from 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 - 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

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

• 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

• Functional outcome following traumatic upper limb amputation and prosthetic limb fitting
  • early fitting better results
  • compare with chevrier1956: lower usage rate at follow up ? because of long interval between diagnosis and referral; but group also different (not just trauma)

Pollicization

• used less in microsurgical age
  • may be best option
    • nearer to CMCJ
  • disadvantages
    • sensation - still IF
    • loss of digit

• 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

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

• 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

• sensory recovery
• flap necrosis
• bone graft resorption - related to flap

• see 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

1. Bradway, J. K., Malone, J. M., Racy, J., Leal, J. M., & Poole, J. (n.d.). Psychological Adaptation to Amputation: An Overview. 5.
2. 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
3. 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.
4. Chevrier, J. M., Gingras, G., Lemieux, R., Mongeau, M., Susset, V., & Voyer, R. (1956). Psycho-social and rehabilitative aspects of upper extremity amputees. Canadian Medical Association Journal, 75(10), 819–823.
5. 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
6. Foucher, G. (1997). Reconstructive surgery in hand mutilation. Martin Dunitz.
7. 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
8. 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
9. How to use the ICF: A Practical Manual for using the International CLassification of Functioning, Disability and Health (ICF). (2013). WHO.
10. 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
11. Pinzur, M. S., Angelats, J., Light, T. R., Izuierdo, R., & Pluth, T. (1994). 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
12. Sabapathy, S. R., & Bhardwaj, P. (2013). Secondary procedures in replantation. Seminars in Plastic Surgery, 27(4), 198–204. https://doi.org/10.1055/s-0033-1360587
13. 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
14. 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

• 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