Purpose of the study: Proximal replantation is a technically feasible but life-threatening procedure. Indications must be restricted to patients in good condition with a good functional prognosis. The goal of replantation must be focused not only on reimplanting the amputated limb but also on achieving a good functional outcome. For the lower limb, simple terminalization remains the best choice in many cases. When a proximal amputation is not suitable for replantation, the main aim of the surgical procedure must be to reconstruct a stump long enough to permit fitting a prosthesis preserving the function of the adjacent joint. If the proximal stump beyond the last joint is very short, it may be possible to restore some length by partial replantation of spared tissues from the amputated part. We present here the results we obtained following this policy. Materials and methods: This series included 16 cases of partial replantations, 14 involving the lower limb and 2 the upper limb. All were osteocutaneous microsurgical transfers. For the lower limb, all transfers recovered protective sensitivity following tibial nerve repair. The functional calcaeoplantar unit was used in 13 cases. The transfer of this specialized weight bearing tissue provided a stable distal surface making higher support unnecessary. In one case, we raised a 13-cm vascularized tibial segment covered with foot skin for additional length. For the upper limb, the osteocutaneous transfer, based on the radial artery, was not reinnervated, but this lack of sensitivity did not impair prosthesis fitting. Results: One vascular failure was finally amputated. This was the only unsuccessful result. For all other patients, the surgical procedure facilitated prosthesis fitting and preserved the proximal joint function despite an initially very proximal amputation. Discussion: The advantages of partial replantation are obvious compared with simple terminalization or secondary reconstruction. There is no secondary donor site and, because there is no major muscle mass in the distal fragment, the overall risk is very low compared with the risk of total proximal leg replantation

Modern microsurgery has allowed severed digits to be salvaged by replantation. A retrospective case review was undertaken of all patients undergoing digital replantation at Middlemore Hospital between February 2004 and February 2009. 48 digits from 28 patients underwent digital replantation during this period. The aim of the analysis was to determine what factors were predictive for survival of the replants. Secondary outcomes of interest included subjective functional recovery, pain and further procedures. Digital replantation over the review period was subject to a 75% survival rate. Smoking and male gender were identified as significant negative prognostic factors (p=0.02). 69% of patients reported post operative stiffness, chronic pain or cold intolerance. The majority of replanted digits underwent secondary procedures. Patients should be counseled prior to digital replantation that while the procedure is subject to a high rate of digit survival, they should expect stiffness and discomfort and are likely to undergo secondary procedures

From January 2000 to March 2004 16 thumbs after total avulsion-amputation were replanted in our hospitals. In 15 cases this was successful. In one case the thumb was lost 28 hours after replantation. Mostly the amputation was in the region of the first phalanx or the IP-joint of the thumb. In all cases our operative procedure for this form of amputation was the reconstruction of the vessels with vein grafts after the osteosynthesis and the reconstruction of the tendons. The donorsite region for the grafts was in 12 cases the dorsal forefoot and in 4 cases the distal forearm. In none of these cases there was the possibility of reconstructing both arteries. Mostly only an anastomosis for one artery and one vein could be done. For none of these patients it was possible to reconstruct the nerves primarily. Until now transphers of neurovascular skinislands of longfingers, free nerve transplantations with coaptations to the proximal stump of the injured nerve, free nerve transplantations with coaptations to the trunk of the median nerve or in one case an end-to-side coaptation have been performed to achieve a resensibility of the thumbs. In one case a patient rejected an operative nervereconstruction, because a sprouting of the proximal stump of the injured nerve lead to a (reduced) sensibility of the thumb. In 4 cases a therapy to achieve a resensibility has so far not been carried out. After replantations of injured thumbs necroses of the skin in different kinds were noticed. In 4 cases secondary skinreconstructions were necessary. All 15 successful replanted thumbs achieved very good results concerning function, strength and patient’s satisfaction. Our results don’t agree with the mostly bad results after total avulsionamputations mentioned in literature. We think that the replantation after total avulsionamputation of the thumb has a high chance of being successful and can achieve very good longtime results

The fingertips are important for not only the function of the hand but also cosmetic reasons. In distal phalanx, arteries especially in zone …Ÿ are less than 0.5 mm in diameter however they can be anastomosed ultramicro-surgically with 11-0 suture. From 1976 to 1999, I have replanted 463 digits in 337 male and 126 female patients whose ages ranged from 4 months to 80 years, with an average of 32.7 years. There were 312 digits with complete amputation, 151 digits of incomplete amputation, 277 digits with trauma in zone …Ÿ and 186 digits in zone … in which more than six months had passed since the replantation. The results in zone … amputations was better then in cases of amputations in zone …Ÿ because anastomoses of arteries and viens are more relibale in zone … amputation. I analyzed the results of zone …Ÿ amputation according to types of injury. The survival rate was 100% in clean-cut amputation, 91.7% in blunt-cut, 66.1% in crush and 67.5% in avulsion. So in cases of crush or avulsion amputation in zone …Ÿ, there is relative indication for replantation. As for postoperative functional recovery, 95% of the survival fingers are in good daily use, or in some use. Compared with stump plasty, our results of survival fingers are far superior functionally and cosmetically. From a survival rate and functinal point of view, replnatation is definitely indicated in cases of zone …Ÿ amputations by clean-cut or blunt-cut and zone … amputations if technically possible

OBJECTIVE: The purpose of this study were to present a new surgical classification, based on types of injuries, and to evaluate significance of our post-operative protocol for fingertip replantation, especially crush-avulsion cases. METHODS:Twenty fingertip amputations in 20 consecutive patients were replanted at our institute for recent 5 years. There were 17 male patients and 3 female patients, ranging in age from 19 to 62 years(mean,45.3years). All cases were classified as crush and avulsion according to Yamano. There were 13 amputations in Zone I and 7 in Zone II according to Tamai’s classification for the level of amputation. Also, we classified our cases based on the type of injury. [New Classification] Type IA: Distal transverse palm arterial arch (DTPA) is remained in the proximal part Type IB: DTPA is remained in the amputated part Type II : Loss of DTPA There were 4 cases in Type IA, 4 in Type IB, and 12 in Type II. Postoperatively, 12000–24000U of urokinase and 500 ml of low molecular-weight dextran were given intravenously for 7 consecutive days. In very severe crush/avulsion cases, 10000–15000 U of heparin were given intravenously for 5 days additionally. RESULTS: The overall survival rate of the 20 replantations was 90.0% (zone I:83.3%, Zone II:100%). The survival rate was 100% in type IA, 100% in type IB, and 83.3% in type II. For arterial repair, vein grafts were necessary in 1 of 4 type IA(25%), 1 of 4 type IB(25%), and 11 of 12 type II(91.7%). In 3 of 4 type IA, end to end anastomosis were possible by the technique of transpositioning DTPA. In 3 of 4 type IB, proper digital artery was anastomosed to central artery of the pulp. Regarding functional outcomes with a follow-up period greater than 6mons, excellent cases were 87.0% (according to Tamai’s functional classification). The mean range of motion of the distal interphalangeal joint was 40 degrees. All patients achieved protective sensation of replanted fingertips. Other complications were cold intolerance(22.2%), nail deformity(66.6%), and pulp atrophy (33.3%). Blood transfusions were not necessary in all cases. CONCLUSIONS: Our new classification of fingertip amputation based on DTPA was available for strategy of arterial repair, because if DTPA is lost, most cases (91.7%) need vein grafts. Also, in crush/avulsion fingertip amputation, our clinical protocol was very useful and raised success rate of fingertip replantation (90.0%) for crush-avulsion cases

Aim. Due to medical and organizational factors, it occurs in everyday practice that spacers are left in place longer than originally planned during a two-stage prosthesis exchange in the case of prosthetic joint infections. Patients are severely restricted in their mobility and, after initial antibiotic administration, the spacer itself only acts as a foreign body. The aim of this study is to analyze whether the duration of the spacer in situ has an influence on the long-term success of treatment and mortality. Method. We retrospectively studied all 204 two-stage prosthesis replacements of the hip and knee from 2012 to 2016 with a minimum follow-up of two years at an arthroplasty center with 3 main surgeons. The duration of the spacer interval was divided into two groups. Patients replanted within ten weeks (as is standard in multiple algorithms) after systemic antibiotic treatment were assigned to the ‘Regular Spacer Interval (< 70 days)’ group. If the spacer interval was longer, they were assigned to the ‘Long Spacer Interval (≥ 70 days)’ group. Results. Patients were on average 67.69 years old (SD 12.3). The mean duration of the spacer-interval was 100.9 days (range: 423.0; SD, 60.0). In 62 patients reimplantation could be performed within 70 days after explantation, in 142 patients this took longer (max. 438 days). In 26 patients, the spacer had to be changed at least once during this period (11 patients in the hip group, and 15 patients in the knee group). In the remaining cases, other medical or organizational reasons delayed replantation. Both groups were comparable concerning Charlson Comorbity Index, age, number of previous surgeries and laboratory infection markers. There was no statistically significant influence of the duration of the spacer interval on the infection free survival (n=204, p=0.32). There was also no influence on mortality (n=204, p=0.35) and aseptic implant failure (n=204, p=0.15). Conclusions. The timely replantation of a knee or hip prosthesis seems to be reasonable in general because the patients are strongly limited in their mobility and daily activities by the spacer. However, there does not seem to be a negative influence on infection eradication and survival due to a long spacer interval

In amputation or amputation-like injuries of lower limbs, only in a few cases reconstructive treatment with microsurgery is encouraged, according to evaluation of lesion by Mangled Extremity Severity Score (MESS). Replantation cases may require substantial bone shortening, as consequence to seriousness of the trauma or a deliberate choice to enable primary vessel and nerve repair. Callus distraction technique by external fixation, circular or axial, is a common method for recover lengthening in these cases of replanted or revascularized extremities. We report six cases of lower limb replantation or revascularisation, with primary bone shortening from 3 to 7 cm and secondary lengthening by callus distraction. It was always obtained equalization of lower extremities, with successful rehabilitation of the patients and low onset of complications during treatment

Aims

The aim of this study was to investigate the safety and efficacy of 3D-printed modular prostheses in patients who underwent joint-sparing limb salvage surgery (JSLSS) for malignant femoral diaphyseal bone tumours.

Endoprosthetic replacement following oncological conditions has shown to be at higher risk of sceptical complications due to the use of implants of unusual size, major soft tissue loss and immunsupression. 373 patients have been treated at our institution for malignant tumours of the bone or soft tissue around the knee with a modular tumour-prostheses of the knee joint since their availability from 1978. Infection or septic complications were identified in 78 patients (20.9%). In 15 cases of superficial wound healing disturbances with a fistula simple excision and revision of the wound was performed. In 48 cases of deep periprosthetic infections patients underwent one-stage revision with explantation of the total prosthetic material except femoral and tibial stems, extensive debridement of the wound and replantation of the disinfected prostheses throughout one operation. In 8 patients two-stage revision of the prostheses was performed, using an antibiotic impregnated cement spacer and Steinmann nails. In 5 patients amputation of the affected limb was indicated, whereas 2 patients could be treated conservatively. Out of the patients treated by one-stage revision 16 developed recurrent infection and had to undergo consecutive surgery. After two-stage surgery 4 patients showed signs of septic recurrence. According to our results deep periprosthetic infection of tumour-prostheses primarily can be treated by one-stage revision, in recurrent infections, however, two-stage revision should be performed. We additionally suggest the use of local or pedicled muscle flaps to obtain better soft tissue coverage of the prostheses after infection

Microsurgical techniques have become useful in reconstructive surgeryn of the hand. Toe-to-hand transplantation is currently the procedure of choice for thumb loss reconstruction, as well traumatical as congenital. For a successful outcome meticulous planning is imperative and presumes a thorough knowledge of pertinent anatomy and surgical technique. The method of thumb reconstruction must be individualized and is dependent on the patient’s functional needs, age, and the level of the amputation. Postoperatvely, diligent nursing care is essential in assuring a positive outcome. From Nov. 1979 to Dec. 2001 53 second toe-to-hand transfers were performed at Center of Replantation of Limbs in Trzebnica/Poland. Mean age was 27 years. Males (79%) and manual workers (91%) dominated the series. The rate of failure was 5,5%. The transfer gave functionally acceptable thumb with 8–12 mm two poin discrimination, on average 55% of strength in pinching (compared with unaffected side), 35 degrees of range flexion (but with flexion contracture)and poor cosmesis. Second toe transfers are preferable in cases with proximal thumb amputations, and in children. Their main advantage is the minimal morbidity of the donor site

Purpose: Surgical treatment with circular external fixation of forearm deformities and shorthening in patients with congenital and posttraumatic pathologies remains controversial. The purpose of the present study was to determine the reasonable indications for operative treatment and to evaluate long-term results of forearm surgery in these patients. We review the results of correction of deformities and length discrepancies of the forearm using circular external fixator. Methods and Materials: We evaluated the results of distraction lengthening in 25 forearms of 24 patients with forearm shortening and deformity. The mean age at the time of surgery was 18.2 years (range 6 to 55 years). Etiologies were: congenital radioulnar synostosis and deformity of the forearm (2), multiple hereditary exostoses (3), distal radial physeal arrest (2), Madelung’s deformity (5), congenital shortening of both bones (1), radial clubhand with Bayne type I deficiency (2), pseudoartrosis (6), malunion correction (3), Forearm Elongation After Hand Replantation (1). The ulna was involved in 14 cases and the radius in 11. The lengthening technique consisted in a subperiosteal osteotomy and progressive distraction after 5 days of waiting period. In majority of cases the deformity and shortening of ulna and radius were different, for this reason we use separate system for lengthening and correction for each bone. That permits to correct wrist deformity and restore normal relationships in the distal radioulnal syndesmosis. Results: All 25 forearms were reviewed at a mean 28,6 months. Mean lengthening was 31.2 mm (range 10 – 68 mm). One patient that in the pass was treated with monolateral fixator, had other two subsequent lengthening and obtains normal length of forearm. One patient has radial nerve palsy after 21 days of distraction. Reducible claw fingers completely regressed after interruption of the lengthening were observed in 4 cases. There were 2 cases with an axial deviation at the end of lengthening and 2 cases of late healing resolving without a secondary bone graft. The healing index was 49.8 days per cm gained length. Conclusion: Lengthening of the forearm was found to improve upper extremity function and appearance of the arm with satisfaction of all patients

Massive disc herniations after surgical decompression develop secondary back pain due to important loss of nucleus material with instability. No earlier proposed method to restore disc function was biological. Chondrocyte culturing allows living repair of lost disc tissue. The contained disc space appears particularly suitable for receiving those tissue cultures. Surprisingly disc replantations had not been attempted before. In 1996 two women and one man (aged 38-55) underwent open resection of a massive disc herniation by hemi-laminotomy, twice at L5-S1, once at L4/5. All the excised disc tissue was given to tissue culture in an identical protocol as in autologous chondrocyte transplantation (ACT) for articular cartilage repair. After sufficient cell multiplication (11.5-23 millions living cells in 750 μl) four weeks later the engineered autolo-gous disc tissue was injected in suspension through a contra-lateral puncture under local anaesthesia. In prospective follow up a simplified Oswestry Disability Index was recorded and functional radiographs and NMR were taken after one, three, six and nine years. All three patients remained freed from radicular pain and vertebral symptoms over the whole follow up period. Two patients never had functional restrictions nor loss of working capacity (Oswestry 1 and 6), one after retirement at 5 years developed rheumatoid disease but is still unchanged at the lumbar spine. The third patient partially recovered from preoperative radiculop-athy (slight loss of strength and sensitivity S1) but still works, with minor adaptations to his original professional activity (Oswestry 18). Functional radiographs up to the last follow up didn’t show vertebral instability. In all cases the replanted intervertebral disc space remained unchanged with minimal widening in one case. In NMR all three discs had partial signal recovery. Twice during the first year a new outgrowth of disc tissue was observed at the site of the primary disc herniation opposite to the replanting injection, without any clinical correlation. Three cases with massive lumbar disc herniations showed good clinical and large anatomical recovery persisting nine years after reimplantation of engineered autologous disc tissue. The encouraging results of this small pilot study led to further closely monitored clinical applications before wider propagation of biological disc repair surgery

The COVID-19 pandemic has disrupted all segments of daily life, with the healthcare sector being at the forefront of this upheaval. Unprecedented efforts have been taken worldwide to curb this ongoing global catastrophe that has already resulted in many fatalities. One of the areas that has received little attention amid this turmoil is the disruption to trainee education, particularly in specialties that involve acquisition of procedural skills. Hand surgery in Singapore is a standalone combined programme that relies heavily on dedicated cross-hospital rotations, an extensive didactic curriculum and supervised hands-on training of increasing complexity. All aspects of this training programme have been affected because of the cancellation of elective surgical procedures, suspension of cross-hospital rotations, redeployment of residents, and an unsustainable duty roster. There is a real concern that trainees will not be able to meet their training requirements and suffer serious issues like burnout and depression. The long-term impact of suspending training indefinitely is a severe disruption of essential medical services. This article examines the impact of a global pandemic on trainee education in a demanding surgical speciality. We have outlined strategies to maintain trainee competencies based on the following considerations: 1) the safety and wellbeing of trainees is paramount; 2) resource utilization must be thoroughly rationalized; 3) technology and innovative learning methods must supplant traditional teaching methods; and 4) the changes implemented must be sustainable. We hope that these lessons will be valuable to other training programs struggling to deliver quality education to their trainees, even as we work together to battle this global catastrophe.

The August 2012 Wrist & Hand Roundup³⁶⁰ looks at: the Herbert ulnar head prosthesis; the five-year outcome for wrist arthroscopic surgery; four-corner arthrodesis with headless screws; balloon kyphoplasty for Kienböck's disease; Mason Type 2 radial head fractures; local infiltration and intravenous regional anaesthesia for endoscopic carpal tunnel release; perilunate injuries; and replanting the amputated fingertip.

The February 2015 Wrist & Hand Roundup360 looks at: Toes, feet, hands and transfers… FCR Tendonitis after Trapeziectomy and suspension, Motion sparing surgery for SLAC/SNAC wrists under the spotlight, Instability following distal radius fractures, Bilateral wrist arthrodesis a good idea?, Sodium Hyaluronate improves hand recovery following flexor tendon repair, Ultrasound treatments for de Quervain’s, Strategies for treating metacarpal neck fractures.

The April 2012 Shoulder & Elbow Roundup³⁶⁰ looks at katakori in Japan, frozen shoulder, if shoulder impingement actually exists, shoulder arthroscopy and suprascapular nerve blocks, why shoulder replacements fail, the infected elbow replacement, the four-part fracture, the acromion index, and arm transplantation