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--- md:secondary_surgery_trauma [2020/07/31 13:15]
admin created
+++ md:secondary_surgery_trauma [2020/08/11 09:27] (current)
admin [Replantation]
@@ Line 3: / Line 3: @@
 ====Introduction====
-I started this section as preparation work for a talk at a 2020 ASSH Meeting precourse.
+===Classification of secondary surgery===
+from [[jnl:rajasabapathy2013]]
+  * repair of structures not primarily repaired
+  * promote healing/enhance function e.g. malunion, nonunion, tenolysis
+  * enhance function - arthrodesis, bone lengthening, tendon transfers etc.
+==== Replantation ====
+  * [[jnl:rajasabapathy2013|Replantation - secondary surgery]]
+    * Rate of secondary surgery in replantation is high, and may be multiple
+    * In replantation - try to do everything primarily -- hard to comeback to do secondary recon
+    * Timing - 3 months - supple skin -- can be delayed by wound problems; junction of native and flap skin is issue for tendon grafts.
+    * Flexion more important than extension
+    * Jupiter - good results with tenolysis in replantation 72 degrees to 130 degrees; Yu 119-159
+====Cases====
+Female MVA
+Initial treatment at a different hospital - external fixation and debridement; came infected
+- overall goal - preserve upper limb and maximise function of hand and upper limb
+D0: debridement and external fixation --> infection
+D7-30+: multiple debridements, shortening, fixation with plates and screws
+Secondary procedures
+- 7 months: Restore passive motion of forearm and digits before tendon transfer --> take down of radioulnar synostosis, MCPJ captulectomy, removal of radial plates
+- 9 months: tendon transfers - IF FDS to FPL, MF FDS to IF & MF FDP, RF FDS to RF & SF FDP
+- complicated by recurrence of HO -- 11 months: re-excision of HO & release of contracture; FFMT gracilis for finger extension
+- 19 months: MF, RF, SF captulectomy, arthrolysis, scar revision
+- outstanding issues: loss of supination
+====Psychological adaptation====
+  * Bradway and Malone
+  * Limited information - UE only < 10% of all amputations
+  * psychiatric intervention needed only for minority
+  * Stages
+    * preop - anticipation/ grief
+    * immediate postop - early acceptance not necessarily good, more optimism in life threatening ijuries
+    * with rehabilitation - denial
+    * at home  - critical phase; learn to adapt or stuck in denial
+  * Guidelines in managing
+    * start pre-op
+    * Amputation as a "reconstructive" procedure
+====Alternatives to secondary reconstruction====
+  * [[jnl:pinzur1994|Functional outcome following traumatic upper limb amputation and prosthetic limb fitting]]
+    * early fitting better results
+    * compare with [[jnl:chevrier1956]]: lower usage rate at follow up ? because of long interval between diagnosis and referral; but group also different (not just trauma)
 ====Options====
+===Pollicization===
+[[md:trauma_pollicization|Pollicization]]
+  * used less in microsurgical age
+    * may be best option
+      * nearer to CMCJ
+    * disadvantages
+      * sensation - still IF
+      * loss of digit
+== Planning ==
+  * IF by far most common - but can use other digits
+    * consider if injured other digits
+Binhammer and Lister's article is quite good
+  * tendon transfer for opposition - FDS RF
+  * Fixation
+  * shortening - distally or proximally -- ? length
+  * check circulation
 ===Thumb lengthening===
 Ivan Matev's chapter in Foucher's book:
-  - 50% easy, 80% possible, sometimes 100% in young
+  * 50% easy, 80% possible, sometimes 100% in young
-  - young - slower (1mm /d) but more lengthening
+  * young - slower (1mm /d) but more lengthening
-  - older - more likely bone graft (45-60 days) if no good callus - in situ
+  * older - more likely bone graft (45-60 days) if no good callus - in situ
-  - problems - union, angulation, infection, MCPJ flexion
+  * problems - union, angulation, infection, MCPJ flexion
-  - need good skin first
+  * need good skin first
-  - can pain nail
+  * can paint nail
-  - make sure CMCJ is good, skin at tip is good first, sometimes need to deepen/widen web
+  * make sure CMCJ is good, skin at tip is good first, sometimes need to deepen/widen web
+===Osteoplastic thumb reconstruction==
+  * flap - groin/abdominal vs radial forearm
+    * size: 6-7 cm
+    * 1-2 cm shortening
+    * avoid circular seam - either oval or zig-zag
+    * seam in palmar side of "thumb"
+  * bone - iliac crest, tibia, radius
+    *  make thumb slightly shorter than other side
+    * bone fixation --> wedge into MC/P1
+  * neurovascular island flap - ulnar side of MF
+    * ulnar side of RF
+    * make sure it is big enough
+  * nerve repair  +/-
+  * Staging - 3 vs 2 vs 1 stage
+==Issues==
+  * sensory recovery
+  * flap necrosis
+  * bone graft resorption - related to flap
+====Outcomes in mutilating hand injuries ====
+  * see [[jnl:giladi2016]]
+  *  MSK Trauma big burden -- especially developing countries
+    *  need for outcome measures -- move towards PROMs
+  *  PROMs context specific -- different countries and cultures --> different
+  *  disability vs impairment -- measures don't map well
+  *  different PROMs don't correlate well too
+  *  individualized treatment - need shared decision making
 ====References====
@@ Line 22: / Line 130: @@
   - Brown, P. W. (1982). Less than ten—Surgeons with amputated fingers. The Journal of Hand Surgery, 7(1), 31–37. https://doi.org/10.1016/S0363-5023(82)80010-5
   - Cheung, K., Hatchell, A., & Thoma, A. (2013). Approach to traumatic hand injuries for primary care physicians. Canadian Family Physician Medecin De Famille Canadien, 59(6), 614–618.
+  - Chevrier, J. M., Gingras, G., Lemieux, R., Mongeau, M., Susset, V., & Voyer, R. (1956). [[jnl:chevrier1956|Psycho-social and rehabilitative aspects of upper extremity amputees]]. Canadian Medical Association Journal, 75(10), 819–823.
   - Foo, A., & Sebastin, S. J. (2016). Secondary Interventions for Mutilating Hand Injuries. Hand Clinics, 32(4), 555–567. https://doi.org/10.1016/j.hcl.2016.07.006
   - Foucher, G. (1997). Reconstructive surgery in hand mutilation. Martin Dunitz.
-  - Giladi, A. M., Ranganathan, K., & Chung, K. C. (2016). Measuring Functional and Patient-Reported Outcomes After Treatment of Mutilating Hand Injuries. Hand Clinics, 32(4), 465–475. https://doi.org/10.1016/j.hcl.2016.06.002
+  - Giladi, A. M., Ranganathan, K., & Chung, K. C. (2016). [[jnl:giladi2016|Measuring Functional and Patient-Reported Outcomes After Treatment of Mutilating Hand Injuries]]. Hand Clinics, 32(4), 465–475. https://doi.org/10.1016/j.hcl.2016.06.002
-  - Gingras, G., & Lemieux, R. (1956). PSYCHO-SOCIAL AND REHABILITATIVE ASPECTS OF UPPER EXTREMITY AMPUTEES. 75, 5.
+  - [[jnl:graham2016|Graham, D.]], Bhardwaj, P., & Sabapathy, S. R. (2016). Secondary Thumb Reconstruction in a Mutilated Hand. Hand Clinics, 32(4), 533–547. https://doi.org/10.1016/j.hcl.2016.07.005
-  - Graham, D., Bhardwaj, P., & Sabapathy, S. R. (2016). Secondary Thumb Reconstruction in a Mutilated Hand. Hand Clinics, 32(4), 533–547. https://doi.org/10.1016/j.hcl.2016.07.005
   - How to use the ICF: A Practical Manual for using the International CLassification of Functioning, Disability and Health (ICF). (2013). WHO.
   - Krueger, C. A., Wenke, J. C., Cho, M. S., & Hsu, J. R. (2014). Common Factors and Outcome in Late Upper Extremity Amputations After Military Injury: Journal of Orthopaedic Trauma, 28(4), 227–231. https://doi.org/10.1097/BOT.0b013e3182a665f5
+  - Pinzur, M. S., Angelats, J., Light, T. R., Izuierdo, R., & Pluth, T. (1994). [[jnl:pinzur1994|Functional outcome following traumatic upper limb amputation and prosthetic limb fitting]]. The Journal of Hand Surgery, 19(5), 836–839. https://doi.org/10.1016/0363-5023(94)90197-X
+  - Sabapathy, S. R., & Bhardwaj, P. (2013). [[jnl:sabapathy2013|Secondary procedures in replantation]]. Seminars in Plastic Surgery, 27(4), 198–204. https://doi.org/10.1055/s-0033-1360587
   - Swiontkowksi, M. F. (2011a). Traumatic and Trauma-Related Amputations: Part I: General Principles and Lower-Extremity Amputations. Yearbook of Orthopedics, 2011, 55–57. https://doi.org/10.1016/j.yort.2011.04.016
-  - Yu, J.-C., Shieh, S.-J., Lee, J.-W., Hsu, H.-Y., & Chiu, H.-Y. (2003). Secondary procedures following digital replantation and revascularisation. British Journal of Plastic Surgery, 56(2), 125–128. https://doi.org/10.1016/S0007-1226(03)00033-X
+  - [[jnl:yu2003|Yu, J.-C.]], Shieh, S.-J., Lee, J.-W., Hsu, H.-Y., & Chiu, H.-Y. (2003). [[jnl:yu2003|Secondary procedures following digital replantation and revascularisation]]. British Journal of Plastic Surgery, 56(2), 125–128. https://doi.org/10.1016/S0007-1226(03)00033-X
+==== History ====
+  * 2020-07-30 I started this section as preparation work for a talk at a 2020 ASSH Meeting pre-course.
+  * 2020-08-08 Combined with notes.rst and rearranged sections

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