Hand Reconstruction Research Articles

Neo-digit functional reconstruction of mutilating hand injury using transplantation of multiple composite tissue flaps.

Functional reconstruction of mutilating hand injuries poses a challenge to the surgeon. We present our experience with use of multiple composite tissue flaps transplant for functional reconstruction of hand in patients with mutilating hand injuries. The associated merits and demerits of these surgical approaches are briefly discussed. From August 2004 to October 2014, functional reconstruction of hand with transplantation of multiple composite tissue flaps was performed in 8 patients. These included the toe with dorsal pedis artery flap, the reverse posterior interosseous artery flap, and the anterolateral thigh flap. Mean interval from injury to functional reconstruction was 10.6 days. All transplanted skin flaps and reconstructed neofingers survived completely. Only 1 patient developed wound infection at the recipient site (hand), which resolved without any debridement or revision surgery. At the donor site (foot), partial skin necrosis was observed in 1 patient, which healed with local wound care. In other patients, all wounds healed without any complications. The average range of movement at the neofinger metacarpophalangeal and interphalangeal joints was 38° and 73°, respectively. None of the patients required revision surgery. Use of negative pressure wound therapy and multiple composite tissue flap transplantation appears to be an effective strategy for hand functional reconstruction in patients with mutilating hand injuries. Among the multiple composite tissue flaps, use of toe transplantation combined with reverse posterior interosseous artery flap appears to be the best option.

Superficial lateral sural artery perforator flap for hand reconstruction

Objective To investigate the clinical efficacy of superficial lateral sural artery perforator flap for hand reconstruction. Methods From March, 2012 to April, 2015, 15 superficial lateral sural artery perforator flaps were planned for hand reconstruction. Of all cases, 11 cases were male, 4 cases were female, age ranged from 21 to 51 years old, with average age of 38.2 years. The skin defects ranged from 1.5 cm × 3.5 cm to 5.0 cm × 6.5 cm. Superficial lateral sural artery perforator flap were harvested uneventfully in 12 cases, the flaps were converted to superficial medial sural artery perforator flap in 3 cases. The flap size ranged from 1.8 cm × 3.8 cm to 5.5 cm × 6.5 cm. All reconstructive surgeries were performed secondarily. Results All of 15 flaps survived well, all donor sites were closed directly. During a mean follow-up of 9 months, the flaps were thin and pliable, none of the patients needed secondary flap thinning. The appearance of donor site was satisfactory, no patients complained about functional restrictions. Conclusion The superficial lateral sural artery perforator flap is feasible for reconstruction of middle-sized defects of the hand. Key words: Hand; Perforator flaps; Superficial sural artery; Microsurgery

Distally based posterior interosseous adipofascial flap with delayed skin grafting for soft-tissue reconstruction of the dorsal hand

Objective To investigate the clinical results of reverse interosseous adipofascial flap with delayed skin grafting in the reconstruction of defects on the dorsal hand. Methods From March 2012 to May 2014, 16 patients with soft tissue defects on the dorsum of the hand were treated dorsal interosseous adipofascial flap in emergency setting. The size of the flaps ranged from 5 cm×4 cm to 10 cm×6 cm. The donor site at the forearm was closed directly. Seven days later, the fascial flap was covered with a full-thickness skin graft taken from the groin area. Vancouver Scar Scale was applied to assess the donor site scar. Five-point Likert scale was used to evaluate the appearance of the recipient site. Results One patient had partial loss of the flap involving 5% of the area at the distal end. All the other flaps survived completely. The skin grafts took well in all 16 patients. The duration of postoperative follow-up ranged from 6 to 12 months, with an average of 8 months. The texture and color of the skin graft were good, and the esthetic result was satisfactory. The mean score of Vancouver Scar Scale was 0.8. The mean score of Five-point Likert scale was 17. Conclusion The described adipofascial flap transfer with delayed skin graft is rather easy to perform without causing significant functional and aesthetic deficits to the donor site. It is a good method for repairing defects of the dorsal hand. Key words: Hand injuries; Treatment ontcome; Adipofascial flap; Posterior interosseous artery

Submillimeter Diameter Poly(Vinyl Alcohol) Vascular Graft Patency in Rabbit Model.

Microvascular surgery is becoming a prevalent surgical practice. Replantation, hand reconstruction, orthopedic, and free tissue transfer procedures all rely on microvascular surgery for the repair of venous and arterial defects at the millimeter and submillimeter levels. Often, a vascular graft is required for the procedure as a means to bridge the gap between native arteries. While autologous vessels are desired for their bioactivity and non-thrombogenicity, the tedious harvest process, lack of availability, and caliber or mechanical mismatch contribute to graft failure. Thus, there is a need for an off-the-shelf artificial vascular graft that has low thrombogenic properties and mechanical properties matching those of submillimeter vessels. Poly(vinyl alcohol) hydrogel (PVA) has excellent prospects as a vascular graft due to its bioinertness, low thrombogenicity, high water content, and tunable mechanical properties. Here, we fabricated PVA grafts with submillimeter diameter and mechanical properties that closely approximated those of the rabbit femoral artery. In vitro platelet adhesion and microparticle release assay verified the low thrombogenicity of PVA. A stringent proof-of-concept in vivo test was performed by implanting PVA grafts in rabbit femoral artery with multilevel arterial occlusion. Laser Doppler measurements indicated the improved perfusion of the distal limb after implantation with PVA grafts. Moreover, ultrasound Doppler and angiography verified that the submillimeter diameter PVA vascular grafts remained patent for 2 weeks without the aid of anticoagulant or antithrombotics. Endothelial cells were observed in the luminal surface of one patent PVA graft. The advantageous non-thrombogenic and tunable mechanical properties of PVA that are retained even in the submillimeter diameter dimensions support the application of this biomaterial for vascular replacement in microvascular surgery.

Pedicled Oblique Para-Umbilical Perforator (OPUP) Flap for Upper Limb Reconstruction.

Groin flap has been considered the workhorse flap for hand reconstruction. However it has certain drawbacks when covering defects over elbow or proximal forearm. Pedicled oblique paraumbilical perforator (OPUP) based flaps provide a good alternative in such cases. We performed OPUP flap in 11 cases of complex upper limb reconstructions over the past one year. We report our experience with this flap. All flaps survived. One patient had marginal necrosis of 1 cm in the proximal end after flap division. Three patients had donor site scar hypertrophy. OPUP flap is superior to groin flap for larger defects or defects around the elbow. The major disadvantage is the donor site scar which is prone to hypertrophy.

How Rheumatoid Arthritis Patients Make Decisions Regarding Hand Reconstruction: A Qualitative Study from the Silicone Arthroplasty in Rheumatoid Arthritis Project.

Previous studies have determined specific factors influencing patients with rheumatoid arthritis to choose to undergo reconstructive hand surgery. However, little is known about how rheumatoid arthritis patients are counseled by physicians regarding surgical options and the concerns that cause patients to decide not to undergo hand surgery reconstruction. The authors conducted a qualitative study to investigate the decision-making process rheumatoid arthritis patients undergo when deciding about surgical treatment, including the specific involvement from their physicians in the decision. Participants were recruited from the ongoing international collaborative Silicone Arthroplasty in Rheumatoid Arthritis study. Twenty semistructured interviews were conducted, and data were analyzed using grounded theory methodology. Eight of the 11 participants that underwent metacarpophalangeal joint arthroplasty indicated that improving hand function was the primary reason they chose to undergo surgery. Four of these participants were concerned about the aesthetics of their hands, whereas five of the eight participants who discussed their reasoning for not undergoing surgery felt aesthetics was not a good enough reason to undergo surgery. Three participants indicated that a negative perception of hand surgery by their rheumatologists discouraged them from the procedure. Finally, most (14 of 18) participants chose to make the final decision about surgery without involvement from their physician. The decision of whether or not to undergo surgery can be personal, and patients may prefer to make the final decision independently. It is important that rheumatoid arthritis patients receive collaborative counseling from their rheumatologists and hand surgeons to ensure they are making a knowledgeable decision.

Pedicled hypothenar perforator flap: Indications and clinical application

Soft-tissue defects of the palm and the palmar aspect of the fifth finger are a constant problem in reconstructive hand surgery. We present a possible approach to planning and harvesting pedicled hypothenar perforator flaps for the reconstruction of such defects. A hypothenar perforator flap was used to reconstruct a soft-tissue defect on the ulnar aspect of the palm and the palmar aspect of the fifth finger of 17 patients. The defects were located over the proximal phalanx of the fifth finger (n=9), the palm (n=5), and across both areas (n=3). The size of the defects was up to 7.9cm(2). Eleven of the flaps healed primarily, out of which partial flap necrosis was observed in six. Four of these six flaps required operative revision, including debridement and delayed primary wound closure, while two healed secondarily. After an average of 26.6 days (range 21-45 days), all 17 patients achieved complete functional recovery. Despite the complications described, all the primary defects remained covered. The pedicled hypothenar perforator flap is an option for reconstruction of ulnar-sided, soft-tissue defects of the palm and little finger. The flap is thin and the donor-site morbidity is low. Hand surgeons may wish to consider this flap when presented with soft-tissue defects in this area.

Active range of motion outcomes after reconstruction of burned wrist and hand deformities

This works aim is to evaluate the efficacy of skin grafts and flaps in reconstruction of post-burn hand and wrist deformities. A prospective study of 57 burn contractures of the wrist and dorsum of the hand was performed. Flaps were used only if there was a non-vascularized structure after contracture release, otherwise a skin graft was used. Active range of motion (ROM) was used to assess hand function. The extension deformity cohort uniformly underwent skin graft following contracture release with a mean improvement of 71 degrees (p<0.0001). The flexion deformity cohort was treated with either skin grafts (8 patients) or flaps (9 patients) with a mean improvement of 44 degrees (p<0.0001). Skin grafts suffice for dorsal hand contractures to restore functional wrist ROM. For flexion contractures, flaps were more likely for contractures >6 months. Early release of burn contracture is advisable to avoid deep structure contracture.

Hand reconstruction using heterotopic replantation of amputated index and little fingers

AbstractIn cases of severe segmental injuryacross the hand and wrist, but one or other fingers are still in peak condition, the fingers can be selected for replantation at the forearm bones to restore pinch function. Here we reported an unusual case with a severe crush-avulsion amputated injuryto the right hand caused by a machine accident. We conducted hand reconstruction using heterotopic replantation of the amputated index and little fingers. During 19 months follow-up, the bone union healed well with satisfactory outcome. The interphalangeal and metac-arpophalangeal joint of the fingers after the heterotopic replantation had a good holding activity. This is a worthwhile procedure and the patient is satisfied with the result. The major disadvantage of this method is the poor appearanceof the reconstructed fingers.

Reconstruction of hand

산업시설의 자동화가 보편화되면서 수부외상의 빈도는 많 이 감소하고 있고 고령화가 진행되면서 환자의 양상도 변화 하고 있다. 국내 수부외과학회에서는 수부외과 세부전문의 제도를 시행하여 치료의 질적 향상을 도모하면서 수부외상 에 대한 전문성을 강조하고 있다. 또한 의료의 접근성이 향 상되고 미용적인 관심이 증가하면서 예전에는 병원문을 두 드리지 않았을 환자들도 포함하여 여전히 많은 사람들이 수 부문제로 병원을 찾고 있다. 수부재건은 외형적 개선도 중요 하지만 수부 본연의 기능회복만큼 중요한 것은 없을 것이다. 따라서 수부재건의 일차적인 목표는 단순히 결손된 부분을 만들어 주는 것이 아니라 실제적으로 기능을 하는 구조의 복 원이라고 봐야 할 것이다. 여기에 더불어 미용적으로도 개선 이 된다면 이상적인 치료라 할 수 있으며 이에 관한 다양한 재건방법에 대해 알아보고자 한다.

Functional outcomes of post-traumatic metacarpal hand reconstruction with free toe-to-hand transfer.

Introduction:We present the functional outcomes of microvascular toe transfer to reconstruct the post-traumatic metacarpal hand deformity. Twelve toe transfers were successfully carried out in 11 patients.Materials and Methods:In each patient, the level of injury was classified according to the Wei classification system. Functional outcome was measured in seven patients using the Tamai score. Additional objective tests of function were carried out in three patients, including the Jebsen test, grip strength, pinch strength, web opening, static and moving two-point discrimination and Semmes–Weinstein monofilament testing.Observation and Results:The average Tamai score was 69 (range 60–83.5). Six patients achieved ‘good’ outcomes and one patient, with a double toe transfer, an ‘excellent’ outcome. The average follow-up time was 43 months (range 10–148 months).Conclusion:This study shows how even a single toe transfer can restore useful function to a hand that has otherwise lost all prehensile ability.

Hand amputations: epidemiology, management and resurfacing options for soft tissue coverage.

Agricultural hand injuries occur mainly among young adults, many affecting the dominant hand, thereby impeding patients' ability to work or cope with social obligations. This study was carried out with the aim of collecting data on the epidemiology and management of agricultural hand injuries in Indian subjects. The study was conducted in the Department of Plastic and Reconstructive Surgery, JN Medical College, AMU, Aligarh, India, from October 2009 to December 2013. Patients with agricultural hand injuries were included. Data collected included socio-demographic details, mode and type of injury, type of reconstruction, complications, length of hospital stay and assessment of post-reconstruction status. These data were tabulated and analysed. The typical patient was young (mean 33.2 years), of lower socio-economic status and with a total disregard for safety regulations. There is clustering of cases during the wheat harvest season (April-June). Wheat thresher injuries were the most common cause of partial hand amputation (51%), especially during this season. This was followed by fodder cutting (kutti/chara) machine injury, especially in females and children (36%). A simple classification for these injuries has been described and Grade II injury was the commonest. Reverse radial forearm flap was the most suitable regional flap for coverage, whereas thoraco-umbilical flap was the most commonly used distant flap. Patients who had the single-stage procedure had a significantly shorter stay. Agricultural hand injuries are not totally avoidable and their incidence can be reduced by proper education, but the low economic and literacy status of the patients is a big hurdle. The forearm offers many flaps for reconstruction of hand, which can be used in defects on dorsal or palmar aspect of hand and results in early discharge from the hospital and early rehabilitation. In patients with associated injury to the forearm, abdominal flaps can be used for cover.

Complex Hand and Wrist Reconstruction Using Free Vascularized Bone Grafts

Complex Hand and Wrist Reconstruction Using Free Vascularized Bone Grafts

Reconstruction for All: The Case for Pediatric Hand Transplantation

The advent of vascularized composite allotransplantation (VCA) has ushered in a new era of reconstructive surgery. Lower rungs on the reconstructive ladder rely on autologous tissue, alloplastic materials and pretreated biologics to reconstruct and mimic the functional and aesthetic components of human anatomy. VCA, however, uniquely provides the exact functional components in the appropriate anatomic configuration to restore both form and function together in a single unit. Following the first successful hand transplant in 1998, the medical community has progressively adopted VCA as a viable restorative option for a multitude of functional defects. Reconstructive Hand Transplantation (RHT) remains the most commonly practiced form of VCA and to date, 72 patients in 16 countries have undergone transplantation of 107 upper extremities over the past 17 y. As this field continues to gain traction and enjoy advances in transplant medicine, it is time we consider pediatric recipients who may have more to gain from our efforts. Noncompliance with immunosuppression and hand therapy may impede outcomes; yet, with proper patient selection and adequate familial and social support we can restore a sense of wholeness and normalcy to our children who have suffered limb loss.

Dorsal plane-shaped advancement flap for the reconstruction of web space in syndactyly without skin grafting: A preliminary report

Skin grafting for syndactyly repair is time-consuming, and it has the potential risks of scar contracture and web creep. Several techniques have been described for web reconstruction without skin grafts in simple syndactyly. Based on the hexagonal advancement flap, we designed a "plane-shaped" advancement flap on the dorsal hand or foot for a web reconstruction with primary closure. Between June 2010 and August 2013, a "plane-shaped" advancement flap was used for web reconstruction in 24 syndactylies of 20 pediatric patients. The patients' age ranged from 1.5 to 8 years (mean age: 2.5 years). The patients were followed up for 15-48 months (mean: 28 months). The mean operation time was 60 min (range: 50-75 min). All incisions were closed primarily without skin grafting. All the flaps survived completely without early complications such as infection, vascular compromise or delayed healing. The mean hospitalization time was 3.5 days. There was no occurrence of long-term complications including web creep, flexion contractures, angulation deformity, or obvious keloid formation during the 15-48 months follow-up. Cosmetic and functional satisfactory outcomes were achieved in all cases without secondary revision. The dorsal plane-shaped advancement flap without skin graft is a solution for web space reconstruction in simple syndactyly, especially in the foot.

Dorsal hand coverage

Dorsal hand coverage

Perforator flaps in the hand

The need for an appropriate flap cover to protect vital structures, restore and preserve function and aesthetics of the hand following tissue loss remains a challenge to the reconstructive hand surgeon. Following the description of the angiosome concept by Taylor and Palmer and the pioneering work of authors such as Koshima & Soeda, Kroll, and Rosenfield, in the late 1980s, the perforator flap technique has moved to the centre stage in reconstructive flap surgery.

David J. Slutsky: The art of microsurgical hand reconstruction

David J. Slutsky: The art of microsurgical hand reconstruction

Perforator flaps in hand reconstruction: the effect of blood vessel twisting.

Background and aimsPerforator flaps increasingly find acceptance and use in hand reconstructive surgery. A propeller flap is an island flap that moves from one orientation to another by rotating around its vascular pedicle. It is now possible to design propeller flaps based on a single perforator, so-called “perforator-based propeller flaps,” but they are more prone to vascular impairment when twisted more than 90°.MethodsWe present a prospective study conducted in the Plastic and Reconstructive Surgery Department of the Rehabilitation Hospital over 17 months. All perforator-based propeller flaps that were used for hand reconstruction were analyzed. The parameters studied included the size and location of the defect, the size and shape of the flap, the perforator (length and location) that was used, the degree of twisting of the perforator, the degree of perforator dissection, the management of the donor site, and flap survival area.ResultsIn this study we investigated the circulatory impairment induced by twisting of the pedicle on a true perforator flap. All flaps survived completely with the exception of partial skin necrosis in few cases. Some of these cases required debridement and skin grafting.ConclusionsPerforator-based propeller flaps provide a reliable option for covering small- to medium-size hand complex tissue defects. They have the advantages of using similar tissues in reconstruction, not damaging another area, they do not require main vessels sacrifice, and the donor site can be generally directly closed.

足趾移植を行った手と筋電義手の機能差&amp;mdash;両手切断の1症例&amp;mdash;

A 45-year old male patient suffered mutilation of his fingers except for the thumb in the right hand, and a crush injury of the whole left hand simultaneously while operating a rolling machine. The right hand was reconstructed with a double 2nd-toe implantation. After training his pinch motion in the right hand, a myoelectric prosthesis was attached to the left hand. He used his right hand for pinching task and the left hand for grasping task. His DASH score was 173 before functional reconstruction of the bilateral hands, and it was 84 at 5 years after treatment. A comparison was made concerning the functional results between the right hand reconstructed with the toe transfer and the left hand with the myoelectric prosthesis in order to discuss the prognosis for each treatment.