patient.

Lambda Repair: A Novel Repair Technique for Chronic Boutonnière Deformity.

SUMMARY: Correction of a boutonnière deformity is one of the most demanding challenges in hand surgery. Surgical interventions are usually considered when functional use of the finger cannot be obtained after intense hand therapy. The authors introduce their newly described lambda (λ) repair, which is an easy-to-learn, straightforward surgical technique. The method involves an end-to-side tenorrhaphy of the lateral bands, resembling the Greek λ. Patients who underwent a lambda repair were retrospectively evaluated with preoperative and postoperative measurements of proximal interphalangeal (PIP) joint movement. Four patients (two male, two female; median age, 35.5 years) with a median follow-up period of 9.1 months were included. Three patients underwent lambda repairs for isolated boutonnière deformities, and one patient received a vascularized free toe transfer combined with a lambda repair. The preoperative average PIP joint extension lag or deficit was 28.75 degrees and could be reduced to 15 degrees. Preoperative average PIP joint active flexion was 60 degrees, which was improved to 88.75 degrees. No complications were observed. The lambda repair is a new tool in the reconstruction of boutonnière deformity, further expanding the armamentarium of hand surgeons.

The perfusion index as a noninvasive method for monitoring revascularized and replanted digits.

BACKGROUND: Monitoring replanted digits remains a challenging task in microsurgical units. Previous studies have indicated the perfusion index (PI), a parameter directly proportional to the blood flow, might be a useful tool. OBJECTIVE: The PI is evaluated as a monitoring tool in patients with replanted digits. METHODS: This prospective, non-interventional study includes 31 patients with revascularized or replanted digits. After successful revascularization or replantation, the PI and peripheral oxygen saturation of the affected finger and its contralateral equivalent were measured simultaneously. The values were detected by the device Radical-97® Pulse CO-Oximeter® (Masimo Corporation, 52 Discovery, Irvine, CA 92618, USA). RESULTS: The median PI of affected fingers was 3.5±0.56 for revascularized and 2.2±0.8 for replanted fingers. The difference between the PI values of replanted digits and the healthy contralateral side was highly significant (p < 0.0001). The area under the curve in the receiver operating characteristics was 0.92 for a PI difference > 80.49% and predicted a loss of replant with a specificity of 100% and a sensitivity of 75%. CONCLUSION: The assessment of the PI in patients with reperfusion of a vascular compromised digit is a useful tool to continuously monitor peripheral perfusion. The dynamic behavior of the PI is essential to detect perfusion disturbance.

A novel nerve block technique for nail surgery.

In pediatric patients, nail unit anesthesia is frequently required for procedures including matrixectomy or nail avulsion. However, nail unit anesthesia is very painful and requires a significant amount of time to take complete effect, causing a great deal of distress for most pediatric patients. By targeting the palmar and dorsal digital nerves in the distal part of the fingers, our method enables fast, simple, and less painful anesthesia.

Comparison of nerve versus tendon transfer for radial nerve palsy.

OBJECTIVE: This study aims to investigate the choice of intervention time and operation mode between nerve and tendon transfer for the treatment of radial nerve palsy (RNP). METHODS: 46 RNP patients underwent nerve transfer (n = 22) and tendon transfer (n = 24). The intraoperative blood loss, main incision length, operation duration, and length of hospital stay and follow-up period of patients in these two groups were recorded and compared. The range of motion (ROM) of the elbow, wrist, fingers, and thumb, the hand grip and pinch strength, the Disabilities of Arm, Shoulder, and Hand (DASH) and the 36-Item Short Form Health Survey (SF-36) scores were measured and compared preoperatively and postoperatively between the two groups. RESULTS: The ROM of thumb and the hand grip strength of patients in the nerve transfer group were greater than that in the tendon transfer (P < 0.05). Both of the two groups indicated significant improvements in the ROM of elbow, wrist, finger, thumb and the hand grip and pinch strength (P < 0.05) postoperatively. The DASH scores decreased significantly at 6 months (P < 0.05) and 12 months (P < 0.05) after surgery in both groups, while the postoperative SF-36 scores significantly increased (P < 0.05). There was no significant difference in postoperative DASH and SF-36 scores between the two groups (P > 0.05). CONCLUSION: In summary, both nerve and tendon transfer techniques are effective treatments for RNP. Nerve transfer is particularly advantageous for early RNP, while tendon transfer is suitable for patients with radial nerve injury more than one year.

Sensory re-education after free neurovascular toe pulp flap for digital pulp reconstruction.

PURPOSE: To evaluate the effectiveness of a sensory re-education (SR) program after free neurovascular toe pulp flap for finger or thumb pulp defect reconstruction. METHODS: From January 2015 to January 2020, 49 patients with finger or thumb pulp defects treated with free fibular side flaps of the great toe or tibial side flaps of the second toe were recruited. The patients were randomly divided into two groups one month after surgery. The training group received the SR program, and the control group underwent the traditional rehabilitation program. Clinical evaluation included Semmes-Weinstein Monofilament (SWM) tests, static two-point discrimination (2-PD), and sensibility grading, measured at 1, 3, 6, 9, and 12 months postoperatively. RESULTS: A total of 42 patients completed the follow-up, including 22 (16 males) patients in the training group and 20 patients (12 males) in the control group. Compared with 1 month after the operation, significant improvements in sensory recovery were observed at 3, 6, 9, and 12 months postoperatively in both groups. In addition, earlier sensory recovery was seen in the SR group compared to the control group, showing significant differences at 3 and 6 months but not at 9 and 12 months postoperatively. CONCLUSION: Although SR seemed to accelerate preliminary sensory recovery after free neurovascular toe pulp flaps for digital defect reconstruction, the program should be reconsidered as it offers no significant improvement over the control group at later follow-up stages.

Isolated Distal Interphalangeal Joint Flexion Contracture of the Ring Finger due to Dupuytren Disease: A Case Report.

Dupuytren disease is a common benign fibromatosis of the palmar and finger fascia caused by pathological cord formation. As both the retrovascular and lateral cords are jointly responsible for the flexion contracture of the distal interphalangeal (DIP) joint, isolated DIP joint contracture caused by Dupuytren disease is rare. We present a 34-year-old right-hand-dominant male patient with a 6-month history of an isolated DIP joint flexion contracture in the right ring finger due to Dupuytren disease. Surgical fasciotomy of the retrovascular cord improved the contracture without adverse events. It is important to pay attention to the anatomical relationships between the pathological cord and neurovascular bundle to avoid neurovascular injury during fasciotomy in patients with Dupuytren disease, especially in isolated DIP joint contracture cases. Level of Evidence: Level V (Therapeutic).

Digital mucous cysts of the finger without osteoarthritis: optimizing outcome of long needle trajectory aspiration and injection.

Digital mucous cysts are common, benign and highly recurrent tumors of the distal interphalangeal joints of the fingers and often associated with osteoarthritis. Multiple treatment modalities have been described, but still no consensus is stated. In the absence of degenerative changes, we promote a novel non-surgical approach. The aim of this study was to examine all patients with digital mucous cysts without underlying osteoarthritis, undergoing this injection technique and to assess outcome and complications of this procedure. This was a single center study (2018-2019) of 17 patients who received a long needle trajectory aspiration and injection for treatment of digital mucous cysts. Exclusion criteria were prior surgical treatment, post-traumatic cyst formation and the presence of radiographic distal interphalangeal joint osteophytosis. A total of 15 patients were found eligible for inclusion. The patient reports were retrospectively analyzed with a follow-up of 6 months. The primary study outcome was resolution of the cyst; secondary outcomes were complications of the procedure. Twelve (80%) resolved completely and three (20%) had limited local recurrence at 6 months. No complications were reported. None of the patients with limited recurrence desired further treatment. We believe that this technique offers a non-invasive, low-cost treatment option for digital mucous cysts, particularly in the subset of patients with ample evidence of degenerative articular changes in the distal interphalangeal joint. The described technique can be performed in an office-based setting and avoids typical surgical as well as aspiration-associated complications.