Hüsrev Purisa

Late results of replantations in tip amputations of the thumb

OBJECTIVES We retrospectively evaluated replantations performed for Tamai type 1 thumb amputations. METHODS The study included 14 patients (12 males, 2 females; mean age 28 years; range 14 to 40 years) whose replanted thumbs survived following replantation for Tamai type 1 amputations in the distal nail fold of the thumb. Central digital artery anastomosis was performed in all the cases. Four patients with an appropriate vein had a single volar vein anastomosis. Nerve repair could be possible in only three patients. Sensory evaluations were made with the Semmes-Weinstein monofilament test, static and moving two-point discrimination tests, and vibration test. In addition, patients were evaluated with respect to atrophy in the replanted part, nail-bed deformities, and cold intolerance. The mean follow-up period was 11 months (range 6 to 48 months). RESULTS The Semmes-Weinstein test was green (range 2.83 to 3.22) in five patients (35.7%), blue (range 3.22 to 3.61) in eight patients (57.1%), and purple (range 3.84 to 4.31) in one patient (7.1%). The mean static and moving two-point discrimination test results were 6.9 mm (range 3 to 10 mm) and 4.5 mm (range 3 to 6 mm), respectively. Compared to the intact fingers, vibration was increased in six thumbs (42.9%), decreased in six thumbs, and the same in two thumbs (14.3%). Atrophy of the replanted parts was observed in five patients (35.7%). Three patients (21.4%) complained about cold intolerance, and three patients had nail-bed deformities. The mean time to return to work was 3.2 months (range 2 to 6 months). CONCLUSION Despite technical difficulties, thumb replantations yield good functional and aesthetic results. Sensory recovery is sufficient even after tip replantations without nerve repair.

Ligament reconstruction using the Fulkerson-Watson method to treat chronic isolated distal radioulnar joint instability: short-term results

OBJECTIVE Isolated distal radioulnar instability may remain unrecognized during the acute period of trauma as it is difficult to diagnose, and does not become obvious until later when it has become chronic. We present early results in patients who underwent stabilization with extraarticular ligament reconstruction (Fulkerson-Watson reconstruction). METHODS Four women and 1 man underwent surgery for chronic isolated distal radioulnar joint instability demonstrated in X-rays and magnetic resonance images. Arthroscopy revealed avulsion of the triangular fibrocartilage complex from the point of insertion in 3 patients, and peripheral tears in 2 patients. The peripheral tears were debrided arthroscopically. All patients had an adequate sigmoid notch and therefore underwent ligament reconstruction using the Fulkerson-Watson method. Postoperative evaluations were done with MRI. RESULTS Mean follow-up was 15.5 months (range 6-26 months). Stability was achieved in all patients. The mean Quick-DASH symptom score decreased from 18.63 (15.90-22.72) to 6.81 (2.27-9.09) after surgery. A mean visual analogue score to assess pain decreased from 7.32 (6.30-8.40) to 1.88 (1.50-2.30) after surgery. Preoperative and postoperative measurements were 26° (passive 44°) and 47° (passive 65°) for active supination, 18° (passive 45°) and 49°(passive 68°) for active pronation, 20° (passive 43°) and 42° (passive 60°) for active wrist flexion,and 38° (passive 52°) and 45° (passive 59°) for active wrist extension. CONCLUSION Surgical revision of distal radioulnar joint instability using Fulkerson-Watson reconstruction is easier than intraarticular techniques and satisfactorily re-establishes stability, provided that the sigmoid notch is adequate.

Intramedullary Venous Drainage System for Distal Fingertip Replantations

Abstract The number of venous anastomoses performed during fingertip replantation is one of the most important factors affecting the success of replantation. However, because vessel diameters decrease in the zone 1 level, vessel anastomoses, especially vein anastomoses, are technically difficult and, thus, cannot be performed in most cases. Alternative venous drainage methods are crucial when any reliable vein repair is not possible. In the literature, so many artery-only replantation techniques have been defined, such as arteriovenous anastomoses, forming an arteriovenous or venocutaneous fistula, manual milking and massage, puncturing, and external bleeding via a fishmouth incision and using a medical leech. It has been shown that, in distal fingertip replantations, the medullary cavity may also be a good way for venous return. In this study, we introduce an alternative intramedullary venous drainage system we developed to facilitate venous drainage in artery-only fingertip replantations. The results of 24 fingertip replantations distal to the nail fold by using this system are presented with a literature review.

Advantages of using volar vein repair in finger replantations

Providing adequate venous outflow is essential in finger replantation surgeries. For a successful result, the quality and quantity of venous repairs should be adequate to drain arterial inflow. The digital dorsal venous plexus is a reliable source of material for venous repairs. Classically, volar digital veins have been used only when no other alternative was available. However, repairing volar veins to augment venous outflow has a number of technical advantages and gives a greater chance of survival. Increasing the repaired vein:artery ratio also increases the success of replantation. The volar skin, covering the volar vein, is less likely to be avulsed during injury and is also less likely to turn necrotic, than dorsal skin, after the replantation surgery. Primary repair of dorsal veins can be difficult due to tightness ensuing from arthrodesis of the underlying joint in flexion. In multiple finger replantations, repairing the volar veins after arterial repair and continuing to do so for each finger in the same way without changing the position of the hand and surgeon save time. In amputations with tissue loss, the size discrepancy is less for volar veins than for dorsal veins. We present the results of 366 finger replantations after volar vein repairs.

Tissue forceps for stabilizing amputated parts in a finger replantation

Tremor of the assistant while holding the amputated finger during preparation for replantation is a problem. Few methods are found in literature to stabilize the amputated part. Reported here is the usage of tissue forceps for stabilizing the amputated part while the surgeon is tagging the nerves and vessels under a microscope.