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md:secondary_surgery_trauma [2020/08/08 03:25]
admin 		md:secondary_surgery_trauma [2020/08/11 09:27] (current)
admin [Replantation]
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 ====Introduction==== ====Introduction====
  
 +===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
  
-General +====Cases====
-******** +
- +
- +
-Semin Plast Surg. 2013 Nov; 27(4): 198–204. +
-doi: 10.1055/s-0033-1360587 +
-PMCID: PMC3842341 +
-PMID: 24872769 +
-Secondary Procedures in Replantation +
-S. Raja Sabapathy, MS, MCh (Plastic Surgery), FRCS (Ed)1 and Praveen Bhardwaj, FNB (Hand & Microsurgery)1 +
- +
-Rate of secondary surgery in replantation is high, and may be multiple +
-********************************************************************** +
- +
-Classification of secondary surgery +
-- repair of structures not primarily repaired +
-- promote healing/enhance function e.g. malunion, nonunion, tenolysis +
-- enhance function - arthrodesis, bone lengthening, tendon transfers etc. +
- +
-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  25 Female MVA 
 Initial treatment at a different hospital - external fixation and debridement; came infected Initial treatment at a different hospital - external fixation and debridement; came infected
Line 46: Line 33:
 - outstanding issues: loss of supination - outstanding issues: loss of supination
  
-Psychological adaptation - Bradway and Malone +====Psychological adaptation====  
-- Limited information - UE only < 10% of all amputations +  * Bradway and Malone 
-- psychiatric intervention needed only for minority +  * Limited information - UE only < 10% of all amputations 
-- Stages +  * psychiatric intervention needed only for minority 
-  - preop - anticipation/ grief +  * Stages 
-  - immediate postop - early acceptance not necessarily good, more optimism in life threatening ijuries +    * preop - anticipation/ grief 
-  - with rehabilitation - denial +    * immediate postop - early acceptance not necessarily good, more optimism in life threatening ijuries 
-  - at home  - critical phase; learn to adapt or stuck in denial +    * with rehabilitation - denial 
-- Guidelines in managing +    * at home  - critical phase; learn to adapt or stuck in denial 
-  - start pre-op +  * Guidelines in managing 
-  - Amputation as a "reconstructive" procedure+    * start pre-op 
 +    * Amputation as a "reconstructive" procedure
      
  
-Alternatives to secondary reconstruction +====Alternatives to secondary reconstruction====
-- Functional outcome following traumatic upper limb amputation and prosthetic limb fitting☆ +
-Author links open overlay panelMichael S.PinzurMDJuanAngelatsMDTerry R.LightMDRicardoIzuierdoMDTeresaPluthRN +
-https://doi.org/10.1016/0363-5023(94)90197-X +
-Abstract +
-Nineteen consecutive patients underwent traumatic upper limb amputation for nonreconstructible or replantible upper limb injury at a Level I trauma center over a 9-year-period. Eleven amputations were at the transradial level, five were transhumeral, and three were shoulder disarticulation. Eighteen patients underwent prosthetic limb fitting. Fifteen of the 18 initially underwent preparatory prosthetic limb fitting within 30 days following amputation with a body-powered, cable-driven prosthesis. Seventeen of the 18 achieved sufficient proficiency with their prostheses to allow them to return to work. Of these, 15 maintained daily functional prosthetic use of at least 8 hours daily at a followup examination of 12 to 110 months. Use of prosthetic limb following traumatic upper limb amputation carries a high probability for functional rehabilitation if limb fitting and prosthetic training are instituted as soon as the residual limb can tolerate the prosthetic socket as opposed to waiting for the residual limb to “mature”.+
  
-Pollicization+  * [[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)
  
-used less in microsurgical age + 
-- may be best option + 
-  - nearer to CMCJ  + 
-  - disadvantages + 
-    - sensation - still IF +====Options==== 
- - loss of digit+===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 +== Planning == 
-- IF by far most common - but can use other digits +  * IF by far most common - but can use other digits 
-  - consider if injured other digits+    * consider if injured other digits
      
 Binhammer and Lister's article is quite good Binhammer and Lister's article is quite good
-- tendon transfer for opposition - FDS RF +  * tendon transfer for opposition - FDS RF 
-- Fixation +  * Fixation 
-- shortening - distally or proximally -- ? length +  * shortening - distally or proximally -- ? length 
-- check circulation +  * check circulation
--  +
-################################## +
-Osteoplastic thumb reconstruction +
-##################################+
  
-## flap - groin/abdominal vs radial forearm +===Thumb lengthening===
-  - 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 +Ivan Matev's chapter in Foucher's book:
-  - make thumb slightly shorter than other side +
-  - bone fixation --> wedge into MC/P1+
  
-## neurovascular island flap - ulnar side of MF +  * 50% easy, 80% possible, sometimes 100% in young 
-  - ulnar side of RF +  * young - slower (1mm /d) but more lengthening 
-  - make sure it is big enough +  * older - more likely bone graft (45-60 days) if no good callus - in situ 
-   +  * problems - union, angulation, infection, MCPJ flexion 
-## nerve repair  +/-+  * need good skin first 
 +  * can paint nail 
 +  * make sure CMCJ is good, skin at tip is good first, sometimes need to deepen/widen web
  
-- Staging - 3 vs 2 vs 1 stage 
  
-Issues +===Osteoplastic thumb reconstruction==
-- sensory recovery +
-- flap necrosis +
-- bone graft resorption - related to flap+
  
 +  * 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
  
-Outcomes +  * neurovascular island flap - ulnar side of MF 
-Outcomes in mutilating hand injuries +    * ulnar side of RF 
-Severe extremity injuries+    * make sure it is big enough 
 +   
 +  * nerve repair  +/-
  
-KCC Hand Clinics 2020+  * Staging - 3 vs 2 vs 1 stage
  
-- MSK Trauma big burden -- especially developing countries +==Issues== 
-- need for outcome measures -- move towards PROMs +  * sensory recovery 
-  - PROMs context specific -- different countries and cultures --> different +  * flap necrosis 
-  - disability vs impairment -- measures don't map well +  * bone graft resorption - related to flap
-  - different PROMs don't correlate well too +
-- individualized treatment - need shared decision making+
  
 +====Outcomes in mutilating hand injuries ====
  
-====Options==== +  * see [[jnl:giladi2016]] 
-===Pollicization=== +  *  MSK Trauma big burden -- especially developing countries 
-[[md:trauma_pollicization|Pollicization]] +    *  need for outcome measures -- move towards PROMs 
- +  *  PROMs context specific -- different countries and cultures --> different 
-===Thumb lengthening=== +  *  disability vs impairment -- measures don't map well 
-Ivan Matev's chapter in Foucher's book: +  *  different PROMs don't correlate well too 
- +  *  individualized treatment - need shared decision making
-  - 50% easy, 80% possible, sometimes 100% in young +
-  - young - slower (1mm /d) but more lengthening +
-  - older - more likely bone graft (45-60 days) if no good callus - in situ +
-  - problems - union, angulation, infection, MCPJ flexion +
-  - need good skin first +
-  - can pain nail +
-  - make sure CMCJ is good, skin at tip is good first, sometimes need to deepen/widen web+
  
 ====References==== ====References====
Line 147: 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   - 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: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   - [[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 ==== ==== History ====
-  * 2020-07-x I started this section as preparation work for a talk at a 2020 ASSH Meeting precourse.+  * 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.1596857104.txt.gz · Last modified: 2020/08/08 03:25 by admin

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