Functional gracilis flap in thenar reconstruction

Single incision thenar muscle reconstruction using the free functional pronator quadratus flap

Background

Injuries to the thenar muscle mass or the thenar branch of the median nerve and resulting loss of thumb opposition lead to a massive impairment of hand function. For decades, reconstructive approaches were based on tendon transfers. To broaden the reconstructive repertoire, we present the free functional pronator quadratus flap as a viable alternative for functional reconstruction and provide a specification for its indication. We demonstrate our surgical technique to a single incision reconstruction using the free functional pronator quadratus flap. Based on a series of three patients, which were analyzed for hand function using Kapandji’s score and the angle of Bourrel, grip strength and nerve conduction velocity in a two year follow up, we present an indication algorithm.

Results

After successful reinnervation of all flaps, we found an improvement of Kapandji’s score from 4.3 ± 0.94 preoperatively, to 8.7 ± 0.47 after two years. Accordingly, the angle of Bourrel decreased from 75.75 ± 3.45 degrees to 36.96 ± 3.68 degree. Grip strength also improved from 14 ± 2.2 kg to 26.2 ± 1.2 kg. No impairment of wrist pronation was observed.

Conclusion

We found excellent functional recovery of thumb opposition and strength, showing similar or even superior results compared to results from tendon transfers. With the benefit of a single incision surgery and therefore minimal donor site morbidity, this free functional muscle transfer is a viable alternative to classic tendon transfers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01308-x.

Simultaneous Opponensplasty and Free Gracilis Muscle Flap for Thenar Reconstruction after Arteriovenous Malformation Resection

We report the case of a thenar eminence arteriovenous malformation presenting with continuous growth and pain that was treated with surgical excision after embolization. Extracapsular resection compromised thenar muscles which function was reconstructed with extensor indicis proprius transfer for opposition and abduction, and neurotized free gracilis muscle flap for opposition and adduction, as well as thenar eminence reconstruction.

The Essential Local Muscle Flaps for Lower Extremity Reconstruction

BACKGROUND

 Lower extremity reconstruction is often a challenging prospect with major implications on a patient's quality of life. For complex defects of the lower extremity, special consideration must be given to ensure suitable and durable coverage. In the following article, we present the essential local muscle flaps for lower extremity reconstruction and discuss guiding principles for the reconstructive surgeon to consider.

METHODS

 A thorough literature review was performed using PubMed to identify commonly used local muscle flaps for lower extremity reconstruction. Common considerations for each identified flap were noted.

RESULTS

 The essential local muscle flaps for lower extremity reconstruction were identified and classified based on anatomical region of the defect to be reconstructed. General considerations and postoperative management were discussed to aid in operative decision making.

CONCLUSION

 While many factors must be taken into account when performing lower extremity reconstruction, there are numerous reliable local muscle flaps which can be used to successfully provide durable coverage for a variety of soft tissue defects of the lower extremity.

Free Functional Muscle Transfer for Thumb Opposition

Traumatic injuries and other conditions resulting in thenar loss and loss of opposition function can cause significant functional limitations. There are limited options available to restore function and bulk to the thenar musculature. A 26-year-old man had an unfortunate accident at work with a machine mixer creating a crush injury to his left hand. This required several debridements due to the tissue injury and resulted in loss of the thenar muscles and ability to oppose the thumb. He recovered well from the initial injury, however, was left with difficulty with grasp and holding objects due to the loss of thenar motion and strength. His function was also affected by the loss of bulk. He successfully underwent a free functional muscle reconstruction with his serratus anterior. This case report is a description of his reconstruction and a review of the literature. The patient had an excellent outcome. He obtained active opposition and improved grip strength, improving his activities of daily living and vocational life. The serratus anterior muscle can successfully be used for thumb opposition reconstruction. This case report demonstrates good outcomes for both motion and bulk restoration.

Functional pectoralis minor myocutaneous flap transplantation for reconstruction of thumb opposition: An anatomic study with clinical applications

OBJECTIVE

To develop a myocutaneous flap for reconstruction of thumb opposition function in patients with loss of the thenar muscles and skin.

METHODS

An anatomic experiment on the dimensions of the pectoralis minor muscle and its neurovascular supply in 10 adult human cadavers was conducted to evaluate the feasibility of microsurgical transplantation using part of the muscle for thumb opposition reconstruction. Based on these results, we performed surgical thenar reconstruction with a pectoralis minor myocutaneous flap in seven patients (34.7 ± 9.8 years of age) from December 2007 to October 2010.

RESULTS

The transferred muscle was reinnervated with the third lumbrical branch of the ulnar nerve. Six to twelve months after the surgery, follow-up assessment showed that all patients had recovered functional opposition of the carpometacarpal joint with survival of the skin and a muscle power of M4 to M5.

CONCLUSION

Our results support the use of this new technique for thenar and opposition reconstruction in patients with severe loss of the thenar muscles and skin and damage to the median nerve and who wish to improve the appearance of the thenar eminence.

Free lateral tarsal artery perforator flap with functioning extensor digitorum brevis muscle for thenar reconstruction: a case report

In this case report, we describe reconstructive surgery in one patient using a free lateral tarsal artery perforator flap with a functioning extensor digitorum brevis muscle. A 47-year-old woman sustained a crush-avulsion injury to her dominant right hand while working in a factory. A large thenar skin and muscle defect (5.5 cm × 4.0 cm) occurred as a consequence of surgical debridement. The skin and muscle defect was repaired using a free lateral tarsal artery perforator flap with a functioning extensor digitorum brevis muscle in a single operation. The donor site defect was repaired using a full-thickness skin graft. The patient recovered without postoperative complications. The patient showed satisfactory functional gain without significant donor site morbidity at the 4-year follow-up visit. Thus, we have demonstrated that a functional reconstruction of a thenar skin defect complicated by muscle loss is possible by transferring a free lateral tarsal artery perforator flap with the underlying extensor digitorum brevis muscle.

Free Functional Muscle Transfers to Restore Upper Extremity Function

Free functional muscle transfer provides an option for functional restoration when nerve reconstruction and tendon transfers are not feasible. To ensure a successful outcome, many factors need to be optimized, including proper patient selection, timing of intervention, donor muscle and motor nerve selection, optimal microneurovascular technique and tension setting, proper postoperative management, and appropriate rehabilitation. Functional outcomes of various applications to the upper extremity and the authors' algorithm for the use of free functional muscle transfer are also included in this article.

Soft tissue coverage of the upper extremity: an overview

Prehension is a complex function of the hand that gives it mechanical precision combined with a standard sensory pattern. The priority in soft tissue reconstruction for the upper extremity is to restore function. Significant injury to the upper extremity may result after trauma because of various etiologies. The timing and choice of soft tissue coverage for upper extremity defects warrant special consideration to avoid prolonged immobilization, which can result in joint stiffness, tendon adhesions, scar contractures, and ultimately, loss of function. This article reviews the various reconstructive options and considerations involved in providing coverage for upper extremity soft tissue defects.

Free muscle flaps for reconstruction of upper limb defects

Restoration of structure, function, and sensation are critical after trauma or tumor resection of the hand. Thorough debridement, reconstruction of functional structures, and immediate soft tissue coverage are most effectively performed in a single stage within approximately 24 hours of the injury. Skin flaps provide robust, pliable, and cosmetically appropriate tissue that is not prone to contracture and that facilitates secondary reconstructive work. Muscle flaps retain indications for complex defects with substantial initial contamination or dead space, or for reanimation. In this article, the indications, options, and surgical techniques for free muscle flap reconstruction of upper limb defects are reviewed.

Open fractures of the hand with soft tissue loss

The evaluation, initial treatment, and definitive reconstruction of open fractures of the hand with associated soft tissue loss are reviewed. Specific attention is given to the literature on open fracture antibiotic prophylaxis in the hand; the timing of bone and soft tissue reconstruction; and options for soft tissue coverage, including local, regional, and distant tissue transfer. Factors that have shown association with outcomes in these injuries are also discussed, and the authors' preferred management is summarized.

Functional anconeus free flap for thenar reconstruction: a cadaveric study

BACKGROUND

Restoration of thumb opposition when significant thenar soft tissue defects occur remains a considerable surgical challenge. While several clinical applications of the anconeus muscle have been developed, free functioning muscle transfer (FFMT) of the anconeus for thenar reconstruction has not been reported previously. This study therefore sought to describe anatomical features of the anconeus that would determine its suitability for use as a FFMT.

METHODS

The anconeus, its corresponding abductor pollicis brevis (APB), and the supplying neurovasculature in eight white British cadaveric upper extremities were identified and dissected. Measurements were performed using standard calipers and ImageJ 1.45d for a quantitative description of muscle architecture and the neurovasculature involved in the operative planning of the anconeus FFMT.

RESULTS

The mean measures of the anconeus were larger than those of the APB (anconeus/APB fiber length = 88.0 ± 9.9/57.7 ± 9.0 mm, area = 1,341.9 ± 230.4/987.7 ± 251.2 mm(2)). There was no significant difference between mean fiber angles (anconeus/APB = 70.5 ± 11.9°/78.4 ± 12.2°; p > 0.05) and neurovasculature (anconeus/APB: artery diameter = 1.9 ± 0.2/2.0 ± 0.5 mm, nerve diameter = 1.7 ± 0.3/2.1 ± 0.4 mm; p > 0.05). The length (31.3 ± 6.9 mm) and caliber (diameter = 1.9 ± 0.2 mm) of the vascular pedicle of the anconeus (recurrent posterior interosseous artery) and its venae comitans (diameter = 1.0 mm) are sufficient for microsurgical anastomosis.

CONCLUSIONS

The anatomic rationale of the anconeus FFMT for thenar reconstruction is sound and, compared to other FFMTs, may provide several advantages: reliable and matching anatomy, minimal donor site morbidity, and the potential to restore a greater degree of opposition and thus function in a one-stage procedure.

Functional pectoralis minor muscle flap transplantation for reconstruction of thumb opposition: an anatomic study and clinical applications

In this report, we present the results of an anatomic study on the dimensions of the pectoralis minor muscle and its neurovascular supply in 10 adult human cadavers, in attempt to evaluate the feasibility of microsurgical transplantation of a part of the muscle for thumb opposition reconstruction. A series of five patients consequently underwent thenar reconstruction with the pectoralis minor muscle flap from December 2004 to October 2006. The transferred muscle was reinnervated with the third lumbrical branch of the ulnar nerve. Follow-up assessment showed that the patients recovered functional opposition of carpometacarpal joint with 24 degrees of pronation, and a muscle power with M4 to M5. All patients were satisfied with the appearance of reconstructed thenar eminence. We recommend this new technique for thenar and opposition reconstruction in patients who have severe loss of thenar muscles, injury to the median nerve, and wish to improve the appearance of thenar eminence.

The transversely split gracilis twin free flaps

The gracilis muscle is a Class II muscle that is often used in free tissue transfer. The muscle has multiple secondary pedicles, of which the first one is the most consistent in terms of position and calibre. Each pedicle can support a segment of the muscle thus yielding multiple small flaps from a single, long muscle. Although it has often been split longitudinally along the fascicles of its nerve for functional transfer, it has rarely been split transversely to yield multiple muscle flaps that can be used to cover multiple wounds in one patient without subjecting him/her to the morbidity of multiple donor areas.