Harold E. Kleinert

Reconstruction of the Amputated Finger Tip with a Triangular Volar Flap: A New Surgical Procedure

A triangular volar flap has been used successfully for the reconstruction of amputated finger tips. It can be applied to most finger amputations except those with extensive soft-tissue loss on the volar side of the amputated finger tip. The distally based triangular flap, carefully prepared with intact nerve and blood supply, is advanced over exposed bone and approximated to the nail matrix. The V incision is closed by converting it to a Y.

Report of the committee on tendon injuries

: Most of the committee members agreed on the material presented. Universal adoption of a single system for measuring and recording tendon function will require additional meetings. It is suggested that TAM and the Dieter Buck-Gramcko systems be more widely publicized and adopted by various hand surgeons before further discussion.

The radial tunnel syndrome

Twenty patients with symptoms present for an average of 21.1 months and who in most cases had been treated by several conservative techniques for chronic tennis elbow were diagnosed as having radial tunnel syndrome, as originally described by Roles and Maudsley. Release of the tunnel was followed by eventual relief in 19 instances (95%).

Replantation of digits and hands: Analysis of surgical techniques and functional results in 71 patients with 86 replantations

Defining replantation as the restoration of a completely amputated part as opposed to simply restoring circulation to an incompletely severed part, the results of replantation of 86 completely amputated parts in 71 patients performed from January, 1970, to December, 1975, were studied. Twenty-eight, or 32.5 percent, were the result of sharp severances of the part; localized crushing accounted for 56, or 65.1 percent. Two were classified as degloving injuries. Twelve amputations were transmetacarpal, six were at the metacarpophalangeal joints, 14 through the proximal phalanx, 15 at the proximal interphalangeal joint, 21 in the middle phalanx, 13 at the distal interphalangeal joint, and five through the distal phalanx. The technique consisted of bone shortening and fixation and repair of all tendons and nerves if possible. Veins are repaired first at least two for each artery, and heparinized saline and lidocaine are used locally. Irrigation of the vessels is not done, but an intravenous bolus of 3,000 U. of heparin is given when the anastamoses are completed. Aspirin and low molecular weight dextran are given for 3 to 7 days. For the more distal replantation, heparin may be used. Antibiotics are given. In the total series of 86 completely amputated hand units, 52 were unsuccessful, primarly due to vascular thrombosis and usually on the venous side. In the year 1975 a success rate of 69.2 percent was achieved, whereas in the last 50 replantations, done between Jan. 1, 1976, and Oct. 15, 1976, the success rate was 90 percent. Results improved with more experience in the technique and with more careful selection of patients.

Flexor Tendon Injuries

There is increasing evidence that synovial fluid plays a major role in the nutrition and healing of tendons, thus it is important to restore the synovial medium after flexor tendon repair. Techniques for primary repair of flexor tendons, which is the therapy of choice in the majority of cases, are detailed.

Methods and results of replantation following traumatic amputation of the thumb in sixty-four patients

Immediate survival and functional results were studied in 64 thumb replantations performed during a 3 year period. The failure rate, 27% overall, was higher in patients over 50 years of age (50%) and following avulsions with or without crushing injuries (58%). Long vein grafts from the radial artery proximally to the thumb arteries distally were employed in 15 patients to bypass the traumatized area in the first web space. A higher survival rate (90%) was associated with the use of vein grafts to restore venous return. Half of the patients followed 6 months or longer had good discriminatory sensibility (less than 10 mm). Sensory return and cold intolerance were worse in older patients and were not related to level of injury, mechanism of amputation, total ischemia time, or number of arteries or veins repaired. Loss of motion of the replanted thumb was a frequent cause for inadequate return of function. All thumbs should be considered for replantation, but the results will be poorer in older patients. If possible, motion of the interphalangeal and metacarpophalangeal joints should be preserved.

Free vascularized bone grafts in surgery of the upper extremity.

Free vascularized fibular grafts were employed in five patients with segmental bone defects following trauma or resection of tumors of the upper extremity with excellent results in three patients and satisfactory results in two. No donor site morbidity was experienced. A comparison with rib and iliac crest grafts indicates that the fibula is more suitable for reconstruction of long bone defects. The advantages of this technique are stability without sacrificing viability and a shorter immobilization period with more rapid incorporation and hypertrophy of the graft. The disadvantages are prolonged operating time, difficulty in assessing patency of anastamoses in the immediate postoperative period, and sacrifice of a major vessel in the lower extremity.

An overview of replantation and results of 347 replants in 245 patients.

A review of 245 patients requiring replantation surgery from 1970 to 1978 revealed a 70% survival rate for complete amputation. In this group, there were 347 replanted parts, including the lower extremity. Upper-extremity survival rates alone (greater than 90%) are higher than for lower extremity replantation. Meaningful assessment of replantation must include not only survival data but functional criteria as well. While functional data are incomplete on several early cases, our assessment criteria are reviewed. Criteria should include two-point discrimination sensibility ratings, grip strength, range of motion, absence of cold intolerance, and return to employment. Evaluation of candidates for replantation is critical, and the importance of teams with microsurgical skills working in special centers is emphasized.

Etiology and Treatment of the So-called Mucous Cyst of the Finger

A series of thirty-six so-called mucous cysts of the finger were reviewed. A new form of surgical treatment for this lesion is presented which includes excision of the cyst, synovectomy, and debridement of osteophytes of the distal interphalangeal joint. Closure of the skin defect was accomplished by a rotational flap created by the initial incision. There were no recurrences when this technique was employed. In all cases a definite pedicle was found connecting the cyst to the distal interphalangeal joint. This finding along with the histological appearance seems to indicate that the lesion is analogous to a ganglion.

Salvage replantation of lower limb amputations.

Three cases are reported in which the microsurgical salvage of parts of traumatic lower extremity amputations associated with degloved proximal skin loss provided sturdy, sensate skin and soft-tissue coverage and thereby preserved functional below-knee amputation levels. In two instances, a free innervated filletted flap was constructed from the foot of the amputated limb, and in the third case, the amputated lower leg was shortened, successfully replanted, and followed later by elective amputation of a foot at the Syme level. At a mean follow-up of 2 years, all three patients are ambulating well in below-knee prostheses.