Correspondence and communications
References 1. Lohman RF, Langevin CJ, Bozkurt M, Kundu N, Djohan R. A prospective analysis of free flap monitoring techniques: physical examination, external Doppler, implantable Doppler, and tissue oximetry. J Reconstr Microsurg 2013;29:51e6. 2. Nahabedian MY, Patel KM. Maximizing the use of the handheld Doppler in autologous breast reconstruction. Clin Plast Surg 2011;38:213e8. 3. Goedhart PT, Khalilzada M, Bezemer R, Merza J, Ince C. Sidestream Dark Field (SDF) imaging: a novel stroboscopic LED ringbased imaging modality for clinical assessment of the microcirculation. Opt Express 2007;15:15101e14.
877 H. Bella R.A. Waters Department of Plastic and Reconstructive Surgery, University Hospitals of Birmingham NHS Foundation Trust, New Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.01.022
J.T. Hardwicke Department of Plastic and Reconstructive Surgery, University Hospitals of Birmingham NHS Foundation Trust, New Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
An alternative tendon lengthening technique
School of Clinical and Experimental Medicine, The Medical School, Vincent Drive, University of Birmingham, Birmingham B15 2TT, UK
Dear Sir,
E-mail address: [email protected]
We recently read with interest about the tendon turnover lengthening technique for reconstruction of tendon defects with a single stage procedure.1 We are concerned with the
Figure 1 Illustration to show the method of tendon lengthening. a) The tendon defect. b) The central portion of the proximal tendon stump is excised and kept. c) A corresponding, but shorter portion is excised from the distal tendon stump. d) The longer segment is placed to span the defect as a graft.
878
Correspondence and communications
bulkiness of the repair, however, even with the tubularisation of the final turned over tendon. We have been performing a similar technique for addressing tendon loss in a single stage procedure that overcomes this problem of a bulky repair. Our technique employs harvesting the central portion of the proximal tendon stump as a tendon graft. A similar shaped, shorter, defect is then created in the distal stump. The segment excised is moved distally to span the defect, and sutured in place as a graft (Figure 1). This can also then be tubularised to improve its profile. We feel that our method of overcoming small tendon defects in a single stage procedure offers benefits in ensuring the tendon thickness is as close as possible to the original donor, allowing its successful employment in extensor zone VII, in addition to other extensor tendon zones. It has not been used for flexor zone II injuries, however, due to the difficulty in accessing a sufficient length of tendon without damaging the pulley system. This technique would not be our first line reconstruction as tendon transfer or tendon graft from elsewhere, if performed appropriately, do not have significant morbidity; but on occasion with multiple tendons to reconstruct it has its place.
Funding None.
Conflict of interest statement None.
Reference 1. Cerovac S, Miranda BH. Tendon ‘turnover lengthening’ technique. J Plast Reconstr Aesthet Surg 2013;66:1587e90.
R.C. Ching S. Southern Department of Plastic Surgery, Pinderfields General Hospital, Aberford Road, Wakefield, UK E-mail address: [email protected] ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.01.015
Avoidance of recurrence of CRPS Type 1 in individuals requiring further surgery for Dupuytren’s contracture Dear Sir, Chronic Regional Pain Syndrome (CRPS) Type 1 is an infrequent, but devastating, complication following Dupuytren’s
Figure 1 Elliot’s hyperextension test showing normal middle finger MCPJ hyperextension and reduced ring finger MCPJ hyperextension as a result of Dupuytren’s disease extending across the palmar surface of the MCPJ of the ring finger. Quantification of this test by measurement of the distance between the corner of the fingernail and the table (black arrow) allows serial recording of progressive loss of MCPJ hyperextension.
surgery. There has been no discussion in the literature in the last fifty years of how to avoid the risk of a recurrence of this complication should further surgery become necessary. A plan of management is suggested. 1. Patients who had developed CRPS Type 1 after Dupuytren’s surgery and their family doctors are instructed to report any further disease as early as possible. While recurrent disease remains within the palm, the patient is seen 6 monthly: monitoring of this small number of patients to identify disease progressing towards the fingers early seems logical and not an excessive burden on any unit. 2. A loss of the normal hyperextension of the metacarpophalangeal joint (MCPJ) is the first indication of a palmar cord crossing this joint. If the MCPJ of the affected ray does not extend as far dorsally as those adjacent to it when passively extended by the patient or examiner (Figure 1), the height of the corner of the nail from the table is recorded. This measurement is repeated on a six monthly basis. Progressive loss of MCPJ passive hyperextension is taken as evidence of the disease advancing towards the finger, with a high likelihood of impending MCPJ contracture. Provided surgery is carried out before the affected finger cannot be lifted off the table, it will be confined to the palm, minimising the degree of surgical trauma. By the time the cord crosses the MCPJ, with a positive Hueston table-top test,1 it will be necessary to open and dissect the finger. 3. McCash’s open palm technique2 is used. Although McCash used this technique specifically to avoid palmar haematoma after radical palmar fasciectomy, he also pointed out that ‘a serous discharge from the wound is normally seen and this may well account for the remarkable freedom from oedema which is a feature of convalescence’. This makes early mobilisation easier
References 1. Lohman RF, Langevin CJ, Bozkurt M, Kundu N, Djohan R. A prospective analysis of free flap monitoring techniques: physical examination, external Doppler, implantable Doppler, and tissue oximetry. J Reconstr Microsurg 2013;29:51e6. 2. Nahabedian MY, Patel KM. Maximizing the use of the handheld Doppler in autologous breast reconstruction. Clin Plast Surg 2011;38:213e8. 3. Goedhart PT, Khalilzada M, Bezemer R, Merza J, Ince C. Sidestream Dark Field (SDF) imaging: a novel stroboscopic LED ringbased imaging modality for clinical assessment of the microcirculation. Opt Express 2007;15:15101e14.
877 H. Bella R.A. Waters Department of Plastic and Reconstructive Surgery, University Hospitals of Birmingham NHS Foundation Trust, New Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.01.022
J.T. Hardwicke Department of Plastic and Reconstructive Surgery, University Hospitals of Birmingham NHS Foundation Trust, New Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
An alternative tendon lengthening technique
School of Clinical and Experimental Medicine, The Medical School, Vincent Drive, University of Birmingham, Birmingham B15 2TT, UK
Dear Sir,
E-mail address: [email protected]
We recently read with interest about the tendon turnover lengthening technique for reconstruction of tendon defects with a single stage procedure.1 We are concerned with the
Figure 1 Illustration to show the method of tendon lengthening. a) The tendon defect. b) The central portion of the proximal tendon stump is excised and kept. c) A corresponding, but shorter portion is excised from the distal tendon stump. d) The longer segment is placed to span the defect as a graft.
878
Correspondence and communications
bulkiness of the repair, however, even with the tubularisation of the final turned over tendon. We have been performing a similar technique for addressing tendon loss in a single stage procedure that overcomes this problem of a bulky repair. Our technique employs harvesting the central portion of the proximal tendon stump as a tendon graft. A similar shaped, shorter, defect is then created in the distal stump. The segment excised is moved distally to span the defect, and sutured in place as a graft (Figure 1). This can also then be tubularised to improve its profile. We feel that our method of overcoming small tendon defects in a single stage procedure offers benefits in ensuring the tendon thickness is as close as possible to the original donor, allowing its successful employment in extensor zone VII, in addition to other extensor tendon zones. It has not been used for flexor zone II injuries, however, due to the difficulty in accessing a sufficient length of tendon without damaging the pulley system. This technique would not be our first line reconstruction as tendon transfer or tendon graft from elsewhere, if performed appropriately, do not have significant morbidity; but on occasion with multiple tendons to reconstruct it has its place.
Funding None.
Conflict of interest statement None.
Reference 1. Cerovac S, Miranda BH. Tendon ‘turnover lengthening’ technique. J Plast Reconstr Aesthet Surg 2013;66:1587e90.
R.C. Ching S. Southern Department of Plastic Surgery, Pinderfields General Hospital, Aberford Road, Wakefield, UK E-mail address: [email protected] ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.01.015
Avoidance of recurrence of CRPS Type 1 in individuals requiring further surgery for Dupuytren’s contracture Dear Sir, Chronic Regional Pain Syndrome (CRPS) Type 1 is an infrequent, but devastating, complication following Dupuytren’s
Figure 1 Elliot’s hyperextension test showing normal middle finger MCPJ hyperextension and reduced ring finger MCPJ hyperextension as a result of Dupuytren’s disease extending across the palmar surface of the MCPJ of the ring finger. Quantification of this test by measurement of the distance between the corner of the fingernail and the table (black arrow) allows serial recording of progressive loss of MCPJ hyperextension.
surgery. There has been no discussion in the literature in the last fifty years of how to avoid the risk of a recurrence of this complication should further surgery become necessary. A plan of management is suggested. 1. Patients who had developed CRPS Type 1 after Dupuytren’s surgery and their family doctors are instructed to report any further disease as early as possible. While recurrent disease remains within the palm, the patient is seen 6 monthly: monitoring of this small number of patients to identify disease progressing towards the fingers early seems logical and not an excessive burden on any unit. 2. A loss of the normal hyperextension of the metacarpophalangeal joint (MCPJ) is the first indication of a palmar cord crossing this joint. If the MCPJ of the affected ray does not extend as far dorsally as those adjacent to it when passively extended by the patient or examiner (Figure 1), the height of the corner of the nail from the table is recorded. This measurement is repeated on a six monthly basis. Progressive loss of MCPJ passive hyperextension is taken as evidence of the disease advancing towards the finger, with a high likelihood of impending MCPJ contracture. Provided surgery is carried out before the affected finger cannot be lifted off the table, it will be confined to the palm, minimising the degree of surgical trauma. By the time the cord crosses the MCPJ, with a positive Hueston table-top test,1 it will be necessary to open and dissect the finger. 3. McCash’s open palm technique2 is used. Although McCash used this technique specifically to avoid palmar haematoma after radical palmar fasciectomy, he also pointed out that ‘a serous discharge from the wound is normally seen and this may well account for the remarkable freedom from oedema which is a feature of convalescence’. This makes early mobilisation easier
