Reconstruction of Thumb Pulp Defects Using Free Lateral Great Toe Flaps

Revision of residual deformities after primary surgery for Wassel-Flatt IV-D thumb duplication using a microsurgical free lateral great toe flap

We report the application and results of skin defect coverage using the free lateral great toe flap in revision surgery for residual postoperative deformities in Wassel-Flatt type IV-D thumb duplications. This retrospective study included five patients treated between June 2020 and September 2021 to correct angular deformity and repair the secondary skin defect. All the flaps survived. The patients were followed up for 8-12 months and all the reconstructed thumbs had a satisfactory appearance. The results of the Japanese Society for Surgery of the Hand scoring system were excellent in one patient, good in three patients and fair in one patient. The results of the Alignment, Ulnar and Radial stability, Range of motion and Aesthetical aspects (ALURRA) scoring system were good in four patients and moderate in one patient.Level of evidence: IV.

Composite classification and algorithmic reconstruction of fingertip defects with free lateral great toe flaps

BACKGROUND

This study aimed to classify fingertip defects according to dimensions and composite content, and present algorithmic reconstruction results with free lateral great-toe flaps.

METHODS

A total of 33 patients who underwent reconstruction for full-thickness defects of fingertips with free lateral great-toe flaps were retrospectively reviewed. Patients were divided into four groups by the algorithm according to the dimension and content of defects. Functional disabilities of the upper extremities, limitations of donor feet, finger cosmetics, sensory recovery, and pinch power were evaluated using the disabilities of the arm, shoulder and hand, foot function index, 5-point Likert satisfaction scales, Semmes-Weinstein monofilament and static 2-point discrimination tests, and pulp pinch-strength test, respectively.

RESULTS

The standardized distribution of patients according to dimensions and content of defects was achieved. When the composite content of defects increase such as group 4, complex surgical skills are required, duration of surgery is extended, return to work is delayed, and donor-site complications are increased. Functional limitations of the hands improved normally after reconstruction (p < 0.00). Sensory recovery of flaps was normal and test scores were strongly correlated (p = 0.78). All patients and observers were satisfied with finger's cosmetics.

CONCLUSION

Our classification and reconstruction algorithm is simple and easy to apply for all fingertip defects without complicated reference points, and it provides information about the surgical and post-surgical periods. When the dimension and composite deformities of the defect increase through groups 1-4, more complex reconstruction, increased donor-site complications, prolonged duration of surgery, and delayed return to work are observed.

Comparison of Treatment Methods of Thumb-Tip Defects With Phalangeal Bone Exposure: Modified Heterodigital Neurovascular Island Flap Versus Free Lateral Great Toe Flap

PURPOSE

Modified heterodigital neurovascular island flaps and free lateral great toe flaps are dependable methods for treating thumb-tip defects with phalangeal bone exposure. We retrospectively analyzed and compared the details and results of the two methods.

METHODS

This retrospective study included 25 patients with thumb injuries with phalangeal bone exposure treated between 2018 and 2021. Patients were categorized as per the following surgical methods: (1) modified heterodigital neurovascular island flap (12 patients, finger flap group) and (2) free lateral great toe flap (13 patients, toe flap group). The Michigan Hand Outcome Questionnaire, aesthetic appearance, Vancouver Scar Scale, Cold Intolerance Severity Score, static 2-point discrimination, Semmes-Weinstein monofilament, and range of motion of the metacarpophalangeal joint of the injured thumb were evaluated and compared. In addition, operation time, hospital stay, return-to-work time, and complications were recorded and compared.

RESULTS

In both groups, the defect was successfully repaired, with no cases of complete necrosis. The 2 groups had similar mean scores in static 2-point discrimination, Semmes-Weinstein monofilament, range of motion, and Michigan Hand Outcome Questionnaire scores. The aesthetic appearance, scarring, and cold tolerance of the toe flap group were better than the finger flap group. The operation time, hospital stay, and return-to-work time in the finger flap group were shorter than the toe flap group. The finger flap group had 2 complications-a superficial infection and 1 case of partial flap necrosis. The toe flap group had 3 complications-a superficial infection, 1 case each of partial flap necrosis, and partial skin graft loss.

CONCLUSION

Both treatments can achieve satisfactory results; however, they each have advantages and disadvantages.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Reverse digital artery island flap with versus without sensory nerve coaptation for finger pulp reconstruction

PURPOSE

Whether an innervated reverse digital artery island flap is superior to a non-innervated reverse digital artery island flap still remains controversial. We aimed to compare the clinical outcomes of the two flaps in repairing finger pulp soft tissue defects.

METHODS

Medical records of patients who underwent finger pulp reconstruction between January 2007 and December 2017 were evaluated retrospectively. A total of 45 patients were included. Twenty underwent sensory nerve reconstruction with cutaneous branches of the proper digital nerve, and 25 underwent the surgery without sensory nerve reconstruction. Surgical results, complications and sensory function were collected for analysis. Sensory function was assessed by static two-point discrimination and the modified sensory evaluation standard of British Medical Research Council.

RESULTS

The average operation time of innervated flaps was 23 min longer than non-innervated flaps. All 45 flaps survived completely. There was no significant difference in complications between groups. The average follow-up was 22 months. At the final follow-up, five non-innervated flaps had no recovery of static two-point discrimination. The average static two-point discrimination of the remaining 20 non-innervated flaps was larger than that of innervated flaps. Innervated flaps consistently achieved higher sensory function grades according to the modified sensory evaluation standard of British Medical Research Council.

CONCLUSION

An innervated reverse digital artery island flap can achieve better sensory function recovery in a shorter time. This procedure did not increase the incidence of complications, although it extended the operation time. It has proven to be a good technique for finger pulp reconstruction.

To Do or Not to Do? Neurorrhaphy in Great Toe Pulp Flap Fingertip Reconstruction

Since its inception, the great toe pulp (GTP) flap has represented a valid therapeutic choice in the reconstruction of defects of the hand. This study illustrates the clinical outcomes of GTP free flaps performed without nerve anastomosis' mainly for fingertip defect reconstruction.

Methods

We performed a retrospective, monocentric cohort study. All patients included in this study presented with fingertip traumatic injury, with tendon or bone exposure; reconstruction with GTP flap, without nerve reconstruction, was performed by the first author (L.T.) from May 2019 to October 2021.

Results

All 37 flaps survived completely. Due to COVID restrictions' we had to send the tests and PROMs to our patients; 28 of them replied. Cold intolerance was reported by 12 patients (moderate in two cases and mild in ten cases). No pain was complained about either in hand or donor site (Visual Analog Score 0, at rest and at movement). Complete range of motion was achieved in 22 of 28 patients. All flaps recovered protective sensitivity. In every section of the Michigan Hand Outcome Questionnaire, all patients expressed a high level of satisfaction based on the reconstruction's function and aesthetics. Regarding the donor site morbidity, no patient complained about gait disturbance.

Conclusions

This study showed that the GTP flap is the optimal choice for fingertip reconstruction, providing excellent functional and aesthetic results with durable and glabrous skin, satisfactory pulp contour, and sensory restoration. These results could be achieved with no need for nerve suture, especially in defects with no injuries proximal to the loss of substance.

Coverage of Big Toe Defects After Wraparound Flap Transfer With a Second-Toe Medial-Side Adjacent Toe Flap

PURPOSE

In finger reconstruction, big-toe wraparound flap (WAF) transfer provides excellent results. However, difficulty in healing and impaired function at the donor site are common. We aimed to explore an ideal method to address these complications.

METHODS

This retrospective study involved 22 patients who were treated with big toe WAF transfer for finger reconstruction between 2016 and 2020. Patients were categorized into cohorts by donor site repair method: second-toe medial-side adjacent toe flap and skin graft (cohort 1) and skin graft alone (cohort 2). Functional outcomes, aesthetic appearance, and complications at the donor site were compared. Functional outcomes were assessed according to the American Orthopaedic Foot and Ankle Society (AOFAS) for hallux metatarsophalangeal-interphalangeal score, Foot Function Index-Verbal Rating Scales (FFI-5 pt), and visual analog scale for pain. Aesthetic appearance was evaluated according to the adjusted question 28 in the Michigan Hand Outcome Questionnaire.

RESULTS

The mean pain scores in AOFAS and FFI-5 pt were 38.00 ± 4.22 and 3.75 ± 2.37, and 32.50 ± 4.52 and 6.60 ± 2.14 in cohorts 1 and 2, respectively, which showed no significant differences. The method in cohort 1 can reduce the level of pain. This was further confirmed by visual analog scale scores of 3.40 ± 0.84 and 6.42 ± 7.93 in cohorts 1 and 2, respectively. The mean functional scores in AOFAS and FFI-5 pt were 38.40 ± 2.37 and 1.25 ± 1.62, and 37.92 ± 2.15 and 1.56 ± 2.11 in cohorts 1 and 2, respectively, which showed no significant differences. Eight patients developed complications: 1 patient (1/10 [10%]) in cohort 1 developed a superficial infection, and in cohort 2, 7 patients (7/12, 58.30%) developed complications, including 2 short-term complications with partial necrosis and 1 delayed healing. Long-term complications included the following: scar discomfort (2 cases), pain discomfort (1 case), and skin ulceration due to repeated wear and tear (1 case). Cohort 2 had significantly more complications than cohort 1.

CONCLUSIONS

Second-toe medial-side adjacent toe flap combined with skin graft had better aesthetic appearance, less complications, and less pain compared with skin graft alone. Hence, it can be a reliable technique for repairing the donor site after big-toe WAF transfer.

First dorsal metacarpal artery flap with dorsal digital nerve with or without dorsal branch of the proper digital nerve produces comparable short-term sensory outcomes

Background

The first dorsal metacarpal artery flap, including dorsal digital nerves with or without dorsal branches of the proper digital nerves, can be used to reconstruct thumb pulp defects with good results. However, it is still unclear whether there are differences in the sensory outcomes between preserving or not preserving the dorsal branches of the proper digital nerves.

Methods

This retrospective cohort study included 137 thumb pulp defect patients who underwent first dorsal metacarpal artery flap reconstruction procedure from October 2015 to June 2019. Patients were divided into two groups according to whether the dorsal branches of the proper digital nerves were preserved. In the non-preservation group (n = 80), the dorsal digital nerves were included in the flap for sensory reconstruction. In the preservation group (n = 57), the dorsal digital nerves and the dorsal branches of the proper digital nerves of the index finger were included in the flap. The stump of the proper digital nerves in the defect was coaptated to the donor nerves of the flap using the end-to-end fashion. At the last follow-up, static two-point discrimination, Semmes–Weinstein monofilament scores, pain, cold intolerance of the reconstructed finger, and patient satisfaction in both groups were compared.

Results

All patients were followed up for at least 17 months. No significant differences were found regarding pain of thumb pulp, static two-point discrimination, Semmes–Weinstein monofilament score, cold intolerance in the injured finger, and patient satisfaction. The non-preservation group presented slightly shorter operative times (p < 0.05).

Conclusion

There are no differences at 2 years in postoperative clinical outcomes when dorsal digital nerves are used to reconstruct flap sensation regardless of preservation of the dorsal branches of the proper digital nerves in the first dorsal metacarpal artery flap.

Level of evidence: Level III, retrospective comparative study.

[Repair of distal phalanx finger wound with modified great toe fibular flap with distal artery pedicle as reflux vein]

OBJECTIVE

To investigate the effectiveness of the modified great toe fibular flap using the distal artery pedicle as reflux vein for repairing distal phalanx finger wound.

METHODS

Between June 2018 and January 2020, 15 patients who suffered tissue defect of the distal phalanx finger were treated, including 12 males and 3 females, the average age was 40.2 years (range, 24-56 years). All of them were caused by machine crush injury. There were 2 cases of thumb, 6 cases of index finger, 3 cases of middle finger, 3 cases of ring finger, and 1 case of little finger. The defects ranged from 1.7 cm×1.3 cm to 3.0 cm×2.0 cm. The time from injury to admission was 0.6-4 hours, with an average of 2.3 hours. The medial fibular proper digital artery was further dissociated to the distal end and anastomosed with the recipient vein as the reflux vein. The area of flaps ranged from 2.0 cm×1.5 cm to 3.2 cm×2.2 cm.

RESULTS

All the flaps survived without vascular crisis, and the wounds healed by first intention. Except for 1 case that the suture was too tight, the incision was partially split after the stitches were removed, and it healed spontaneously after dressing change, the other patients had good healing of the donor site incision and normal foot function. All 15 patients were followed up 3-18 months, with an average of 9.3 months. The appearance of finger pulps were satisfactory with full and threaded. The color, texture, and elasticity of the flaps were good, and the two-point discrimination was 6-8 mm at last follow-up. The flexion and extension of fingers were normal. At last follow-up, hand function was evaluated according to the upper limb function evaluation trial standard of the Chinese Medical Association Hand Surgery Society, and the results were 13 cases of excellent and 2 cases of good.

CONCLUSION

Modified great toe fibular flap using the distal arterial pedicle as a reflux vein can improve the venous drainage of the flap and contribute to increase the success rate of the flap without additional injury.