Thumb Defects Research Articles

Neurotized first dorsal metacarpal artery flap for reconstruction of thumb defects: does it helps to improve sensory outcomes?

Restoration of tactile sensation after reconstruction of a thumb pulp defect is important for hand function. We have evaluated the functional, sensory and aesthetic outcomes of neurotized first dorsal metacarpal artery (FDMA) flap in reconstruction of various soft tissue defects of the thumb. For a period of 18 months (January 2021 to June 2022), a total of 20 patients were considered for the study and divided into two groups that is neurotized (group A) and conventional (group B) FDMA flaps. One flap in each group underwent complete necrosis. Results were compared with patients treated by the conventional Foucher’s FDMA flap without nerve repair. At the final follow-up, flap sensation was assessed using static two-point discrimination and Semmes–Weinstein monofilament (SWM) testing. The mean values for active range of motion, total time for procedure, average time to return to routine work and time period of cortical reorientation were statistically significantly different from the values in the control group (p value <0.05). 2-PD, SWM and cold severity score were found to be statistically non-significant. Neurotized FDMA island flap provides a stable, sensate and reliable option for sensory reconstruction of thumb pulp defects with earlier cortical reorientation that allows easier physical rehabilitation and earlier ability to return to previous work to the patients.

Revisiting Elliot's Modification of Moberg's Flap and Our Improvisation.

Thumb tip injuries constitute one of the most common hand injuries. There are various reconstructive options for thumb tip injuries. We present our series of thumb tip injuries reconstructed using Elliot's modification of the Moberg flap, which provides like-for-like tissue. We also present our flap improvisation, which can be useful in the armamentarium of plastic surgeons. Background Moberg described the advancement flap for thumb defects in 1964, which was modified by O'Brien in which the proximal part of the flap is incised and advanced. Although it is a popular flap, it has the disadvantage of interphalangeal (IP) joint flexion deformity. Among the various modifications of the Moberg flap, Elliot's flap provided more tissue with minimal donor site morbidity and no usage of skin grafts or first web skin. Methods We retrospectively analyzed the patients who underwent reconstruction of thumb defects by Elliot's modified Moberg's flap. The size of the defect, etiology, and IP joint movement were analyzed. Two patients underwent our improvised flap where a daughter flap was elevated within Elliot's flap. Results Between January 2021 and September 2023, 12 patients underwent reconstruction by Elliot's flap. All flaps settled well. There was no IP joint deformity. Two patients had scar hypertrophy that was managed conservatively. Conclusion Elliot's modification of the Moberg flap is a very useful but underutilized flap for thumb tip injuries that provides like tissue with sensation and with little donor site morbidity. It can be used for thumb tip defects of up to 3 cm . It is possible to incorporate a second V-Y flap in patients for whom additional movement is required for tension-free closure.

Reverse homodigital dorsoradial flap for thumb soft tissue reconstruction

Primary and secondary reconstruction of the thumb is a common reconstructive challenge for the hand and plastic surgeons. Currently, The kite flap or the First dorsal metacarpal artery flap remains the regular choice and is believed to be the best for distal thumb defects, but it’s the first time we have utilized a reverse homodigital dorsal radial flap for the thumb with an expected outcome. A 37 - year - old male patient suffered partially, obliquely, and radially necrotic thumb tip in the second week following conservation stitching of the wound due to a motorcycle accident. The necrotic tissues were desbrided and the residual defect was covered simultaneously by reverse homodigital dorsoradial flap. The Interphalange (IP) and Metacarpalphange (MCP) joints were flexible, and the active rang of motion (ROM) of the affected thumb was not limited at 3 months post - op. The reverse homodigital dorsoradial flap has become a useful and valuable material for thumb reconstruction. The flap provides acceptable aesthetic results with primary closure of the donor site and returns the essential functionality to the affected thumb.

Free lateral tarsal artery perforator flap for repair of volar skin defect of thumb.

To investigate the effect of free lateral tarsal artery perforator flap in the repair of the volar skin defect of the thumb. From January 2020 to December 2022, the free lateral tarsal artery perforator flap was used to repair the skin defect of the palmar side of the thumb in 11 cases. There were 9 males and 2 females with an average age of 45 years (range, 35-62 years). The causes of injury were mechanical injury in 8 cases, traffic accident in 3 cases, combined with different degrees of tendon and bone exposure and injury. The time from injury to operation was 1 to 4 hours, with an average of 2.5 hours. The size of the flap ranged from 3.0 cm × 3.0 cm to 5.5 cm × 5.0 cm, and the donor site was repaired with the skin graft. All the flaps and skin grafts survived successfully, and the wounds healed in the first stage. All patients were followed up for 6 to 24 months, with an average of 15 months. The appearance of the flap was good, with normal color, no pigmentation, and a soft texture. The 2-point discrimination of the flap was 6 to 11 mm, with an average of 8.5 mm at 6 months after operation. At the last follow-up, 8 cases were excellent and 3 cases were good according to the trial standard of upper limb function evaluation of the Chinese Society of Hand Surgery of the Chinese Medical Association, and the excellent and good rate was 100%. There was no significant effect on the sensation and function of the feet in the donor site, and the patient satisfaction was high. Free lateral tarsal artery perforator flap is a good choice to repair the skin defect of the palmar side of the thumb because of its simple operation, high survival rate and good sensory recovery of the recipient area.

First dorsal metacarpal artery flap in soft tissue reconstruction of recurrent thumb squamous cell carcinoma

Background. Subungual squamous cell carcinoma (SCC) of thumb is a rare disease. However, it is the most common malignancy affecting the nail bed. Early recognition is crucial and important for prompt diagnosis and effective treatment. Often this tumour needs to be treated surgically with wide local resection, which results in a defect in the thumb. If not handled appropriately, such defects render restriction in functionality of the involved thumb as well as a poor aesthetic outcome. In the worst-case scenario, it may result in a poor function of involved hand. Thus, reconstruction of the involved thumb is necessary. The main aim of reconstruction is to regain the hands' function and preserved the thumbs' sensation. Secondarily, to have an aesthetically pleasing hand. Our hands carry out delegate job and important duty for daily function. Especially, the thumb working together with the other fingers to carry out the hand function as one unit. Loss of thumb function affects the whole performance of the hand. Case descriptions. We report a case of recurrent subungual squamous cell carcinoma of thumb, which had wide local resection and subsequently underwent soft tissue coverage with an islanded first dorsal metacarpal artery (FDMA) perforator flap. One month after surgery, the patient was able to regain a good functional outcome of the hand. In this report, we discussed the procedures that had been done. Conclusion. The patient regained full functional hand after reconstruction with preserved sensation over distal thumb. The aesthetic outcome is satisfactory. The FDMA perforator flap is a very pliable and robust flap for reconstruction of distal thumb defect.

Utility of First Dorsal Metacarpal Artery Flap for Thumb Defects

Background: Thumb defects induced by trauma lead to significant functional disability. The goal of this study was to identify the safety, versatility, and limitations, benefits, and functional outcomes, range of motion and reestablish sensory experience. These characteristics, in addition to a secure soft tissue cover, are needed for thumb restructuring. Study design: This was a retrospective study carried out in the Plastic Surgery Department of Shaheed Mohtarma Benazir Bhutto Institute of Trauma, Karachi from November 2021 to December 2022. Methods: The total 17 participants with traumic thumb defects which insert and treated with island flaps. The participants included 5 females and 12 males, the age group was 20-50 years and the average age (36 years). All patients were evaluated for the occurrence of early post-operative complications in terms of flap necrosis. Results: The operative time was 1 hours. The 15 participants underwent island FDMA flap except 2 participants which show necrosis but without again treatment recover. To evaluate the esthetic and functional outcome by Kapandji score, 2-PD, SS score and esthetic outcome follow by one year. Regarding the functional recovery Kapandji, 2-PD, the esthetic and subjective satisfactory score outcome was evaluated and show significant changes p<0.005. Conclusion: FDMA is one of the best choices for reconstituting distal thumb injuries, and it is a simple technique that has the potential to enhance the island's survival and lowering the rate of distal necrosis. The FDMA flap provides good functional results while causing little donor-site morbidity. Keywords: Cortical reorientation, Metacarpal artery, Island Flap, Two point discriminate.

Reconstruction of Thumb Defects Using the Second Dorsal Metacarpal Artery Flap with Two Pivot Points.

This study aimed to introduce reconstruction of thumb defects using the second dorsal metacarpal artery (DMA) flap with two pivot points. A retrospective study was conducted with 43 patients (group A) who underwent thumb reconstruction using the second DMA flap with two pivot points from July of 2012 to May of 2019. For comparison, the authors reviewed another cohort of 34 patients (group B) undergoing thumb reconstruction using the first DMA flap. Flap sensation and donor-site morbidity were assessed. In group A, the mean two-point discrimination was 8.7 mm (range, 6 to 12 mm) and 9.7 mm (range, 7 to 12 mm) on the innervated and noninnervated flaps at the final follow-up, with a significant difference ( P = 0.012). In group B, the mean two-point discrimination of the flaps was 7.4 mm (range, 6 to 10 mm). By comparison, group B presented better discriminatory sensation than innervated flaps with double pivot points ( P = 0.002). Based on the visual analogue scale score, the mean score of scar pain and appearance of the donor site were 0.1 (range, 0 to 3) and 0.4 (range, 0 to 2) in group A, and 0.5 (range, 0 to 3) and 1.0 (range, 0 to 4) in group B. By comparison, group A presented lower incidence of scar pain ( P = 0.020) and better appearance of the donor site ( P = 0.019). The second DMA flap with two pivot points has a long vascular pedicle, which allows the flap to repair thumb defects. It is associated with low donor-site morbidity but suboptimal sensory recovery. Therapeutic, III.

Comments on "Utility of First Dorsal Metacarpal Artery Flap for Thumb Defects".

I reviewed the study “Utility of First Dorsal Metacarpal Artery Flap for Thumb Defects,” by K. Aggarwal and K. Singh, published online in the Indian Journal of Plastic Surgery.[1] The study is well designed and the findings are presented in the discussion section accompanied by the literature.

Hand Injuries at Work: Causes, Spectrum and Management

Background: Hand injuries are common and an increased surge has been seen secondary to the use of machines.The spectrum of injuries is wide ranging from injuries requiring few stitches to requiring specific reconstructive procedures such as skin grafting, pedicled flaps to free flaps or amputations depending on severity and pattern of injury. Methods: This was a hospital-based single-arm prospective study conducted in the Department of Plastic and Reconstructive Surgery for 3 years. 46 patients were included.Each record was analyzed as per the etiology, the treatment received, the reconstructive procedures done, and the functional and aesthetic outcomes. Results: Most of the affected individuals were young, the mean age of the patients was found to be 23 years. Among the injured 85% were males. The dominant hand (right hand) was more frequently injured in 74% of cases. In total 18 patients had some of the affected areas amputated; this included formalization of traumatic amputations. It is also significant that twelve patients underwent revascularization and four reimplantations. Twelve patients underwent groin flaps as a primary or delayed primary in the same admission. Ten patients required split skin grafting and three. Two patients were managed with FDMA flap for thumb defect, one patient was managed with reverse radial forearm flap for compound defect dorsum of thumb, and another with free lateral arm flap for compound defect of thumb. Conclusion: The management of machine injuries of the upper limb and hand requires specific and unique methods of treatment. A "reconstructive ladder" of techniques was utilized, ranging from "simple" (e.g., direct closure, skin grafts, and local flaps) to "complex" (free flaps, toe-to-thumb transfer) procedures. The individual procedure selected is the most straightforward, consistent with expediency and early return of a functional hand. The return of these hands to function has been facilitated by recent advances in tissue assessment, free tissue transfer, and skilled hand therapy. Keywords: Dominant hand, machine injury, band saw, brush cutter, rotator drill.

The second dorsal metacarpal artery flap relaying the dorsal island flap of the index finger for the repair of soft tissue defect of thumb

To investigate the effectiveness of the second dorsal metacarpal artery fascial vascular pedicle retrograde island flap relaying the dorsal island flap of the index finger in repairing skin and soft tissue defects of the thumb. The clinical data of 8 patients with skin and soft tissue defects of thumb between October 2019 and January 2021 were retrospectively analyzed. There were 3 males and 5 females with an average age of 35 years (range, 18-52 years). The causes of injury included machine injury in 2 cases, crush injury in 3 cases, and cutting injury in 3 cases. There were 2 cases of dorsal defect of the proximal part, 1 dorsal defect of the distal part, and 5 instances of the distal part defect. The skin and soft tissue defects ranged from 1.7 cm×1.4 cm to 3.0 cm×2.5 cm. The time from injury to flap repair was 7-21 days, with an average of 14 days. Firstly, the dorsal island flap of the index finger (dorsal side of the proximal part of the index finger) was used to repair the defect of the thumb. Then the second dorsal metacarpal artery fascia vascular pedicle retrograde island flap (near the radial side of the back of the hand) was used to repair the dorsal defect of the index finger; the donor site was sutured directly. Vascular crisis of the flap occurred in 1 case within 48 hours after operation, and the flap was bloated and bruised in 1 case due to excessive suture tension, and all the flaps survived after symptomatic treatment; partial skin margin of the flap was necrotic in 1 case after operation, and the incision healed after dressing change; the other 5 flaps survived, and all the wounds in the donor and recipient sites healed by first intention. All the 8 patients were followed up 3-10 months, with an average of 6 months. One patient had mild scar; the other patients had no significant difference in the color of the flap and the surrounding skin, no adhesion of tendons, and little interference of index finger function, and there was no obvious pain and dysfunction in the donor and recipient sites of the flap. At last follow-up, the extension-flexion range of motion of the metacarpophalangeal joint of the thumb was 0°-55°, and that of the interphalangeal joint was 0°-75°; the extension-flexion range of motion of the metacarpophalangeal joint of the index finger was 0°-82°, that of the proximal interphalangeal joints was 0°-90°, and that of the distal interphalangeral joints was 0°-65°. The application of the second dorsal metacarpal artery fascial vascular pedicle retrograde island flap relaying the dorsal island flap of the index finger to repair skin and soft tissue defect wounds of thumb is a feasible treatment with reliable blood supply, less postoperative complications, no need for skin grafting, less interference to the function of the index finger, and satisfactory wound repair effect.

Reconstruction of Soft-Tissue Defects of the Thumb Using Reverse-Flow Homodigital Flaps: A Systematic Review

IntroductionSoft-tissue thumb defects are common reconstructive challenges, the main goals being restoration of tactile sensibility, range of movement, pulp padding, length, and cosmesis. The reverse-flow dorsoulnar and dorsoradial collateral artery flaps are homodigital flaps used to cover both distal dorsal and volar thumb defects. These flaps can be used as compound flaps including skin, fat, and/or nerves. As there is no critical analysis of these studies, this study aims to create a synthesized comprehensive systematic review. MethodsSystematic review was performed using the databases PubMed, Embase, and Medline. Eligible studies followed the inclusion criteria: English language and all studies published to date. The primary outcome was flap survival. Other data collected included anatomical area of the defect, flap constituents and dimensions, donor-site closure and complications, transfer method, reoperation, revision, and functional outcomes. ResultsA total of 19 articles incorporating 189 flaps met the inclusion criteria. These flaps were categorized and analyzed as dorsoradial (50%), dorsoulnar (39%), and turnover flaps (11%). Dorsoradial flaps were used in fasciocutaneous fashion alone. Partial flap failures occurred in five cases. Dorsoulnar flaps were used as fasciocutaneous or as osteocutaneous flaps. Complete flap failure was reported in one patient alone, whereas partial necrosis was reported in four patients. Adipofascial turnover flaps had two partial flap failures reported but no complete failures. The overall complete and partial flap failure rates were 0.5 and 6.5%, respectively. ConclusionReverse-flow homodigital random or axial-based flaps provide a reliable means of reconstruction for soft-tissue defects with reasonable success rate and good functional outcomes. They have a consistent anatomy with a good potential for personalization and therefore increased versatility.

Soft tissue reconstruction of the thumb: Classification of defects and standardisation of treatment

The aim of this article is to share our experience of thumb defects based on the defect irrespective of the etiology of the defect and to work towards standardizing the treatment for thumb defects. This study was conducted at the Burns and plastic surgery center at Hayatabad Medical complex from 2018 to 2021. Thumb defects were divided into small (< 3 cm), medium (4-8cm) and large defects (> 9cm). Post-operatively, patients were evaluated for complications. The type of flaps were stratified for size and site of the soft tissue defects to generate a standardized algorithm for thumb soft tissue reconstruction. After scrutinizing the data, 35 patients qualified for the study, including 71.4% (25) males and 28.6% (10) females. The mean age was 31.17+15.8SD. Right thumb was affected in majority of the study population (57.1%). Majority of the study population was affected by machine injury and post-traumatic contractures, affecting 25.7% (n=9) and 22.9% (n=8) respectively. First web-space and injuries distal to IPJ of thumb were the most common areas affected, accounting for 28.6% (n=10) each. First dorsal metacarpal artery flap was the most common flap followed by retrograde posterior interosseous artery flap, observed in 11 (31.4%) and 6 (17.1%) cases. The most common complication observed in the study population was flap congestion (n=2, 5.7%) with a complete flap loss in 1 patient (2.9%) cases. Based on the cross tabulation of flaps against the size and location of defects, an algorithm was developed to help standardize reconstruction of thumb defects. Thumb reconstruction is critical in restoring hand function of the patient. The structured approach towards these defects make their assessment and reconstruction easy especially for novice surgeons. This algorithm can further be extended to include defects of the hand irrespective of etiology. Most of these defects can be covered with local easy to do flaps without the need for a microvascular reconstruction.

Utility of First Dorsal Metacarpal Artery Flap for Thumb Defects.

Background Reconstruction of thumb tip, while providing a durable and sensate flap, is a challenging task. It is important as thumb accounts for 50% of hand functions. Options for coverage are: healing by secondary intention, local/regional flaps, microsurgical toe wraparound flap, etc. First dorsal metacarpal artery (FDMA) flap is one regional flap that has been used for thumb cover, usually for defects till interphalangeal joint or just distal to it. We present our case series for FDMA flap and its variations for thumb reconstruction. We also report reverse FDMA flap cover for reconstruction of defects over distal phalanx of thumb. Methods The procedure was performed in patients with partial loss of thumb soft tissue in 16 patients presenting during 2017 to 2020. The FDMA flap was performed according to the standard technique. In case after "planning in reverse," it was seen that the reach of FDMA flap was insufficient, reverse FDMA flap was done. Physiotherapy for index finger and thumb was started on day 10. Patient satisfaction, in terms of cosmesis and function was recorded (graded as poor, good, and very good). Static two-point discrimination (2-PD) was assessed at 6 months' follow-up. Patients were followed up for 6 months. Results The operative time was 1 to 2 hours. Out of total 16 cases, 8 patients underwent racquet-shaped (intact skin paddle) FDMA flap. Islanded flap was performed in five and reverse FDMA flap in three. Twelve patients had uneventful recovery and four patients (three islanded and one reverse FDMA) had partial skin loss. Static 2-PD was assessed at the 6 months postoperative period. Conclusion FDMA flap is a useful regional flap for thumb reconstruction. It provides good supple, durable, and sensate cover. The reverse FDMA flap that increases the pedicle length can be used for more distal defects, where conventional FDMA flap is doubtful.

Restoration of Sensibility Following Reconstruction of Soft Tissue Defect of Thumb with the First Dorsal Metacarpal Artery Island Flap

Introduction: Thumb injuries constitute a challenge for the plastic surgeon because the loss of its function compromises the function of the entire upper limb. If there is a soft tissue defect in thumb where tendons, joints, or bones is exposed, it requires stable vascularized flap reconstruction preferably with a local or regional flap. The First Dorsal Metacarpal Artery (FDMA) island flap from the dorsum of the index finger is an option for reconstructing such thumb defect. Objectives: To assess the quality of sensitivity at flap site following reconstruction of soft tissue defect in thumb with the FDMA island flap. Materials and Methods: A prospective observational study was conducted from July 2012 to June 2013 among 31 patients admitted with soft tissue defect of thumb with exposure of tendon, bone, joint or loss of pulp and were treated with innervated FDMA island flap. Recovery of sensation was evaluated by static-2PD test. Results: Out of 31 patients 28 were male and 3 were female with male to female ratio is 9:1. The mean age was 26.2±8.8 years. A large number of patient was manual worker (construction worker, mechanic). Most of them sustained injury in their dominant thumb (61%). Most common cause of injury was electric burn (78%) rest were due to machinery injury. Average s-2PD over the flap area 9.1 mm (range, 8-12 mm) compared with 7.4 mm (range, 7-11 mm) over the donor site of opposite index finger and 5.5 mm (range, 3-9 mm) over corresponding site of opposite thumb. Average loss of s-2PD over the flap area compared with the donor area was 1.4 mm (19.2%). Every patient was satisfied with the outcome. Conclusion: Restoration of sensibility is quite satisfactory after reconstruction of soft tissue defect of thumb by first dorsal metacarpal artery island flap. JAFMC Bangladesh. Vol 18, No 1 (June) 2022: 34-38

Mid-Term Results of the First Dorsal Metacarpal Artery Flap for Thumb Defects.

Background: The thumb plays an important role in the function of the hand. Sensate reconstruction of the pulp is important in restoring function to the thumb. The aim of this study is to present outcomes of a sensate islanded first dorsal metacarpal artery (FDMA) flap used for the reconstruction of skin defects of the thumb. Methods: Patients who had a FDMA flap reconstruction of thumb pulp defects in the orthopaedics and traumatology clinic of affiliated hospital were included in the study. This included eight thumbs of eight patients. The range of motion, sensation and cosmetic satisfaction in the donor and recipient areas were evaluated at a minimum of 2-year follow-up. Results: There were no partial or complete flap failures. The mean static 2-point discrimination was 15 mm and the mean Semmes-Weinstein monofilament test score was 3.93. Cortical re-orientation was observed in 65% of patients. Near normal range of motion and Kapandji scores were regained in all patients. Conclusions: Excellent motion and sensory outcomes were obtained following the FDMA flap reconstruction of thumb pulp defects. The donor morbidity of the flap is minimal, and this flap can be considered as one of the primary options for reconstruction of thumb pulp defects. Level of Evidence: Level V (Therapeutic).

Clinical effects of free hallux-nail flap combined with the second toe composite tissue flap in the reconstruction of damaged thumb after electrical burns

Objective: To explore the clinical effects of free hallux-nail flap combined with the second toe composite tissue flap in the reconstruction of damaged thumb after electrical burns. Methods: A retrospective observational study was conducted. From May 2018 to April 2021, 12 male patients with thumb destructive defects caused by electrical burns who met the inclusion criteria were admitted to Zhengzhou First People's Hospital, aged 27 to 58 years, including 10 cases with degree Ⅲ thumb defect and 2 cases with degree Ⅳ thumb defect after thorough debridement. The thumb was reconstructed with free hallux-nail flap combined with composite tissue flap of the second phalangeal bone, joint, and tendon with skin island. The donor site of hallux-nail flap was covered with artificial dermis in the first stage and performed with continuous vacuum sealing drainage, and covered with medium-thickness skin graft from the groin site in the second stage. The donor site in the second toe was filled and fixed with iliac bone strips. The survival of reconstructed thumb was observed 1 week after the reconstruction surgery, the survival of skin graft in the donor site of hallux-nail flap was observed 2 weeks after skin grafting, and the callus formation of the reconstructed thumb phalanx and the second toe of the donor foot was observed by X-ray 6 weeks after the reconstruction surgery. During the follow-up, the shape of reconstructed thumb was observed and the sensory function was evaluated; the function of reconstructed thumb was evaluated with trial standard for the evaluation of the functions of the upper limbs of the Hand Surgery Society of the Chinese Medical Association; whether the interphalangeal joints of the hallux and the second toe were stiff, the scar hyperplasia of the foot donor site, and whether the walking and standing functions of the donor feet were limited were observed. Results: One week after the reconstruction surgery, all the reconstructed thumbs of the patients survived. Two weeks after skin grafting, the skin grafts in the donor site of hallux-nail flap of 11 patients survived, while the skin graft in the donor site of hallux-nail flap of 1 patient was partially necrotic, which was healed completely after 10 days' dressing change. Six weeks after the reconstruction surgery, callus formation was observed in the reconstructed thumb and the second toe of the donor foot of 10 patients, the Kirschner wires were removed; while callus formation of the reconstructed thumb was poor in 2 patients, and the Kirschner wires were removed after 2 weeks of delay. During the follow-up of 6 to 24 months, the shape of reconstructed thumb was similar to that of the healthy thumb, the discrimination distance between the two points of the reconstructed thumb was 7 to 11 mm, and the functional evaluation results were excellent in 4 cases, good in 6 cases, and fair in 2 cases. The interphalangeal joints of the hallux and the second toe of the donor foot were stiff, mild scar hyperplasia was left in the donor site of foot, and the standing and walking functions of the donor foot were not significantly limited. Conclusions: The application of free hallux-nail flap combined with the second toe composite tissue flap in the reconstruction of damaged thumb after electrical burns adopts the concept of reconstruction instead of repair to close the wound. It can restore the shape and function of the damaged thumb without causing great damage to the donor foot.

A Comparison of Outcomes of Reconstruction of Palmar versus Dorsal Defects of the Thumb Using a First Dorsal Metacarpal Artery Flap with a Cutaneous Bridge Segment.

Background: The aim of this study is to compare outcomes of reconstruction of palmar versus dorsal defects of the thumb using the first dorsal metacarpal artery (FDMA) flap with a cutaneous bridge segment. Methods: All FDMA flaps done at our centre for reconstruction of traumatic thumb defects in the period from November 2017 to May 2019 were included in this study. Data with regard to the patient, the injury and the flap were recorded. The outcome measures recorded include flap survival, complications, duration of follow-up, static two-point discrimination (2-PD), cortical reorientation, paresthesia at the flap and donor site, pain at the flap and donor site, Kapandji score and aesthetic outcome. Results: The study included 11 patients with an average age of 35 years. All patients were men, and the injury involved the dominant thumb in seven patients. There were five dorsal defects and six palmar defects, and the average defect size was 7.22 sq cm. All flaps survived and there were no complications. The mean follow-up period was 15.2 months. The mean static 2-PD was 9.35 mm, cortical reorientation was complete in six patients, paresthesia score at the flap was 0.27 and at the donor site was 0.36. The visual analogue scale (VAS) pain for the flap was 1.09 and for the donor site was 1.27. The average Kapandji score was 8.64 and patients rated the aesthetic outcome of the flap at 8 and of the donor site at 7.36. There were no differences in outcomes between palmar and dorsal defects except for the aesthetic outcome of the flap that was rated better for dorsal defects. Conclusion: The FDMA flap designed with a cutaneous bridge segment provided reliable, single-stage reconstruction of dorsal and palmar thumb defects with good outcomes. Patients rated the aesthetic outcome of flaps used for dorsal reconstruction higher. Level of evidence: Level IV (Therapeutic).

Evaluation of versatility and outcomes of the first dorsal metacarpal artery flap in thumb defects.

It is clinically vital to determine the best technique to reconstruct thumb defects with satisfactory esthetic and functional outcomes. We aimed to quantitatively present the safety, versatility, limitations, advantages, and functional results of the first dorsal metacarpal artery flap (FDMAF) and evaluate its outcomes in thumb defect reconstruction by comparing it with the other current surgical options. A total of 21 patients underwent thumb defect reconstruction. They were evaluated with the following parameters: Etiology, age, timing of reconstruction, flap vitality, Semmes-Weinstein monofilament (SWM) test, static two-point discrimination (2PD) test, pain, cortical reorientation, cold intolerance questionnaire, and Michigan hand outcomes questionnaire. Their functional outcomes were evaluated by comparing their scores with the other current surgical options published in the literature. The mean follow-up period was 22.3 months. The mean pain score of the flap was 0.4±0.6 and no patient had pain in the donor area (range, 0-10). The sensory outcome was 'good' (8.6 mm) based on the static 2PD test. The mean SWM test score was 4.02 g. Patient satisfaction was 4.6 according to the Michigan hand outcomes questionnaire (range, 0-5). The cold intolerance questionnaire scores showed that the patients had mild cold intolerance (mean, 10.5; range 0-100). Complete cortical reorientation was seen in 81% of the patients. Restoration of the innervation of thumb defects is possible with the FDMAF with high satisfaction rates based on our results. The absence of the microsurgical vessel or nerve repair facilitates the surgery, shortens its duration, and reduces morbidity, reserving the microsurgical options for more complicated cases. Therefore, it can be concluded that the FDMAF is an effective flap with great modifications for complicated thumb defects but surgeons should consider their clinical outcomes and prolonged surgery when choosing which technique to be used.

Workhorse flaps for thumb reconstruction

Posttraumatic thumb defects result in significant functional impairment. Multiple reconstructive procedures have been described for the management and improvement of function. Compared with no treatment, all reconstructive methods are beneficial. Each of the available procedures may be more applicable under certain conditions, can offer great benefits, and have its own downsides as well. With a thorough assessment and meticulous technique, the results of thumb reconstruction can be excellent. We present a review of the current reconstructive procedures for traumatic thumb amputation.

Second dorsal metacarpal artery-based index finger dorsal island flap for the management of thumb defects

Index finger dorsal island flaps were frequently utilized by hand surgeons to reconstruct thumb defects. However, the blood supply of the traditional index finger dorsal island flap comes from the first dorsal metacarpal artery, which has a smaller diameter, more anatomical variation, and can be injured in conjunction with thumb injuries. Therefore, we design an alternative index finger dorsal island flap based on the second dorsal metacarpal artery to treat thumb skin defects. From August 2015 to October 2018, we used the index finger dorsal island flaps with the second dorsal metacarpal artery to treat 11 patients with thumb skin defects. All the flaps and skin grafts survived completely without complications. At the last follow-up, the mean 2PD of the flap was 6.4mm (45.5% for excellent, 54.5% for good), the mean ROM of the injured thumbs was 115.9° (72.7% for excellent, 27.3% for good), and the mean cosmetics score was 8.6. Our results demonstrate that the index finger dorsal island flap with the second dorsal metacarpal artery is suitable for the reconstruction of thumb skin defects. The flap has an excellent survival rate and good coverage with satisfactory results and represents a promising treatment for the selected patients. Level of Evidence: Therapeutic, level IV.