Brunelli Club – Welcome Remarks

May I take the opportunity of addressing this letter to

Giorgio Brunelli, esteemed teacher, colleague, and friend,

in his 91st year.

None have been more influential, as a leader in hand and

nerve surgery, a humanitarian, an accomplished

photographer, and a lover of old cars.

On behalf of the 55 member societies of the International Federation, and

as a friend, I wish you, all presenters, and registrants, a most successful

9th International Symposium on Experimental Spinal Cord Repair and

Regeneration.

In particular, I am disappointed not to be with you on December 5th for

the 4th Brunelli Club reunion, including presentations on the subject of

hand palsies.

My best wishes are with you, Giorgio, and with all.

With fond regards,

Michael Tonkin

President, IFSSH

Carissimi amici e colleghi

È per me un grande piacere ed onore avere l’opportunità di ospitarvi, per la

quarta edizione del Brunelli Hand Surgery Club, a Brescia e in particolar

modo qui alla Facoltà di Medicina dell’Università dove, per oltre 40 anni, ho

insegnato Ortopedia e tenuto Corsi di aggiornamento sulla Chirurgia della

mano.

Una specialità nella specialità: la più fine e complessa che ho iniziato ad

amare sin da subito, appena laureato. La guerra era finita da poco, la

siderurgia bresciana era in forte espansione e le aziende fiorivano nelle

nostre valli. La prevenzione degli incidenti sul lavoro era inesistente e così

gli operai riportavano frequenti lesioni alle mani che in ospedale erano

trattate dagli assistenti più giovani; io, tra quelli. Fu Proprio la complessità

e la difficoltà di trattare bene queste lesioni che mi affascinò e mi spinse a studiare, ad aggiornarmi e a

viaggiare in tutto il mondo per andare dai Maestri di questa chirurgia che in Italia era ancora pressoché

sconosciuta. Si era negli anni ’60, ed io iniziai a ideare tecniche chirurgiche per la cura di lesioni tendinee,

ossee, nervose e vascolari della mano. La mano paralitica rappresentò subito per me una grande sfida. Ero

allora primario all’ Ospedale di Chieti “Santissima Annunziata“ ed ero anche responsabile di una struttura a

Francavilla a Mare dove erano ricoverate bambine affette da esiti di poliomielite, allora la causa più

frequente di paralisi nervosa periferica. Furono queste le prime piccole braccia, le prime piccole mani flaccide

che operai per cercare di dare loro una funzione valida. I risultati allora non erano sicuramente brillanti come

quelli che oggi si ottengono, grazie alle fini tecniche chirurgiche, per la cura di altre patologie (vedi le paralisi

ostetriche o per esiti di lesioni traumatiche dei nervi) ma erano comunque soddisfacenti ed utili per dare ai

piccoli pazienti la possibilità di affrontare il loro futuro con le loro mani rimesse in grado di funzionare. Negli

anni seguenti continuai ad interessarmi di arti poliomielitici ma anche di paralisi flaccide da traumi nervosi

alle quali si aggiunsero poi paralisi di tipo diverso, spastiche, la cui patogenesi divenne sempre più frequente

con il diffondersi dei traumi stradali. Già all’inizio del secolo scorso Stoffel aveva avuto l’idea di diminuire la

spasticità (iponeurotizzazione) sezionando i rami terminali dei nervi motori (lo faceva sezionando fascicoli

motori all’interno dei nervi) ma, data la mancanza di mezzi di ingrandimento, la sua chirurgia era molto

approssimativa. Con l’ausilio dei mezzi tecnici comparsi dopo di Lui già 40 anni or sono pensai di eseguire la

iponeurotizzazione con la microchirurgia resecando i rami terminali dei nervi motori ottenendo così una più

mirata e sicura diminuzione degli impulsi motori. Ovviamente combinando l’intervento di diminuzione degli

impulsi motori con transfers tendinei ed eventuali altri accorgimenti chirurgici (artrodesi, transfers tendinei

etc.). Oggi non c’è tipo di paralisi degli arti superiori che non possa essere trattata e migliorata con alcune

delle tecniche messe a punto negli anni restituendo una funzione alle mani. Anche se non si è mai finito di

ricercare per migliorare le tecniche chirurgiche oggi possiamo dire di avere a disposizione una panoplia di

cure efficaci per correggere ogni tipo di paralisi degli arti superiori nella quale scegliere l’intervento che di

volta in volta sembrerà il più adatto. Sono orgoglioso che il 4 B.H.S.C. possa oggi ospitare a Brescia molti tra

di voi che negli ultimi decenni hanno contribuito al miglioramento della chirurgia e dei suoi risultati nel

trattamento delle paralisi flaccide e spastiche dell’arto superiore.

Benvenuti a Brescia

Giorgio Brunelli

Dear Friends and Colleagues

It is a great pleasure and an honour for me to have the opportunity to host you, for the fourth edition of the

Brunelli Club, in Brescia and, in particular, here at the Faculty of Medicine of the University where I taught

Ortopaedics and held updating courses for over 40 years.

A speciality within the speciality: the finest and most complex one which I started to love since the beginning,

right after my graduation. The war had just finished, the iron and steel industry in the Brescia area was

expanding rapidly and companies were flourishing in our valleys. Prevention from accidents at the workplace

was non existent and therefore factory workers received frequent injuries to their hands which were treated

in hospital by very young assistants: and I was one of them.

Just the complexity and the difficulty in treating these injuries properly fascinated me and pushed me to

study, to update myself and to travel all over the world to meet the Masters of this surgery which was still

pretty well unknown in Italy. It was the 1960s and I started to devise surgical techniques to treat tendon,

bone, nervous and vascular injuries to the hand.

The paralytic hand represented a huge challenge from the start. At the time I was Head Physician at the

“Santissima Annunziata” hospital in Chieti and I was also in charge of another centre in Francavilla a Mare

where little girls suffering from poliomyelitis, then the most frequent cause of peripheral nerve palsy, were

admitted. These were the first little arms, the first little flabby hands I operated on, trying to give them a

working function. The results we got then in the treatment of other pathologies (see obstetric palsy or

traumatic nerve injuries) were not as brilliant as the ones we get today thanks to fine surgical techniques, but

they were nevetheless satisfactory and useful to give these young patients the possibility to face the future

with their hands functioning again.

Over the following years I continued to be interested in limbs affected by poliomyelitis but also in flabby

palsies caused by nerve traumas with the addition of different types of paralyses like spastic palsies whose

pathogenesis became increasingly more frequent with the spread of traumas caused by road accidents.

At the beginning of the last century Stoffel had already thought of reducing spasticity ( hyponeurotization) by

selecting the terminal branches of the motor nerves (he did it by selecting motor fasciculations within the

nerves) but, given the lack of magnifying equipment, his surgery was very approximate.

With the help of the technical equipment in use after him, about 40 years ago I thought of carrying out the

hyponeurotization through microsurgery by severing the terminal branches of the motor nerves thus

obtaining a more aimed and certain reduction of the motor impulses.

Obviously this is achieved combining the intervention to reduce the motor impulses with tendon transfers and

other possible surgical adaptations (arthrodesis, tendon transfers etc.).

Today every kind of palsy to the upper limbs can be treated and improved thanks to some techniques

developed throughout the years which give the hands their functions back.

Even though the research to improve surgical techniques has never stopped, we can say that today we have

an array of effective treatments to improve any kind of palsy to the upper limbs from which to choose the

intervention that seems the most suitable each time.

I am proud that the 4 B.H.S.C. can today host in Brescia many of you who in the last few decades have

contributed to the improvement of surgery and its results in the treatment of flaccid and spastic palsies to the

upper limb.

Welcome to Brescia

Giorgio Brunell

Dear Friends,

the fourth meeting of the people (hand surgeons, orthopaedic surgeons, plastic surgeons, neurosurgeons,

nurses, researchers and many others) who were lucky enough to stay at Giorgio Brunelli side, is a special

event as it marks Giorgio Brunelli’s 90th birthday and it is held in Brescia, Prof. Brunelli’s home town, a

historical milestone in hand surgery, where so many important courses and congresses have been held over

a really long period of time.

Giorgio Brunelli gave me the privilege and the honour to introduce this short scientific meeting that will

focus mainly on nerve problems, one of Brunelli’s favourite topics, simply because I started the first reunion

in Torino.

I am sure that even this meeting will be the occasion to discuss clinical problems, starting from the lessons

which Prof. Brunelli taught to his students and collaborators, and that he personally presented in the

countless courses and congresses he attended or organized.

It will also be a special opportunity for us, who share common clinical experiences and friendship, to spend

some time together and honour Giorgio Brunelli’s career on the occasion of his umpteenth success: the

achievement of an age, which is the age on his birth certificate but certainly not the age he is, considering

his continuous presence and activity among us.

Bruno Battiston

M.D, PhD, Torino (Italy)

5th December 2015

4th BRUNELLI

HAND SURGERY

CLUB

HAND PALSIES

(SPASTIC AND FLACCID)

University of Brescia Medical School

viale Europa 11, Brescia (Italy

09.00 - 11.00 Registration

11.00 - 13.30 Morning session

11.00 - 11.30 Welcome remarks Bruno Battiston (Italy), Max Haerle (Germany) Roberto Adani (Italy), Pierluigi Tos (Italy), Adolfo Vigasio (Italy)

11.30 - 11.40 Giorgio Brunelli introduced by Alessandro Caroli 11.40 - 12.00 Lecture Giorgio Brunelli

12.00 - 13.30 Free papers (12’) The avascular proximal pole in carpal scaphoid nonunion P. Borelli (Italy) Arterial anatomy of the thumb: anatomical study and clinical applications F. Brunelli (France) The arthritis of the base of the thumb: anatomical study, causes and treatment G. Brunelli (Italy) Vascular anomalies: red – blue does not mean “angioma” J. Enriquez de Salamanca (Spain) Iatrogenic nerve lesions I. Marcoccio, A. Vigasio (Italy)

Robotic microsurgery G. Gili Cirera (Spain) Diagnosis and treatment of upper limb paralysis Y. Yamano (Japan) Surgical treatment of elbow flexion contractions in obstetrical birth palsy and twenty-year experience A. Yuceturk (Turkey)

13.30 - 14.30 Snack lunch

Afternoon Session 14.30 - 19.00

14.30 - 16.00 Flaccid Palsies Chairpersons: R. Adani (Italy), B. Battiston (Italy),R. Luchetti (Italy), A. Vigasio (Ital

14.30 - 14.35 Introduction R. Adani (Italy) 14.35 - 14.45 Nerve transfers versus tendon transfers in

the treatment of flaccid palsies P. Tos (Italy)

14.45 - 14.55 Median nerve palsies R. Luchetti (Italy) 14.55 - 15.05 Ulnar nerve palsies B. Battiston (Italy) 15.05 - 15.15 Radial nerve palsies A. Vigasio (Italy) 15.15 - 16.00 General discussion 16.00 - 17.30 Plexus Palsies

Chairpersons: G. Brunelli (Italy), A. Gilbert (France), J. Monsivais (Texas, USA), P. Raimondi (Italy)

16.00 - 16.10 Introduction P. Raimondi (Italy) 16.10 - 16.25 Plexus repair in late presentation A. Gilbert (France) 16.25 - 16.40 Tentative experimental repair of brachial

plexus lesions by means of grafts in the C.S.T. G. Brunelli (Italy)

16.40 - 16.55 An alternative method for hand re-animation following severe brachial plexus injury J. J. Monsivais (USA)

16.55 - 17.30 General discussion 17.30 - 18.30 Spastic Palsies

Chairpersons: V.R. Hentz (California, USA), M. Haerle (Germany), C. Leclercq (France), P. Soukakos (Greece)

17.30 - 17.45 Etiology and clinical examination M. Haerle (Germany)

17.45 - 18.00 Botulinum toxin and surgical treatment C. Leclercq (France)

18.00 - 18.15 Spasticity and tetraplegia V.R. Hentz (USA) 18.15 - 18.30 Reconstruction procedures for wrist

and hand spasticity P. Soukakos (Greece) 18.30 - 19.00 General Discussion

A B S T R A C T S

The avascular proximal pole in carpal scaphoid nonunion Pierpaolo Borelli, Brescia, Italy

The surgical treatment of scaphoid nonunion is a challenge for even the most ex- perienced surgeon. The problem is to make a puzzle with many little problems such as nonunion debridment, preserving the residual blood supply in the proximal frag- ment, revascularization of an avascular proximale pole, anatomical reduction of 2 or 3 ( in case of an interpositional cortcocancellous graft) fragments, carpal insta- bility (DI€I) correction, rigid fixation. Matti-Russe bone graft (1, 2), Fisk-Fernandez bone graft (3, 4, 5), various types of vascularized bone graft (6-19), elettrical stimulation (20, 21) has been proposed in the past with sometimes impressive reported union rates, which in most cases reach 100%. In the last ten years minimally invasive surgical approaches moved forward the standards of treatment. Moreover wrist arthroscopy is now proposed in scaphoid nonunions for debridment, bone grafting and internal fixation with the goal of avoidingpost-operative morbidity, minimize post-operative stiffness and maximize functional out-come (22) . The bone graft varies from injectable bone graft substitutes (23) to autogenous bone graft and avascular proximal pole is not an absolute controindications now (24,25). This technique requires special- ized training and should be indicated in early staged scaphoid nonunions with- out a complete avascular necrosis of the proximal pole and is contrindicated in hump-back-deformity with dorsal intercalated segmental instability ( DISI ), but is increasingly known pushing the wrist surgeon, even if not experienced in wrist arthroscopy, to have a more three-dimensional view of the scaphoid to obtain the most appropriate rigid fixation. Avascular Necrosis of the proximal pole As noted, the last 2 cases presented in this article have been treated with non vas- cularized bone graft (NVBG), even with the obvious lack of blood supply, so a simple question arises: when is it really necessary to use a vascularized bone graft ( VBG)? Actually, in the last 10 years we have found acceptable union rates in fixing the proximal pole without the use of VBG, even in the presence of poor or absent vas- cular supply ( 26-31 ). However, the use of pedicled bone grafts has been advocated for avascular proximal pole in a number of publications with successfull results (16,17,32,33,34) or “less ideal results” (18, 35, 36). On the other hand free VBGs have been considered too demanding procedures and have to be reserved for special circumstances (37,38). In fact all these studies cannot be compared easily because of often disomogene- ous patterns of nonunions have been introduced in the studies, and because of the term of “avascular necrosis” and how to evaluate it, is still subject to discussion ( “bleeding points”, “healthy cancellous bone”, “MRI scans”) , and the use of VBG remains controversial.

There is a general consensus about the indications of a VBG: A truly avascular necrosis in the proximal pole and a secondary reconstruction after failed fixation with NVBG. The choise among a dorsal or volar pedicled vascularized bone graft or a free vas- cularized bone graft depends not only on the morphology of nonunion but also on the surgeon’s personal attitude towards a particular kind of vascularized graft. Among all the VBGs, after an undisputed dominance of the dorsal Zaidenberg bone graft, today the most used is the volar bone graft proposed by Kuhlmann (13). First described only in case of a failure of the classical techniques, is now recom- mended as a primary treatment of Scaphoid non-union to speed consolidation. (19) The value of a primary vascularized bone graft pedicled on the transverse volar carpal artery is because this technique may be performed as a day of admission surgery, through a single incision, under locoregional anesthesia, as a primary in- tervention. Many studies reported a better consolidation rate with this kind of VBG ( 15, 39-43) but, as Mathoulin itself declares in his study, too many variables exist in vascular- ized nonunions to validate today the use of a VBG also in a classic vascular non- union. Moreover we have to consider the limit, recognized by literature, of a VBG. Even if you are extremely precise in harvesting the graft, if you don’t want to disturb the delicate equilibrium between the pedicle and the bone graft, the fixation is often unstable, because it often requires k wires to avoid the risk of destroying the bone graft, thus aiming more to biology than stability, so requiring long period of immo- bilisation to reach a sound consolidation (Fig.1). Waist nonunion (a) with avascular necrosis of the proximal pole (b). A Kuhlmann VBG is fixed with 2 k wires (c), achieving the bone healing (d). With permission of

F. Niestedt.). As an alternative, if one woulkd like to aim to the stability of fixation more than bi- ology, 2 aspects that are not always possible to combine in a therapeutic strategy of an avascular scaphoid nonunion, one may choose a NVBG and performe a more stable fixation with a new generation self-compressive headless screw, which is easier to perform than a VBG, which needs to be harvested with a long pedicle, making the procedure more demanding. Sound consolidation may take a long time anyway, even taking advantage by elettrical stimulation ( 20,21), but the patient is free to move the wrist earlier (Fig. 2). (Fig. 2. 23 y.o. manual worker, right wrist. Junctional nonunion (a) with avascular necrosis of the proximal pole (b). A non vascularized bone graft (NVBG) from distal radius and a stable fixation with a new generation headless screw may achieve late bone healing (c), with the help of electrical stimulation ( d,e,f) also demonstrated by CBCT (g,h,i), still allowing an early motion of the wrist.) In conclusion we don't have to forget that the screw fixation, when stable, may pro-

vide revascularisation of an avascular proximal pole, as long as the proximal pole size is appropriate for screw fixation, with a classic NVBG. And again we don’t have to forget how, in an avascular very little proximal pole, good results may be obtained with the most simple surgical tecnique, that is to say a spongious graft from radius associated to retrograde volar Kirschner wires fixa- tion, properly bended around the tubercle to be left inside for a long time. If properly inserted the K wires may be left inside for a very long period, without limiting the funtional result. (Fig.3). (Fig. 3. 24 y.o. manual worker, left wrist. Proximal pole nonunion (a) with avascular changes in the proximal pole (b). Spongious graft from radius and 2 K wires, still in- side after 14 years at the time of this standard x-ray (c), achieved bone healing (d,e) In conclusion VBG, in my opinion, should always be an option and not be consid- ered mandatory.

Surgıcal treatment of elbow flexıon contractures ın obstetrıcal bırth palsy (20 years experıence)

Aydın Yuceturk, MD, Asıbadem University, Fulya Asıbadem Hospital, Department of Hand Surgery, Istanbul

Introduction: The consequences of an elbow with a fixed flexion contracture may be both es- thetic and functional, especially when one considers that all these children exhibit some length discrepancy. The fixed flexed elbow exaggerates the apperance of a short limb and further decreases the movement of the affected limb. The paradox of development of an elbow flexion contracture in a patient with weak biceps was investigated by Aitken . No one has been able to explain why this progressive elbow deformity develops. €urgical treatment was mentioned as difficult to impossible . Since there some articles about surgical treatment about elbow contractures due to trauma there not any about obstetrical brachial plexus related elbow contrac- tures. Elbow flexion contractures are generally extraarticuler and rarely intraarticu- lar. Intraarticular elbow contractures in OBP are usually combined with extraarticu- lar contractures. Materials, methods and results: Between 1997-2015 81 patients who has over 30 degrees of elbow flexion con- tracture due to OBP were operated. 40 patients were male and 41 were female. 54 patients were Erb palsy and 27 were total palsy. Average age was 13 (8-42 years of age). Preoperative contracture degrees were between 30 to 90 degrees (average 45 degrees). Follow up was between 15 years to 3 months and average was 6 years. 42 patients are still followed up by physical examination or phone calls and elbow pictures and video movies. Postoperative residuel contracture was between 0-25 degrees average 10 degrees. When the age is young result is better. During the surgery most common contracted structure was the brachialis muscle, the others were anterior capsula, fascia antebrachii, biceps brachii muscle, elbow collateral ligaments and rarely flexor pronator origin. During the surgery ulnar, me- dian ,radial nerves and brachialis artery and veins were disected and protected. Only 2 cases had transient nerve palsies after surgery and recovered in 6 months. Brachialis muscle tendon fascial strips were cut first and if it was not enough to- tally released with Z plasty technique. 3 patients needed olecranon tip excision. 6 patients had radial head dislocation, one reduced and biceps tendon transfered to ulna. 4 patients over 10 years of age, radial heads were excised during contracture release. Only 5 patients had biceps lengthening who had severe contracture, since 4 patient had no loss of function one lost some function and he was flexing the elbow up to 90 degrees and this patient was a total palsy . All patients elbows were immobilized for 3-4 weeks in splint cast. In last 10 years elbow active extension splint was routinely used for one year 3-4 times 30 minutes

per day and according to me this most effective procedure to prevent the recur- rence of elbow contracture. Only small portion of patients had effective physical theraphy because of lack of opportunity . When triceps muscle function is good before surgery results were better acording to the non-functioning group Conclusion: 81cases series results showed that in selected patients release of OBP related el- bow flexion contractures, results are satisfactory. Over 30 degrees of contracture surgery can be done. Contracture causing major structure was found is the bra- chialis muscle in this series. After the surgery active extension splints must be used and physical therapy is important. Since elbow flexion contractures are not rare in OBP, active extension splints must be used also to prevent contracture. Nerve transfers in radial nerve palsies Adolfo Vigasio, Hand Surgery and Orthopaedic Microsurgery Unit, Istituto Clinico “Città di Brescia” - Gruppo San Donato – Brescia (Italy) In radial nerve palsy can be distinguished the complete, high palsy, in which the tri- ceps muscle in preserved, and the posterior interosseous nerve palsy or low palsy. In complete high palsy patients present loss of wrist extension, MP joint exten- sion and thumb extension and abduction. Sensibility impairment is also present, in particular at the dorsal first web and on the dorsum of the thumb and on the first phalanx of the 2nd and 3rd fingers. In posterior interosseous palsy, function of Exten- sor Carpi Radialis Longus muscle is preserved and patients can extend the wrist in radial deviation and the motion loss involves only the MP joint extension and thumb extension and abduction. Tendon transfers are used in radial nerve palsy in case of failed nerve reconstruc- tion or when nerve repair is not indicated . Success or failure of this technique depends upon the correct technique and on the correct choice of the tendons to transfer. In fact, in the case of isolated radial nerve palsy, many tendons may be available for the transfer, as the extrinsic muscles innervated by the median and ulnar nerves and in this condition, a correct combination of muscles to transfer is mandatory. On the contrary, sensory impairment can usually be ignored, unless patients present painful neuroma. Pioneer of tendon transfer was Jones, that in the post first World War proposed the following multiples transfers:

Pronator Teres pro Extensor Carpi Radialis Brevis and Long (PT pro ECRB+ECRL);

Flexor Carpi Ulnaris pro Extensor Digitorum Communis III-IV-V (FCU pro EDC III-IV-V);

Flexor Carpi Radialis pro Extensor Indicis Proprius and Communis, Exten- sor Pollicis Brevis and Longus , Abductor Pollicis Longus (FCR pro ECD II, EPII, EPB, EPL, APL).

Nowadays, to reanimate wrist extension, PT transfer is universally accepted. On the contrary, the contemporary sacrifice of both wrist flexors was abandoned when Zachary, in 1946 , suggested to save one of the wrist flexors proposing the follow- ing technique:

Pronator Teres pro Extensor Carpi Radialis Brevis (PT pro ECRB);

Flexor Carpi Ulnaris pro Extensor Digitorum Communis (FCU pro EDC);

Palmaris Longus pro Extensor Pollicis Longus (PL pro EPL) according to Starr ( 1922 )

€cuderi refined this technique in 1ª4ª suggesting the rerouting of the PL on the palmar aspect of the wrist and emphasizing the important principle that function is better when transfer is done into only one tendon ( “one tendon one function” ) . Boyes in 1962 proposed the transfer of the FCR as an alternative to the FCU, for the convincement that FCU is a more important wrist flexor than the FCR . He also pro- posed the use of Flexor Digitorum €uperficialis tendons for fingers extensor (FDSIV pro EPB and EPL and FDSIII pro EDC). The present author, according to his experience in the treatment of radial nerve palsy, presents the following combination of transfers: Complete radial nerve palsy (high palsy) : PT pro ECRB + FCU pro EDC + PL pro re- routed EPL. Flexor Digitorum Superfisialis IV or III are used in case of the absence of PL. Posterior interosseous nerve palsy (low palsy): as patients extend wrist in radial deviation for the isolated function of ECRL, PT transfer is not necessary. For this reason the use of F‡U to restore fingers extension is considered a mistake as its sacrifice may worsenwrist radial deviation. In this case, the following combination is preferred: FCR pro ECD + PL pro rerouted EPL . Flexor Digitorum Superfisialis IV or III are used in case of the absence of PL. Technical aspects and clinical results are presented.

Reconstruction Procedures for Wrist and Hand Spasticity Panayotis N. Soucacos, MD, FAGS

Professor of Orthopaedic Surgery, University of Athens, School of Medicine Director, Orthopaedis Researsh & Education Center,

"Attikon" University Hospital President, Board of Directors, University of Ioannina

Palliative surgery for wrist and hand spasticity consists of an ensemble of sec- ondary procedures that are used to improve function of the upper extremity. Such procedures consist of muscle-tendon transfers, tenodeses, capsulodesis and/or arthrodeses. In order for secondary reconstructive procedures to effectively en- hance overall function the surgeon must be aware of the natural history and evolu- tion of the particular patient, as well as the particular functional deficits presented by the patient. (This is essential since it is function that is re-established and not reanimation of paralyzed muscles). In addition, the surgeon must evaluate and verify the passive mobility of the joints, as well as their stability. The reconstruc- tive possibilities available to the surgeon are dependent on the number of available active muscles and the condition of the entire limb. Joint stiffness, contractures, deformities, and associated skin, vessel and bony problems must be considered in treatment planning. A general rule of thumb, is that all contractures should be treated before surgical reconstruction of the paralysis. Various procedures are performed for correction of forearm and hand deformities. The preferred palliative surgical procedures to correct deformities or restore func- tion include: flexor or extensor tendon transfers, free muscle transfers, opponens- plasty, and bone fusion. Secondary procedures such as muscle transfers and wrist fusion are necessary to improve function, especially in late cases where the muscle targets have atrophied. Pedicled muscle or tendon transfers are used to enhance the functionality of the paretic arm. Advances in microsurgery brought the era of free functional muscle transfer for brachial plexus paralysis management. The transferred free muscles are neurotized either by previously banked nerve grafts or directly from local motor donors (i.e intercostal nerves). The most commonly re- stored functions are elbow flexion and extension, finger flexion and extension and, in some cases, shoulder abduction and intrinsic substitution. Latissimus dorsi and rectus femoris transfer, are good candidates for elbow flexion restoration. For hand reanimation, gracillis and rectus femoris can be used. Some surgeons prefer to restore two functions with one muscle transfer i.e elbow flexion and finger flexion or elbow extension and finger extension. The surgical procedures selected depend upon the pathology of the involved soft tissues, joints and the overall muscular condition. In general, a severe shoulder deformity should be corrected before any surgical procedure is attempted on the forearm. On the other hand, mild or moderate flexion contractures of the elbow do

not contraindicate forearm surgery. Supination deformities and dorsiflexion and ulnar deviation of the wrist can be corrected next. The final step is any surgical correction of the hand.

An Alternative Method for Hand Re-animation Following Severe Brachial

Plexus Injury Jose J. Monsivais, MD, FACS, Hand and Microsurgery Center of El Paso, El

Paso, Texas (USA) The last three decades have seen the development of innovative reconstructive techniques for brachial plexus injuries. The development of nerve grafting, nerve transfers, and functional muscle transfers have significantly improved our arma- mentarium over the traditional tendon transfers and selective arthrodesis. How- ever, poor results for shoulder, elbow and hand are still seen frequently in the most severe cases. Shoulder arthrodesis has been studied in the past, with disappoint- ing results. The outcome is inferior to reinnervation procedures in tendon transfers. Wrist arthrodesis has a limited role but definite in some circumstances by allowing wrist motor tendons to be available for digital motion. However, overall poor results prompts a reassessment of current strategies for severe cases. Recently, the development of a spontaneous elbow ankyloses in one plexus pa- tient with concomitant improvement in hand function triggered the idea that this procedure needs to be re-evaluated. The procedure has been applied in additional patients with controlled ankylosis and arthrodesis, with the premise that reinnerva- tion of fewer motor units with higher density of nerve fibers creates an increase in motor power and improved quality of life.

Iatrogenic nerve lesion Ignazio Marcoccio - Adolfo Vigasio

Hand Surgery and Orthopaedic Microsurgery Unit Istituto Clinico Città di Brescia - Gruppo San Donato, - BRESCIA

Iatrogenic peripheral nerve injuries are a major source of distress and disability and since the majority occurs peri-operatively, surgeons and anesthesiologists are mainly implicated in litigation even if it is provided that these injuries are not the province of any particular medical specialty. The word iatrogenic does not mean professional responsibility. The iatrogenic le- sion is a percentage of pathology bound to the medical practice, which is gener- ally defined as adverse event. It is possible to distinguish the professional mis- take which is guilty because inexcusably incongruous and or performed under the minimum standard level for the lack of competence, prudence and diligence. It is defined as negligence, also known as malpractice and it represents 1/5th of the adverse events. On the contrary, the technical mistake, is unexpected because un- predictable and the borderline with “bud luck” and fatality is light and vague. This is defined as non-negligence. Technical mistake it is also defined as “error scientiae” according to the principle that an error is not the same of negligence. This kind of lesions is considered to be the consequence of the diagnostic or therapeutic activ- ity whose application presents an intrinsic risk of complications. Fortunately, for those lesions there is not a direct correlation between medical mistake and medical guilty. They represent 4/5th of the adverse events. Unfortunately, patients pretend from physician not the obligation of means, but the obligation of results. This mis- understanding triggers the medico-legal claims, not only in the case of inadvertent mistake, but also in the case of surgical failure and or complication. In case of accidental nerve lesion, surgeon’s behaviour should be as follow:

Do not ignore the lesion;

Describe the accidental lesion occurred;

Describe contingent anatomic anomalies and/or technical difficulties;

If recognized, promptly repair the lesion;

If the lesion is recognized after few days and if indicated, re-explore the le- sion or act to support spontaneous recovery;

If not technically competent suggest the patient to contact another sur- geon. On the contrary, the following deceitful self-defence mechanisms may be encoun- tered:

Modify records of surgical proceedings and medical charts in roughly and approximately way;

Mislead patients of a spontaneous recovery that will never happen;

Include colleagues and friends in the disinformation campaign;

Discourage patients from asking a second opinion to specialized surgeon for fear to be the unmasked.

In peripheral nerve lesion, and in iatrogenic nerve lesions in particular, the timing of repair represents a crucial factor as it is nowadays accepted that delays in referral for evaluation and repair compromises outcomes, as nerve recovery is best follow- ing prompt repair. Generally, functional outcome is adversely affected if more than six months have passes between injury and repair. Rarely patients are referred from the primary surgeon and these lesions are approached with a mixture of thera- peutic nihilism and negligence, some surgeons exhibit inaccurate optimism and even deny that the lesion is present, moreover these lesions are merely observed for several months, with the unrealistic expectation of an unrealistic improvement. When the lesion finally reaches the surgeons, a thoroughly evaluation is mandatory to establish the degree of damage and the potential for spontaneous recovery. The extreme fragmentation of these lesions, along with the difficulty that medico-legal implications may cause, create great difficulty even for experienced surgeons to understand and define the features of nerve lesions and establish the correct man- agement. When the mechanism of lesion is unknown a different approach is needed as the lesional spectrum ranges from a possible nerve transection with no chance to spontaneous recovery, to in-continuity lesion, reasonably potential for spontane- ous recovery. Regardless the type of injury, if after a congruous period of some months, called “wait-and-see” period, that should not exceed 4-6 months, spontaneous recovery did not occur, or regenerative signs are insufficient according to the level of injury, surgery is mandatory. Unfortunately, most of the iatrogenic nerve injuries remain unrecognized by the surgeon, at least at the moment of the lesion.

La chirurgia tardiva del plesso brachiale e’ possibile. A.Gilbert et P. Raimondi

E’ comunemente accettata l’idea che la riparazione del plesso brachiale oltre l’anno dalla lesione non sia in grado di condurre a risultati funzionalmente utili. Ciò è probabilmente vero per le riparazioni mediante innesti ma il progressivo sviluppo dei transfers nervosi ha permesso delle riparazioni molto distali (oltre che mirate ad obiettivi puramente motori) che non tengono più conto degli usuali tempi di recupero. Gli autori presentano i risultati di 93 transfers nervosi in 52 pazienti realizzati oltre un anno dalla lesione. Si tratta di 22 bimbi (paralisi ostetriche) e 30 adul- ti (paralisi traumatiche) nei quali le riparazioni sono state effettuate oltre l’anno dall’insorgenza della paralisi e sino a 7 anni. Sono stati riparati con transfers i nervi soprascapolare, muscolocutaneo ed ascellare. In tutti I casi è stata verificata elettromiograficamente la presenza di fibrillazione della musculature che ci si proponeva di reinnervare,. I risultati hanno dimostrano negli adulti: - per la ricostruzione del bicipite: 30% di insuccessi, 42% di risultati parziali, 28% di risultati eccellenti - per la ricostruzione del nervo soprascapolare: 23% di insuccessi, 45% di risultati parziali e 32% di risul- tati eccellenti mentre nei bambini: - per la ricostruzione del bicipite le 15% di insuccessi, 85% di risultati eccellenti - per la ricostruzione del nervo soprascapolare : 25% di insuccessi, 25 % di risultati

parziali, 50% di risultati eccellenti. Non vengono presentati i risultati della ricostruzione del deltoide, dagli autori uti- lizzata solo di recente, sia per il ridotto numero di casi sia per il follow up ancora insufficiente. In conclusion si può affermare che i transfers nervosi consentono di ottenere dei risultati funzionalmente utili anche se effettuati molto tardivamente (fino a 7 anni); questo permette quindi di indicare riparazioni nervose sia in casi in cui I risultati della chirurgia primaria si erano deteriorati o non erano stati ottenuti, sia nei casi giunti tardi alla nostra osservazione. e comunque ben al di la dei limiti temporali comunemente accettati.

The arthritris of the base of the thumb: anatomical study, causes and treatment Giovanni Brunelli – Brescia (Italy)

The thumb carpometacarpal (CMC) joint is the most common site of surgical re- construction for osteoarthritis in the upper extremity and affects almost 50% of women in post-menopausal period, females being hit about 20 times more than males. Nonsurgical treatment options include hand therapy, splinting, and injection. Surgical treatment is tailored to the extent of arthritic involvement and may in- clude stabilization with ligament reconstruction, metacarpal extension osteotomy, arthroscopic partial trapeziectomy, implant arthroplasty, and trapeziectomy with or without ligament reconstruction and tendon interposition. This paper includes a detailed description of the anatomy of the TMC joint (bones, ligaments, tendons, capsule) and of its normal stability, the anatomical research carried out in cadavers, the pathogenesis of TMC joint arthritis and a review of all of the possible treatment options. A review of the literature is also included.

Vascularisation of the thumb: anatomy and surgical applications

Francesco Brunelli, Institut de la Main, Paris (France) In the last few years a multitude of useful new flaps has been presented for the coverage of loss of substance of the thumb whose accomplishement (especially those of the last generation which base their survival on extremelyfine vascular axes) presupposes an adequate knowledge of surgical and microsurgical anatomy. If anatomy of the nerves is relatively simple and if the veins are sufficiently abun- dant so thatany small mistake can be overlooked, the arteries are essential for the survival of the flap and, as soon as the surgeon sketches out the lines of incision, he should be able to pinpoint the exact anatomical location of the arteries which will keep the flap alive. The following section will therefore be devoted to arterial anatomy; it details the results of the dissection of 50 thumbs (25 volar and 25 dor- sal dissections) carried out with the help of an optical microscope, having previ- ously injected the arteries with Latex at the humeral level. The palmar and volar surfaces will be discussedseparately. Anatomy - The arteries of the volar aspect The volar surface of the thumb, which we define as being the length between the opposition crease and the apex, has been subdivided into three different segments, delimited from the interphalangeal (IP) and metacarpophalangeal (MP) flexion creases.The mean length of each examined anatomical fragment was 10.4 cm; the proximal segment was invariably the longest, whilst the intermedian was the shortest. The pulp measured an average of 3.3 cm.Two incisions were made: the first transversal at the level of the opposition skin crease, the second longitudinal corresponding to the median axis of the thumb, thus enabling the surgeon to har- vest two large cutaneous flaps and to study the transit and connections of the ar- teries and veins beneath (fig) . The topographical position of the palmar arteries of the thumb is much more complex than that of the other fingers, the arterial course and calibre of which, if not constant, are much more regular. According to the clas- sical layout, the "princips pollicis” artery, having crossed the first intermetacarpal space, runs along the ulnar side of the first metacarpal bone and along the volar surface of the adductor muscle, emerging onto the subcutaneous palmar tissue at the level of the cutaneous flexion crease of the metacarpophalangeal joint. Here it divides into two terminal rami, namely the collateral palmar arteries of the thumb, which run along the digital tunnel symmetrically and are of equal calibre, heading distally to finally unite in the pulp arcade (fig. ). During their transit in the digital tunnel, they break off into numerous collateral branches, either cutaneous, articular or osseous. An arcade located deep in the flexor tendon joins together the two ar-

teries at the level of the distal metaphysis of the first phalanx, from where (and from another similar arcade, but more narrow and inconstant, situated at the level of the distal tendon insertion) the “vincula” vessels originate and supply the flexor tendon. If the preceding is considered the classical description of the palmar arteries of the thumb, it cannot be defined as "typical”: let us recall that in our anatomical studies, only 15% of dissections fell into such a category.Signifisant variations san modify the origin, the transit and the size of the two arteries. Variations Regarding Origin: -Only the radial collateral artery was consistently found to be the origin of the ex- ternal division branch of the “Princeps pollicis”, at which point the latter emerges onto the volar surface at the MP flexion crease. A narrow branch originating from the superficial arcade could sometimes also be found with the above, however the “princeps” represented in every case the main and often the sole source of the ex- ternal collateral artery. -The ulnar collateral artery on the contrary originates from three different sourc- es: 1) From the internal division of the “Princeps Pollicis”, 2) From an anastomo- sis originating in the superficial arcade, 3) From a "commissural” artery originat- ing from the radial artery, before penetrating more deeply into the muscles of the first interosseous space and becoming palmar. €uch an artery runs superficially through or among the first interosseous muscle to join up with the distal extremity of the first commissura, bypasses it and thus gives rise to the internal collateral ar- tery. The “Princeps Pollicis” is usually predominant in the formation of the internal collateral artery but the two other sources can also play a fundamental role, and can sometimes even be considered as the main component of the origin of the col- lateral artery. An anastomosis originating from the superficial arcade was present in 25% of cases (fig. ); the commissural artery in 10% of cases only (fig. ). Variations Relative to Transit: The transit of the internal collateral artery was regular and superficial in the sub- cutaneous tissue, from the point of its formation to the pulp region where we find it again. Nevertheless, in four cases, the internal collateral artery was absent. This was not, however, really a true deficiency but an anatomical variation of its transit. In fact, in all the above cases, an ulnar dorsal collateral artery of comparable di- mensions to those of the collateral palmar artery was present. The entire or major part of the external collateral artery was often located deep in the second segment. In 30% its dissection required the opening of the fibrous shaft of the flexor tendon, and sometimes the removal of the external sesamoid as well. Variations Relative to Size: The size of the internal collateral artery was predominant: in 40% of cases it was more voluminous, measuring up to four times the size of the controlateral artery. The external collateral artery was on occasions composed of two or three narrow arteries which joined together at the level of the interphalangeal flexion crease. Location of the arteries in the three different segments

- First segment: It is rare to find arteries of surgical interest on the volar suface of the thumb be- tween the opposition crease and the metacarpophlangeal flexion crease. Although arteries of a significant size can sometimes be found emerging from the superficial arcade or the commissural artery, the artery of this region is located deeply and is more easily accessible from the dorsal surface. This is represented by the “Princips Pollicis”. - Second segment: The two arteries run alongside the flexor tendon and behind the collateral nerves. In this area, the main artery is the ulnar collateral artery.Although sometimes absent in which case it is replaced by the dorsal artery, it is most often easier to dissect than the latter, and its size enables the surgeon to achieve a more reliable microa- nastomosis.If we discuss the pulp in greater depth, we can see how, at this level, the two collateral arteries are of a similar size, that is to say that it falls upon the subtendinous anastomosis situated at the level of the neck of the first phalanx to play the role of “moderator” between the two arteries. Also in cases where the pal- mar internal collateral artery is absent, the dorsal artery takes its place, by means of a branch through the subtendinous arcade from which the artery originates. The latter then joins up with the controlateral artery to form the pulp arcade. - Third segment: In the pulp segment the two arteries are of similar size, and run

through the thick fatty subcutaneous padding, which later cross over and convert into the ends of the digital nerves at the level of the median axis. At mid-length of the pulp, the latter are brought together by the arcade of the pulp, which can appear in three different forms:

(1)Inverted ‘”U” shape: This is the shape that is most commonly found (65%). The two arteries converge gradually towards the centre, making a proximal concavity curve shape from which thin vessels intended for periosteal, osseous and tendi- nous purpose emerge. Three to five arteries of quite a large size stem from the convex side and branch out to feed (supply) the most distal segments of the pulp and of the nail bed, (2)”H” shape: The two collateral arteries continue distally fol- lowing the same direction as they had in the proximal segment, and are united at one and a half centimetres distally to the interphalangeal crease, by a horizontal anastomosis. Such a pattern was found in 3 anatomical preparations out of 25, (3) Inverted “Y” shape: In just one case, the two arteries diverged medially forming an acute open angle proximally resulting in a sole arterial trunk, which after about half a centimetre, branched out in its turn into the distal extremities. In three anatomical preparations, the arterial pattern of the pulp was more complex and could not be identified as any of the above: the two arteries were joined togeth- er by multiple arcades (2 or 3) which did not have any particular characteristics.

-The arteries of the dorsal aspect To our knowledge, the dorsal arteries of the thumb have not yet been the subject of an in-depth anatomical study and are described in the classical anatomical litera- ture as:”stemming from the terminal branches of the radial artery at the level of the anatomical snuff-box and heading distally towards the dorsal surface of the thumb where they end up as periosteal and bony skin rami at first phalanx level" (Testut). Such a description only partially corresponds to reality in that the quoted arter- ies are intended for the vascularization of the area corresponding to the posterior surface of the first metacarpal and metacarpophalangeal joint. The posterior area of the thumb is mainly vascularized by two arteries which originate from the pal- mar arteries at the level of the first metacarpal. After having run laterally along the metacarpophalangeal joint, and continuing obliquely from volar to dorsal, these ar- teries then head in a distal direction remaining on the side of the phalanges. At the level of the neck of the first phalanx, an anastomosis can be found which originates from the palmar arteries which co-feed its territory. Similarly to the palmar arteries, they are joined together by three arcades: (1)one inconstant arcade located under the extensor tendon at the level of the neck of the first phalanx (2)the arcade of the nail matrix (3)the arcade of the nail bed. Internal dorso-collateral artery: Generally it stems from the “Princeps Pollicis” onto the internal border of the neck of the first metacarpal and heads distally remaining on the lateral surface of the first phalanx. It joins together at the level of the distal metaphyseal of the first pha- lanx, receiving an anastomotical rami coming from the palmar collateral artery or from the subtendinous anastomosis located deeply in the flexor tendon. It then proceeds onto the internal side of the second phalanx and proximally to the base of the nail, continues laterally to meet up with the controlateral artery forming the arcade of the nail matrix. At the level of the neck of the first phalanx, its distance from the median axis of the thumb is between 0.7 and 1.4 cm (average = 1.0 cm). This artery can be large and dissected under the naked eye (fig. 8), or thin and ne- cessitate the use of a microscope in order to identify it (fig. ª); however an accurate dissection enabled to demonstrate its presence in every one of the 25 anatomical examinations. We will successively look at the clinical applications of this artery which form the basis of the “dorso-ulnar island flap of the thumb” in the chapters dedicated to the techniques of skin coverage. Radial dorso-collateral artery In the proximal segment, located between the neck of the first phalanx and that of the first metacarpa, the external collateral artery, originating from the palmar blood supply, is inconstant and often extremely fine. Although it is slightly reminiscent of the internal collateral artery, as far as origin and connections are concerned, its identification was demonstrated in only 52% of all dissections despite the use of an optical microscope. On the contrary in the distal segment it is

constant providing that the anastomosis coming from the volar surface at the level of the head of the first phalanx are always present. This represented the departure point from the dis- tal section of the external collateral artery, which after having flowed alongside part of the second phalanx, deviated medially finally to meet up with the contralateral artery in the arcade of the nail matrix. The arcade of the nail matrix Located at a mean distance of 0.7 cm from the proximal line of the nail (min. 0.6 and max. 0.ªcm), it is very slender but firm. It can be described as a proximal con- cave curve, from where various arterial branches for osseous or tendinous purpose emerge through the distal insertion of the long extensor.On the external side, it con- tinues into the external dorso-collateral artery. The subtendinous arcade This reunites the two dorsal collateral arteries at the level of the distal metaphysis of the first phalanx. Narrow and inconstant, it was discovered in 18 out of 25 of the anatomical tests (72%).Amongst the origins of the previously described anas- tomoses, which besides feeding the vascular axis of the dorso-collateral arteries, supply a branch which stems towards the median axis of the thumb and joins up with the contro-lateral artery underneath the extensor tendon forming the arcade in question. Inspite of the smallness in size of the arteries of which it is composed, the dorsal vascularization of the thumb presents a surprising regularity (more than palmar vascularization). Some arteries, as the dorso-ulnar artery, are quite constant and, most often, of uniform size. The layout of the arterial blood supply of the dorsal surface of the thumb varies so greatly from that of the other fingers. If we examine an X-ray of the dorsal skin of a thumb and a finger, having previously injected it with Latex colouring mixed with lead (Fig. ) , it becomes obvious straight away in the case of the thumb that a con- tinuous longitudinal arterial vessel is present on the ulnar side (and in some cases also on the radial side). However, with the fingers, vascularization is extremely seg- mented, dependent almost exclusively on numerous, variable and small vessels which stem from the palmar arteries at different levels. Clinical Applications The arteries of the thumb vary in both size and number, thus making any surgical reconstruction quite delicate. Before starting any intervention, we need to clearly understand the anatomical layout of the arteries, and this is even more important if we intend carrying out an island flap or a microsurgical intervention. We have tried to schematize the most common variations of the palmar arteries, dividing the thumb into three segments, delimited from the metacarpophalangeal and in- terphalangeal flexion crease. Although no constant arteries exist in anatomy, the above concepts can often make any gesture of research or dissection of the ves-

sels easier and less traumatic. The layout of the arteries is the result of innumer- able variations regarding origin, transit, connections and size; some of these are sufficiently frequent to serve as a reasonable basis for surgical technique, but we must always be prepared for any eventual modification which may become neces- sary during an intervention. Let us imagine, for example, that we have to perform a free flap of the pulp and that the vascular anastomosis has to be carried out in the first segment: we know that the arteries which intersect the volar surface of such a region, do not generally hold much interest for the surgeon as far as size and con- stancy are concerned. Therefore we can avoid frustration while searching in vain for such an artery by starting our dissection in the dorsal compartment, where we will have a much better chance of finding an artery suitable in every aspect. Let us now imagine that we are reimplanting a thumb in the second segment: the ulnar collateral artery should be the artery that we look for first, because it is usually the biggest, the most superficial, and nearly always composed of one single trunk. Let us not forget, however, that the controlateral artery can, and not infrequently, have all the necessary requirements for an adequate anastomosis.In the third segment, the layout of the vessels is rather difficult to schematize; if it is true that the "in- verted Y” or “H” shape can make a microanastomosis easier in cases of distal reim- plantation, it is also true that such a pattern is impossible to foresee, and therefore, the interest of such classification is more academic than practical (fig. 6). Local advancement flaps at the level of the thumb constitute an excellent indica- tion in cases of mutilated or slightly oblique amputation. Some of them, such as Hueston’s, Tranquilli-Leali’s or Kutler’s flap (the latter having been proven to be less reliable than the others from a vascular point of view), do not present substantial differences as far as their realization or indications with respect to the long fingers are concerned.Others, such as Moberg’s or O’Brien’s flap, are only used at thumb level as they exploit the independence from the vascularization and the innervation from the dorsal compartment which is peculiar to the first finger.Other flaps have also been described, such as Venkataswami’s or the “reverse flow” flap, recently proposed for the long fingers, which are difficult (if not impossible) to carry out at the thumb level because of the shortness of the digital segment and the arterial anatomy peculiar to the thumb.The advancement offered by a “direct” island f lap (Ref. 10, 5ª, 62, 80) at middle finger level involves in fact the lengthening of a pedi- cle to obtain a length of about 10 cm; at thumb level the arteries are dissected on average at a length of only 6.5 cm (from which the length of the loss of substance is deducted).The “inverted” flow flap (Ref. 12, 44, 62) which bases its vascularization on the subtendinous arcades, is, at thumb level, extremely risky due to the distance between the loss of substance and the hypothetical flap which if raised, would be too small. It is only these flaps that can be used in the reconstruction of great loss of sub-

stance. As we have already seen, they can be pedicled, “island” (or “pseudo-island”) and “free”. Although “out of fashion”, they are of fundamental importance, especially for sur- geons who do not practise hand surgery every day.These flaps enable the surgeon to cover any loss of substance with a relatively simple technique (even if two stage surgery is envisaged).All of them have their own indication, but it should be noted that the majority of them (namely the hypothenar, cross-finger or groin flap) pre- sent a particular historical interest as far as reconstruction of isolated pulp is con- cerned. Nowadays, these represent the most common technique in reconstruction of great loss of pulp substance which cannot be covered with local flaps.The technique involves harvesting a distant island flap from the zone to be covered, and raising it onto a subcutaneous pedicle (which will most often be the “pseudoisland”) con- taining the artery, veins and sensitive nerve.During its transposition, the pedicle is buried into the subcutaneous tissue.Three “island” flaps are available at the mo- ment, which can be used to reconstruct almost any loss of pulp substance of aver- age size.The results are acceptable with all three at the thumb level both from an aesthetic and a functional point of view.If it is true that it is more essential than ever, regarding the thumb and the finger, to recuperate good sensibility enabling the lat- ter to “see” what is being touched (as Moberg says) it is also true that in everyday practice the best results are obtained at a level such as this, and also with non resensitized flaps.This is mainly due to the fact that, with the first finger, reeduca- tion (which represents the most important aspect of recuperation of sensibility) is "obligatory”. The patient will in fact be forced to use this finger and will not be able to "forget” it as he would if, on the contrary, it were a long finger where it could easily be included in the grasp of the neighbouring finger.

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