Long-term outcome of fingertip reconstruction with the homodigital neurovascular island flap

A case series study in new restorative surgery in thumb amputation: The Adiposofaciocutaneous flap technique for distal thumb amputation replantation

Thumb distal amputation refers to the loss of a portion of the thumb at or near the tip, which can be caused by various injuries such as crush injuries, lacerations, or avulsions. Several surgical methods can be used to repair thumb distal amputations, including composite graft, flap reconstruction, replantation, and amputation revision. In this case report, we describe a successful surgical procedure performed on three healthy men (19, 26, and 44 years old) who suffered a sharp amputation of their left and right hands thumb. In one case initial fixation of the amputated part was performed by a general orthopedic surgeon as a composite graft, two other cases were referred us without any procedure. The procedure involved irrigation and minimal debridement and deepithelializing the amputated part and fixation it with one or two 1.5 mm steinman pins and repairing the nail bed with7/0 absorbable sutures. An adiposofaciocutaneous flap from the index finger was used to cover the pulp of the thumb and the nail bed, while a full-thickness grafts from the same wrist in one case and medial part of ipsilateral arm in others were used to repair the defect on the dorsal side of the index finger. The wound was dressed, and the sutures were removed after two weeks. The base of the flap was detached from the index finger after three weeks, and the kwires were removed after six weeks. The flap and graft were successfully taken, except for a small part of the tip of the thumb. Two years after the operation, in two patients and 3 months in whom was operated recently, all the patient's thumbs had a reasonable shape and length with minimal nail deformity. The use of an index finger based adiposofaciocutaneous flap and full-thickness graft in these cases allowed for successful reconstruction of the thumb and, improving both function and appearance.

Outcomes of antegrade homodigital neurovascular island flap in fingertip amputations

BACKGROUND

Antegrade homodigital neurovascular island flap (AHIF) is one of the methods used in fingertip amputations to cover the defect area, preserve finger length and obtain a painless and sensitive fingertip. The aim of this study was to evaluate the functional and sensory outcomes in patients who underwent AHIF for fingertip amputation and to analyze the relationship between patient satisfaction and outcome measures.

METHODS

Twenty patients with a mean age of 37 (18-63) years were analyzed retrospectively. The patients were evaluated in terms of hook nail development, active interphalangeal joint movements, cold intolerance, and sensory function of the flap covered area. Static two-point discrimination test and Semmes Weinstein monofilament test were performed for sensory evaluation.

RESULTS

All flaps survived completely at the end of follow-up (mean, 36 months; range 11-64 months). Five patients had cold intolerance and two had hook nails. In total, proximal interphalangeal or distal interphalangeal joint flexion contracture developed in 25 % of the patients. The mean static two-point discrimination score was 4.6 ± 1.6 (2-8) and Semmes-Weinstein monofilament test score was 3.48 ± 0.6 (2.44-4.17). Subjective satisfaction levels of the patients were found to be high and did not show a statistical relationship with the measured clinical outcome parameters (p > 0.05).

CONCLUSIONS

Since AHIF contains a solid and continuous neurovascular pedicle, the probability of necrosis and loss of sensation is low in AHIF. In addition, the graft need of the donor area is not high. Its disadvantage is the rate of restriction of joint movements.

LEVEL OF EVIDENCE

IV.

Long-term patient-reported outcome measures of fingertip coverage with a homodigital unipedicle neurovascular island flap

We report the long-term patient-reported outcomes and objective outcomes of a homodigital neurovascular island flap for distal phalangeal amputations in the fingers (with the thumb excluded) for 20 patients at a median follow-up of 4.4 years (IQR 2.2 to 12.3). We assessed the global subjective and aesthetic outcomes, range of motion, sensitivity and strength. The patient-reported median subjective global score was 7.5/10 points (IQR 7 to 9) and the aesthetic score was 8/10 points (IQR 8 to 9). Range of motion, sensitivity and strength were similar to the uninjured side. Stiffness was present in more than half of the cases; 14 patients had a hook nail deformity and seven patients reported symptomatic cold intolerance. At a long-term follow-up, the patient-reported outcome measures and objective outcomes of this flap are satisfactory and it is a safe and reliable flap.Level of evidence: IV.

Homodigital Unipedicled Islanded Neurovascular Pulp Advancement Flap/Colombo Flap for Fingertip Reconstruction: A Case Series with a Novel Technique

Fingertip injury is the most common type of upper extremity injury. Operative treatment with flap cover is required for tissue loss causing bone exposure and when there is a compelling need to preserve the length, unless microvascular replantation is possible. There are many techniques described for this purpose offering varying degrees of good outcomes. Yet there are limitations and long-term problems. We report a case series with a novel technique named "Colombo flap," which is a neurovascular islanded advancement flap based on a single pedicle. Five fingers of four consented patients were operated using this technique and they were followed up for 2.5 years. All had satisfactory sensory recovery (S3 +/S4), preserved range of motion (ROM) at interphalangeal joints, good grip strengths, and satisfactory outcomes based on Michigan Hand Questionnaire (MHQ). There were no complications such as flap necrosis, infection, and neuroma formation. Hook nail deformity was minimal and none had pain or cold intolerance.

The Efficacy of Antegrade Homodigital Neurovascular Island Flaps in Distal Fingertip Reconstruction: A Systematic Literature Review

BACKGROUND

Antegrade homodigital neurovascular island flaps (AHIFs) are a heterogeneous group of pedicled flaps used for reconstruction of traumatic digital detipping injuries. While numerous single-center studies have documented their use, there are no large or multicentre studies validating their efficacy, applicability, and functional outcomes. We performed a systematic review of the contemporary literature to establish the safety and functional outcomes of this technique.

METHODS

Electronic searches were performed using PubMED, Embase, and MEDLINE from inception date to October 2020, with further studies identified from study reference lists and independent searches. Relevant studies reported on complications and functional outcomes of the AHIFs, as used for digital detipping injuries. Data were then extracted and analyzed.

RESULTS

Twenty-seven studies published between 1974 and 2019 yielded 744 patients. Four studies provided incomplete epidemiologic data, resulting in a total of 559 patients with 584 digital injuries. Index and middle fingers were most frequently involved. Mean final 2-point discrimination (2-PD) was 4.9 mm static and 5.1 mm dynamic, with dynamic 2-PD reported in 2 studies. Mean total active motion of the digit was 200.3°. Mean time to return to work was 6.7 weeks in 10 studies. Flap survivorship was found to be 99.6% in 23 studies. Cold intolerance was the most common complication at 18%, followed by pain and hypersensitivity.

CONCLUSIONS

Antegrade homodigital neurovascular island flaps provide a safe and effective method of treating distal finger amputations, yielding satisfactory functional outcomes across all ages. Further studies comparing outcomes between the AHIFs and other reconstructive modalities would be useful.

Long-term outcomes of homodigital neurovascular island flap reconstruction of fingertip injuries in children

We evaluated the long-term functional and cosmetic results of homodigital neurovascular island flap (NIF) used to reconstruct extensive pulp defects with bone exposure in children. Twenty-three children (mean age 4.8 years, range 1-10 years) with fingertip injuries were reconstructed with a pedicled homodigital NIF and evaluated in terms of sensation quality, cold intolerance, scar formation, nail deformity, range of motion and overall finger length at a mean follow up of 7.8 years (range 2-13). Eleven patients reported cold sensitivity in the operated fingertip, and 15 presented with hook nail deformities at the final follow-up. The total active motion of the injured finger was significantly lower than that of the uninjured side (p < 0.001). NIFs is a safe, reliable reconstructive treatment for fingertip loss in children, but commonly encountered issues in the long term include an extension lag of the interphalangeal joints, hook nail deformities and cold intolerance.     Level of evidence: IV.

Facilitated harvesting of a radial artery superficial palmar branch flap for reconstruction of moderate finger skin defects

Radial artery superficial palmar branch harvesting is technically challenging, especially for inexperienced hand surgeons. The short pedicle and a damaged recipient digital artery require proximal digital artery dissection and relatively long pedicles. Herein, we describe a facilitated flap elevation technique and its application in various cases. From 2013 to 2021, 10 patients with finger injuries received radial artery superficial palmar flaps. We assessed flap survival, sizes, complications, two-point discrimination, and the Semmes-Weinstein monofilament test results. The main shortcoming of a radial artery superficial palmar flap is its short pedicle. Therefore, we developed a long skin flap design in the long axis direction, and the accompanying vein was dissected proximally to the radial artery to obtain a long pedicle. All flaps survived. The median flap dimension was 5.0 × 2.2 cm (maximum size: 6.0 × 2.0 + 5.0 × 2.0 cm [for a bilobed flap]). While nerve reconstruction was performed in one patient, all patients had preserved sensation. A sufficiently long pedicle can be obtained by dissecting the accompanying vein proximally to the radial artery. Perforators found in the skin around the scaphoid tubercle in all cases suggest value in including this region in flap design. To obtain a longer pedicle, the flap was developed with the long-skin design in the long-axis direction. Although the accompanying vein is usually thin and difficult to anastomose with the finger vein, its proximal dissection led to the accompanying vein of the radial artery that facilitated the harvesting of a sufficiently long vein.

Comparative Study of the Clinical Effects of Reverse Digital Artery Island Flaps and Antegrade Homodigital Neurovascular Island Flaps for Fingertip Reconstruction

OBJECTIVE

This retrospective study aimed to compare the clinical effects of reverse digital artery island flaps and antegrade homodigital neurovascular island flaps in fingertip reconstruction.

PATIENTS AND METHODS

We retrospectively analyzed the data of 30 consecutive patients with fingertip defects who had undergone 2 types of surgery from January 2016 to January 2019. We used reverse digital artery island flaps and antegrade homodigital neurovascular island flaps in 14 and 16 patients, respectively. Flap sensitivity was evaluated using the Semmes-Weinstein monofilament test and static 2-point discrimination test. Finger appearance was assessed using the Michigan Hand Outcomes Questionnaire. The operation time, flap sensitivity, range of motion of the interphalangeal joint, and complications were evaluated.

RESULTS

The static 2-point discrimination results of the fingers were significantly different between the antegrade homodigital neurovascular island flap group and reverse digital artery island flap group (8.07 ± 1.54 vs 5.94 ± 1.73; P < 0.05). The appearance of the fingers was significantly better in the antegrade homodigital neurovascular island flap group. Surgery using antegrade homodigital neurovascular island flaps required less time than surgery using reverse digital artery island flaps. No significant differences were found between the 2 groups in the range of motion of the interphalangeal joint or complications.

CONCLUSIONS

The functional outcomes were identical between the reverse digital artery island flap and antegrade homodigital neurovascular island flap methods for fingertip reconstruction. Antegrade homodigital neurovascular island flaps lead to a shorter operation time, a more satisfying appearance, and better sensory recovery.

Long-term outcome of a "short" anterograde homodigital neurovascular island flap with a simple or double V-Y plasty

INTRODUCTION

Anterograde homodigital neurovascular island flaps are very useful for reconstructing proximal fingertip amputations with exposed bone but have the disadvantage of bringing about proximal interphalangeal joint (PIPJ) stiffness. The addition of a single or double V-Y plasty increases mobility without having to extend the dissection beyond the PIPJ. The purpose of this study was to examine the long-term functional outcome of patients who received a "short" anterograde homodigital neurovascular island flap with a single or double V-Y plasty. Our primary hypothesis was that this flap did not induce PIPJ stiffness and our secondary hypothesis was that it preserved good fingertip sensation.

MATERIALS AND METHODS

This was a retrospective study of patients operated between August 2017 and February 2019. The inclusion criteria were the following: a fingertip amputation caused by either a crush or laceration injury with exposed bone, treated during the acute phase of the injury or for secondary necrosis (attempted replantation or subtotal amputation) and classified as type II oblique palmar, type III or type IV amputations according to the Allen classification system. The assessment criteria were: joint mobility, sensory evaluation with the two-point discrimination and Semmes-Weinstein monofilament tests, time to healing, postoperative complications, postoperative splinting, duration of work stoppage, perioperative smoking, cold intolerance, touch hypersensitivity, nail deformity and excluded finger.

RESULTS

Nine patients (mean age 53.9 years [32-67]) were operated, of which eight long fingers and one thumb. One procedure was complicated by skin flap necrosis. At the mean follow-up of 22.4 months [16-31], the mean mobility for the metacarpophalangeal joint (MCPJ), proximal interphalangeal joint and distal interphalangeal joint (DIPJ) were 92-0-0°, 97.8-1.5-0° and 60.3-6.8-0°, respectively. In comparison to the contralateral side, a significant difference was only detected in the DIPJs. The mean two-point discrimination in the proximal portion of the flaps were 7.1mm on the ulnar side (p<0.05) and 7.6mm on the radial side (p<0.01), while in the distal portion they were 7.3mm (p<0.01) and 7.8mm (p<0.01). The Semmes-Weinstein monofilament test also detected significantly reduced sensation.

CONCLUSION

The combination of a "short" anterograde homodigital neurovascular island flap with a single or double V-Y plasty seems to avoid PIPJ stiffening while preserving good fingertip sensation.

LEVEL OF EVIDENCE

IV; retrospective study.

Fingertip injuries managed by a thenar flap: Follow-up and long-term outcomes of 32 cases

While various techniques are used for the reconstruction of fingertip injuries, the main goals remain the same: preserve finger length, sensation, and function. The thenar flap is a well-described technique and simple procedure in fingertip amputations. This study aimed to evaluate the long-term functional and esthetic outcomes along with patient satisfaction of thenar flaps done for fingertip defects. Thenar flaps used in 32 patients operated between January 2010 and December 2016 were analyzed retrospectively to assess sensory recovery, range of motion, cold intolerance, pain relief, appearance, patient satisfaction, and QuickDASH score. All flaps survived, without adverse events. The flap was detached after 10-14 days (mean 12.5 days). The mean follow-up was 31 months (range, 20-45 months). According to Semmes-Weinstein monofilament test results, protective sensation was achieved in 25 patients (78%). The mean static 2-point discrimination was 6.1 mm. There were no functionally significant finger flexion contractures at the final follow-up. Complications such as pain, donor site morbidity and cold intolerance were not encountered. The thenar flap is an excellent technique for coverage of total or subtotal tissue loss of radial-side fingertips that is not accessible to local flaps. It provides good sensory function and appearance when fundamental technical principles (flap design, timing of division, and early mobilization) are respected.

Flap Repair Technique for Soft Tissue Defects of the Hand

ABSTRACT

Repair for the soft tissue defects of hand has been a major challenge of hand or reconstructive surgery. A lot of flaps are used, free or pedicle flap, but there are no comprehensive description of these flaps. In this article, we retrospectively reviewed the repair technique of the fingertip defect, palmar or dorsal defect of the hand, by using different flaps in 14 cases, between June 2010 and December 2014, and the advantages and limitation of each flap are simply stated. We have shown a lot of surgical pictures, with a small amount of text, providing a wide range of ideas for the surgeon to freely choose an easy and effective method for his own technology. Overall, these approaches are simple, safe, and effective for repairing the soft tissue defect of the hand.

Understanding and Measuring Long-Term Outcomes of Fingertip and Nail Bed Injuries and Treatments

There are many outcome measures to choose from when caring for or studying fingertip and nail bed trauma and treatments. This article outlines general outcome measures principles as well as guidelines on choosing, implementing, and interpreting specific tools for these injuries. It also presents recent results from the literature for many of these measures, which can help learners, educators, and researchers by providing a clinical knowledge base and aiding study design.

Locoregional Options for Acute Volar Pulp Fingertip Defects

The volar fingertip is a unique anatomic structure, delicate yet durable, that allows us to navigate the world, acquire information from our surroundings, and express ourselves. Injuries to the volar finger can cause permanent dysfunction and should be taken seriously. In treating injuries of the volar fingertip, the surgeon has an opportunity to choose from a host of reconstructive options and provide the patient with an outcome suitable to their needs. In doing so, the hand surgeon is well-positioned to aim for the reconstructive ideal of restoring both structure and function.

Secondary Management of Nonnail Perionychial Deformities: Restoring Aesthetic and Functional Subunits

Delayed finger and thumb tip reconstruction should try to optimally reconstruct perioncyhial aesthetic and functional units by replacing tissue as closely resembling the original loss as possible. Avoid thinking in terms of a "reconstructive ladder" but rather going directly to the reconstructive choice that seems most suited to the task. Some reconstructive choices may seem more attractive because of their simplicity, but may not necessarily give the best functional and aesthetic result. Free flaps and the newer advancements with vascular island flaps give many more and versatile reconstructive options.

Modified Oblique Triangular Neurovascular Island Flap Technique to Prevent the Development of Hooked Nail Deformity

Hooked fingernail deformity can develop after any type of fingertip amputation. A more proximal amputation is associated with a higher probability of developing hooked fingernails. Proximal fingertip amputations with very short remaining nail beds are recommended for revision amputation with nail bed ablation. This procedure eliminates the possibility that the patient may have a functional nail. When the nail matrix is still retained, an oblique triangular neurovascular island flap may preserve the nail and digit length. At our institution, the modified oblique triangular neurovascular island flap is routinely used for patients who underwent fingertip amputation with a retained nail bed. These modifications may aid in preventing the development of hooked nail deformity and creating a round pulp contour without the need for fixation, composite grafts, or distant soft tissue transfer.

[Homodigital neurovascular island flap according to Venkataswami]

OBJECTIVE

Reliable wound coverage of the fingertip and palmar aspect of the middle finger with a sensate flap in order to restore early function.

INDICATIONS

Palmar, oblique pulp defects or amputations at the distal finger phalange with uncovered bone, tendons, and/or neurovascular structures.

CONTRAINDICATIONS

Peripheral perfusion deficiency, size of defect exceeding flap capacity, obliteration of the flap artery, i.e. contralateral finger artery.

SURGICAL TECHNIQUE

Harvesting of adipocutane, midlateral triangle based on proper digital vessel flap; distal flap transposition and primary closure of the harvesting defect, flap dimension 4-5 mm larger than defect.

POSTOPERATIVE MANAGEMENT

Finger splint for 2 weeks, followed by exercises with flap conditioning.

RESULTS

Very reliable defect coverage with 9% minor and temporary complications, all of which healed without consequences.

Maximal advancement of homodigital neurovascular island flaps

We investigated the maximal advancement of the homodigital neurovascular island flap with the digit in full extension and its correlation to the digital length. In 32 adult cadaveric digits, flaps measuring 1 × 1 cm were sequentially elevated to different dissection points. Dissection of the flap to the proximal interphalangeal joint crease, palmo-digital crease, division of adjacent digital artery and the superficial arch resulted in flap advancement of 8, 12, 15 and 18 mm, respectively. The degree of advancement correlated to the length of the finger and was approximately 19% of the finger length. We conclude that dissection of a homodigital antegrade neurovascular island flap to the proximal interphalangeal joint, palmo-digital crease, after ligation of adjacent digital artery and the superficial arch allows progressively more advancement. The advancement obtained by flap dissection to the palmo-digital crease was about 19% of the finger length.