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Journal of Reconstructive Microsurgery Sep 2023Reconstruction of the mutilated hand is one of the most difficult challenges for hand microsurgeons. When multiple digits are amputated, orthotopic digital... (Review)
Review
BACKGROUND
Reconstruction of the mutilated hand is one of the most difficult challenges for hand microsurgeons. When multiple digits are amputated, orthotopic digital replantation of the available remnants may not adequately restore the hand function. In such cases, heterotopic digital replantation may provide a more functional reconstruction.
METHODS
Between 1997 and 2018, 53 patients with mutilating hand injuries were treated with heterotopic digital replantation at our institution. A retrospective chart review was conducted to determine the details of the injury, indications for heterotopic digital replantation, and functional outcomes.
RESULTS
In total, 173 digits were amputated from 53 patients (one patient suffered from bilateral hand injuries, so totally 54 hands). Sixty-eight digits underwent heterotopic digital replantation, 30 digits had orthotopic digital replantation, and 75 stumps were terminalized. The survival rate of digits treated by heterotopic digital replantation and orthotopic digital replantation was 83.8% (57/68) and 86.7% (26/30), respectively ( = 1). Tripod grip was achieved in 83.3% (45/54) of patients following replantation and optional secondary reconstructive surgeries.
CONCLUSION
Heterotopic digital replantation is a practical and reliable method for achieving optimal hand function following mutilating hand injuries. The basic principles are to restore a functional thumb in the first instance, followed by at least two adjacent fingers against which the thumb can oppose. This method is particularly indicated when orthotopic digital replantation of the available amputated parts would yield a suboptimal result.
Topics: Humans; Finger Injuries; Amputation, Traumatic; Retrospective Studies; Fingers; Hand Injuries; Replantation
PubMed: 36720252
DOI: 10.1055/s-0043-1761288 -
BMC Sports Science, Medicine &... Jul 2023The main aim of this paper is to present the feasibility of rigorously designed multiple N-of-1 design in prosthetics research. While research of adequate power and high...
BACKGROUND
The main aim of this paper is to present the feasibility of rigorously designed multiple N-of-1 design in prosthetics research. While research of adequate power and high quality is often lacking in rehabilitation, N-of-1 trials can offer a feasible alternative to randomized controlled group trials, both increasing design power at group level and allowing a rigorous, statistically confirmed evaluation of effectiveness at a single patient level. The paper presents a multiple N-of-1 trial protocol, which aim is to evaluate the effectiveness of Unity, a prosthetic add-on suspension system for amputees, on patient-reported comfort during daily activities (main outcome measure), prosthesis wearing time, perception of limb-prosthesis fitting and stump volume and functional walking parameters.
METHODS
Multicenter, randomized, prospective, double-blind multiple N-of-1 trial using an introduction/withdrawal design alternating Unity connected/disconnected phases of randomized length on twenty patients with unilateral transtibial amputation. The primary outcome measure is the Prosthetic Socket Comfort Score (SCS), a validated measure of comfort, administered daily by an phone app designed for the study. Secondary outcomes measures will be collected during the 50 days period of the N-of-1 trial: (1) by the same app, daily for patient-reported limb-prosthesis fitting, stump volume variation, and daily wearing time of the prosthesis; (2) by a pedometer for the number of steps per day; (3) by blind assessors in the rehabilitation center during adjustment visits for functional walking parameter (L-Test, 6-minute walk test), and by the patient for the QUEST, and ABC-S. Effectiveness of the Unity system regarding SCS and daily secondary outcome measures will be tested by randomization test. The secondary outcome measures assessed during visits in the rehabilitation center will be analyzed by Non Overlap of All pairs. An estimate of the effect on the amputee population will be generated by aggregating each individual clinical trial (N-of-1 trial) by Hierarchical Bayesian methods.
DISCUSSION
This study protocol was designed to answer the question "which device is best for THIS patient" and to conclude at a group level on the effectiveness of a new devic, using a Multiple N-of-1 trial, which is promising but underused in prosthetics research so far.
TRIAL REGISTRATION
N° ID-RCB 2020-A01309-30 Clintrial.gov : NCT04804150 - Retrospectively registered March 20th 2021.
PubMed: 37452356
DOI: 10.1186/s13102-023-00694-4 -
Cureus Aug 2023Traumatic amputation is a severe injury that requires urgent surgical care. A fillet-free flap from the amputated limb is the most conservative way to ensure proper...
Traumatic amputation is a severe injury that requires urgent surgical care. A fillet-free flap from the amputated limb is the most conservative way to ensure proper coverage of the stump when replantation is not possible. We report the case of a male patient who suffered from a traumatic limb amputation in a motorcycle accident. A free fillet flap from the posterior compartment of the leg carrying the posterior tibial pedicle, the soleus muscle, and skin tissue harvested from the amputated limb was performed to cover the amputation stump and thus allow preservation of the knee joint. In our case report, the patient conserved almost maximal knee joint range of motion (130°). He regained the ability to walk only two months after the initial trauma. Prosthetic fitting occurred quickly and without any particular issues throughout the process. Regarding quality of life, after one year, our patient had a five-level EQ-5D version (EQ-5D-5L) score of 21,221, and his 36-Item Short Form Survey (SF-36) score was divided between the five components in 85 points in physical functioning, 100 points in role limitations due to physical health, 100 points in role limitations due to emotional problems, 50 points in energy/fatigue, 68 points in emotional well-being, 75 points in social functioning, 45 points in pain, and 95 points in general health. This technique helped provide good coverage of the stump while preserving a functional knee joint, allowing for effective prosthetic fitting in the future and therefore optimizing our patient's quality of life.
PubMed: 37664396
DOI: 10.7759/cureus.42917 -
Plastic and Reconstructive Surgery.... Jun 2024Patients without proper covering of the bone stump with soft tissues after below-knee amputation have limited opportunities for prosthesis. The resulting high degree of...
Patients without proper covering of the bone stump with soft tissues after below-knee amputation have limited opportunities for prosthesis. The resulting high degree of disability severely restricts their proper functioning in social and professional life. The commonly used significant reduction of the bone length for local coverage limits rehabilitative options to the less comprehensive prosthesis. We aimed to describe a delayed reconstruction with soft tissues of the lower leg stump using free anterolateral thigh flap as an alternative surgical method allowing for optimal prosthesis. A 20-year-old patient was consulted because of right lower leg stump, covered only with a skin graft following posttraumatic amputation. Previously, the patient had ineffective attempts of using a prosthesis. He asked to determine the possibility of recovering the functionality of the lower limb. We performed reconstruction of soft tissues of the stump with a free anterolateral thigh flap. Postoperatively, the patient achieved good coverage of the remaining part of the tibia with a thick layer of soft tissues, allowing the subsequent adequate forming of the stump. Therefore, a fixed prosthesis with the dynamic foot could be implemented. A significant increase in physical activity contributed to a full return to the patient's professional and private life. In conclusion, the free anterolateral thigh flap provides a robust amount of good-quality tissues for supportive function of the lower limb stump. The resulting adaptation of the stump to numerous modern prosthetic devices significantly increases the range of physical activity and contributes to the full return of the patient to their professional and private life.
PubMed: 38868619
DOI: 10.1097/GOX.0000000000005905 -
International Journal of Surgery Case... Feb 2024Circumcision is the most common surgical procedure done in boys. Its complication varies from minor to severe. In most of African countries circumcision is often...
"A successful reconstruction of remnants of corporal bodies and penile urethra after Total Glans Penis amputation following surgical circumcision in a 5-year-old boy". A case report and literature review.
INTRODUCTION AND IMPORTANCE
Circumcision is the most common surgical procedure done in boys. Its complication varies from minor to severe. In most of African countries circumcision is often performed by traditional circumcisers. The management of penile glans amputation depends on the duration before presentation with auto-transplantation being the favorable management in acute phase of presentation. The amputation of the glans is a serious complication of circumcision because it can derange the urinary and sexual functions of a patient and may lead into psychological instability and low self-esteem.
CASE PRESENTATION
We report a case of total glansectomy in a 5-year old boy who presented 12 months after surgical circumcision which was done by inexperienced medical personnel at his house. Patient presented with a pinhole urethra opening, missing glans, buried phallus with remnants of corporal bodies. Penile exploration was done, with successful significant phallus stump of about 5 cm, phallus reconstruction and meatoplasty was achieved. Partial Skin thickness grafting of the phallus stump was performed. At six- month follow up, the patient had both satisfactory cosmetic and functional outcomes.
CLINICAL DISCUSSION
Total glansectomy is a rare surgical emergency with auto transplantation being the best option in acute management however successful outcome for a delayed glansectomy depends on proficient surgical penile exploration and comprehensive post operative care. Based on the clinical presentation, the goals of management for our patient were to achieve a largely patent urethral opening in the long term and to prevent further urethral meatal stenosis as well as achieving adequate phallus stump for sexual function.
CONCLUSION
The amputation of the glans is a serious complication of circumcision because it can derange the urinary and sexual functions of a patient if neglected. Findings on this case report highlight the importance of raising awareness among traditional health care workers to prevent urinary and sexual function disabilities. Prevention of penile amputation can be prevented by providing proper training for circumcisers and providing public education for hospital circumcision.
PubMed: 38232418
DOI: 10.1016/j.ijscr.2024.109267 -
Journal of Plastic Surgery and Hand... Sep 2023Replantation is widely regarded as the first choice of treatment for finger amputations. However, if the fingertip of a traumatic finger amputation is missing after an...
Replantation is widely regarded as the first choice of treatment for finger amputations. However, if the fingertip of a traumatic finger amputation is missing after an injury, the following procedures are often performed to reconstruct this portion: flap surgery, stump surgery, or conservative treatment, including occlusive dressings. To our knowledge, no existing English literature reports using negative-pressure wound therapy (NPWT) to treat traumatic finger amputations. We postulated that NPWT may be applied as a conservative treatment for traumatic finger amputations, promoting the growth of granulation tissue and achieving early epithelialization of the fingertips. Among the case series of five patients, we included six injured fingers comprising two index, two middle, and two ring fingers. The fingertip of each traumatic finger amputation was either missing or highly crushed, making replantation impossible. To preserve finger length with conservative treatment, we adapted an NPWT device for finger amputations. It took an average of 22.7 days for the fingertips to epithelialize. Immediately after epithelialization, there was a slight decrease in sensory perception; however, all patients showed good recovery of sensory perception after 3 months. Range of motion remained unrestricted, with no reduction in grip strength. Patients were highly satisfied with their fingertip appearance. The regenerated nail exhibited slight deformation and shortening. No complications were observed. Our novel study regarding this new conservative treatment and its outcomes revealed that healing was achieved in a relatively short period; therefore, NPWT may serve as a new conservative treatment option in the future.
Topics: Humans; Conservative Treatment; Negative-Pressure Wound Therapy; Finger Injuries; Amputation, Traumatic; Metaplasia; Amputation, Surgical
PubMed: 37768149
DOI: 10.2340/jphs.v58.18351 -
Journal of Personalized Medicine Jan 2024Lower limb trauma often results in mangled extremities, and in some cases, complete amputation may be necessary. However, limiting the extent of amputation and...
Lower limb trauma often results in mangled extremities, and in some cases, complete amputation may be necessary. However, limiting the extent of amputation and preserving the major knee joint are crucial to enhance mobility and overall functionality. By providing painless soft tissue coverage on the stump, early prosthesis use and the initiation of physiotherapy become more feasible. Soft tissue transfers hold the potential to benefit patients in two essential aspects: first, resolving soft tissue deficiencies without causing bone shortening, and second, preparing the stump to enhance overall functionality. A retrospective study conducted at Chang Gung Memorial Hospital (2009-2016) focused on lower limb amputation patients who underwent soft tissue transfers at different time periods compared to those without stump reconstruction. Out of the 2391 cases of lower limb injuries treated operatively, 117 amputations were performed in 110 patients (44 above the knee and 73 below the knee). Among them, 12 patients received soft tissue transfers for limb salvage and soft tissue deficiency after amputations. It was observed that patients in this group were typically younger, predominantly female, had longer hospital stays, and underwent a greater number of surgical procedures ( < 0.05). Through the use of soft tissue transfers, successfully preserved tibial bone length and functional knee joint in selected patients was achieved. This approach effectively resolved soft tissue deficiencies following lower limb amputations, optimizing physiotherapy and facilitating functional rehabilitation.
PubMed: 38392593
DOI: 10.3390/jpm14020160 -
Archives of Plastic Surgery Sep 2023This article portrays the authors' experience with a complex lower limb bone and soft tissue defect, following chronic osteomyelitis and pathological fracture, which was...
This article portrays the authors' experience with a complex lower limb bone and soft tissue defect, following chronic osteomyelitis and pathological fracture, which was managed by the multidisciplinary orthoplastic team. The decision for functional amputation versus limb salvage was deemed necessary, enhanced by the principles of "spare parts" in reconstructive microsurgery. This case describes the successful use of the osteocutaneous distal tibia turn-up fillet flap that allowed "lowering the level of the amputation" from a through knee to a below-knee amputation (BKA) to preserve the knee joint function. We comprehensibly review reports of turn-up flaps which effectively lower the level of amputation, also applying "spare-parts" surgery principles and explore how these concepts refine complex orthoplastic approaches when limb salvage is not possible to enhance function. The osteocutaneous distal tibia turn-up fillet flap is a robust technique for modified BKA reconstructions that provides sufficient bone length to achieve a tough, sensate stump and functional knee joint.
PubMed: 37808330
DOI: 10.1055/a-2033-5803 -
Plastic and Reconstructive Surgery.... Aug 2023Degloving traumatic lower extremity injuries can lead to an above-knee amputation with decreased functional capacity compared with below-knee amputation. The unique...
Degloving traumatic lower extremity injuries can lead to an above-knee amputation with decreased functional capacity compared with below-knee amputation. The unique properties of the deep inferior epigastric artery perforator flap providing a substantial amount of skin and subcutaneous tissue combined with reliability and low donor-site morbidity makes the flap ideal for coverage of below-knee amputation stumps when soft tissue is required. A bipedicled four-zone deep inferior epigastric artery perforator flap with a skin area of 13 × 33 cm was used as coverage of a degloved lower leg amputation stump, in a 27-year-old woman with a left-sided Gustillo type 3B comminute diaphyseal tibial fractur and major degloving injury. Hereby, above-knee amputation was avoided. Ten months postoperatively the patient had achieved full prosthetic function.
PubMed: 37583396
DOI: 10.1097/GOX.0000000000005195 -
Prosthetics and Orthotics International Apr 2024Among the different factors affecting socket comfort, the pressure applied on residual limb tissues is a crucial parameter for the success or failure of any prosthetic...
BACKGROUND
Among the different factors affecting socket comfort, the pressure applied on residual limb tissues is a crucial parameter for the success or failure of any prosthetic device. However, only a few incomplete data are available on people with transfemoral amputation, in this regard. This work aims at filling this gap in the literature.
METHODS
Ten people with transfemoral amputation wearing 3 different socket designs were recruited in this study: 2 ischial containment sockets featured by proximal trim lines that contain the ischial tuberosity and ramus and greater trochanter, 2 subischial sockets with proximal trim lines under the ischium level, and 6 quadrilateral sockets with proximal trim lines that contain the greater trochanter and create a horizontal seat for the ischial tuberosity. The pressure values at the anterior, lateral, posterior, and medial areas of the socket interface were recorded during 5 locomotion tasks (ie, horizontal, ascent, and descent walking, upstairs and downstairs) by using an F-Socket System (Tekscan Inc., Boston, MA). Gait segmentation was performed by exploiting plantar pressure, which was acquired by an additional sensor under the foot. Mean and standard deviation of minimum and maximum values were calculated for each interface area, locomotion task, and socket design. The mean pressure patterns during different locomotion tasks were reported, as well.
RESULTS
Considering all subjects irrespective of socket design, the mean pressure range resulted 45.3 (posterior)-106.7 (posterior) kPa in horizontal walking; 48.3 (posterior)-113.8 (posterior) kPa in ascent walking; 50.8 (posterior)-105.7 (posterior) kPa in descent walking; 47.9 (posterior)-102.9 (lateral) kPa during upstairs; and 41.8 (posterior)-84.5 (anterior) kPa during downstairs. Qualitative differences in socket designs have been found.
CONCLUSIONS
These data allow for a comprehensive analysis of pressures acting at the tissue-socket interface in people with transfemoral amputation, thus offering essential information for the design of novel solutions or to improve existing ones, in this field.
Topics: Humans; Amputation Stumps; Prosthesis Design; Artificial Limbs; Amputation, Surgical; Femur
PubMed: 37379468
DOI: 10.1097/PXR.0000000000000251