Tsu-Min Tsai

Major replantation versus revision amputation and prosthetic fitting in the upper extremity: a late functional outcomes study.

The functional outcomes of amputated arms that were either replanted or had a prosthesis were compared. In addition, factors that influenced the functional outcome of replants were evaluated. The Carroll test was used to evaluate functional capacity of 22 successful upper extremity replantations at or proximal to the wrist as well as 22 amputees (at similar levels) fitted with a variety of prosthetic devices. The outcome was excellent or good in 8 (36%) replanted limbs. This proportion was statistically higher than those grades in the prosthetic group. When the groups were more closely matched (adults with below elbow injuries), the replantation group had 6 (50%) good or excellent outcomes and the prosthetic group had none. An analysis of covariance of the replantations demonstrated a statistical association between a better outcome in younger patients with more distal injuries. This study indicates that replantation produces superior functional results compared with amputation and a prosthesis.

Methods and results of replantation following traumatic amputation of the thumb in sixty-four patients

Immediate survival and functional results were studied in 64 thumb replantations performed during a 3 year period. The failure rate, 27% overall, was higher in patients over 50 years of age (50%) and following avulsions with or without crushing injuries (58%). Long vein grafts from the radial artery proximally to the thumb arteries distally were employed in 15 patients to bypass the traumatized area in the first web space. A higher survival rate (90%) was associated with the use of vein grafts to restore venous return. Half of the patients followed 6 months or longer had good discriminatory sensibility (less than 10 mm). Sensory return and cold intolerance were worse in older patients and were not related to level of injury, mechanism of amputation, total ischemia time, or number of arteries or veins repaired. Loss of motion of the replanted thumb was a frequent cause for inadequate return of function. All thumbs should be considered for replantation, but the results will be poorer in older patients. If possible, motion of the interphalangeal and metacarpophalangeal joints should be preserved.

An overview of replantation and results of 347 replants in 245 patients.

A review of 245 patients requiring replantation surgery from 1970 to 1978 revealed a 70% survival rate for complete amputation. In this group, there were 347 replanted parts, including the lower extremity. Upper-extremity survival rates alone (greater than 90%) are higher than for lower extremity replantation. Meaningful assessment of replantation must include not only survival data but functional criteria as well. While functional data are incomplete on several early cases, our assessment criteria are reviewed. Criteria should include two-point discrimination sensibility ratings, grip strength, range of motion, absence of cold intolerance, and return to employment. Evaluation of candidates for replantation is critical, and the importance of teams with microsurgical skills working in special centers is emphasized.

Reconstruction of the hand with free microneurovascular toe-to-hand transfer: experience with 54 toe transfers.

Over a period of 6 years, 54 toe-to-hand transfers were performed, 24 for thumb and 30 for finger reconstruction. Refinements in evaluation, preparation, and surgical technique are detailed. Forty-nine toes (90.7 percent) survived. Exploration was required for circulatory compromise following 13 transfers (34.2 percent), to good effect in 9 (69.2 percent). Secondary surgery was performed in 26 cases, consisting of tendolysis, osteotomy, and deepening of the first web space. Review was undertaken at an average of 1 year and 9 months after transfer. Power grip averaged 28.5 percent of the normal hand and pinch strength 26.6 percent, great toe transfer giving 35.7 percent and second toe transfer to thumb giving 15.6 percent strength compared with normal. Static two-point discrimination of less than 10 mm was present in 37.5 percent of those studied under 2 years after surgery and in 75 percent of those studied more than 2 years later. The choice of procedure for thumb reconstruction is discussed in detail, as are supplementary skin cover, vascular considerations, and the high exploration rate.

Reconstruction of severe transmetacarpal mutilating hand injuries by combined second and third toe transfer

This paper reports on nine instances of combined second and third toe-to-hand transfers in eight patients for severe transmetacarpal mutilating hand injuries. In four cases, the transfer included an innervated flap from the fibular side of the great toe to provide sensibility to a previously constructed osteoplastic thumb. Prehensile.function was significantly improved by providing chuck or tripod pinch as well as improved pulp-to-pulp and lateral pinch. At a mean follow-up of 20.3 months, there was only one failure.

Salvage replantation of lower limb amputations.

Three cases are reported in which the microsurgical salvage of parts of traumatic lower extremity amputations associated with degloved proximal skin loss provided sturdy, sensate skin and soft-tissue coverage and thereby preserved functional below-knee amputation levels. In two instances, a free innervated filletted flap was constructed from the foot of the amputated limb, and in the third case, the amputated lower leg was shortened, successfully replanted, and followed later by elective amputation of a foot at the Syme level. At a mean follow-up of 2 years, all three patients are ambulating well in below-knee prostheses.

Results of surgical treatment of painful neuromas of the hand

The surgical treatment of 50 patients with 101 neuromas over the last 10 years is reported. Simple excision and implantation into local muscle resulted in an unacceptable reoperative rate of 65%. Ray amputation for symptomatic neuromas resulted in the highest reoperation rate but resulted in little or no subjective improvement. There appears to be a correlation between delayed healing after the initial injury and the severity of neuroma symptoms. Dorsal translocation of the neuroma consistently resulted in decreased sensitivity without longterm recurrence.

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.

Functional results of vascularized versus nonvascularized nerve grafting.

Functional results of vascularized nerve grafts (VNG), end-to-end (E-E) repair, and nonvascularized nerve grafts (NNG) were compared using 75 rats. For all three groups, the sciatic function index (SFI) was measured for 12 weeks. For the vascularized nerve graft and nonvascularized nerve graft groups, it was measured every 4 weeks to week 36. The vascularized nerve graft and end-to-end repair groups showed significantly better recovery than the nonvascularized nerve graft group 4 weeks after surgery, and this pattern continued throughout the experiment. Results from the vascularized nerve graft and end-to-end repair groups did not differ significantly. Twelve weeks after surgery, morphologic and electrophysiologic assessments were used to compare the experimental and contralateral legs. The vascularized nerve graft group showed significantly better recovery than the nonvascularized nerve graft group on all measures except muscle weight and axon count, even though the grafts were completed in a normal bed.

Complications and vascular salvage of free-tissue transfers to the extremities.

Complications were examined in 122 free flaps to lower and upper extremities in 104 patients, and vascular salvage was examined in 182 free flaps to lower and upper extremities in 158 patients. All patients were treated by the same surgeon. The overall survival rate of flaps was 96 percent. Complications occurred in 22 percent of the flaps. Complication rates were lower in patients with one free flap than in patients with two. Flaps had more vascular complications than nonvascular. Accompanying skin islands were found to be necessary to monitor vascularized bone transfers in order to avoid flap failure. Flow in the pedicle was reestablished in all flaps, but a higher percentage of flaps with longer ischemic times were lost. Although vascular compromise occurred frequently (15 percent), prompt surgical exploration and reexploration were thought to have greatly increased free-flap survival.