Treatment of complex soft-tissue defects at the metacarpophalangeal joint of the thumb using the bilobed second dorsal metacarpal artery-based island flap.

BACKGROUND: The purpose of this study is to report on reconstruction of complex soft-tissue defects around the metacarpophalangeal joint of the thumb using a bilobed second dorsal metacarpal artery-based island flap taken from the dorsum of the proximal phalanges of the index and long fingers. METHODS: From March of 2007 to October of 2009, the bilobed second dorsal metacarpal artery-based island flap was transferred in 13 patients. There were two defects on the metacarpophalangeal joint of the thumb. The mean size of the dorsal defects was 2.4 × 3.2 cm; the mean size of the volar defects was 2.6 × 4.0 cm. The mean size of the flaps taken from the index and long fingers was 2.6 × 3.4 cm and 2.8 × 3.2 cm, respectively. The mean pedicle length was 4.9 cm. RESULTS: All flaps survived completely. At a mean follow-up of 14 months, the mean active motion arc of the thumb metacarpophalangeal joints was 42 degrees. The motion of the donor fingers was similar to that on the opposite side. The mean values of static two-point discrimination of the donor sites of the index and long fingers were 6 and 7 mm, respectively. CONCLUSION: Transferring the bilobed second dorsal metacarpal artery-based island flap is a useful and reliable technique for reconstructing complex defects around the metacarpophalangeal joint of the thumb. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic IV.

The use of a third metacarpal base osteoarticular flap for treatment of metacarpophalangeal joint traumatic defects.

PURPOSE: To describe the use of a pedicled osteoarticular flap harvested from the base of the third metacarpal for the treatment of traumatic defects of the metacarpophalangeal (MCP) joints. METHODS: From February 2006 to January 2008, we included in the study 15 patients with posttraumatic defects of the MCP joints. The mean age of the patients was 35 years. The injured MCP joints were located in the thumb (n = 6) and index (n = 4), middle (n = 4), and ring fingers (n = 1). Of the 15 patients, 10 presented with acute injuries and 5 with old injuries. At follow-up, we assessed active motion and pinch strength and compared all measurements with those from the opposite hand. In patients with old MCP joint injuries, we also compared preoperative and postoperative motion and pinch strength. We assessed hand function using the Disabilities of the Arm, Shoulder, and Hand questionnaire. RESULTS: At the final follow-up (mean, 28 mo), the mean motion arc of the reconstructed MCP joints and the opposite joints was 46° and 91°, respectively, and the mean pinch strength of the injured and opposite sides was 5.4 and 7.1 kg, respectively. For the 5 patients with old injuries to the fingers, the mean preoperative and postoperative motion arc was 2° and 43°, and the mean preoperative and postoperative pinch strength was 1.6 and 5.3 kg, respectively. The mean Disabilities of the Arm, Shoulder, and Hand score of the entire patient series was 9, whereas the mean preoperative and postoperative scores of the 5 patients with old injuries were 44 and 17, respectively. CONCLUSIONS: The use of a pedicled osteoarticular flap harvested from the base of the third metacarpal is a reliable technique for the treatment of traumatic defects of the MCP joints.

Osteoarticular pedicle flap from the capitate to reconstruct traumatic defects in the head of the proximal phalanx.

PURPOSE: To describe the reconstruction of traumatic defects in the head of the proximal phalanx using an osteoarticular pedicle flap from the capitate. METHODS: From January 2004 to December 2007, we treated 15 patients with traumatic defects of the head of the proximal phalanx at our institution. All of these injuries involved 1 condyle of the proximal phalanx. There were 11 male and 4 female patients; the mean age was 32 years. The injuries occurred in the index (n = 6), middle (n = 7), and ring (n = 2) fingers. At the final follow-up, we assessed space narrowing of the proximal interphalangeal joint and flap necrosis using plain radiography. We measured active motion and pinch and grip strength of the hand and compared all measurements with those on the opposite side. Patients rated injured-joint pain and donor-joint pain using a visual analog scale. We assessed hand function using the Disabilities of the Arm, Shoulder, and Hand scale. RESULTS: Patient follow-up averaged 52 months. At the final follow-up, we noted narrowing of the proximal interphalangeal joint in 3 cases, but we observed no flap necrosis. The mean active motion arc of the injured and opposite proximal interphalangeal joints was 50° and 96°, respectively. The mean pinch strength of the injured and opposite hands was 5.8 and 6.5 kg, respectively. The mean grip strength of the injured and opposite hands was 39 and 40 kg, respectively. We noted mild recipient joint pain in 6 patients and mild donor joint pain in 1 patient. The mean score of the Disabilities of the Arm, Shoulder, and Hand questionnaire was 9. CONCLUSIONS: We used an osteoarticular pedicle flap from the capitate to resurface traumatic defects of the head of the proximal phalanx. This approach is acceptable for restoring the contour of the phalangeal head.

Treatment of a Bennett fracture using tension band wiring.

PURPOSE: To describe and assess a tension band wiring technique for the treatment of Bennett fractures and to compare this technique of open reduction and internal fixation versus closed reduction and percutaneous pinning. METHODS: From July 2005 to April 2008, we treated 56 Bennett fractures in 56 patients using tension band wiring. The mean age of the patients was 32 years. There were 37 dominant hands and 19 nondominant hands. The mean time between the injury and operation was 5 days. In this open tension band fixation group, the mean joint surface involvement was 39%, and all injuries were associated with carpometacarpal joint subluxation. At final follow-up, we assessed the thumbs for range of motion and assessed the hands for pinch and grip strength. For comparison, we also included 21 patients who were treated using closed reduction and percutaneous pin fixation from January 2003 to May 2005. RESULTS: We noted no fixation failures in the open reduction internal fixation group. Radiographic fracture healing was achieved in all patients at a mean time of 4 weeks. Patient follow-up averaged 39 months. At final follow-up, the mean extension-flexion arc of the first carpometacarpal joint was 49°. Mean thumb abduction was 82° and mean pinch and grip strength of the injured hands were 7.4 and 43.0 kg, respectively. There were no significant differences between groups regarding the extension-flexion arc of the first carpometacarpal joint and grip strength. The 2 groups were similar in thumb abduction and pinch strength. CONCLUSIONS: Open tension band wiring is a useful and reliable technique and presents another fixation option for the treatment of Bennett fractures.

Coverage of dorsal-ulnar hand wounds with a reverse second dorsal metacarpal artery flap.

This article introduces the use of a modified reverse dorsal hand flap harvested from the radial portion of the dorsal hand and wrist and the distal portion of the dorsal forearm for reconstruction of a large defect involving the third to fifth metacarpophalangeal (MCP) joints and the proximal phalanges. From May 2005 to August 2008, a modified reverse dorsal hand flap was transferred in 12 hands in 12 patients (9 male and 3 female). The mean age at flap transfer was 34.2 years (range: 23 to 50 years) old. All flaps survived. At final follow-up (mean, 28 months; range: 25 to 32 months), the mean active range of motion arcs of the third, fourth, and fifth MCP joints were 85 degrees (range: 65 to 97 degrees), 84 degrees (range: 60 to 90 degrees), and 83 degrees (range: 58 to 94 degrees), respectively. Our technique is useful and reliable for coverage of a large defect involving the third to fifth MCP joints and the proximal phalanges.

Use of the second dorsal metacarpal artery-based bilobed island flap for thumb reconstruction.

We report the use of the second dorsal metacarpal artery-based bilobed island flap harvested from the index and middle fingers for thumb reconstruction. From October 2006 to March 2008, the flap was performed in 13 hands in 13 patients (10 males and 3 females). The mean age at the time of operation was 45 years (range, 38 to 57 years). The flaps of the index fingers ranged in size from 2.1 × 2.5 cm to 4.2 × 3.2 cm. The flaps of the middle fingers were from 2.5 × 2.5 cm to 4.7 × 3.0 cm. The mean pedicle length was 6.5 cm (range, 5.1 to 8.0 cm). Flap survival was achieved in all cases. At final follow-up (mean 43 months; range, 36 to 52 months), the mean static two-point discrimination of the thumb pulps was 7 mm (range, 5 to 10 mm). Our technique is useful and reliable for the thumb reconstruction in select cases, with minimal donor-site morbidity.

Reconstruction of thumb pulp defects using a modified kite flap.

PURPOSE: We report on a modified kite flap for the reconstruction of thumb pulp defects. We performed nerve repair to improve thumb pulp sensation. METHODS: From May 2005 to December 2008, 42 thumbs in 42 patients were treated. The average size of the thumb pulp defects was 2.1 × 2.6 cm (range, 1.6 × 1.8 cm to 2.8 × 3.1 cm). The mean flap size was 2.5 × 2.9 cm (range, 1.8 × 2.2 cm to 3.2 × 3.5 cm). The radial branch of the second dorsal digital nerve was coapted to one of the proper digital nerves of the thumb. The required average length of the nerve branch was 1.2 cm (range, 0.7 to 1.6 cm). At follow-up, flap sensation was assessed using a static 2-point discrimination (2PD) test. For comparison, we also included 32 patients without nerve repair from April 2003 to April 2005. Outcomes were rated using the modified American Society for Surgery of the Hand Guidelines for Stratification of 2PD. RESULTS: In the study group, full flap survival was achieved in 40 thumbs, and partial distal flap necrosis was noted in 2 thumbs. At final follow-up (mean, 26 mo; range, 24 to 27 mo), we obtained a fair result, with a mean 2PD of 7.9 mm (range, 7 to 10 mm) on all flaps. In the comparison group without nerve repair, there were 26 fair and 6 poor results, with a mean 2PD of 12 mm (range, 8 to 18 mm) at final follow-up (mean, 24 mo; range, 22 to 26 mo). There was a highly significant difference between the 2 groups. CONCLUSIONS: We suggest performing nerve repair to improve the sensation of the kite flap when reconstructing a thumb pulp defect. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Use of a bilobed second dorsal metacarpal artery-based island flap for thumb replantation.

PURPOSE: An extensive traumatic defect at the level of the proximal phalanx of the thumb presents difficulty in replantation. We report bilobed second dorsal metacarpal artery-based island flap harvested from both the index and middle fingers for reconstruction of the defect and preservation of the normal thumb length. METHODS: From March 2004 to October 2008, 15 patients (11 men and 4 women; mean age, 35 y; range, 18 to 55 y) with completely or incompletely amputated thumbs associated with extensive defects in the proximal phalanx had replantation and reconstruction. In all cases, a bilobed second dorsal metacarpal artery-based island flap was used due to the large size of the defect. After flap transfer, anastomoses between the veins of the distal part of the thumb and the flap were performed. At the final follow-up, we assessed the mean active range of motion of the metacarpophalangeal and interphalangeal joints of the thumb and the span of the first web in the thumbs that survived. Active motion of the donor fingers was also assessed. RESULTS: In this series, 13 thumbs survived and 2 failed. All flaps survived completely. At the mean follow-up of 27 months (range, 24 to 29 mo), the mean active motion arcs of metacarpophalangeal and interphalangeal joints were 32° (range, 15° to 45°) and 31° (range, 0° to 47°), respectively. Full active range of motion was observed in all patients in both the metacarpophalangeal and the proximal interphalangeal joints of the donor index and middle fingers. CONCLUSIONS: Bilobed second dorsal metacarpal artery-based island flap transfer is a useful and reliable technique for thumb replantation when there is an extensive defect in the proximal phalanx and when a single-digit dorsal metacarpal artery island flap is too small. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Reconstruction of circulation in the fingertip without vein repair in zone I replantation.

PURPOSE: In fingertip replantation, adequate venous drainage is important for success. As the level of amputation becomes more distal, anastomosis of veins becomes more technically difficult. External bleeding is a common solution to venous congestion, but the process is burdensome because of duration of bleeding for 3 or more days after surgery. We present a new technique for reconstructing circulation without vein anastomosis in zone I replantation and analyze the outcomes of this technique in terms of eliminating external bleeding and of a high survival rate of the replanted digits. METHODS: Between 1997 and 2007, we performed 120 replantations in 112 patients (83 male and 29 female; mean age, 33 years; range, 3-54 years). All were zone I amputations, based on the Tamai classification. We surgically repaired both proper digital arteries, excluded the vein, and then ligated 1 of the arteries. Using this technique, circulation was restored. Included in the outcome evaluation were 91 digits in the 87 patients (mean age, 35 years; range, 14-54) who returned for outcome assessments 12 months after surgery. RESULTS: Of 120 digits replanted, 115 digits survived, corresponding to an overall success rate of 96%. No patients received alternative means to alleviate venous congestion, such as leeches or other means of external bleeding. Nearly all of the 87 patients (91 digits) were satisfied with the results of the replantations. CONCLUSIONS: Our technique reconstructs circulation without vein anastomosis in zone I replantation. This alternative to venous congestion involves a simple surgical procedure and straightforward postoperative care. Follow-up assessments of a series of 120 replantations show that the majority of zone I replantations led to satisfactory function. We therefore propose this technique as an effective method for zone I replantation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Posterior tibial artery-based multilobar combined flap free transfer for repair of complex soft tissue defects.

In this report, the posterior tibial artery (PTA) based multilobar combined flap is introduced for the repair of complex soft tissue defects. The flap was designed based on the perforatoring branches of PTA in the anterior soleus muscle septum, which supply the skin over the medial side of the calf and the entire soleus muscle. The saphenous nerve was included in one perforator flap of the combined flap for reinnervation. The tibial artery was repaired with a vein graft after harvest of flap. From October 2005 to February 2007, eight patients (6 males, 2 females) underwent PTA-based multilobar combined flap transfer for coverage of soft tissue defects involving the foot (three cases), hand (two cases), and calf (three cases). Each combined flap composed of two to three perforator flaps, and the size of the perforator flaps ranged from 4 x 2 cm to 10 x 8 cm. With an average follow-up of 6 months, all flaps survived without complications and injured extremities showed a good functional recovery with restoration of the partial protective sensation on the flap with reinnervation. This clinical report has shown that a reliable multilobar combined flap can be designed based on the perforators of the posterior tibial artery and used for coverage of the complex wound.