Alphonsus Chong's Personal Wiki

• repair of structures not primarily repaired
• promote healing/enhance function e.g. malunion, nonunion, tenolysis
• enhance function - arthrodesis, bone lengthening, tendon transfers etc.

{where is this definition from?}

• 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

1. preop - anticipation/ grief
2. immediate postop - early acceptance not necessarily good, more optimism in life threatening ijuries
3. with rehabilitation - denial
4. at home - critical phase; learn to adapt or stuck in denial

- Guidelines in managing

1. start pre-op
2. Amputation as a “reconstructive” procedure

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

used less in microsurgical age - may be best option

1. nearer to CMCJ
2. disadvantages
   1. sensation - still IF
3. loss of digit

Planning - IF by far most common - but can use other digits

1. 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 - ################################## Osteoplastic thumb reconstruction ##################################

## flap - groin/abdominal vs radial forearm

1. size: 6-7 cm
2. 1-2 cm shortening
3. avoid circular seam - either oval or zig-zag
4. seam in palmar side of “thumb”

## bone - iliac crest, tibia, radius

1. make thumb slightly shorter than other side
2. bone fixation –> wedge into MC/P1

## neurovascular island flap - ulnar side of MF

1. ulnar side of RF
2. 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 Outcomes in mutilating hand injuries Severe extremity injuries

KCC Hand Clinics 2020

- MSK Trauma big burden – especially developing countries - need for outcome measures – move towards PROMs

1. PROMs context specific – different countries and cultures –> different
2. disability vs impairment – measures don't map well
3. different PROMs don't correlate well too

- individualized treatment - need shared decision making

Pollicization

Ivan Matev's chapter in Foucher's book:

1. 50% easy, 80% possible, sometimes 100% in young
2. young - slower (1mm /d) but more lengthening
3. older - more likely bone graft (45-60 days) if no good callus - in situ
4. problems - union, angulation, infection, MCPJ flexion
5. need good skin first
6. can pain nail
7. make sure CMCJ is good, skin at tip is good first, sometimes need to deepen/widen web

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. 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
5. Foucher, G. (1997). Reconstructive surgery in hand mutilation. Martin Dunitz.
6. 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
7. Gingras, G., & Lemieux, R. (1956). PSYCHO-SOCIAL AND REHABILITATIVE ASPECTS OF UPPER EXTREMITY AMPUTEES. 75, 5.
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. 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
12. 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
13. 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