Joseph E. Kutz

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.

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.

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.

Graft vasculopathy in clinical hand transplantation.

Allogeneic hand transplantation is now a clinical reality. While results have been encouraging, acute rejection rates are higher than in their solid‐organ counterparts. In contrast, chronic rejections, as defined by vasculopathy and/or fibrosis and atrophy of skin and other tissues, as well as antibody mediated rejection, have not been reported in a compliant hand transplant recipient. Monitoring vascularized composite allograft (VCA) hand recipients for rejection has routinely involved punch skin biopsies, vascular imaging and graft appearance. Our program, which has transplanted a total of 6 hand recipients, has experience which challenges these precepts. We present evidence that the vessels, both arteries and veins may also be a primary target of rejection in the hand. Two of our recipients developed severe intimal hyperplasia and vasculopathy early post‐transplant. An analysis of events and our four other patients has shown that the standard techniques used for surveillance of rejection (i.e. punch skin biopsies, DSA and conventional vascular imaging studies) are inadequate for detecting the early stages of vasculopathy. In response, we have initiated studies using ultrasound biomicroscopy (UBM) to evaluate the vessel wall thickness. These findings suggest that vasculopathy should be a focus of frequent monitoring in VCA of the hand.

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.

Vascularized autogenous whole joint transfer in the hand—A clinical study

Nine vascularized autogenous whole joint transfers were employed in the reconstruction of traumatized joints of six male patients ages 6 to 38 years. The proximal interphalangeal joint was involved in four patients, the thumb metacarpophalangeal (MP) joint in two, and the small finger MP joint in one. In five patients, the donor joint came from the foot, and in one patient an MP joint was transferred from a digit that had sustained a more distal amputation. The mean follow-up was 24 months (range 13 to 38). Bony union as well as full radiographic preservation of the articular space has occurred in each case. Four joints were transferred with an open epiphysis and three demonstrated longitudinal growth and an intact epiphyseal plate. The mean range of active motion was 22°/55°. We believe the early results demonstrate the feasibility of this method of joint reconstruction in the young patient.

Chronic exertional compartment syndrome of the forearm: A case report

A 40-year-old man sustained a circumferential crush injury to his right forearm. Four months after injury, he experienced the onset of numbness and tingling in the distribution of the median nerve after exercise. Elevated compartment pressures of the palmar forearm and slowing of median nerve conduction after exercise suggested chronic exertional compartment syndrome. A flexor fasciotomy led to complete relief of symptoms, which allowed the patient unrestricted activity.

Primary microsurgical repair of ring avulsion amputation injuries

Patients with ring avulsion injuries of the fourth and fifth digits often demand attempts at reconstruction rather than completion of the amputation. In the past, this has led to reconstruction involving a staged series of operations with results that were often less than desirable. Seven patients with ring avulsion amputation injuries that were reconstructed by use of microsurgical reanastomoses are reported. All were classified as either Carroll type IV or Urbaniak type III. Six patients (85%) had a successful replantation leading to a useful finger. The operating time averaged 5.5 hours. On average, 1.9 arteries (range 1 to 2) and 3.3 veins (range 2 to 5) were repaired for each digit. Average hospital stay was 6.7 days (range 4 to 15). Average range of motion was 0(2)/84(2) for metacarpophalangeal joint and 15(2)/90(2) for proximal interphalangeal joint (PIP) with distal interphalangeal joint ankylosis at between 0(2) and 15(2) of flexion. Sensibility was protective in all cases and good in three. If the PIP joint was damaged, completion of amputation was the treatment of choice. If the amputation is distal to the PIP with a functional superficialis tendon, primary microsurgical repair is the treatment of choice in complex ring avulsion injuries.

Post-Operative Management of Flexor Tendon Grafting

This paper reviews the post-operative management of 145 tendon grafts in 127 patients. 80 grafts were managed post-operatively by a period (three to four weeks) of immobilisation followed by gentle active mobilisation. 65 grafts were managed by immediate controlled mobilisation (Kleinert technique) for three to four weeks. The final motion obtained was independent of the post-operative management. However, the rates of graft rupture (nine against four) and of tenolysis (sixteen against eight) were higher in the immobilised group.

Improvement in motor function after brachial plexus surgery

Motor functional recovery of 52 patients with brachial plexus surgery followed up for more than 2 years was evaluated. Fifty-eight surgical procedures were done, including autologous nerve grafting (38 cases), neurolysis (14 cases), and neurotization (6 cases). Overall results, evaluated according to the 0 to 5 formula of the Medical Research Council, were as follows: good, 58%; fair, 15%; and poor, 27%. Good results were evident in 58% of patients with nerve grafts and in 64% of those with neurolysis. In patients with neurotization, no good recovery and only one fair recovery were seen. Patients with open injuries showed good recovery, whereas the group with closed injury showed good recovery in only 48%. Patients with closed injuries caused by traffic accidents showed a worse recovery than those caused by other means. Patients with closed injuries and nerve grafting done within 3 months of injury or neurolysis within 6 months showed better recovery.