Long-Term Outcomes of Atasoy Flap in Children With Distal Finger Trauma

Evaluation of electrophotobiomodulation as a recent tool in the armamentarium of treatment of fingertip injuries

BACKGROUND

Traditional reconstructive options of fingertip injuries are technically difficult, usually need donor site skin grafting, leave visible scars, and need a protracted period of finger immobilization resulting in joint stiffness. Electro-photobiomodulation (EPBM), is the process of combining intense pulsed light and radiofrequency to modify tissues to help the body heal itself, lower inflammation, and promote wound healing.

PATIENTS AND METHODS

This study included 60 patients presented with fingertip injuries. Patients were randomly divided into two groups. Group 1 includes patients who were treated by EPBM. Group 2 includes patients who were treated by cross finger flap (CFF). Six months after complete healing, evaluation was performed for aesthetic and functional outcome and patient satisfaction.

RESULTS

Compared to group 2 patients, group 1 patients had statistically significant better sensory outcome, better total active motion of affected digits, grip strength, patient satisfaction, healing time, and plastic surgeon general aesthetic evaluation and also, they had statistically significant less adverse events and cold intolerance with absent donor site pain and deformity.

CONCLUSION

EPBM is safe and effective treatment of fingertip injuries which shortens the healing time, produces the best aesthetic and functional result while avoiding donor site morbidity of the traditional reconstructive options.

Fingertip amputations in children: Atasoy flap's indications and limitations

INTRODUCTION

The Atasoy flap is considered simple and reliable for covering distal digital defects in adults. Various studies in children have shown more contrasting results, particularly in terms of aesthetics and function. The aim of this study is to evaluate the long-term results of this flap specifically in children, in order to determine its limitations and indications.

HYPOTHESIS

The Atasoy flap is reliable and reproducible for coverage of distal digital substance loss up to zone 2 in children.

MATERIALS AND METHODS

Fifty-six children who benefited from an Atasoy flap operated on between January 2017 and January 2020 were included. Lesion area, operative technique, postoperative complications (infection, healing difficulties, necrosis), and ultimately nail appearance, cold intolerance or finger pain, finger eviction, extension defect, and final parental satisfaction were analyzed.

RESULTS

Forty-nine children were evaluated with a mean follow-up of 18 months (min = 3 months, max = 38 months, SD = 11.3 months). Eighteen children had a hook nail, resulting in 6 of them having their finger excluded. The majority of hook nails were found in zone III and in proximal zone II lesions (12 cases). Eighty-nine percent of children with distal suture fixation to the nail bed (8 children) had this complication. Cold intolerance was present in 9 children. There were no cases of extension failure or early post-operative complications. Final parent satisfaction was 9.1/10 (min = 5, max = 10, SD = 1.3).

CONCLUSION

The Atasoy flap in children appears reliable for covering loss of distal digital substance. The main complication is the occurrence of hook nails. Compliance with its indications (transverse substance loss not exceeding the proximal third of zone II) and a precise surgical technique (distal needle fixation without suturing to the nail bed, deep flap lift, non-closure of the donor site) help limit this risk.

LEVEL OF EVIDENCE

IV; retrospective study.

V advancement eversion flap for fingertip injury: Preventing ischemia and hook-nail deformity

Introduction

Traumatic fingertip amputation is the most common type of upper extremity injuries. The V-Y advancement flap is a reliable method for reconstructing fingertip defects, but it is associated with complications such as hook-nail deformity and suture site ischemia. Here, we describe our modifications to V-Y advancement flap technique, termed as "V advancement eversion flap" and review the outcomes of this procedure in 21 patients with fingertip amputation.

Methods

This was a retrospective review of 21 consecutive patients with fingertip injury who were treated surgically using the V advancement eversion flap technique at a single trauma center between 2006 and 2019. We analyzed the age, injury location and mechanism, Allen classification, injury geometry, and objective and subjective clinical outcomes.

Results

Twenty-three fingertip amputations with defect sizes greater than 1.0 cm2 from the tip to lunula were included in this study. The mean age of the patients was 43.6 years (range, 24-65 years). The average follow-up period was 20 months (range, 12-37 months). The average wound healing time (apparent epithelization) was 29.4 days (range, 14-41 days). At the final follow-up, all flaps had healed uneventfully without noticeable hook-nail deformity. In the static two-point discrimination test, the mean value was 4.61 mm in the injured finger. Patient ratings of the outcomes were "excellent" in 18 and "good" in 5 cases.

Conclusion

The V advancement eversion flap technique, when properly designed and executed in fingertip amputation cases, can minimize morbidity and result in successful wound healing without flap necrosis and hook-nail deformity.

Reconstruction of a Pediatric Distal Phalanx Amputation With Stacked Integra Dermal Substitute: A Case Report

Finger amputations in children present unique challenges and require special considerations compared to their adult counterparts. Maximizing length and preserving fingertip bulk and sensation is essential for maintaining a functional digit. Synthetic dermal substitutes have been recently used for soft tissue coverage for pediatric syndactyly as well as burn injuries; however, the literature discussing pediatric amputation cases with soft tissue damage proximal to the bony level is limited.In this case, we report a two-year-old patient who developed dry gangrene of her right index finger after multiple rabbit bites and underwent an amputation through the distal interphalangeal joint. Circumferential soft-tissue debridement proximal to the tip of the middle phalanx was required, leaving substantial exposed bone with no soft tissue envelope. We report our experience of single-stage stacking Integra dermal substitute directly onto the exposed bone to provide both finger bulk and soft tissue coverage.The patient displayed no functional limitations three years post-surgery.For instances when local or distant flap coverage may not be feasible, we present a novel technique to reconstruct, provide bulk, and preserve length in pediatric finger amputations. This case highlights that the utility of dermal substitutes is expanding and are providing more technical options.

Hook nail deformity

Hook-nail deformity is frequently seen after a fingertip amputation, whether or not flap reconstruction has been done. It is more frequent if the bony support is missing. The deformity results in esthetic and functional impairment which can lead to complete finger amputation. Correction is surgical, but is difficult and surgical series are small. Soft-tissue flap augmentation is simple, but does not add a bony support. Bone augmentation using local flaps is limited by the small size of the distal phalanx remnant. Toe transfer is more logical but, as it is a highly demanding technique, only a few cases have been published. The present study sought to review all the published techniques and their results, to help the reader choose the one best suited to their patient.

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.

Fingertip Amputation Reconstruction with VY Advancement Flap: Literature Review and Comparative Analysis of Atasoy and Kutler Flaps

BACKGROUND

Many different flaps had been described to cover exposed bone in fingertip amputations and injuries. The variants of VY advancement flap, by far the simplest, had proven to render good functional and aesthetic outcome. We aimed to revisit and compare the various VY advancement flaps in fingertip reconstruction.

METHODS

PubMed [MEDLINE] database was searched for VY advancement flap in fingertip reconstruction. Demographic and outcome data were extracted from relevant studies and comparative analysis was made. Patients with fingertip amputations undergoing reconstruction by either Kutler of Atasoy flaps in our institute, were assessed for sensory recovery, cold intolerance, joint's range of motion, and aesthetic outcomes and results were analysed.

RESULTS

Among the 744 articles, 32 citations went full text review and were included, while data of 13 articles were tabulated. Weighted mean of 2PD in Kutler and Atasoy estimated to be 6 and 7.5 mm respectively. Hook nail deformity was in 29% and 35%, pain was present in 71% and 30% patients, in Kutler and Atasoy flaps respectively. Forty fingertips with Allen type II/III were reconstructed. Sensory outcomes of Atasoy flap and Kutler flaps were better than the previous study results. Four patients had cold intolerance. All patients achieved satisfactory aesthetic outcome.

CONCLUSION

Over time, VY advancement flap have been successfully used for reconstruction of Allen type II-IV fingertip amputations, as suggested by the good sensory, functional and aesthetic outcomes.

Coverage of soft tissue defects in the thumb: Essential flaps in daily practice

Coverage of soft tissue defects in the thumb involves a variety of techniques ranging from simple second-intention healing to skin grafting with or without dermal substitutes, to local homodigital or heterodigital flaps and partial toe transfers. The arsenal in terms of skin coverage and especially flaps is very diverse. Our objective is not to make an exhaustive catalog of all the technical possibilities described in the literature, but rather to present in detail the options we have adopted in our daily practice. For each of these techniques, we present the rules for their implementation (anatomical bases, surgical techniques) and their topographical indications.

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.

Pediatric Fingertip Injuries

Pediatric fingertip injuries are common and peak at 2 years of age. These injuries most frequently result from a crush mechanism and half sustain an associated fracture. The presence of a physis results in unique injury patterns and management considerations in the growing child. Due to a substantial healing potential in children, an initial conservative approach to management for many soft tissue and nail bed injuries is recommended. This article reviews the evidence and approach for treating pediatric fingertip injuries and amputations.

Treatment of Fingertip Injuries

The goal of care when treating fingertip injuries is to minimize the risk of infection while maximizing function, tactile sensation, digit length, pulp padding, and appearance. This outcome can be achieved with careful soft-tissue coverage and, if possible, nail-bed preservation. When replantation for a fingertip amputation is not possible for anatomic or logistical reasons, local or regional flap reconstruction can be a useful alternative to gain early soft-tissue coverage and allow more functional rehabilitation. Reviewing current fingertip soft-tissue coverage procedures and demonstrating key anatomic and technical points with cadaveric dissections provides a foundation for the incorporation of these techniques into practice.