Tarek Abdalla El-Gammal

Metacarpal hand: classification and guidelines for microsurgical reconstruction with toe transfers.

&NA; Metacarpal hand refers to the hand that has lost its prehensile ability through amputation of all fingers with or without amputation of the thumb. Functional restoration can be achieved by a wide variety of microvascular toe transfer techniques. When deciding which procedure should be used, careful consideration must be given to the level of amputation of the fingers as well as the functional status of the remaining thumb. In this article we propose a classification for the various patterns of the metacarpal hand along with guidelines for selection of the proper toe transfer procedure.

The lateral arm fascial free flap for resurfacing of the hand and fingers.

&NA; The lateral arm free flap can be harvested as a fascial flap or fasciocutaneous flap. In this report we describe the use of the lateral arm fascial flap for degloving injuries of the fingers and for skin loss on the dorsum of the hand with exposure of tendons and bones. Concomitant reconstruction of a missing phalanx with a portion of the distal humerus is also described. The use of the fascial flap allows a large area of tissue to be harvested, and still, the donor site can be closed primarily. The fascia is thin and pliable and so conforms well to the contour of the fingers. Its bulk does not interfere with finger motion, and its undersurface creates a gliding surface for tendons. Complications in the reported cases were negligible.

Digital Periarterial Sympathectomy for Ischaemic Digital Pain and Ulcers

Digital periarterial sympathectomy was performed on 11 digits in three patients with chronic digital ischaemia which was a manifestation of either Raynaud’s disease, C.R.E.S.T. syndrome or traumatic ulnar artery thrombosis. Before operation, all patients had pain in the affected fingers and five digits had ulcers, two of which were infected. Using the operating microscope, the adventitia was stripped circumferentially over the distal 2 cm. of the common digital arteries, the bifurcation and the proximal 1 cm. of the proper digital arteries distal to the bifurcation. The same procedure was repeated, at the wrist level, for the ulnar artery and/or the radial artery and its dorsal branch. Follow-up ranged from three to 16 months. After two weeks, all patients reported relief of pain and the ulcers were progressively healing. By three months, all ulcers had healed.

Tendon transfer around the shoulder in obstetric brachial plexus paralysis: clinical and computed tomographic study.

Abstract: One hundred nine obstetrical palsy patients with defective shoulder abduction and external rotation had subscapularis release and transfer of teres major to infraspinatus with or without pedicle transfer of the clavicular head of pectoralis major to deltoid. The age at surgery averaged 67 months (11-192) and follow-up averaged 36 months (12-80). Thirty-nine cases had follow-up CT scan of both shoulders. Improvement of abduction averaged 64 degrees and that of external rotation 50 degrees, 100% and 290% gain, respectively. Both negatively correlated with the age at surgery (P < 0.001), and were significantly higher in patients operated younger than 4 years. On computed tomographic scans, the degree of glenoid retroversion positively correlated (P < 0.001) with the age at surgery, and was significantly higher in patients operated older than 4 years. The degree of posterior subluxation showed no significant difference between different ages. There was no significant difference between the operated and normal sides in patients operated younger than 4years with regard to glenoid retroversion and in those operated younger than 2 years with regard to posterior subluxation. The operation is useful for correction of defective shoulder abduction and external rotation in obstetric palsy. It is best performed before the age of 2 to get maximal improvement in motion and prevent secondary bone changes. Between the ages of 2 and 4, it also resulted in significant improvement in motion and prevented glenoid retroversion, but not posterior subluxation. After the age of 4, the improvement in motion was not significant and secondary bone changes were not prevented.

Motion after metacarpophalangeal joint reconstruction in rheumatoid disease

The outcome of reconstruction of the rheumatoid metacarpophalangeal joint may deteriorate with time, especially with respect to active motion. This study assesses active finger motion after crossed intrinsic transfer and Swanson implant arthroplasty at increasing durations of follow-up to determine the effect of time. In a total of 58 patients, 21 hands had the crossed intrinsic transfer operation and 49 had the arthroplasty. Follow-up time averaged 6 years for the crossed intrinsic transfers and 21 months for the arthroplasties. Measurement of metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joint active motion at each follow-up interval were analyzed by the univariate repeated measures analysis of variance method. After crossed intrinsic transfer the overall average active range of motion decreased significantly (18 degrees) at the metacarpophalangeal joint. Proximal interphalangeal and distal interphalangeal average range of motion significantly increased during the first 5 years as a result of increases in flexion. After implant arthroplasty, the overall average metacarpophalangeal range of motion analysis at the different follow-up intervals showed that the metacarpophalangeal average range of motion significantly increased during the first 2 years and then gradually declined through the duration of follow-up. Active proximal interphalangeal flexion was also significantly increased during the first 2 postoperative years. The effects of metacarpophalangeal joint reconstruction on active finger joint motion are related to the duration of postoperative follow-up; this concept should be considered when one is planning metacarpophalangeal joint reconstruction in rheumatoid patients.

Toe-to-hand transfer for traumatic digital amputations in children and adolescents.

&NA; In the period from July of 1990 to August of 1994, 45 toe or toe tissue transfers were performed in 28 children and adolescents with traumatic amputation of digits. The average age at the time of transfer was 12 years (range, 3 to 16 years), and the median age was 10 years. The methods of reconstruction included transfer of 6 trimmed great toes, 2 great toe pulps, 24 second toes, 1 vascularized metatarsophalangeal joint from the second toe, 2 third toes, 4 combined second and third toes, and 1 combined third and fourth toes. All of the transferred toes, except one second toe, ultimately survived. Exploration and reanastomosis were required in three cases owing to arterial insufficiency. Partial pulp loss occurred in two digits. Follow‐up ranged from 1 to 5 years (average, 3 years). Bony union occurred uneventfully in all patients. Two‐point discrimination averaged 5 mm (static) and 6 mm (moving). Active range of the motion averaged 69, 38, and 13 degrees at the metaphalangeal proximal interphalangeal and distal interphalangeal joints of the reconstructed fingers, respectively, and 15 degrees at the interphalangeal joint of the reconstructed thumbs. None of the children required subsequent tenolysis. Pulp plasty was performed in nine digits in seven patients. Radiologically, the transferred phalanges showed the some growth as the nontransferred ones. Trimming the great toe before transfer did not result in premature physeal closure or growth retardation. The donor foot maintained a satisfactory appearance. None of the patients complained of difficulty in running or jumping. Toe‐to‐hand transfer in children, performed meticulously, can provide a valuable option for reconstruction of traumatic digit loss. (Plast. Reconstr. Surg. 100: 605, 1997.)

Anatomy of the oblique retinacular ligament of the index finger

The available literature includes conflicting descriptions of the anatomy and function of the oblique retinacular ligament. We have studied this ligament in the index finger to better define its presence, configuration, points of attachment, length, and relationship to the proximal interphalangeal joint axis. Twenty fresh frozen index fingers were dissected. Five additional specimens were decalcified, mounted, sectioned transversely at 1 mm intervals and studied under the microscope. An oblique retinacular ligament was identified on the radial side of the index finger in 95% and on the ulnar side in 90% of the specimens. The radial oblique retinacular ligament was usually longer and more developed than the ulnar oblique retinacular ligament. Proximally, the ligament arose from the middle third of the proximal phalanx and the A-2 pulley whereas, distally, it inserted into the lateral extensor band with a fan-shaped expansion centered 4 to 6 mm distal to the proximal interphalangeal joint line. In 70% of the specimens, the oblique retinacular ligament was supplemented by a contribution from the proximal cruciform pulley (C-1). Histologic cross sections also confirmed the presence of the oblique retinacular ligament but not the supplemental contribution arising from the C-1 pulley. The relationship of the oblique retinacular ligament to the proximal interphalangeal joint axis is dependent on the proximal interphalangeal joint position; the ligament lies palmar to the proximal interphalangeal joint axis only when the proximal interphalangeal joint is flexed.

Current Concepts of Toe-To-Hand Transfer: Surgery and Rehabilitation†

Optimal functional recovery after toe-to-hand transfer depends on skillful surgery as well as aggressive motor and sensory rehabilitation. The patient should be well motivated and willing to incorporate the involved hand in daily living and carry out the rehabilitation program on a daily basis. This article presents the current recommendations for the different toe-to-hand transfers and their postoperative rehabilitation programs.

Telescoping vascularized fibular graft: a new method for treatment of congenital tibial pseudarthrosis with severe shortening.

Vascularized fibular grafts have proved reliable in the treatment of congenital pseudarthrosis of the tibia with a high success rate. However, severe shortening cannot be primarily corrected by this technique and requires a second-stage lengthening procedure. Ilizarovs method allows correction of shortening and axial malalignment together with the non-union. However, in the dysplastic type with severe shortening, corticotomy of the affected bone may result in delayed consolidation or recurrence of disease. In addition, the large distraction distance (equal to the amount of shortening plus the resulting defect after excision of the pseudorthrosis site) requires prolonged frame application, which may not be tolerated by the patient. We present a new technique combining vascularized fibular graft and Ilizarov distraction that allows simultaneous correction of shortening while treating the non-union in a single-stage operation. This method avoids corticotomy in the congenitally affected bone and markedly shortens the time of frame application.

Delayed selective neurotization for restoration of elbow and hand functions in late presenting obstetrical brachial plexus palsy.

The published experience of obstetrical brachial plexus palsy (OBPP) cases with poor recovery and late neurosurgical intervention are sparse. This study included 19 cases who presented after the age of 1 year with poor recovery of elbow and/or hand function and electrophysiological evidence of reinnervation. Age at surgery averaged 41 months, and the follow-up averaged 50 months. Distal neurotization was performed for restoration of elbow flexion in 11 cases, elbow extension in 3 cases, and finger flexion and/or sensibility in 5 cases. Active elbow flexion increased from an average of 2.7 to 91.8 degrees with an average gain of 89 degrees. Active elbow extension increased from an average of 10 to 56.7 degrees with an average gain of 46.7 degrees. Although, three out of five cases (60%) showed satisfactory recovery of finger flexion, all cases scored<2 using Raimondi score. Four cases gained protective sensation and one case gained discriminative sensation. The results of neurotization in late OBPP are variable. The best and most consistent results are obtained by necrotizing the biceps by the intercostal nerves or, in selected cases, by the flexor carpi ulnaris fascicle of the ulnar nerve. Delayed neurotization is the only way to recover sensory function in the hand.