Reconstruction of distally degloved fingers with a cross-finger flap and a composite-free flap from the dorsum of the second toe

Donor Finger Morbidity in Cross-Finger Flap: A Systematic Review and Meta-Analysis

Background The morbidity of donor finger in a cross-finger flap has not received as much importance as the outcomes of the flap itself. The sensory, functional, and aesthetic morbidity of donor fingers, reported by various authors, are often contradictory to each other. In this study, objective parameters for the sensory recovery, stiffness, cold intolerance, cosmetic outcome, and other complications in the donor fingers, reported in the previous studies, are systematically evaluated.

Methods This systematic review is reported using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) protocol and was registered with the International prospective register of systematic reviews (PROSPERO registration no. CRD42020213721). Literature search was done using “cross-finger,” “heterodigital,” “donor finger,” and “transdigital” words. Data regarding demography, patients' number and age, follow-up duration and outcomes of donor finger, including 2-point discrimination, range of motion (ROM), cold intolerance, questionnaires, etc. were extracted from included studies. Meta-analysis was performed using MetaXL and risk of bias was evaluated using Cochrane risk of bias tool.

Results Out of the total 16 included studies, 279 patients were objectively evaluated for donor finger morbidity. Middle finger was most frequently used as donor. Static two-point discrimination seemed to be impaired in donor finger in comparison to contralateral finger. Meta-analysis of ROM suggested that statistically there is no significant difference in ROM of interphalangeal joints in donor and control fingers (pooled weighted mean difference: −12.10; 95% confidence interval: −28.59, 4.39; I2 = 81%, n = 6 studies). One-third of donor fingers had cold intolerance.

Conclusion There is no significant effect on ROM of donor finger. However, the impairment that seems to be in sensory recovery and aesthetic outcomes needs to be further evaluated objectively.

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.

Time of return back to work and complications following cross-finger flaps in industrial workers: Comparison between immediate post operative mobilization versus immobilization until flap division

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Previous authors have immobilized the hand following cross finger flaps.

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We studied two groups of injured industrial workers.

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Group I (n = 12) had immediate postoperative mobilization.

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Group II (n = 12) had immobilization till the time of flap division.

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Complications were similar but Group I returned back to work earlier.

Introduction

Previous authors have immobilized the injured hand or digits following cross finger flaps.

Patients and methods

About 3 years ago, the author adopted a protocol of immediate postoperative active and passive mobilization (without a splint) following cross finger flap surgery in industrial workers. The current study is a retrospective audit comparing postoperative complications and time of return back to work following cross-finger flaps in two groups of injured industrial workers: Group I (n = 12) had immediate postoperative mobilization; and Group II (n = 12) had immobilization till the time of flap division.

Results

The complication rate was similar in both groups. However, patients in Group I returned to work earlier than those in group II and the difference was statistically significant.

Conclusion

Immediate postoperative mobilization following cross-finger flaps in industrial workers does not increase the risk of complications and has the advantage of early return to work.

Treatment of degloving injury involving multiple fingers with combined abdominal superficial fascial flap, dorsalis pedis flap, dorsal toe flap, and toe-web flap

BACKGROUND

Our aim was to summarize the treatment of degloving injury involving multiple fingers using combined abdominal superficial fascial flap, dorsalis pedis flap, dorsal toe flap, and toe-web flap.

PATIENTS AND METHODS

Each degloved finger was debrided under microscopic guidance and embedded in the superficial layer of the abdominal fascia. The abdominal skin was sutured to the skin on the back and side of the hand to promote circumferential healing. After removal, the only remaining injured region was on the flexor surface, and this was repaired by multiple dorsal toe flaps, toe-web flaps, and dorsalis pedis flaps to provide blood vessels and sensory nerves. All fingers had proper flap thickness 3-6 months after surgery, and required only lateral Z-plasty modification with web deepening and widening to narrow the fingers and extend their relative length.

RESULTS

We completed flap-graft and finger narrowing for 25 fingers in eight patients. Abdominal skin flaps and dorsal toe flaps were grafted, and resulted in both firmness and softness, providing finger flexibility. The dorsal toe flap provided good blood circulation and sensory nerves, and was used to cover the finger-flexor surface to regain sensation and stability when holding objects. During the 1-8 years of follow-up, sensation on the finger-flexor side recovered to the S3-4 level, and patient satisfaction based on the Michigan Hand Outcomes Questionnaire was 4-5. Flap ulcers or bone/tendon necrosis were not observed.

CONCLUSION

Treatment of degloving injury involving multiple fingers with combined abdominal superficial fascial flap, dorsalis pedis flap, dorsal toe flap, and toe-web flap was effective and reliable.

Use of a distal ulnar artery perforator-based bilobed free flap for repairing complex digital defects

PURPOSE

To retrospectively evaluate the effectiveness and safety of using a distal ulnar artery perforator (DUAP)-based bilobed free flap (BFF) for the repair of complex digital defects in the hand.

METHODS

We retrospectively studied 15 patients who sustained traumatic digital defects with complicating tendon and phalanx exposure and were hospitalized for repair using a DUAP-based BFF. Main outcome measures included patients' self-assessed physical appearance, total active motion, and 2-point discrimination.

RESULTS

The flaps survived and the wounds healed with primary intention in all patients except one who experienced partial flap necrosis of the distal margin and required treatment with a second skin graft. Patients were observed for a mean of 13 months. The physical appearance and texture of the repaired fingers were assessed as good with minimal scarring. Total active motion and 2-point discrimination were 113° to 255° (contralateral, 255° to 275°) and 6 to 11 mm (contralateral, 5 to 8 mm), respectively.

CONCLUSIONS

Use of the DUAP-based BFF is a feasible, effective, and safe treatment alternative for repairing complex digital defects with favorable aesthetic and sensorimotor outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Direct and reversed dorsal digito-metacarpal flaps: a review of 24 cases

BACKGROUND AND AIM

The common source for reconstruction of soft tissue defects of the fingers is either the same finger or the adjacent finger. However, when the donor areas are damaged by concomitant injuries, these options are not available. The purpose of this study was to report on reconstruction of these complex digital injuries using the dorsal digito-metacarpal flaps (DDMFs) and to evaluate the efficacy of this technique.

METHODS

A retrospective study was conducted with 24 patients who had their fingers reconstructed using the DDMF from April 2009 to September 2011. The patients were divided into two groups based on the flow direction of the blood supply. Among them, nine patients had their fingers reconstructed with the direct DDMFs. Fifteen patients underwent tissue reconstruction in the distal phalanx with the reversed DDMFs.

RESULTS

At a mean follow-up of 20 months (range, 18-24 months), the mean static two-point discrimination on the flaps was 8.3 mm (range, 7-10 mm) in the direct DDMF group and 10.4 mm (range, 9-14 mm) in the reversed DDMF group, with a significant difference (P=0.001). The range of motion of the donor fingers was similar to that of the opposite hands. According to the Michigan Hand Outcomes Questionnaire, 11 patients were very satisfied, 10 were satisfied and three were neither satisfied nor dissatisfied with functional recovery of the reconstructed finger.

CONCLUSIONS

The DDMF is an additional option for coverage of a soft tissue defect of the finger when the commonly used local and regional flaps are not feasible.

CLINICALTRIALSGOV ID

NCT 01927003.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic/IV.

Palmar island flaps used to cover dorsolateral finger defects

Soft-tissue injuries of the hand are devastating injuries that may need coverage. Dorsal and/or lateral defects of the fingers with exposed tendon and/or bone are challenging obstacles in reconstructive hand surgery. There are several options for coverage of dorsal defects of the fingers, but all have shortcomings. A reliable 1-stage local flap to coverage the dorsolateral finger defects is needed. Anatomic study of Omokawa and their colleagues showed that palmar area is supplied by several perforators from the superficial palmar arch, and the common and proper digital arteries. The distal portion of the palm has numerous (range, 8 to 15) and large diameter (range, 0.1 to 0.5) perforators with good vascularity. Therefore, on the basis of this anatomic consideration, palmar island flap can be elevated. This flap is a simple, reliable, effective, and versatile flap which could be borne in mind as the best option to the hand surgeons treating soft-tissue defects of the hand.

Bone loss in the hand

Traumatic bone loss in hand surgery is challenging for the patient as well as the doctor. Whereas the patient is threatened with a possible amputation or severe disability, the hand surgeon focuses on reconstruction, restoration of the function, bony union, and appearance of the injured hand. Both are confronted with a long-standing and staged treatment coupled with a high risk of complications. This review encompasses the classifications and treatment options of bone loss in hands. The optimal treatment is still prevention of the trauma itself.

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.