Reconstruction of multiple fingertip injuries with reverse flow homodigital flap

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.

Clinical Outcomes and Complications of Primary Fingertip Reconstruction Using a Reverse Homodigital Island Flap: A Systematic Review

BACKGROUND

Reverse homodigital island flaps (RHIFs) are increasingly used to reconstruct traumatic fingertip injuries, but there is limited evidence on the efficacy of this technique. We performed a systematic review of the literature to establish the safety and functional outcomes of RHIF for traumatic fingertip injuries.

METHODS

Electronic searches were performed using 3 databases (PubMed, Ovid Medline, Cochrane CENTRAL) from their date of inception to April 2020. Relevant studies were required to report on complications and functional outcomes for patients undergoing RHIF for primary fingertip reconstruction. Data were extracted from included studies and analyzed.

RESULTS

Sixteen studies were included, which produced a total cohort of 459 patients with 495 fingertip injuries. The index and middle fingers were involved most frequently (34.6% and 34.1%, respectively), followed by the ring finger (22%), the little finger (6.7%), and the thumb (2.6%). The mean postoperative static and moving 2-point discrimination was 7.2 and 6.7 mm, respectively. The mean time to return to work was 8.4 weeks. The mean survivorship was 98.4%, with the pooled complication rate being 28%. The pooled complication rate of complete flap necrosis was 3.6%, of partial flap necrosis was 10.3%, of venous congestion was 14.6%, of pain or hypersensitivity was 11.5%, of wound infection was 7.2%, of flexion contractures was 6.3%, and of cold intolerance was 17.7%.

CONCLUSIONS

Reverse homodigital island flaps can be performed safely with excellent outcomes. To minimize complications, care is taken during dissection and insetting, with extensive rehabilitation adhered to postoperatively. Prospective studies assessing outcomes of RHIF compared with other reconstruction techniques would be beneficial.

Repair of fingertip defect with reverse digital artery island flap and repair of donor site with digital dorsal advancement flap

Objective

The reverse digital artery island flap (RDAF) is widely used in repairing fingertip skin defects based on its good appearance and practicability. However, the donor area of the flap needs skin grafting, which can lead to complications. This retrospective study explored the clinical application of digital dorsal advance flap (DDAF) in repairing the donor site of the reverse digital artery island flap.

Method

From June 2019 to February 2022, 17 patients with a soft tissue defect of the finger had been restored with the reverse digital artery island flap, and at the same time, the donor area was repaired with digital dorsal advance flap (DDAF). The sensitivity, the active range of motion (ROM) and patient satisfaction were assessed after the operation.

Results

All flaps survived completely without skin grafting with only one linear scar. The sensory and motor functions of all patients recovered well. Assessment based on the Michigan Hand Outcomes Questionnaire (MHQ) showed satisfactory functional recovery for all patients.

Conclusions

Reconstruction using RDAF combined with DDAF represents an effective alternative for repairing fingertip skin defects.

A Review and Meta-analysis of Adverse Events Related to Local Flap Reconstruction for Digital Soft Tissue Defects

We reviewed the current literature to estimate incidence rates for adverse events with pedicled flaps in the hand. We identified 241 different studies reporting adverse events for 6693 flaps. The average incidence rate was 5.4% and total or partial loss of flap constituted 65% of all reported complications. Flaps with reverse or perforator-based flow may be more prone to vascular complications compared with flaps with antegrade flow or skin pedicle. The incidence rates were acceptable in all flaps (1%-10%) and thus the flap can be chosen primarily based on considerations other than risk of adverse events.

Supermicrosurgery in fingertip defects-split tibial flap of the second toe to reconstruct multiple fingertip defects: A case report

BACKGROUND

Injuries to multiple fingertips pose a significant treatment dilemma. Numerous reconstructive options exist, all with the ultimate goal of restoring function and sensibility to the injured fingertips.

CASE SUMMARY

A 24-year-old male suffered injury to multiple fingertips of the right hand, resulting in exposed distal phalanges of the middle, ring, and small fingers. The amputated distal stumps were not possible for replantation. Free flap coverage was selected in order to achieve better functional outcome. The fingertip defects were covered by performing a right second toe split tibial flap using local anesthesia at the harvest site and brachial plexus nerve block for the right upper extremity. At 6-month follow-up, all three of the reconstructed fingertips had some preserved nail growth, Semmes-Weinstein Monofilaments testing was equal to the contralateral side and the Static Two-Point Discrimination were comparable to the contralateral side.

CONCLUSION

This report provides a novel reconstructive option for the management of multiple fingertip injuries and demonstrates the utility of supermicrosurgery in management of these injuries.

Comparison of Innervated Digital Artery Perforator Flap Versus Homodigital Reverse Flow Flap Techniques for Fingertip Reconstruction

PURPOSE

The aim of this study was to investigate and compare outcomes of 2 different flap techniques for fingertip reconstruction: innervated digital artery perforator (IDAP) flap and homodigital reverse-flow flap.

METHODS

Medical records of 33 patients who underwent fingertip reconstruction either with an IDAP flap (15 patients) or with a homodigital reverse-flow flap (18 patients), between 2014 and 2016, were evaluated retrospectively. In both study groups, full-thickness skin grafts harvested from the proximal/volar side of the forearm were used to cover the flap donor site. Flap survival, venous congestion, cold intolerance, static 2-point discrimination, flap size, duration of surgery, time to return to work, proximal and distal interphalangeal joint range of motion, Disability of the Arm, Shoulder, and Hand questionnaire scores, and follow-up time were evaluated.

RESULTS

All the major outcomes, including flap survival, cold intolerance, static 2-point discrimination, flap size, time to return to work, range of motion values for proximal and distal interphalangeal joints, Disability of the Arm, Shoulder, and Hand questionnaire scores, and follow-up time, were similar between the 2 flap methods. Mean duration of surgery was shorter in the IDAP flap group. Marginal flap necrosis occurred in 1 IDAP flap, and there was complete survival of the remainder of the flap after debridement. Temporary venous congestion was seen in 3 IDAP flaps, all of which resolved with nonsurgical measures.

CONCLUSIONS

Similar success rates and satisfactory outcomes were achieved with IDAP flap and reverse-flow flap techniques used for fingertip reconstruction.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Extended thenar flap for two adjacent fingertip amputations

The thenar flap is a well-described technique, but reports about its use in patients with multiple fingertip injuries are limited. This study aims to introduce a surgical technique of using an extended thenar flap for two adjacent fingertip amputations and to evaluate the clinical outcomes and related complications. From October 2013 to October 2016, 12 patients (24 fingers) underwent soft tissue reconstruction of two adjacent fingers with an extended thenar flap. At the last follow-up, the patients were assessed for cold intolerance in the reconstructed fingers; two-point discrimination (2PD); range of motion (ROM); functional outcomes using the quick disabilities of the arm, shoulder, and hand (DASH) score; functional and appearance outcomes using the Michigan Hand Outcome Questionnaire (MHQ); and time taken to return to work. The mean follow-up time was 13.5 (range: 12-16) months. All flaps survived. The mean total active ROM in flexion measured at the last follow-up was 255° (range: 245°-260°). Objective sensibility in the flaps was ascertained as an average static 2PD of 6.9 (range: 3-10) mm. The mean quick DASH score was 3.3 (range: 0-9.1). The mean MHQ score was 93.8 (range: 88-100). All patients returned to work within 6.2 weeks on average. There were no complications. The extended thenar flap technique is a good alternative for simultaneous coverage of small-to-large defects in two adjacent fingertips.

Preliminary Study on Functional and Aesthetic Reconstruction by Using a Small Artery-only Free Medial Flap of the Second Toe for Fingertip Injuries

OBJECTIVES

This study was designed to introduce the feasibility of fingertip reconstruction by using a free medial flap of the second toe without vein anastomosis.

METHODS

In total, 8 patients with fingertip injuries were treated successfully with this method. Patients who underwent reconstruction from September 2016 to October 2017 in our hospital with an artery-only free medial flap transfer of the second toe for fingertip injuries were included, and patients who underwent additional procedures that may impact the postoperative results and were followed up for less than 6 months were excluded. Clinical trial registration: ChiCTR19000021883.

RESULTS

According to the Allen classification, five patients had Type 3 injuries, and three patients had Type 4 injuries. One arterial nerve and one digital nerve were repaired at the same time. No additional dissection was performed in either the donor or recipient site of the dorsal or volar vein. Postoperative venous congestion was monitored based on the color, temperature and the degree of tissue oxygen saturation. The flap size ranged from 1.20*1.0 cm2 to 1.80*1.0 cm2. The reconstruction time was 71.86 (SD 14.75) minutes. The two-point discrimination and the monofilament results were satisfying; cold intolerance did not appear in five patients, and the other three patients had cold intolerance with grades of 4, 12 and 26, which were considered satisfactory. Moreover, leech therapy, continuous bleeding and needle sutures were not utilized in any cases.

CONCLUSIONS

Reconstruction with a small artery-only free medial flap transfer of the second toe led to satisfactory sensory and motor function in the selected patients with fingertip injuries.

Retrospective study to evaluate the treatment of digital pulp lesions using a homodigital flap

Objective

To assess the homodigital flap surgical procedure, as well as the function of the finger, pain, sensation, esthetics, and patient satisfaction.

Method

Retrospective analysis of records and questionnaires of patients who underwent this surgical technique between the months of May 2013 and October 2016. Eight were included in the study, with an average follow-up period of 23 months. Patients with digital pulp lesions of the thumbs and those who did not perform rehabilitation were excluded. All underwent the two-point discrimination test, the Semmes–Weinstein test, and range of motion evaluation. The age varied from 22 to 59 years (average of 32.9), six (75%) being male patients.

Results

Three patients (37.5%) had involvement of the right hand and five of the left (62.5%). Regarding the etiology, seven suffered injury and one a chemical burn. The average distance obtained from the two-point discrimination test was 7.3 mm. All patients who underwent the Semmes–Weinstein test obtained response to the purple filament. The average sum of the range of motion of the affected digit was 98.9%. The flap area was on average 294.4 mm². The return to work averaged seven weeks. A positive Tinel sign was found in the donating area and two reported intolerance to cold. Partial or total necrosis of the flap was not observed.

Conclusion

The homodigital flap technique presented satisfactory esthetics and functional results regarding feasibility, sensation, and digital mobility in pulp lesions.

Reconstruction of two fingertip amputations using a double thenar flap and comparison of outcomes of surgery using a single thenar flap

BACKGROUND

Although thenar flap for single fingertip amputation is a common and popular surgical technique, double thenar flap technique for patients with two fingertip amputations has rarely been reported in the literature. The purpose of this case-control study was to introduce the double thenar technique and compare the clinical outcomes between single thenar flap and double thenar flap surgical treatments.

METHODS

From January 2005 to December 2014, 92 patients with single fingertip amputations were treated with thenar flap (Group I) and 28 patients with two fingertip amputations were treated with double thenar flap (Group II). These 120 patients were followed-up for a minimum of 12 months postoperatively. At the latest follow-up, the two groups were assessed for pain, cold intolerance in the reconstructed finger, functional outcomes by Chen's criteria, and subjective patient satisfaction.

RESULTS

At the final follow-up, all flaps in both groups had survived. No flap failure occurred. There was no significant difference in cold intolerance (p=0.783), donor site pain (p=0.728), fingertip pain (p=1.000), or paresthesia (p=0.514) between the two groups. A total of 100 (83.3%) patients were completely or fairly satisfied. There was no significant difference in satisfaction between the two groups (p=0.801). According to the Chen criteria, 102 (85%) patients had excellent or good results.

CONCLUSION

This study demonstrated that the double thenar flap technique used for patients with two fingertip amputations produced complete survival with functional outcomes comparable to those of the single thenar flap technique at the last follow-up.

Factors affecting planned return to work after trauma: A prospective descriptive qualitative and quantitative study

The use of patient reported outcome measures (PROMs) in trauma is limited. The aim of this pilot study is to evaluate qualitative responses and factors affecting planned return to work following significant trauma, for which there is currently a poor evidence base. National ethical approval was obtained for routine prospective PROMs data collection, including EQ-5D, between Sept 2013 and March 2015 for trauma patients admitted to the Sussex Major Trauma Centre (n=92). 84 trauma patients disclosed their intended return to work at discharge. Additional open questions asked 'things done well' and 'things to be improved'. EQ-5D responses were valued using the time trade-off method. Statistical analysis between multiple variables was completed by ANOVA, and with categorical categories by Chi squared analysis. Only 18/68 of patients working at admission anticipated returning to work within 14days post-discharge. The injury severity scores (ISS) of those predicting return to work within two weeks and those predicting return to work longer than two weeks were 14.17 and 13.59, respectively. Increased physicality of work showed a trend towards poorer return to work outcomes, although non-significant in Chi-squared test in groups predicting return in less than or greater than two weeks (4.621, p=0.2017ns). No significant difference was demonstrated in the comparative incomes of patients with different estimated return to work outcomes (ANOVA r²=0.001, P=0.9590ns). EQ-5D scores were higher in those predicting return to work within two weeks when compared to greater than two weeks. Qualitative thematic content analysis of open responses was possible for 66/92 of respondents. Prominent positive themes were: care, staff, professionalism, and communication. Prominent negative themes were: food, ward response time, and communication. This pilot study highlights the importance of qualitative PROMs analysis in leading patient-driven improvements in trauma care. We provide standard deviations for ISS scores and EQ-5D scores in our general trauma cohort, for use in sample size calculations for further studies analysing factors affecting return to work after trauma.

A Systematic Review of Outcomes and Complications of Primary Fingertip Reconstruction Using Reverse-Flow Homodigital Island Flaps

BACKGROUND

Fingertip reconstruction using reverse-flow homodigital island flaps has been very popular over the years. However, the outcomes of reconstruction have not been clearly understood. In these circumstances, a systematic review of available literature is warranted.

OBJECTIVE

To assess the outcomes and complications of fingertip reconstruction using reverse-flow homodigital island flaps. To justify the usage of reverse-flow homodigital island flaps for fingertip reconstruction.

SEARCH METHODS

A PubMed [MEDLINE] electronic database was searched (1985 to 15 April 2015).

SELECTION/ELIGIBILITY CRITERIA

Retrospective case series that met the following criteria were included: (1) Study reported primary data; (2) Study included at least five cases of fingertip defects treated using reverse-flow homodigital island flaps; (3) Study reported outcomes and complications of fingertip reconstruction, either primary or delayed, using reverse-flow homodigital island flaps; (4) The study presented at least one of the following functional outcomes: Static two-point discrimination, return-to-work time, range of motion of distal interphalangeal joints; (5) The study presented at least one complication.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed search results, and two other review authors analyzed the data and resolved disagreements. The following endpoints were analyzed: survival rate of the flap, sensibility, and functional outcomes and complications.

MAIN RESULT

Eight studies were included in this review. The included studies were published between 1995 and 2014, and a total of 207 patients with 230 fingertip defects were reported. The overall survival rate of the flap was 98 % (including partial survival). The mean static two-point discrimination (2PD) was 7.2 mm. The average range of motion of the DIP joint was 63°. The average return-to-work time was 7 weeks after injury. On average, 2 % of the patient had complete flap necrosis, 5 % had partial flap necrosis, 4 % developed venous congestion, 4 % developed flexion contracture, and 12 % experienced mild-to-moderate cold intolerance.

AUTHORS' CONCLUSIONS

Survival of reconstructed fingertips (98 %) is better with reverse-flow homodigital island flaps than fingertip replantation (86 %). The sensibility outcome using sensate flaps (mean s2PD = 7.2 mm) is similar to the sensibility outcome following replantation (mean s2PD = 7 mm). The common complications include cold intolerance, venous congestion, and flexion contracture. Therefore, reverse-flow homodigital island flaps may not be the ideal choice but are a very reliable alternative for fingertip reconstruction.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Comparison of Shoulder Management Strategies after Stage I of Fingertip Skin Defect Repair with a Random-Pattern Abdominal Skin Flap

BACKGROUND

In the absence of scientific evidence regarding the effectiveness of shoulder management strategies after stage I of fingertip reconstruction, the purpose of this study was to compare the clinical outcomes of various rehabilitation procedures.

MATERIAL AND METHODS

Patients who underwent fingertip reconstruction with a random-pattern abdominal skin flap between March 2007 and February 2013 were enrolled in the study (n=95). Thirty performed only active exercise (group A), 29 performed only passive exercise (group B), and 32 received a combination of active exercise and pulsed electromagnetic field (PEMF) (group C). The mean age at the time of treatment was 30.2 years in group A, 29.6 years in group B, and 31.8 years in group C.

RESULTS

At the final follow-up, there were significant differences between group A and B in terms of Constant score (P=.001), VAS (P=.047), forward flexion of the shoulder (P=0.049), and muscle strength with forward flexion and external rotation (P=0.049 and P=0.042, respectively). A higher Constant score was observed in group C compared to group A, and although there were no differences in the other evaluations between groups A and C, a trend toward better function of the shoulder was demonstrated in group C.

CONCLUSIONS

The most important findings in our study are that a combination of active exercise and PEME produces superior patient-reported outcomes regarding relief of shoulder signs and symptoms. Given the limitations of this study, better-designed studies with large sample sizes and long-term follow-up are required.