Richard M. Fakin

Primary functional and aesthetic restoration of the fingernail in distal fingertip amputations with the eponychial flap

Fingertip injuries often result in fingernail defects. Reconstruction of this structure is important for adequate functional and aesthetic results. This study evaluates the eponychial flap reconstruction technique in 45 fingertip amputations with loss of more than half the fingernail. In 33 cases the procedure was performed in combination with a palmar island flap for pulp reconstruction. Average follow up was 5 months. All eponychial flaps healed uneventfully. In 44 cases, the pulp volume was restored without nail growth disturbance. Five complications (9%) were observed (pain, soft nail, and nail deformity). Only one hook nail deformity required reoperation. All patients were satisfied with the aesthetic and functional outcome. We found eponychial flap fingernail reconstruction effective even for injuries proximal to the lunula and have extended the indication for this technique to very proximal fingernail defects. Eponychial flap reconstruction is a simple, safe, and time-effective technique without donor site morbidity. Simultaneous reconstruction of dorsal and palmar injuries should both be performed primarily resulting in the restoration of a satisfying fingertip.

Long-term clinical outcome after epineural coaptation of digital nerves

This study evaluates the long-term clinical outcome and complication rate after digital nerve repair in adults and aims to identify possible prognostic factors of sensory recovery. End-to-end epineural coaptation was performed under magnification. A total of 93 coapted digital nerves were clinically evaluated with a mean follow-up of 3.5 years (range 1–6 years). The mean two-point discrimination was 10.6 mm (versus 4.4 mm for the contralateral side). Cutaneous pressure threshold tested with Semmes–Weinstein monofilaments showed a mean value of 2.7 (versus 2.2 for the contralateral side). Only 2% of our patients developed painful neuromas. None of our patients recovered normal functional sensibility, however, recovery of protective sensation contributed to a high reported level of satisfaction. No correlation was observed between the sensory outcome and age, smoking, mechanism of injury, lesion to or anastomosis of a digital artery, or time of immobilization. The only identified predictor of the result was the surgeon’s level of experience. This highlights the importance of adequate training and practice in the surgical repair of smaller peripheral nerves. Level of evidence: IV

Reconstruction of Penile Shaft Defects Following Silicone Injection by Bipedicled Anterior Scrotal Flap

Purpose: Numerous causalities, including attempts at penile augmentation with silicone or paraffin, can lead to extensive circular penile shaft defects. Reconstruction is challenging and skin grafting is a suboptimal option despite its widespread use. We present a surgical technique for penile shaft reconstruction with a bipedicled anterior scrotal flap. Materials and Methods: A retrospective data analysis was performed of patients treated for symptomatic penile siliconomas who underwent subsequent penile reconstruction with a bipedicled anterior scrotal flap between 2010 and 2015. The surgical technique is described and depicted in detail. Results: A total of 43 men were treated with radical circular excision of penile siliconomas and extensive shaft defects were reconstructed with a bipedicled anterior scrotal flap. Mean ± SD age was 36.95 ± 11.27 years, mean followup duration was 10.69 ± 9.54 months and mean operative time was 2.53 ± 0.46 hours. The operation proved uneventful in all cases. Only minor complications were observed, such as partial necrosis in 9% of patients, hematoma of the donor site in 12% and partial wound disruption in 19%. The mean patient satisfaction score was 4.37 on a scale of 1 to 5. All patients reported postoperative erection ability and the ability to achieve sexual intercourse. Conclusions: We present a surgical technique to reconstruct extensive penile shaft defects with an axial scrotal flap, which provides well vascularized coverage with comparable donor skin quality and thickness. The results are associated with minor donor site morbidity, good functional and aesthetic outcomes, and high patient satisfaction.

Evaluation of Cutaneous Spatial Resolution and Pressure Threshold Secondary to Digital Nerve Repair.

Background: As the sophistication of functional reconstruction procedures continues to increase, so does the need for valid, precise, and reliable instruments to assess their clinical results. The authors compare two tests for spatial resolution and two for cutaneous pressure threshold in an adult patient cohort having undergone microsurgical digital nerve repair after traumatic transection. Methods: Patients who underwent epineural coaptation after digital nerve transection at the authors’ institution between June of 2006 and December of 2011 were asked to participate in a follow-up examination assessing spatial resolution (two-point discrimination and grating orientation test) and cutaneous pressure threshold (Semmes-Weinstein monofilament test and pressure-specifying sensory device). Interinstrument correlations were conducted and critically elucidated. Results: Eighty-one patients (26 female and 55 male patients; median age, 42 years; interquartile range, 23 years) were examined with a mean follow-up period of 3.5 ± 1.4 years. Although all tests could differentiate between the healthy and operated fingers, poor to moderate correlations were found between two-point discrimination and grating orientation test (&rgr;operated = 0.483, p < 0.0001; &rgr;healthy = 0.350, p < 0.0001), and between Semmes-Weinstein monofilament test and Pressure-Specified Sensory Device testing (&rgr;operated = 0.287, p = 0.01; &;healthy = 0.382, p < 0.001), indicating that they measure different properties. Altogether, the grating orientation test proved superior to two-point discrimination, whereas Pressure-Specified Sensory Device testing was superior to Semmes-Weinstein monofilament testing. Conclusions: Thoughtful use of test instruments is advisable when assessing sensibility of the hand. This study suggests including Pressure-Specified Sensory Device testing to assess cutaneous pressure threshold and the grating orientation test to assess spatial resolution in clinical, routine test batteries. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, III.

The novel treatment of SVF-enriched fat grafting for painful end-neuromas of superficial radial nerve

None of the existing treatments in the management of painful end‐neuromas of the superficial branch of the radial nerve (SBRN) has been proven superior due to high levels of pain relapse. Fat grafts enriched with the stromal vascular fraction (SVF) could act as a mechanic barrier with biological effects decreasing the resorption rate and boosting the grafts regenerative potential. This study describes the novel surgical treatment technique of SVF‐enriched fat grafting.

Bilateral pedicle anterolateral thigh (ALT) flap combined with bilateral sartorius muscle flap for reconstruction of extensive perineoscrotal and medial thigh defect because of Fournier's gangrene.

Fourniers gangrene is an acute and potentially lethal necrotizing fasciitis that can lead to extensive defects of the perineoscrotal area and lower abdominal wall as well. Such defect poses challenging tasks for both functional and cosmetic reconstruction. Local perforator pedicle flaps and muscle flaps can be employed and combined for such a reconstruction. In this report we present a case of reconstruction of a massive perineoscrotal and upper medial thigh defect because of Fourniers gangrene using a bilateral pedicle anterolateral thigh (ALT) flap and sartorius muscle flap. A 61 year‐old male who suffered from Fourniers gangrene resulted in a perineal, scrotal, and medial thigh defect of 27 × 30 cm2 with exposure of the femoral vessels. A bilateral pedicle ALT flap measuring 30 × 9 cm2 based on two perforators and a bilateral sartorius muscle flap were harvested for soft tissue defect reconstruction and inguinal vessels coverage, respectively. The flaps survived completely, with no recipient or donor site morbidity. The length of follow‐up was 6 months and was uneventful. A bilateral pedicle ALT flap combined with bilateral sartorius flap may be considered as a valid and safe option for an extensive inguinal and perineoscrotal reconstruction in selected cases.

Pathophysiologie der Verbrennungskrankheit

Ein Verbrennungstrauma mit Beteiligung bereits ≥20 % der Korperoberflache kann bis zum Multiorganversagen mit fatalen Folgen fuhren. Es entsteht eine systemische Reaktion u. a. mit signifikanter Flussigkeitsverschiebung aus dem intravasalen in den interstitiellen Raum und somit eine Odembildung. Bei der Entstehung eines Verbrennungsschocks spielt neben der Hypovolamie auch die Aktivierung der zahlreichen Mediatoren eine zentrale Rolle. Dieses Kapitel befasst sich hauptsachlich mit systemischen Reaktionen der Verbrennungskrankheit bei schwerverbrannten Patienten. Dabei werden die Mechanismen auf zellularer Ebene und der Effekt der wichtigsten Mediatoren beschrieben sowie die Auswirkung auf einzelne Organsysteme dargestellt.

Modified Suzuki frame for the treatment of difficult Rolando fractures.

Fifteen consecutive patients with severely comminuted Rolando fractures were treated by closed reduction and fixation with a modified Suzuki frame without rubber bands, followed by immediate mobilization. All the fractures healed within 5 weeks. At 3 months, no rotational deformity was observed. The Kapandji score was equal that of the contralateral thumb in eight cases. No residual pain was recorded. Grip strength was 78% and pinch strength was 78% of the contralateral hand. One patient needed the frame tension modified. One patient developed a sensory deficit in the area of the superficial branch of the radial nerve that resolved spontaneously in 3 months. One patient healed with a 2-mm articular step-off, but the clinical outcome was good. Our retrospective study suggests that the small modification we made to the Suzuki frame provides a relatively simple and minimally invasive technique for the treatment of comminuted Rolando fractures.

Replantation by palmar arteriovenous anastomosis in complex finger amputations.

Digital replantation is a well-established and increasingly common procedure in specialized hand surgery units worldwide. Replantation after complex trauma is often challenging due to severely injured, small-diameter vessels, especially at the distal level. Digit salvage by arteriovenous anastomosis has been inadequately described in the literature for such cases. The objective of this study was to evaluate the outcomes and complications of arteriovenous digital replantation in complex amputations. We reviewed five cases of digital replantation using a single palmar afferent arteriovenous anastomosis and drainage via a dorsal vein. The postoperative protocol followed our standard replantation protocol. All digits survived with no revision procedures. No major complications were observed. One digit developed partial epidermolysis and one thumb developed marginal skin necrosis, both treated conservatively. The color of the replanted digits was not a reliable monitoring parameter but capillary refill was consistently visible. Microangiography performed four months after surgery demonstrated good digit perfusion. Our results support palmar arteriovenous anastomosis as a reliable alternative in digital replantation if distal arteries are unavailable for anastomosis. The results also suggest that this digit salvage procedure can be carried out at a more proximal level than previously reported.

Outcome of Stromal Vascular Fraction-Enriched Fat Grafting Compared to Intramuscular Transposition in Painful End-Neuromas of Superficial Radial Nerve: Preliminary Results

Introduction The management of painful end-neuromas of the superficial branch of the radial nerve (SBRN) remains challenging due to high levels of pain relapse. The novel technique of stromal vascular fraction (SVF)-enriched fat grafting showed continuous pain relief, although failed to prove statistically significant. Besides acting as a mechanical barrier, SVF-enriched fat grafting might also affect the cellular level. The aim of this study was to compare clinical outcomes of SVF to the widely popular intramuscular transposition technique. Patients and methods In this cohort study, 10 consecutive patients treated for painful end-neuromas of the SBRN between 2010 and 2013 were analyzed retrospectively. Microsurgical resection of end-neuromas was performed in all patients. Five patients were treated with subsequent intramuscular transposition into the brachioradialis muscle and five patients received SVF-enriched fat grafting. Five different pain modalities and various predictors were compared pre- and up to 36 months post-operatively. Results In the transposition group, sustained pain reduction was not observed after an initial significant reduction 2 months’ post-surgery, resulting in pain relapse at 36 months and comparable to the preoperative assessment. In the graft group, some degree of pain reduction was observed at 2 months after the surgery and proved to be constant in the long-term outcome, although not statistically significant compared to preoperative levels. Conclusion Both SVF-enriched fat grafting and intramuscular transposition failed to prove statistical significant pain reduction in treating symptomatic neuromas of peripheral nerves.