Name:
Combined Onycho-Osteal Graft with Local Flap Reconstruction of Fingertip Amputations
Description:
Combined Onycho-Osteal Graft with Local Flap Reconstruction of Fingertip Amputations
Thumbnail URL:
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Duration:
T00H07M41S
Embed URL:
https://stream.cadmore.media/player/2d3f74b5-c539-46ff-b4b6-5a88295992ef
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/2d3f74b5-c539-46ff-b4b6-5a88295992ef/v-005706.mp4?sv=2019-02-02&sr=c&sig=AXb7DPhBvY2P14j4xGnWYr%2FMlGOzfCH4nqx1HB50mkY%3D&st=2024-11-21T17%3A34%3A13Z&se=2024-11-21T19%3A39%3A13Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
VIJAY MALSHIKARE: In this video, we demonstrate graft reposition on flap, which is called a GRF in Allen type IV amputation by Dr. Vijay Anandrao Malshikare, Pune, India and I don't have any disclosure. Graft deposition flap is a reattachment of the bone and the free nail bed separately covered with a local flap.
VIJAY MALSHIKARE: This is a schematic diagram of GRF. Inclusion criteria for GRF Allen type IV amputation and exclusion criteria is Allen I to III type amputation. Case example, a 44-year-old male factory worker, non-smoker came with history of crushed fingertip, amputation of index finger while working in the factory. Replantation is the gold standard in Allen type IV amputation, but not always possible because of lack of expertise or severely crush amputation. In our patient,
VIJAY MALSHIKARE: severely crush amputation was the problem so we couldn't find the vessel so we opt for a GRF. Surgical Technique. This procedure was performed under regional anesthesia and under tourniquet. This is type IV amputation of index finger showing amputated part and amputation through lingular and this is volar, part of the amputated finger where we see the severely crushed nature of the tissue
VIJAY MALSHIKARE: so we can't find the vessels. This shows loss of [?] of the distal phalanx. First step is to separate the nail plate from the amputated part. Then we remove the pulp tissue from the bone. Then we separate nail bed from the dorsal cortex of the bone and we debride the bone.
VIJAY MALSHIKARE: The next step is to make a multiple drill hole into the bone by using 1 mm k-wire, make two or three drill holes into the bone. Then we do meshing of the nail bed by using 15 number blade so this will increase the surface area of the nail bed. After that, we prepare the stump by taking two incisions on the nail fold and elevating the nail fold to expose the germinal matrix.
VIJAY MALSHIKARE: Then we take out the nail bed from the bone edges so that it will not come in between while fixing the bone to the proximal part by k-wire. This is the final picture of the three parts, which is separated from amputated part and preparation of the stump. Then we fix the bone with the k-wire 0.8 mm or 21 gauge needle to the proximal stump.
VIJAY MALSHIKARE: Then we suture back nail bed graft by 6-O catgut to the germinal layer. Depending upon the geometry of the amputation, finger flap cover is given either thenar flap, cross finger flap or VY flap used. So we hear this is a volar defect. So thenar flap is chosen. We did a Rinker's modification of the thenar flap because this flap is more lateral
VIJAY MALSHIKARE: so it is away from the gripping area of the thumb. This is the primary closure of the flap. Flap is elevated and before fixing the flap, we fix the finger to the thenar eminence so that it will not move while inserting the flap. Then we suture the tip of the flap to the tip of the nail bed by 6-0 catgut, two or three stitches.
VIJAY MALSHIKARE: Then we deposit the nail plate and suture to the flap to prevent air dry necrosis. This is final construct of the GRF. In post-op, do not change the dressing before 14 days as it is a composite free graft and this will cause soft tissue necrosis if you do frequent dressing. Protect with POP slab for two weeks.
VIJAY MALSHIKARE: After two weeks flap devision is done. One year result of the same patient. There is a good cosmetic appearance of the nail. There is no hook nail deformity and in volar surface you can see the thenar print and good pulp contour and there is a shortening of only three millimeter. One year post-op X-ray shows healing of the graft, but there is also resorption of the bone seen on the X-ray.
VIJAY MALSHIKARE: This technique was published in 2015 as a six case report in Journal of Hand Surgery Asia-Pacific and then we published the mid-term result of Graft Reposition on Flap in 2019. Similar kind of results were published by J Terrence Jose of GRF in 40 cases. Till now we are about 30 patients Follow up of five years, nail appearance was 87% excellent.
VIJAY MALSHIKARE: There was a shortening of 5.2 millimeter average. VAS score was 0, PD was 5-9 millimeter and 100% bone consolidation was seen in our series. Only four patient develops a complication of nail bed necrosis due to infection. Our ROM at PIP and DIP was full. No donors had problem. Cosmesis was the concern in four cases due to color mismatch and none of them has developed the cold intolerance.
VIJAY MALSHIKARE: Survival of the graft is due to the following factor. One is the suppression of the bone and the nail bed as a free graft increases the surface area, the drilling of the bone increases perfusion to the nail bed from the flap by plasmatic imbibition, meshing of the nail bed again increases the surface area for take up of the nail bed graft. Reposition of the nail plate in the nail fold avoids the necrosis of the nail bed due to the air drying
VIJAY MALSHIKARE: and this is a very important step in GRF. Always deposit the plate into the nail fold and this will avoid the nail bed necrosis. And in conclusion, GRF has proven to be a simple and reliable procedure. It does not require advanced skill, and it can be done by a well-trained resident or fellow in hand surgery. GRF is recommended as a technique for Allen's type IV amputation, with emphasis as a valuable role and alternative to the other reconstructive procedure
VIJAY MALSHIKARE: and it is also used as a bailout procedure when there is a severely crush amputation. Thank you very much.
