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md:secondary_surgery_trauma [2020/08/08 03:05]
admin 		md:secondary_surgery_trauma [2020/08/11 09:27] (current)
admin [Replantation]
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 ====Introduction==== ====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==== 
 +25 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==== ====Options====
 ===Pollicization=== ===Pollicization===
 [[md:trauma_pollicization|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=== ===Thumb lengthening===
 +
 Ivan Matev's chapter in Foucher's book: 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==== ====References====
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   - 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   - 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.   - 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   - 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.   - 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   - [[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
   - How to use the ICF: A Practical Manual for using the International CLassification of Functioning, Disability and Health (ICF). (2013). WHO.   - 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   - 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   - 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
-  - [[jnl:yu2003|Yu, J.-C.]], Shieh, S.-J., Lee, J.-W., Hsu, H.-Y., & Chiu, H.-Y. (2003). [[jnl:yu2003Secondary 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
md/secondary_surgery_trauma.1596855928.txt.gz · Last modified: 2020/08/08 03:05 by admin

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