Hand Reconstruction Research Articles

Prace konserwatorskie przy kamiennej rzeźbie Matki Boskiej autorstwa Andrzeja Pruszyńskiego z elewacji kościoła pw. Matki Bożej Pocieszenia w Żyrardowie – wybrane zagadnienia historyczne i technologiczne

SUMMARY
 The stone sculpture of the Virgin Mary from the facade of the church Our Lady of Consolation in Żyrardów is one of the numerous sculptural implementations of Andrzej Pruszyński workshop. In 2018 the monument was under conservation and restoration works. Preliminary macroscopic examination of the monument showed that under the numerous secondary layers of paint on the stone sculpture there is a dark green, multi-deck colour layer that could imitate a statue had made in bronze casting technique. As a result samples were taken and subjected to laboratory analysis. The research carried out allowed us to conclude that the described layer is kind of a secondary nature and is a testimony to the restoration of the monument probably after the end of World War I. It was decided not to remove the patina and to fill in the gaps in the course of the ongoing restoration and conservation works. This layer had historical and documentary value and was a testimony to the popular in the 19th century and probably known at the beginning of the 20th century practice of patinating sculptures made in less noble and less durable material than bronze. Moreover, in the course of conservation works later layers of paint and cement repairs were removed. Then the structure of weakened limestone rock was strengthened and numerous small losses of stone were filled in. As a witness the defect on the left knee of the figure was left without filling in. It is a trace of the bullet that was probably created during World War I. Moreover, the missing figure’s right hand was reconstructed. A reconstruction of the gilded halo was also made. The design of the conservation work programme is always a very complex process as it requires the simultaneous consideration of many factors. The aesthetic and historical interpretation of the work is important, the understanding of the author’s concept and the essence of the destructive processes. In the case of the described sculpture from Żyrardów it was also necessary to take into account the technical possibilities, take into account the expectations of the owner and users, or customers in general, as well as the conservation community. Preservation and restoration solutions adopted in the work programme, including hand reconstruction and unveiling of the following items and the restoration of a painting layer imitating a green patina, restored historical artistic values to the monument. The aesthetic effect achieved this way brings a new quality to work that can be the object of criticism but by restoring the sculpture’s lost aesthetic values it is possible to continue to function as an object of religious worship.

Vascularized Olecranon Bone Graft: An Anatomical Study and Novel Technique

Autologous bone grafting is commonly used in reconstructive hand surgery. Various sources of nonvascularized autologous bone grafts have been described in the literature. However, in some situations, a vascularized bone graft may be needed. Popular vascularized bone grafts aretaken from the distal radius, iliac crest, and medial femoral condyle. The purpose of this study was to examine the feasibility of harvesting a free vascularized bone flap from the proximal ulna. Latex was injected via the brachial artery to facilitate visualization of perforators in 10 cadaveric specimens. Dissections were performed of the olecranon; all periosteal perforators were noted, and their lengths and diameters recorded. Corticocancellous bone flaps with their supplying pedicles were harvested. Three additional fresh specimens were injected with india ink via the pedicles to demonstrate perfusion of the harvested bone flap. Consistent vascular anatomy supplied the olecranon. A perforator from the posterior ulnar recurrent artery supplied the proximal ulna and olecranon, from which a vascularized bone flap can be harvested. Branches to the flexor carpi ulnaris muscle may allow chimeric flaps to be harvested. Average pedicle length was 5.8 cm and average pedicle diameter was 2.4 mm. India ink injection of the pedicles showed perfusion of the periosteum as well as intraosseous cancellous bone. A vascularized olecranon free flap can be harvested based on the posterior ulnar recurrent artery. Vascular anatomy is consistent and flap harvest is simple and straightforward in all cadaveric specimens. A vascularized olecranon free flap represents a potential new surgical option when vascular bone flap reconstruction is considered.

Reconstruction of Hand and Upper Extremities Defects by Thin Random Pedicle Abdominal Flaps, Still a Valid Option in Developing Countries: A Cross Sectional Study

Reconstruction of Hand and Upper Extremities Defects by Thin Random Pedicle Abdominal Flaps, Still a Valid Option in Developing Countries: A Cross Sectional Study

One stage thumb opponensplasty and polygonal flap in congenital spade hand reconstruction

Objective To explore the clinical efficacy of one-stage metacarpal osteotomy, thumb opponensplasty and polygonal flap in congenital spade hand reconstruction. Methods From January 2013 to March 2017, 8 cases of congenital spade hand were treated by metacarpal osteotomy, thumb opponensplasty and reconstruction of first web space by dorsal rectangle flap. The thumb web space and fingernail fold of thumb and index finger were reconstructed by rotation of polygonal flap. The dorsoulnar side of thumb and radial side of proximal segment of index finger were repaired by skin grafting. Results The thumb opposition and first web space of all the children achieved one-stage reconstruction. All the flaps and skin grafts survived. The average follow-up period was 16.1 months (range, 13 to 29 months). At the last follow-up, there was no significant difference in skin color between the first web space of the injured side and of the healthy side. The distance of the first web space ranged from 3.5 to 5.0 cm with an average of 4.2 cm. According to the modified Tada score, the results were rated as excellent in 7 cases and good in 1 case. Conclusion One-stage reconstruction of thumb opposition combined with polygonal skin flap for congenital spade hand deformity has improved hand function. The design of the flap is reasonable and can cover important areas effectively. The operation is safe and reliable for clinical application. Key words: Surgical flaps; Hand deformities,congenital; Spade hand; Microsurgery

Evaluation of different chrominance models in the detection and reconstruction of faces and hands using the growing neural gas network

Physical traits such as the shape of the hand and face can be used for human recognition and identification in video surveillance systems and in biometric authentication smart card systems, as well as in personal health care. However, the accuracy of such systems suffers from illumination changes, unpredictability, and variability in appearance (e.g. occluded faces or hands, cluttered backgrounds, etc.). This work evaluates different statistical and chrominance models in different environments with increasingly cluttered backgrounds where changes in lighting are common and with no occlusions applied, in order to get a reliable neural network reconstruction of faces and hands, without taking into account the structural and temporal kinematics of the hands. First a statistical model is used for skin colour segmentation to roughly locate hands and faces. Then a neural network is used to reconstruct in 3D the hands and faces. For the filtering and the reconstruction we have used the growing neural gas algorithm which can preserve the topology of an object without restarting the learning process. Experiments conducted on our own database but also on four benchmark databases (Stirling’s, Alicante, Essex, and Stegmann’s) and on deaf individuals from normal 2D videos are freely available on the BSL signbank dataset. Results demonstrate the validity of our system to solve problems of face and hand segmentation and reconstruction under different environmental conditions.

Patient-Reported Outcome Measures for Toe-to-Hand Transfer: A Prospective Longitudinal Study.

Patient-reported outcome measures are an important metric in evaluating treatment efficacy of reconstructive surgery. Toe-to-hand transfer can restore vital prehensile function; however, this surgery is complex, extensive rehabilitation is required, and there are concerns about donor-site morbidity. This study longitudinally explores the benefits of this procedure, from the patient's perspective, using patient-reported outcome measures. Twenty-three patients who underwent free toe-to-hand transfers from 2012 to 2015 were evaluated preoperatively and postoperatively using the following validated questionnaires: the Michigan Hand Outcomes Questionnaire, the 36-Item Short-Form Health Survey, and the Lower Limb Outcomes Questionnaire. Subgroup analysis was performed between dominant and nondominant reconstructed hands. Mechanism of injury was crush in 83 percent; the remainder sustained cutting, avulsion, and burn injuries. Thirty-four toes were transferred: nine great toes, 20 second toes, and five third toes. Michigan Hand Outcomes Questionnaire results showed significant improvement in overall activities of daily living, work, aesthetics, and patient satisfaction (p < 0.05). The results of the 36-Item Short-Form Health Survey showed significant improvements in physical and emotional roles (p < 0.05). The Lower Limb Outcomes Questionnaire showed no deterioration of foot function (p = 0.55). Subgroup analysis showed significant improvement in patient-reported outcome measures for patients undergoing dominant hand reconstruction but no difference between thumb reconstruction and finger-only reconstruction. Patient-reported outcome measures demonstrate the significant utility of toe-to-hand transfer procedures in both functional and psychosocial domains in that there are relatively greater benefits in reconstructing the dominant hand, and that donor-site morbidity is well tolerated. Therapeutic, IV.

Abstract 84: Single Locally Implanted Tacrolimus Disk Promotes Long-term Vascularized Composite Allograft Survival via Site Specific Immunosuppression and without Systemic Side Effects

PURPOSE: More than 185,000 amputations occur in United States each year. The most common is a partial hand amputation (61,000), and the majority (77%) of cases are due to traumatic accidents. Vascularized composite allotransplantation (VCA), in the form of hand allotransplantation, provides another option for hand reconstruction. The skin component of VCA is highly antigenic and mandates daily intake of systemic immunosuppressive drugs. Currently tacrolimus (TAC) and mycophenolic acid (MPA) are the two primary immunosuppressive drugs used in transplant patients. These drugs have narrow therapeutic window, significant pharmacokinetic variability, non-adherence to these drugs, putting the patients at risk for rejection or toxicity. These drug related complications compromise the long-term outcomes. We prepared a novel, re-loadable drug delivery system that consists of an encapsulated sustained-release version of oral TAC alone or combined with other drugs that provides sustained drug release into the graft tissues and regional lymph nodes, while minimizing systemic blood levels. This results in lower overall systemic drug exposure, while the sustained loco-regional delivery facilitates long-term VCA survival. METHODS: TAC loaded polycaprolactone disk were prepared by solvent casting. Following orthotopic hind limb allotransplantation, animals (n=6/group) received no treatment (Group 1), TAC 1mg/kg/day intraperitoneally (Group 2), or one TAC disk in the transplanted limb (Group 3) or in the contralateral un-transplanted limb (Group 4). TAC levels in blood and tissues were measured using LC-MS/MS. In addition to allograft survival, systemic toxicity was evaluated using metrics such as % change in body weight (BW), blood glucose, and creatinine clearance (CrCl). RESULTS: A single TAC disk (5mg, 5 % w/w) resulted in blood levels between 2 to 5 ng/ml for nearly 100 days. High levels of TAC were achieved locally in the transplanted limbs, when compared to levels in the contralateral limbs (***p<0.001). These levels could inhibit immune activation and sustained allografts survival for >150 day (Group 3). While animals received no treatment or TAC disks in the un-transplanted limbs (Group 1 and 4) had median survival 8 ± 4 days and 71 ± 7 days. Long term allograft exposure to locally delivered TAC induced donor specific hypo-responsiveness. Lower levels of IFNα+ cytotoxic T cells, while higher levels of IL-10+ T regulatory cells were observed in draining lymph nodes isolated from transplanted limbs. This could suggest the mechanism behind long term survival by locally delivered TAC. No signs of systemic toxicity were observed in animals received TAC disks, as compared to animals received standard systemic immunotherapy. CONCLUSION: A single TAC disk implanted into the transplanted limb was effective in sustaining allograft survival via loco-regional immunosuppression, without systemic side effects. Therapeutic modulation of the loco-regional immunity may influence the outcome of VCA and underline that tissue-specific immune-response warrants further investigation in VCA. Our study offers an alternative to the current treatment paradigms which use systemic immunosuppression, to one of loco-regional immunosuppression using locally implantable biomaterials. With this research, we hope to establish the basis for the development of more advanced technologies for targeted immunosuppressive drug therapy.

One-stage thumb opponensplasty and polygonal flap in congenital spade hand reconstruction

To explore the effectiveness of one-stage metacarpal osteotomy, thumb opponensplasty and polygonal flap reconstruction in the treatment of congenital spade hand deformity. Eight cases of congenital spade hand were treated between January 2013 and March 2017. There were 5 males and 3 females, with an average age of 17.5 months (range, 13-35 months). The clinical manifestations of all the children were congenital spade hand and the affected hand was shorter than the healthy side. The contralateral hand was normal and there was no chest, skull, or facial deformity. The operation was performed with metacarpal osteotomy and thumb opponensplasty, and through the dorsal metacarpal rectangular flap to reconstruct the first web and through rotation of polygonal skin flap to reconstruct thumb web and lateral fold of thumb index nail. The dorsal ulnar and proximal radial segment of thumb were repaired by skin grafting. A vernier caliper was used to measure the first web space and the thumb function was evaluated by modified Tada score. The reconstruction of palmar function and the formation of first web were completed in one stage in 8 children. Skin grafting on the dorsal ulnar side of thumb and radial side of index finger survived after operation. All the children were followed up 13-29 months, with an average of 16.1 months. There was no infection, skin flap necrosis, lateral deviation of thumb, scar contracture, or other complications. At last follow-up, there was no significant difference in skin color between the healthy side and the first web of the affected hand. The opening distance of first web space was 3.5-5.0 cm, with an average of 4.2 cm. According to the modified Tada scoring system, the results were excellent in 7 cases and good in 1 case, with an excellent and good rate of 100%. The thumb could grasp and pinch actively, and the palm opposition function was good. One-stage thumb opponensplasty combined with polygonal flap for reconstruction of congenital spade hand deformity can improve hand function very well. The reasonable designing of skin flap can effectively cover important areas, and the operation is safe and reliable.

Reach out and grasp the opportunity: reconstructive hand surgery in tetraplegia.

Reconstructive upper extremity surgeries in tetraplegia are technically challenging because of the many complicated real-time decisions that need to be made, e.g. extent of release of donor muscle-tendon complex, routing of donor muscles, tissue preparation and optimization, tensioning of muscle-tendon units, balancing joints and suturing tendon-to-tendon attachments. Nerve transfer surgeries can add functionality but also make the reconstruction planning more complex. In this overview, we present some of the fundamental muscle-tendon-joint mechanics studies that allow for single-stage surgical reconstruction of hand function as well as early postoperative activity-based training in patients with cervical spinal cord injuries. We foresee an increased need for studies addressing combined nerve and tendon transfer reconstructions in parallel with patient-perceived outcome investigations. These should be combined with implementation of assistive technology such as functional electrical stimulation for diagnostic, prognostic and training purposes.

Septocutaneous perforator mapping and clinical applications of the medial arm flap

The medial arm flap has a long history but remains underused despite providing multiple advantages. We reviewed our experience with using the medial arm flap to clarify the distribution of septocutaneous perforators and its relationship with pedicled flap design. This retrospective study included 36 consecutive patients who underwent reconstructive surgery with a medial arm flap (42 arms). Septocutaneous perforator mapping was conducted using a refined coordinate system originating at the medial epicondyle, with the y-axis running to the axillary apex. At least three perforators were identified along the medial intermuscular septum of the arm, located densely at 88 ± 8%, 49 ± 9%, and 20 ± 6% of the distance between the medial epicondyle and axillary apex (i.e., arm length), with a prevalence of 95.2%, 100%, and 85.7%, respectively. All arms had at least one medium- or large-sized perforator, and 90.5% of arms had at least two such perforators. Twenty-nine flaps were transferred as pedicled distant flaps for head and neck reconstruction or hand reconstruction, while the remaining 13 were transferred as perforator-based propeller flaps for axillary, elbow, or chest wall reconstruction. Thirty-six flaps underwent pre-transfer expansion. The average flap size was 157.9 ± 64.5cm2 (range: 40-330cm2). All flaps were successful, except for one perforator-based flap, which was replaced due to partial loss. Donor site morbidity was minimal. Given its rich septocutaneous perforator distribution, the medial arm flap can be harvested reliably with versatile design and minimal donor site morbidity, thus deserving more attention in reconstructive surgery.

Reverse radial forearm perforator plus flaps for the reconstruction of postelectrical burn sequelae of hand and forearm defects

Background: The reverse radial forearm perforator flaps are useful in softtissue reconstruction of the hand and forearm. Certain modifications in the flap and usage of hyperbaric oxygen therapy as an adjunct in reconstruction could aid in better outcome of the surgical procedure. The conventional reverse radial artery forearm flap incorporates the radial artery along with its venae commitants along with the flap providing less chances of venous congestion. The per-foratoronly flap may cause a twist in a pedicle which may not affect the artery much, but a small increase in pressure may obstruct the tiny veins running along with the perforator resulting in chances of venous congestion which is a common problem in propeller or perforator flaps. This can be overcome by designing a flap with adequate venous outflow and reducing the postoperative inflammatory edema to prevent pressure to the tiny perforators with arterial and venous components. Aims and Objectives: To focus on flap harvest in a perforator plus model to increase the venous outflow and use of hyperbaric oxygen therapy as an adjunct to prevent the inflammatory edema on the perforator vessels. Materials and Methods: Reverse radial artery perforator plus flaps used for the reconstruction of hand and forearm soft-tissue loss in a series of patients due to electrical burns. We used hyperbaric oxygen therapy as an adjunct for reconstruction. Results: No flap related complication in the series. One patient developed venous congestion at the distal tip region which settled without any further intervention. Conclusion: Defects of the hand and forearm due to the electrical burns could be effectively managed with radial forearm perforator plus flap with allowing adequate venous outflow, and hyperbaric oxygen therapy as an adjunct in electrical burns.

Spare-part fillet cross-finger flaps: A series of two cases

IntroductionThe concept of ‘spare-part’ flaps in hand reconstruction is most commonly applied using finger fillet flaps to cover dorsal or volar hand defects. In this paper, we introduce the concept of utilization of spare-part finger fillet flaps in a cross-finger fashion. Case reportsThe technique is demonstrated in two case reports. In both cases, there was one finger that was severely crushed requiring amputation. The bones from that finger were removed and the fillet finger flap was utilized to reconstruct a complex defect in an adjacent digit. Immediate post-operative physiotherapy was employed and flap division was done 17–18 days later. Both patients were satisfied with the outcome and returned back to work as manual workers. DiscussionDifferences between previous techniques / types of cross-finger flaps and the current spare-part fillet cross-finger flap technique are discussed. ConclusionWe introduce the concept of utilization of spare-part finger fillet flaps in a cross-finger fashion.

Anatomy of a perforator flap based on the superficial circumflex iliac artery. A cadaveric study

Introduction: The groin flap, based on the superficial circumflex iliac artery (SCIA), was the first successful free flap. It has mainly been used in lower-limb and hand reconstruction with few reports in the literature of its use in soft-tissue head and neck reconstruction.Methods: Five fresh cadaveric dissections were performed and the following parameters were recorded; the presence or absence of the SCIA, and if present, its branching pattern, the diameter of the SCIA and the length of the pedicle.Results: The superficial circumflex iliac vessels were absent in 40%. When present, the SCIA branches off separately from the femoral artery. A deep branch of the SCIA was found in 40%. The mean diameter at origin was 1.5 mm on average.Conclusion: The small vessel calibers and the short pedicle length along with the variable anatomy of the region make the SCIP flap a challenging reconstructive option.

Preoperative Modeling for Mirror Hand: Simplifying a Difficult Problem Using 3-Dimensional Printing and Simulation.

Mirror hand is an extremely rare congenital anomaly. We modeled and simulated the reconstruction of mirror hand in a 2-year-old boy utilizing a preoperative 3-dimensional model to aid surgical planning. A soft-tissue hand model was created using preoperative imaging, 3-dimensional printing, and silicone casting, and the model was used to perform trial surgery. Given the complexity of the deformity, the model greatly facilitated the final operative plan for reconstruction.

Vascularisation des nerfs sensitifs superficiels de l’avant-bras, applications cliniques en reconstruction de la main et des doigts

A vascularized nerve graft is recommended when the recipient bed has poor vascularization, nerve defect is > 1 cm, or for a thick nerve. Sensory innervation also improves tissue healing, multi-tissular injuries of hand and fingers traumatisms can though benefit from flaps containing a vascularized sensitive nerve. The objective of this study was to specify the vascularization of the superficial sensitive nerves of the forearm to develop donor sites of vascularized nerves in finger and hand reconstruction. We studied the vascularization of the lateral, medial, posterior antebrachial nerves (LAbN, MAbN, PAbN) and the superficial branch of the radial nerve (SBRN) in 12 fresh cadavers injected limbs. Deep vascularization origin, location and size of the nutrient perforators, neurocutaneous vascularization data were collected. We also measured the calibre of the collateral digital pedicles for comparison. LAbN's vascularization is provided by the radial artery (92%) by 2 to 4 direct perforators > 0.5 mm diameter, located in the proximal or median third of the forearm. LAbN measures 1.33 to 1.83 mm diameter and the perforators length was 14 to 28 mm. MAbN's vascularization comes from the ulnar (67%) or brachial (25%) artery issuing 2 to 3 musculo-cutaneous perforators through the flexor carpi ulnaris muscle in the proximal third of the forearm or direct perforators in the median third. MAbN measures 1.11 to 1.21 mm diameter and the perforators were 13 to 24 mm long. These perforators vascularize the skin in more than 90% and a superficial vein in 50% of the cases for LAbN and MAbN. SBRN's vascularization comes from the radial artery. There are 1 to 2 direct perforators > 0.5 mm and 12 to 16 mm long. The skin is vascularized by the perforators in 82% of the cases and a vein in 44%. PAbN's vascularization comes from the posterior interosseous artery by musculo-cutaneous perforators The dominant nerve of every finger measures more than 2 mm diameter except for D5. The dominant artery measures 1.5 to 2 mm. This work aims to precise knowledge of the forearm cutaneous nerves vascularization for finger and hand reconstruction purposes. LAbN and MAbN are potential donor sites according to their size, vascularization type, constant location of the nutrient perforators and low donor site morbidity.

Bilateral Metacarpal Hands: Reconstruction With 6 Toe Transfers.

Background: Bilateral metacarpal hand injuries are extremely rare, but probably represent the most difficult reconstructive challenge in hand surgery. Methods: We discuss the various options for metacarpal hand reconstruction, including the Krukenberg procedure, bionic prostheses, multiple toe-to-hand transfers, and possibly hand transplantation, and present the long-term functional outcomes, gait analysis, and psychological evaluation after a 4-stage reconstruction of bilateral metacarpal hands in a child using 6 toe-to-hand transfers-bilateral great toe transfers to reconstruct both thumbs and bilateral combined second-third monobloc transfers to reconstruct 2 fingers in each hand. Results: Reconstruction of bilateral metacarpal hands with 6 toe transfers yielded excellent functional results and patient satisfaction. Conclusions: Bilateral metacarpal hand injuries result in a devastating functional deficit and a major psychological impact. Multiple toe transfers (4, 5, or 6) provide an excellent reconstructive outcome with acceptable donor site morbidity.

Propeller perforator flaps in forearm and hand reconstruction.

After a long history in flaps' surgery, the perforator flaps became the most used flaps nowadays. From the beginning, their use as free flaps diminished substantially the donor site morbidity. In the attempt to not only diminish the donor site morbidity, but also to achieve more similar reconstructions, a new concept appeared 20years ago: local perforator flaps. The local perforator flaps offer as main advantages the absence of microsurgical sutures ("microsurgical non-microvascular flaps"), same surgical field, the sparing of muscles and main vascular pedicles, and shorter hospitalization time. They can be used as V-Y advancement flaps, transposition flaps, propeller flaps, and keystone flaps (multiperforator flaps). The present study will refer to the use of local perforator flaps in forearm and hand reconstruction, and will point on the most important technical aspects of their harvesting, the main indications, advantages and disadvantages, and possible complications.

Modified thin anterolateral thigh flaps for reconstruction of hand and foot defects

Objective To evaluate the clinical efficacy of modified thin anterolateral thigh flaps for reconstruction of hand and foot defects. Methods Between March, 2016 and September, 2017, 17 patients were reconstructed with modified thin anterolateral thigh flap. There were 6 cases for reconstruction of hand, and 3 of them were located in the back dorsal of hand defects. There were 11 cases for reconstruction of ankle and foot, and 5 of them were located in the dorsal of foot. The size of the flap was 5 cm×3 cm-33 cm×10 cm. The traditional perforator flap was elevated just above the deep fascial plane. The debulking procedures could follow before the pedicle was cut off. The modified method was that the flap was elevated from the superficial fascia and the plane between deep and superficial fat without intraoperative debulking procedures. Results Three flaps were eventually survived after secondary exploratory operation caused by the hematoma. Two flaps had partial loss, 1 of which needed secondary skin grafting, and the other flap healed with additional intention. Followed-up period was 3-18(average, 7) months . All flaps showed relatively good contour and the patients were satisfied with clinical outcomes. Conclusion It is a safe and reliable way that perforator flap can be elevated from the superficial fascia and the plane between deep and superficial fat. It can obtain a thin flap immediately and reduce donor-site morbidity without additional defatting and time-consuming. The flap is soft with good contour. This technique is an ideal option for covering defects composed of dorsal of the hand or foot and the head and neck regions. Key words: Anterolateral thigh flap; Perforator flap; Modified method of thin type flap; Microsurgical operation

Vascularized toe joint transfers to the hand for PIP or MCP reconstruction

Vascularized toe joint transfers are used for proximal interphalangeal (PIP) or metacarpophalangeal reconstruction of the fingers in children or young adults, as an alternative to joint arthroplasty. In children, this reconstruction aims to restore range of motion (ROM) and the growing capacities. The typical donor sites are the PIP or metatarsophalangeal joints of the second toe. These transfers are performed with short vascular pedicles in order to simplify the surgical technique and reduce the overall morbidity. Local flaps and joint fusion are used to reconstruct the donor toe. Indications for these transfers are mainly compound defects due to trauma or infection. While these reconstructions provide a long-lasting result, the ROM achieved is always smaller than the normal ROM of the recipient joint.

Treatment of Apert Hand Syndrome: Strategies for Achieving a Five-Digit Hand.

Apert hand reconstruction requires complex surgical planning. The purpose of this study was to describe the authors' 8-year surgical experience with Apert syndrome hand reconstruction, and provide specific surgical strategies for achieving a five-digit hand in Upton type I and II hands. A retrospective analysis of consecutive Apert syndrome patients who underwent web-space releases between 2007 and 2015 was performed. Demographic, surgical, and outcome data were verified through medical records, clinical photographs, radiographic images, and patient interviews. A total of 41 Apert syndrome patients [23 boys (56.1 percent) and 18 girls (43.9 percent)] have been treated at our hospital since 2007. A five-digit hand was achieved in all patients (100 percent) with Upton type I and II hands, and in eight patients (72.7 percent) with Upton type III hands. A four-digit hand was obtained in three of 11 patients (27.3 percent) with Upton type III hands. Four of 20 patients (25 percent) with Upton type I hands, three of 10 patients (30 percent) with Upton type II hands, and six of 11 patients (54.5 percent) with Upton type III hands required subsequent revision for aesthetic reasons. Upton type III hands have demonstrated higher revision rates than type I and II hands, regardless of whether a four- or five-digit hand is obtained. Treatment strategies for Apert syndrome hands based on hand type are offered to guide four-web-space release in all patients with Upton type I and II hands. Therapeutic, IV.