Web Contracture Research Articles

Usefulness of the lateral arm free flap for hand defect reconstruction

Purpose: Although various surgical reconstruction methods are available for multidigit defects or soft tissue defects of the hand, they often require a thin flap due to the hand’s unique physical characteristics. We performed a total of 13 cases of lateral arm free flap surgery at our hospital. The purpose of this study was to report the usefulness of this technique. Methods: This study included the following cases: four cases of multiple digit amputations, seven cases of hand dorsum skin defects, one case of first web reconstruction due to web contracture, and one case of an index finger bone and soft tissue defect with only the ulnar-side neuro-vascular bundle remaining. After emergency simple debridement, subsequent reconstruction was performed using a lateral arm free flap. Results: All 13 cases healed without necrosis. Patients who underwent finger amputation were able to preserve the length of their fingers without any additional amputation. Patients who initially had hand dorsum defects were able to maintain grasping function after flap stabilization. The patient with web contracture was able to recover the lost pinching function, and the patient with a combined loss of osteoarticular and soft tissue of the index finger maintained the shape and length of the finger despite the absence of joint function. Conclusion: The lateral arm free flap is a useful reconstruction method that can be easily performed with a single session of regional anesthesia. Since the flap is thin, it is suitable for hand defect reconstruction. If necessary, vascularized bone grafting is possible.

Comparison Study of 5-Flap Z-Plasty and Double Z-Plasty for Interdigital Pocket Web Contractures

The aim of this study was to compare the improvement in abduction and change in web slope between 5-flap z-plasty and double z-plasty for post-burn or post-trauma interdigital pocket web contractures. We retrospectively reviewed 16 webs in 11 patients with post-burn or post-trauma interdigital pocket web contractures. Seven patients underwent 5-flap z-plasty and 4 double z-plasty. The abduction and slope angles of the affected fingers were measured before surgery and every 3 months after surgery. The follow-up time ranged from 12 to 36 months. The postoperative abduction angle improved in both groups. There was an increase of 19° ± 4° in the mean abduction angle after surgery in the 5-flap z-plasty group compared with a mean of 12° ± 2° in the double z-plasty group; the postoperative decrease in the web slope angle was 30° ± 5° and 22° ± 2°, respectively. All patients were able to actively move the affected webs and fingers with no pain or other discomfort. Five-flap z-plasty can be considered a better alternative to double z-plasty for interdigital pocket web contractures based on the improvement in abduction angle and changes in the slope angle. Therapeutic IV.

Outcomes of a Trans-Web Approach to Fractures around the Finger Metacarpophalangeal Joint.

Background: A fracture around the finger metacarpophalangeal joint (MCPJ) can be difficult to access. We developed a trans-web approach that could lead surgeons directly to this site. An incision across the web is believed to result in a web contracture. The aim of this study is to present the outcomes of the trans-web approach. Methods: This is a retrospective study of all patients in whom a trans-web approach was used to fix fractures around the MCPJ in the period from October 2008 and September 2020. The outcomes of the trans-web approach were evaluated by appearance of the scar, presence of pain in relation to the scar, grading web creep, range of motion at the MCPJ and degree of abduction and adduction of the finger. Any complications of surgery were also recorded. Results: This study included 10 patients with 11 fractures around the MCPJ (6 avulsion fractures and 5 extra-articular fractures). The mean follow-up was 5 months. Skin contractures did not occur in any avulsion fracture case where original or extended trans-web skin incisions were used. However, they occurred in 2 extra-articular cases treated via a trans-web plus a mid-lateral approach. The mean range of motion of the MCP joint in all the patients was 80° (range, 70°-95°). There was a 10° loss of abduction in one patient and temporary sensory disturbance in another patient. Both these patients had been treated with extended incisions. Conclusions: The trans-web incision is a useful approach for the open reduction of fractures around the finger MCPJ, especially in avulsion fractures of the lateral volar base of the proximal phalanx with minimal risk of scar contracture. The risk of scar contracture is higher when the trans-web incision is combined with a mid-lateral incision for extra-articular fractures. Levels of Evidence: Level IV (Therapeutic).

Square Flap Method for Reconstruction of Palmar and Dorsal Web Space Burn Contractures.

Postburn web space contractures can result in serious in hand function impairments along with cosmetic disfigurement. In our study, we introduce our experience with the use of the square flap method to release palmar or dorsal web space contractures. From March 2019 to May 2021, the square flap method was conducted in 12 patients with 13 digital web space contractures. The average patient's age was 6 years old (range, 2.5-16 years old). The most common affected web space was the second web. Web contractures were palmar in 9 patients and dorsal in 4 patients. The average duration of scar maturity was 13.6 months (range, 8-24 months). All the square flaps were effective in releasing the web space contracture and healed uneventfully with no postoperative complications. The average follow-up period was 11 months (range, 2-24 months). All patients or their parents were satisfied with the procedure outcomes in terms of independent finger function and esthetic appearance. The square flap technique is safe, reliable, and effective in management of both dorsal and palmar interdigital web scar contracture. It completely eliminates the contracture and restores commissural anatomy with good cosmetic outcomes.

A novel technique to widen the 1st web space by using 'spare parts' of thumb polydactyly

First web space contracture causes significant morbidity and hence their release is important to make use of normal hand functions. First web space helps in improving the grasp. There are several methods of normalizing the 1st webspace. In this article we are describing a local flap that uses the spare tissue of the thumb polydactyly for recovering the defect created from the release of the first web contracture, thereby providing coverage with a tissue that has good vascularity and also giving sensation to the resurfaced part.

Cross-finger Flap to the Thumb: Quest for an Alternate Donor.

Background Distal thumb injuries are managed by multiple local and regional flaps. The cross-finger flap (CFF) is one versatile flap used to cover such defects. The donor finger to the thumb is classically described to be the index finger (IF). However, with the index finger being the second most important finger, it causes further debilitation of the already injured hand. Our aim was to find an alternate donor finger to spare the index finger. Methods and Materials A prospective observational study was conducted on 10 patients with distal thumb injuries who were admitted between November 2018 and July 2019. Ring finger (RF) was used as donor for CFF in all the cases. The subjects were assessed for first web space angle, Kapandji score, total range of movement (TRM) of long fingers, and global hand function using Michigan hand outcome questionnaire (MHQ) after flap division. Results There was no first web contracture and TRM of IF remained unaffected. However, TRM of RF was significantly reduced. But this being a relatively unimportant finger, there was no significant reduction in global hand function, as evaluated by the MHQ score. Conclusion The ring finger is a good alternative for index finger as donor for CFF to the thumb, because it provides adequate tissue along with comfortable positioning and easy maintenance of local hygiene. Moreover, it preserves global hand function by sparing the IF.

Repair of donor site of reverse digital artery island flap with transverse V-Y fascial advancement flap of proximal dorsum of the finger

Objective To summarize the clinical efficacy of transverse V-Y fascial advancement flap of proximal dorsum of the finger for the repair of the donor site of reverse digital artery island flap. Methods From January 2017 to February 2018, 14 patients with fingertip defect were treated, including 4 emergency cases and 10 sub-emergency cases. The range of fingertip defect was 1.6 cm×0.6 cm to 2.5 cm×1.4 cm. The fingertip wound was repaired by reverse digital artery island flap and the donor site was covered by transverse V-Y fascial advancement flap of proximal dorsum of the finger. Results The flaps survived uneventfully after operation, and all the donor and recipient wounds achieved primary healing. The follow-up period ranged from 9 to 15 months with an average of 10.6 months. The skin flaps were of good texture, color, shape and no tenderness at the fingertips. At the last follow-up, the two-point discrimination of reverse digital artery island flaps was 7 to 12 mm, with an average of 8.6 mm. The two-point discrimination of V-Y advancement flaps of dorsal fingers was 5 to 9 mm, with an average of 6.2 mm. There was no web contracture, and the maximum abduction angle was 38° to 45° with an average of 42°. According to the total active range of motion (TAM) system, 12 cases were excellent and 2 cases were good. Conclusion The transverse V-Y fascial advancement flap of proximal dorsum of the finger was used to repair the donor site of reverse digital artery island flaps. The appearance, function and sensation of the fingers recovered well, and the related complications of free skin grafting were avoided. Key words: Finger injuries; Surgical flaps; Donor site; Wound repair

Application of modified pentagonal dorsal finger flap in the congenital syndactyly release

Objective To explore the clinical efficacy of modified pentagonal dorsal finger flap in the congenital syndactyly release. Methods From January 2010 to January 2014, 20 cases of simple cutaneous syndactyly were treated by modified pentagonal dorsal finger flap combined with finger Zigzag flap. The flap coverage scope, the occurrence of infection and necrosis of the skin flap and other early complications were recorded. The web depth and finger extension angle were measured and compared with the healthy side. Finger web creep and finger web scar were scored, and whether reoperation was performed due to the above complications was recorded. Questionnaire was used to evaluate parents' satisfaction. Results Twenty patients were follow-up for 30 to 75 months, with an average of 38 months. No complications such as infection and necrosis of skin flaps occurred after operation. The shape of the web was wide. The web depth of the affected side was (2.37±0.56) cm, and the finger extension angle was (24.50±4.74)°. There was no significant difference between the affected and healthy side. The reoperation rate due to web creep, web contracture and scar flexion contracture was 0. Family members were satisfied with the treatment outcome. Conclusion The modified pentagonal dorsal finger flap combined with finger Zigzag flap can reconstruct web space to the level of proximal interphalangeal joint, reduce the complications such as web creep and scar contracture after operation. Wide web is good for fingers to grasp large objects with high operative safety. Key words: Hand deformities,congenital; Syndactyly; Modified pentagonal dorsal finger flap; Web reconstruction; Web contracture

Durability of Collagenase Treatment for Dupuytren Disease of the Thumb and First Web After at Least 2 Years’ Follow-Up

The aim of this study was to analyze the durability of the treatment results of the thumb and first web contractures in Dupuytren disease with collagenase Clostridium histolyticum. Twelve patients (14 hands) were followed for an average of 35 months (range, 24-42 months). Two patients (3 hands) were excluded, yielding 11 hands available for assessment. Nondurability was defined as a worsening of at least 20° of passive extension deficit at a treated joint or any decrease greater than 5 mm in intermetacarpal head distance, both relative to 30 days after injection or as intervention to correct new/worsening contracture. Durability was compared with that of a historic cohort of treated finger contractures. Five out of 11 patients with a metacarpophalangeal or interphalangeal joint contracture or first web contracture had a nondurable result at an average of 35 months. Results obtained at metacarpophalangeal joints of thumbs were more durable than those of interphalangeal joints. Most of the recurrences occurred in interphalangeal joints. Treatment of thumb and first web contractures was not durable in nearly half of the cases at an average follow-up of 35 months, and durability was clearly less than that of treated finger contractures. Therapeutic IV.

Clinical application of penta-flaps plastic operation for treatment of web contracture with volar finger contracture

Objective To investigate the clinical efficacy of penta-flaps plastic operation in the treatment of web contracture with volar finger contracture. Methods From May 2012 to February 2015, 12 patients with web contracture and volar finger contracture were treated by penta-flaps plastic operation 0.5 to 3 years after injury. Penta-flaps were designed according to the contracted web. Simultaneously, the palm scar was released laterally at the level of metacarpophalangeal crease, and then the flaps staggered to cover the wound with one-stage correction. All the patients wore splint after surgery. Results All the flaps survived uneventfully except one flap occurred slight blood supply obstruction due to severe adhesion of finger web and healed by itself. All the patients were follow-up for 12 to 18 months postoperatively. The flaps were of suitable thickness, soft texture, good color and sensation recovery without contracture recurrence. Conclusion Application of penta-flaps plastic operation for treatment of web contracture with volar finger contracture can achieve satisfactory clinical efficacy, which is worthy of clinical promotion. Key words: Surgical flaps; Treatment outcome; Penta-flaps plastic operation; Web contracture

Application of free medial sural artery perforator flap for repair of severe thumb web scar contracture

Objective To explore the clinical effect of free medial sural artery perforator (MSAP) flap for repair of severe thumb web scar contracture. Methods From October 2012 to March 2015, 14 cases of severe thumb web scar contracture were repaired with free MSAP flap after scar excision. The flap areas ranged from 5 cm×4 cm to 9 cm×6 cm. The clinical outcomes were evaluated by the appearance of transplanted flaps, sensory recovery, opening angle and width of thumb web and donor site recovery at postoperative follow-up. Results All 14 flaps survived uneventfully. The thumb webs were well-stacked with satisfactory shapes. There was no secondary contracture. Primary healing was achieved at donor sites. Postoperative follow-up ranged from 12 to 18 months, with an average of 14 months. Postoperative angle of repaired thumb webs was enlarged to (80±6)° from preoperative angle of (15±5)°. And the width was enlarged to (45.0±5.6) mm from (20.0±3.5) mm. Thumb functions of abduction, adduction and opposition were all improved obviously. All flaps restored protective sensation. Six cases with anastomosis of medial sural cutaneous nerve recovered to S3. No functional damage was observed at donor sites. Conclusion MSAP flap is an effective way to repair severe thumb web contracture because of its constant perforator, satisfactory shape of repaired thumb webs and minor damages to donor sites. Key words: Surgical flaps; Transplantation; Medial sural artery perforator; Thumb web contracture

Algorithmic approach to the prevention of unnecessary fasciotomy in extremity snake bite

BackgroundIn the literature, there is a lack of a consensus about the occurrence of the compartment syndrome due to the snake bites. There are different concepts for the surgical treatment of the threshold value of the chamber pressure. There are many different classifications and assessment criteria for the snakebites. PurposeThere is not any appropriate classification in order to the assessment of extremity snake bites while making a decision for fasciotomy. We aimed to standardize the follow-up and decision making to perform fasciotomy with a new classification system for the snakebites using objective data. Patients and methodsThe data of all patients were recorded prospectively between 2006 and 2011. A total of 97 patients (64 male, 33 female) with a mean age of 30.94±14.04 were followed-up. During the evaluation of the patients, we used a new classification system that was improved for the extremity bites. We classified the patients due to their signs into four groups as for the classification system. Results40 patients with compartment like symptoms were carefully followed for 48–72h, and only three patients required fasciotomy where full recovery was achieved in 37 patients. Coverage of the defects was performed with full thickness skin grafting in 4 patients and cross finger flap in two patient. In two patients, the defects were located on the palmar aspect of the thumb. Thus, we applied Kite flap for skin coverage. Reverse dorsal digital artery flap was performed in eight patients and dorsal interosseous metacarpal flap in six patients. Four patients underwent an amputation. Two patients had web reconstruction due to first web contracture. ConclusionsWe present a large series of snake bite injuries and propose a classification and treatment recommendations. Fasciotomy should only be done while the measurement of intra-compartment pressure is above 55mmHg as snakebite can mimic the compartment syndrome. Level of evidenceIII–IV.

RECONSTRUCTION OF POSTBURN CONTRACTURE OF FIRST WEB SPACE OF THE HAND

Background: Soft tissue reconstruction of the first web space remained a challenge for plastic and reconstructive surgeons. First web space adduction contractures are a common consequence of hand burns. Many reconstructive techniques are used and investigation for more effective methods continues. Objective: assess the range of movement as regard opposition, palmar abduction and thumb extension. Also assessed the depth of web space after reconstruction of post burn contracted first web space to ass the method of covering the defect after release.. Materials and Methods: 35 patients’ ages ranged from 12 to 59 years (with mean 31.7), years; 23 males and 12 females admitted to our Hospital during the period from June 2008 to May 2012. All patients were suffering from post-burn first web contractures. The patients underwent a variety of surgical procedures. The follow-up period ranged from one to three years. Results: Full range of motion achieved in most patients, but not those with joint affections. Conclusions: In our experience, surgical correction of first web space contractures- in the form of flaps good results followed by skin grafts- results in meaningful functional enhancement. The outcomes depend primarily on the severity of contracture. Functionally limiting recontracture is rare in our experience and its best prevented by appropriate therapy Keywords: Contracture; Burns; First web space reconstruction.

Collagenase Treatment for Dupuytren Disease of the Thumb and First Web

To evaluate the short-term effectiveness of collagenase Clostridium histolyticum to treat thumb and first web contractures in Dupuytren disease. We prospectively included 14 thumbs in 12 patients with a contracture at the metacarpophalangeal or interphalangeal joint of at least 20° with a palpable cord in the thumb (n= 8) or an adduction contracture of the thumb with palpable cords in the first web (n= 6). They received an injection containing 0.58 mg of collagenase Clostridium histolyticum in the fibrous cord divided over 3 spots. The contracture was released by carefully manipulating the thumb under local anesthesia 1 day later. The extension and abduction deficits were measured before and after the intervention (follow-up at 7 and 30 days and 6 months). Wilcoxon signed rank test was used to analyze the data. In the total sample, postintervention extension deficits were statistically significantly lower than preintervention deficits except in one patient who had a recurrence at 6 months compared with the 30-day posttreatment result. Intermetacarpophalangeal head distance (IMD) also improved significantly. In an analysis of subgroups, we compared the separate contributions of treatment of a pretendinous cord and a first web cord on both extension deficit and IMD. Treatment of pretendinous cords significantly affected both extension deficit and IMD. However, treatment of first web contractures did not significantly improve extension or IMD. Collagenase Clostridium histolyticum is a good treatment option for pretendinous cords in thumbs affected with Dupuytren disease because it provides good results, is minimally invasive, and has minor adverse events. Therapeutic IV.

The Modification of Five-Flap Z-Plasty for Web Contracture.

Web contractures are fairly commonly encountered in those who have suffered from burn injury or other trauma. Numerous local flaps have been adopted previously. The five-flap Z-plasty is one that has been used frequently. To release the scar as much as possible, based on the traditional design, we developed a modified technique of the five-flap Z-plasty to reconstruct the axillary and elbow web contractures. Hence, the length of the axis of the cicatrix could be much lengthened. Twenty patients (12 females and 8 males, 7 to 48 years-old) with 27 web contractures were arranged for the operation using the new flap. The contractures were formed on by burn injury in 17 patients, surgery in 2 patients, and traumatic cicatrix in 1 case. All patients were operated on using a modified five-flap Z-plasty to reach the aim of maximum contracture relaxation. All flaps survived well. No flap tip necrosis occurred. Good function was gained in all patients postoperatively by the one year average follow-up. There was no recurrence. The contracture band was freed satisfactorily. The technique is very easy to execute and can be used both in web and linear contractures. With the virtue of extending the length of the scar axis to a higher degree compared to the traditional method, we suggest this modified five-flap Z-plasty application. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Palmar crease release and secondary full-thickness skin grafts for contractures in primary full-thickness skin grafts during growth spurts in pediatric palmar hand burns.

Pediatric palmar hand burns are a difficult problem because of the serious hand deformity, with functional impairment resulting from rapid growth. In cases of severe pediatric palmar hand burns, a secondary full-thickness skin graft after a primary full-thickness skin graft offers a reliable way of obtaining the required functional and aesthetic outcomes.This study retrospectively evaluated 28 children who required palmar crease releases and secondary full-thickness skin grafts during the past 12 years. The case records were reviewed for sex and age distributions, injury mechanism, and time interval between the primary and secondary full-thickness skin grafts. Surgical procedures included secondary full-thickness skin grafts and incisional releases of grafted skin on the involved creases. There were 19 men and 9 women. The mean age at the time of the burn injury was 10.1 months (range, 5-19 months). The mean age at the time of the secondary full-thickness skin graft was 8.3 years (range, 3-17 years). The most common mechanism of burn injury was steam (n = 24). The median time interval from the primary to the secondary full-thickness skin graft was 67 months (range, 8-156 months). The number of released creases was 81. The number of palmar web contractures in 23 patients was 52. A secondary full-thickness skin graft was more frequently necessary in patients with a primary full-thickness skin graft in the proximal digital crease and palmar web areas. All patients achieved adequate digital length and palmar web contour after surgery. Our patients should be observed until the rapid pubertal growth period.

Clinical application of dorsal proximal phalangeal flap for covering donor site defect of reverse digital

Objective To introduce the surgical techniques of repairing donor site defect of reverse digital artery island flap by perforator flap from the dorsum of the proximal phaalanx. Methods Fifteen cases with skin defects of the fingertips were treated with reverse digital artery island flap transfer.Defects at the donor site were repaired with perforator flap from the dorsum of the proximal phalanx. Results All 30 flaps survived in 15 cases.The patients were follow-up for 5 months to 2 years.The appearance and the texture of the flaps were good.The fingers were pain free.Two-point discrimination was 7 to 8 mm for the island flaps and 8 to 10 mm for the perforator flaps.According to the hand function evaluation criteria issued by the Chinese Hand Society,the hand function was graded as excellent in 13 cases and good in 2 cases.There were no obvious complications of the donor sites.The width and depth of the web space were not affected.There was no web contracture and finger abduction reached 30° to 40°, close to normal. Conclusion This procedure is easy and effective.The treatment result is satisfactory.It is an improvement over conventional donor site defect repairing techniques in reverse digital artery island flap transfer. Key words: Finger injuries; Surgical flaps; Tissue defect

The Reverse Posterior Interosseous Artery Flap: Technical Considerations in Raising an Easier and More Reliable Flap

Major injuries of the hand with skin loss often require early flap cover, which should be versatile, simple in technique, and safe. The reverse posterior interosseus flap satisfies all of these requirements. Over the years, refinements in the technique of harvesting this flap have evolved to prevent venous congestion and flap necrosis. This study presents adaptations to avoid such complications and raise a successful flap. A total of 21 patients underwent this flap reconstruction between January 2008 and November 2010 for injuries around the wrist and hand. The average follow-up period was 6 months; 19 were male and 2 were female. The average age was 33 years (range, 9-70 y). In 17 patients, the flap reconstructions were done for posttraumatic injuries, in 2 after skin defects following tumor resection, and 1 each after defects resulting from release of first web contracture in multiple congenital contractures and burns. Average size of the flap was 51 cm(2) (range, 90- 30 cm(2)). The donor area was covered by a split skin graft. All flaps survived without major complications. Generally the flap matched the surrounding skin except for palmar defects. No patients reported donor skin graft color mismatch. The reverse posterior interosseous flap is a reliable and safe flap for soft tissue cover to the wrist, palm, dorsum of hand, first web space, and metacarpophalangeal joints. Thorough attention to the technical details, including performing a proximo-distal flap dissection with the deep fascia, avoiding dissection of the anastomotic arc between posterior and anterior interosseous artery, creating a broad pedicle with a cutaneous handle, and avoiding its tunneling for inset, will contribute to survival of the flap.

Prevention of Web Creep Using a New Frame After Synpolydactyly Surgery

The main goal in syndactyly surgery is to create a normal web space; however, it is difficult to achieve the best clinical results in older and complex cases with bony fusions and joint deformities requiring osteotomies. In these complex cases, proper postoperative wound care is difficult to achieve due to the web contractures and deformities. In our report, we introduce a new technique using a frame that we called the "Hittite Sun," which helps in proper wound management to reduce wound healing problems that lead to web creep. Between 2002 and 2006, this frame was used in operations for 46 webs, and the results were compared with those of 30 operated webs in which conventional wound management technique was used. It was found that significantly lower complication rate and lesser web creep formation was seen in these patients, which were managed using the frame, compared with the cases with conventional wound care. The frame was found to be effective for prevention of severe web creep especially in complex synpolydactyly surgery.

Refinements in Dorsoulnar Flap of the Thumb: 15 Cases

We report 2 modifications of the classic Brunelli flap to avoid vascular compromise and first web contracture, common when using medium or large flaps. We treated 15 patients with posttraumatic loss of palmar surface and distal amputation of the thumb, with dorsoulnar flap associated with 2 refinements. The first technical tip was an adipofascial extension proximal in the flap aimed to decrease the morbidity of the donor site without changing the potential covering of the flap. The second was always to graft the pedicle of the flap, avoid vascular compression problems, and moreover, to use the pedicle to cover the traumatic area. All ulnar dorsal digital nerves of the flaps were reconnected to one of the volar digital nerves. The minimum patient follow-up was 12 months. All flaps achieved primary healing without major complications. There were no donor site problems. Cosmetic debulking of the flap over the pedicle has not been required. The Brunelli flap is a good technique to cover small and moderate defects of the thumb, although the drawback of this procedure is the lack of sensory recovery. The refinements of this series can help to improve the use of this flap and avoid complications in the donor site.