Digital Stumps Research Articles

New finger reconstruction technologies using 3D printing

Introduction The use of 3D printing technology in finger reconstruction improves accuracy of the procedure minimizing the donor defect and optimizing the appearance and function of the finger. The use of this technology in the finger reconstruction with an osteocutaneous radial forearm flap with axial blood supply and lengthening of the digital stumps and metacarpals remains poorly explored.The objective of the study was to demonstrate new methods of preoperative planning for finger reconstruction and improve surgical outcomes.Material and methods Outcomes of five patients treated with original methods based on 3D technology were retrospectively evaluated during preoperative planning, reconstruction of the thumb using an osteocutaneous radial forearm flap with axial blood supply, relocation of the stump of the third finger and lengthening of the stumps of the first and second metacarpals. The patients could achieve consolidation of interpositional bone allografts following lengthening of the finger stumps, stability of the bone base of the finger, organotypic restructuring of the marginal allograft during plastic surgery with an osteocutaneous radial forearm flap, and a functional position of the reconstructed thumb using the middle finger stump.Results and discussion An individual device for planning finger reconstruction allows identification of the optimal size and position of the finger in three planes, which is essential for patients with severe hand deformities to avoid corrective procedures. An individual guide was used to osteotomize the radius to harvest a vascularized graft providing a cutout of a given size and shape and a cortical-cancellous allograft being identical in shape and size to replace the donor bone defect. The combined use of Masquelet technology and distraction of the finger stump or a metacarpal improved conditions for consolidation and restructuring of the interpositional allograft preventing fractures and infection.Conclusion The use of 3D technology in finger reconstruction using an osteocutaneous radial forearm flap with axial blood supply and distraction of the finger stumps and metacarpals can improve surgical outcomes.

Beauty and Function: The Use of Trimmed Great Toe in Thumb and Finger Reconstruction.

Background:Finger amputations are one of the most common traumas of daily life. Regularization of the digital stump is the most widely used option in the literature today. The aim of this study was to evaluate a valid functional and aesthetic alternative to amputation.Methods:We retrospectively investigated our prospective database‚ selecting the patients who underwent trimmed great toe flap reconstruction for the amputation of a digit from September 2019 to November 2021. All the operations were performed by the first author (L.T.) in the Reconstructive Microsurgery Service of the University Department of Hand Surgery and Rehabilitation of MultiMedica Group.Results:No flap required anastomosis revision or had major complications. The length of the amputated finger was maintained, with a high functional and aesthetic result achieved.Conclusions:The trimmed great toe flap has proven to be a viable alternative to finger amputation in the reconstruction of thumb and long finger defects, leading to high aesthetic results. The morbidity of the donor site is reduced compared with the classic great toe flap, allowing a direct closure in most cases.

Пересадка культи трехфалангового пальца противоположной кисти на микрососудистых анастомозах у больных с последствиями отморожений кистей и стоп (случаи из практики)

in frostbite patients. Material and methods Medical histories and long-term results of treatment of two frostbite patients with finger stumps of both hands were reviewed. The triphalangeal finger and the thumb were reconstructed by transplanting the opposable finger stump together with the metacarpophalangeal joint using microvascular and microneural anastomoses. The stumps were mobilized and transplanted to the distal ulnar artery with the venous drainage performed using the dorsal saphenous vein of the hand. Long-term results were examined at 10 years and 2.5 years of surgery. Clinical, radiological, biomechanical and biophysical investigations were produced. Results The bilateral gripping function was restored in recipient stumps without functional damage to the donor stumps. Discriminatory sensitivity of reconstructed fingers was 6mm and 8 mm, the range of active motion in the transplanted joint was 55 and 66 degrees. Discussion Opposable digital stump transplantation with microvascular anastomoses has significant advantages over the classical surgery. The technique allows for one-stage restoration of a finger to have sufficient length, function, adequate blood supply and innervation due to a short digital stump being transplanted with the metacarpophalangeal joint. The advantage over a toe transplant consists of the use of digital structures of the hand that are identical in functionality and the anatomy reducing the need for secondary interventions. Conclusion The method of management can be successfully applied for frostbite patients with hand stumps according to indications.

QS4: Fat Grafting for the Dysesthetic Digit: A Discussion of Technique And Pilot Data

Purpose:Digital amputation represents a common injury requiring acute hand surgery intervention. These injuries are often complicated by pain, hypersensitivity, dysesthesia, cold intolerance, and contour deficits/pulp atrophy. Many secondary procedures exist to address these concerns; however, they are often limited by undesirable donor site morbidity and/or complex rehabilitation. There is currently no single gold standard for treatment of the dysesthetic digit. Free adipose transfer via lipofilling offers to correct these defects by providing soft, healthy bulk to the amputated site with minimal comorbidity. Here we describe a protocol and preliminary data for providers considering adipose transfer to the dysesthetic digit.Methods:We examined 113 patients who sustained digit amputations between 2010 and 2019. Patients sustained an average of 1.6+/-0.9 amputations per trauma. 13 patients were identified with chronic pain, dysethesia, cold intolerance, or hypersensitivity that persisted after therapy. Controlling for reversible nail bed pathology, 10 patients demonstrated primary chronic dysesthesia.Results:4 of 10 patients presenting for chronic amputation stump dysesthesia elected for fat grafting to the fingertip. All patients reported improved pain and reduced dysesthesia/hypersensitivity post-intervention. 3 patients required no further intervention after one round of grafting; 1 patient underwent repeat grafting. Of the non-grafted group, 66.7% (4/6) progressed to revision amputation. There were no operative revision amputations after grafting.Conclusions:Fat grafting to the fingertip offers a simple, safe, and easily accessible technique to augment soft tissue bulk at the digital stump. Our preliminary data suggests that this may be an effective option to manage digital dysesthesia/hyperesthesia.

Management of metacarpophalangeal bone defects after hand trauma by distraction osteogenesis with mini external fixation

Objective To evaluate the outcomes of distraction osteogenesis with mini external fixation in management of metacarpophalangeal bone defects after hand trauma. Methods From June 2010 to December 2015, 16 patients with metacarpophalangeal bone defects after hand trauma received distraction osteogenesis at our department. They were 11 men and 5 women, from 20 to 45 years of age (average, 32.5 years). There were altogether 20 bone defects: 8 cases had single metacarpal bone defect, 2 unilateral second and third metacarpal bone defects and 6 phalangeal shortening after repair of digital stump (involving thumb in 4 cases, index finger in one and index and middle fingers in one). The metacarpophalangeal bone defects averaged 1.8 cm (from 1.0 to 3.1 cm). Under the fluoroscopic guide, 4 or 6 mini half-pins in one line were directly drilled into the dorsal aspect of the involved metacarpophalangeal bone before the Orthofix fixator was mounted. The proximal (18 digits) or distal (2 digits) osteotomy between the second and third pinholes was performed via the dorsal approach. The external fixator and pins were removed without anesthesia after callus maturation. Results Average follow-up period was 12.2 months (range, from 9 to 26 months). All the metacarpal bone defects were reconstructed and all the phalangeal shortenings were lengthened; the bony callus was completely calcified at the lengthened part. The mean lengthening was 1.9 cm (from 1.0 to 3.1 cm); the percentage of lengthening ranged from 26% to 51% (average, 34%). The bone lengthening index (time cost by average 1 cm) was 70.9 d/cm (from 60.0 to 87.1 d/cm). According to the Tentative Assessment Criteria for Upper Extremity Function by Hand Surgery Society, Chinese Medical Association, the total activity of motion (TAM) was excellent in 13 cases, good in 4, fair in 2, and poor in one, yielding an excellent to good rate of 85.0%. Conclusion Distraction lengthening using mini external fixation is a valid option with a minor rate of complications which allows for early functional exercise to help restore the appearance and function of the affected fingers. Key words: Hand; Injury; External fixators; Bone lengthening; Bone defect

Mains avec lésions de blast en situation sanitaire précaire

The hands of "blast" resulting from the handling of unstable explosives. Their repercussion is functional and vital in trauma patients. The authors report their experience of care from the hands of blast in precarious health situation. Between 2001 and 2012, 33 hand blasts were supported in 30 injured civilians and military, received emergency, during and after armed conflict. Two women (6.7%) and 28 men (93.3%) were received, including four teenagers (13.3%) and 26 adults (86.7%). During the war, 15 officers weapon (50%) and three civilians (10%) underwent surgery, or 60% of hand injuries. In peacetime, civilians were mostly operated in 33.3% of cases, against 6.7% of cases of agents' weapon. Nineteen hands blast (57.6%) were observed during the war and 14 in peacetime, or 42.4% of cases. The average age was 25.2 years, with extremes of 12 and 50 years. Thirteen left hands (39.4%) and 20 right hands (60.6%) were operated. The lesion concerned all the anatomical structures of the hand. It was unilateral in 27 cases (81.9%) and bilateral in three cases (9.1%). Three types of hand trauma were observed and were as follows: trauma patients with injuries of the hand (18.2%), trauma of severe and isolated proximal hand or finger amputations (75.7%), and trauma of the hand without apparent seriousness (6.1%). The associated lesion was eye (one case), chest (one case), abdominal (five cases). Debridement was performed immediate emergency (93.9%) and delayed (6.1%). The treatment was surgical hemostasis, made mainly of amputations (69.7%) and regularization of digital stumps (12.1%). The repair was performed in 18.2% of cases. One death has been reported in a polytrauma patient with chest blast. Blast injuries of the hand are common in times of war in armed agents. The young people, manual workers and children are paying a heavy price in peacetime. As land mines which affect feet, instable hand grenades are left exposed in nature. In precarious health situation, instead of a functional salvage surgery of the hand, it is a hemostasis surgery that makes many mutilated hand. The psycho-social aspect and vocational rehabilitation are additional difficulties supported.

Fitting very short finger stumps with silicone prosthesis

The fitting of short finger stumps with silicone prosthesis is a challenge because of the suboptimal finger-prosthesis contact due to length and distal tapering of digital stumps. The purpose of this report was to describe and evaluate the Micropore(™)-polyvinyl chloride tube technique for fitting short finger stumps. For a total of 10 patients, short finger stumps were fitted using the technique. A short length of polyvinyl chloride tube, trimmed and contoured to fit, was secured on the distal stump tip with Micropore tape. The prosthesis was worn over the polyvinyl chloride tube extension. Three different fitting methods were evaluated: fitting with and without the Micropore-polyvinyl chloride tube technique, and with the use of skin adhesive on the stump. All patients achieved a very secure prosthetic fit with the Micropore-polyvinyl chloride tube technique. No incidences of prosthesis slippage were reported at the longest follow-up of 30 months. The Micropore-polyvinyl chloride tube technique is an effective method for fitting short finger stumps.

Application of Ilizarov Device for Transfer of Deformed Digits, Digital Stumps, and Metacarpal Stumps

Digital transfer on a pedicle comprising only the neurovascular bundle may lead to irreversible ischemia in cases of severe hand tissue scarring. Previously described methods of such a transfer are conditional on the donor stump's being longer than both the recipient stump and the reconstructed digit. The aim was to develop a method of transferring deformed digits and their stumps after prior distraction of both neurovascular bundles and cutaneosubcutaneous pedicles with the help of the Ilizarov device. We performed 2-staged transfer of mutilated digits, digital stumps, or metacarpals using the Ilizarov device for stretching pedicles at the first stage and subsequent segment transfer. The method was applied in 65 patients, with 77 digits reconstructed in 67 hands. Segments were transferred on palmar or both palmar and dorsal pedicles containing lipocutaneous bridges and neurovascular bundles. In 67 of 77 cases, amputation levels of transferred stumps were roughly comparable to those of stumps reconstructed. X-ray length of reconstructed digits averaged 84.44 +/- 3.55 mm. Successful acceptance of transferred segments and complete or partial recovery of the hand grip was achieved in all cases. Use of the Ilizarov device enables the digital reconstruction of short digits, allows transferring various hand segments, including pathologically changed ones, and ensures success even in cases where the donor digit is too short to consider single-stage pedicle transfer.

Symbrachydactylie

Symbrachydactyly is literally defined as a combination of short fingers with syndactyly. Blauth and Gekeler described four types of symbrachydactyly, ranging from simple shortness of middle phalanges to complete absence of digital rays. In type I (short finger) function is quite normal and syndactyly release is usually the only procedure needed. In type II (cleft hand), presence of a thumb and at least one ulnar finger allows pinch function. Surgical treatment, when needed, consists in separation of webbed fingers, resection of nonfunctional digital stumps, or finger translocation. In type III (monodactyly) all long fingers are absent. Pinch function can be created between the thumb and a toe transfer in ulnar location. Bone lengthening is an alternative procedure to create a pincer. Surgery is not always indicated in type IV (peromely) as function can only be restored if active motion is already present at wrist or carpometacarpal levels.

Pollicization of the Mutilated Hand by Transposition of Middle and Ring Finger Remnants

Traumatic injuries to the thumb are frequently associated with mutilation of one or more of the remaining digits. The most common digital injuries associated with thumb loss are partial or complete amputation of the index finger or index and long fingers. Occasionally, satisfactory index finger function will be preserved with damage or amputation of the middle or ring fingers, making them the best candidates for transposition. Although pollicization of the index finger has received considerable attention in the literature, pollicization of injured middle and ring finger remnants has not. Transposition of these comparatively useless digital stumps, which may be sacrificed without significant functional deficit to the rest of the hand, may be advantageously performed to create a well-functioning thumb. This procedure facilitates the conversion of a useless, mutilated hand into a well-functioning one in a single operation. We present our experience with pollicization of middle and ring finger remnants in four patients including indications, technique, and functional outcome.

The Role of Nonvascularized Toe Phalanx Transplantation

Stabilization of boneless finger stumps or lengthening of partially aplastic digits in congenital malformations is difficult, because the bone graft, placed on top of the existing bone, will undergo resorption. Only the periosteum-covered proximal toe phalanx will withstand resorption and show a complete take. With the toe phalanx, including the plantar plate and the collateral ligaments of the metatarsophalangeal joint as a half-joint, it is possible to construct a new joint with the cartilage-covered distal end of the recipient bone (metacarpal or proximal phalanx) as the proximal half-joint. Flexor and extensor tendons exist in almost all cases. Between 1976 and 1990, 97 toe phalanx transplantations were performed in 57 children. The indications were boneless digital stumps with partial absence of digits and large bone defects in fingers in symbrachydactyly and ring-constriction syndrome. Follow-up examinations of 44 patients with 69 transplanted toe phalanges (95% of the patients operated on by March 1989) have shown a 100% take of the bone graft, provided it had been unsplit and the periosteal cover undamaged. The earlier in life the operation was performed, the more postoperative growth was recorded. The shortening of the donor toe was less because a tendon interposition was used. A joint construction was attempted in 64 digits with variable results. The range of active motion varied between 0 (fusion) and 90 degrees.

Proximal toe phalanx transplantation for bony stabilization and lengthening of partially aplastic digits

In congenital malformations the lengthening of partially aplastic digits, by on-top plasty of a bone graft or the bony stabilization of finger stumps consisting of soft tissues without skeletal elements, is extremely difficult. The usual bone graft, taken from the iliac crest or the fibula, will undergo resorption and will have disappeared a few months postoperatively. Experience has shown that the proximal toe phalanx will with-stand any resorption if it is taken whole, covered by its periosteum. Another advantage is the possibility of the construction of a new joint between the metatarsophalangeal articular surface of the toe phalanx and the distal end of the recipient bone in the hand, which is usually covered by cartilage. Flexor and extensor tendons exist in most cases. Between 1976 and 1988, 69 transplantations of proximal toe phalanges were performed in 43 children. The indications were: boneless digital stumps or partial absence of digits in symbrachydactyly and ring constriction syndrome. Follow-up examinations of 40 patients with 63 transplanted phalanges at an interval of 36 months (12 to 160 months) has shown a 100% take of the bone graft provided it had not been split and the periosteum was undamaged. The earlier in life the operation was performed, the more postoperative growth was recorded. A joint construction was attempted in 46 digits with variable results; active mobility ranged from 0 degrees to 90 degrees. With the use of a tendon interposition, there is a less degree of shortening of the toes.

Dominantly Inherited Unilateral Terminal Transverse Defects of the Hand (Adactylia) in Twin Sisters and One Daughter

Most previous cases of unilateral terminal transverse defects of the hand have not been familial. Several previously reported cases of apparent autosomal dominant inheritance of such defects have subsequently been reclassified as type B brachydactyly. We report a pair of adult twin women with unilateral terminal transverse defects affecting the left hand in one woman and the right hand in the other woman. The latter woman has one daughter with a unilateral terminal transverse defect affecting the left hand. The hand anomaly is characterized by absence of the terminal portions of digits 2 to 5 with a mildly hypoplastic thumb (adactylia). Tiny nail remnants are evident on the remaining digital stumps, and no soft tissue syndactyly is apparent. At 2 years of age, the daughter has hypoplastic first, fourth, and fifth metacarpals with no ossification of the second or third metacarpals or any of the phalanges. The affected mother has hypoplastic metacarpals for digits 2 to 4 and a vestigial fifth proximal phalanx on the affected hand, with no other phalanges evident by roentgenogram other than those of the thumb. The mother's twin sister has similar findings, except the ossified phalangeal remnant is on her second and third fingers rather than her fifth finger. Doppler flow arterial patterns appeared normal in each hand of affected family members. The other hand and both feet are clinically and radiologically normal in each case, and the family history is negative for any other individuals with limb anomalies. A review of the literature suggests that this family may very well be unique.

THE EARLY TREATMENT OF HAND INJURIES

For first aid the wound is covered by a sterile dressing and the patient. taken to a well-equipped surgery where the definitive treatment is done under the best aseptic surgical conditions. A careful examination and diagnosis of the injured structures is made. A plan of reconstruction is then decided upon. Consideration is given to the patient, his work, and his outlook. At this first treatment, digits may even be made to oppose each other for practical prehension and a plan of cover may be provided. One should consider what is left of the hand and the best way to preserve it and utilize it for prehension and sensation. Early treatment is merely the acute phase of plastic, orthopaedic, and peripheral-nerve surgery, all of which are needed for hand surgery. The surrounding parts are shaved, washed with soap and water, and the wound is thoroughly irrigated with normal salt solution. Aseptic precautions are taken not to contaminate the wound with virulent germs from mouth and nose droplets or other contacts. The field is rendered bloodless by a pneumatic tourniquet, and the wound is debrided with as little trauma as possible. All usable parts are saved, particularly the nerves and tendons. Fractured bones are set, digits are placed in a position of function, and the skin cover is applied. Maximal length of the thumb is saved, and good workable cover is provided to the digital stumps. If a digit is discarded, its skin with vessels and nerves may be utilized for cover. At first the damage is solely from the injury, but later there may be many complications, such as stiffened joints in the position of non-function and the others of the six main types of crippling already described in detail. These may be superimposed on the injury, but are directly due to the treatment. Stiffening may be prevented by affording cover early, with the use of even a pedicle graft if necessary, by preventing infection, and by avoiding swelling and maintaining activity. The available measures to prevent infection are early operation, early covering of all vulnerable parts with skin, the use of antibiotics, and refraining from attempting repair of deep structures where the wound is too old or too much traumatized. Swelling can be avoided by elevation, fluff pressure dressings, and activity of the hand, exercising as much of it as possible and as early as possible, until the return to work. Flexion contractures are avoided by preventing infection, establishing cover early, avoiding excess of granulations, and maintaining the position of function. The latter is maintained by attentions to the key joints, keeping the wrist. in dorsiflexion, the proximal finger joints in flexion, the metacarpal arch curved, and the thumb in moderate opposition. Elastic splints may be used to change the deformed hand to one in the positions of function. Malalignment of bones is prevented by setting fractures and reducing dislocations early. Motion is preserved by repairing muscles and tendons early, whenever conditions permit, but never late in wounds or in traumatized tissue. Paralysis and loss of sensation are guarded against by recognizing early that nerves are injured and repairing them as soon as the conditions are right. The repair is usually done temporarily by merely securing the nerve ends together with one stitch of stainless-steel wire; secondary careful repair is done later. It is important that nerve repair be given priority over that of bones and joints, or fibrous degeneration of muscles and nerves will become irreversible. Ischaemic contractures are avoided by not constricting the forearm and hand with dressings or casts, especially in the anticubital space and over the hand itself. A developing contracture may be aborted by prompt. decompression and freeing the vessels. Vasomotor disturbances are prevented by early recognition of the condition and by insisting on activity and the performance of work by the involved hands. On reviewing these six main types of crippling and their mechanism of production, it is seen that much of the disability from injured hands can be prevented.