Hand Reconstruction Research Articles

Low-Temperature Burn on Replanted Fingers and Free Flaps in Hand.

Patients who have undergone microsurgery for reconstruction with a free flap or finger replantation are vulnerable to heat injury. Moreover, some of these injuries can occur at low temperatures. Although the temperature does not reach the threshold to cause burns in the adjacent normal tissues, burns can occur in the areas that underwent microsurgery. On the other hand, this type of burn is not completely understood and there are few reports of the clinical prognosis. The medical records of patients who received warm therapy using an infrared heat lamp with the appropriate temperature after hand surgery from January 2009 to December 2016 were reviewed. The patients were classified into 2 groups. Group A comprised patients who underwent free flap or replantation surgery of the hand. Group B comprised patients who underwent other hand surgeries without microsurgery, such as tenorrhaphy, tenolysis, or joint surgery. Through the medical records, all patients with second- or third-degree thermal burns were selected. The relationship between the 2 types of surgery and thermal injury and the timing of the burn after microsurgery were analyzed. Groups A and B were composed of 370 (mean age, 48.2 years) and 7010 patients (mean age, 44.5 years), respectively. Burns requiring treatment occurred in 4 patients in group A and in 1 patient in group B. The proportion of low-temperature burns was 4 of 370 in group A and 1 of 7010 in group B. The occurrence of low-temperature burns was more associated with patients who had undergone microsurgery for a hand reconstruction with free flap or finger replantation (P < 0.05). In the patients who underwent microsurgery, all 4 patients had thermal burns within 1 year after surgery. Low-temperature thermal burns can occur in patients who have undergone microsurgery for a hand reconstruction. This is believed to be related to a disruption of the thermoregulatory function of the skin and poor nerve regeneration, as well as more heat accumulation in the surgical area after microsurgery.

The First Dorsal Metacarpal Artery Flap Family: A Review.

Deep soft tissue injuries around the thumb can severely hinder hand function if not treated correctly. Many different surgical options have been described for the treatment of these serious lesions, including microsurgical flaps, such as toe to hand flaps, local flaps, and distant pedicled flaps. The first dorsal metacarpal artery family of flaps belongs to this last category. These flaps can be performed in different ways, as a racquet, as an island flap, and as a bilobed flap including the second metacarpal artery, among others.The aim of the following article is to review the basic concepts involved in the use of these flaps in reconstructive hand surgery.

Vascularized second metatarsophalangeal joint transfer for radial deficiency - an update.

Vascularized second metatarsophalangeal joint transfer offers a possibility to reconstruct the radial support which is lacking in radial dysplasia. Our experience from 1987 to 2017 with 34 congenital radial club hand reconstructions have allowed a possibility for long-term evaluation of the method. Compared with conventional methods, second metatarsophalangeal joint transfer results in better wrist mobility and does not restrict typical ulnar growth. The balance of the wrist remains good until age 11. Thereafter, the growth of the vascularized bone graft transfer matches only partially the distal ulnar growth in adolescence, resulting in mild recurrence of radial deviation. A new option to create a two-bone forearm in selected Bayne-Klug Type III radial dysplasia cases will allow a relatively good pro-supination ability. Potentially, a proximal fibular epiphyseal transfer could be a future solution. Currently, a safe harvest of the proximal fibula at childhood remains controversial.

Perioperative Glucocorticoid Treatment of Soft Tissue Reconstruction in Patients on Long-term Steroid Therapy: The Experience of 6 Cases Using Reversed Posterior Interosseous Flap for Hand Neoplasm Surgery.

IntroductionLong-term steroid therapy is associated with increased postoperative morbidity. Whether to use a stress dose of glucocorticoids (GCs) in surgical patients remains controversial. In the present study, we reported our experience in perioperative GC treatment of 6 patients on long-term steroid therapy for autoimmune diseases undergoing hand reconstruction using reversed interosseous flap.MethodsThe reversed interosseous flap reconstructions were performed after local extended resection of hand neoplasms. The patients were all diagnosed with autoimmune diseases and were undergoing long-term steroid therapy. Stress dose of GCs was not given in any case, and all the patients either remained on their baseline maintenance dose or decreased the dose until the morning of the operation day. Hypotension, water-electrolyte imbalance, hypoglycemia, and other symptoms of adrenal insufficiency were carefully assessed. Appearances of flap complications were recorded.ResultsNone of the patients developed hypotension or other symptomatic adrenal insufficiency. Flap infection, venous congestion, or complete or partial loss of flap was not observed in any patient. Effusion underneath the flap was developed in only 1 case and was solved by proper drainage.ConclusionsIt is safe, reliable, and versatile to use reversed interosseous flap to repair hand defects in patients on long-term steroid therapy. A stress dose of GCs might not be necessary in this procedure and other equally moderate soft tissue reconstructive surgeries.

Latest developments in tissue engineering in hand surgery. Review of the literature

In the past decades, an exponential acceleration in the development of tissue engineering methods has taken place. This accelerated expansion can be found in hand surgery, too, and tissue replacements can be applied with the aid of various scaffolds. In his review article, the author discusses the present possibilities of tissue engineering in cases of the tendons, ligaments, nerves, bone- and cartilage tissues, and vascular injuries. These pioneering experimental results and promising novel technologies may play an important role in reconstructive hand surgery in the immediate future. Orv Hetil. 2018; 159(34): 1385-1389.

Distally based ulnar artery perforator flap for hand reconstruction and wrist defect closure

Background: Reconstruction of soft tissue defects of the hand and wrist with exposed tendons, joints, and neurovascular structures challenging for plastic surgeons. Such defects require a flap for coverage to preserve hand and wrist function. We used the distally based ulnar artery perforator flap for reconstruction in patients with soft tissue deformities and defects of the wrist and hand. Methods: Between June 2015 and August 2017, 8 patients were operated upon to correct deformities of the hand and wrist using the distally based ulnar artery perforator flap. Their ages ranged from 1.5 to 32 years, and the male-to-female ratio was 1:1. Five of the patients had post-burn contractures, and the remaining were post-trauma, with 1 gunshot wound and the other 2 resulting from road traffic accidents. The flap was islanded in 3 patients and pedicled in 5. Results: All of the flaps survived, and donor site defects in all patients were covered with split-thickness skin grafts. There was minimal donor site morbidity. Conclusions: The distally based ulnar artery perforator flap is a convenient and reliable flap for reconstruction of soft tissue defects and post-burn contractures of the hand and wrist. Its main advantages are that it is a single-stage procedure with no sacrificing of major vessels. Keywords: ulnar artery; perforators; hand and wrist; Kenya

Versatility of Anterolateral Thigh Flap in Dorsal Hand Reconstruction

Versatility of Anterolateral Thigh Flap in Dorsal Hand Reconstruction

Outcomes of reconstructive hand surgery in patients with tetraplegia and neuropathic pain.

Retrospective cohort study OBJECTIVES: To evaluate the impact of preoperative neuropathic pain on outcome and postoperative compliance after grip reconstructive surgery in people with tetraplegia. Specialized tetraplegia upper-limb surgery center in Sweden. All patients who underwent grip reconstructive surgery and attended a 6 month follow up during January 2012 and May 2015 were included. Participants were divided into two groups, pain group and no pain group, based on preoperative rating of experienced pain on a visual analog scale. The main outcome measures were grip strength, grasp ability (Grasp and Release Test) and prioritized activity outcome (Canadian Occupational Performance Measure) together with compliance to the rehabilitation plan. The study include 37 patients (86% of the cohort). Seventeen patients experienced preoperative pain (46%). There were no differences in outcome between the pain- and the no pain group regarding grip strength (5 vs. 4.6 kg), grip ability or activity performance and satisfaction (COPM improvement of 3.1 vs. 3.0 for performance and 3.6 for both groups in satisfaction). Both groups experienced improvements in all aspects and there were no differences in the ability to fulfill postoperative treatment. Individuals with tetraplegia and preoperative neuropathic pain in the arm/hand improve after grip reconstructions in a similar way to those without pain. Patients with neuropathic pain therefore should be considered as surgery candidates to the same extent as those without pain.

Hand function reconstruction by tendon transfers in patients with cervical spinal cord injury

To explore the effectiveness of functional reconstruction of hand grasp and pinch by tendon transfers in patients with cervical spinal cord injury. Between July 2013 and January 2016, tendon transfer surgery were performed in 21 patients (41 hands) with cervical spinal injury that motion level was located at C 6 to reconstruct hand grasp and pinch function. There were 18 males and 3 females with a mean age of 42.3 years (range, 17-65 years). Nineteen patients were with complete spinal cord injury [American Spinal Injury Association (ASIA) grading A], 1 patient was with central cord syndrome whose bilateral hands were completely paralyzed and lower limbs were normal (ASIA grading D), and 1 patient was with cervical spondylotic myelopathy (AISA grading D). The time from injury to hospitalization was 12-22 months (mean, 16.8 months). According to the International classification of surgery of the hand in tetraplegia (ICSHT), there were 6 cases of grade O3, 10 of grade O4, 3 of grade OCu5, and 2 of grade O5. The surgery was divided into two stages with an interval of 6-11 months. At the first stage, grip function was reconstructed in all patients by transfering the extensor carpi radialis longus from radialis side to palmar side through subcutaneous tunnel, and braided and sutured with the flexor pollicis longus and flexor digitorum profundus. At the second stage, the lateral pinch function of the thumb and index finger was reconstructed by braiding and suturing the radial half of the extensor carpi ulnaris (the patients graded as ICSHT O3) or pronator tere (the patients graded above ICSHT O3) with extensor pollicis longus and abductor pollicis longus. The grasp force, the thumb and index finger lateral pinch force, and the maximum fingertips distance between the thumb and index finger were measured at preoperation and at different time points after operation. The modified Lamb and Chan questionnaire, based upon the activities of daily living, was used to evaluate the hand function of all patients at 6 months after sencond stage surgery. There was 1 patient with elbow skin lesion, 1 patient with wrist stiffness; both of them recovered after corresponding treatment. All the 21 patients were followed up 15-32 months (mean, 19.6 months) without wound infection, tendon adhesion, tendon rupture, and other complications. The grasp forces of all patients were significantly improved at 4 weeks, 3 months, 6 months, and 1 year after the first stage surgery when compared with preoperative value ( P<0.05); and no significant difference was found between different time points after operation ( P>0.05). The thumb and index finger lateral pinch force and the maximum fingertips distance between the thumb and index finger of all patients were also significantly improved at 4 weeks, 3 months, 6 months, and 1 year after the second stage surgery when compared with preoperative values ( P<0.05); and no significant difference was found between different time points after operation ( P>0.05). And there was no significant difference of above indexes between the patients graded as ICSHT O3 and above ICSHT O3 ( P>0.05). The functional outcome was good in 19 cases, fair in 1 case, and poor in 1 case according to modified Lamb and Chan questionnaire at 6 months after second stage surgery. Tendon transfer can significantly improve the hand function and the quality of life of the patients with complete cervical spinal cord injury.

The Impact of Specialty on Cases Performed During Hand Surgery Fellowship Training

Hand surgery fellowship programs in the United States are predominately sponsored by departments or divisions of orthopaedic surgery or plastic surgery. This study compares the operative experiences of hand surgery fellows graduating from orthopaedic or plastic surgery hand surgery fellowships. Operative case logs of 3 cohorts of hand surgery fellows graduating during the academic years of 2012-2013, 2013-2014, and 2014-2015 were analyzed. The median case volumes were compared by specialty via Mann-Whitney U tests. An arbitrary 1,000% change between the 90th and 10th percentiles of fellows was used as a threshold to highlight case categories with substantial variability. In this study, 413 orthopaedic hand surgery fellows (87%) and 62 plastic surgery hand surgery fellows (13%) were included. Plastic surgery fellows reported more cases in the following categories: wound closure with graft; wound reconstruction with flap; vascular repair, reconstruction, replantation, or microvascular; closed treatment of fracture or dislocation; nerve injury; and congenital (p < 0.05). Orthopaedic surgery fellows reported more cases in the following categories: wound irrigation and debridement fasciotomy or wound preparation; hand reconstruction or releases; wrist reconstruction, releases, or arthrodesis; forearm, elbow, or shoulder reconstruction or releases; hand fractures, dislocation, or ligament injury; wrist fractures or dislocations; forearm and proximal fractures or dislocations; miscellaneous insertion or removal of devices; shoulder arthroscopy, elbow arthroscopy, and wrist arthroscopy; decompression of tendon sheath, synovectomy, or ganglions; nerve decompression; Dupuytren; and tumor or osteomyelitis (p < 0.05). Plastic surgery fellows reported substantial variability for 12 case categories (range, 1,024% to 2,880%). Orthopaedic surgery fellows reported substantial variability for 9 case categories (range, 1,110% to 9,700%). Orthopaedic and plastic hand surgery fellowships afford disparate operative experiences. Understanding these differences may help to align prospective trainees with future career goals and to guide discussions to better standardize hand surgery training.

Extensor indicis proprius muscle and its variants together with the extensor digitorum brevis manus muscle: a common classification. Clinical significance in hand and reconstructive surgery.

The extensor indicis proprius (EIP) is a muscle of the forearm that originates from the posterior surface of the ulna and the adjacent interosseous membrane and attaches to the index finger. Many anatomical variations of this muscle have been reported in the literature. The extensor digitorum brevis manus (EDBM) is a variant muscle found on the back of the wrist and hand. These muscle variants should be considered in the context of clinical syndromes and reconstructive hand surgery. The aim of the present study was to describe in detail the normal and variant anatomy of these muscles and propose new systematic classifications. Formol-carbol-fixed Europid upper limbs (n = 176) were examined in the Department of Anatomy, Histology and Embryology at the Medical University of Sofia for variations of the EIP and occurrences of the EDBM. We found normal anatomy in 147 (84%) of the specimens examined and we measured the length and width of the muscle belly and tendon of the EIP. Variations of the EIP in the other 29 upper limbs (16%) included replacement of the EIP by an EIB, coexistence of the EIP and EIB, presence of accessory tendons, and additional muscles. Knowledge of anatomical variations of forearm muscles is important because they can cause clinical syndromes or have implications for reconstructive surgery, most often as tendon transfers in response to functional loss of other forearm muscles.

Three-Dimensional Hand Reconstruction by Single-Shot Structured Light Line Pattern

3-D hand reconstruction is required in many applications, e.g., hand gesture controls, hand modeling, biomechanical analysis, humanoid robot hand design and analysis, hand surgery, and so on. In most situations, it is impossible or difficult for one to keep his hand static. Thus, real-time single-shot 3-D hand reconstruction is usually required in most applications. As a result, the popular phase shift-based structured light methods could not meet the requirement, because they need at least three images to reconstruct the hand. In this paper, we propose a single-shot 3-D hand reconstruction approach based on the structured light line pattern. The proposed approach calculates a line coordinate shift map from the distorted line pattern in a single image and then reconstructs the 3-D hand with the line coordinate shift map and the calibration parameters. To calculate the line coordinate shift map accurately, we propose a specific line clustering method based on the features of the hand. We also propose a slope-based compensation method to correct the distorted line coordinate shift map. Experimental results verified the effectiveness of the proposed line clustering method based on hand features, the proposed coordinate shift map correction method, and the proposed 3-D hand reconstruction approach.

Suprafascial dissection of the pedicled groin flap: A safe and practical approach to flap harvest.

The groin flap has been relied upon for more than 4 decades and is well suited for reconstruction of the mutilated hand. Classic groin flap harvest is subfascial and includes the superficial circumflex iliac artery (SCIA). SCIA perforator flaps have shown that one perforator is sufficient to supply a large flap without breaching fascia. Accordingly, we routinely preserve the fascia and rely wholly on the superficial branch of the SCIA, sparing the deep branch. We aim to investigate the safety of suprafascial flap elevation and encourage a paradigm shift in reconstruction with groin flap transfer. Between 2008 and 2013, 77 hand injuries were treated with pedicled groin flap transfers. According to surgeons' preference, 49 flaps were elevated with conventional technique ("subfascial") and 28 were harvested with suprafascial approach ("fascia sparing"). Demographic data including flap size, operative time, and outcome were reviewed in both approaches and compared. Suprafascial flaps were taken as large as 32 × 12 cm2 and subfascial flaps large as 30 × 10 cm2 (p = 0.08). Operative time was 268.2 ± 104.7 minutes in the suprafascial group and 227.4 ± 89.0 in the subfascial group (p = 0.14). One suprafascial flap (3.6%) had partial necrosis compared to four subfascial flaps (8.2%) (p = 0.65). All patients were followed for a minimum of six months. All the wounds finally healed without further flap reconstruction, and all the patients were back to the normal life with activities. Suprafascial dissection is safe and does not adversely influence outcomes. Thinner flaps are expected to facilitate flap insetting and reduce revisionary debulking surgery. III (Therapeutic).

Restoration of active pick-up function in patients with total brachial plexus avulsion injuries.

IV.

Hand reconstruction by transplanting the fostered residual finger and second toe which share the same blood supply system

Objective To investigate the methods and results of hand reconstruction by transplanting the fostered residual finger and the second toe, which share the same blood supply system. Methods From January, 2014 to January, 2016, 3 cases with destructive hand injuries in our hospital; and debridement was performed in one session during the early stage of trauma, with skin grafting to cover the wrist stump and foster the residual finger to a branch of the dorsalis pedis artery. The first dorsal metatarsal artery around the toe web was identified and then grad-ually isolated proximally with dissection of the branches of the dorsalis pedis artery supplying the fostered finger until the convergence of the two blood vessels. Then , reconstructed hand by residual finger and combined second toe transplantation. Results After a follow-up period of 3 months to 2 years, the reconstructed hand had a good appearance and was able to complete basic mundane actions. The function of the limb was restored to a large extent and the patient was satisfied with the reconstructed hand. Conclusion Transfer of a fostered residual finger and combined second toe which have the same blood supply system for hand reconstruction as a new method need to anasto-mose only one set of arteries, and it is feasible with the good appearance and function of the reconstructed hand. Key words: Destructive hand injuries; Foster finger; Second toe; Reconstruction; Combined transfer

Toe-to-finger combined with free flap transfer for primary one-stage post-traumatic reconstruction of the complex fingerless hand

Toe-to-finger transplantation is intimately related to the development of microsurgical free tissue transplantation, which is one of the most important advances in the history of reconstructive surgery. It is also generally acknowledged that a mangled hand with massive tissue loss and amputation of multiple digits presents a challenge for plastic and reconstructive surgeons. In this retrospective study we reviewed 11 cases of primary one-stage post-traumatic reconstruction of complex fingerless hands using a combination of toe-to-finger and free tissue transplantation performed in Shanghai Jiao Tong University affiliated Sixth People's Hospital and Shanghai Jiao Tong University School of Medicine affiliated Ninth People's Hospital from January 2001 to November 2014. Primary healing was achieved in 10 cases, while in the other case partial flap loss was documented and secondary healing was achieved by skin grafting. We concluded from this study that, by selecting suitable patients, use of a combination of toe-to-finger and free tissue transplantation may provide an alternative option for mangled hand salvage with satisfactory functional and esthetic results.

Postoperative gluteal compartment syndrome following microsurgical free-flap hand reconstruction: the importance of early recognition and treatment

Compartment syndrome, a surgical emergency, is caused by an increase in pressure within a closed osseofascial space, often due to trauma. This causes a decrease in tissue perfusion and ultimately...

Free super-thin peroneal artery perforator flap containing neurovascular axis for coverage of hand or foot tissue defects

Objective To investigate the clinical results of free super-thin peroneal artery perforator flap containing neurovascular axis in reconstruction of hand or foot soft tissue defects. Methods A retrospective case series study was made on 23 cases of hand or foot soft tissue defects admitted from January 2006 to March 2013. There were 16 males and 7 females, with a mean age of 33 years (range, 17-51 years). Wounds were located in dorsal hand (n=12), dorsal pedis or amputated forefoot (n=8), greater thenar (n=2) and index finger (n=1) respectively. Defects ranged in size from 5.0 cm×3.5 cm to 11.5 cm×7.5 cm. Flap elevating was performed underneath the deep fascia and the perforator supplying the flap was dissected thoroughly, ligated and cut at the location arose from the peroneal artery. Most of the deep fascia except stripe shaped areas along the main blood supply chains was moved sharply and the fat underlying thinned primarily to the subdermal vascular network. After transferred to the recipient site, the flaps were revascularized by anastomosis of the perforating artery and its venae comitantes to appropriate recipient vessels. A total of 15 cases received innervated flap reconstruction. Flap vascularity and cosmetic results were recorded. Hand function was evaluated with the standard set up by the hand surgery branch of Chinese Medical Association. For foot reconstruction, shoe wearing status, gait, pressure-sore, flap sensibility, donor site appearance and complications were evaluated. Results All flaps were transplanted successfully with satisfactory cosmetic results, except that one flap used to cover dorsal ring finger defect left slightly bulky appearance. Mean duration of follow-up was 19 months (range, 11-26 months). For hand reconstruction, the functional results were excellent in 6 cases and good in 9 cases. Repairing of foot defects with the flaps caused no problem of shoe wearing and no sore occurred. Normal gait was acquired except two cases of partially amputated foot. If innervated, flap sensibility was restored at least to the degree of S3. Protective sensation and touch-pressure sensation were restored in eight non-innervated cases, and two of them were recovered to the degree of S3. There was only suture or small grafting scars on the donor leg and partially sensibility loss of lateral foot without functional defects in 13 cases. Conclusion Free super-thin peroneal artery perforator flap containing neurovascular axis is an easy and reliable technique that can attain satisfactory results for accurate coverage of hand or foot soft tissue defects. Key words: Surgical flaps; Hand injuries; Foot

Anatomical Study of Cutaneous Venous Flow of the Palm.

Various flaps elevated from the palm have been widely used for finger and hand reconstruction. Recently, perforator-based free flaps or venous free flaps have received popularity due to several advantages. The cutaneous venous system has been chosen as the circulatory outlet when designing and harvesting the flap from the palmer area due to the small size and thin nature of the flap. However, there have been few descriptions about the anatomy of the palmar cutaneous veins. A more detailed knowledge will be valuable for elevating various flaps from the palmar area. Whole-body and hand venography with a contrast medium was performed on 9 fresh cadavers. Dissection and investigation of the skin and subcutaneous tissue were performed using a soft x-ray system with a stereogram. During all the processes that involved elevating the tissue, observations were made on the macroscopic structure of the palmar vein. In the palm, a complex network of veins are connected with the distal branches of the cephalic vein, basilic vein, and dorsal venous arch. The pattern and geometric formation of the venous network in all cases showed distinctive features according to each region of the palm. The venous branches create a network extending to palmar margins and webs between fingers. Venous arrangement should be considered when designing flaps from the palm to prevent venous congestion and safely extend the length of the flap.

Combined multi-lobed flaps: A series of 39 extensive hand and multi-digit injuries one-staged reconstructions using modified designs of ALT, DPA and chimeric linking flaps

IntroductionThe use of multiple small flaps linked in a “chain-linked” flap microanastomosed chimeric system is recommended in distal hand and digital defects reconstruction. The aim of this study is to demonstrates our experience utilizing microsurgical fabrication, multi-lobed and linking combined flaps for the reconstruction of hand degloving injuries with complex multidigit soft tissue defects. MethodsMicroanastomosed chimeric flap systems using ALT and DPA modified designed flaps were combined in five selections to cover extensive soft tissue defects involving the hands and multiple digits of 39 patients (M:F − 36:3) from October 2009 to February 2013. Five different microsurgical combined chimeric flap systems utilised in extensive hand and multidigit injuries; innervated ALT flaps, multilobed DPA flaps, innervated ALT flap with multilobed DPA flap, innervated ALT flap with sensate ALT flap and bilobed ALT flap with multilobed DPA flap. All DPA donor sites were reconstructed using free ALT flap and anterior tibial artery propeller flap. ResultsThirty-nine combined free flap extremities reconstructions on 39 patients (M:F − 36:3) with average age 28.5 (18–45) years sustained traumatic degloving injuries, 24 from road traffic accidents and 15 from industrial devices. Five different designs of combined multi-lobed flaps have be successfully used without any peri-operative complications. Average follow-up of 12 months, all flaps survived without complications. Operated extremities showed favorable functional recovery with restoration of the diminished protective sensation on the flap through reinnervation. All flaps survived uneventfully with coverage matching the texture and color of the recipients. Donor sites healed without complication. ConclusionThe microsurgical fabrication of chimeric ALT flaps and multilobed DPA flaps is a valuable alternative for the reconstruction of hand degloving injury with complex multidigit soft tissue defects.Level of evidence: Level IV, therapeutic study.