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=====Secondary Surgery after Extremity Trauma=====

====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

====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====
===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
  * 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 paint nail
  * 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====
  - Bradway, J. K., Malone, J. M., Racy, J., Leal, J. M., & Poole, J. (n.d.). Psychological Adaptation to Amputation: An Overview. 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.
  - 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). [[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
  - [[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.
  - 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
  - [[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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