During replantation of digits amputated at the distal phalanx level, venous anastomosis is often impossible, and it is important to take measures to prevent congestion after surgery. Based on the retrospective examination of postoperative results, we previously demonstrated the usefulness of medical leeches. This report is a supplemental study including the surgeries performed after the previous study. Between May 2013 and April 2016, we performed 62 artery-only fingertip replants in 59 patients. Of 62 fingertips, 45 (73%) replanted fingertips survived. Medical leeches were used for continuous bleeding in 39 fingertips, 36 (92%) of which survived. Arterial insufficiency occurred in 2 patients, and another replantation failed due to an excessively short bloodletting period, for a total of 3 salvage failures. A fish-mouth incision was used for continuous bleeding in 7 fingertips, and 4 (57%) survived. There was no bloodletting in 16 fingertips, and 5 (31%) survived. Even if the vein cannot be reconstructed, taking proper anti-congestion measures will lead to reliable success, and using medical leeches is highly useful for this purpose.
Adhesion neuropathy of the median nerve with persistent wrist pain can be challenging. In the present study, we introduced a novel method using a radial artery perforator (RAP) adipose flap for coverage of the neurolysed median nerve to minimize reformation of scar adhesion. Seven patients who had previously undergone median nerve surgeries, repair of a median nerve laceration or primary open carpal tunnel release were included. As all patients had substantial median nerve hypersensitivity, secondary neurolysis and coverage with the RAP adipose flap were performed. The average follow-up was 15 months (range 6-28 months). The RAP adipose flap size ranged from 750 to 1,800 mm² (average 1,093 mm²), and was sufficient to cover the exposed median nerve. After surgery, the positive Tinel sign at the wrist disappeared in all patients and the mean visual analogue pain scale score decreased. Furthermore, the average scores for the Quick DASH and Hand 20 improved postoperatively. The results of interposing the RAP adipose flap between dysesthetic volar wrist skin and the neurolysed median nerve were positive in terms of both pain relief and restoration of hand function.
A 25-year-old man was injured in a single-car accident and diagnosed with traumatic subarachnoid hemorrhage, multiple right rib fractures, and open fracture of the right medial malleolus. Osteosynthesis of the open fracture of the right medial malleolus was performed at another hospital. However, it became infected postoperatively, and he was transferred to our hospital for curative treatment. First, the wound was debrided. The bone fragments of the medial malleolus had undergone osteolysis, and the remaining free-floating bone fragments were removed. There was a 14 × 6-cm soft tissue defect and a 4-cm osteochondral defect of the medial malleolus. After the signs of infection disappeared, reconstruction surgery was performed. A flap consisting of a 15 × 7-cm skin island and a 4 cm × 2-cm scapular flap were raised, and used to reconstruct the medial malleolus and cover the open wound. There were no signs of postoperative infection, and synostosis was achieved 3 months postoperatively. After 1 year, the patient was able to walk independently with no ankle instability and was able to return to work. The use of a vascularized scapular flap to reconstruct the medial malleolus was effective in preserving the ankle joint.
The number of patients with secondary lymphedema will likely increase as the population ages. For elderly patients, it is difficult to put on elastic stockings for reasons such as muscular weakness. We present two secondary lymphedema patients who underwent lymphaticovenular anastomosis (LVA) prior to physical therapy. The results of preoperative lymph scintigraphy for both patients indicated that the contraction of the lymph smooth muscles remained. After successful LVA, the patients could wear elastic stockings. Recently, LVA is becoming popular for the treatment of lymphedema. However, complex physical therapies, such as lymph drainage, wearing elastic sleeves or stockings, and multilayered compression bandages, are considered to be the primary course of treatment, and elderly patients have difficulty managing their condition by themselves. To maintain lymphatic flow after LVA, contraction of the smooth muscles plays a crucial role. Therefore, evaluation of the remaining function of the lymph vessels is important to determine if LVA should be recommended. These cases suggest that LVA should be considered before complex physical therapy for elderly patients.
In cases of multiple finger amputation, replantation of all amputated fingers may not be possible depending on the condition of the amputated fingers. Therefore, other reconstructive procedures should be considered, such as ectopic replantation, which is an important treatment option, especially when the thumb is one of the amputated fingers. We report the case of a 22-year-old man with complete amputation of his left thumb and index finger. The thumb amputation level was distal of the carpometacarpal joint and the amputated thumb was crushed too severely to perform replantation. We ectopically replanted the amputated index finger to the thumb stump at the anatomical position because the amputated index finger was less damaged. Good results were obtained in terms of both function and appearance.
A 32-year-old sailor's right arm was caught in a rope and injured. His upper limb became ischemic, and this was complicated by sternoclavicular joint dislocation, scapula fracture, rib fracture, and pneumothorax of the ipsilateral side. Although vein bridging grafting was performed for brachial artery rupture, the brachial artery blood flow was weak. A more proximal artery injury was considered based on ultrasonography. Another end-to-side vein graft was placed for the subclavian artery that had intimal injury, and the blood circulation improved. His upper limb was salvaged without reperfusion toxemia or severe adverse events after the operation, but brachial plexus injury, as well as median nerve rupture and radial and ulnar nerve traction injuries were noted. Scapulothoracic dissociation is associated with a large spectrum of concomitant injuries, including osseous injury to the shoulder girdle, subclavian vascular injury, brachial plexus injury, muscle injury, and severe soft tissue injury. The diagnosis can be made based on Anterior-Posterior (AP) radiographs demonstrating lateral displacement of the scapula, and multiple vascular injury should be taken into consideration in the presence of injuries such as in the present case.