Jae-Won Yang

Challenges in Fingertip Replantation

Fingertip amputation is a challenging injury to manage. Among various reconstructive procedures, replantation results in superior outcome, but is seldom considered in many institutions. From the identification of vessel ends to reanastomosis of the submillimeter vessels, fingertips highly specialized anatomy requires technical excellence. By addressing these anatomic challenges, fingertip replantation can be a routine reconstructive option for microvascular surgeons.

Lateral Nail Fold Incision Technique for Venous Anastomosis in Fingertip Replantation.

BackgroundSuccessful venous anastomosis is one of the most important factors in fingertip replantation. Volar veins in the fingertip course proximally in a random pattern, which makes it difficult to find out the exact locations. Although dorsal veins in the lateral nail fold have constant location and adequate diameter for anastomosis, they have been known as hard to dissect from the immobile subcutaneous tissue. The authors present a new lateral nail fold incision technique for venous anastomosis in the fingertip amputations. MethodsFrom February 2010 to October 2010, 9 replantations using the new incision and venous anastomosis technique were performed in 9 patients. The levels of amputations were from the nail base to half of the nail bed. After repairing the proper digital arteries, a skin incision was made along the junction between the lateral nail fold and nail bed. Careful dissection was performed to isolate the veins in the lateral nail fold. After evaluation of the suitability of the vessel, venous anastomosis was performed. ResultsSeven male and 2 female patients were enrolled in this study. Appropriate dorsal veins for anastomosis could be found in 8 of 9 patients. All the replanted stumps survived without venous congestion and following additional procedures. A sizable volar or dorsal vein could not be found in 1 patient. The salvage technique was required in this patient. ConclusionsDorsal veins in the lateral nail fold can be found easily because of the constant anatomical location. The new incision on the lateral nail fold provides not only sufficient operative field for anastomosis but also additional opportunity of successful venous anastomosis in the selected cases. The authors, therefore, propose this technique as an effective method for an alternative venous anastomosis in the zone I replantation.

Percutaneous cerclage wiring technique for phalangeal fractures.

Comminuted fractures of phalanx are challenging to reduce properly. Commonly, the fragments are distracted by various ligaments as well as flexor and extensor tendons. Splints, skeletal traction, Kirschner wire, plate and screws, and cerclage wires have all been used to manage such fractures. Among these, the cerclage wires are able to effectively contain the distracting forces and maintain a proper concentric reduction of the hollow tube structure of phalangeal bones. The resulting tissue-hardware construct is stable and allows early rehabilitation. Despite the obvious mechanical advantages, cerclage wiring of phalangeal fractures require open incisions. Inevitably, this approach leads to periosteal stripping, upon which the distracting forces exaggerate the displacement of comminuted fragments and the blood supply to the injured bone is compromised. To overcome the disadvantages of open approach, the authors have devised a minimally invasive technique in which the cerclage wire is introduced using a hypodermic needle for fractures of the proximal phalanx and distal phalanx base.

Comparison between Intramedullary Nailing and Percutaneous K-Wire Fixation for Fractures in the Distal Third of the Metacarpal Bone

Background To compare clinical and radiographic outcomes between intramedullary nail fixation and percutaneous K-wire fixation for fractures in the distal third portion of the metacarpal bone. Methods A single-institutional retrospective review identified 41 consecutive cases of metacarpal fractures between September 2009 and August 2013. Each of the cases met the inclusion criteria for closed, extra-articular fractures of the distal third of the metacarpal bone. The patients were divided by the method of fixation (intramedullary nailing or K-wire). Outcomes were compared for mean and median total active motion of the digit, radiographic parameters, and period until return to work. Complications and symptoms were determined by a questionnaire. Results During the period under review, 41 patients met the inclusion criteria, and the fractures were managed with either intramedullary nailing (n=19) or percutaneous K-wire fixation (n=22). The mean and median total active range of motion and radiographic healing showed no statistically significant difference between the two groups. No union failures were observed in either group. The mean operation time was shorter by an average of 14 minutes for the percutaneous K-wire fixation group. However, the intramedullary nailing group returned to work earlier by an average of 2.3 weeks. Complications were reported only in the K-wire fixation group. Conclusions Intramedullary nailing fixation is advisable for fractures in the distal third of the metacarpal bone. It provides early recovery of the range of motion, an earlier return to work, and lower complication rates, despite potentially requiring a wire removal procedure at the patients request.

Microsurgical reconstruction of soft-tissue defects in digits

Injuries that cause soft tissue defects could threaten the function and viability of the involved digit. Reconstruction of such defects can be challenging and requires careful consideration in restoring both the aesthetic and functional deficit. The purpose of this review is to describe appropriate reconstructive technique using various free tissue transfers. According to the location and the size of a defect, a proper reconstructive option is indicated. Owing to the specialized mechano-sensory property of its volar soft tissue, fingertip injury, when significant defects exist, are reconstructed using specialized free flaps with appropriate histological and functional similarities. Composite tissue including bone may be required in selected cases. Additional procedures, such as secondary skin graft or division of the flap, should be done after several weeks of the first operation. Refinements and improvements in free tissue transfer allow an expanse of reconstructive options for soft tissue defect in the digit.

Short-Term Strength Deficit Following Zone 1 Replantations

Background Hand strength deficit following digital replantation is usually attributed to the mechanical deficiency of the replanted digit. Zone 1 replantation, however, should not be associated with any mechanical deficit, as the joint and tendon are intact. We evaluate short-term motor functions in patients who have undergone single-digit zone 1 replantation. Methods A single-institution retrospective review was performed for all patients who underwent zone 1 replantation. Hand and pinch strengths were evaluated using standard dynamometers. Each set of measurements was pooled according to follow-up periods (within 1 month, 1 to 2 months, 2 to 3 months, and after 3 months). The uninjured hand was used as reference for measurements. Results The review identified 53 patients who had undergone zone 1 replantation and presented for follow-up visits. Compared to the uninjured hand, dynamometer measurements revealed significantly less strength for the hand with replanted digit at one month. The relative mean grip, pulp, and key pinch strength were 31%, 46%, and 48% of the uninjured hand. These three strength measurements gradually increased, with relative strength measurements of 59%, 70%, and 78% for 4-month follow up. Conclusions Despite the lack of joint or tendon injury, strength of the injured hand was significantly lower than that of the uninjured hand during the 4 months following replantation. Improved rehabilitation strategies are needed to diminish the short-term negative impact that an isolated zone 1 replantation has on the overall hand strength.

Palmar Hand Wound Coverage with the Free Flaps

While tissue defects vary greatly in presentation, all successful attempts at reconstruction share a singular character. In all such examples, the reconstructive surgeon had chosen a donor that is most similar to the tissue lost to an injury or pathologic process. This fundamental character delineates between beautiful and ugly and divides what is functionally sound to what is painful, stiff, frail, and consequently useless. Nowhere in the human body is this fundamental principle of reconstruction more obvious−and its violation more treacherous−than in the management of hand reconstruction. Palmar defects are notoriously difficult to manage if the reconstructive surgeon believes the glabrous skin to be a passive envelope, which exists solely to cover the underlying tendinoskeletal framework. The successful reconstruction begins with appreciation of three functional sets of the palmar tissue: 1) The provision of a tactile surface towards the outer world; 2) soft tissue of smooth surface for the tendons gliding within; and 3) sensory recovery. Upon this recognition, the surgeon must now decide on the donor site with minimal morbidity and maximal function. Local flaps perform admirably but with a couple of caveats. First, the defect cannot be too great of a size. An injured hand can only give up so much donor tissue before there is no more of the hand left. Second, the defect cannot be in a location that requires prolonged immobilization. Unfortunately, these caveats place a significant limit on the types of palmar defects that can be address with a local flap reconstruction. Setting aside the reimbursement issue and technical demand of microsurgery, free flaps provide an expansive set of reconstructive options with which to repair the wide variety of palmar defects. Name a palmar defect of any size, shape, or location.