|| The rotational osteotomy of a thumb metacarpal is a particularly worthwhile procedure when good sensation is present, for example, in a proximal palm or higher replant where intrinsic functional return is unlikely. Again, newer miniplating or external fixation techniques are of value. Ray resection and ray transposition should be considered carefully. Despite improved cosmetic appearance, one must consider that a narrowed palm reduces twist grip strength, important to both male and female patients. The rest of the palm is also an important interpersonal tactile contact area when shaking hands, a universal form of initial communication. A "spidery," narrow, threefingered palm is immediately noticed by everyone, whereas the same deformity on the left hand may go unnoticed indefinitely. The use of ray resection to remove painful amputation stumps is not always successful. More proximal neuromas may still plague the patient, leading to even more proximal dissections. Though not widely accepted, a better way to treat such a painful amputation stump is to give the obviously viable nerve endings a place to grow by anastomosing the nerves into a toe transplant to the missing digital stump.
Secondary Nerve Operations
Restoration of useful protective sensation is as important as, if not more important than, restoring anatomic integrity. Replanted parts are seldom used before some form of sensory return. The degree of disability varies tremendously from patient to patient, depending upon individual needs and objectives. Work stains and calluses are more important signs of useful nerve regeneration and function than the measurement of static, moving twopoint touch or filament pressure. A patient with a two-point touch of 20 mm may be functioning better than another with 10 mm of hyperaesthetic sensory feedback. The old adage that "when you have nothing, a little goes a long way," may well be a factor in such cases. Although controversial, the sensory functional result often does not correlate with the initial injury or quality of nerve repair. Shredded, stretched nerve stumps brought together in a perfunctory manner may give a more useful result than the finest microanatomical repairs of sharply incised structures. Axon "oomph," like many physiologic responses, decreases with age but still depends on anatomic alignment. Despite these variables, nerve repairs should be still executed with the same, if not greater, attention to detail as that given to vascular repairs.59
Table 33-3 Second Procedures in Proximal Level l Upper Extremity Replants.