RECOVERY OF HAND GRASPING BY TRANSPOSITION OF THE FINGERS, FINGER STUMPS, AND METACARPAL BONES AFTER INJURIES AND THEIR CONSEQUENCES

Aims. To improve the efficacy of the finger repair method due to transposition of hand segments, including cicatricial and deformed ones. Materials and methods. The article presents the experience of surgical treatment of 184 patients with traumatic absence of fingers through the use of donor resources of the damaged hand itself. The fingers were repaired by transposition of the intact, defective finger, finger stump, or metacarpal bone. Thumb repair was carried out in 177 cases, pointer finger – in 12, middle finger – in 5, ring finger – in 8, and little finger – in 1 case. Recovery of one finger (usually the thumb) was implemented in 186 cases, the thumb and one of the triphalangeal fingers – in 5 cases, the thumb and two triphalangeal fingers – in 1 case, and two triphalangeal fingers – in 2 cases. With tissues that were intact and not very altered, the prevention of ischemic complications was performed by preserving or repairing the finger vessels and veins. With pathologically altered tissues, the segment was transpositioned in two stages, after its presurgical training. If there was a short finger donor stump, distraction of pedicles was additionally carried out. Results. The developed methods based on ischemic preconditioning, preforming of the transpositioned segments, and distraction of pedicles, extended the potential of using the pathologically changed tissues, provided sturdy engraftment and recovery of the hand grasping with minimal donor deformity. The immediate and long-term treatment outcomes were analysed. The method for mechanical training of the donor finger for ischemia before its transposition was suggested. This method has provided the possibility for transposition of any hand segment regardless of its location relative to the finger under repair, scarring severity, and nature of the hand deformation. The possibility for transposition of the finger stumps and metacarpal bones with more proximal amputation levels (P = 0.01) and ulnar location (Р = 0.0001) was shown. Conclusions. Application of the method allowed for recovery of hand grasping in 93.3% of the victims, despite the heavy scar deformation of the donor segment and the hand caused by mechanical, gunshot, thermal, and combined injuries.

or its stump. This provides a reduction of the donor part damage and the degree of blood circulation disturbances in the transferred segment due to a milder injury of vascular bundles and the transferred skin flaps [1; 5]. However, the existing technologies do not allow surgeons to transpose short finger and metacarpal stumps located far from the recipient area and deformed fingers in patients with damaged great vessels and severe disturbances of tissue blood supply [5]. The The aim of the study was to expand a set of indications for the method of reconstruction of fingers with transposition of hand segments, including cicatricial and deformed ones.

MATERIALS AND METHODS.
The study protocol followed guidelines for experimental investigation with human subjects in accordance with the Declaration of Helsinki and was approved by the ethics committee. Written informed consent was obtained from each patient (or official representative) before the study.
The authors analyzed the results of the treatment of 184 patients with 189 hands that underwent primary and secondary reconstruction of 203 fingers by the method of transposition of different segments of the deformed hand with conventional (85 fingers) and original (118 fingers) techniques. In the majority of cases, mechanical injuries of hand were observed (101 -54.9%).

Figure 1. Types of hand deformities
The character of the transferred segments in patients with different types of deformities and types of reconstruction is presented in Table 1. Thumb reconstruction was performed in 177 of cases, reconstruction of finger IIin 12 cases, reconstruction of finger IIIin 5 cases, reconstruction of finger IVin 8 cases, and reconstruction of finger Vin 1 case. Reconstruction of one finger (primarily, finger I) was performed in 186 cases, I and one of three-phalange fingersin 5 cases, I and two of three-phalanges fingersin 1 case, and two three-phalanges fingersin 2 cases. The levels of amputation of the reconstructed finger are presented in Table 2. It was also shown that the transposition of finger and metacarpal bone stumps after distraction was primarily used in patients with distal amputations. As a rule, the stump of finger II or the adjoining finger was transferred, and after the distraction, ulnar stumps at proximal levels.  Clinical case.
Man, 42 years old, was admitted to the clinic with total deformity of the radial side of the right hand; flexing dermato-teno-arthrogenic contractures of fingers II, III and IV; deformity of soft tissues and bones; damage of palmar digital arteries of finger II, extensive contracture of the right hand after severe mechanical injury (Figures 2-4).       The published data and the authors' experience show that primary or venous revascularization of the donor segment is feasible only in cases when the vessels are not damaged, intact tissues are preserved or there are no severe cicatricial alterations when the risk of ischemic complications is relatively low [7][8][9]. The results of the present study showed that the hypoxic preconditioning of the segment was an effective method of prevention of post-operational ischemic complications. It activates the mechanisms of adaptation at different levels of systemic organization of tissues in response to a short, mild, and undamaging ischemic stimulus. Dosed controlled ischemic load on tissues, achieved during pre-training of the transferred complex, improves its resistance to hypoxia, induces cellular metabolic adaptation, the longitudinal orientation of pedicle vessels, and an increase in the blood rate, which improves the retention of the segment tissues.
Besides, an elongation of feeding pedicles is observed, which allows for the transposition of remote stump of the metacarpal bone and any three-phalanges finger at the primal levels, including the cases with two feeding pedicles, via the remaining fingers or stumps, and perform the reconstruction of the first and/or one of the other fingers with minimal damage to the donor area [10].
The obtained results showed that the developed approaches expand the set of indications for the transposition of hand segments and provide adequate functional results even in cases with severe cicatricial deformities.

CONCLUSIONS.
Ischemic preconditioning and preformation of cicatricial donor segments provided their 100% retention and restoration of the handgrip in the majority of patients (93.3%) with different types of hand deformity of a mechanical, gunshot, and thermal etiology. .

FINANCIAL SUPPORT AND SPONSORSHIP
Nil.