Reconstruction of traumatic hand defects with shunt-restricted arterialised venous flaps — a surgical process flow and our experience

Abstract

Arterialised venous flaps (AVFs) are a flexible reconstructive option for hand defects with advantages including minimal donor site morbidity, abundant donor sites and relative ease of harvest. However, venous congestion and partial necrosis remain common drawbacks. Shunt restriction is a reported method of optimising the latter and improving flap survival. We illustrate a ‘how-to’ surgical process flow and report our experience with a series of these flaps in the reconstruction of hand defects. Hand defects from 9.4 to 18.8 cm2 (Median 14.1 cm2) within 2 weeks of injury were included in this series. Type III and IV AVFs, with ‘II’ and ‘H’ donor venous patterns, were harvested from the volar forearm. Survival, ischaemia/necrosis, venous congestion and total active motion (TAM) were assessed during follow-up. A total of six shunt-restricted AVFs were performed (2013 to 2017). One flap was lost to efferent venous thrombosis day 10 post-operative secondary to noncompliance and unrelated trauma sequelae. The remainder maintained good perfusion with no partial full-thickness loss, despite anticipated mild–moderate congestion and pre-emptive leeching. TAM at 7 months post-operative or later varied according to original underlying joint involvement. AVFs are a potentially underutilised reconstructive option for hand defects which provide thin, pliable and well-contoured soft tissue whilst minimising donor-site morbidity and hand stiffness. Strategies such as shunt restriction have been shown in previous studies to enhance their reliability and outcomes, avoiding partial thickness necrosis, and may hence broaden the use of AVFs. Level of evidence: Level IV, therapeutic study.