Reconstruction of thumb loss complicated by skin defects in the thumb-index web space by combined transplantation of free tissues

Repair of distal finger soft-tissue defects with free fibular great toe neurovascular flaps

BACKGROUND

This work aimed to investigate the change in fingerprint depth and the recovery rule of fingerprint biological recognition function after repairing finger abdominal defects and rebuilding fingerprint with a free flap.

METHOD

From April 2018 to March 2023, we collected a total of 43 cases of repairing finger pulp defects using the free flap of the fibular side of the great toe with the digital nerve. After surgery, irregular follow-up visits were conducted to observe fingerprint clarity, perform the ninhydrin test or detect visible sweating with the naked eye. We recorded fingerprint clarity, nail shape, two-point discrimination, cold perception, warm perception and fingerprint recognition using smartphones. The reconstruction process of the repaired finger was recorded to understand the changes in various observation indicators and their relationship with the depth of the fingerprint. The correlation between fingerprint depth and neural repair was determined, and the process of fingerprint biological recognition function repair was elucidated.

RESULT

All flaps survived, and we observed various manifestations in different stages of nerve recovery. The reconstructed fingerprint had a clear fuzzy process, and the depth changes of the fingerprint were consistent with the changes in the biological recognition function curve.

CONCLUSION

The free flap with the digital nerve is used to repair finger pulp defects. The reconstructed fingerprint has a biological recognition function, and the depth of the fingerprint is correlated with the process of nerve repair. The fingerprint morphology has a dynamic recovery process, and it can reach a stable state after 6-8 months.

Comparison of Thigh-Based versus Groin-Based versus Lateral-Thoracic-Based Flaps for Hand Resurfacing: A Review Article

BACKGROUND

Thigh-based, groin-based and lateral-thoracic-based flaps are available for microsurgical hand resurfacing – which is the best?

METHODS

BestBETS methodology was used to systematically evaluate the advantages and disadvantages. PubMed, EMBASE and Cochrane databases were searched up until Sep 2020, using the search strategy: hand re-surfacing, free-flap, groin-flap, thigh-flap, lateral thoracic-flap, advantages, and disadvantages.

RESULTS

Overall, 31 papers were identified which were used to synthesize the discussion and conclusions.

CONCLUSION

Thigh-based anterolateral thigh (ALT) flaps offer the greatest versatility.

Superficial Peroneal Neurocutaneous Flap for Coverage of Donor Site Defect After the Combined Transfer of Toe and Dorsal Foot Flap

BACKGROUND

Reconstruction of digital loss with soft tissue defects remains a tough challenge. Although a combined flap of toe and dorsal foot skin provides a good option for "like-for-like" hand reconstruction, the disappointed donor site morbidity prevents it from popularity. In this study, we presented experiences of the superficial peroneal neurocutaneous (SPNC) flap for donor site closure after the combined toe and dorsal foot flap transfer.

METHODS

Superficial peroneal neurocutaneous flaps were used to cover foot donor site defects in 9 patients. The flaps harvested from feet including 3 cases of wrap-around flap with dorsal foot flap, 4 cases of 2nd toe flap with dorsal foot flap, 2 cases of 2nd and 3rd toe flap with dorsal foot flap. The flap size, operation time, and complications were documented, and the donor sites were evaluated by the subjective outcome measure, the foot evaluation questionnaire, and the Vancouver Scar Scale.

RESULTS

All flaps but one survived completely without complications. Marginal necrosis occurred in the distal part of the flap in one case, which was treated by daily dressings. The skin grafts on the lower leg healed uneventfully. The average operation time of flap transfer was 40 minutes. Follow-up ranged from 9 to 16 months, and patients were content with the results of the foot donor site according to the outcome measures. All the patients were able to wear normal shoes walking and running with a normal gait, and none sustained complications of skin erosion or ulceration. Protective sensibility was obtained in all the flaps. Two patients complained of cold intolerance and 2 could not wear a thong sandal. The donor site scars on the lower leg were measured 3.2 on average on the Vancouver Scar Scale.

CONCLUSIONS

The SPNC flap is a practical procedure for donor site closure on the foot, especially when extra dorsal foot skin is elevated with a toe flap for hand reconstruction.

Extreme Thumb Losses: Reconstructive Strategies

BACKGROUND

Historically, complex amputations of the thumb have been managed in two stages and often require additional soft-tissue and tendon transfer for successful outcomes. This article provides several novel strategies to address these problems in a single stage using existing muscles, immediate free tissue transfer, and toe transfer.

METHODS

From a personal experience of 482 toe transfers, 24 cases were performed to reconstruct extreme thumb losses. All thumbs were reconstructed in one stage. In only one case, the thumb was reconstructed with a second toe transfer; the remainder had a great toe (or a part of it) used for reconstruction. Suture, advancement, or tendon transfers were performed in all to restore intrinsic muscle function. In 19 cases, the web needed to be resurfaced with free (n = 18) or local (n = 1) flaps.

RESULTS

All toes and flaps survived. Three patients required a secondary adductorplasty. Six of the seven patients with a metacarpal hand were able to perform tripod pinch. The rest had an average Kapandji opposition score of 7.5. Patients rated their functional and cosmetic result with a visual analogue scale score (ranging from 0 to 10) of 8.5 and 8.4, respectively.

CONCLUSIONS

In proximal thumb amputations, the surgeon should pay attention not only to the obvious thumb loss but also to the first web and the thenar muscles. The author recommends abandoning the standard approach of a pedicled groin flap followed by a toe. Otherwise, the thenar muscles become useless, the first metacarpal contracts, and the need for tendon transfers skyrockets. Further studies are required to compare the outcomes of these results to those of more classic transfers.

CLINICAL QUESTION/LEVEL OF EVIDECE

Therapeutic, IV.

Simultaneous Reconstruction of Both Facial Paralysis and Temporomandibular Joint Ankylosis With a Composite Flap From Dorsum of Foot

Free extensor digitorum brevis muscle flap in facial paralysis, and the second metatarsophalangeal joint flap is used at the temporomandibular joint reconstruction for a long time. Anatomically, these flaps can be harvested through even the same pedicle flap even on the same regions. Literature is available of their usage along with the use of hand and upper extremity reconstruction. Unlike this example, the authors have used these flaps in maxillofacial region where facial paralysis and temporomandibular joint reconstruction will be performed together. In this study, clinical report and surgical details of this flap have been shared.

Repair of hand defects by transfer of free tissue flaps from toes

INTRODUCTION

There are very few reports on the use of a free composite flap from the toe to repair small tissue defects in the hand. Here, we describe our experience using a free composite flap from the great toe and second toe.

METHOD

Fifteen patients sought surgical treatment for tissue defects of the hand at our medical institution from July 2008 to December 2010. These defects included: dorsal defect of the distal thumb, dorsal-radialis defect of the proximal thumb, degloving injury of distal index finger, pulp defect of the middle finger and these were repaired with toe side pulp flaps. In five subjects, treatment of the metatarsophalangeal joint (MPJ) or proximal interphalangeal joint (PIPJ) involved a combined extensor tendon defect with a composite flap with MPJs and PIPJs and the extensor tendon of the second toe. All flaps were transferred as free flaps.

RESULTS

All flaps survived. At 34.8 months of follow-up, the average subjective satisfaction score was 8. Eleven patients (73.3 %) experienced cold intolerance, and one patient (6.7 %) dysesthesia. The Semmes-Weinstein Sensitivity Score was 3.48-4.71 at the flap and 0-4.21 at the donor site. The mean two-point discrimination was 7.13 mm. Grip strength was 10 % less than in the unaffected hand. Mobility loss in the MPJ and PIPJ was <10°. No patients had complications at the donor sites.

CONCLUSION

Based on the unique characteristics of the free flap from toes, we consider them to be good options for reconstruction of small tissue defects in the hand according to various sizes, shapes, and sites.

Scar contractures of the hand

This article discusses scar contracture of the hand. It contains a brief outline of the anatomy of the hand and upper extremities and the types of injuries involved. Hand reconstruction, including examination, nonoperative treatment, surgery, excision and skin grafting, flaps, postoperative management, and complications, are covered.

Mid-term functional outcome after the internal fixation of distal radius fractures

Background

Distal radius fracture is a common injury with a variety of operative and non-operative management options. There remains debate as to the optimal treatment for a given patient and fracture. Despite the popularity of volar locking plate fixation, there are few large cohort or long term follow up studies to justify this modality. Our aim was to report the functional outcome of a large number of patients at a significant follow up time after fixation of their distal radius with a volar locking plate.

Methods

180 patients with 183 fractures and a mean age of 62.4 years were followed up retrospectively at a mean of 30 months (Standard deviation = 10.4). Functional assessment was performed using the Disabilities of the Arm, Shoulder and Hand (DASH) and modified MAYO wrist scores. Statistical analysis was performed to identify possible variables affecting outcome and radiographs were assessed to determine time to fracture union.

Results

The median DASH score was 2.3 and median MAYO score was 90 for the whole group. Overall, 133 patients (74%) had a good or excellent DASH and MAYO score. Statistical analysis showed that no specific variable including gender, age, fracture type, post-operative immobilisation or surgeon grade significantly affected outcome. Complications occurred in 27 patients (15%) and in 11 patients were major (6%).

Conclusion

This single centre large population series demonstrates good to excellent results in the majority of patients after volar locking plate fixation of the distal radius, with complication rates comparable to other non-operative and operative treatment modalities. On this basis we recommend this mode of fixation for distal radius fractures requiting operative intervention.

Multiple toe transfer and sensory free flap use after a traumatic amputation of multiple digits. Surgery done in a single setting: a case study

Crush avulsion injuries to the hand with concomitant traumatic amputation of multiple digits can be a devastating injury to the patient. These injuries have multiple issues occurring under emergency conditions. When feasible, replantation of the multiple digits is optimal, but in many cases, it is not possible. Because of the crushing force on the digits, they are not viable candidates for replantation. The usual course of treatment for these patients is a two stage procedure, usually involving a groin flap. Here, we present the case of a patient who had a left hand skin avulsion of the whole palm and P1 of index, long, ring and small fingers. The left index finger had a complete amputation at the P2 level, the long, ring and small fingers all had complete amputations at the P1 level. This injury was dealt with by a left foot second and third toe transplant, a sensory free flap from the left big toe and a fourth toe microvascular free transfer to the left hand. The remainder of the defect was managed with a 10 × 14 cm reversed radial forearm flap and a combination of full and split thickness skin grafts. The procedure was performed in a single operation, obviating the need for a second surgery. This procedure optimized the patient's outcome during a single setting, making it an ideal choice in an emergency setting.

The reconstruction of the mutilated hand

The challenging reconstructive treatment of defects in the upper extremity requires a sound working knowledge of a variety of flaps. As the hand surgeon weighs the pros and cons of each possible flap to obtain definitive closure, he or she must also integrate the priorities of function, contour, and stability as well as the anticipation of further reconstructive surgery in choosing the flap of choice. This review describes the various flaps available for closure of soft tissue defects of the upper extremity. The principles of management of wounds of the upper extremity is described to guide hand surgeons in the early treatment of massive wounds that will eventually need free tissue coverage. Currently used flaps include fasciocutaneous, fascial, musculocutaneous, muscle, and osteocutaneous flaps. Flap selection is based on the characteristics of the defect including size, shape, and location, the availability of donor sites, and the goals of reconstruction. Improved techniques of microsurgery and an ever increasing repertoire of flaps provide the framework for hand surgeons to offer the most appropriate flap based on donor site, thickness, amount of tissue needed, and composition. A discussion of the selection of ideal flaps for any given defect should enable the reconstructive hand surgeon to provide the most appropriate coverage of wounds to the hand and upper extremity.

Anterolateral Thigh Flap Salvage Following Failed Deep Inferior Epigastric Artery Perforator Breast Reconstruction

The deep inferior epigastric artery perforator flap is an option for women desiring autologous tissue breast reconstruction. If this reconstruction fails, other autologous tissue flaps, including the gluteal artery perforator and latis-simus dorsi flaps, may be used for salvage. The anterolateral thigh (ALT) flap offers adequate tissue volume for breast reconstruction, acceptable fat quality and a long vascular pedicle. Other advantages include obviating the need for intraoperative position changes and harvesting tissue outside of the radiation field. Two cases involving ALT flaps used in the setting of deep inferior epigastric artery perforator failure are presented with favourable results. A review of the anatomy of the ALT flap is included.

Predictors of successful outcomes in first web space contracture release

BACKGROUND

The success of a first web space contracture release is dependent on the individual parameters of thumb movement. Examining these parameters individually, it is possible to predict which components are important for providing successful outcomes.

METHODS

We identified all patients who underwent a first web space contracture release over 7 years. Patients were examined for the following: radial abduction-abduction of the thumb in the plane of the hand; palmar abduction-abduction of the thumb 90° to the plane of the hand; and opposition-distance between first and fifth palmar digital crease. Measurements were compared between affected and unaffected hands, and correlations between components and patients' Disability of the Arm, Shoulder, and Hand (DASH) scores were determined.

RESULTS

Thirty-nine patients underwent release of a first web space contracture; 11 agreed to participate. Opposition distance was significantly greater in the affected hand than in the unaffected hand. Grip strength was significantly lower in the affected hand. There were no significant differences in the radial or palmer abduction angles between hands. There was a moderate relationship between opposition distance and DASH score. There was no relationship between DASH and the other physical measurements.

CONCLUSIONS

It is possible to obtain normal radial and palmar abduction angles after first web space release; however, success is not dependent on these absolute angles of abduction. Success of a release is related to the amount of opposition obtained, and it is difficult to achieve equivalent opposition to the unaffected hand. Grip strength and opposition remain decreased following contracture release.

Long-term functional results of microvascular toe-to-thumb reconstruction

The purpose of this study was to evaluate the long-term functional results of microvascular toe-to-thumb reconstruction after trauma. Forty-one patients meeting the inclusion criteria were available for a clinical follow-up study. The function of the hand was assessed with questionnaires as well as with modified Tamai and Sollerman hand function tests. According to the questionnaires, most activities were considered easy or quite easy and the majority of the patients (36/41) managed with no or minor complaints. Clinical tests showed good recovery of function. Patient satisfaction was high. There were superficial infections in five hands and in six donor feet. In total, 16 late corrective operations were done to eight patients. Microvascular toe transfer is a good option for grip reconstruction after thumb amputation. The extent of the initial injury influences the achievable outcome, yet even a single toe transfer can restore adequate grip function.

Severe mutilating injuries to the hand: guidelines for organizing the chaos

Major hand injuries have become a rarity in Western countries. The fact that there are well trained teams devoted to their management, should not obscure the fact that the first emergency surgeon has the major role of setting the foundations for a reconstruction. Understanding the goal to be sought: the 'acceptable hand' (one with three fingers, with near normal length, near normal sensation and a functioning thumb), is hoped to be of great help in primary care. Preservation of vital structures such as joints, flexor tendons, and vessels, in the initial debridement, which will help to build this 'acceptable hand' are discussed. The general guidelines for management of finger amputation and soft tissue problems are also given.

One-stage reconstruction of complicated thumb injury with combination of microsurgical transplantations

Complicated thumb loss of the hand still remains a great challenge to hand and microsurgeons. In this article, we report our technique and outcomes in 10 cases using one-stage microsurgical procedures. In each case, three tissue transplants in combination with a sequential vascular anastomoses was performed, i.e. the second toe for the thumb, the extensor digitorum brevis for thenar opponent muscle, and the anterolateral thigh flap for the first web space, and adjacent soft tissue defects. All the transplants survived eventually. After an average of 6 years follow-up, the results were very inspiring. Combined tissue transfer can hasten patient recovery and improve functional outcomes. However, this method needs meticulous technique and great experience in microsurgery.

Predictors of functional outcomes after surgical treatment of distal radius fractures

PURPOSE

Identifying predictors of outcomes is important in anticipating and treating patients with underlying factors that may affect recovery. The predictors of functional outcomes after distal radius fracture (DRF) treatment have not been well defined in the past.

METHODS

This was a prospective cohort study designed to identify predictors of hand outcomes after DRF treatment. The study included consecutive patients with inadequately reduced DRFs who had open reduction and internal fixation with volar plating. Demographic and socioeconomic data were collected at the time of the initial treatment. Outcome data were collected 3, 6, and 12 months after surgery. Outcome evaluation consisted of radiographic measurements and the Michigan Hand Outcomes Questionnaire (MHQ). We hypothesized that the following factors are important predictors of functional outcomes: (1) age, (2) socioeconomic status, (3) severity of fracture pattern, and (4) postsurgical radiographic measurements. Regression models were developed using the overall MHQ score as the outcome variable at 3 months and 1 year after surgery.

RESULTS

Sixty-six patients had data available at 3 months and 49 patients had data available at 1 year. At 3 months after surgery, radiographic incongruity (step + gap) was a significant predictor after controlling for age, fracture type, dorsal-volar tilt angulation, and income. Patients with increased incongruity reported lower MHQ scores (worse functional outcomes). At 1 year after surgery, however, only age and income were significant predictors after controlling for fracture type. Increased age and decreased income were associated with lower MHQ scores.

CONCLUSIONS

After successful surgery and hand therapy, only age and income were significantly associated with long-term outcomes 1 year after surgery. Precise anatomic reduction enhances short-term functional outcomes in DRF treatment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic, Level I.

2004-2005 Sterling Bunnell Traveling Fellowship report

The Bunnell Traveling Fellowship was established in 1982 with the purpose of sponsoring a young hand surgeon in the development of national and international relationships that contribute to his/her pursuit of higher learning and that foster the principles of scholarship of the American Society for Surgery of the Hand. I was fortunate to be selected as the 24th Sterling Bunnell Fellow, and I had the opportunity to follow in the footsteps of the 23 former fellows. In Bunnell's Surgery of the Hand, Fourth Edition (Boyes JH, ed. Philadelphia, Lippincott; 1964:561-567), a man with a brachial plexus injury was described. The recommended treatment was shoulder arthrodesis and transhumeral amputation, followed by fitting of an above-elbow prosthesis. Sterling Bunnell has been quoted as saying, "To someone who has nothing, a little is a lot." Nowhere in the field of hand surgery is this more true than in patients with brachial plexus injuries. The theme and purpose of my traveling fellowship was to evaluate the status and advances of adult brachial plexus surgery throughout the world, to determine the utility of the contralateral C7 nerve transfer, to evaluate the optimal reconstruction of grasp, and finally to determine the philosophies of experts around the world regarding the treatment of these patients.