Phalangeal Defects Research Articles

New strategy for shortening the consolidation period in distraction lengthening of phalanges or metacarpal bone

Distraction lengthening of digits enhances hand function in patients with congenital phalangeal defects or traumatic hand amputations. Although callotasis is a useful distraction lengthening method, it is challenging and often results in various complications and prolonged fixation. Based on our experiences, we attempted to develop innovations to reduce the fixation period. We included 12 digits from nine patients with digital bone defects; lengthening was performed on seven proximal phalanges and five metacarpal bones using an Ilizarov mini-fixator device. In three digits, cancellous bone grafting within the cavity of the distraction callus, concomitant with internal fixation using an intramedullary screw, was performed to shorten the Healing Index. The mean achieved lengthening was 24mm for proximal phalanges and 22mm for metacarpal bones, with a Healing Index of 37.9 and 42.6 days/cm, respectively. Additionally, the Healing Index was significantly shorter in the three digits treated with cancellous bone grafting and internal fixation (mean 27.0 days/cm) than in the nine with no bone grafting (mean 44.1 days/cm). Major complications included early bone union, insufficient fingertip skin, and callus fractures during the consolidation period, affecting two, two, and one patient, respectively. Bone grafting within the distraction callus cavity promotes rapid bone formation, while internal fixation enables earlier removal of external fixators, thereby shortening the Healing Index.

Soft tissue surgical reconstruction of distal phalanges in children. Review

Distal phalangeal traumas are among the most common injuries in children. Nowadays, no unified approach has been established for the treatment of children with distal phalangeal defects. Very few domestic publications have devoted to fingertip injuries in children. To date, one of the most common methods of treating children with distal phalangeal defects is the shortening of the finger with stump formation. In cases of distal phalangeal injuries, the most complete restoration of their length, contour, and sensitivity with the preservation of the widest range of motion, and lowest donor site morbidity are necessary. In this literature review, conservative and surgical treatments of patients with distal phalangeal defects are described. The main advantages and disadvantages of different treatment methods are highlighted. The systematic search was performed in databases of PubMed, Web of Science, eLibrary, Russian Science Citation Index, and CyberLeninka, and 86 publications devoted to the surgical treatment of patients with fingertip defects were selected. This problem and its treatment require wider coverage and introduction into domestic healthcare.

A V-Y shaped flap with digital artery nerve at metacarpophalangeal joint was used to repair the defect of middle and distal phalanx

To explore a surgical method for the reconstruction of volar soft tissue defect and sensory and vascular repair in middle and far phalangeal digits. From January 2016 to January 2020, a total of 14 patients , 9 males and 5 females, ages ranging from 22 to 69 years old, and with volar soft tissue defects in the middle and distal digits 2 to 4, underwent surgical reconstruction using the V-Y shaped flap with digital artery and nerve at the metacarpophalangeal joint. The defect area was (2.0~2.5) cm×(1.5 ~2.0) cm. The procedure involved the harvest of a V-Y shaped flap with the digital artery and nerve from the metacarpophalangeal joint. Flap design, dissection of blood vessels and nerves, and anastomosis with the digital artery and nerve were performed according to a standardized protocol., Functional exercise of affected finger was initiated 3 weeks postoperatively. Subsequent assessments were conducted to evaluate finger pulp sensation, shape and other relevant parameters. According to the upper extremity functional evaluation standard set up by Hand Surgery Branch of Chinese Medical Association, the surgical outcomes were evaluated. All 14 cases demonstrated successful tissue transplantation, , with immediate recovery of sensation observed in 10 cases with distal finger pulp defects. Four patients with middle phalangeal defects experienced gradual sensory recovery within 2 to 3 months postoperatively. Thirteen patients were followed up for a mean duration of (8.8 ± 4.49) months, during which satisfactory outcomes were observed. The average two-point resolution of the finger pulp was 4-6mm, and sensory function evaluation yielded a score of S3 or above. Patients exhibited realistic finger shape, normal skin color and temperature, good wear resistance, and cold resistance. Furthermore, finger joint function was essentially normal. The V-Y shaped flap with digital artery and nerve at the metacarpophalangeal joint offers a suitable solution for repairing the defect of the middle or distal phalangeal finger. This technique is characterized by its simplicity, low risk, and favorable outcomes, including restored finger shape, blood supply and sensation. Moreover, high patient satisfaction was achieved.

Two clinical cases of the reconstruction of distal phalanges of hand in children by combination of the regional flap and scrap bone and nailbed graft

BACKGROUND: The hand and its distal phalanges, especially in children, are among areas mostly exposed to trauma while contacting the environment. Injuries causing loss of soft tissue and bone component are both challenging and interesting. This report presents the treatment results of children with soft tissue and bone defects of distal phalanges, in which reconstructions including combination of regional flaps, bone, and nailbed grafts were performed.
 CLINICAL CASE: This report presents clinical cases of the surgical treatment of 4- and 6-year-old children with fingertip injuries who underwent reconstructions including the combination of regional flaps, bone, and nailbed grafts. A combination of the scrap graft was performed in the first case with antegrade homodigital island flap and in the second case with thenar flap. The results were assessed 6 and 7 months after surgery.
 DISCUSSION: The primary aim of the surgical treatment of children with distal phalangeal defects is coverage of those defects. The restoration of the bone component of the defect is recommended to prevent postoperative deformations of the distal phalanges. Fingertip replantation or microsurgical transplantation of vascularized tissue complexes are technically difficult and require thorough care and monitoring of the childs condition in the postoperative period as all these measures may fail.
 CONCLUSIONS: The possibility to combine the scrap bone and nailbed graft with existing reliable surgical methods open new prospects for the successful treatment of fingertip injuries.

The Role of Reversed Homodigital Island Flap in Digital Reconstruction

Background: Fingertip injuries are very common. Reconstructionof extensive distal phalangeal defects with exposureof tendon, bone, or joint can be particularly a difficult problem.Options are local, regional and free flaps. SSG on bone andtendon is unsuccessful and nondurable. The primary goals ofdigital reconstruction are to preserve digital length and maintainfull mobility of the digit with providing adequate protectivecover of the deeper vital structures with soft tissue and skinof good quality. Homodigital artery island flap has been foundto be very useful and is commonly used for the recon‌structionof fingertip amputations.Patients and Methods: We used the reversed homodigitalartery island flap to reconstruct fingertip injuries in 8 patientsat Minia University Hospital and private sector in the periodbetween January to December 2017. We retrospectivelyanalyzed patients for: Age, sex, mechanism of injury, locationof defect, flap survival, sensory recovery and donor sitecoverage.Results: Five patients were males and 3 females. Agefrom 18 to 42 years mean (27.3 years). Six patients hadcomplete flap survival and two patients suffered venouscongestion that resolved completely by conservative measures.Donor site closure was directly closed in all cases. Nearnormal sensory recovery was noted.Conclusion: The reverse homodigital island flap is a safemethod for distal phalangeal reconstruction offering multipleadvantages over other local, regional and free flaps with analmost negligible donor site defect. Venous congestion andinability to reconstruct proximal finger defects are drawbacks

New reconstruction for bone integration of non-vascularized autogenous bone graft with better bony union and revascularisation.

Phalangeal defects are often seen after tumor resection, infections, and in complex open hand fractures. In many cases, reconstruction is difficult and amputation is performed to avoid prolonged rehabilitation that is often associated with a poor outcome. In these cases, the maintenance of length and function presents a reconstructive challenge. We reviewed 11 patients who underwent extensive phalangeal reconstruction with non-vascularized bone graft from the iliac crest using a key-in-slot-joint technique to provide acceptable function and bony union. In each case, non-vascularized bone graft with a length of 1.4-6.0cm was used to reconstruct the phalanx. Follow-up ranged from 6 weeks to 5 months, and in all cases, there was bony union after 6 weeks. We evaluated range of motion, function, and as well pain and grip strength of the fingers. This case series suggests that a key-in-slot technique allows non-vascularized bone graft to be used in complex large phalangeal bone defects. Due to better bone contact, a sufficient perfusion and revascularisation of the non-vascularized bone graft can be achieved for a quicker and stable bony union. This method appears to be an alternative to amputation in selected cases with a satisfactory soft-tissue envelope.

Re: End-of-Skin Grafts in Syndactyly Release: Description of a New Flap for Web Space Resurfacing and Primary Closure of Finger Defects

Sir, I read with great interest the article “End-of-skin grafts in syndactyly release; description of a new flap for web space resurfacing and primary closure of finger defects” by Sharma et al. published in Hand in 2009 [7]. The method of using an islanded dorsal flap without additional skin grafts for syndactyly release was first described by Sherif et al. in 1998 [8], being subsequently reported and modified by many authors [1, 3, 5, 9, 11]. While they all agree that this method of web space reconstruction provides an excellent basis for a long-lasting good result, most of them also admit that it is not suitable for all syndactyly types, and that releasing complete and complex syndactylies most often still requires the use of skin grafts and local flaps [3, 5, 9, 11]. The authors described a method of closing the middle and distal phalangeal defects that result from syndactyly release through direct closure or secondary intention healing following defatting of skin flaps. This technique produces a linear scar in the mid-lateral line of the digit, which will, with time, lead to contracture and finger and nail deformity. Although the authors reported one patient in their series having had complex syndactyly, they did not report any additional procedures performed to reconstruct the fingertip in this patient. The reconstruction of the lateral nail fold in complex syndactyly release usually requires some form of pulp flap method to cover exposed bone, of which the technique described by Buck-Gramcko is probably the best known [2]. Previously used methods of nail plate, matrix and pulp fat reduction to achieve the direct closure have failed the test of time, very often resulting in cosmetically unacceptable fingertips with deformed nails and absent or deformed lateral nail folds [4]. Indeed, taking a closer look at the follow-up photograph of one of the released digits in the article (Fig. 1), it is clearly visible that there is extensive scarring and notching of the lateral nail fold and deformation of the nail plate, which the authors did not consider as a problem. Fig. 1 Close-up of the follow-up photographs of one of the released digits (with kind permission from Springer Science+Business Media [7]) Considering the relatively small number of patients reported, various syndactyly types included in the study group and relatively short follow-up time, it is difficult to accept conclusions about the long-term outcomes. Unfortunately the authors also failed to quantify their results using parameters traditionally used in syndactyly release outcome reports [6], such as joint ROM, web creep, as described by Withey [10], and scar evaluation by the Vancouver Scar Scale or some other scar score. A normal sensation is reported, although it is admitted that sensory testing can be challenging in this age group (10 months to 3 years plus 1–3 years follow-up). Although many reports provide ample evidence that dorsal island flap techniques can provide long-lasting good result in incomplete syndactylies, thus avoiding the need to use skin grafts and shortening the operation time, complete and especially complex syndactylies necessitate the use of skin grafts and local flaps if a cosmetically pleasing fingertip is to be achieved.

Reverse dorsolateral proximal phalangeal island flap: a new versatile technique for coverage of finger defects

All flaps described for the reconstruction of finger defects have limited indications and many disadvantages. In this study, I successfully developed a reverse digital artery flap raised from the overall side and dorsal aspects of the proximal phalanx, excluding the digital nerve, for closure of fingertip and middle phalangeal defects, and called this the 'reverse dorsolateral proximal phalangeal island flap'. The donor site defect was covered by another flap called the 'dorsal metacarpal V-Y island flap'. The method was used for 12 complicated phalangeal defects in 11 patients. Flap sizes ranged from 2 x 1.5 cm to 3 x 2.5cm. The flap was applied with versatile designs including distal interphalangeal (DIP) (9) or proximal interphalangeal (PIP) anastomoses-based flaps (3); homodigital (10) or heterodigital flaps (2) from the injuries or adjacent finger, respectively; multiple flaps from the two distinct fingers in the same hand (1); and a sensate flap (1). The average follow-up time was 11.5 months. All reverse flaps and V-Y donor site flaps survived completely. Finger lengths and motions were satisfactory with favourable aesthetic results in all cases. The mean value of static two-point discrimination was 9.3mm. I strongly advocate this new flap, as a single versatile flap, for repair of different-sized or complex phalangeal defects. By means of this 'dual-flap manoeuvre', any defect distal to the PIP joint in various dimensions can safely be covered without using a skin graft in the donor area. I also suggest the dorsal metacarpal V-Y island flap alone for dorsal phalangeal defects proximal to this point.

Reconstruction of distal phalangeal injuries with the reverse homodigital island flap

Reconstruction of extensive distal phalangeal defects with exposure of tendon, bone, or joint can be particularly a difficult problem. For assessment of the value of the reverse homodigital island flap patients with distal phalangeal avulsion and crush injuries who were treated from January 2005 to April 2006 were analysed retrospectively. Main outcome measurements included flap survival rate, sensory restoration, occurrence of cold intolerance, length of occupational disability, and joint mobility. Eleven patients were included in the study. Only one patient suffered from venous congestion with partial flap necrosis, requiring debridement with subsequent skin grafting. The minimum follow-up was 6 months. The static 2-point discrimination had a mean value of 9 mm. None of our patients complained of cold intolerance or residual joint contracture. All patients returned to full occupational activity within an average time period of 4.5 weeks. In conclusion, the reverse homodigital island flap is an excellent option for 1-stage reconstruction of distal phalangeal defects.

Le lambeau interosseux antérieur dans la chirurgie du poignet et de la main : à propos de 15 cas

Fifteen anterior interosseous flaps were used to reconstruct wrist and hand defects in fifteen patients (thirteen men and two women) with a mean of 38 years (27-42 years). Seven anterior interosseous osteoperiosteal flaps and eight anterior interosseous osteocutaneous flaps were used. Seven island flaps and eight free flaps based on the anterior interosseous artery were raised. The indications were scaphoid non-union (4 cases), first metacarpal non-union (2 cases), proximal phalanx non-union (1 case), Kienböck's disease (2 cases), osteocutaneous phalangeal defects (3 cases), osseous capitatum defect (1 case) and intracarpal arthrodesis (2 cases). Postoperatively, one fracture of the distal end of the radius was noted because of a large osteoperiosteal corticotomy. Osseous reconstruction was usually consolidated at three months. One failure was noticed (Kienböck's disease). No significant deformity was noticed in the donor site. The anterior interosseous flap seems to be a useful alternative to reconstruct small or moderate defects in wrist and hand surgery.

A mutational analysis of the 5′ HoxD genes: dissection of genetic interactions during limb development in the mouse

Using gene targeting in mice, we have undertaken a systematic mutational analysis of the homeobox-containing 5' HoxD genes. In particular, we have characterized the limb defects observed in mice with independent targeted disruptions of hoxd-12 and hoxd-13. Animals defective for hoxd-12 are viable, fertile, and appear outwardly normal yet have minor autopodal defects in the forelimb which include a reduction in the bone length of metacarpals and phalanges, and a malformation of the distal carpal bone d4. The limb phenotypes observed in hoxd-13 mutant mice are more extensive, including strong reductions in length, complete absences, or improper segmentations of many metacarpal and phalangeal bones. Additionally, the d4 carpal bone is not properly formed and often produces an extra rudimentary digit. To examine the genetic interactions between the 5' HoxD genes, we bred these mutant strains with each other and with our previously characterized hoxd-11 mouse to produce a series of trans-heterozygotes. Skeletal analyses of these mice reveal that these genes interact in the formation of the vertebrate limb, since the trans-heterozygotes display phenotypes not present in the individual heterozygotes, including more severe carpal, metacarpal and phalangeal defects. Some of these phenotypes appear to be accounted for by a delay in the ossification events in the autopod, which lead to either the failure of fusion or the elimination of cartilaginous elements. Characteristically, these mutations lead to the overall truncation of digits II and V on the forelimb. Additionally, some trans-animals show the growth of an extra postaxial digit VI, which is composed of a bony element resembling a phalange. The results demonstrate that these genes interact in the formation of the limb. In addition to the previously characterized paralogous interactions, a multitude of interactions between Hox genes is used to finely sculpt the forelimb. The 5' Hox genes could therefore act as a major permissive genetic milieu that has been exploited by evolutionary adaptation to form the tetrapod limbs.

Histological and in vitro studies supporting decreased uteroplacental blood flow as explanation for digital defects after administration of vasodilators

In a recent study, the vasodilating drugs nifedipine, nitrendipine, felodipine, and hydralazine induced phalangeal defects in rabbits, when given on day 16 of pregnancy. Histologically, the changes were characterized by disturbed chondrogenesis. In order to elucidate mechanisms behind the defects, the fetal concentration of felodipine was measured, and the fetal limb plates were examined histologically, at 0, 2, 4, 8, 12, and 24 hours after single oral administration of felodipine (12 mumol/kg) on day 16 in pregnant rabbits. The effects of nifedipine, nitrendipine, and felodipine were also investigated in an in vitro system, in which chick embryonic mesenchymal limb bud cells differentiated into chondrocytes. In this system, no inhibition of chondrogenesis was observed below concentrations 3 x 10(5) M. At this concentration, unspecific cytotoxicity was found. The highest fetal concentrations of felodipine were more than 500 times lower than what was required for in vitro toxicity. Histologically, the digital areas of the limb plates showed extensive edema and dilatation of marginal sinus within 2 hours. After 8 hours, rupture of the thin-walled vessels occurred with hemorrhages. Finally, small necroses and blisters were observed. Similar early changes have been reported in experiments where digital defects were induced by clamping uterine vessels. This study thus indicates that the phalangeal defects after administration of high doses of vasodilators are secondary to pharmacological action (associated with a significant reduction in the uteroplacental blood flow), and not a direct effect on fetal chondrogenesis.

Digital defects induced by vasodilating agents: relationship to reduction in uteroplacental blood flow.

The effects of nifedipine (40-100 mumol/kg), nitrendipine (40 and 80 mumol/kg), hydralazine (381 and 763 mumol/kg), felodipine (12 mumol/kg), and the pharmacologically inactive first-step metabolite of felodipine, H152/37 (80 mumol/kg) were studied in rabbits (New Zeeland White) after oral administration on day 16 of gestation. The vasodilating drugs--nifedipine, nitrendipine, felodipine, and hydralazine--all induced digital defects in the fetuses. The defects consisted of a reduction, absence, or abnormal structure of the distal phalanx of especially the fourth digit on the hind paw(s). Histologically, a disturbed differentiation of the cartilage, and secondarily also of the ossification centre and joint structure of the distal phalanx, was observed. In contrast, no digital abnormalities were observed after administration of vehicle or H152/37. The findings that vasodilators with different structures, like dihydropyridines and hydralazine, induced the same type of digital defects strongly suggest that the observed phalangeal defects are secondary to pharmacological action, and not related to chemical structure. A decrease in uteroplacental blood flow, caused by excessive hypotension, is discussed as the most probable mechanism underlying the observed defects.

The use of demineralized xenogeneic bone implants to correct phalangeal defects: A case report

Demineralized bovine bone blocks and powder were used to reconstruct phalangeal defects created by excision of bulging endochondromas . Bony reconstruction was documented by roentgenography at 9 weeks and by biopsy at 7 months. Follow-up at 22 months has shown stability of the implants, further ossification, and no recurrence of the phalangeal endochondromas . The use of xenogeneic demineralized bone implants promotes induced osteogenesis and rapid healing, avoids harvesting procedures, and offers a potentially unlimited supply of banked material.

Reconstruction of Distal Phalangeal Injuries with Homodigital Island Flap: a Case Report

Background: Reconstruction of distal phalangeal defects with exposure of bone, tendon, or joint can be a difficult reconstructive problem, particularly since immediate coverage is of paramount importance for preserving function. The objectives of distal phalangeal defect or fingertip reconstruction included preservation of functional length and sensibility, prevention of symptomatic neuromas, acceptable donor site morbidity, the absence of cold intolerance, mineralization of aesthetic deformity, and quick return to occupational activities.Patients and Method: A review of one case, 26 years old male with phalangeal defect at tip to radial site of 3th finger of right hand, with tendon and bone exposed. After adequate debridement, shape and size of the defect are measured, the flap designed at the ulnar site of the same finger and the vascular of the flap is marked to palmar arch. Lazy “S” incision performed, donor flap is elevated with pedicle and transferred to the recipient site. Donor site was covered up with skin graft. Result: After follow up the homo digital island flap was healed nicely and the skin graft take was 100%, length is less diminish, sensibility conformed with two-point description, joint flexibility is good.Summary: Homodigital island flap is a useful safe option for fingertip or distal phalangeal reconstruction because it offers multiple advantages in comparison with advancement, regional, and free flaps, with an almost negligible donor site defect and can be done in a 1-stage procedure.