AAHS ASPN ASRM - 2013 Annual Meeting - American Association ...

ASRM Concurrent Scientific Paper Presentations A-2
Replantation in Developing Countries
Institution where the work was prepared: SOS Mano Santo Domingo, Hand group, Santo Domingo, Dominican Republic
Hector Herrand, MD; Marcos Nuñez, MD; Otoniel Diaz, MD; SOS Mano Santo Domingo
From January 1995 to January 2006 we have done 42 hands replantation including one bilateral case, in Santo Domingo, Dominican Republic, by our group
SOS Mano Santo Domingo. Males were involved in 95% of the cases. Age ranges from 10 years to 59 years with and average of 26 years.The most common
mechanism of action was agression 38/41 (93%), and machete was the instrument used during the agression in all cases.36 patients were right hand dominant
and the majority of cases involved the non dominant hand. The most common amputation level was the Radiocarpal area with 22 cases (52%).Most of
patients (19/41) 46% arrived between 4 and 6 hours after the trauma. 16 hands were correctly preserved and 26 hands were incorrectly transported under cold
or warm ischemia. Our local temperature range from 29 to 32 centigrades. Operative time range from 6 hours to 13 hours, average 9.36 hours. All cases were
done under loupes magnification (3.5X and 4.5X). Only one case was fixed with plates and screws the others were done with pins and wires. Residents participate
very actively in most of the cases. We have 2 important complications associated to postop bleeding, one case developed a transitory acute renal failure
that require dialysis. 12 cases developed vascular insufficiency, one of them could be solved and the hand survived. 31 hands (74%) do succesfully and we lost
11 hands (26%). 23 patients showed good or excellent results, 8 patients did regularly or poorly (4 and 4) when we compared return to daily activities, ROM,
and 2PD static. The maximum follow up is 10 years and the minimal 4 months. Only 20 patients have been followed by personal contact during at least one
year. We performed this 41 patients in 7 different institutions: 3 public, 1 semiprivate and 4 private. We calculate an average of 2,600 dollars in hospitalization
and OR expenses per patient, and we only have charged private fees in only 5 patients with an income average of 1,394 dollars per patient. In the public
hospital we have only the payment of the monthly salary equivalent to 606 dollars.
Reconstruction of Congenital Differences of the Hand Using Microsurgical Toe Transfers
Institution where the work was prepared: University of California, Los Angeles, Los Angeles, CA, USA
Neil F. Jones, MD; University Of California Los Angeles
Introduction:
A large series of children with congenital differences of the hand was analyzed retrospectively to develop a more simplified classification system for congenital
absence of the digits and to develop an algorithm which directly predicts which microsurgical toe-to-hand transfers will provide the best hand function.
Materials and Methods:
78 toe transfers have been performed in 65 children for congenital anomalies of the hand, classified by the Swanson system as transverse deficiencies or symbrachydactyly
(32); radial longitudinal deficiencies (5); cleft hand (9) and congenital constriction ring syndrome (17). Preoperative X-rays and photographs were analyzed to determine
which rays were missing and their level of absence. A new classification system was developed to describe nine phenotypes of congenital absence of the digits.
Results:
Optimal reconstruction of the severe radial deficiency phenotypes involving the thumb, index and middle fingers is a toe-to-thumb transfer using either the second toe
(21) or great toe (14). For severe transverse deficiencies involving all four fingers, there are two options - either a single second toe transfer into the ring or small finger
position (25); or bilateral second toes transferred either simultaneously or in sequential procedures into the middle finger and small finger positions to provide three
point pinch (5). The aplastic hand with absence of all five digits is best reconstructed with bilateral second toe transfers into the thumb and small finger positions (6).
Six toe transfers required re-exploration of the microsurgical anastomoses for a re-exploration rate of 7.7%. Two toe transfer failed for a success rate of 97.5%.
All the children have regained sensation in the transferred toes and improvement in hand function.
Discussion:
Retrospective analysis of a large series of children with congenital anomalies of the hand has resulted in the development of a simplified classification system
and a treatment algorithm, which directly predicts which of four possible microsurgical toe-to-hand transfers will provide the most optimal reconstruction of
severe transverse and longitudinal deficiencies of the hand.
Simultaneous Double Second Toe Transplantation for Reconstruction of Multiple Digit Loss in Traumatic Hand
Injuries
Institution where the work was prepared: The Buncke clinic and Division of Microsurgery, CPMC, San Francisco, CA, USA
Fernando A. Herrera Jr, MD; Alfonso Camberos, MD; Jacob J. Freiman; Charles K. Lee; Rudy Buntic; Gregory M. Buncke; California Pacific Medical Center
Purpose:
To review our recent 10-year experience of simultaneous double second toe transplants for reconstruction of traumatic injuries following multiple digit loss.
Methods:
Retrospective chart review of 11 cases of traumatic hand injuries resulting in multi-digit loss of the index, long, ring, or small fingers (excluding the thumb)
that underwent simultaneous double second toe transplantation for digital reconstruction.
Results:
From 1995 to 2005, 11 patients underwent a simultaneous double second toe transplantation. Mean age was 36 years (range 6 to 60 years); all patients were male,
all were right hand dominant. Index and long fingers were reconstructed in 3 patients, long and ring finger in 7 patients, and ring and small finger in 1 patient.
All patients had undergone completion amputation after mutilating crush/avulsion injuries obviating replantation. A simultaneous 3-Team approach was used in
all cases. The average operating time was 9 hrs (Range 7-15hrs). The mean time to reconstruction was 5.7 months following injury (range 2 to 15 months).
Complications included microvascular venous thrombosis, loss of the transplanted toe, bleeding, and infection. All donor sites were closed primarily and there was
minimal donor-site morbidity. 21/22 (95%) toe transplants survived. Secondary surgery was performed in 10/11 patients, including tenolysis, flap debulking, and
skin grafting. Average moving-2 point discrimination was 5mm in each digit after 7 month follow-up. Mean grip strength approached 50% of the contralateral
hand. Mean time to work return after digital reconstruction was 10 months. 8/11 of the patients returned to work after vocational rehabilitation.
Conclusion:
Simultaneous double second toe transplantation is a viable and efficient procedure for multi-digit reconstruction. The 3-Team approach allows for a single stage
reconstruction to a multi-level problem. Functional and aesthetic improvement to the hand can be significant with minimal donor site morbidity to the feet.
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