Background. At present, there are multiple approaches to the treatment of macrodactylia in children. Additionally, there are no comparative data on the cosmetic and functional aspects of corrective surgery versus microsurgical transplantations performed in children with a marked disproportion of the segment, making this study particularly relevant. Aim. The aim of this study was to determine the role of microsurgical transplantation of the toes in the treatment of children with isolated macrodactylia, based on a comparative analysis of various surgical interventions. Materials and methods. Twenty-five children with congenital macrodactylia of the hand were examined and surgically treated in the department of reconstructive microsurgery from 2013 to 2017. Of these, 13 (52%) had macrodactyly of the 2nd and/or 3rd fingers, and of the total number of hyperplastic hand segments (n = 45), 17 rays had hyperplasia greater than 25%. Results and discussion. Stage-by-stage modeling resections of enlarged segments were performed in all children with ray hyperplasia that was about 25% of the size of intact fingers. In 4 cases, excision of soft tissues was combined with marginal resection of phalanges. When hyperplasia of the segment reached up to 10% of macrodactylia, single isolated modeling resection of soft tissues and bones was performed. Repeated modeling plasties in 16% (n = 4) of the children were accompanied by gross postoperative scars with the development of secondary angular deformities and loss of function of interphalangeal joints. Nine children (n = 14) underwent amputation of hyperplastic fingers followed by microsurgical reconstruction of rays by autografting of toes. In 4 cases, the first finger was reconstructed, and in the other 5 cases, toes of both feet were transplanted to the positions 2 and 3 (n = 4) or 3 and 4 of fingers (n = 1). It was found that in cases of significant hyperplasia of the affected segments of the hand (hyperplastic segment is 1.5–2 times greater compared to normal ones), microsurgical autografting of toes is more effective and acceptable compared to bone and soft tissue resections. Conclusions. In cases of segment hyperplasia less than 1.25-times the normal size, the optimal surgical interventions are stage-by-stage modeling resections. An alternative surgical treatment for children with hyperplasia of more than 1.25-times the normal size is microsurgical transplantation of the toes in the position of the involved rays of the hand, which results in good cosmetic and functional outcomes in these patients.
Background. Congenital radial club hand (CRCH) is characterized by longitudinal underdevelopment of the forearm and hand on the radial surface. Underdevelopment can range from hypoplasia to aplasia of the radius. More than 50 methods to correct the forearm deformities, depending on the degree of radius underdevelopment, have been proposed. Aim. We evaluated the results of CRCH treatment using microsurgical technique and external fixation. Methods. We analyzed 16 patients (age, 4.6 0.9 years) with CRCH type II, according to the classification of Bayne and Klug, treated between 1994 and 2017. The patients were divided into two groups: Group 1 were patients undergoing microsurgical autotransplants of the epimetaphyseal second metatarsal bone with growth plate to the position of the radius defect and group 2 were patients treated by lengthening of the radius with external fixation. We analyzed the types of deformities, size of the radius defects, and range of motion in upper limb joints before the stage of the lengthening. External fixation index and number of complications also were determined. The type and number of recurrent deformities and timing of their detection were analyzed. Results. The observation period ranged from 12 months to 10 years (average, 3.8 years). In group 1, good results were obtained in 62.5% of cases. After transplantation of the metatarsal bone growth plate, the work of the growth plate continued, characterized by increasing radius length in the later observation period. In group 2, good results were obtained in 50% of cases. Clinical and X-ray examinations showed recurrent hand deviation and radius shortening, which required repeated radius lengthening. Conclusion. Microsurgical transplantation of the second metatarsal bone with growth plate is accepted more in reconstruction of the radial bone in patients with CRCH type II due to creation of a growth zone in the distal part of the radius. Radius lengthening via external fixation is applicable while maintaining the distal epimetaphysis and normal transverse dimensions of the radial bone.
Актуальность. В настоящее время отсутствует единая тактика при возникновении сосудистых нарушений при микрохирургических аутотрансплантациях пальцев стопы в позицию пальцев кисти, что является актуальной проблемой. Цель исследования -изучить и проанализировать ишемические осложнения при микрохирургических опе-рациях у детей с патологией кисти для улучшения качества хирургического лечения с использованием данного метода. Материалы и методы. За период с 2007 по 2016 г. в ФГБУ «НИДОИ им. Г.И. Турнера» Минздрава России вы-полнено 210 микрохирургических аутотрансплантаций пальцев стопы в позицию пальцев кисти. Перемещено 306 аутотрансплантатов. Из них 267 (87,3 %) при врожденной патологии кисти у детей и 39 (12,7 %) при при-обретенных деформациях верхних конечностей. Всего проведена реконструкция 352 пальцев. Результаты. По данным проведенного нами исследования, сосудистые осложнения в перемещенных ауто-трансплантатах отмечены в 19 (6,2 %) случаях из 306. Большинство из них приходится на ранний послеопе-рационный период (73,7 %). Основной причиной нарушения кровообращения являлся тромбоз венозных или артериальных стволов (8 случаев). У 6 пациентов сосудистые нарушения возникли в результате тромбоза ауто-венозных вставок. Компрессию сосудов из-за отека окружающих тканей или образовавшейся гематомы мы на-блюдали в трех клинических случаях. У двоих пациентов повторное вмешательство не выполнялось и попытки консервативного лечения нарушения кровообращения закончились некрэктомией на 7-е и 18-е сутки. Выводы. Методом выбора при появлении первых признаков недостаточности микроциркуляции в аутотран-сплантате является консервативная терапия, которая включает дезагреганты, антикоагулянты и гирудотера-пию. В случае отсутствия эффекта от консервативной терапии повторное оперативное вмешательство необхо-димо проводить в течение 3 часов от момента начала ишемии. В ходе оперативного вмешательства следует выполнить декомпрессию мягких тканей, механическое покачи-вание сосудистых анастомозов и при необходимости иссечение нефункциональных участков с последующей аутопластикой.Ключевые слова: микрохирургия; аутотрансплантация пальцев стопы на кисть; осложнения. Background. Complications after microsurgical toe-to-hand transfer is a problem for which there is no common approach to treatment. The aim of this study was to analyze the ischemic complications after microsurgical operations in children with pathologies of the hand to improve the quality of surgical treatment. COMPLICATIONS AFTER TOE-TO-HAND TRANSFERS IN CHILDREN WITH PATHOLOGIES OF THE HAND
BACKGROUND: Extensive and deep limb defects remain a difficult problem of reconstructive surgery in children. Free microsurgical flaps are used to resolve this problem. Free flaps can be complex in composition and include muscles and bone parts, which allow replacing large and multicomponent limb defects. The technique is used in patients with posttraumatic deformities, burns, acquired limb deformities, and congenital deformities of the extremities. AIM: To retrospectively analyze free flaps in children for the replacement of limb defects. MATERIALS AND METHODS: This single-center retrospective study analyzed 120 cases of microsurgical autotransplantation of free flaps to replace defects of the upper and lower extremities in children. The patients were children aged 117 years who had injuries and burns, acquired limb deformities, and congenital limb deformities. RESULTS: The average age of the patients was 9.5 years, and 72% of the patients were boys. Moreover, 95% of the children had posttraumatic deformities, burns, and acquired pathologies. Free latissimus dorsi flaps were used in 70% of the patients. The recipient area was the upper limb in 53% of the cases. The survival rate of free flaps was 96%. The general surgical complications were inflammation, pneumothorax, deformities, and specific vascular thrombosis. CONCLUSIONS: Replacement of extensive limb defects with free flaps remains a practical method in children.
Intraoperative combination of monolateral spinal anesthesia and prolonged brachial plexus block is evaluated in 65 children with autotransplantation of fingers from foot to hand. Variability of heart rhythm demonstrated autonomous stability in the main group. Dynamical study of skin temperature and dopplerographic evaluation demonstrated local sympatholysis in the blocked extremity. Significant improvement of circulation and quality of analgesia is revealed in case of prolonged perineural use of local anesthetics in the postoperative period. Described combination of intra- and postoperative treatment of such patients makes complex treatment more effective.
Резюме. Вывихи в запястно-пястных суставах трехфаланговых пальцев являются редким видом повреждения. Их клинические проявления зачастую оказываются завуалированы отеком, а рентгенограммы в стандартных проекциях малоинформативны, что обусловливает сложность в диагностике и высокую частоту нераспознанных при первичном обращении вывихов. В статье рассмотрены основные положения диагностики и лечения данного вида травм, представлен клинический случай оперативного лечения недиагностированного в остром периоде вывиха II-V пястных костей и отдаленные результаты лечения.Ключевые слова: вывих, пястная кость, запястно-пястный сустав, кисть.
This article is a brief historical review of distraction osteogenesis development in hand surgery. It describes the key steps in the evolution of methods beginning with immobilization and external fixation up to the distraction method in orthopaedics and its introduction in hand surgery.
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